ABSTRACTBackgroundHydration and urine alkalinization are the mainstays for the prevention of methotrexate‐induced nephrotoxicity. Current oncology protocols recommend pediatric patients who are administered high‐dose methotrexate (HDMTX) to be aggressively hydrated with an alkaline solution, which may lead to overhydration. This pilot study sought to determine whether reduced posthydration results in a shorter time to methotrexate elimination without increasing adverse effects.MethodsA prospective randomized controlled crossover study design of pediatric patients with acute lymphoblastic leukemia was performed. Patients were randomized to begin with standard or reduced volume intravenous fluids. Over the course of four cycles of HDMTX, patients alternated between the standard rate of 125 mL/m2/h and a reduced volume rate of 62.5 mL/m2/h. The primary endpoint was the time from the start of HDMTX to a serum methotrexate concentration less than 0.1 µmol/L.ResultsData from 37 HDMTX courses were analyzed in 10 patients aged 1–17 years. The median time to methotrexate elimination was similar between the standard and reduced hydration regimens at 71.7 h (60.8–115.6 h) versus 72.9 h (59.9–132 h, p value = 0.6539). There was no difference in the change from baseline to maximum creatinine (10% vs. 18.9%, p value = 0.6566), maximum weight gain (0.7 kg vs. 0.4 kg, p value = 0.0967), or rates of severe mucositis between hydration regimens.ConclusionReduced posthydration appeared to be safe and provided similar time to HDMTX elimination. A multicenter study is indicated to confirm the use of reduced hydration to optimize supportive care in pediatric patients administered HDMTX.Trial Registration: NCT03964259.

BACKGROUND AND OBJECTIVES: Prompt antibiotics have been shown to improve outcomes in pediatric sepsis, which continues to be a leading cause of death in children. We describe the quality improvement (QI) efforts of a single academic children’s hospital to improve antibiotic timeliness. METHODS: Using the electronic health record, we report time from order to the administration of stat intravenous (IV) antibiotics from 2012 to 2020 using statistical process control charts. We describe QI interventions initiated over the study period. These include the formation of a Pediatric Sepsis Committee, routine use of automated dispensing machines for stat IV antibiotics, creation of sepsis order sets, manual and automated sepsis screening implementation, participation in national sepsis QI collaboratives, creation of difficult intravenous access guidelines, and an automated notification system for charge nurses. As a balancing measure, we assessed stat IV antibiotic use normalized to total emergency department visits and inpatient days. RESULTS: Multiple quality improvement interventions were initiated and sustained under the direction of the hospital Pediatric Sepsis Committee. We improved our stat IV antibiotics given within 1 hour of order from 33% in 2012 to 77% in 2019 and maintained this through the end of the study period in July 2020. CONCLUSIONS: By using a multipronged quality improvement approach, we demonstrated consistent and sustained improvement in the timely administration of stat IV antibiotics over an 8-year period at our institution. Further study is needed to assess whether this is associated with reduced length of stay or improved survival in children with sepsis.

