Alan Schroeder

All Publications

• Reducing Variability in the Infant Sepsis Evaluation (REVISE): A National Quality Initiative. Pediatrics Biondi, E. A., McCulloh, R., Staggs, V. S., Garber, M., Hall, M., Arana, J., Barsotti, B., Natt, B. C., Schroeder, A. R., Schroeder, L., Wylie, T., Ralston, S. L., AMERICAN ACADEMY OF PEDIATRICS REVISE COLLABORATIVE 2019

  Abstract

  BACKGROUND: Substantial variability exists in the care of febrile, well-appearing infants. We aimed to assess the impact of a national quality initiative on appropriate hospitalization and length of stay (LOS) in this population.METHODS: The initiative, entitled Reducing Variability in the Infant Sepsis Evaluation (REVISE), was designed to standardize care for well-appearing infants ages 7 to 60 days evaluated for fever without an obvious source. Twelve months of baseline and 12 months of implementation data were collected from emergency departments and inpatient units. Ill-appearing infants and those with comorbid conditions were excluded. Participating sites received change tools, run charts, a mobile application, live webinars, coaching, and a LISTSERV. Analyses were performed via statistical process control charts and interrupted time series regression. The 2 outcome measures were the percentage of hospitalized infants who were evaluated and hospitalized appropriately and the percentage of hospitalized infants who were discharged with an appropriate LOS.RESULTS: In total, 124 hospitals from 38 states provided data on 20570 infants. The median site improvement in percentages of infants who were evaluated and hospitalized appropriately and in those with appropriate LOS was 5.3% (interquartile range = -2.5% to 13.7%) and 15.5% (interquartile range = 2.9 to 31.3), respectively. Special cause variation toward the target was identified for both measures. There was no change in delayed treatment or missed bacterial infections (slope difference 0.1; 95% confidence interval, -8.3 to 9.1).CONCLUSIONS: Reducing Variability in the Infant Sepsis Evaluation noted improvement in key aspects of febrile infant management. Similar projects may be used to improve care in other clinical conditions.

  View details for DOI 10.1542/peds.2018-2201

  View details for PubMedID 31434688

• Medical Overuse and Appendicitis Treatment-Reply. JAMA pediatrics Coon, E. R., Schroeder, A. R. 2019

  View details for DOI 10.1001/jamapediatrics.2019.2399

  View details for PubMedID 31329244

• Aligning Inpatient Pediatric Research With Settings of Care: A Call to Action. Pediatrics McDaniel, C. E., Jennings, R., Schroeder, A. R., Paciorkowski, N., Hofmann, M., Leyenaar, J. 2019

  View details for PubMedID 31018987

• Right Care for Children: Top Five Do's and Don'ts AMERICAN FAMILY PHYSICIAN Schefft, M., Schroeder, A. R., Liu, D., Nicklas, D., Moher, J., Quinonez, R. 2019; 99 (6): 376–82

  View details for Web of Science ID 000461536700006

• 2018 Update on Pediatric Medical Overuse: A Review. JAMA pediatrics Coon, E. R., Quinonez, R. A., Morgan, D. J., Dhruva, S. S., Ho, T., Money, N., Schroeder, A. R. 2019

  Abstract

  Importance: Efforts to combat medical overuse have gained traction in recent years, but success has been intermittent and shortcomings have been recognized. A commitment to a strong evidence base is needed to more broadly engage clinicians and reduce overuse.Observations: A structured MEDLINE search and a manual review of tables of contents from selected high-impact journals was performed to identify original research published in 2017 relevant to pediatric overuse. Articles were scored from low to high for 3 categories: quality of methods, magnitude of potential harm, and number of patients potentially harmed. The top-scoring articles presented in this review highlight examples of safe reductions in treatment intensity, including in the setting of cancer, appendicitis, acute respiratory tract infection, and elective anesthesia. This year's articles also provide cautionary examples of rational interventions adopted without a full understanding of potential harms, including pharmacologic migraine therapies, docosahexaenoic acid supplementation for preterm neonates, tight glycemic control for individuals with critically illness, and prophylactic antibiotics for children with vesicoureteral reflux.Conclusions and Relevance: The articles represent high-quality, original research from 2017 that may help mitigate overuse. These works should be fundamental to the maturation of the pediatric overuse field.

  View details for PubMedID 30776069

• Negative Urinalyses in Febrile Infants Age 7 to 60 Days Treated for Urinary Tract Infection JOURNAL OF HOSPITAL MEDICINE Schroeder, A. R., Lucas, B. P., Garber, M. D., McCulloh, R. J., Joshi-Patel, A. A., Biondi, E. A. 2019; 14 (2): 101–4

  View details for DOI 10.12788/jhm.3120

  View details for Web of Science ID 000457470400007

• Association of Diagnostic Criteria With Urinary Tract Infection Prevalence in Bronchiolitis: A Systematic Review and Meta-analysis. JAMA pediatrics McDaniel, C. E., Ralston, S., Lucas, B., Schroeder, A. R. 2019

  Abstract

  Importance: Concomitant urinary tract infection (UTI) is a frequent concern in febrile infants with bronchiolitis, with a prior meta-analysis suggesting a prevalence of 3.3%. However, the definition of UTI in these studies has generally not incorporated urinalysis (UA) results.Objective: To conduct a systematic review and meta-analysis examining the prevalence of UTI in infants with bronchiolitis when positive UA results are incorporated into the UTI definition.Data Sources: Medline (1946-2017) and Ovid EMBASE (1976-2017) through August 2017 and bibliographies of retrieved articles.Study Selection: Studies reporting UTI prevalence in bronchiolitis.Data Extraction: Data were extracted in accordance with meta-analysis of observational studies in epidemiology guidelines via independent abstraction by multiple investigators. Random-effects models generated a weighted pooled event rate with corresponding 95% confidence intervals.Main Outcomes and Measures: Prevalence of UTI.Results: We screened 477 unique articles by abstract, with full-text review of 30 studies. Eighteen bronchiolitis studies reported a UTI prevalence and 7 of these reported UA data for inclusion in the meta-analysis. The overall reported prevalence of UTI in bronchiolitis from these 18 studies was 3.1% (95% CI, 1.8%-4.6%). With the addition of positive UA results (defined as the presence of pyuria or nitrites) as a diagnostic criterion, the prevalence of UTI as reported in the 7 studies in bronchiolitis was 0.8% (95% CI, 0.3%-1.4%). Sensitivity analyses yielded similar results, including for infants younger than 90 days. Heterogeneous definitions of UTI and UA criteria introduced uncertainty into prevalence estimates.Conclusions and Relevance: When a positive UA result is added as a diagnostic criterion, the estimated prevalence of concomitant UTI is less than recommended testing thresholds for bronchiolitis.

  View details for PubMedID 30688987

• Parent Attitudes and Preferences for Discussing Health Care Costs in the Inpatient Setting. Pediatrics Beck, J., Wignall, J., Jacob-Files, E., Tchou, M. J., Schroeder, A., Henrikson, N. B., Desai, A. D. 2019

  Abstract

  To explore parent attitudes toward discussing their child's health care costs in the inpatient setting and to identify strategies for health care providers to engage in cost discussions with parents.Using purposeful sampling, we conducted semistructured interviews between October 2017 and February 2018 with parents of children with and without chronic disease who received care at a tertiary academic children's hospital. Researchers coded the data using applied thematic analysis to identify salient themes and organized them into a conceptual model.We interviewed 42 parents and identified 2 major domains. Categories in the first domain related to factors that influence the parent's desire to discuss health care costs in the inpatient setting, including responsibility for out-of-pocket expenses, understanding their child's insurance coverage, parent responses to financial stress, and their child's severity of illness on hospital presentation. Categories in the second domain related to parent preference regarding the execution of cost discussions. Parents felt these discussions should be optional and individualized to meet the unique values and preferences of families. They highlighted concerns regarding physician involvement in these discussions; their preference instead was to explore financial issues with a financial counselor or social worker.Parents recommended that cost discussions in the inpatient setting should be optional and based on the needs of the family. Families expressed a desire for physicians to introduce rather than conduct cost discussions. Specific recommendations from parents for these discussions may be used to inform the initiation and improvement of cost discussions with families during inpatient encounters.

