Tag Archive for: Parikh

Boy lying in a hospital bed, surrounded by medical equipment

Black, Hispanic children at greater risk for complications during hospitalization

Boy lying in a hospital bed, surrounded by medical equipment

The research team found that patients who are Black and Medicaid-insured patients experienced the greatest disparities in postoperative sepsis, a rare complication in which patients suffer from infection that can cause multi-organ failure.

Evaluating more than 5 million pediatric hospital stays nationwide, researchers found children who are Black, Hispanic or insured with Medicaid face a greater risk of health events after surgeries than white patients, according to a new study published in the journal Pediatrics.

“We looked at the data, and we calculated the risks,” said Kavita Parikh, M.D., MSHS, medical director of Quality & Safety Research, research director of the Division of Hospital Medicine and first author on the multi-institute study. “Despite decades of focus on eliminating medical errors, we know that children continue to suffer substantial harms in hospital settings, and our study highlights where children who are Black, Hispanic or insured with Medicaid are at the greatest risk.”

The big picture

The study analyzed data from more than 5.2 million hospitalizations collected by the 2019 Kids’ Inpatient Database, a national repository of data on hospital stays. It includes a 10% sample of newborns and an 80% sample of other pediatric discharges from 4,000 U.S. hospitals. More than 80% of patients were younger than 1 year of age.

The research team found that patients who are Black and Medicaid-insured patients experienced the greatest disparities in postoperative sepsis, a rare complication in which patients suffer from infection that can cause multi-organ failure. Patients who are Hispanic experienced the greatest disparity in postoperative respiratory failure, a complication that can limit breathing and ventilation.

Plausible factors cited include structural racism in the U.S. healthcare system, clinician bias, insufficient cultural responsiveness, communication barriers and limited access to high-quality healthcare.

What’s ahead

The study – “Disparities in Racial, Ethnic, and Payor Groups for Pediatric Safety Events in U.S. Hospitals” – is foundational in understanding what is happening among pediatric patients. Dr. Parikh said that researchers now must conduct further studies into these alarming disparities and qualitative work to understand drivers, with the action-oriented goal of developing interventions to improve patient safety in the hospital for all children.

“We brought together leaders in pediatric medicine, health policy and public health to analyze this data, and we are committed to taking the next steps to improve outcomes for pediatric patients,” Dr. Parikh said. “It will take more patient-centered work and research, resources and multifaceted strategies to resolve these worrying disparities for our pediatric patients nationwide.”

doctor talking to young girl with asthma

Caregiver language preference is associated with asthma outcomes

doctor talking to young girl with asthma

A team of researchers found that language barriers can contribute to increased asthma-related healthcare utilization including emergency department (ED) visits, hospitalizations and intensive care unit (ICU) visits.

Asthma is one of the most common chronic pediatric diseases, affecting more than 4 million children and accounting for approximately 24% of pediatric hospitalizations nationwide. Asthma disproportionally impacts historically marginalized racial and ethnic minorities in the United States, with these populations experiencing increased unscheduled asthma-related healthcare utilization and worse asthma outcomes. Families that speak languages other than English can experience increased patient safety events and worse outcomes in other disease processes, but limited data exists on the role of caregiver language preference on asthma morbidity.

The big picture

In a study published in Pediatrics, a team of researchers found that language barriers can contribute to increased asthma-related healthcare utilization including emergency department (ED) visits, hospitalizations and intensive care unit (ICU) visits.

“Families who speak languages other than English can experience significant barriers to quality healthcare from how they navigate a complex healthcare system to how they are able to communicate with their healthcare providers and receive timely care,” said Mickey Emmanuel, M.D., a pediatric emergency medicine fellow at Children’s National Hospital and lead author of the study. “Understanding how caregiver language preference contributes to pediatric asthma outcomes is crucial.”

What’s been the hold up in the field?

Prior research has characterized that caregivers with non-English language preference or NELP were less likely to receive education on asthma disease management and to be given asthma action plans in their preferred language or use asthma action plans. To date, limited data exists on the role of caregiver language preference on asthma utilization.

“Future studies utilizing qualitative and quality improvement methodology that puts the family’s needs at the center are key,” says Dr. Emmanuel. “Efforts to reduce asthma-related ED visits and hospitalizations for families who speak languages other than English must focus on understanding the unique barriers that caregivers face in caring for their children with asthma, and on delivering linguistically competent asthma care in the ambulatory and hospital settings.”

What’s next?

“This work has allowed us to identify that caregiver language preference is an important determinant for asthma outcomes and will hopefully fuel additional research focused on improving care for this population,” says Dr. Emmanuel.

From here, Children’s National will continue to work with notable mentors and leaders in the Language Equity space, with a clear commitment toward improving care for this population of patients.

