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Importance Delayed diagnosis of appendicitis is associated with worse outcomes than timely diagnosis, but clinical features associated with diagnostic delay are uncertain, and the extent to which delays are preventable is unclear. Objective To determine clinical features associated with delayed diagnosis of pediatric appendicitis, assess the frequency of preventable delay, and compare delay outcomes. Design, setting, and participants This case-control study included 748 children treated at 5 pediatric emergency departments in the US between January 1, 2010, and December 31, 2019. Participants were younger than 21 years and had a diagnosis of appendicitis. Exposures Individual features of appendicitis and pretest likelihood of appendicitis were measured by the Pediatric Appendicitis Risk Calculator (pARC). Main outcomes and measures Case patients had a delayed diagnosis of appendicitis, defined as 2 emergency department visits leading to diagnosis and a case review showing the patient likely had appendicitis at the first visit. Control patients had a single emergency department visit yielding a diagnosis. Clinical features and pARC scores were compared by case-control status. Preventability of delay was assessed as unlikely, possible, or likely. The proportion of children with indicated imaging based on an evidence-based cost-effectiveness threshold was determined. Outcomes of delayed diagnosis were compared by case-control status, including hospital length of stay, perforation, and multiple surgical procedures. Results A total of 748 children (mean [SD] age, 10.2 [4.3] years; 392 boys [52.4%]; 427 White children [57.1%]) were included in the study; 471 (63.0%) had a delayed diagnosis of appendicitis, and 277 (37.0%) had no delay in diagnosis. Children with a delayed diagnosis were less likely to have pain with walking (adjusted odds ratio [aOR], 0.16; 95% CI, 0.10-0.25), maximal pain in the right lower quadrant (aOR, 0.12; 95% CI, 0.07-0.19), and abdominal guarding (aOR, 0.33; 95% CI, 0.21-0.51), and were more likely to have a complex chronic condition (aOR, 2.34; 95% CI, 1.05-5.23). The pretest likelihood of appendicitis was 39% to 52% lower in children with a delayed vs timely diagnosis. Among children with a delayed diagnosis, 109 cases (23.1%) were likely to be preventable, and 247 (52.4%) were possibly preventable. Indicated imaging was performed in 104 (22.0%) to 289 (61.3%) children with delayed diagnosis, depending on the imputation method for missing data on white blood cell count. Patients with delayed diagnosis had longer hospital length of stay (mean difference between the groups, 2.8 days; 95% CI, 2.3-3.4 days) and higher perforation rates (OR, 7.8; 95% CI, 5.5-11.3) and were more likely to undergo 2 or more surgical procedures (OR, 8.0; 95% CI, 2.0-70.4). Conclusions and relevance In this case-control study, delayed appendicitis was associated with initially milder symptoms but worse outcomes. These findings suggest that a majority of delayed diagnoses were at least possibly preventable and that many of these patients did not undergo indicated imaging, suggesting an opportunity to prevent delayed diagnosis of appendicitis in some children.