  View details for DOI 10.1542/peds.2018-4029

  View details for PubMedID 31270139

• Testing for Meningitis in Febrile Well-Appearing Young Infants With a Positive Urinalysis. Pediatrics Wang, M. E., Biondi, E. A., McCulloh, R. J., Garber, M. D., Natt, B. C., Lucas, B. P., Schroeder, A. R. 2019

  Abstract

  To determine factors associated with cerebrospinal fluid (CSF) testing in febrile young infants with a positive urinalysis and assess the probability of delayed diagnosis of bacterial meningitis in infants treated for urinary tract infection (UTI) without CSF testing.We performed a retrospective cohort study using data from the Reducing Excessive Variability in Infant Sepsis Evaluation quality improvement project. A total of 20 570 well-appearing febrile infants 7 to 60 days old presenting to 124 hospitals from 2015 to 2017 were included. A mixed-effects logistic regression was conducted to determine factors associated with CSF testing. Delayed meningitis was defined as a new diagnosis of bacterial meningitis within 7 days of discharge.Overall, 3572 infants had a positive urinalysis; 2511 (70.3%) underwent CSF testing. There was wide variation by site, with CSF testing rates ranging from 64% to 100% for infants 7 to 30 days old and 10% to 100% for infants 31 to 60 days old. Factors associated with CSF testing included: age 7 to 30 days (adjusted odds ratio [aOR]: 4.6; 95% confidence interval [CI]: 3.8-5.5), abnormal inflammatory markers (aOR: 2.2; 95% CI: 1.8-2.5), and site volume >300 febrile infants per year (aOR: 1.8; 95% CI: 1.2-2.6). Among 505 infants treated for UTI without CSF testing, there were 0 (95% CI: 0%-0.6%) cases of delayed meningitis.There was wide variation in CSF testing in febrile infants with a positive urinalysis. Among infants treated for UTI without CSF testing (mostly 31 to 60-day-old infants), there were no cases of delayed meningitis within 7 days of discharge, suggesting that routine CSF testing of infants 31 to 60 days old with a positive urinalysis may not be necessary.

  View details for DOI 10.1542/peds.2018-3979

  View details for PubMedID 31395621

• Early, Unanticipated PICU Transfers: Is There a Need for Improvement? Hospital pediatrics Flaherty, B. F., Schroeder, A. R. 2019

  View details for PubMedID 31023787

• Patterns of Electrolyte Testing at Children's Hospitals for Common Inpatient Diagnoses. Pediatrics Tchou, M. J., Hall, M., Shah, S. S., Johnson, D. P., Schroeder, A. R., Antoon, J. W., Genies, M. C., Quinonez, R., Miller, C. W., Shah, S. P., Brady, P. W. 2019

  Abstract

  Overuse of laboratory testing contributes substantially to health care waste, downstream resource use, and patient harm. Understanding patterns of variation in hospital-level testing across common inpatient diagnoses could identify outliers and inform waste-reduction efforts.We conducted a multicenter retrospective cohort study of pediatric inpatients at 41 children's hospitals using administrative data from 2010 to 2016. Initial electrolyte testing was defined as testing occurring within the first 2 days of an encounter, and repeat testing was defined as subsequent testing within an encounter in which initial testing occurred. To examine if testing rates correlated across diagnoses at the hospital level, we compared risk-adjusted rates for gastroenteritis with a weighted average of risk-adjusted rates in other diagnosis cohorts. For each diagnosis, linear regression was performed to compare initial and subsequent testing.In 497 719 patient encounters, wide variation was observed across hospitals in adjusted, initial, and repeat testing rates. Hospital-specific rates of testing in gastroenteritis were moderately to strongly correlated with the weighted average of testing in other conditions (initial: r = 0.63; repeat r = 0.83). Within diagnoses, higher hospital-level initial testing rates were associated with significantly increased rates of subsequent testing for all diagnoses except gastroenteritis.Among children's hospitals, rates of initial and repeat electrolyte testing vary widely across 8 common inpatient diagnoses. For most diagnoses, hospital-level rates of initial testing were associated with rates of subsequent testing. Consistent rates of testing across multiple diagnoses suggest that hospital-level factors, such as institutional culture, may influence decisions for electrolyte testing.

  View details for DOI 10.1542/peds.2018-1644

  View details for PubMedID 31171587

• Dangers of Opioid Prescribing for Young Adults After Dental Procedures-Reply. JAMA internal medicine Schroeder, A. R., Newman, T. B., Park, K. T. 2019

  View details for DOI 10.1001/jamainternmed.2019.0213

  View details for PubMedID 31107504

• Negative Urinalyses in Febrile Infants Age 7 to 60 Days Treated for Urinary Tract Infection. Journal of hospital medicine Schroeder, A. R., Lucas, B. P., Garber, M. D., McCulloh, R. J., Joshi-Patel, A. A., Biondi, E. A. 2019; 14 (2): 101–4

  Abstract

  The role of the urinalysis (UA) in the management of young, febrile infants is controversial. To assess how frequently infants are treated for urinary tract infection (UTI) despite having normal UA values and to compare the characteristics of infants treated for UTI who have positive versus negative UAs, we reviewed 20,570 wellappearing febrile infants 7-60 days of age evaluated at 124 hospitals in the United States who were included in a national quality improvement project. Of 19,922 infants without bacteremia and meningitis, 2,407 (12.1%) were treated for UTI, of whom 2,298 (95.5%) had an initial UA performed. UAs were negative in 337/2,298 (14.7%) treated subjects. The proportion of infants treated for UTI with negative UAs ranged from 0%-35% across hospitals. UA-negative subjects were more likely to have respiratory symptoms and less likely to have abnormal inflammatory markers than UA+ subjects, indicating that they are mounting less of an inflammatory response to their underlying illness and/or might have contaminated specimens or asymptomatic bacteriuria.

  View details for PubMedID 30785417

• Reporting and Categorization of Blood Culture Contaminants in Infants and Young Children: A Scoping Review. Journal of the Pediatric Infectious Diseases Society Chappell-Campbell, L., Schwenk, H. T., Capdarest-Arest, N., Schroeder, A. R. 2018

  Abstract

  Background: Blood cultures are obtained routinely for infants and young children for the evaluation for serious bacterial infection. Isolation of organisms that represent possible contaminants poses a management challenge. The prevalence of bacteremia reported in this population is potentially biased by inconsistent contaminant categorization reported in the literature. Our aim was to systematically review the definition and reporting of contaminants within the literature regarding infant bacteremia.Methods: A search of studies published between 1986 and mid-September 2016 was conducted using Medline/PubMed. Included studies examined children aged 0 to 36 months for whom blood culture was performed as part of a serious bacterial infection evaluation. Studies that involved children in an intensive care unit, prematurely born children, and immunocompromised children or those with an indwelling catheter/device were excluded. Data extracted included contaminant designation methodology, organisms classified as contaminants and pathogens, and contamination and bacteremia rates.Discussion: Our search yielded 1335 articles, and 69 of them met our inclusion criteria. The methodology used to define contaminants was described in 37 (54%) study reports, and 16 (23%) reported contamination rates, which ranged from 0.5% to 22.8%. Studies defined contaminants according to organism species (n = 22), according to the patient's clinical management (n = 4), and using multifactorial approaches (n = 11). Many common organisms, particularly Gram-positive cocci, were inconsistently categorized as pathogens or contaminants.Conclusions: Reporting and categorization of blood culture contamination are inconsistent within the pediatric bacteremia literature, which limits our ability to estimate the prevalence of bacteremia. Although contaminants are characterized most frequently according to organism, we found inconsistency regarding the classification of certain common organisms. A standardized approach to contaminant reporting is needed.

  View details for PubMedID 30544178

• Association of Opioid Prescriptions From Dental Clinicians for US Adolescents and Young Adults With Subsequent Opioid Use and Abuse. JAMA internal medicine Schroeder, A. R., Dehghan, M., Newman, T. B., Bentley, J. P., Park, K. T. 2018

  Abstract

  Importance: Through prescription writing, dental clinicians are a potential source of initial opioid exposure and subsequent abuse for adolescents and young adults.Objective: To examine the association between index dental opioid prescriptions from dental clinicians for opioid-naive adolescents and young adults in 2015 and new persistent use and subsequent diagnoses of abuse in this population.Design, Setting, and Participants: This retrospective cohort study examined outpatient opioid prescriptions for patients aged 16 to 25 years in the Optum Research Database in 2015. Prescriptions were linked by National Provider Identifier number to a clinician category.Exposures: Individuals were included in the index dental opioid (opioid-exposed) cohort if they filled an opioid prescription from a dental clinician in 2015, had continuous health plan coverage and no record of opioid prescriptions for 12 months before receiving the prescription, and had 12 months of health plan coverage after receiving the prescription. Two age- and sex-matched opioid-nonexposed control individuals were selected for each opioid-exposed individual and were assigned a corresponding phantom prescription date.Main Outcomes and Measures: Receipt of an opioid prescription within 90 to 365 days, a health care encounter diagnosis associated with opioid abuse within 365 days, and all-cause mortality within 365 days of the index opioid or phantom prescription date.Results: Among 754 002 individuals with continuous enrollment in 2015, 97 462 patients (12.9%) received 1 or more opioid prescriptions, of whom 29 791 (30.6%) received prescriptions supplied by a dental clinician. The opioid-exposed cohort included 14 888 participants (7882 women [52.9%], 11 273 white [75.7%], with mean [SD] age, 21.8 [2.4] years), and the randomly selected opioid-nonexposed cohort included 29 776 participants (15 764 women [52.9%], 20 078 [67.4%] white, with mean [SD] age, 21.8 [2.4] years). Among the 14 888 individuals in the index dental opioid cohort, 1021 (6.9%) received another opioid prescription 90 to 365 days later compared with 30 of 29 776 (0.1%) opioid-nonexposed controls (adjusted absolute risk difference, 6.8%; 95% CI, 6.3%-7.2%), and 866 opioid-exposed individuals (5.8%) experienced 1 or more subsequent health care encounters with an opioid abuse-related diagnosis compared with 115 opioid-nonexposed controls (0.4%) (adjusted absolute risk difference, 5.3%; 95% CI, 5.0%-5.7%). There was only 1 death in each cohort.Conclusions and Relevance: The findings suggest that a substantial proportion of adolescents and young adults are exposed to opioids through dental clinicians. Use of these prescriptions may be associated with an increased risk of subsequent opioid use and abuse.