Additional Children’s National researchers include: Rachel Margolis, Ph.D., Ranjodh Badh, B.A., Nikita Kachroo, A.E.-C., Stephen J. Teach, M.D., MPH,  and Kavita Parikh, M.D., MSHS.

girl being examined by doctor

Pediatric hospitals underutilize systems to get at social challenges impacting health

 

girl being examined by doctor

Physicians treating hospitalized children rarely use a coding system established in 2015 for flagging social challenges and stressors that may be impacting patient health, according to new research from Children’s National Hospital.

 

Physicians treating hospitalized children rarely use a coding system established in 2015 for flagging social challenges and stressors that may be impacting patient health, according to new research from Children’s National Hospital published in Pediatrics. Known as social determinants of health (SDOH), these factors include food insecurity, homelessness and adverse childhood events like substance abuse at home, and they can greatly affect a child’s well-being.

“We only get so many touchpoints with our patients,” said Kaitlyn McQuistion, M.D., pediatric hospital medicine fellow at Children’s National and co-lead author of the paper. “Our research shows the screening itself provides valuable insight into our patients, making identification an important part of inpatient and post-discharge care. With this information, doctors can help families tap into social workers, community supports and other resources aimed at providing a more holistic approach to child health.”

The big picture

The American Academy of Pediatrics advises screening for unmet social needs and using the codes laid out in the International Classification of Disease, 10th Revision (ICD-10), to flag risk factors for some of a hospital’s most vulnerable patients. In 2018, the American Hospital Association (AHA) clarified that the coding can be added by any healthcare professional accessing the chart, including nurses, social workers, case managers and physicians. The study looked at data from 4,000 hospitals in 48 states and the District of Columbia and found that use of the codes has remained low, even with the AHA’s clarification.

In practice, physicians know that screening and documentation are the essential first steps to help families find resources. Yet less than 2% of pediatric inpatients were coded as needing support. Most commonly, “problems related to upbringing” – a broad category indicating social needs and adverse childhood events – was used.

What’s ahead

Some providers are using these SDOH codes, or Z Codes, more often to address and improve health disparities. “Our mental health colleagues and those working with the Native American population, in particular, are using these tools more often to capture and disseminate critical information related to their patients’ social needs,” said Stacey Stokes, M.D., a hospitalist at Children’s National and co-lead author on the paper.  “Their innovative approaches to address and improve health disparities may provide learning opportunities for institutions.”

The researchers said that more work needs to be done to take these successes to other populations, find ways to incentivize this work in billing and ensure that providers have community resources to address the needs that they uncover.

“The ultimate goal of this work is to identify patients with social needs affecting their health and connect them with resources,” said Kavita Parikh, M.D., director for the Research Division of Hospital Medicine. “There are many avenues to explore to find ways to better utilize this tool, including language learning models, improved training and stronger community resources.”

ambulance bay at Children's National Hospital

AAP names Children’s National gun violence study one of the most influential articles ever published

ambulance bay at Children's National Hospital

The American Academy of Pediatrics (AAP) has named a 2019 study led by clinician-researchers at Children’s National Hospital one of the 12 most influential Pediatric Emergency Medicine articles ever published in the journal Pediatrics.

The American Academy of Pediatrics (AAP) has named a 2019 study led by clinician-researchers at Children’s National Hospital one of the 12 most influential Pediatric Emergency Medicine articles ever published in the journal Pediatrics.

The findings showed that states with stricter gun laws and laws requiring universal background checks for gun purchases had lower firearm-related pediatric mortality rates but that more investigation was needed to better understand the impact of firearm legislation on pediatric mortality.

The study, State Gun Laws and Pediatric Firearm-Related Mortality, was led by Monika Goyal, M.D., M.S.C.E., associate chief of Emergency Medicine, along with Gia M. Badolato, M.P.H., coauthor; Shilpa J. Patel, M.D., MPH, coauthor and emergency medicine specialist; and Kavita Parikh, M.D., MSHS, coauthor and hospitalist, all of Children’s National.

The big picture

In 2019, firearm injuries were the second-leading cause of death for U.S. children. Presently, they are the leading cause of death.

“We have learned that interventions to tackle gun violence are not a ‘one size fits all’ and we need to start developing and scaling tailored interventions that embrace and center community voices and partnerships,” Dr. Goyal said. “The good news is that over the last 5-7 years, there has been a groundswell of energy to address the firearm epidemic in our nation that has led to the growth of investigators, funding and advocacy efforts dedicated to developing and disseminating evidence-based interventions and policies for gun violence prevention. But we need more dedicated funding to support these efforts and continue to invest in those who wish to dedicate their careers to this work.”

About the recognition

The AAP Section on Emergency Medicine (SOEM), founded in 1981, is among the AAP’s largest sections, providing a forum for advocacy, education and research on patient care in pediatric emergency medicine (PEM). The AAP Committee on PEM (COPEM), a national committee founded in 1985, is the principal author of PEM-related AAP policies.

