Reduced Bronchodilator Use, Customized Care, Early Intervention for Autism, Antibiotic Stewardship

Starting out on the right path often depends on having a true desire to solve a problem that will make a difference in people’s lives. In this week’s news roundup, we share four examples of researchers determined to find better ways to approach pediatric health challenges. Find out how they reduced bronchodilator use in young children, developed interdisciplinary integrated teams to customize care, gave clinicians and families the evidence-based tools they need to provide early intervention for autism spectrum disorder, and helped pediatricians make better decisions about prescribing antibiotics for common childhood infections. 

Quality Improvement Project Reduces Use of Bronchodilators in Bronchiolitis

A multidisciplinary quality improvement team of CHOP physicians, nurses, and respiratory therapists redesigned a clinical pathway and order sets for bronchiolitis, which substantially reduced albuterol use without affecting admission rate, length of stay, and revisit rates. Bronchiolitis is one of the most common reasons for hospitalization in young children.

In light of bronchiolitis guidelines released in 2014 by the American Academy of Pediatrics (AAP) recommending against the use of bronchodilators, the study team engaged in the study during the bronchiolitis season of October 2015 to March 2016. They focused on a three-part intervention: updating an existing clinical pathway addressing bronchiolitis care; providing educational interventions to physicians, nurses, and respiratory therapists noting that albuterol is not recommended for an infant with a typical presentation of bronchiolitis; and providing explicit clinical decision support within the electronic health record to physicians against albuterol use in order sets for bronchiolitis care.

A data analyst created a clinical application allowing ongoing tracking of project metrics during the six-month intervention period, which included 3,834 emergency department visits and 1,119 inpatient hospitalizations. Albuterol use in the emergency department decreased from 43 percent of patients with bronchiolitis to 20 percent after the intervention. Inpatient albuterol use decreased from 18 percent of patients with bronchiolitis receiving albuterol to 11 percent after the 2015 changes. The quality improvement project successfully reduced the number of patients exposed to a likely unnecessary therapy with potential side effects. 

The study team published results of the quality improvement project in the journal Pediatrics and encouraged future researchers to apply methods used in the study to other diagnoses in which there is overuse of testing and interventions.

Innovative Population Health Strategies Provide Customized Care

Combining technology solutions and interdisciplinary integrated care teams led to 50 fewer hospital admissions each month and 3,600 fewer bed days over the course of a year among 93,000 Medicaid-enrolled children, according to a team of PolicyLab researchers and colleagues.  The results, published in JAMA Network Open, show promise in using innovative population health strategies to provide customized care for families who need it most.

The researchers attributed the success of this population-level intervention to their ability to deliver services to families within their existing health care system, investments to develop strong integrated care teams, alignment of clinical and quality improvement methods and a wide variety of electronic health record tools. 

“Fundamentally, what we are talking about is identifying those patients who need the most proactive care, surrounding them with an expert team — from physicians, to nurses, to social workers, to navigators — and then equipping that team with supportive technology,” said David Rubin, MD, director of Population Health Innovation and PolicyLab at CHOP and lead author on the study. “In doing that, we saw that we can deliver the type of care our patients want while providing value and efficiency throughout the whole health care system.”

The CHOP intervention, implemented over two years, sought to identify high-risk, Medicaid-enrolled children with special health care needs and provide solutions that would keep them out of the hospital or reduce their stays if they were admitted. A set of reporting tools in patients' electronic medical record notified clinicians and staff if their patients visited the emergency department or were admitted into the hospital. Then, an integrated care team would connect with these families to help them schedule and prepare for follow-up appointments, assist with locating needed services, and answer questions they had about their care. These clinical teams also utilized technological tools to improve coordination and communication between them.

Read more in a PolicyLab press release.

Updated Guidelines Emphasize Early Identification of Autism 

Updated autism spectrum disorder (ASD) guidelines from the American Academy of Pediatrics (AAP), which CHOP experts informed, take into account new research and give providers the latest information to ensure families are getting the care and support they need. The previous AAP recommendations were published in 2007.  