  View details for PubMedID 30508022

• Oral Rehydration Solution-An Essential Therapy for Childhood Gastroenteritis Reply JAMA PEDIATRICS Coon, E. R., Quinonez, R. A., Schroeder, A. R. 2018; 172 (10): 991–92

  View details for PubMedID 30178045

• Medical Overuse in Pediatric End-of-Life Care Reply JAMA PEDIATRICS Ralston, S. L., Schroeder, A. R. 2018; 172 (5): 496

  View details for PubMedID 29532065

• Outcomes of Follow-up Visits After Bronchiolitis Hospitalizations. JAMA pediatrics Schroeder, A. R., Destino, L. A., Brooks, R., Wang, C. J., Coon, E. R. 2018

  View details for PubMedID 29379947

• "GAPPS" in Patient Safety. Pediatrics Quinonez, R. A., Schroeder, A. R. 2018

  View details for PubMedID 30006444

• 2017 Update on Pediatric Medical Overuse: A Review. JAMA pediatrics Coon, E. R., Young, P. C., Quinonez, R. A., Morgan, D. J., Dhruva, S. S., Schroeder, A. R. 2018

  Abstract

  Medical overuse has historically focused on adult health care, but interest in how children are affected by medical overuse is increasing. This review examines important research articles published in 2016 that address pediatric overuse.A structured search of PubMed and a manual review of the tables of contents of 10 journals identified 169 articles related to pediatric overuse published in 2016, from which 8 were selected based on the quality of methods and potential harm to patients in terms of prevalence and magnitude. Articles were categorized by overtreatment, overmedicalization, and overdiagnosis. Findings included evidence of overtreatment with commercial rehydration solution, antidepressants, and parenteral nutrition; overmedicalization with planned early deliveries, immobilization of ankle injuries, and use of hydrolyzed infant formula; and evidence of overdiagnosis of hypoxemia among children recovering from bronchiolitis.The articles were of high quality, with most based on randomized clinical trials. The potential harms associated with pediatric overuse were significant, including increased risk of infection, developmental disability, and suicidality.

  View details for PubMedID 29582079

• Trends in Imaging Findings, Interventions, and Outcomes Among Children With Isolated Head Trauma. Pediatric emergency care Coon, E. R., Newman, T. B., Hall, M., Wilkes, J., Bratton, S. L., Schroeder, A. R. 2018

  Abstract

  The aim was to analyze the impact of decreased head computed tomography (CT) imaging on detection of abnormalities and outcomes for children with isolated head trauma.The study involves a multicenter retrospective cohort of patients younger than 19 years presenting for isolated head trauma to emergency departments in the Pediatric Health Information System database from 2003 to 2015. Patients directly admitted or transferred to another facility and those with a discharge diagnosis code for child maltreatment were excluded. Outcomes were ascertained from administrative and billing data. Trends were tested using mixed effects logistic regression, accounting for clustering within hospitals and adjusted for age, sex, insurance type, race, presence of a complex chronic condition, and hospital-level case mix index.Between 2003 and 2015, 306,041 children presented for isolated head trauma. The proportion of children receiving head CT imaging was increasing until 2008, peaking at just under 40%, before declining to 25% by 2015. During the recent period of decreased head CT imaging, the detection of skull fractures (odds ratio [OR]/year, 0.96; 95% confidence interval [CI], 0.95-0.97) and intracranial bleeds (OR/year, 0.96; 95% CI, 0.94-0.97), hospitalization (OR/year, 0.96; 95% CI, 0.95-0.96), neurosurgery (OR/year, 0.91; 95% CI, 0.87-0.95), and revisit (OR/year, 0.98; 95% CI, 0.96-1.00) also decreased, without significant changes in mortality (OR/year, 0.93; 95% CI, 0.84-1.04) or persistent neurologic impairment (OR/year, 1.03; 95% CI, 0.92-1.15).The recent decline in CT scanning in children with isolated head trauma was associated with a reduction in detection of intracranial abnormalities, and a concomitant decrease in interventions, without measurable patient harm.

  View details for PubMedID 29698347

• Epidemiology of Cerebrospinal Fluid Cultures and Time to Detection in Term Infants PEDIATRICS Leazer, R., Erickson, N., Paulson, J., Zipkin, R., Stemmle, M., Schroeder, A. R., Bendel-Stenzel, M., Fine, B. R. 2017; 139 (5)

  Abstract

  Although meningitis is rare in previously healthy term infants, lumbar puncture is often performed to evaluate for source of illness. This study was performed to determine the time to detection for positive cerebrospinal fluid (CSF) cultures and to provide an update on the current epidemiology of bacterial meningitis in term infants.This study was a multicenter, retrospective review of positive CSF cultures in infants ≤90 days of age. Specimens were drawn in the emergency department or inpatient setting between January 2000 and December 2013. Cultures were deemed true pathogens or contaminant species based on the attending physician's treatment plan. Cultures from premature infants, an operative source, or those with significant medical history were excluded.A total of 410 positive CSF culture results were included, with 53 (12.9%) true pathogens and 357 (87.1%) contaminant species. The mean ± SD time to detection for true pathogens was 28.6 ± 16.8 hours (95% confidence interval, 24-33.2); for contaminant species, it was 68.1 ± 36.2 hours (95% confidence interval, 64.3-71.9). Forty-three true-positive cases (81.1%) were positive in ≤36 hours. The most common pathogen was group B Streptococcus (51%), followed by Escherichia coli (13%) and Streptococcus pneumoniae (9%).The majority of pathogenic bacteria in CSF exhibit growth within 36 hours. Most growth from CSF cultures in febrile infants is treated as contamination. The epidemiology of meningitis has remained constant, with group B Streptococcus as the predominant pathogen, despite changes noted in the epidemiology of bacteremia in this population.

  View details for DOI 10.1542/peds.2016-3268

  View details for Web of Science ID 000400371500026

  View details for PubMedID 28557739

• Developing the PedsValue Modules - A National Pediatric High Value Care Curriculum. Academic pediatrics Avery, C. S., Beck, J., Padrez, R., LaRue Walker, L., Herrmann, L. E., Woods, S., Schroeder, A. R., Schickedanz, A. 2017

  View details for DOI 10.1016/j.acap.2017.04.006

  View details for PubMedID 28428096

• Categorization of National Pediatric Quality Measures PEDIATRICS House, S. A., Coon, E. R., Schroeder, A. R., Ralston, S. L. 2017; 139 (4)

  Abstract

  The number of quality measures has grown dramatically in recent years. This growth has outpaced research characterizing content and impact of these metrics. Our study aimed to identify and classify nationally promoted quality metrics applicable to children, both by type and by content, and to analyze the representation of common pediatric issues among available measures.We identified nationally applicable quality measure collections from organizational databases or clearinghouses, federal Web sites, and key informant interviews and then screened each measure for pediatric applicability. We classified measures as structure, process, or outcome using a Donabedian framework. Additionally, we classified process measures as targeting underuse, overuse, or misuse of health services. We then classified measures by content area and compared disease-specific metrics to frequency of diagnoses observed among children.A total of 386 identified measures were relevant to pediatric patients; exclusion of duplicates left 257 unique measures. The majority of pediatric measures were process measures (59%), most of which target underuse of health services (77%). Among disease-specific measures, those related to depression and asthma were the most common, reflecting the prevalence and importance of these conditions in pediatrics. Conditions such as respiratory infection and otitis media had fewer associated measures despite their prevalence. Other notable pediatric issues lacking associated measures included care of medically complex children and injuries.Pediatric quality measures are predominated by process measures targeting underuse of health care services. The content represented among these measures is broad, although there remain important gaps.

  View details for DOI 10.1542/peds.2016-3269

  View details for Web of Science ID 000398602400036

  View details for PubMedID 28298481

• Update on Pediatric Overuse PEDIATRICS Coon, E. R., Young, P. C., Quinonez, R. A., Morgan, D. J., Dhruva, S. S., Schroeder, A. R. 2017; 139 (2)

  Abstract

  As concerns over health care-related harms and costs continue to mount, efforts to identify and combat medical overuse are needed. Although much of the recent attention has focused on health care for adults, children are also harmed by overuse. Using a structured PubMed search and manual tables of contents review, we identified important articles on pediatric overuse published in 2015. These articles were evaluated according to the quality of the methods, the magnitude of clinical effect, and the number of patients potentially affected and were categorized into overdiagnosis, overtreatment, and overutilization. Overdiagnosis: Findings included evidence for overdiagnosis of hypoxemia in children with bronchiolitis and skull fractures in children suffering minor head injuries. Overtreatment: Findings included evidence that up to 85% of hospitalized children with radiographic pneumonia may not have a bacterial etiology; many children are receiving prolonged intravenous antibiotic therapy for osteomyelitis although oral therapy is equally effective; antidepressant medication for adolescents and nebulized hypertonic saline for bronchiolitis appear to be ineffective; and thresholds for treatment of hyperbilirubinemia may be too low. Overutilization: Findings suggested that the frequency of head circumference screening could be relaxed; large reductions in abdominal computed tomography testing for appendicitis appear to have been safe and effective; and overreliance on C-reactive protein levels in neonatal early onset sepsis appears to extend hospital length-of-stay.