Importance The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotic use by 50% by 2020, but the extent of inappropriate outpatient antibiotic use is unknown. Objective To estimate the rates of outpatient oral antibiotic prescribing by age and diagnosis, and the estimated portions of antibiotic use that may be inappropriate in adults and children in the United States. Design, Setting, and Participants Using the 2010-2011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, annual numbers and population-adjusted rates with 95% confidence intervals of ambulatory visits with oral antibiotic prescriptions by age, region, and diagnosis in the United States were estimated. Exposures Ambulatory care visits. Main Outcomes and Measures Based on national guidelines and regional variation in prescribing, diagnosis-specific prevalence and rates of total and appropriate antibiotic prescriptions were determined. These rates were combined to calculate an estimate of the appropriate annual rate of antibiotic prescriptions per 1000 population. Results Of the 184 032 sampled visits, 12.6% of visits (95% CI, 12.0%-13.3%) resulted in antibiotic prescriptions. Sinusitis was the single diagnosis associated with the most antibiotic prescriptions per 1000 population (56 antibiotic prescriptions [95% CI, 48-64]), followed by suppurative otitis media (47 antibiotic prescriptions [95% CI, 41-54]), and pharyngitis (43 antibiotic prescriptions [95% CI, 38-49]). Collectively, acute respiratory conditions per 1000 population led to 221 antibiotic prescriptions (95% CI, 198-245) annually, but only 111 antibiotic prescriptions were estimated to be appropriate for these conditions. Per 1000 population, among all conditions and ages combined in 2010-2011, an estimated 506 antibiotic prescriptions (95% CI, 458-554) were written annually, and, of these, 353 antibiotic prescriptions were estimated to be appropriate antibiotic prescriptions. Conclusions and Relevance In the United States in 2010-2011, there was an estimated annual antibiotic prescription rate per 1000 population of 506, but only an estimated 353 antibiotic prescriptions were likely appropriate, supporting the need for establishing a goal for outpatient antibiotic stewardship.

ContextOf children with sore throat, 15% to 36% have pharyngitis caused by group A β-hemolytic streptococci (GABHS). Performance of a GABHS test prior to antibiotic prescribing is recommended for children with sore throat. Penicillin, amoxicillin, erythromycin, and first-generation cephalosporins are the recommended antibiotics for treatment of sore throat due to GABHS.ObjectivesTo measure rates of antibiotic prescribing and GABHS testing and to evaluate the association between testing and antibiotic treatment for children with sore throat.Design, Setting, and ParticipantsAnalysis of visits by children aged 3 to 17 years with sore throat to office-based physicians, hospital outpatient departments, and emergency departments in the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 1995 to 2003 (N = 4158) and of a subset of visits with GABHS testing data (n = 2797).Main Outcome MeasuresNational rates of antibiotic prescribing, prescribing of antibiotics recommended and not recommended for GABHS, and GABHS testing.ResultsPhysicians prescribed antibiotics in 53% (95% confidence interval [CI], 49%-56%) of an estimated 7.3 million annual visits for sore throat and nonrecommended antibiotics to 27% (95% CI, 24%-31%) of children who received an antibiotic. Antibiotic prescribing decreased from 66% of visits in 1995 to 54% of visits in 2003 (P = .01 for trend). This decrease was attributable to a decrease in the prescribing of recommended antibiotics (49% to 38%; P = .002). Physicians performed a GABHS test in 53% (95% CI, 48%-57%) of visits and in 51% (95% CI, 45%-57%) of visits at which an antibiotic was prescribed. GABHS testing was not associated with a lower antibiotic prescribing rate overall (48% tested vs 51% not tested; P = .40), but testing was associated with a lower antibiotic prescribing rate for children with diagnosis codes for pharyngitis, tonsillitis, and streptococcal sore throat (57% tested vs 73% not tested; P