“Physicians now have a greater understanding of the medical and behavioral conditions that often co-occur with autism, and the body of research supporting evidence-based interventions has grown substantially,” states an AAP press release about the new clinical report “Identification, Evaluation, and Management of Children with Autism Spectrum Disorder.”

The AAP continues to recommend developmental and behavioral surveillance of children at every well child visit, developmental screening at 9-, 18-, and 30-month visits, as well as specific screening for ASD at ages 18 and 24 months. The AAP also supports the use of behavioral interventions for skill building, based on the most recent research, and noted the combinations of therapies and approaches that include parents are increasingly used in community settings.

“Families play a key role in treatment and advocacy for a child with autism spectrum disorder,” said Susan E. Levy, MD, MPH, a co-author of the report, CHOP developmental and behavioral pediatrician, and a professor of pediatrics at the Perelman School of Medicine at the University of Pennsylvania. “They also need the support of the professional team, the clinicians, educators and therapists who are working alongside them.”

On a related note, we’re proud to report that the AAP’s journal Pediatrics recognized research by the Center for Autism Research on universal autism screening in its list of Best Pediatrics Articles of 2019. 

In the first large, real-world study of universal screening for ASD in toddlers, CHOP researchers found that the most widely used and researched screening tool, the Modified Checklist for Autism in Toddlers with Follow-Up (M-CHAT/F), is less accurate than shown in previous studies conducted in research laboratory settings. The new study also revealed significant disparities in detecting early autism symptoms in minority, urban, and low-income children. While the study team continues to support universal autism screening, they emphasized the importance of recognizing these limitations and making improvements to autism screening tools and processes to ensure early and accurate diagnoses that can help children access effective autism-specific therapies.

PCORI Approves Outpatient Antibiotic Stewardship Project

Although antibiotics can be lifesaving drugs, up to half of all antibiotic use is inappropriate. Excessive antibiotic use can lead to antibiotic-resistant bacteria, which sicken at least 2 million Americans each year and are hard to treat. 

Principal investigators Jeffrey S. Gerber, MD, PhD, and Alexander Fiks, MD, MSCE, will use tested strategies to improve antibiotic prescribing in outpatient settings for children with acute upper respiratory infections (ARTIs) in the CHOP-based Broad Implementation of Outpatient Stewardship (BIOS) project, one of 21 projects approved recently by the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors. The project is expected to kick off in early 2020.

Prior PCORI-funded work by this project team compared the effectiveness of broad- vs. narrow-spectrum antibiotics in children treated for three common types of ARTIs — ear infections, sinus infections, and strep throat. They found that broad-spectrum antibiotics did not improve patient outcomes compared to narrow-spectrum antibiotics, but did increase harmful side effects like diarrhea, rash, or upset stomach. 

Locally, the CHOP project team successfully used education coupled with report cards to clinicians on their own and their colleagues’ antibiotic prescribing (called the PARTI intervention) to decrease rates of unnecessary broad-spectrum antibiotic prescribing for ARTIs across the CHOP Primary Care Network. The goal of the BIOS Project is to broadly implement the evidence-based PARTI intervention to improve how clinicians caring for children in varied outpatient settings make decisions about antibiotics for ARTIs. 

The CHOP-based team will work with health systems in Ohio (Cleveland MetroHealth and Nationwide Children’s), Central Pennsylvania (Penn State Hershey) and Florida (Pediatric Associates) as well as the CHOP Emergency Department and Urgent Care settings to adapt, implement and evaluate the intervention. The AAP Pediatric Research in Office Settings network will provide overall coordination and opportunities to disseminate project outcomes.

ICYMI

Catch up on our headlines from our Dec. 13 In the News:

• Scientists Detail How Chromosomes Reorganize After Cell Division 
• CHOP and Bayer Collaborate on Research for Oral Treatment of Hemophilia
• Study Seeks Obesity-Cardiovascular Disease Link in Pediatric Chronic Kidney Disease
• New Algorithm Better Detects Disease-Causing Genetic Variants

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