  View details for DOI 10.1542/peds.2016-2797

  View details for Web of Science ID 000393035100053

  View details for PubMedID 28049113

• US Preventive Task Force cites insufficient evidence for pediatric lipid screening. journal of pediatrics Schroeder, A. R., Newman, T. B. 2017; 180: 291-294

  View details for DOI 10.1016/j.jpeds.2016.10.059

  View details for PubMedID 28010798

• When technology creates uncertainty: pulse oximetry and overdiagnosis of hypoxaemia in bronchiolitis. BMJ (Clinical research ed.) Quinonez, R. A., Coon, E. R., Schroeder, A. R., Moyer, V. A. 2017; 358: j3850

  View details for PubMedID 28814557

• Viral Testing for Pediatric Respiratory Infections: Why Precise Diagnoses Do Not Always Translate to Patient Benefit. JAMA Schroeder, A. R., Ralston, S. L. 2017; 318 (5): 472–73

  View details for PubMedID 28763534

• Why It Is So Hard to Talk About Overuse in Pediatrics and Why It Matters. JAMA pediatrics Ralston, S. L., Schroeder, A. R. 2017

  View details for PubMedID 28828471

• Re: Balancing Breastfeeding Promotion. Pediatrics Garber, M. D., Schroeder, A. R., Flaherman, V. 2017; 140 (5)

  View details for DOI 10.1542/peds.2017-2658A

  View details for PubMedID 29089405

• Randomized Trials in Children With UTI. Pediatrics Schroeder, A. R., Newman, T. B. 2017; 140 (6)

  View details for PubMedID 29187581

• Physician Preferences Surrounding Urinary Tract Infection Management in Neonates. Hospital pediatrics Joshi, N. S., Lucas, B. P., Schroeder, A. R. 2017

  Abstract

  Variability exists in the treatment of neonates with urinary tract infection (UTI), potentially reflecting an overuse of resources. A cross-sectional vignette survey was designed to examine variability in physician preferences for intravenous (IV) antibiotic duration, genitourinary imaging, and prophylactic antibiotics and to evaluate drivers of resource use.The survey was administered to a random sample of pediatricians through the American Medical Association's Physician Masterfile. Respondents were provided with a case vignette of a 2-week-old neonate with a febrile UTI and asked to indicate preferences for IV antibiotic duration and rank drivers of this decision. Respondents were also asked whether they would obtain a voiding cystourethrogram (VCUG) and, regardless of preference, randomly presented with a normal result or bilateral grade II vesicoureteral reflux. The survey was delivered electronically to facilitate skip logic and randomization.A total of 279 surveys were completed. Preference for total IV antibiotic duration differed significantly (P < .001) across specialty, with a median duration of 2 days for general pediatricians/hospitalists, 7 days for neonatologists, and 5 days for infectious disease pediatricians. For the 47% (n = 131) who did not want a VCUG, 24/61 (39%) wanted prophylactic antibiotics when presented with grade II vesicoureteral reflux (P < .001).Subspecialty status appeared to be the most influential driver of IV antibiotic duration in the treatment of UTI. A substantial proportion of pediatricians who initially expressed a preference against ordering a VCUG wished to prescribe prophylactic antibiotics when results were abnormal, which suggests that even unwanted diagnostic test results drive treatment decisions.

  View details for PubMedID 29196453

• Teaching High-Value Care in Pediatrics: A National Survey of Current Practices and Guide for Future Curriculum Development. Journal of graduate medical education Tchou, M. J., Walz, A., Burgener, E., Schroeder, A., Blankenburg, R. 2017; 9 (6): 741–47

  Abstract

  Health care expenditures in the United States are increasing at an unsustainable pace. There have been calls to incorporate education on resource stewardship into medical training, yet the perceived need for and current use of high-value care (HVC) curricula in pediatrics residency programs is unknown.We described the current national landscape of HVC curricula in pediatrics residencies, including characterization of current programs, barriers to the practice of HVC, and clarification of preferred curricula types.Using a cross-sectional study design, we conducted a national, anonymous, web-based survey of pediatrics residency program directors and pediatrics chief residents in fall 2014.We received responses from 85 of 199 (43%) pediatrics program directors and 74 of 199 (37%) pediatrics chief residents. Only 10% (8 of 80) of program directors and 12% (8 of 65) of chief residents reported having a formal curriculum on HVC. Respondents identified the largest barriers to HVC as a lack of cost transparency (program directors) and attending physicians having the final say in treatment decisions (chief residents). The majority of respondents (83%, 121 of 146) agreed their program needs a HVC curriculum, and 90% (131 of 145) reported they would use a curriculum if it was available. Respondents significantly preferred a case-based conference discussion format over other approaches.Most pediatrics residency programs responding to a survey lacked formal HVC curricula. There is a desire nationally for HVC education in pediatrics, particularly in a case-based discussion format.

  View details for DOI 10.4300/JGME-D-17-00139.1

  View details for PubMedID 29270265

  View details for PubMedCentralID PMC5734330

• UTI and Faulty Gold Standards. Pediatrics Schroeder, A. R. 2017; 139 (3)

  View details for PubMedID 28246347

• Urinary Imaging Findings in Young Infants With Bacteremic Urinary Tract Infection. Hospital pediatrics Chang, P. W., Abidari, J. M., Shen, M. W., Greenhow, T. L., Bendel-Stenzel, M., Roman, H. K., Biondi, E. A., Schroeder, A. R. 2016; 6 (11): 647-652

  Abstract

  To describe renal ultrasound (RUS) and voiding cystourethrogram (VCUG) findings and determine predictors of abnormal imaging in young infants with bacteremic urinary tract infection (UTI).We used retrospective data from a multicenter sample of infants younger than 3 months with bacteremic UTI, defined as the same pathogenic organism in blood and urine. Infants were excluded if they had any major comorbidities, known urologic abnormalities at time of presentation, required intensive unit care, or had no imaging performed. Imaging results as stated in the radiology reports were categorized by a pediatric urologist.Of the 276 infants, 19 were excluded. Of the remaining 257 infants, 254 underwent a RUS and 224 underwent a VCUG. Fifty-five percent had ≥1 RUS abnormalities. Thirty-four percent had ≥1 VCUG abnormalities, including vesicoureteral reflux (VUR, 27%), duplication (1.3%), and infravesicular abnormality (0.9%). Age <1 month, male sex, and non-Escherichia coli organism predicted an abnormal RUS, but only non-E coli organism predicted an abnormal VCUG. Seventeen of 96 infants (17.7%) with a normal RUS had an abnormal VCUG: 15 with VUR (Grade I-III = 13, Grade IV = 2), 2 with elevated postvoid residual, and 1 with infravesical abnormality.Although RUS and VCUG abnormalities were common in this cohort, the frequency and severity were similar to previous studies of infants with UTIs in general. Our findings do not support special consideration of bacteremia in imaging decisions for otherwise well-appearing young infants with UTI.

  View details for PubMedID 27707778

• Overuse of Medical Imaging and Its Radiation Exposure: Who's Minding Our Children? JAMA pediatrics Schroeder, A. R., Duncan, J. R. 2016; 170 (11): 1037-1038

  View details for DOI 10.1001/jamapediatrics.2016.2147

  View details for PubMedID 27654817

• Is Tradition Trumping Evidence in the Treatment of Young, Febrile Infants? Hospital pediatrics Schroeder, A. R., Roberts, K. B. 2016; 6 (4): 252-253

  View details for DOI 10.1542/hpeds.2016-0013

  View details for PubMedID 26980753

• Intranasal dexmedetomidine: an effective sedative agent for electroencephalogram and auditory brain response testing. Paediatric anaesthesia Baier, N. M., Mendez, S. S., Kimm, D., Velazquez, A. E., Schroeder, A. R. 2016; 26 (3): 280-285

  Abstract

  Dexmedetomidine is an α2 agonist with sedative, anxiolytic, and analgesic properties. The intranasal (IN) route avoids the pain of intravenous (i.v.) catheter placement but limited literature exists on the use of IN dexmedetomidine. This study examines the effectiveness and safety of IN dexmedetomidine for sedation of patients undergoing electroencephalogram (EEG) and auditory brain response (ABR) testing.This was a review of all outpatients sedated with IN dexmedetomidine for EEG or ABR between October 1, 2012 and October 1, 2014. An initial dose of 2.5-3 μg·kg(-1) IN dexmedetomidine was given with a repeat dose of 1-1.5 μg·kg(-1) IN if needed 30 min later. Prospectively entered patient information was extracted from a quality assurance database and additional information gathered via retrospective chart review.Intranasal dexmedetomidine was used in 169 patients (EEG = 117, ABR = 52). First-dose success rates were 90.4% for ABR and 87.2% for EEG. Total success rates (with one or two doses of IN dexmedetomidine) were 100% for ABR and 99.1% for EEG. The median time to onset of sleep was 25 min (IQR, 20-32 min). The median duration of sedation was 107 min (IQR, 90-131 min). Adverse events included: 18 patients (10.7%) with hypotension which resolved without intervention, six patients with oxygen desaturation <90%, two of whom received supplemental oxygen, and one patient with an underlying upper airway abnormality who was treated with continuous positive airway pressure.IN dexmedetomidine is an effective and noninvasive method of sedating children for EEG and ABR.

