- Email: [email protected]
Bronchiolitis: The Challenge of Delivering High Value Care through Restraint
October 2014 13. Lieh-Lai MW, Stanitski DF, Sarnaik AP, Uy HG, Rossi NF, Simpson PM, et al. Syndrome of inappropriate antidiuretic hormone secretion in children following spinal fusion. Crit Care Med 1999;27:622-7. 14. Robertson GL. Regulation of arginine vasopressin in the syndrome of inappropriate antidiuresis. Am J Med 2006;119:S36-42. 15. Shahani L. Hyponatraemia masking the diagnosis of cryptococcal meningitis. BMJ Case Rep 2012;2012. 16. Huang CH, Chou KJ, Lee PT, Chen CL, Chung HM, Fang HC. A case of lymphocytic hypophysitis with masked diabetes insipidus unveiled by glucocorticoid replacement. Am J Kidney Dis 2005;45:197-200. 17. Iida M, Takamoto S, Masuo M, Makita K, Saito T. Transient lymphocytic panhypophysitis associated with SIADH leading to diabetes insipidus after glucocorticoid replacement. Intern Med 2003;42:991-5.
EDITORIALS 18. Chen S-J, Wen Y-K, Tank Y, Chang C-C. Pituitary apoplexy: an overlooked cause of hyponatremia in the elderly. Acta Nephrol 2005;19: 135. 19. Bettinelli A, Longoni L, Tammaro F, Fare PB, Garzoni L, Bianchetti MG. Renal salt-wasting syndrome in children with intracranial disorders. Pediatr Nephrol 2012;27:733-9. 20. Ellison DH, Berl T. Clinical practice. The syndrome of inappropriate antidiuresis. N Engl J Med 2007;356:2064-72. 21. Sherlock M, Thompson CJ. The syndrome of inappropriate antidiuretic hormone: current and future management options. Eur J Endocrinol 2010;162(Suppl 1):S13-8. 22. Chehade H, Rosato L, Girardin E, Cachat F. Inappropriate antidiuretic hormone secretion: long-term successful urea treatment. Acta Paediatr 2012;101:e39-42.
Bronchiolitis: The Challenge of Delivering High Value Care through Restraint
W
ith accelerating healthcare costs, the imperative to tals is “no.”7 The study provides important data on the state reduce waste in the healthcare system and provide of affairs for hospitalized infants with bronchiolitis in US high value care has become paramount. National children’s hospitals. Florin et al used the Pediatric Health Ininitiatives directed at physicians and/or patients to promote formation Systems database to study 64 994 infants less than this change, such as the American Board of Internal Medi12 months of age who were hospitalized for less than 7 days cine’s “Choosing Wisely” campaign and with bronchiolitis in 42 children’s hospitals. See related article, p 786 the American College of Physicians “High They retrospectively analyzed the use of Value, Cost Conscious Care” program are in full gear.1-3 nonrecommended tests and treatments as suggested by the 2006 American Academy of Pediatrics bronchiolitis guideFor several common conditions seen in pediatric hospital lines,8 before and after these guidelines were published. The medicine, such as febrile seizures, urinary tract infections, and pneumonia, the evolving evidence base also has told us results reveal only modest reductions in the use of nonrethat “less is more.” commended tests and treatments 6 years after publication Nowhere is this adage more true than in the management of the guidelines and the persistence of striking across hospiof bronchiolitis, the fourth most common reason for hospital tal variations suggesting poor compliance with guideline reccare and the eighth most cumulatively expensive condition in ommendations. After adjusting for differences in patient US children’s hospitals.4 Systematic reviews and metacharacteristics across hospitals, they observed a median hospital use of nonrecommended tests and treatments to be the analysis of a large body of evidence have shown evidence of following: albuterol 52.4% (range 3.5%-81.0%), racemic a lack of effectiveness for a range of active medical treatments, epinephrine 20.1% (0.6%-78.8%), corticosteroids 10.9% specifically drug therapies including corticosteroids and (4.1%-46.6%), chest radiograph 54.9% (24.1%-76.6%), and inhaled bronchodilators.5 Thus, the focus of inpatient manantibiotics 38.4% (27.1%-50.1%). The use of albuterol, agement is on supportive management (monitoring vital racemic epinephrine, and antibiotics did not change over signs and hemoglobin oxygen saturation, providing oxygen time, and there was only a modest decrease in corticosteroid supplementation for hypoxia, and nutritional and/or fluid use (3.3%) and chest radiography (8.6%). Furthermore, use supplementation through nasogastric feeds