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      Prevalence of Continuous Pulse Oximetry Monitoring in Hospitalized Children With Bronchiolitis Not Requiring Supplemental Oxygen

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          Key Points

          Question

          What percentage of children hospitalized with viral bronchiolitis who are not receiving any supplemental oxygen are continuously monitored with pulse oximetry?

          Findings

          In this cross-sectional study that included 56 hospitals and 3612 patient observations of children hospitalized with bronchiolitis without receipt of supplemental oxygen, pulse oximetry use ranged from 2% to 92%, with a mean of 46%.

          Meaning

          Continuous pulse oximetry monitoring among a sample of hospitalized children with bronchiolitis but without an apparent indication for its use had high prevalence.

          Abstract

          Importance

          US national guidelines discourage the use of continuous pulse oximetry monitoring in hospitalized children with bronchiolitis who do not require supplemental oxygen.

          Objective

          Measure continuous pulse oximetry use in children with bronchiolitis.

          Design, Setting, and Participants

          A multicenter cross-sectional study was performed in pediatric wards in 56 US and Canadian hospitals in the Pediatric Research in Inpatient Settings Network from December 1, 2018, through March 31, 2019. Participants included a convenience sample of patients aged 8 weeks through 23 months with bronchiolitis who were not receiving active supplemental oxygen administration. Patients with extreme prematurity, cyanotic congenital heart disease, pulmonary hypertension, home respiratory support, neuromuscular disease, immunodeficiency, or cancer were excluded.

          Exposures

          Hospitalization with bronchiolitis without active supplemental oxygen administration.

          Main Outcomes and Measures

          The primary outcome, receipt of continuous pulse oximetry, was measured using direct observation. Continuous pulse oximetry use percentages were risk standardized using the following variables: nighttime (11 pm to 7 am), age combined with preterm birth, time after weaning from supplemental oxygen or flow, apnea or cyanosis during the present illness, neurologic impairment, and presence of an enteral feeding tube.

          Results

          The sample included 3612 patient observations in 33 freestanding children's hospitals, 14 children's hospitals within hospitals, and 9 community hospitals. In the sample, 59% were male, 56% were white, and 15% were black; 48% were aged 8 weeks through 5 months, 28% were aged 6 through 11 months, 16% were aged 12 through 17 months, and 9% were aged 18 through 23 months. The overall continuous pulse oximetry monitoring use percentage in these patients, none of whom were receiving any supplemental oxygen or nasal cannula flow, was 46% (95% CI, 40%-53%). Hospital-level unadjusted continuous pulse oximetry use ranged from 2% to 92%. After risk standardization, use ranged from 6% to 82%. Intraclass correlation coefficient suggested that 27% (95% CI, 19%-36%) of observed variation was attributable to unmeasured hospital-level factors.

          Conclusions and Relevance

          In a convenience sample of children hospitalized with bronchiolitis who were not receiving active supplemental oxygen administration, monitoring with continuous pulse oximetry was frequent and varied widely among hospitals. Because of the apparent absence of a guideline- or evidence-based indication for continuous monitoring in this population, this practice may represent overuse.

          Abstract

          This study characterizes use of continuous pulse oximetry monitoring in hospitalized children with bronchiolitis who do not require supplemental oxygen in Canadian and US hospitals.

          Related collections

          Most cited references32

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          Waste in the US Health Care System

          The United States spends more on health care than any other country, with costs approaching 18% of the gross domestic product (GDP). Prior studies estimated that approximately 30% of health care spending may be considered waste. Despite efforts to reduce overtreatment, improve care, and address overpayment, it is likely that substantial waste in US health care spending remains.
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            Trends in bronchiolitis hospitalizations in the United States, 2000-2009.