Background Traditional primary care practice change approaches have not led to full implementation of national asthma guidelines. Objective To evaluate the effectiveness of 2 asthma care improvement strategies in primary care. Design Two-year randomized controlled clinical trial. Setting Forty-two primary care pediatric practices affiliated with 4 managed care organizations. Participants Children aged 3 to 17 years with mild to moderate persistent asthma enrolled in primary care practices affiliated with managed care organizations. Interventions Peer leader education consisted of training 1 physician per practice in asthma guidelines and peer teaching methods. Planned care combined the peer leader program with nurse-mediated organizational change through planned visits with assessments, care planning, and self-management support, in collaboration with physicians. Analyses compared each intervention with usual care. Main Outcome Measures Annualized asthma symptom days, asthma-specific functional health status (Children's Health Survey for Asthma), and frequency of brief oral steroid courses (bursts). Results Six hundred thirty-eight children completed baseline evaluations, representing 64% of those screened and eligible. Mean ± SD age was 9.4 ± 3.5 years; 60% were boys. Three hundred fifty (55%) were taking controller medication. Mean ± SD annualized asthma symptom days was 107.4 ± 122 days. Children in the peer leader arm had 6.5 fewer symptom days per year (95% confidence interval [CI], − 16.9 to 3.6), a nonsignificant difference, but had a 36% (95% CI, 11% to 54%) lower oral steroid burst rate per year compared with children receiving usual care. Children in the planned care arm had 13.3 (95% CI, − 24.7 to −2.1) fewer symptom days annually (−12% from baseline; P = .02) and a 39% (95% CI, 11% to 58%) lower oral steroid burst rate per year relative to usual care. Both interventions showed small, statistically significant effects for 2 of 5 Children's Health Survey for Asthma scales. Planned care subjects had greater controller adherence (parent report) compared with usual care subjects (rate ratio, 1.05 [95% CI, 1.00 to 1.09]). Conclusions Planned care (nurse-mediated organizational change plus peer leader education) is an effective model for improving asthma care in the primary care setting. Peer leader education on its own may also serve as a useful model for improving asthma care, although it is less comprehensive and the treatment effect less pronounced.

Children with persistent asthma underuse controller medications and overuse relievers. A better understanding of the appropriateness of regimens, medication adherence, and adequacy of asthma control is needed.To describe use of asthma medications and disease burden in children with persistent asthma, to determine whether use of controllers and relievers is consistent with national guidelines, and to estimate adequacy of asthma control.Cross-sectional cohort study.Forty-two primary care practices participating in 3 regions of the United States.Parents of 638 children aged 3 to 15 years with asthma.Asthma symptom-days, use of reliever and controller medications, and adequacy of asthma control, ascertained by face-to-face questionnaire.The mean age was 9.4 years, and 59.9% were boys. In the preceding 2 weeks, two thirds (67.5%) of subjects had 0 to 4 symptom-days, 15.8% had 5 to 9 symptom-days, and 16.6% had 10 to 14 symptom-days (percentages do not total 100 because of rounding). One third (32.6%) of children using relievers had high levels of use. One third (34.3%) of children using controllers used them 4 or fewer days per week. Among children with some evidence of persistent disease (use of controllers, excess symptoms, or excess reliever use), almost two thirds (64.3%) were inadequately controlled. This group consisted both of children reportedly using controllers less than recommended and those reporting not receiving controller medication at all.In this insured population, inappropriate reliance on relievers and nonadherence to controllers were common. Inadequate asthma control was common regardless of whether controllers were prescribed.

Objective To determine the effect of a pediatric hospitalist system on housestaff education and experience. Setting Free-standing academic children's hospital. Hospitalists were introduced in June 24, 1998, to supervise teaching and care on the general pediatric wards. Methods On 2 surveys, housestaff rated their skills, knowledge, and experiences on the wards (experiences survey), and the quality of teaching and supervision by attending physicians (attending survey). Responses before and after the introduction of the hospitalist system were compared using Wilcoxon nonparametric tests. Results Seventy-six (70%) of the 109 interns and 54 (62%) of the 87 senior residents responded to the experiences survey. Following introduction of the hospitalist system, the interns' mean overall rating of the general pediatrics wards rose from 4.1 to 4.7 on a 5-point Likert scale ( P = .01). Their ratings of comparison rotations did not change significantly. Interns' satisfaction with the educational experience (3.2 to 3.5 of a 4-point Likert scale, P P P P P P P P Conclusions Overall, hospitalists were rated significantly higher as educators than were traditional attending physicians. Introduction of a hospitalist system was associated with improved intern experience and quality of life on general pediatrics wards, and with improved self-reported skills and knowledge in general pediatrics.