  View details for DOI 10.1111/pan.12851

  View details for PubMedID 26814037

• Bacteraemic urinary tract infection: management and outcomes in young infants. Archives of disease in childhood Schroeder, A. R., Shen, M. W., Biondi, E. A., Bendel-Stenzel, M., Chen, C. N., French, J., Lee, V., Evans, R. C., Jerardi, K. E., Mischler, M., Wood, K. E., Chang, P. W., Roman, H. K., Greenhow, T. L. 2016; 101 (2): 125-130

  Abstract

  To determine predictors of parenteral antibiotic duration and the association between parenteral treatment duration and relapses in infants <3 months with bacteraemic urinary tract infection (UTI).Multicentre retrospective cohort study.Eleven healthcare institutions across the USA.Infants <3 months of age with bacteraemic UTI, defined as the same pathogenic organism isolated from blood and urine.Duration of parenteral antibiotic therapy, relapsed UTI within 30 days.The mean (±SD) duration of parenteral antibiotics for the 251 included infants was 7.8 days (±4 days), with considerable variability between institutions (mean range 5.5-12 days). Independent predictors of the duration of parenteral antibiotic therapy included (coefficient, 95% CI): age (-0.2 days, -0.3 days to -0.08 days, for each week older), year treated (-0.2 days, -0.4 to -0.03 days for each subsequent calendar year), male gender (0.9 days, 0.01 to 1.8 days), a positive repeat blood culture during acute treatment (3.5 days, 1.2-5.9 days) and a non-Escherichia coli organism (2.2 days, 0.8-3.6 days). No infants had a relapsed bacteraemic UTI. Six infants (2.4%) had a relapsed UTI (without bacteraemia). The duration of parenteral antibiotics did not differ between infants with and without a relapse (8.2 vs 7.8 days, p=0.81).Parenteral antibiotic treatment duration in young infants with bacteraemic UTI was variable and only minimally explained by measurable patient factors. Relapses were rare and were not associated with treatment duration. Shorter parenteral courses may be appropriate in some infants.

  View details for DOI 10.1136/archdischild-2014-307997

  View details for PubMedID 26177657

• Detection of abnormalities is not synonymous with patient benefit. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne Coon, E. R., Schroeder, A. R. 2016; 188 (1): 63-?

  View details for DOI 10.1503/cmaj.1150077

  View details for PubMedID 26729485

• Lipid Screening in Children: Low-Value Care. JAMA internal medicine Newman, T. B., Schroeder, A. R., Pletcher, M. J. 2016

  View details for PubMedID 27533131

• Doing More vs Doing Good Aligning Our Ethical Principles From the Personal to the Societal JAMA PEDIATRICS Ralston, S. L., Schroeder, A. R. 2015; 169 (12): 1085-1086

  View details for DOI 10.1001/jamapediatrics.2015.2702

  View details for Web of Science ID 000366334600006

  View details for PubMedID 26502277

• Association Between Hyponatremia and Higher Bronchiolitis Severity Among Children in the ICU With Bronchiolitis. Hospital pediatrics Hasegawa, K., Stevenson, M. D., Mansbach, J. M., Schroeder, A. R., Sullivan, A. F., Espinola, J. A., Piedra, P. A., Camargo, C. A. 2015; 5 (7): 385-389

  Abstract

  It remains unclear whether hyponatremia independently predicts a higher severity of bronchiolitis in children. The objective of this study was to investigate the association between hyponatremia and bronchiolitis severity in children hospitalized in the ICU for bronchiolitis.We conducted a 16-center, prospective cohort study of hospitalized children aged <2 years with bronchiolitis during the winters of 2007 through 2010. Patients were classified into 2 groups (normonatremic [135-145 mEq/L] and hyponatremic [<135 mEq/L]) based on the first-measured serum sodium concentration on the day of hospitalization. Outcomes were use of mechanical ventilation and ICU length of stay (LOS). To examine the association of sodium status with outcomes, we fit logistic and linear regression models with propensity score adjustment.Of 231 children hospitalized in the ICU for bronchiolitis, 193 (84%) were categorized into the normonatremic group and 38 (16%) into the hyponatremic group. Compared with children with normonatremia, those with hyponatremia had higher risks of mechanical ventilation use (40% vs 58%; P = .04) and longer ICU LOS (median, 3 vs 6 days; P = .007). Likewise, in the adjusted analyses, children with hyponatremia had significantly higher risks of mechanical ventilation use (odds ratio, 2.14 [95% confidence interval, 1.03-4.48; P = .04) and longer ICU LOS (β-coefficient, 2.21 days [95% confidence interval, 0.68-3.73; P = .005]).In this prospective, multicenter study of children hospitalized for bronchiolitis, hyponatremia on the day of hospitalization was associated with a higher severity of disease. Our data support hyponatremia as a prognostic factor that might improve the ability of clinicians to predict the disease course of children with severe bronchiolitis.

  View details for DOI 10.1542/hpeds.2015-0022

  View details for PubMedID 26136313

• Diagnostic Accuracy of the Urinalysis for Urinary Tract Infection in Infants < 3 Months of Age PEDIATRICS Schroeder, A. R., Chang, P. W., Shen, M. W., Biondi, E. A., Greenhow, T. L. 2015; 135 (6): 965-971

  Abstract

  The 2011 American Academy of Pediatrics urinary tract infection (UTI) guideline suggests incorporation of a positive urinalysis (UA) into the definition of UTI. However, concerns linger over UA sensitivity in young infants. Infants with the same pathogenic organism in the blood and urine (bacteremic UTI) have true infections and represent a desirable population for examination of UA sensitivity.We collected UA results on a cross-sectional sample of 276 infants <3 months of age with bacteremic UTI from 11 hospital systems. Sensitivity was calculated on infants who had at least a partial UA performed and had ≥50 000 colony-forming units per milliliter from the urine culture. Specificity was determined by using a random sample of infants from the central study site with negative urine cultures.The final sample included 245 infants with bacteremic UTI and 115 infants with negative urine cultures. The sensitivity of leukocyte esterase was 97.6% (95% confidence interval [CI] 94.5%-99.2%) and of pyuria (>3 white blood cells/high-power field) was 96% (95% CI 92.5%-98.1%). Only 1 infant with bacteremic UTI (Group B Streptococcus) and a complete UA had an entirely negative UA. In infants with negative urine cultures, leukocyte esterase specificity was 93.9% (95% CI 87.9 - 97.5) and of pyuria was 91.3% (84.6%-95.6%).In young infants with bacteremic UTI, UA sensitivity is higher than previous reports in infants with UTI in general. This finding can be explained by spectrum bias or by inclusion of faulty gold standards (contaminants or asymptomatic bacteriuria) in previous studies.

  View details for DOI 10.1542/peds.2015-0012

  View details for PubMedID 26009628

• Safely Doing Less and the New AAP Bronchiolitis Guideline PEDIATRICS Quinonez, R. A., Schroeder, A. R. 2015; 135 (5): 793-795

  View details for DOI 10.1542/peds.2014-3703

  View details for PubMedID 25847807

• Hospital Course and Discharge Criteria for Children Hospitalized With Bronchiolitis JOURNAL OF HOSPITAL MEDICINE Mansbach, J. M., Clark, S., Piedra, P. A., Macias, C. G., Schroeder, A. R., Pate, B. M., Sullivan, A. F., Espinola, J. A., Camargo, C. A. 2015; 10 (4): 205-211

  Abstract

  For children hospitalized with bronchiolitis, there is uncertainty about the expected inpatient clinical course and when children are safe for discharge.Examine the time to clinical improvement, risk of clinical worsening after improvement, and develop discharge criteria.Prospective multiyear cohort study.Sixteen US hospitals.Consecutive hospitalized children age <2 years with bronchiolitis.We defined clinical improvement using: (1) retraction severity, (2) respiratory rate, (3) room air oxygen saturation, and (4) hydration status. After meeting improvement criteria, children were considered clinically worse based on the inverse of ≥1 of these criteria or need for intensive care.Among 1916 children, the median number of days from onset of difficulty breathing until clinical improvement was 4 (interquartile range, 3-7.5 days). Of the total, 1702 (88%) met clinical improvement criteria, with 4% worsening (3% required intensive care). Children who worsened were age <2 months (adjusted odds ratio [AOR]: 3.51; 95% confidence interval [CI]: 2.07-5.94), gestational age <37 weeks (AOR: 1.94; 95% CI: 1.13-3.32), and presented with severe retractions (AOR: 5.55; 95% CI: 2.12-14.50), inadequate oral intake (AOR: 2.54; 95% CI: 1.39-4.62), or apnea (AOR: 2.87; 95% CI: 1.45-5.68). Readmissions were similar for children who did and did not worsen.Although children hospitalized with bronchiolitis had wide-ranging recovery times, only 4% worsened after initial improvement. Children who worsened were more likely to be younger, premature infants presenting in more severe distress. For children hospitalized with bronchiolitis, these data may help establish more evidence-based discharge criteria, reduce practice variability, and safely shorten hospital length-of-stay.