or intravenous of these tests and treatments was not associated with better fluids) and reducing unnecessary testing and treatments. outcomes. In fact, use was associated with a longer length Four of the five recommendations for reducing waste in peof stay with no reduction in rate of readmission. diatric hospital medicine from the Choosing Wisely Although the study and data source do not allow us to campaign are directed at bronchiolitis care.1 Specifically understand the reasons for the observed use and the acrossthese are do not: order chest radiographs in uncomplicated hospital variations of the nonrecommended tests and treatcases, routinely use bronchodilator drugs, use systemic cortiments, we can speculate on the reasons. The American costeroids, or use pulse oximetry when supplemental oxygen has been discontinued. Cost-effective analyses have shown that the biggest cost savings lie in those interventions that reduce duration or prevent bronchiolitis hospital stay.6 But Supported by the Ontario Opportunity Trust Fund, SickKids Research Institute, The Hospital for Sick Children, and the Geneva University Hospitals (A.M.). Grant have we been able to implement this “less is more” philosofunding received from the Children’s Hospital Association for support of the Pediphy in the management of infants hospitalized with bronatric Research in Inpatient Settings (PRIS) network (S.M.). The Pediatric Outcomes Research Team receives support from the SickKids Foundation. The authors chiolitis? declare no conflicts of interest. In this issue of The Journal, the study by Florin et al suggest 0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc. All rights reserved. that the answer to this question at many US children’s hospihttp://dx.doi.org/10.1016/j.jpeds.2014.07.025 655
THE JOURNAL OF PEDIATRICS
www.jpeds.com
Academy of Pediatrics guidelines recommend that a trial of bronchodilator therapy is a reasonable option,8 and the study by Florin et al could not distinguish between a prescription of a routinely scheduled bronchodilator vs a trial, which then might be followed by more bronchodilator use if judged to be beneficial. Ineffective mechanisms for discontinuance may exist at hospitals for bronchodilator drug prescriptions after a failed trial, leading to overuse. Furthermore, there likely are subgroups of infants in the cohort who would benefit from chest radiography, antibiotic treatment, or corticosteroids because of their clinical presentation (eg, symptoms and signs of a bacterial co-infection) or prior medical history (eg, recurrent wheezing, bronchopulmonary dysplasia). However, these hypotheses would not justify such high rates of antibiotic use and chest radiography, which was up to 50% and 77%, respectively at some hospitals. During the study period, results of a multicenter trial were published, which found a possible benefit to the combined use of corticosteroids and racemic epinephrine.9 Perhaps, early adopters of this finding lead to their overuse at some centers. Lastly, guideline implementation strategies, their effectiveness and barriers to guideline adoption likely differed across sites. What are the broader implications of the study findings? First, implementing guidelines into clinical practice is not a simple task and requires a multifaceted, tailored, and iterative approach to change, targeting barriers at different levels (ie, individual, team, organization).10 We know from other multicenter studies examining the uptake of bronchiolitis guideline evidence that large-scale improvement is difficult.11,12 One recent single-center study demonstrated significant reduction in the use of nonrecommended tests and treatments 2 seasons postchange implementation and showed an associated reduction in length of stay.13 They employed a multifaceted implementation strategy that included involvement of the emergency medicine and inpatient units, with multidisciplinary stakeholder input, education of providers, easy online access to the clinical practice guideline, use of electronic order sets, objective measures for some of the recommended measures (eg, use of a respiratory distress score to assess bronchodilator trial benefit), audit and feedback, and monthly team meetings to improve implementation. Although considerable efforts recently have been placed into understanding the science behind successful implementation of guidelines and evidence into practice, there is still much for us to learn. The Florin et al study provides valuable data on what happened over time, but we also need a better understanding of why. Why are some hospitals low or high utilizers of unnecessary tests and treatments? We need knowledge translation studies in pediatric hospital medicine that evaluate implementation strategies and study contextual factors important to successful adoption of guidelines into practice. Second, when there is growing evidence that a practice is ineffective, we then need to learn how to support the process of abandoning this practice. This “de-implementation” concept has emerged recently and is challenging.14 We may 656