Background Mounting evidence suggests that indoor allergens and irritants contribute to childhood asthma. National asthma guidelines highlight the importance of their reduction as part of comprehensive asthma treatment. Objectives To assess the prevalence of potential environmental triggers, to identify risk factors for such exposures, and to determine whether prior parental education about trigger avoidance is associated with fewer such exposures. Setting and Patients Children with asthma in practices affiliated with 3 managed care organizations. Interventions Parents of 638 children, aged 3 to 15 years, were interviewed on enrollment in a randomized trial of asthma care improvement strategies. Parents reported recent asthma symptoms and exposures to potential environmental triggers. Multivariate models were used to identify specific demographic risk factors for environmental exposures and to determine if prior education was associated with fewer such exposures. Results Exposures to environmental triggers were frequent: 30% of households had a smoker, 18% had household pests, and 59% had furry pets. Other exposures included bedroom carpeting (78%) and forced-air heat (58%). Most children did not have mattress (65%) or pillow (84%) covers. Of the parents, 45% reported ever receiving written instructions regarding trigger avoidance and 11% reported them given in the past year. However, 42% reported discussing triggers in the home environment with a clinician in the past 6 months. In multivariate models, predictors of smoking at home included low annual family income and lower parental educational attainment. Dog ownership was associated with low educational attainment, and dog and cat ownership were less likely with black race. Reports of pests were increased for black children compared with white children. Black race was associated with lower rates of other exposures, including bedroom carpeting. After controlling for potential confounders, there was no association of reduced exposures with prior receipt of environmental control instructions. Conclusions Exposure to potential environmental triggers is common, and recommended trigger avoidance measures are infrequently adopted. While specific exposures may vary with demographic and socioeconomic variables, all children are at risk. New methods for educating parents to reduce such exposures should be tested.

Background: Many factors affect use of inhaled therapy in asthma. Relatively little is known about current patterns of use of anti-inflammatory medication in children with asthma and whether variations occur with age and use of bronchodilator medication. Objective: To study the factors associated with dispensing of anti-inflammatory (controller) asthma medication to children in 3 managed care organizations (MCOs). Methods: Using automated databases, a 1-year crosssectional study of children with asthma aged 3 to 15 years cared for in 3 MCOs was used to evaluate the association of age and other factors with controller medication use. Results: A total of 13352 children were studied. Significantly fewer children aged 3 to 5 years were dispensed any ($1) controller medication than older children (P,.001). Among children dispensed 6 or more b-agonists, only 39% also received 5 or more controller dispensings, with adolescents significantly less likely than younger children to receive 5 or more controllers (33%; P,.001). Significant differences were seen among MCOs in proportions of patients dispensed controller medication. In a multiple logistic regression model, controlling for frequency of b-agonist dispensing and MCO, significantly lower dispensing of any controller medication was seen for those aged 3 to 5 years (odds ratio [OR], 0.8; 95% confidence interval [CI], 0.7-0.9) and for girls (OR, 0.9; 95% CI, 0.8-0.96). In contrast, for repeated ($5) controller dispensing there were significantly fewer dispensings to adolescents (OR, 0.7; 95% CI, 0.6-0.9) and girls (OR, 0.8; 95% CI, 0.7-0.9). Conclusions: There may be differences in the use of preventive asthma medication in children that are affected by age, sex, and health care organization. Few children with frequent symptoms are using controllers regularly, as is recommended by national guidelines. Arch Pediatr Adolesc Med. 2001;155:501-507

Our 1991 article 1 examined the health and developmental status of homeless children living in shelters in Philadelphia, Pa. When we began this study in 1988, with the exception of the 1986 report by Bassuk et al, 2 there were few published data on the health of homeless children. Over the past 4 years, several studies 3-5 have contributed to an understanding of the problems these children face. Herein, we reflect briefly on the current plight of homeless children, and what we have learned since 1988 regarding potential solutions. Determining the number of homeless children has always been difficult. In Philadelphia, the number of families housed in city-operated shelters has decreased over the past 2 years. 6 This is more a reflection of changes in eligibility for city services than of the size of the population in need. On a national level the number of homeless children has swelled considerably.