  View details for DOI 10.1002/jhm.2318

  View details for Web of Science ID 000352631400001

  View details for PubMedID 25627657

• Diagnosis and management of bacteremic urinary tract infection in infants. Hospital pediatrics Roman, H. K., Chang, P. W., Schroeder, A. R. 2015; 5 (1): 1-8

  Abstract

  To report the prevalence of bacteremia by age in a sample of infants<1 year of age with urinary tract infections (UTIs), to compare characteristics of infants with UTIs with and without bacteremia, and to describe treatment courses and 30-day outcomes in infants with UTIs with and without bacteremia.We used a retrospective cross-sectional design to determine the prevalence of bacteremia in infants with UTIs at our institution. A double cohort design matching for age and gender was used to compare clinical characteristics and outcomes between infants with bacteremic versus nonbacteremic UTIs.We identified 1379 UTIs, with blood cultures obtained in 52% of cases. The prevalence of bacteremia was 4.1% (95% confidence interval 3.1%-5.3%) for all UTIs and 8% (95% confidence interval 6.1%-10.2%) for UTIs in which blood culture was obtained. Fifty-five infants with bacteremic UTIs were compared with 110 infants with nonbacteremic UTIs. Except for minor differences in the urinalysis and serum band count, there were no significant differences in clinical presentation between the 2 groups. Bacteremic infants received longer parenteral treatment courses than nonbacteremic infants (mean 6.7 vs 2.4 days, P<.001). Treatment courses in the bacteremic group were variable and predicted by age but not severity of illness. No bacteremic infant had recurrent UTI or bacteremia with the same organism within 30 days of discharge.Treatment was variable but outcomes were excellent in infants with bacteremic UTIs.

  View details for DOI 10.1542/hpeds.2014-0051

  View details for PubMedID 25554753

• Overdiagnosis: How Our Compulsion for Diagnosis May Be Harming Children PEDIATRICS Coon, E. R., Quinonez, R. A., Moyer, V. A., Schroeder, A. R. 2014; 134 (5): 1013-1023

  Abstract

  Overdiagnosis occurs when a true abnormality is discovered, but detection of that abnormality does not benefit the patient. It should be distinguished from misdiagnosis, in which the diagnosis is inaccurate, and it is not synonymous with overtreatment or overuse, in which excess medication or procedures are provided to patients for both correct and incorrect diagnoses. Overdiagnosis for adult conditions has gained a great deal of recognition over the last few years, led by realizations that certain screening initiatives, such as those for breast and prostate cancer, may be harming the very people they were designed to protect. In the fall of 2014, the second international Preventing Overdiagnosis Conference will be held, and the British Medical Journal will produce an overdiagnosis-themed journal issue. However, overdiagnosis in children has been less well described. This special article seeks to raise awareness of the possibility of overdiagnosis in pediatrics, suggesting that overdiagnosis may affect commonly diagnosed conditions such as attention-deficit/hyperactivity disorder, bacteremia, food allergy, hyperbilirubinemia, obstructive sleep apnea, and urinary tract infection. Through these and other examples, we discuss why overdiagnosis occurs and how it may be harming children. Additionally, we consider research and education strategies, with the goal to better elucidate pediatric overdiagnosis and mitigate its influence.

  View details for DOI 10.1542/peds.2014-1778

  View details for Web of Science ID 000344385900051

  View details for PubMedID 25287462

• Palliative care is critical to the changing face of child mortality and morbidity in the United States. Clinical pediatrics Bogetz, J. F., Schroeder, A. R., Bergman, D. A., Cohen, H. J., Sourkes, B. 2014; 53 (11): 1030-1031

  View details for DOI 10.1177/0009922814534767

  View details for PubMedID 24817074

• Intravenous Antibiotic Durations for Common Bacterial Infections in Children: When is Enough Enough? JOURNAL OF HOSPITAL MEDICINE Schroeder, A. R., Ralston, S. L. 2014; 9 (9): 604-609

  Abstract

  Durations of intravenous antibiotic therapy for bacterial infections in hospitalized children sometimes extend well beyond clinical recovery and are often the primary determinants of length of stay. These durations, however, are not always based on solid evidence. Moreover, fixed durations are invariant to important individual factors. We review guidelines and the available evidence for durations of intravenous antibiotic therapy for meningitis, bacteremia, urinary tract infection, and osteomyelitis, conditions where intravenous antibiotics often extend beyond resolution of clinical symptoms. We propose a framework for the duration of therapy that is intended to serve as a guide when standards of care are either nonexistent, dated, conflicting, or contrary to evidence from published studies. This framework incorporates patient-centered factors such as severity of infection, response to therapy, ease of intravenous access, harms and costs of ongoing intravenous treatment, and family preferences.

  View details for DOI 10.1002/jhm.2239

  View details for Web of Science ID 000342679100010

  View details for PubMedID 25044445

• Recent evidence on the management of bronchiolitis CURRENT OPINION IN PEDIATRICS Schroeder, A. R., Mansbach, J. M. 2014; 26 (3): 328-333

  Abstract

  Bronchiolitis is a common condition in children less than 2  years of age and is a leading cause of infant hospitalization. Although there is significant variability in testing and treatment of children with bronchiolitis, diagnostic testing rarely improves care, and no currently available pharmacologic options have been proven to provide meaningful benefits or improve outcomes.Beta-agonists continue to be used frequently despite evidence that they do not reduce hospital admissions or length of stay. In general, therapies initially considered promising were subsequently proven ineffective, a pattern seen in studies on corticosteroids, and more recently with nebulized racemic epinephrine and hypertonic saline. Recent research has improved our understanding of the viral epidemiology of bronchiolitis, with increasing recognition of viruses other than respiratory syncytial virus and better awareness of the role of viral coinfections. How these findings will translate into improved outcomes remains uncertain.Much of the emphasis of the last few decades of bronchiolitis clinical care and research has centered on the identification and testing of novel therapies. Future quality improvement efforts should focus more on the limitation of unnecessary testing and treatments. Future research should include identification of subgroups of children with bronchiolitis that may benefit from focused clinical interventions.

  View details for DOI 10.1097/MOP.0000000000000090

  View details for Web of Science ID 000335956800011

  View details for PubMedID 24739493

• The never-ending quest to detect bacteremia: time for a culture change. Hospital pediatrics Schroeder, A. R. 2014; 4 (2): 85-87

  View details for DOI 10.1542/hpeds.2013-0122

  View details for PubMedID 24584977

• Apnea in Children Hospitalized With Bronchiolitis PEDIATRICS Schroeder, A. R., Mansbach, J. M., Stevenson, M., Macias, C. G., Fisher, E. S., Barcega, B., Sullivan, A. F., Espinola, J. A., Piedra, P. A., Camargo, C. A. 2013; 132 (5): E1194-E1201

  Abstract

  To identify risk factors for inpatient apnea among children hospitalized with bronchiolitis.We enrolled 2207 children, aged <2 years, hospitalized with bronchiolitis at 16 sites during the winters of 2007 to 2010. Nasopharyngeal aspirates (NPAs) were obtained on all subjects, and real-time polymerase chain reaction was used to test NPA samples for 16 viruses. Inpatient apnea was ascertained by daily chart review, with outcome data in 2156 children (98%). Age was corrected for birth <37 weeks. Multivariable logistic regression was performed to identify independent risk factors for inpatient apnea.Inpatient apnea was identified in 108 children (5%, 95% confidence interval [CI] 4%-6%). Statistically significant, independent predictors of inpatient apnea included: corrected ages of <2 weeks (odds ratio [OR] 9.67) and 2 to 8 weeks (OR 4.72), compared with age ≥ 6 months; birth weight <2.3 kg (5 pounds; OR 2.15), compared with ≥ 3.2 kg (7 pounds); caretaker report of previous apnea during this bronchiolitis episode (OR 3.63); preadmission respiratory rates of <30 (OR 4.05), 30 to 39 (OR 2.35) and >70 (OR 2.26), compared with 40 to 49; and having a preadmission room air oxygen saturation <90% (OR 1.60). Apnea risk was similar across the major viral pathogens.In this prospective, multicenter study of children hospitalized with bronchiolitis, inpatient apnea was associated with younger corrected age, lower birth weight, history of apnea, and preadmission clinical factors including low or high respiratory rates and low room air oxygen saturation. Several bronchiolitis pathogens were associated with apnea, with similar apnea risk across the major viral pathogens.

