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Objective To create definitions for complications for 16 serious pediatric conditions using the International Classification of Diseases, 10th Revision, Clinical Modification or Procedure Coding System (ICD-10-CM/PCS), and to assess whether complication rates are similar to those measured with ICD-9-CM/PCS. Data sources The Healthcare Cost and Utilization Project State Emergency Department and Inpatient Databases from five states between 2014 and 2017 were used to identify cases and assess complication rates. Incidences were calculated using population counts from the 5-year American Community Survey. Data collection/extraction methods Patients were identified by the presence of a diagnosis code for one of the 16 serious conditions. Only the first encounter for a given condition by a patient was included. Encounters resulting in transfer were excluded as the presence of complications was unknown. Study design We defined complications using data elements routinely available in administrative databases including ICD-10-CM/PCS codes. The definitions were adapted from ICD-9-CM/PCS using general equivalence mappings and refined using consensus opinion. We included 16 serious conditions: appendicitis, bacterial meningitis, compartment syndrome, new-onset diabetic ketoacidosis (DKA), ectopic pregnancy, empyema, encephalitis, intussusception, mastoiditis, myocarditis, orbital cellulitis, ovarian torsion, sepsis, septic arthritis, stroke, and testicular torsion. Using data from children under 18 years, we compared incidences and complication rates across the ICD-10-CM/PCS transition for each condition using interrupted time series. Principal findings There were 61 314 ED visits for a serious condition; the most common was appendicitis (n = 37 493). Incidence rates for each condition were not significantly different across the ICD-10-CM/PCS transition for 13/16 conditions. Three differed: empyema (increased 42%), orbital cellulitis (increased 60%), and sepsis (increased 26%). Complication rates were not significantly different for each condition across the ICD-10-CM/PCS transition, except appendicitis (odds ratio 0.62, 95% CI 0.57-0.68), DKA (OR 3.79, 95% CI 1.92-7.50), and orbital cellulitis (OR 0.53, 95% CI 0.30-0.95). Conclusions For most conditions, incidences and complication rates were similar before and after the transition to ICD-10-CM/PCS codes, suggesting our system identifies complications of conditions in administrative data similarly using ICD-9-CM/PCS and ICD-10-CM/PCS codes. This system may be applied to screen for cases with complications and in health services research.

The Global Initiative for Asthma (GINA 2002), in its Practical Guide to Asthma Management provides an evidence-based management strategy that addresses severity assessment, pharmacotherapy, monitoring, environmental control and the patient-provider partnership (GINA 2002). Despite the existence of effective therapies, including inhaled anti-inflammatory and long-acting bronchodilators, current practice falls short of guidelines and consequently, inadequate asthma control continues to be the norm. Although evidence based guidelines have been established, there is significant variation among practitioners in treating this condition, indicating a significant gap between what we know is optimal care and current practice (Finkelstein 2000, Finkelstein 2002, Lozano 2003). We propose to undertake a review of interventions to improve the management of asthma in primary care. A variety of approaches have been taken to improve asthma care including; patient self-management support, provider directed education and behavior change, and organizational approaches. Considerable work has been done in reviewing patient self-management support interventions. For example, Gibson found that information only patient education programs did not appear to improve outcomes (Gibson 2001). Toelle found insufficient evidence about the effectiveness of written management plans for adults and children (Toelle 2001). Reviews of more complex self-management interventions have shown positive results: self-management support education for children directed at prevention and attack management showed demonstrably improved outcomes (Wolf 2002). Positive outcomes were found in studies of asthma education for adults that included self-monitoring of either peak flow or symptoms, when combined with regular medical review and a written action plan (Gibson 2002). Another review of multifaceted adult interventions showed equivalent effects for control of asthma management by regular medical review of inhaled corticosteroid use vs. control by self-adjustment using written self management plan (Powell 2002). To complement these reviews, we will focus our review on provider-directed interventions and organizational approaches, only including patient-oriented interventions when they are part of a multi-focus study. The objectives of this review are to determine the effectiveness of various interventions to improve the management of asthma in primary care settings.

Background Prescribing decisions are subject to a myriad of external forces, including patient requests for advertised medications. Although numerous factors influence prescribing, resources to support unbiased evidence-based prescribing are not widely available. Methods To guide future interventions, we surveyed clinicians about influences on prescribing, awareness of pharmaceutical costs and attitudes towards computerized decision support. A 21-item survey was sent to 604 prescribing clinicians in a large multi-specialty group practice that employs a robust electronic medical record. Results Surveys were returned from 405 clinicians (67%). Most respondents (87%) felt that direct-to-consumer (DTC) advertising prompts patients to request inappropriate medications, and more than one in five clinicians (22%) reported difficulty declining patients' requests for advertised medications. Providers with more clinical sessions per week reported greater difficulty. Although 93% of clinicians felt they have access to the information needed to guide prescribing, only about half (54%) reported they are aware of how much patients pay for prescription medications. Clinicians' awareness of medication costs varied considerably by specialty, with behavioural health clinicians being the most aware. The majority of providers (79%) stated that computerized prescribing alerts are a clinically useful source of information. Conclusions Although the majority of clinicians reported that DTC advertising leads many patients to request medications that are inappropriate for their condition, a sizable proportion of clinicians reported difficulty declining these requests, and many are unaware of medication costs. Interventions to support prescribing decisions should provide the busiest clinicians with up-to-date, specialty-specific evidence and cost information.