            To examine temporal trend in the national incidence of bronchiolitis hospitalizations, use of mechanical ventilation, and hospital charges between 2000 and 2009.
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              Is Open Access

              Towards understanding the de-adoption of low-value clinical practices: a scoping review

              Background Low-value clinical practices are common in healthcare, yet the optimal approach to de-adopting these practices is unknown. The objective of this study was to systematically review the literature on de-adoption, document current terminology and frameworks, map the literature to a proposed framework, identify gaps in our understanding of de-adoption, and identify opportunities for additional research. Methods MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the Cochrane Database of Abstracts and Reviews of Effects, and CINAHL Plus were searched from 1 January 1990 to 5 March 2014. Additional citations were identified from bibliographies of included citations, relevant websites, the PubMed ‘related articles’ function, and contacting experts in implementation science. English-language citations that referred to de-adoption of clinical practices in adults with medical, surgical, or psychiatric illnesses were included. Citation selection and data extraction were performed independently and in duplicate. Results From 26,608 citations, 109 were included in the final review. Most citations (65 %) were original research with the majority (59 %) published since 2010. There were 43 unique terms referring to the process of de-adoption—the most frequently cited was “disinvest” (39 % of citations). The focus of most citations was evaluating the outcomes of de-adoption (50 %), followed by identifying low-value practices (47 %), and/or facilitating de-adoption (40 %). The prevalence of low-value practices ranged from 16 % to 46 %, with two studies each identifying more than 100 low-value practices. Most articles cited randomized clinical trials (41 %) that demonstrate harm (73 %) and/or lack of efficacy (63 %) as the reason to de-adopt an existing clinical practice. Eleven citations described 13 frameworks to guide the de-adoption process, from which we developed a model for facilitating de-adoption. Active change interventions were associated with the greatest likelihood of de-adoption. Conclusions This review identified a large body of literature that describes current approaches and challenges to de-adoption of low-value clinical practices. Additional research is needed to determine an ideal strategy for identifying low-value practices, and facilitating and sustaining de-adoption. In the meantime, this study proposes a model that providers and decision-makers can use to guide efforts to de-adopt ineffective and harmful practices. Electronic supplementary material The online version of this article (doi:10.1186/s12916-015-0488-z) contains supplementary material, which is available to authorized users.
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                Author and article information