Vol. 165, No. 4 continue to investigate or treat despite good evidence to the contrary, that is not “de-implement,” for a variety of reasons. There may be pressure from parents to do more, impatience with observation and supportive care, lack of confidence in relying on clinical assessment, or comfort in practicing expectant medicine, poor information systems that lead to duplicating tests, and financial incentives.14,15 In addition, clinicians may seek evidence of the potential harms of de-implementing ingrained practices, which often is lacking, or is of limited quality. This lack of evidence then becomes a barrier to change. Furthermore, the culture in which we practice plays an important role in influencing our behavior. Many of us practice in environments that reward “doing more” as a sign of thoroughness and better clinical care. Nowhere is this truer than in our academic centers. As others have advocated, we need a culture change in our training centers toward role modeling and rewarding restraint in testing and treatment as part of high value care efforts.15,16 We need to reflect on and highlight this philosophy of practice at the bedside with our medical students and residents. It is easy to think we do well at managing conditions commonly seen in practice. We see a lot, accumulate experience, develop our practice routines, and think that our ways of doing, thus, represent high quality care. Its takes a bit of humility to look deeper and understand where we can improve as individual practitioners and as a healthcare system. And even more humility to learn how to realize improvement. Transformational improvement for these highly prevalent and cumulatively expensive conditions in pediatric hospital medicine will have a significant impact on the health of our patients and the healthcare system. The study by Florin et al is another reminder of this opportunity. n We thank Dr Anu Wadhwa (Division of Infectious Diseases, Department of Pediatrics, Hospital for Sick Children, University of Toronto) for comments on a draft of the manuscript.
Arnaud Merglen, MD Division of Pediatric Medicine Pediatric Outcomes Research Team (PORT) Department of Pediatrics Hospital for Sick Children University of Toronto Division of General Pediatrics University Hospitals of Geneva Faculty of Medicine University of Geneva Geneva, Switzerland Sanjay Mahant, MD, FRCPC, MSc Division of Pediatric Medicine Pediatric Outcomes Research Team (PORT) Department of Pediatrics Hospital for Sick Children University of Toronto
EDITORIALS
October 2014 Child Health Evaluative Sciences Research Institute Hospital for Sick Children Institute for Health Policy, Management, and Evaluation University of Toronto Toronto, Canada Reprint requests: Sanjay Mahant, MD, Division of Pediatric Medicine, Hospital for Sick Children, 555 University Ave, Toronto, Canada M5G1X8. E-mail: sanjay. [email protected]
References 1. Quinonez RA, Garber MD, Schroeder AR, Alverson BK, Nickel W, Goldstein J, et al. Choosing wisely in pediatric hospital medicine: Five opportunities for improved healthcare value. J Hosp Med 2013;8:479-85. 2. Marcotte L, Moriates C, Milstein A. Professional organizations’ role in supporting physicians to improve value in health care. JAMA 2014; 312:231-2. 3. Kuehn BM. Guidelines, online training aim to teach physicians to weigh costs of care, become better stewards of medical resources. JAMA 2014; 311:2368-70. 4. Keren R, Luan X, Localio R, Hall M, McLeod L, Dai D, et al. Prioritization of comparative effectiveness research topics in hospital pediatrics. Arch Pediatr Adolesc Med 2012;166:1155-64. 5. Hartling L, Fernandes RM, Bialy L, Milne A, Johnson D, Plint A, et al. Steroids and bronchodilators for acute bronchiolitis in the first two years of life: Systematic review and meta-analysis. BMJ 2011;342:d1714.