Members of the SOEM’s executive committee and COPEM reviewed every issue from the 75-year history of Pediatrics and selected 15 landmark papers in total, which names the study led by Dr. Goyal and her team.

What they’re saying

“This paper was the result of years of hard work and the beginning of many other collaborations as a research team. I am thankful to work with this team as we continue to add to this important area of research,” said Dr. Patel.

“I was honored to have our article chosen as one of the most influential Pediatric Emergency Medicine articles. I feel encouraged by this recognition that PEM physicians and researchers can be the bridge to the community and work together to make a difference for children,” added Badolato.

Led by their determination to change the status quo and improve the quality of life for children, the clinician-research team established Safer Through Advocacy, Firearm Education and Research (SAFER). It’s a group that works to fill the gaps in hopes of stimulating the change needed to help move the national landscape towards policies that make it safer for children and communities.

“We have created collaborations with pediatricians and researchers throughout the country and continue to work to fill the gaps,” Dr. Parikh said.

Other authors of the study include: Robert McCarter Jr., ScD, co-author; and Sabah F. Iqbal, M.D., PM Pediatrics, co-author.

child in hospital bed

Children’s National team develops trigger program for improved safety

child in hospital bed

Children’s National Hospital developed a unique pediatric triggers program that offers customized, near real-time reports of potential safety events.

Errors and adverse events continue to be a source of patient harm despite many hospitals creating safety programs. However, there are opportunities to improve patient safety using novel tools. For example, trigger programs.

A new study, published in Pediatrics, shows how a team at Children’s National Hospital developed a unique pediatric triggers program that offers customized, near real-time reports of potential safety events.

The big picture

The team defined a measure to quantify clinical utility of triggers, termed “trigger signal,” as the percentage of cases that represent true adverse or near-miss events (numerator) per total triggers activated (denominator). A Key Driver Diagram focused on unifying the program structure, increasing data analytics, promoting organizational awareness and supporting multidisciplinary end user engagement.

What we did

Using the Model for Improvement, the team of experts aimed to double overall trigger signal from 8% to 16% and sustain for 12 months.

“The Triggers Program used data analytics with quality and process improvement tools to employ novel strategies to improve trigger signal,” said Parissa Safari, M.H.A., Triggers Program project lead at Children’s National Hospital and one of the study’s authors. “This included shifting to multiple trigger committees, integrating electronic health record data with end user feedback and promoting organizational awareness.”

What we learned

Relying on the model, the team found that:

  • Trigger signal increased from 8% to 41% and sustained during the COVID-19 pandemic.
  • A balancing measure of time to implement a new trigger decreased.
  • Key interventions to increase trigger signals were changing the program structure, increasing stakeholder engagement and development of self-service reports for end users.

The triggers program developed by the team at Children’s National highlights successful evolution of an iterative, customized approach to increase clinical utility which hospitals can implement to impact real-time patient care.

Authors on the study from Children’s National include: Richelle M. Reinhart, M.D.; Ranjodh Badh, B.S.; Solomon Abera, Pharm.D., M.Sc.; Anit Saha, M.S.H.A., M.B.A.; Jessica Herstek, M.D.; Rahul K. Shah, M.D., M.B.A.; Kavita Parikh, M.D., M.S.H.S.

boy using asthma inhaler

Social determinants of health and asthma morbidity in youth

boy using asthma inhaler

Researchers believe these findings can help develop localized interventions that can improve pediatric asthma in affected communities.

In a study published in the journal Pediatrics, researchers from Children’s National Hospital found that census-tract measures of decreased educational attainment and increased violent crime were associated with increased census-tract rates of pediatric asthma morbidity.

“Knowing these adverse measures of social determinants are associated with increased asthma-related emergency department and hospitalization at-risk rates, may be an opportunity to inform community-based interventions to reduce pediatric asthma morbidity,” says Jordan Tyris, a hospitalist and lead author of the study.

Researchers evaluated data from 15,492 children with asthma, ages 2-17, living in Washington, D.C., from January 2018 to December 2019. The team discovered that living in areas with greater violent crime and less educational achievement were associated with higher rates of hospitalizations and emergency department visits for asthma, in comparison to other social determinants.

The study authors suggest that there may be complex reasons behind this data, noting that violent crime can reflect toxic stress, less education can be associated with less knowledge about health and medicine and that children in these communities may be less likely to have primary care doctors. Researchers believe these findings can help develop localized interventions that can improve pediatric asthma in affected communities and that more research is needed on the drivers of asthma related sickness, including toxic stress, structural racism and access to medical care.