                Journal
                JAMA
                JAMA
                JAMA
                JAMA
                American Medical Association
                0098-7484
                1538-3598
                21 April 2020
                21 April 2020
                21 October 2020
                : 323
                : 15
                : 1467-1477
                Affiliations
                [1 ]Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
                [2 ]Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
                [3 ]Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
                [4 ]Perelman School of Medicine, Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania
                [5 ]Perelman School of Medicine, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
                [6 ]Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
                [7 ]James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
                [8 ]Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
                [9 ]Division of General Pediatrics, Boston Children's Hospital, Massachusetts
                [10 ]Harvard Medical School, Boston, Massachusetts
                [11 ]Perelman School of Medicine, Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
                [12 ]Leonard Davis Institute of Health Economics, Penn Implementation Science Center, University of Pennsylvania, Philadelphia
                [13 ]Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor
                [14 ]National Clinician Scholars Program and TACTICAL Scholar, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
                [15 ]Department of Pediatrics, Children’s Hospital Colorado, Denver
                [16 ]Array BioPharma, Boulder, Colorado
                [17 ]Perelman School of Medicine, Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia
                [18 ]Perelman School of Medicine, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
                Author notes
                Article Information
                Corresponding Author: Christopher P. Bonafide, MD, MSCE, Research Director for Pediatric Hospital Medicine, CHOP Buerger Center for Advanced Pediatric Care, 3500 Civic Center Blvd, Philadelphia, PA 19104 ( bonafide@ 123456email.chop.edu ).
                Group Information: The Pediatric Research in Inpatient Settings (PRIS) Network members appear at the end of the article.
                Accepted for Publication: February 24, 2020.
                Author Contributions : Drs Bonafide and Xiao had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
                Concept and design: Bonafide, Brady, Landrigan, Brent, Wolk, Bettencourt, McLeod, Barg, Beidas, Schondelmeyer.
                Acquisition, analysis, or interpretation of data: Bonafide, Xiao, Brady, McLeod, Barg, Schondelmeyer.
                Drafting of the manuscript: Bonafide, Xiao, Bettencourt, Beidas.
                Critical revision of the manuscript for important intellectual content: Bonafide, Xiao, Brady, Landrigan, Brent, Wolk, McLeod, Barg, Beidas, Schondelmeyer.
                Statistical analysis: Bonafide, Xiao.
                Obtained funding: Bonafide, Landrigan, Barg, Schondelmeyer.
                Administrative, technical, or material support: Landrigan, Brent, Bettencourt, McLeod, Schondelmeyer.
                Supervision: Landrigan, McLeod, Barg.
                Other - implementation science aspects of the project: Wolk.
                Conflict of Interest Disclosures: Dr McLeod reported participating in this project when she was a faculty member at Children’s Hospital Colorado and being currently employed by Array BioPharma, where her work is unrelated to this project. Dr Bonafide reported receiving grants from the National Institutes of Health/National Heart, Lung, and Blood Institute during the conduct of the study and grants from the Agency for Healthcare Research and Quality and National Science Foundation outside the submitted work. Dr Landrigan reported receiving personal fees having equity in I-PASS Institute outside the submitted work and receiving monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety and serving as an expert witness in cases regarding patient safety, handoffs, and sleep deprivation. Ms Brent reported receiving grants from the National Heart, Lung, and Blood Institute during the conduct of the study. Dr Wolk reported receiving grants from the National Institutes of Health during the conduct of the study and grants from the National Institutes of Health, Institute of Education Science, and Health Resources and Services outside the submitted work. Dr Bettencourt reported receiving grants from the National Heart, Lung, and Blood Institute during the conduct of the study. Dr Beidas