Clinical Commentary Children and adolescents who regularly participate in sports have a lower risk of obesity, chronic disease, alcohol and drug use, and criminal activity, and have higher self-esteem compared with nonparticipants.1–3 However, only 24% of youth engage in the 60 minutes of physical activity per day recommended by national guidelines.4 Participation in structured sports has decreased from 45% to 38% in the past 10 years, and children in low-income households are one-half as likely to participate regularly in sports compared with children from higher-income households.4 The Aspen Institute found growing disparities in physical activity by income;the percentage of inactive children in households with annual incomes less than $25,000 increased from 24% in 2012 to 33% in 2018, whereas the percentage of inactive children in households earning more than $100,000 decreased from 14% to 9.9% during the same time frame.4 In the United States, 49 states and the District of Columbia require a preparticipation physical evaluation before participation in school sports (Vermont leaves the decision to screen to individual school districts).5 The major components of the preparticipation physical evaluation are a detailed family history, medical history, symptom history, and physical examination.6,7 Concern about undiagnosed cardiac disease in athletes has grown over the past several decades following high-profile cases of sudden cardiac death.8 Rates of sudden cardiac death in young athletes range from 0.4 to 4 per 100,000 athlete-years.8,9 One suggested role of the preparticipation physical evaluation is preventing these deaths through early identification of children at high risk. Israel implemented mandatory preparticipation physical evaluations with ECGs and exercise stress testing in 1997, but sudden cardiac death rates have not changed.19 When studied in the United States, preparticipation physical evaluation with or without an ECG did not significantly predict or reduce sudden cardiac death.9 Most athletes in the Football Association (England, soccer) with cardiac death had normal screening results despite mandatory preparticipation physical evaluations, ECGs, and echocardiography.20 Preparticipation physical evaluation with an ECG has a high false-positive rate (40%) and false-negative rate overall (4% to 5%), with both preparticipation evaluations and ECGs having higher false-negative rates specifically for hypertrophic cardiomyopathy (10%).11,21,22 A cost analysis showed that implementing preparticipation physical evaluations with ECGs in the United States would cost $470 per athlete per year or $51 billion to $69 billion over 20 years.23 Sudden cardiac death in an athlete is rare, totaling fewer than 100 deaths per year in the United States, at a rate of 1 in 150,000 athletes per year.8,9 In Denmark, the rate of sudden cardiac death in the general population is more than 20 times greater than the rate in teenaged and young adult athletes (0.43 to 0.47 per 100,000 athlete person-years).24 The preintervention rate in the Veneto study (4 per 100,000 athlete-years) was much higher than that observed in more contemporary studies. Considering the lower rates of sudden cardiac death in the United States, even if the benefit in the Veneto study could be replicated, the number of ECGs needed to prevent one sudden cardiac death would be 33,000 to 192,000.23 An estimated 2% of children are disqualified from sports participation through the screening process when it includes an ECG.22 Approximately 45 million children and adolescents participate in sports in the United States;therefore, 900,000 children and adolescents would be unable to participate in organized physical activity without clear evidence of benefit if universal ECG screening were recommended.25 Intensive exercise commonly causes cardiac remodeling, termed athlete’s heart, that can lead to asymptomatic bradyarrhythmia, first-degree heart block, and ventricular hypertrophy.25 ECG and echocardiogram changes can be mistaken for concerning pathology, prompting unnecessary testing. Screening patients at high risk during well-child examinations may be underused, regardless of sports participation;one survey of pediatricians found that 24% had never ordered an ECG.28 Notably, rates of sudden cardiac death are equivalent or lower in athletes compared with nonathletes.12,13,23 Emergency response plans that include training staff in resuscitation and use of an automated external defibrillator are recommended and have been shown to save lives.29–31 In an eight-year follow-up study of professional soccer players who screened negative for cardiac risk, three athletes experienced cardiac arrest during competition or training, and all of them were successfully resuscitated.32 TAKE-HOME MESSAGES FOR RIGHT CARE Screening for undiagnosed cardiac disease during well-child examinations using a validated tool such as the American Heart Association 14-element evaluation is a high-value, low-cost intervention for children and adolescents regardless of sports participation.