6. Langley JM, Wang EEL, Law BJ, Stephens D, Boucher FD, Dobson S, et al. Economic evaluation of respiratory syncytial virus infection in Canadian children: A pediatric investigators collaborative network on infections in Canada (PICNIC) study. J Pediatr 1997;131:113-7. 7. Florin TA, Byczkowski T, Ruddy RM, Zorc JJ, Test M, Shah SS. Variation in the management of infants hospitalized for bronchiolitis persists after the 2006 bronchiolitis guidelines. J Pediatr 2014;165:786-92. 8. American Academy of Pediatrics. Subcommittee on Diagnosis and Management of Bronchiolitis. Clinical practice guideline: Diagnosis and management of bronchiolitis. Pediatrics 2006;118:1774-93. 9. Plint AC, Johnson DW, Patel H, Wiebe N, Math M, Correll R, et al. Epinephrine and dexamethasone in children with bronchiolitis. N Engl J Med 2009;360:2079-89. 10. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003;362:1225-30. 11. Ralston S, Garber M, Narang S, Shen M, Pate B, Pope J, et al. Decreasing unnecessary utilization in acute bronchiolitis care: Results from the value in inpatient pediatrics network. J Hosp Med 2013;8:25-30. 12. Parikh K, Hall M, Teach SJ. Bronchiolitis management before and after the AAP guidelines. Pediatrics 2014;133:e1-7. 13. Mittal V, Darnell C, Walsh B, Mehta A, Badawy M, Morse R, et al. Inpatient bronchiolitis guideline implementation and resource utilization. Pediatrics 2014;133:e730-7. 14. Prasad V, Ioannidis JP. Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices. Implem Sci 2014; 9:1. 15. Detsky A, Verma AA. A new model for medical education: celebrating restraint. JAMA 2012;308:1329-30. 16. Dhaliwal G. Bringing high-value care to the inpatient teaching service. JAMA Intern Med 2014;174:1021-2.
The Effect of Monitor Design and Implementation on Patient Management
R
etinopathy of prematurity (ROP) continues to be a als has yet to be determined. Further complicating these significant morbidity in the neonatal intensive care findings was the low amount of actual time spent in the asunit. Due to the strong association between hypersigned target range. Why was it so difficult to keep these inoxia exposure and ROP, oxygen saturation levels of >95% fants within the oxygen saturation target range and was the are generally avoided in infants requiring supplemental oxelectronically altered study pulse oximeter design a contribygen. However, the optimal oxygen saturauting factor? See related article, p 666 tion target remains unknown. To assess In this issue of The Journal, the investigawhether oxygen supplementation can be safely decreased tors from the Canadian Oxygen Trial explore the role that without detrimental consequences, recent collaborative the oximeter masking algorithm may have played in the multicenter trials randomized more than 5000 extremely outcome of the trials.4 Caregivers were instructed to keep preterm infants to low (85%-89%) vs high (91%-95%) oxthe infant within 88%-92%. The study oximeter was then ygen saturation targets to compare the effect of oxygen satudesigned to display oxygen saturation either 3% above or ration targeting on the rate of death or disability. The below the true values within the range of 88%-92%, thereby outcomes varied among the multinational trials with the blindly moving the infant into either the low or high oxygen Surfactant, Positive Pressure, and Pulse Oximetry Randomsaturation target, while true values were displayed below ization Trial1 and Benefits of Oxygen Saturation Targeting 84% and above 96%. If the oximeter alterations worked as anticipated, the high and low target groups should have II2 trials finding a lower incidence of severe ROP but an unhad similar displayed (or blinded) oxygen saturation distriexpected increase in mortality in the low target group. In butions. Contrary to expectation, infants in the low target contrast, the Canadian Oxygen Trial3 found no effect of oxygen saturation target on death or disability. The reason for both the increased mortality and inconsistency between triThe author declares no conflicts of interest.