  View details for DOI 10.1542/peds.2013-1501

  View details for Web of Science ID 000326475000010

  View details for PubMedID 24101759

• Ruling out bacteremia and bacterial meningitis in infants less than one month of age: is 48 hours of hospitalization necessary? Hospital pediatrics Fielding-Singh, V., Hong, D. K., Harris, S. J., Hamilton, J. R., Schroeder, A. R. 2013; 3 (4): 355-361

  Abstract

  The appropriate duration of hospitalization for infants ≤ 30 days admitted for fever or other concerns for a serious bacterial infection is an understudied area. We sought to determine the risk of a positive, pathogenic bacterial culture of blood or cerebrospinal fluid (CSF) in this population beyond 24 hours after collection.This study was a retrospective review of 1145 infants aged ≤30 days who had a blood or CSF culture from 1999 to 2010 at Santa Clara Valley Medical Center, a county health system in San Jose, California. Time to notification and the probability of a positive culture result after 24 hours were calculated. Infants were considered high risk if they had either a white blood cell count <5000 or >15 000 per µL, a band count >1500 per µL, or an abnormal urinalysis.We identified 1876 cultures (1244 blood, 632 CSF) in 1145 infants aged ≤30 days; 901 (79%) of 1145 were hospitalized and 408 (45%) of 901 hospitalizations were for fever without source (FWS). Thirty-one (2.7%) of the 1145 infants had pathogenic cultures; 6 of 1145 infants (0.5% [95% confidence interval: 0.2-1.1]) had a time to notification >24 hours. All 6 patients had FWS (1.5% of hospitalized FWS sample) and met high-risk criteria on presentation. No low-risk patients had a time to notification >24 hours. Low-risk characteristics were found in 57% (232 of 408) of the entire hospitalized FWS population.Low-risk infants hospitalized for FWS or other concerns for serious bacterial infection may not need hospitalization for a full 48 hours simply to rule out bacteremia and bacterial meningitis.

  View details for DOI 10.1542/hpeds.2013-0009

  View details for PubMedID 24435193

• Choosing wisely in pediatric hospital medicine: Five opportunities for improved healthcare value JOURNAL OF HOSPITAL MEDICINE Quinonez, R. A., Garber, M. D., Schroeder, A. R., Alverson, B. K., Nickel, W., Goldstein, J., Bennett, J. S., Fine, B. R., Hartzog, T. H., McLean, H. S., Mittal, V., Pappas, R. M., Percelay, J. M., Phillips, S. C., Shen, M., Ralston, S. L. 2013; 8 (9): 479-485

  Abstract

  Despite estimates that waste constitutes up to 20% of healthcare expenditures in the United States, overuse of tests and therapies is significantly under-recognized in medicine, particularly in pediatrics. The American Board of Internal Medicine Foundation developed the Choosing Wisely campaign, which challenged medical societies to develop a list of 5 things physicians and patients should question. The Society of Hospital Medicine (SHM) joined this effort in the spring of 2012. This report provides the pediatric work group's results.A work group of experienced and geographically dispersed pediatric hospitalists was convened by the Quality and Safety Committee of the SHM. This group developed an initial list of 20 recommendations, which was pared down through a modified Delphi process to the final 5 listed below.The top 5 recommendations proposed for pediatric hospital medicine are: (1) Do not order chest radiographs in children with asthma or bronchiolitis. (2) Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection. (3) Do not use bronchodilators in children with bronchiolitis. (4) Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy. (5) Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.We recommend that pediatric hospitalists use this list to prioritize quality improvement efforts and include issues of waste and overuse in their efforts to improve patient care.

  View details for DOI 10.1002/jhm.2064

  View details for Web of Science ID 000324022200001

  View details for PubMedID 23955837

• The Harm in Looking JAMA PEDIATRICS Schroeder, A. R., Redberg, R. F. 2013; 167 (8): 693-695

  View details for DOI 10.1001/jamapediatrics.2013.356

  View details for Web of Science ID 000323551200003

  View details for PubMedID 23753832

• Fever Literacy and Fever Phobia CLINICAL PEDIATRICS Wallenstein, M. B., Schroeder, A. R., Hole, M. K., Ryan, C., Fijalkowski, N., Alvarez, E., Carmichael, S. L. 2013; 52 (3): 254-259

  Abstract

  To identify the percentage of parents who define the threshold for fever between 38.0°C and 38.3°C, which has not been reported previously, and to describe parental attitudes toward fever and antipyretic use.Thirteen-question survey study of caregivers.Overall, 81% of participants defined the threshold for fever as <38.0°C, 0% correctly defined fever between 38.0°C and 38.3°C, and 19% defined fever as >38.3°C. Twenty percent of children brought to clinic for a chief complaint of fever were never truly febrile. Ninety-three percent of participants believed that high fever can cause brain damage. For a comfortable-appearing child with fever, 89% of caregivers reported that they would give antipyretics and 86% would schedule a clinic visit.Our finding that 0% of parents correctly defined fever is both surprising and unsettling, and it should inform future discussions of fever between parents and clinicians.

  View details for DOI 10.1177/0009922812472252

  View details for Web of Science ID 000317849900007

  View details for PubMedID 23349363

• Utility of Clinical and Radiographic Findings in the Management of Traumatic Epidural Hematoma PEDIATRIC NEUROSURGERY Flaherty, B. F., Loya, J., Alexander, M. D., Pandit, R., Ha, B. Y., Torres, R. A., Schroeder, A. R. 2013; 49 (4): 208-214

  Abstract

  There are currently no clear guidelines for the management and radiological monitoring of pediatric patients with epidural hematomas (EDH). We aim to compare clinical and radiographic characteristics of pediatric EDH patients managed with observation alone versus surgical evacuation and to describe results of repeat head imaging in both groups.We performed a retrospective observational study of pediatric patients diagnosed with traumatic EDH at a level II trauma center.Forty-seven cases of EDH were analyzed. Sixty-two percent were managed by observation alone. Patients undergoing surgery were more likely to have an altered mental status (17 vs. 72%, p < 0.001), but there were no other significant clinical differences between the groups. The mean initial EDH thickness and volume were 8.0 mm and 8.6 ml in the observed group and 15.5 mm and 35 ml in the surgery group, respectively (p < 0.001 for both comparisons). Eighty-six percent of the observed and all surgery patients underwent repeat CT imaging. The initial repeat CT scan results led to surgery in 1 patient who was initially treated with observation.Most pediatric patients with EDH can be managed with observation. Mental status and radiographic findings should guide the need for surgical intervention. Multiple repeat CT scans have minimal utility in changing management.

  View details for DOI 10.1159/000363143

  View details for Web of Science ID 000342731700003

• Saving a Life After Discharge: CPR Training for Parents of High-Risk Children JOURNAL FOR HEALTHCARE QUALITY Knight, L. J., Wintch, S., Nichols, A., Arnolde, V., Schroeder, A. R. 2013; 35 (1): 9-17

  Abstract

  Pediatric patients with chronic disease are at risk for cardiopulmonary arrest (CPA). Outcomes of CPA are improved if prompt quality cardiopulmonary resuscitation (CPR) is performed. This study examined the efficacy of the CPR Anytime™ Kit as a standardized method of CPR discharge training to families of high-risk children. The kit was provided to parents of 117 high-risk pediatric patients prior to hospital discharge. A telephone survey was used at 1, 3, and 6 months to assess retention of CPR knowledge and skills, parental comfort levels with CPR, and kit dissemination to family members. A second survey was used 1 year after implementation of program to assess nursing satisfaction. CPR comfort levels were reported as confident, knowledge and skills were reported as moderate on follow-up telephone surveys. A total of 82% of subjects reviewed the video at least once after discharge, and 79% of subjects shared the kit with at least two other family members or friends. A total of 72 of 74 nurses (97% ) surveyed were either "satisfied" or "very satisfied" with the program. Provision of the CPR Anytime Kit™ to families of high-risk pediatric patients prior to discharge leads to sustained levels of CPR knowledge and confidence.

  View details for DOI 10.1111/j.1945-1474.2012.00221.x

  View details for Web of Science ID 000209221500001

• Cholesterol Screening and Management in Children and Young Adults Should Start Early - NO! CLINICAL CARDIOLOGY Schroeder, A. R., Redberg, R. F. 2012; 35 (11): 665-668

  Abstract

  In 2011, an expert panel from the National Heart, Lung, and Blood Institute released recommendations for universal lipid screening and treatment of high cholesterol in children. There is no evidence that universal screening will help children lead longer, healthier lives. These recommendations will, however, fuel the epidemic of overtreatment that is currently threatening our healthcare system and our patients.