Other study authors include Anand Gourishankar, M.D., Nikita Kachroo AE-C, Stephen Teach, M.D., Kavita Parikh, M.D., all of Children’s National Hospital and Maranda C. Ward, Ed.D., MPH, of George Washington School of Medicine and Health Sciences.

child reaching into drawer for gun

Sociodemographic factors linked to intentional youth firearm injuries

child reaching into drawer for gun

A new study led by researchers at Children’s National Hospital, finds that sociodemographic factors related to intent of injury by firearm may be useful in guiding policy and informing tailored interventions for the prevention of firearm injuries in at-risk youth.

Firearm injuries are a leading and preventable cause of injury and death among youth – responsible for an estimated 5,000 deaths and 22,000 non-fatal injury hospital visits each year in American kids. And while hospital systems are poised to tackle this issue using a public health approach, prevention efforts and policies may be differentially effective. A new study led by researchers at Children’s National Hospital, finds that sociodemographic factors related to intent of injury by firearm may be useful in guiding policy and informing tailored interventions for the prevention of firearm injuries in at-risk youth.

“We sought to explore differences by injury intent in a nationally representative sample of youth presenting to the emergency department with firearm injury,” said Shilpa Patel, M.D., M.P.H., emergency medicine physician at Children’s National Hospital. “We are hopeful that hospitals will support programs that are targeted, patient-centered and relevant to their communities to prevent firearm injury among youth.”

In one of the first comparative studies of factors and outcomes associated with intentionality of youth firearm injury in a large nationally representative sample, researchers identified more than 178,200 weighted hospital visits for firearm injuries with data collected from the Nationwide Emergency Department Sample (NEDS) from 2009 through 2016. Dr. Patel and her colleagues identified distinct risk profiles for individuals aged 21 and younger, who arrived at emergency departments with firearm injuries over an 8-year period.

Using NEDS data, researchers found that approximately one third of the injuries were categorized as unintentional, another third as assault and a small proportion as self-harm. The majority of visits were among youth age 18 to 21 years with almost 90% male, and more than 40% publicly insured. Nearly a third were admitted to the hospital and 6% died as a result of their firearm injuries. In addition, the study showed that the likelihood of unintentional injury was higher among children age 12 and younger.

Unintentional firearm injuries were also associated with rural hospital location, southern region, emergency department discharge and extremity injury. Self-harm firearm injuries were associated with older age, higher socioeconomic status, rural hospital location, transfer or death, and brain, back and spinal cord injury.

“These findings provide insight into the overlap between risk factors, outcomes and intentionality of youth firearm injury,” says Dr. Shilpa.  “For hospitals looking to implement programs to reduce youth firearm injury, distinct risk profiles identified in our study align with prior evidence to support the following: screen for firearm access and provide counseling on safe storage targeting families with younger children; screen suicidal patients for access to lethal means, especially those hospitals in rural areas; and screen for firearm access especially among children exposed to violence or at risk for assault presenting to urban hospitals.”

Other researchers who contributed to this study include members of S.A.F.E.R. (Safer through Advocacy, Firearm Education and Research) — a firearm safety advocacy group at Children’s National: Gia M. Badolato, M.P.H., Kavita Parikh, M.D., M.S.H.S., and Monika K. Goyal, M.D., M.S.C.E, all of Children’s National, and Sabah F. Iqbal, M.D., of PM Pediatrics.

 

Children's National Hospital

Safety at every level: a cultural transformation

Children's National Hospital

In early December, Children’s National Quality & Safety leadership team led participants through the hospital’s high-reliability journey and actionable tools at the Institute for Healthcare Improvement National Forum in Orlando, Fla.

In early December 2019, leadership from Children’s National Hospital quality and safety team attended and presented at the Institute for Healthcare Improvement National Forum in Orlando, Fla. The presentation, titled Safety at Every Level: A Cultural Transformation, provided attendees with an overview of Children’s National Hospital’s high reliability journey and actionable tools they could use to improve quality and safety.

Rahul Shah, M.D., MBA., vice president and chief quality and safety officer, Lisbeth Fahey, MSN, RN., executive director of quality and safety, Kavita Parikh, M.D., MSHS, pediatric hospitalist, and Kathryn Merkeley, MHSA, RN, director of patient safety, led the participants through each step of our journey, highlighting where the organization started, key steps in the process and lessons learned along the way.

The presentation demonstrated the integration of safety tools such as error prevention training, safety briefings, safety event reporting, cause analysis, safety culture measurement and transparency with high reliability principles to produce tangible gains in safety, quality and organizational culture. Dr. Shah emphasized the overarching theme of continuous learning and iterative change that is needed to be successful with this type of work.

“We’re always learning and looking to make things better by benchmarking our work against other pediatric organizations,” Dr. Shah said. “It’s important to ensure that we use the best practices to make sure we have the latest, best and most-evidence based practices to remain a top performing pediatric hospital.”