ROP
Retinopathy of prematurity
0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.06.049
657
EDITORIALS 18. Chen S-J, Wen Y-K, Tank Y, Chang C-C. Pituitary apoplexy: an overlooked cause of hyponatremia in the elderly. Acta Nephrol 2005;19: 135. 19. Bettinelli A, Longoni L, Tammaro F, Fare PB, Garzoni L, Bianchetti MG. Renal salt-wasting syndrome in children with intracranial disorders. Pediatr Nephrol 2012;27:733-9. 20. Ellison DH, Berl T. Clinical practice. The syndrome of inappropriate antidiuresis. N Engl J Med 2007;356:2064-72. 21. Sherlock M, Thompson CJ. The syndrome of inappropriate antidiuretic hormone: current and future management options. Eur J Endocrinol 2010;162(Suppl 1):S13-8. 22. Chehade H, Rosato L, Girardin E, Cachat F. Inappropriate antidiuretic hormone secretion: long-term successful urea treatment. Acta Paediatr 2012;101:e39-42.
Bronchiolitis: The Challenge of Delivering High Value Care through Restraint
W
ith accelerating healthcare costs, the imperative to tals is “no.”7 The study provides important data on the state reduce waste in the healthcare system and provide of affairs for hospitalized infants with bronchiolitis in US high value care has become paramount. National children’s hospitals. Florin et al used the Pediatric Health Ininitiatives directed at physicians and/or patients to promote formation Systems database to study 64 994 infants less than this change, such as the American Board of Internal Medi12 months of age who were hospitalized for less than 7 days cine’s “Choosing Wisely” campaign and with bronchiolitis in 42 children’s hospitals. See related article, p 786 the American College of Physicians “High They retrospectively analyzed the use of Value, Cost Conscious Care” program are in full gear.1-3 nonrecommended tests and treatments as suggested by the 2006 American Academy of Pediatrics bronchiolitis guideFor several common conditions seen in pediatric hospital lines,8 before and after these guidelines were published. The medicine, such as febrile seizures, urinary tract infections, and pneumonia, the evolving evidence base also has told us results reveal only modest reductions in the use of nonrethat “less is more.” commended tests and treatments 6 years after publication Nowhere is this adage more true than in the management of the guidelines and the persistence of striking across hospiof bronchiolitis, the fourth most common reason for hospital tal variations suggesting poor compliance with guideline reccare and the eighth most cumulatively expensive condition in ommendations. After adjusting for differences in patient US children’s hospitals.4 Systematic reviews and metacharacteristics across hospitals, they observed a median hospital use of nonrecommended tests and treatments to be the analysis of a large body of evidence have shown evidence of following: albuterol 52.4% (range 3.5%-81.0%), racemic a lack of effectiveness for a range of active medical treatments, epinephrine 20.1% (0.6%-78.8%), corticosteroids 10.9% specifically drug therapies including corticosteroids and (4.1%-46.6%), chest radiograph 54.9% (24.1%-76.6%), and inhaled bronchodilators.5 Thus, the focus of inpatient manantibiotics 38.4% (27.1%-50.1%). The use of albuterol, agement is on supportive management (monitoring vital racemic epinephrine, and antibiotics did not change over signs and hemoglobin oxygen saturation, providing oxygen time, and there was only a modest decrease in corticosteroid supplementation for hypoxia, and nutritional and/or fluid use (3.3%) and chest radiography (8.6%). Furthermore, use supplementation through nasogastric feeds or intravenous of these tests and treatments was not associated with better fluids) and reducing unnecessary testing and treatments. outcomes. In fact, use was associated with a longer length Four of the five recommendations for reducing waste in peof stay with no reduction in rate of readmission. diatric hospital medicine from the Choosing Wisely Although the study and data source do not allow us to campaign are directed at bronchiolitis care.1 Specifically understand the reasons for the observed use and the acrossthese are do not: order chest radiographs in