reported receiving grants from the National Heart, Lung, and Blood Institute during the conduct of the study and royalties from Oxford University Press; personal fees from Merck Sharpe & Dohme, Camden Coalition of Healthcare Providers, and the Oregon Social Learning Center; and awards from the American Psychological Association and the Association for Behavioral and Cognitive Therapies outside the submitted work. Dr Schondelmeyer reported receiving grants from the National Heart, Lung, and Blood Institute and grants from Agency for Healthcare Research and Quality during the conduct of the study and grants from the Association for the Advancement of Medical Instrumentation Foundation outside the submitted work. No other disclosures were reported.
                Funding/Support: Research reported in this publication was supported by a cooperative agreement awarded to Dr Bonafide from the National Institutes of Health/National Heart, Lung, and Blood Institute under award number U01HL143475.
                Role of the Funder/Sponsor: As a cooperative agreement, National Institutes of Health scientists participated in study conference calls and provided ongoing feedback on the conduct and findings of the study. The funding organization had no role in the design of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
                Group Information: We thank the PRIS Network collaborators for their major contributions to data collection: Akron Children’s Hospital: Jaclyn Urquiola Sorzano, DO; Karuna Ramcharran, MPH; Prabi Rajbhandari, MD, FAAP; Thomas Mike, MD. Alberta Children’s Hospital: Christopher Andrews, BSc (H), MD, FRCP(C); Lindsay Long, BSc, MD, FRCP(C); Michelle Bailey, BSc (H), MSc, MD, FRCP(C). American Family Children’s Hospital: Kristin Shadman, MD; Rhonda Yngsdal-Krenz, MBA; Sarah MacKay, MD. Ann & Robert H. Lurie Children’s Hospital of Chicago: Kate Lucey, MD, MS; Kristin Van Genderen, MD; M. Katherine Stone, MD, MPH; Michael Spewak, MD; Victoria A. Rodriguez, MD; Waheeda Samady, MD, MSCI. Antelope Valley Hospital: Della Archambo, MSN, RN-BC; Lynne Ellison, DO, MT. Boston Children’s Hospital: Deanna Chieco, MD; Elizabeth Pingree, MD; Patricia Stoeck, MD. C.S. Mott Children’s Hospital: Hiral Mehta, MD; Katrina Foo, MD; Kimberly Monroe, MD, MS; Luzum Matthew, MD, MPH; Mayya Malakh, MD; Nora Biary, MD; Rebekah Shaw, MD. Children’s Hospital & Medical Center Omaha: Chelsea Bloom Anderson, MD; Gregory Johnson, MD; Jacquie Hanks, DNP; Jodi Cantrel, MD; Katherine MacKrell, MD; Melissa England, MD; Russell McCulloh, MD; Sharon Stoolman, MD; Sheilah Snyder, MD. Children’s Hospital at Montefiore: Alyssa Silver, MD; Priya Jain, MD. Children’s Hospital Colorado: Amy Tyler, MD; Michael Tchou, MD. Children’s Hospital Los Angeles: Christopher Russell, MD, MS; Maria Santos, MD; Phillip Abarca, BA; Susan Wu, MD; Vivian Lee, MD. Children’s Hospital New Orleans: Amanda Messer, MD; George Hescock, MD. Children’s Hospital of Oklahoma: Monique Naifeh, MD, MPH; Rachna May, MD; Stephanie Deleon, MD. Children’s Hospital of Philadelphia: Laura El-Hage, MD; Padmavathy Parthasarathy, MD; Stan Oliveira, RN, BSN. Children’s Hospital of Richmond at Virginia Commonwealth University: Amy Spinella, NP; Christine Sirota, NP; Hadi Anwar, MD; Jennifer Schrecengost, NP. Children’s Hospital of The King’s Daughters: Bradley Sieckman, MD; Hope Breckenridge, MSN; Judith Roberts, MSN, RN; Kyrie Shomaker, MD; Megan Brinkley, MSN; Mishi Bhushan, MD, MPH. Children’s Medical Center Dallas: Caitlin Layton, BSN, RN; Courtney Solomon, MD; Danielle Dukellis, MD; Hailee Scoggins, BSN; Mayra Garcia, DNP, RN, PCNS-BC. Children’s Mercy Kansas City: Amita Amonker, MD; Ashley Daly, MD; Kathleen Berg, MD; Matthew Johnson, MD. Children’s National Medical Center: Lynsey Watry, MD; Margaret Rush, MD, MSHS; Tamara Gayle, MD, MEd; Tina Halley, MD. CHOP Care Network at Virtua: Rashida Pittalwala, MD; Shraddha Mittal, MD. Cincinnati Children’s Hospital Medical Center: Sarah Ferris, BA. Cohen Children’s Medical Center: Alexandra Kilinsky, DO; Alyssa Churchill, MD; Ann Le, DO; Erin P. Allmer, MD; Hayley Wolfgruber, MD; Kimberly Lau, MD; Kriti Gupta, MD; Nicole Irgens-Moller, MD. Connecticut Children’s Medical Center: Amy Blodgett, MD; Aseel Dabbagh, DO; Chelsea Lepus, DO; Danielle Klima, DO; Ilana Waynik, MD; Owen Kahn, MD. Cook Children’s Medical Center: Amy Turner, NP; Karen Schultz, MD; Stacey VanVliet, MD. Cox Medical Center South: Jessica Sears, MD; Kayce Morton, DO. Dayton Children’s Hospital: Beth Sullivan, MD; Merrilee Cox, MD. Diamond Children's Medical Center: Adam Walpert, MD; Chan Lowe, MD; Geetha Gopalakrishnan, MD; Janet Lau, MD; Jasna Seserinac, MD; Melissa Cox, DO; Rachel Cramton, MD. Grand View Hospital: Andrew Chu, MD; Kathleen Shafer, RN; Krista Zehr, RN; Mary Nicolai, RN; Sheila Knerr, MD; Valarie