In a pediatric setting, safety is the keystone for performance excellence. As organizations work toward becoming high-reliability organizations they become more sensitive to operations, committed to resilience and are more reluctant to simplify their observations. Through implementing these tools and continually evaluating and learning, Children’s National was able to institute the evolution of a new safety culture by being more systematic, proactive and generative.

“Our goal was to provide the audience with tools they could use on their own journey to high-reliability,” said Merkeley. “We not only wanted to share our successes in creating positive culture change, but also the many lessons we’ve learned along the way and the desire to always be learning and improving.”

little boy looking at gun

A ‘compelling call’ for pediatricians to discuss firearm safety

little boy looking at gun

The Children’s commentators point to the “extremely dangerous” combination of “the small curious hands of a young child” and “the easily accessible and operable, loaded handgun” and suggest that pediatricians who counsel families about safely storing weapons tailor messaging to the weapon type and the family’s reason for owning a firearm.

Paradoxically, as overall firearm ownership decreased in U.S. households with young children from 1976 to 2016, the proportion of these families who owned handguns increased. This shift in firearm preferences over decades from mostly rifles to mostly handguns coincided with increasing firearm-mortality rates in young children, researchers report Jan. 28, 2019, in Pediatrics.

“Almost 5 million children live in homes where at least one firearm is stored loaded and unlocked,” Kavita Parikh, M.D., a pediatric hospitalist at Children’s National Health System, and co-authors write in an invited commentary. “This study is a loud and compelling call to action for all pediatricians to start open discussions around firearm ownership with all families and share data on the significant risks associated with unsafe storage. It is an even louder call to firearm manufacturers to step up and innovate, test and design smart handguns, inoperable by young children, to prevent unintentional injury,” Dr. Parikh and colleagues continue.

The Children’s commentators point to the “extremely dangerous” combination of “the small curious hands of a young child” and “the easily accessible and operable, loaded handgun” and suggest that pediatricians who counsel families about safely storing weapons tailor messaging to the weapon type and the family’s reason for owning a firearm.

They also advocate for childproofing firearms stored in the home – through free or discounted locks, storing weapons separately from ammunition, and using personalized technology that limits the firearm’s potential to be used by children accidentally. According to a retrospective, cross-sectional study led by Children’s researchers, younger children are more likely to be shot by accident.

“The development of effective safety controls on firearms is not only attainable but could be the next big step towards reducing mortality, especially among our youngest. We as a society should be advocating for continued research to ‘childproof’ firearms so that if families choose to have firearms in the home, the safety of their children is not compromised,” Dr. Parikh and co-authors write.

In addition to Dr. Parikh, the senior author, the Pediatrics commentary co-authors include Lead Author Shilpa J. Patel M.D., MPH, emergency medicine specialist; and co-author Monika K. Goyal M.D., MSCE, assistant division chief and director of research in Children’s Division of Emergency Medicine.

inhaler

Keeping kids with asthma out of the hospital

inhaler

Pediatric asthma takes a heavy toll on patients and families alike. Affecting more than 7 million children in the U.S., it’s the most common nonsurgical diagnosis for pediatric hospital admission, with costs of more than $570 million annually. Understanding how to care for these young patients has significantly improved in the last several decades, leading the National Institutes of Health (NIH) to issue evidence-based guidelines on pediatric asthma in 1990. Despite knowing more about this respiratory ailment, overall morbidity – measured by attack rates, pediatric emergency department visits or hospitalizations – has not decreased over the last decade.

“We know how to effectively treat pediatric asthma,” says Kavita Parikh, M.D., M.S.H.S., a pediatric hospitalist at Children’s National Health System. “There’s been a huge investment in terms of quality improvements that’s reflected in how many papers there are about this topic in the literature.”

However, Dr. Parikh notes, most of those quality-improvement papers do not focus on inpatient discharge, a particularly vulnerable time for patients. Up to 40 percent of children who are hospitalized for asthma-related concerns come back through the emergency department within one year. One-quarter of those kids are readmitted.

“It’s clear that we need to do better at keeping kids with asthma out of the hospital. The point at which they’re being discharged might be an effective time to intervene,” Dr. Parikh adds.

To determine which interventions hold promise, Dr. Parikh and colleagues recently performed a systematic review of studies involving quality improvements after inpatient discharge. They published their findings in the May 2018 edition of the journal, Pediatrics. Because May is National Asthma and Allergy Awareness month, she adds, it’s a timely fit.

The researchers combed the literature, looking for research that tested various interventions at the point of discharge for their effect on hospital readmission anywhere from fewer than 30 days after discharge to up to one year later. They specifically searched for papers published from 1991, the year after the NIH issued its original asthma care guidelines, until November 2016.