uncomplicated hospital variations of the nonrecommended tests and treatcases, routinely use bronchodilator drugs, use systemic cortiments, we can speculate on the reasons. The American costeroids, or use pulse oximetry when supplemental oxygen has been discontinued. Cost-effective analyses have shown that the biggest cost savings lie in those interventions that reduce duration or prevent bronchiolitis hospital stay.6 But Supported by the Ontario Opportunity Trust Fund, SickKids Research Institute, The Hospital for Sick Children, and the Geneva University Hospitals (A.M.). Grant have we been able to implement this “less is more” philosofunding received from the Children’s Hospital Association for support of the Pediphy in the management of infants hospitalized with bronatric Research in Inpatient Settings (PRIS) network (S.M.). The Pediatric Outcomes Research Team receives support from the SickKids Foundation. The authors chiolitis? declare no conflicts of interest. In this issue of The Journal, the study by Florin et al suggest 0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc. All rights reserved. that the answer to this question at many US children’s hospihttp://dx.doi.org/10.1016/j.jpeds.2014.07.025 655
THE JOURNAL OF PEDIATRICS
www.jpeds.com
Academy of Pediatrics guidelines recommend that a trial of bronchodilator therapy is a reasonable option,8 and the study by Florin et al could not distinguish between a prescription of a routinely scheduled bronchodilator vs a trial, which then might be followed by more bronchodilator use if judged to be beneficial. Ineffective mechanisms for discontinuance may exist at hospitals for bronchodilator drug prescriptions after a failed trial, leading to overuse. Furthermore, there likely are subgroups of infants in the cohort who would benefit from chest radiography, antibiotic treatment, or corticosteroids because of their clinical presentation (eg, symptoms and signs of a bacterial co-infection) or prior medical history (eg, recurrent wheezing, bronchopulmonary dysplasia). However, these hypotheses would not justify such high rates of antibiotic use and chest radiography, which was up to 50% and 77%, respectively at some hospitals. During the study period, results of a multicenter trial were published, which found a possible benefit to the combined use of corticosteroids and racemic epinephrine.9 Perhaps, early adopters of this finding lead to their overuse at some centers. Lastly, guideline implementation strategies, their effectiveness and barriers to guideline adoption likely differed across sites. What are the broader implications of the study findings? First, implementing guidelines into clinical practice is not a simple task and requires a multifaceted, tailored, and iterative approach to change, targeting barriers at different levels (ie, individual, team, organization).10 We know from other multicenter studies examining the uptake of bronchiolitis guideline evidence that large-scale improvement is difficult.11,12 One recent single-center study demonstrated significant reduction in the use of nonrecommended tests and treatments 2 seasons postchange implementation and showed an associated reduction in length of stay.13 They employed a multifaceted implementation strategy that included involvement of the emergency medicine and inpatient units, with multidisciplinary stakeholder input, education of providers, easy online access to the clinical practice guideline, use of electronic order sets, objective measures for some of the recommended measures (eg, use of a respiratory distress score to assess bronchodilator trial benefit), audit and feedback, and monthly team meetings to improve implementation. Although considerable efforts recently have been placed into understanding the science behind successful implementation of guidelines and evidence into practice, there is still much for us to learn. The Florin et al study provides valuable data on what happened over time, but we also need a better understanding of why. Why are some hospitals low or high utilizers of unnecessary tests and treatments? We need knowledge translation studies in pediatric hospital medicine that evaluate implementation strategies and study contextual factors important to successful adoption of guidelines into practice. Second, when there is growing evidence that a practice is ineffective, we then need to learn how to support the process of abandoning this practice. This “de-implementation” concept has emerged recently and is challenging.14 We may 656