  View details for DOI 10.1002/clc.22075

  View details for Web of Science ID 000311103200008

  View details for PubMedID 23161509

• Safely Doing Less: A Missing Component of the Patient Safety Dialogue PEDIATRICS Schroeder, A. R., Harris, S. J., Newman, T. B. 2011; 128 (6): E1596-E1597

  View details for DOI 10.1542/peds.2011-2726

  View details for Web of Science ID 000298131400026

  View details for PubMedID 22123887

• Impact of a More Restrictive Approach to Urinary Tract Imaging After Febrile Urinary Tract Infection ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Schroeder, A. R., Abidari, J. M., Kirpekar, R., Hamilton, J. R., Kang, Y. S., VyThao Tran, V., Harris, S. J. 2011; 165 (11): 1027-1032

  Abstract

  To determine the impact of using an algorithm requiring selective rather than routine urinary tract imaging following a first febrile urinary tract infection (UTI) on imaging use, detection of vesicoureteral reflux (VUR), prophylactic antibiotic use, and UTI recurrence within 6 months.Retrospective review comparing outcomes during periods before algorithm use (September 1, 2006, to August 31, 2007) and after algorithm use (September 1, 2008, to August 31, 2009). The new algorithm, which adapted recommendations from the United Kingdom's National Institute for Health and Clinical Excellence 2007 guidelines, was implemented in 2008. The algorithm calls for renal ultrasonography in most cases and restricts voiding cystourethrography for use in patients with certain risk factors.County health system.Children younger than 2 years with a first febrile UTI.Selective algorithm for urinary tract imaging.Urinary tract imaging use, detection of VUR, prophylactic antibiotic use, and UTI recurrence within 6 months.After introduction of the new algorithm, voiding cystourethrography and prophylactic antibiotic use decreased markedly. Rates of UTI recurrence within 6 months and detection of grades 4 and 5 VUR did not change, but detection of grades 1 to 3 VUR decreased substantially. Patients in the prealgorithm group with grades 1 to 3 VUR who would have been missed with selective screening underwent no interventions other than successive urinary tract imaging and prophylactic antibiotic use.By restricting urinary tract imaging after an initial febrile UTI, rates of voiding cystourethrography and prophylactic antibiotic use decreased substantially without increasing the risk of UTI recurrence within 6 months and without an apparent decrease in detection of high-grade VUR. Clinicians can be more judicious in their use of urinary tract imaging.

  View details for Web of Science ID 000296656500010

  View details for PubMedID 22065183

• A continuous heparin infusion does not prevent catheter-related thrombosis in infants after cardiac surgery PEDIATRIC CRITICAL CARE MEDICINE Schroeder, A. R., Axelrod, D. M., Silverman, N. H., Rubesova, E., Merkel, E., Roth, S. J. 2010; 11 (4): 489-495

  Abstract

  To determine whether a continuous infusion of heparin reduces the rate of catheter-related thrombosis in neonates and infants post cardiac surgery. Central venous and intracardiac catheters are used routinely in postoperative pediatric cardiac patients. Catheter-related thrombosis occurs in 8% to 45% of pediatric patients with central venous catheters.Single-center, randomized, placebo-controlled, double-blinded trial.Cardiovascular intensive care unit, university-affiliated children's hospital.Children <1 yr of age recovering from cardiac surgery.Patients were randomized to receive either continuous heparin at 10 units/kg/hr or placebo. The primary end point was catheter-related thrombosis as assessed by serial ultrasonography.Study enrollment was discontinued early based on results from an interim futility analysis. Ninety subjects were enrolled and received the study drug (heparin, 53; placebo, 37). The catheter-related thrombosis rate in the heparin group, compared with the placebo group, was 15% vs. 16% (p = .89). Subjects in the heparin group had a higher mean partial thromboplastin time (52 secs vs. 42 secs, p = .001), and this difference was greater for those aged <30 days (64 secs vs. 43 secs, p = .008). Catheters in place > or = 7 days had both a greater risk of thrombus formation (odds ratio, 4.3; p = .02) and catheter malfunction (odds ratio, 11.2; p = .008). We observed no significant differences in other outcome measures or in the frequency of adverse events.A continuous infusion of heparin at 10 units/kg/hr was safe but did not reduce catheter-related thrombus formation. Heparin at this dose caused an increase in partial thromboplastin time values, which, unexpectedly, was more pronounced in neonates.

  View details for DOI 10.1097/PCC.0b013e3181ce6e29

  View details for PubMedID 20101197

• Heparin and catheter-related thrombosis in infants following cardiac surgery: Interim results from a randomized trial 80th Annual Scientific Session of the American-Heart-Association (AHA) Schroeder, A. R., Silverman, N., Axelrod, D. M., Merkel, E., Roth, S. J., Packard, L. LIPPINCOTT WILLIAMS & WILKINS. 2007: 515–15

  View details for Web of Science ID 000250394302357

• Choice of urine collection methods for the diagnosis of urinary tract infection in young, febrile infants Annual Meeting of the Pediatric-Academic-Societies Schroeder, A. R., Newman, T. B., Wasserman, R. C., Finch, S. A., Pantell, R. H. AMER MEDICAL ASSOC. 2005: 915–22

  Abstract

  The optimal method of urine collection in febrile infants is debatable; catheterization, considered more accurate, is technically difficult and invasive.To determine predictors of urethral catheterization in febrile infants and to compare bag and catheterized urine test performance characteristics.Prospective analysis of infants enrolled in the Pediatric Research in Office Settings' Febrile Infant Study.A total of 219 practices from within the Pediatric Research in Office Settings' network, including 44 states, the District of Columbia, and Puerto Rico.A total of 3066 infants aged 0 to 3 months with temperatures of 38 degrees C or higher.We calculated adjusted odds ratios for predictors of catheterization. Diagnostic test characteristics were compared between bag and catheterization. Urinary tract infection was defined as pure growth of 100 000 CFU/mL or more (bag) and 20 000 CFU/mL or more (catheterization).Seventy percent of urine samples were obtained by catheterization. Predictors of catheterization included female sex, practitioner older than 40 years, Medicaid, Hispanic ethnicity, nighttime evaluation, and severe dehydration. For leukocyte esterase levels, bag specimens demonstrated no difference in sensitivity but somewhat lower specificity (84% [bag] vs 94% [catheterization], P<.001) and a lower area under the receiver operating characteristic curve for white blood cells (0.71 [bag] vs 0.86 [catheterization], P = .01). Infection rates were similar in bag and catheterized specimens (8.5% vs 10.8%). Ambiguous cultures were more common in bag specimens (7.4% vs 2.7%, P<.001), but 21 catheterized specimens are needed to avoid each ambiguous bag result.Most practitioners obtain urine from febrile infants via catheterization, but choice of method is not related to the risk of urinary tract infection. Although both urine cultures and urinalyses are more accurate in catheterized specimens, the magnitude of difference is small but should be factored into clinical decision making.

  View details for Web of Science ID 000232322000002

  View details for PubMedID 16203935

• Prolonged infusion of dexmedetomidine for sedation following tracheal resection PEDIATRIC ANESTHESIA Hammer, G. B., Philip, B. M., Schroeder, A. R., Rosen, F. S., Koltai, P. J. 2005; 15 (7): 616-620

  Abstract

  Dexmedetomidine is a centrally acting alpha-2 adrenergic agonist that is currently approved by the US Food and Drug Administration for short-term use (< or = 24 h) to provide sedation in adults in the ICU. This drug has been shown to be efficacious in adult medical and surgical patients in providing sedation, anxiolysis, and analgesia. Dexmedetomidine has been associated with rapid onset and offset, hemodynamic stability, and a natural, sleep-like state in mechanically ventilated adults. To date, there are few publications of the use of this drug in children, and prolonged infusion has not been described. We report our use of dexmedetomidine in a child during a 4-day period of mechanical ventilation following tracheal reconstruction for subglottic stenosis.

  View details for DOI 10.1111/j.1460-9592.2005.01656.x

  View details for PubMedID 15960649

• Impact of pulse oximetry and oxygen therapy on length of stay in bronchiolitis hospitalizations 40th State-of-the-Art Program on Compound Semiconductors (SOTAPOCS XL)/2nd Narrow Bandgap Optoelectronic Materials and Devices Symposium Schroeder, A. R., Marmor, A. K., PANTELL, R. H., Newman, T. B. AMER MEDICAL ASSOC. 2004: 527–30

  Abstract

  Infants hospitalized with bronchiolitis are frequently monitored with a pulse oximeter. However, there is little consensus on an acceptable lower limit of oxygenation. No previous studies have examined how the use of pulse oximetry and supplemental oxygen therapy affects length of stay.To determine the extent to which bronchiolitis hospitalizations are prolonged by a perceived need for supplemental oxygen based on pulse oximetry readings. Design and Patients Retrospective case series of subjects younger than 2 years who were hospitalized with bronchiolitis at an academic medical center. Two investigators independently reviewed the hospitalization records of 73 infants and determined at what point an infant met all discharge criteria except oxygenation. We then calculated the extent to which hospitalizations were prolonged by a perceived need for supplemental oxygen therapy based on pulse oximetry readings alone.Sixty-two infants met inclusion criteria. There was high interrater reliability in determining whether hospitalizations were prolonged (kappa = 0.75). In 16 (26%) of 62 patients (95% confidence interval, 15%-37%), the hospitalization was prolonged because of oxygenation concerns. Length of stay was prolonged an average of 1.6 days (range, 1.1-2.0 days) per hospitalization for these 16 patients, or 0.4 day (range, 0.2-0.6 day) per hospitalization for all 62 patients.Hospitalizations of some infants with bronchiolitis are prolonged by a perceived need for supplemental oxygen therapy based on pulse oximetry readings. Further investigation into outcomes of different levels and durations of oxygen desaturation is needed and would have the potential to reduce practice variability and shorten the length of stay.

  View details for Web of Science ID 000221827700004

  View details for PubMedID 15184214

• Pulse oximetry in bronchiolitis patients PEDIATRICS Schroeder, A. R., Marmor, A., Newman, T. B. 2003; 112 (6): 1463-1463

  View details for Web of Science ID 000186957500059

  View details for PubMedID 14654639