The “Things We Do for No ReasonTM (TWDFNR)” series reviews practices, which have become common parts of hospital care, may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards, but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. Pulmonary function testing (PFT) is used to evaluate lung health through the measurement of airflow and volumes. They help confirm clinical diagnoses like chronic obstructive pulmonary disease (COPD) and asthma and monitor response to therapy and progression of the disease. Lung volumes vary widely across a population and must be compared to reference values to determine the degree of lung health. Common reference values incorporate variables such as age, height, sex, and race.1 Lung volume reference values for Black/African American (AA) patients are typically 10%–15% lower than values for Caucasian patients.2 Spirometry reference equations recommend using norms derived from the National Health and Nutrition Examination Survey (NHANES), which provides values for Caucasians, Black/AA, and Mexican Americans.3 NHANES does not include reference values for Asian American patients due to inadequate representation.3 Subsequent studies attempted to set a standard for Asian patients, but the standardized correction factor varied widely from 0.88 to 0.94 times the reference values for Caucasians.2, 4, 5 In developing spirometry, various studies from the last century identified differences in lung function among races leading to the implementation of race adjustment factors.3 Health care providers often use skin color as a proxy for genetic risk of common conditions and diseases. The examples of sickle cell disease, colon cancer, or cystic fibrosis clustering in racial groups help support the notion. Researchers applied these beliefs to lung function testing. The race adjustment factor for PFTs is harmful because: (1) accepting the race factor impedes the examination of other social, environmental, and genetic factors as drivers of disease, (2) it leads to the underdiagnosis of pulmonary disease in racial minority patients and impacting timely diagnosis, access to effective treatments, and ultimately outcomes,6 and (3) it continues the focus on race, a social construct that imprecisely categorizes people, instead of population categories that group by genetic clusters. The race adjustment in PFTs prevents us from truly exploring the perception, rooted in slavery and eugenics, that Black patients have smaller lung volumes. Many practitioners even remain unaware that race factor exists for PFTs. Modern PFT equipment and software thought to produce “objective data” automatically apply race factors in the background, invisible to providers. Yet a closer examination identifies that structural racism and underlying structural and social determinants of health (SDOH) such as exposure to air pollution, types of employment, and lack of access to preventative healthcare contribute to differences in benchmark PFT values.7-9 One systematic review and meta-analysis showed that ‘low socioeconomic circumstances were associated with a 0.31 L reduction in forced expiratory volume in the first second (FEV1).9 We must practice race-conscious medicine, where we purposefully acknowledge systemic and institutional racism's effect on our patients and move towards abolishing these practices. Additionally, race adjustments can lead to clinical harm through underdiagnosis. In a study of biracial children, there was a 16.5% difference in forced vital capacity (FVC) when classified as “Black” compared to when they were reclassified as “White.” Some patients met the criteria for obstructive disease only when classified as White.10 Another study that examined 14,080 PFTs of individuals who identified as Black or African-American found that removing the race adjustment led to an additional 414 patients diagnosed with obstructive disease and 665 patients diagnosed with restrictive disease. This correlates to a 1.7% and 4.7% increase in the prevalence of obstructive and restrictive disease, respectively. Furthermore, among Black patients already diagnosed with an obstructive, restrictive, or mixed pulmonary defect, nearly half would then be diagnosed with higher severity of disease such as COPD.11 In a 10+ year study following over 3000 patients, FEV1 or FVC percentages using race-based equations do not improve prediction of chronic lower respiratory diseases and mortality compared to race-neutral equations.12 In fact, people identifying as Black may have more emphysematous changes on computed tomography (CT) despite normal spirometry.13 Race-based underdiagnosis of COPD may also lead to race-based increases in rates of lung cancer mortality. In a study from Detroit, MI, 78% of AA individuals with lung cancer who did not report a previous diagnosis of COPD had clinical evidence of COPD.14 Since lung diseases such as COPD confer an increased risk of lung cancer, receiving appropriate care for COPD may decrease the risk of future lung cancer through more aggressive smoking cessation and accelerated efforts for early detection through screening.15 Assigning or assuming a patient's race imprecisely or inaccurately categorizes individuals. Our patients are members of a diverse global community. Self-identified race is a socially accepted standard, yet there are no reference values for self-identified race. When a categorical race structure limits the choices, many patients will not find a race category that fits their diverse identity or correctly identifies their underlying genetics.10 For example, there are no standardized reference values for biracial individuals.10 Attempting to create reference PFT levels for “Asians” highlights the inaccuracy and variability that occurs when one race label is applied to a diverse population. Racial proxies assume all patients of one racial category meet the same epidemiologic parameters. Little effort has been made to distinguish subgroups of “Asian” individuals or “Black” individuals or account for genetic and geographic differences within Asia and Africa.5, 10 As our understanding of genetics has evolved in the era of modern medicine, we have moved away from the categorization of populations based on race or skin color toward clusters of genetic variation and ancestry. We now know that most genetic variability occurs between individuals, and little is explained by race.7 Research shows that using genetic markers indicating African ancestry leads to more accurate predictions of lung function than those derived from the standard reference equation based on an “African American” race category.16 Our medical technology and references must adapt accordingly to better inform clinical decision-making. Some worry that removing the race factor will lead to overdiagnosis. However, the risks of overdiagnosis of lung disease are outweighed by the risks of underdiagnosis and it is uncommon for a diagnosis to be made on PFT values alone. It is known that underdiagnosis is common, has its roots in racism, contributes to increased morbidity and mortality for under-represented minority patients, and the evidence supporting race correction is poor quality and has racist roots.7, 8, 11, 14 Research has not identified a genetic variation that can explain racial differences in lung functions. Multiple studies, however, show the effect of socioeconomic status, environmental toxins, and other SDOH.8, 9 While additional research is needed to further quantify the impact of SDOH, the medical community should not continue to use race as an inaccurate proxy for the differences in lung capacity. The medical community should follow the lead of other equations, like eGFR estimation and the VBAC calculator, which have successfully removed race factors.17 Cease using the race factor in calculating PFTs. If your institution uses spirometers with a race factor, enter every patient as “White” to apply a race factor of 1. Inform patients whenever a race factor is applied in assessing their health. Advocate for the development and manufacturing of spirometers that do not include race factors. Advocate for further research into the relationship between lung capacity and social determinants of health that disproportionately impact people of color. Utilize an individualized and patient-centered approach to the diagnosis of pulmonary disorders and inquire about social factors that increase the risk of lung disease. In our clinical scenario, a deeper look into our patient's history reveals that he lives in a community with high levels of pollutants, previously worked at a chemical plant, and has difficulty finding high-quality housing. A more nuanced approach to the diagnosis of COPD would have valued these historical factors. Closer follow-up might have led to more adequate medication therapy, quicker integrations of newer therapies, and more comprehensive care, including screening for lung cancer. PFT is an important component of diagnosing a variety of diseases and assessing patients' lung health. Understandably, many healthcare practitioners may have concerns about unintentional harm caused by removing the race adjustment. However, supporting race adjustment perpetuates healthcare disparities. As a profession, we must practice race-conscious medicine that values individualized care, recognizes the contributions of structural racism and social determinants in patient health, and standardize care when possible, based on objective metrics. What do you do? Do you think this is a low-value practice? Is this truly a “Thing We Do for No Reason™”? Share what you do in your practice and join in the conversation online by retweeting it on Twitter (#TWDFNR) and liking it on Facebook. We invite you to propose ideas for other “Things We Do for No Reason™” topics by emailing [email protected]. The hospitalist admitted a 49-year-old man with a 20-pack-year history of tobacco use and chronic cough for a viral illness featuring dyspnea and hypoxia. After a short observation period, his symptoms resolved, but the hospitalist suspects that the patient has COPD and refers him for PFT. His PFT results, using race adjustment to account for his black race, do not meet the criteria for a diagnosis of COPD. As a result, he only receives tobacco cessation counseling from his primary care physician. He continues to have a chronic cough with sputum production but does not receive COPD-specific therapies and is lost to follow-up after finding out he does not have COPD. The authors declare no conflict of interest.