Their search netted 30 articles that met these criteria. A more thorough review of each of these studies revealed common themes to interventions implemented at discharge:

  • Nine studies focused on standardization of care, such as introducing or revising a specific clinical pathway
  • Nine studies focused on education, such as teaching patients and their families better self-management strategies
  • Five studies focused on tools for discharge planning, such as ensuring kids had medications in-hand at the time of discharge or assigning a case manager to navigate barriers to care and
  • Seven studies looked at the effect of multimodal interventions that combined any of these themes.

When Dr. Parikh and colleagues examined the effects of each type of intervention on hospital readmission, they came to a stunning conclusion: No single category of intervention seemed to have any effect. Only multimodal interventions that combined multiple categories were effective at reducing the risk of readmission between 30 days and one year after initial discharge.

“It’s indicative of what we have personally seen in quality-improvement efforts here at Children’s National,” Dr. Parikh says. “With a complex condition like asthma, it’s difficult for a single change in how this disease is managed to make a big difference. We need complex and multimodal programs to improve pediatric asthma outcomes, particularly when there’s a transfer of care like when patients are discharged and return home.”

One intervention that showed promise in their qualitative analysis of these studies, Dr. Parikh adds, is ensuring patients are discharged with medications in hand—a strategy that also has been examined at Children’s National. In Children’s focus groups, patients and their families have spoken about how having medications with them when they leave the hospital can boost compliance in taking them and avoid difficulties is getting to an outside pharmacy after discharge. Sometimes, they have said, the chaos of returning home can stymie efforts to stay on track with care, despite their best efforts. Anything that can ease that burden may help improve outcomes, Dr. Parikh says.

“We’re going to need to try many different strategies to reduce readmission rates, engaging different stakeholders in the inpatient and outpatient side,” she adds. “There’s a lot of room for improvement.”

In addition to Dr. Parikh, study co-authors include Susan Keller, MLS, MS-HIT, Children’s National; and Shawn Ralston, M.D., M.Sc., Children’s Hospital of Dartmouth-Hitchcock.

Funding for this work was provided by the Agency for Healthcare Research and Quality (AHRQ) under grant K08HS024554. The content is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ.

Kavita Parikh

Discharge strategies to prevent asthma readmissions

“Improving how we care for children who are hospitalized with asthma includes preparing them for a successful return home with the best tools to manage their illness and prevent a future hospital visit,” says Kavita Parikh, M.D., M.S.H.S.

Readmission rates at three months for kids hospitalized for acute asthma dropped when families received comprehensive education prior to discharge, the only single component of discharge bundles that was strongly associated with lowered readmissions, finds a multicenter retrospective cohort study published online Feb. 1, 2018, in The Journal of Pediatrics.

According to the Centers for Disease Control and Prevention, asthma is the most common chronic lung disease of childhood, affecting roughly 6 million U.S. children. Hospitalization for asthma accounts for $1.5 billion in annual hospital charges and represents almost one-third of childhood asthma costs.

Children who are hospitalized for asthma have a roughly 20 percent chance of returning to the hospital in the next year, and individual hospital readmission rates can range from 5.7 percent to 9.1 percent at three months, writes the study team. While the National Institutes of Health (NIH) has published evidence-based guidelines for discharge planning, there is no single, standardized asthma discharge process used across all pediatric hospitals in the U.S. that impacts 30-day readmission rates.

“Improving how we care for children who are hospitalized with asthma includes preparing them for a successful return home with the best tools to manage their illness and prevent a future hospital visit,” says Kavita Parikh, M.D., M.S.H.S., an associate professor of pediatrics at Children’s National Health System and lead study author. “Our study underscores the importance of increasing the intensity of select discharge components. For example, ensuring that children hospitalized for asthma receive asthma medication at discharge along with comprehensive education and environmental mitigation may reduce asthma readmissions.”

The study team analyzed records from a national sample of tertiary care children’s hospitals, looking at hospitalizations of 5- to 17-year-olds for acute asthma exacerbation during the 2015 calendar year. They characterized how frequently hospitals used 13 separate asthma discharge components by distributing an electronic survey to quality leaders. Forty-five of 49 hospitals (92 percent) completed the survey.

The 45 hospitals recorded a median of 349 asthma discharges per year and had a median adjusted readmission rate of 2.6 percent at 30 days and a 6.6 percent median adjusted readmission rate at three months. The most commonly used discharge components employed for children with asthma were having a dedicated person providing education (76 percent), providing a spacer at discharge (67 percent) and communicating with a primary medical doctor (58 percent).

Discharge components that were trending toward reduced readmission rates at three months include:

  • Comprehensive asthma education, including having dedicated asthma educators
  • Medications and devices provided to patients at discharge, such as spacers, beta-agonists, controller medication and oral steroids
  • Communication and scheduled appointments with a primary medical doctor
  • Post-discharge activities, including home visits and referrals for environmental mitigation programs.