Vol. 165, No. 4 continue to investigate or treat despite good evidence to the contrary, that is not “de-implement,” for a variety of reasons. There may be pressure from parents to do more, impatience with observation and supportive care, lack of confidence in relying on clinical assessment, or comfort in practicing expectant medicine, poor information systems that lead to duplicating tests, and financial incentives.14,15 In addition, clinicians may seek evidence of the potential harms of de-implementing ingrained practices, which often is lacking, or is of limited quality. This lack of evidence then becomes a barrier to change. Furthermore, the culture in which we practice plays an important role in influencing our behavior. Many of us practice in environments that reward “doing more” as a sign of thoroughness and better clinical care. Nowhere is this truer than in our academic centers. As others have advocated, we need a culture change in our training centers toward role modeling and rewarding restraint in testing and treatment as part of high value care efforts.15,16 We need to reflect on and highlight this philosophy of practice at the bedside with our medical students and residents. It is easy to think we do well at managing conditions commonly seen in practice. We see a lot, accumulate experience, develop our practice routines, and think that our ways of doing, thus, represent high quality care. Its takes a bit of humility to look deeper and understand where we can improve as individual practitioners and as a healthcare system. And even more humility to learn how to realize improvement. Transformational improvement for these highly prevalent and cumulatively expensive conditions in pediatric hospital medicine will have a significant impact on the health of our patients and the healthcare system. The study by Florin et al is another reminder of this opportunity. n We thank Dr Anu Wadhwa (Division of Infectious Diseases, Department of Pediatrics, Hospital for Sick Children, University of Toronto) for comments on a draft of the manuscript.
Arnaud Merglen, MD Division of Pediatric Medicine Pediatric Outcomes Research Team (PORT) Department of Pediatrics Hospital for Sick Children University of Toronto Division of General Pediatrics University Hospitals of Geneva Faculty of Medicine University of Geneva Geneva, Switzerland Sanjay Mahant, MD, FRCPC, MSc Division of Pediatric Medicine Pediatric Outcomes Research Team (PORT) Department of Pediatrics Hospital for Sick Children University of Toronto
EDITORIALS
October 2014 Child Health Evaluative Sciences Research Institute Hospital for Sick Children Institute for Health Policy, Management, and Evaluation University of Toronto Toronto, Canada Reprint requests: Sanjay Mahant, MD, Division of Pediatric Medicine, Hospital for Sick Children, 555 University Ave, Toronto, Canada M5G1X8. E-mail: sanjay. [email protected]
References 1. Quinonez RA, Garber MD, Schroeder AR, Alverson BK, Nickel W, Goldstein J, et al. Choosing wisely in pediatric hospital medicine: Five opportunities for improved healthcare value. J Hosp Med 2013;8:479-85. 2. Marcotte L, Moriates C, Milstein A. Professional organizations’ role in supporting physicians to improve value in health care. JAMA 2014; 312:231-2. 3. Kuehn BM. Guidelines, online training aim to teach physicians to weigh costs of care, become better stewards of medical resources. JAMA 2014; 311:2368-70. 4. Keren R, Luan X, Localio R, Hall M, McLeod L, Dai D, et al. Prioritization of comparative effectiveness research topics in hospital pediatrics. Arch Pediatr Adolesc Med 2012;166:1155-64. 5. Hartling L, Fernandes RM, Bialy L, Milne A, Johnson D, Plint A, et al. Steroids and bronchodilators for acute bronchiolitis in the first two years of life: Systematic review and meta-analysis. BMJ 2011;342:d1714.