BACKGROUND AND OBJECTIVESThe American Academy of Pediatrics recommends against the routine use of β-agonists, corticosteroids, antibiotics, chest radiographs, and viral testing in bronchiolitis, but use of these modalities continues. Our objective for this study was to determine the patient, provider, and health care system characteristics that are associated with receipt of low-value services.METHODSUsing the Virginia All-Payers Claims Database, we conducted a retrospective cross-sectional study of children aged 0 to 23 months with bronchiolitis (code J21, International Classification of Diseases, 10th Revision) in 2018. We recorded medications within 3 days and chest radiography or viral testing within 1 day of diagnosis. Using Poisson regression, we identified characteristics associated with each type of overuse.RESULTSFifty-six percent of children with bronchiolitis received ≥1 form of overuse, including 9% corticosteroids, 17% antibiotics, 20% β-agonists, 26% respiratory syncytial virus testing, and 18% chest radiographs. Commercially insured children were more likely than publicly insured children to receive a low-value service (adjusted prevalence ratio [aPR] 1.21; 95% confidence interval [CI]: 1.15–1.30; P < .0001). Children in emergency settings were more likely to receive a low-value service (aPR 1.24; 95% CI: 1.15–1.33; P < .0001) compared with children in inpatient settings. Children seen in rural locations were more likely than children seen in cities to receive a low-value service (aPR 1.19; 95% CI: 1.11–1.29; P < .0001).CONCLUSIONSOveruse in bronchiolitis remains common and occurs frequently in emergency and outpatient settings and rural locations. Quality improvement initiatives aimed at reducing overuse should include these clinical environments.

Introduction: Inpatient electrolyte testing rates vary significantly across pediatric hospitals. Despite evidence that unnecessary testing exists, providers still struggle with reducing electrolyte laboratory testing. We aimed to reduce serum electrolyte testing among pediatric inpatients by 20% across 5 sites within 6 months. Methods: A national quality improvement collaborative evaluated standardized interventions for reducing inpatient serum electrolyte testing at 5 large tertiary and quaternary children’s hospitals. The outcome measure was the rate of electrolyte laboratory tests per 10 patient-days. The interventions were adapted from a previous single-site improvement project and included cost card reminders, automated laboratory plans via electronic medical record, structured rounds discussions, and continued education. The collaborative utilized weekly conference calls to discuss Plan, Do, Study, Act cycles, and barriers to implementation efforts. Results: The study included 17,149 patient-days across 5 hospitals. The baseline preintervention electrolyte laboratory testing rate mean was 4.82 laboratory tests per 10 patient-days. Postimplementation, special cause variation in testing rates shifted the mean to 4.19 laboratory tests per 10 patient-days, a 13% reduction. There was a wide variation in preintervention electrolyte testing rates and the effectiveness of interventions between the hospitals participating in the collaborative. Conclusions: This multisite improvement collaborative was able to rapidly disseminate and implement value improvement interventions leading to a reduction in electrolyte testing; however, we did not meet our goal of 20% testing reduction across all sites. Quality improvement collaboratives must consider variation in context when adapting previously successful single-center interventions to a wide variety of sites.