“In addition to being aligned with NIH asthma recommendations, connecting the family with a primary care provider after discharge helps to improve patients’ timely access to care if symptoms recur when they return home,” Dr. Parikh adds. “Bundling these discharge components may offer multiple opportunities to educate patients and families and to employ a range of communication styles such as didactic, visual and interactive.”

Study co-authors include Matt Hall, Ph.D., Children’s Hospital Association; Chén C. Kenyon, M.D., M.S.H.P., The Children’s Hospital of Philadelphia; Ronald J. Teufel II, M.D., M.S.C.R., Medical University of South Carolina; Grant M. Mussman, M.D., M.H.S.A. and Samir S. Shah, M.D., M.S.C.E., Cincinnati Children’s Hospital Medical Center; Amanda Montalbano, M.D., M.P.H., Children’s Mercy; Jessica Gold, M.D., M.S., Lucile Packard Children’s Hospital Stanford; James W. Antoon, M.D., Children’s Hospital; Anupama Subramony, M.D., Cohen Children’s Medical Center; Vineeta Mittal, M.D., M.B.A. and Rustin B. Morse, M.D., Children’s Health; and Karen M. Wilson, M.D., M.P.H., Icahn School of Medicine at Mount Sinai.

Research reported in this post was supported by the Agency for Healthcare Research and Quality, K08HS024554.

Kavita Parikh

Keeping children safe from firearm-related harm

Kavita Parikh

“While this preventable public health crisis occurs in the home, pediatricians who see children in clinic or at hospitals can play a pivotal role in helping to reduce gun violence,” says Kavita Parikh, M.D., M.S.H.S.

A review led by Children’s National Health System researchers presents new insights about pediatric firearm-related injuries. The findings, published May 23, 2017 in Hospital Pediatrics, show that up to 64 percent of U.S. households have firearms, and almost 40 percent of parents erroneously believe that their children are unaware of where weapons are stored. Additionally, about 22 percent of parents wrongly think that their children have never handled household firearms.

According to the Centers for Disease Control and Prevention, firearm-related injuries are leading causes of injury deaths for youths. Younger children are more likely to be victims of unintentional firearm injuries, the majority of which occur in the home. Older adolescents are more likely to suffer from intentional injuries. Homicide by firearm is the second-leading cause of death for 15- to 19-year-olds, and suicide by firearm ranks as the third-most common cause of death for children aged 10 to 19. Estimates suggest that the cost of medical treatment for firearm-related injuries suffered by youths younger than 21 exceeds $330 million.

“While this preventable public health crisis occurs in the home, pediatricians who see children in clinic or at hospitals can play a pivotal role in helping to reduce gun violence,” says Kavita Parikh, M.D., M.S.H.S., associate professor of pediatrics in the Division of Hospitalist Medicine at Children’s National and study lead author. “In the course of providing care, pediatricians can ask patients and their families about children’s access to firearms, can encourage safe storage of firearms in the home and can support research into firearm-related injury prevention.”

The review article provides an overview of the prevalence of pediatric firearm-related injuries around the nation and a summary of legislative efforts and health care-related advocacy efforts to reduce firearm injuries around the nation. It includes research by four Children’s National co-authors who comprise the institution’s newly formed firearm-injury prevention research work group. Alyssa Silver, M.D., Children’s Hospital at Montefiore, is another co-author.

The study team found that about 20,000 children are transported to Emergency Departments each year for firearm-related injuries. Youths aged 12 to 19 make up 90 percent of this total. On average, 20 U.S. children and youths are hospitalized daily for firearm-related injuries. About 50 percent of the children who are hospitalized for firearm-related injuries are discharged with a disability.

The researchers identified regional variations in the percentage of households with firearms, as well as differences in firearm ownership by race and ethnicity. Across a number of surveys, 6 percent to nearly 50 percent of families reported storing firearms safely by using such methods as trigger locks and locked storage containers. There is a mismatch in what parents report — with many saying their child would never touch a firearm – compared with children who tell researchers they handle “hidden” firearms, including by pulling the trigger. One survey of 5,000 fifth-graders and their caregivers living in three metropolitan areas found 18 percent had household firearms. Of this group, African American and Latino households had lower odds of firearm ownership than families of white, non-Latino children. Among these survey respondents, families of white non-Latino children were less likely than families of African American children to use safer strategies for firearm storage.

“While public health interventions have had varying degrees of success in improving firearm safety, the most effective programs have offered families free gun safety devices,” says Monika Goyal M.D., M.S.C.E., assistant professor of pediatrics and emergency medicine at Children’s National and senior study author. “The stark differences in how parents perceive their children would act and the children’s own recollections to researchers underscore the importance of the combination of counseling parents to talk to their children about firearms and instituting safe storage practices for household guns.”