Polk, RN. Hassenfeld Children’s Hospital at NYU Langone: Jasmine Gadhavi, MD. Inova Children’s Hospital: Alexandru Firan, MD; Carolina Saldarriaga Perez, MD; Meredith Carter, MD, MEd. Lucile Packard Children’s Hospital Stanford: Alan Schroeder, MD; Kevin Chi, MD. Mary Washington Hospital: Allison Markowsky, MD, MSHS; Katherine Donowitz, MD; Nailah Coleman, MD; Summer Peters, DO. MUSC Children’s Hospital: Ronald Teufel II, MD, MSCR; Sasha Wee, MD. Nationwide Children’s Hospital: Allison Heacock, MD; Kimberly Tartaglia, MD; Matthew Emery, MD; Michael Perry, MD; Nancy Liao, MD; Ryan Bode, MD; Stephanie Kwon, MD. Nemours/A.I. duPont Hospital for Children: Samuel Stubblefield, MD. Poudre Valley Hospital & Medical Center of the Rockies: Elizabeth Ballard, MD. Primary Children’s Hospital: Ashley Dennis, MD; Glen Huff, MD; John Mulcaire-Jones, MD; Karee Nicholson, RN, MSN; Katie Mailey, MD; Robert Willer, DO. Princeton Medical Center: Alicia Brennan, MD; Anupa Dalal, MD; Geetha Lingasubramanian, MD; Joel Krauss, MD; Julianne Prasto, MD; Koel Guha, MD; Marissa Castellano, MD. Riverton Hospital: Glen Huff, MD. Seattle Children’s Hospital: Kaitlyn McQuistion, MD; Sarah Zaman, MD. St Louis Children’s Hospital: Christine Hrach, MD; Erik Hoefgen, MD; Laura Hulteen, MD; Shakila Mathew, MD; Tosin Adeyanju, MD. St Mary’s Hospital: Ann Allen, MD. Texas Children’s Hospital: Imgard Carolina Molleda Castro, MD; Mohammad Ovais Aziz, MD; Mohammed Nassif, MD; Ricardo Quinonez, MD. The Hospital for Sick Children: Amna Hilal, MD; Brie Yama, MD, MSc, MEd (c), FRCPC, FAAP; Brigitte Parisien, MD; Catherine Diskin, MB, BCH, BAO, MRCPI (Paid) MSc; Dana Arafeh, BSc, CAPM; Sanjay Mahant, MD, MSc, FRCPC. Tufts Medical Center Floating Hospital for Children: Elena Aragona, MD, MS; Jana Leary, MD, MS. UCSF Benioff Children’s Hospital Mission Bay: Glenn Rosenbluth, MD; Manisha Israni-Jiang, MD; Matt Pantell, MD, MS. University Hospitals Rainbow Babies and Children’s Hospital: Allayne Stephans, MD; Amanda Lansell, MD. University of Iowa Stead Family Children’s Hospital: Guru Bhoojhawon, MBBS, MD; Katherine Patrick, MD; Kelly Wood, MD; Kristen Sandgren, MD. University of Vermont Children’s Hospital: Leigh-Anne Cioffredi, MD, MPH. UPMC Children’s Hospital of Pittsburgh: Kishore Vellody, MD; Sylvia Choi, MD. Upstate Golisano Children’s Hospital: John Andrake, MD; Melissa Schafer, MD. Valley Children’s Hospital: Angela Veesenmeyer, MD, MPH; Katie Chan-Boeckh, RN; Laura Grant, RN; Nicole Webb, MD. Vanderbilt University Medical Center: Derek Williams, MD, MPH; Emily Datyner, MD; Gregory Plemmons, MD; Jakobi Johnson, BS. Wake Forest Baptist Medical Center: Jeanna Auriemma, MD; John Darby, MD; Nicholas Potisek, MD; Sean Ervin, MD, PhD. WVU Children’s Hospital: Chickajajur Vijay, MD, MBBS; Christy Glass, MSN; Kamakshya Patra, MD; Kudora Maize, MSN, APRN; Meghan Williams, MSN, FNP-C; Travis Kennedy, MSN, APRN, FNP-BC. Yale-New Haven Children’s Hospital: Adam Berkwitt, MD.
                Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
                Meeting Presentation: Results of this study were presented at the Pediatric Hospital Medicine Annual Meeting; July 26, 2019; Seattle, WA.
                Additional Contributions: We thank the Center for Outcomes Research & Evaluation at Yale School of Medicine for sharing the Centers for Medicare & Medicaid Services SAS pack for risk standardization, which is freely available to the public upon request from cmsmortalitymeasures@ 123456yale.edu . We acknowledge the National Heart, Lung, and Blood Institute scientists who contributed their expertise to this project as part of the U01 cooperative agreement funding mechanism as federal employees conducting their official job duties: Lora Reineck, MD, MS; Karen Bienstock, MS; and Cheryl Boyce, PhD. We thank Justin Lakkis, BA, a PhD student at the University of Pennsylvania, for his contributions to statistical analysis. He did not receive compensation for his role in the study. We thank the Executive Council of the Pediatric Research in Inpatient Settings Network for their contributions to the early scientific development of this project. The Network assessed a collaborative support fee for access to the hospitals and support of this project.
                Article
                PMC7175084 PMC7175084 7175084 joi200026
                10.1001/jama.2020.2998
                7175084
                32315058
                8954b083-11e5-4226-b4fd-172107ff3efe
                Copyright 2020 American Medical Association. All Rights Reserved.
                History
                : 26 November 2019
                : 24 February 2020
                Categories
                Research
                Research
                Original Investigation

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