Inspired by the ABIM Foundation's Choosing Wisely ® campaign, the “Things We Do for No Reason™” (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion .

OBJECTIVES:Despite 2011 guidelines in which it is suggested that treatment of acute immune thrombocytopenia purpura (aITP) is not needed for patients without significant bleeding, only 14% of children treated for aITP have bleeding symptoms. Our aim was to decrease the percentage of children with first-episode aITP who were unnecessarily treated by 50% within 12 months of guideline implementation.METHODS:An intervention was designed by using the precaution-adoption-process model. A standard-of-practice meeting was organized and focused on clinician readiness for change. After education on current evidence and common cognitive errors, consensus clinical guidelines were created. After implementation, an article in a statewide professional newsletter was published to educate community providers. Unnecessary treatment (UT) was defined as treatment of any patient who only had bruising and/or self-resolving nose bleeds. Statistical process control charts were used to track progress, midline shifts were determined by Nelson's rules, and hospital costs were derived from administrative billing data.RESULTS:One hundred children with aITP were seen from January 2013 to September 2018. UT decreased from 70% to a sustained rate of <30% (P = .008), including a mean of 7% over the past 12 months. The admission rate decreased from 100% to 52% (P = .013), and the total percentage of patients treated decreased from 100% to 48% (P = .016), with both numbers continuing to decline. No adverse bleeding events occurred. An estimated 12 admissions, 4 readmissions, and 5 adverse events were avoided annually.CONCLUSIONS:We demonstrated successful improvement in UT of aITP through an educational intervention informed by the precaution-adoption-process model change theory.

Underuse and overuse of medical interventions, failure to use interventions known to be effective, and provision of tests or interventions in which benefits do not exceed harms are types of low-value care. The Lown Institute's Right Care Alliance Children's Health Council identified five "do" recommendations that highlight underuse and five "don't" recommendations that highlight overuse in children's health care. The five "do" recommendations include: do provide access to long-acting reversible contraception for adolescents, do use nonpharmacologic interventions first for treatment of attention-deficit/hyperactivity disorder, do discuss quality of life for children with complex medical conditions using a shared decision-making model and access resources such as palliative care subspecialists, do promote childhood literacy development by providing free, age-appropriate books in clinical settings, and do screen for socioeconomic status of the patient and family and provide access to community health and wellness resources. The five "don't" recommendations include: don't routinely prescribe antibiotics in children two to 12 years of age with a middle ear infection, don't perform computed tomography of the head for children with minor head trauma, don't use albuterol in children with bronchiolitis, don't routinely screen for hyperlipidemia in children and adolescents, and don't routinely perform preparticipation sports evaluations. These 10 examples of underuse and overuse were identified with the intent of improving health care value and promoting "Right Care."

Vaso‐occlusive crisis (VOC) is frequent in children with sickle cell disease (SCD) creating significant burden on patients, families, and emergency departments (ED). The objective of the project was to reduce the admission rate for children with SCD presenting to our ED with VOC by >20% within 6 months of initiating individualized pain plans (IPP).

BACKGROUND AND OBJECTIVES: To determine the effect of discharge criteria on discharge readiness and length of stay (LOS). Discharge inefficiency is a common barrier to hospital flow, affecting admissions, discharges, cost, patient satisfaction, and quality of care. Our center identified increasing discharge efficiency as a method to improve flow and better meet the needs of our patients. METHODS: A multidisciplinary team was assembled to examine discharge efficiency and flow. Discharge criteria were created for the 3 most common diagnoses on the hospital medicine service then expanded to 10 diagnoses 4 months into the project. Discharge workflow was evaluated through swim lane mapping, and barriers were evaluated through fishbone diagrams and a key driver diagram. Progress was assessed every 2 weeks through statistical process control charts. Additional interventions included provider education, daily review of criteria, and autotext added to daily notes. Our primary aim was to increase the percentage of patients discharged within 3 hours of meeting discharge criteria from 44% to 75% within 12 months of project implementation. RESULTS: Discharge within 3 hours as well as 2 hours of meeting criteria improved significantly, from 44% to 87% and from 33% to 78%, respectively. LOS for the 10 diagnoses decreased from 2.89 to 1.47 days, with greatest gains seen for patients with asthma, pneumonia, and bronchiolitis without a change in the 30-day readmission rate. CONCLUSIONS: Discharge criteria for common diagnoses may be an effective way to decrease variability and improve LOS for hospitalized children.