Sabah F. Iqbal, M.D., assistant professor of pediatrics and emergency medicine at Children’s National and study co-author, adds: “Most families are willing to discuss firearm safety with health care providers. It is encouraging that when families receive safety counseling from health care professionals, they store firearms more safely within the home. Pediatricians need to ask children and their families about the presence of firearms in the home. These essential conversations can occur in any medical setting and need to begin before a child begins to walk and explore their own home.”

Screening for access to firearms within the health care setting where youths receive routine care may represent a beneficial strategy, the authors write. A recent survey conducted among 300 adolescents seen in an Emergency Department found that 16 percent reported having a gun in the home and 28 percent said they could access a loaded gun within three hours. About 50 percent of adolescents screened for firearm access said a friend or relative owned a gun.

The study authors also discuss the benefit of “rigorous, well-conducted” research of firearm-related injuries to guide the work of public health agencies, policymakers and pediatricians, as well as supporting state-level laws shown to be effective in preventing firearm injuries, such as universal background checks and firearm identification.

“Rigorous investigations, with the use of validated scoring systems, large comprehensive databases and accurate detailed reporting and surveillance of firearm access and related injury are urgently needed,” Shilpa J. Patel, M.D., M.P.H., assistant professor of pediatrics and emergency medicine at Children’s National, and co-authors conclude. “A collective, data-driven approach to public health is crucial to halt the epidemic of pediatric firearm-related injury.”

Sabah IqbShilpa Patel, Monika Goyal

Stronger firearm laws reduce ED visits

Sabah Iqbl, Shilpa Patel, Monika Goyal

Children’s National researchers Sabah F. Iqbal, M.D., Shilpa J. Patel, M.D., and Monika K. Goyal, M.D., M.S.C.E., found that regions of the United States with the strictest gun laws also have fewer emergency department visits for pediatric firearm-related injuries.

A new study by researchers from Children’s National Health System find that regions of the United States with the strictest gun laws also have the fewest emergency department visits for pediatric firearm-related injuries. The work is among the few studies to evaluate the association between local laws and firearm-related injury to children and youth. The results, presented at the 2017 annual meeting of the Pediatric Academic Societies, could inform policies at the state and regional levels.

“Our results suggest an association between regional gun laws and firearm-related injuries in children,” says Monika K. Goyal, M.D., M.S.C.E., director of research within Children’s Division of Emergency Medicine and senior author of the poster. “Regions with stricter gun laws had lower incidence rates of firearm-related emergency department visits by children.”

Firearm-related injuries are a leading cause of death and disability among children and adolescents in the United States. It is well established that states with more restrictive gun laws have fewer firearm-related fatalities. However, it has been unclear how these laws affect the rates of firearm-related injuries among children.

To investigate this question, Children’s National researchers gathered data from the Nationwide Emergency Department Sample (NEDS), a set of hospital-based emergency department databases created by the federal Agency for Healthcare Research and Quality to aggregate data about emergency department visits across the country. The researchers matched NEDS data from 2009 to 2013 in patients 21 and younger with state-level Brady Gun Law Scores, a measure of the strength of firearm laws, in four geographic regions: The Midwest, Northeast, South and West.

The researchers found that during this five-year study period, there were 111,839 emergency department visits for pediatric firearm-related injuries nationwide, an average of 22,368 per year. The mean age of patients was 18 years, and the vast majority was male. Just over one-third were publicly insured. About 30 percent of these recorded injuries resulted in hospital admission, and about 6 percent resulted in death.

Overall, firearm-related visits to emergency departments remained consistent over time at a rate of 65 per every 100,000 visits until 2013, when they decreased slightly to 51 per 100,000 visits. However, these rates varied significantly by geographic region. The Northeast had the lowest rate at 40 per 100,000 visits. This was followed by the Midwest, West and South at 62, 68 and 71 per 100,000 visits, respectively.

These numbers roughly matched the Brady Gun Law Scores for each region. The Northeast had the highest Brady score at 45, followed by 8, 9 and 9 for the South, West and Midwest.

These findings, the study authors say, suggest that stricter gun laws might lead to fewer fatalities as well as fewer gun-related injuries among children. Future studies about the role of regional gun culture and its impact on firearm legislation at the regional level, they say, is an important next step in advocating for changes to firearm legislation and reducing pediatric firearm-related injuries.

“Future research work should seek to elucidate the association of specific gun laws with the incidence rates of pediatric firearm-related injuries,” says Shilpa Patel, M.D., M.P.H., an assistant professor of pediatrics and emergency medicine at Children’s National and co-author of the poster. “This work also could evaluate how regional differences — such as social gun culture, gun ownership and other factors — contribute to the significant regional variation in firearm legislation.”

The American Academy of Pediatrics, an organization of 66,000 pediatricians, has repeatedly advocated for stricter gun laws, violence prevention programs, research for gun violence prevention and public health surveillance, physician counseling to patients on the health hazards of firearms and mental health access to address exposure to violence.