Recent concerns regarding the potential for intentional release of bioterrorism agents, particularly regarding the threat of anthrax exposure, have drawn attention to the possible need for large-scale post-exposure antibiotic prophylaxis. Treatment choices should reflect a balance between the expected benefits and risks of alternative treatment strategies. As data are limited regarding treatments’ relative effectiveness in preventing infection, the anticipated risks related to each agent’s use should play an important role in developing treatment recommendations. For adult and pediatric post-exposure anthrax prophylaxis, the Infectious Diseases Society of America and the U.S. Centers for Disease Control and Prevention (CDC) recommend a 60-day course of ciprofloxacin, doxycycline, or amoxicillin.1–3 A recent study reported that amoxicillin was the third most common drug implicated in adverse drug events (ADEs) treated in U.S. emergency departments, and tetracyclines account for approximately 0.5% of ADEs.4 However, most antimicrobial drug use is of short duration; antibiotic courses for acute infections typically range up to fourteen days duration,5, 6 and data are limited regarding the safety of long-term antibiotics. The risk of some adverse outcomes may be proportional to the duration of antibiotic exposure, resulting from cumulative dose effects. Antibiotic-associated diarrhea might fit this model. Conversely, other adverse event risks could fall over time, for example because of depletion of susceptible individuals in the treatment population.7–9 Allergic reactions might fit this model. Case studies of individuals offered anthrax prophylaxis following the Fall 2001 bioterrorist attack suggest that minor adverse events are common and frequently result in therapy discontinuation, although they are not always attributable to antimicrobial therapy.10, 11 It is much more difficult to estimate the risk of rare but life-threatening adverse events,12 and whether they increase with exposure time. Premarketing studies are not usually designed to reveal risks under 1/1000 exposed individuals;13–15 postmarketing data come mostly from anecdotal reporting and do not provide population-based risk estimates.15–17 Electronic medical record (EMR) and administrative databases provide an opportunity to evaluate these risks on a larger scale. While minor ADEs may not be reliably documented, these data should have better sensitivity and specificity for severe adverse events such as hospitalizations.12, 18 This study uses data from 3 large observational databases to estimate risks of long-term exposure to amoxicillin, ciprofloxacin, and doxycycline. Our objectives are to describe and compare the frequency of hospitalizations for severe adverse events temporally linked to long-term antibiotic use in the three databases, and to determine if risks of severe ADEs increase with prolonged use.

Purpose To estimate the prevalence of use of prescription drugs with a potential for fetal harm among pregnant women in the United States. Methods A retrospective study was conducted using the automated databases of eight health maintenance organizations involved in the HMO Research Network Center for Education and Research on Therapeutics (CERT). Women who delivered an infant from January 1996 to December 2000 were identified. The frequency of use of prescription drugs with a potential for fetal harm was based upon the expert review of a clinical teratologist and the U.S. Food and Drug Administration (FDA) risk classification system, assuming a gestational duration of 270 days. Results Among the 114 165 women with no documentation of a diagnosis suggesting potential pre-term birth or dispensing of ovulation stimulants in the 270 days before delivery, 1305 (1.1%) received a teratogenic drug during the 270 days before delivery, based upon the expert review of a clinical teratologist. A larger proportion of women received U.S. FDA category D or X drugs (5.8%; N = 6600). However, the general patterns of use were similar, with higher use in early pregnancy compared to later trimesters. The proportion of women dispensed a teratogen during pregnancy was substantially higher among women who received a teratogen in the 90 days before pregnancy compared to women who did not (adjusted RR = 38.9, 95%CI, 33.5, 45.3). Conclusions Our results suggest that further efforts directed at physicians to counsel women or at the women themselves about the potential risks of particular medications appear warranted. Copyright © 2006 John Wiley & Sons, Ltd.

Summary Background An association between antibiotic use in early life and asthma in childhood has been reported in five retrospective studies and one longitudinal study. Objective To examine the relation between the use of oral antibiotics in the first year of life and asthma in early childhood. Methods Longitudinal follow-up of 4408 children enrolled in a health maintenance organization (HMO) from birth to the age of 5 years. Results After adjusting for sex and illnesses of the lower respiratory tract (LRIs), we found a significant association between antibiotic use in the first year of life and asthma between the ages of 1 and 2 years (odds ratio (OR) for 1–2 vs. no courses of antibiotics=1.9, 95% confidence interval (CI)=1.3–2.7; OR for 3–4 vs. no courses of antibiotics=1.6, 95% CI=1.1–2.4; OR for at least 5 vs. no courses of antibiotics=2.1, 95% CI=1.5–3.2). After adjustment for sex and LRIs in the first year of life, there was no significant association between antibiotic use in the first year of life and asthma that was initially diagnosed between the ages of 2 and 5 years and that persisted up to the age of 5 years (OR for 1–2 vs. no courses of antibiotics=1.1, 95% CI=0.8–1.4; OR for 3–4 vs. no courses of antibiotics=1.3, 95% CI=0.9–1.8; OR for at least 5 vs. no courses of antibiotics=1.0, 95% CI=0.7–1.4). Conclusions Our findings do not support the hypothesis that antibiotic use in early life is associated with the subsequent development of asthma in childhood but rather suggest that frequent antibiotic use in early life is more common among asthmatic children.

Objective To characterize and describe variability in processes of asthma care and services tailored for low–income populations in practice sites participating in Medicaid managed care (MMC).

Objective To highlight the unique challenges of evaluative research on practice behavior change in the “real world” settings of contemporary managed-care organizations, using the experience of the Pediatric Asthma Care PORT (Patient Outcomes Research Team).