6. Langley JM, Wang EEL, Law BJ, Stephens D, Boucher FD, Dobson S, et al. Economic evaluation of respiratory syncytial virus infection in Canadian children: A pediatric investigators collaborative network on infections in Canada (PICNIC) study. J Pediatr 1997;131:113-7. 7. Florin TA, Byczkowski T, Ruddy RM, Zorc JJ, Test M, Shah SS. Variation in the management of infants hospitalized for bronchiolitis persists after the 2006 bronchiolitis guidelines. J Pediatr 2014;165:786-92. 8. American Academy of Pediatrics. Subcommittee on Diagnosis and Management of Bronchiolitis. Clinical practice guideline: Diagnosis and management of bronchiolitis. Pediatrics 2006;118:1774-93. 9. Plint AC, Johnson DW, Patel H, Wiebe N, Math M, Correll R, et al. Epinephrine and dexamethasone in children with bronchiolitis. N Engl J Med 2009;360:2079-89. 10. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003;362:1225-30. 11. Ralston S, Garber M, Narang S, Shen M, Pate B, Pope J, et al. Decreasing unnecessary utilization in acute bronchiolitis care: Results from the value in inpatient pediatrics network. J Hosp Med 2013;8:25-30. 12. Parikh K, Hall M, Teach SJ. Bronchiolitis management before and after the AAP guidelines. Pediatrics 2014;133:e1-7. 13. Mittal V, Darnell C, Walsh B, Mehta A, Badawy M, Morse R, et al. Inpatient bronchiolitis guideline implementation and resource utilization. Pediatrics 2014;133:e730-7. 14. Prasad V, Ioannidis JP. Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices. Implem Sci 2014; 9:1. 15. Detsky A, Verma AA. A new model for medical education: celebrating restraint. JAMA 2012;308:1329-30. 16. Dhaliwal G. Bringing high-value care to the inpatient teaching service. JAMA Intern Med 2014;174:1021-2.
The Effect of Monitor Design and Implementation on Patient Management
R
etinopathy of prematurity (ROP) continues to be a als has yet to be determined. Further complicating these significant morbidity in the neonatal intensive care findings was the low amount of actual time spent in the asunit. Due to the strong association between hypersigned target range. Why was it so difficult to keep these inoxia exposure and ROP, oxygen saturation levels of >95% fants within the oxygen saturation target range and was the are generally avoided in infants requiring supplemental oxelectronically altered study pulse oximeter design a contribygen. However, the optimal oxygen saturauting factor? See related article, p 666 tion target remains unknown. To assess In this issue of The Journal, the investigawhether oxygen supplementation can be safely decreased tors from the Canadian Oxygen Trial explore the role that without detrimental consequences, recent collaborative the oximeter masking algorithm may have played in the multicenter trials randomized more than 5000 extremely outcome of the trials.4 Caregivers were instructed to keep preterm infants to low (85%-89%) vs high (91%-95%) oxthe infant within 88%-92%. The study oximeter was then ygen saturation targets to compare the effect of oxygen satudesigned to display oxygen saturation either 3% above or ration targeting on the rate of death or disability. The below the true values within the range of 88%-92%, thereby outcomes varied among the multinational trials with the blindly moving the infant into either the low or high oxygen Surfactant, Positive Pressure, and Pulse Oximetry Randomsaturation target, while true values were displayed below ization Trial1 and Benefits of Oxygen Saturation Targeting 84% and above 96%. If the oximeter alterations worked as anticipated, the high and low target groups should have II2 trials finding a lower incidence of severe ROP but an unhad similar displayed (or blinded) oxygen saturation distriexpected increase in mortality in the low target group. In butions. Contrary to expectation, infants in the low target contrast, the Canadian Oxygen Trial3 found no effect of oxygen saturation target on death or disability. The reason for both the increased mortality and inconsistency between triThe author declares no conflicts of interest.
ROP
Retinopathy of prematurity
0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.06.049
657