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Introduction: Early antibiotic administration is recommended in newborns presenting with febrile illness to emergency departments (ED) to avert the sequelae of serious bacterial infection. Although ED crowding has been associated with delays in antibiotic administration in a dedicated pediatric ED, the majority of children that receive emergency medical care in the U.S. present to EDs that treat both adult and pediatric emergencies. The purpose of this study was to examine the relationship between time to antibiotic administration in febrile newborns and crowding in a general ED serving both an adult and pediatric population.Methods: We conducted a retrospective chart review of 159 newborns presenting to a general ED between 2005 and 2011 and analyzed the association between time to antibiotic administration and ED occupancy rate at the time of, prior to, and following infant presentation to the ED.Results: We observed delayed and variable time to antibiotic administration and found no association between time to antibiotic administration and occupancy rate prior to, at the time of, or following infant presentation (P > 0.05). ED time to antibiotic administration was not associated with hospital length of stay, and there was no inpatient mortality.Conclusion: Delayed and highly variable time to antibiotic treatment in febrile newborns was common but unrelated to ED crowding in the general ED study site. Guidelines for time to antibiotic administration in this population may reduce variability in ED practice patterns. [West J Emerg Med. 2013;14(5):518-524.]

Introduction: This article presents results of the second phase of a project to develop a patient‐centered dental home (PCDH) model. Aims of PCDH model development include broadening the scope of prior dental home definitions to include populations across the lifespan, developing a quality measurement framework to facilitate quality assessment and improvement, and promoting opportunities for medical‐dental integration through alignment with existing PCMH models. This phase determined the components, or conceptual subdivisions, associated with a previously developed PCDH definition and characteristics. Methods: We used a modified Delphi process to obtain structured feedback and gain consensus among the project national advisory committee (NAC). The process included a web‐based survey that asked NAC members to rank the importance of each potential component on a scale of 1–9. Criteria for consensus on component inclusion/exclusion combined a median rating and measure of disagreement. Respondents were also encouraged to provide open‐ended feedback regarding rationale for component ratings and additional suggested components. Results: A total of 47 out of 51 members completed the survey. All 34 components met the quantitative criteria for inclusion in the PCDH model. Changes were made to components based on open‐ended feedback. Conclusions: This project phase further developed a PCDH measurement framework that aims to guide practice transformation, quality measurement and improvement in dental care delivery, as well as integration between medicine and dentistry. Using a Delphi approach with a broad group of stakeholders ensured that components had face validity and were conceptually aligned with the PCDH definition and characteristics. [ABSTRACT FROM AUTHOR]

Objectives: This quality improvement study evaluates the impact of a caries risk assessment (CRA) registry on the following: percentage of children with a documented CRA, receipt of preventive and restorative services, and costs of care.Methods: We used 2014-2019 data for patients aged 0-17 years from 22 locations in a group practice in Wisconsin. Paired t-tests and Wilcoxon signed-rank tests were used to evaluate changes over time in the following practice-level outcomes: CRA documentation, fluoride receipt, continuing care procedures, restorative procedures, total procedures, and inflation-adjusted costs of care. The same tests were used to compare average procedures and cost for patients a) enrolled and not enrolled in the registry, b) with and without CRA documentation, and c) at high and low caries risk.Results: CRA documentation increased from 13 percent in 2014 to 87 percent in 2019 (P < 0.0001). There were statistically significant increases in the average number of continuing care procedures (from 1.47 to 1.54, P < 0.001), average total procedures (from 7.40 to 8.36, P < 0.001), and inflation-adjusted average cost (from $491.51 to $553.37, P < 0.001) after accounting for multiple comparisons. The average number of restorative procedures decreased, with borderline statistical significance. Average cost was stable for registry-enrolled patients and increased for those not enrolled.Conclusions: The registry achieved the primary goal of improving CRA documentation among children. This quality improvement initiative appears to have had value-enhancing effects by promoting increased receipt of preventive services and decreased restorative services, while maintaining stable average cost of care for registry-enrolled patients over time. [ABSTRACT FROM AUTHOR]

Use of the all-or-none model of monopsony to analyze the relationship between a monopsonistic health insurer and health care providers is discussed. Additional information on the contract between the dominant health insurer and physicians for medical services is included.

Objectives: Health registries are commonly used in medicine to support public health activities and are increasingly used in quality improvement (QI) initiatives. Illustrations of dental registries and their QI applications are lacking. Within dentistry, caries risk assessment implementation and documentation are vital to optimal patient care. The purpose of this article is to describe the processes used to develop a caries risk assessment registry as a QI initiative to support clinical caries risk assessment, caries prevention, and disease management for children.Methods: Developmental steps reflected Agency for Healthcare Research and Quality recommendations for planning QI registries and included engaging "champions," defining the project, identifying registry features, defining performance dashboard indicators, and pilot testing with participant feedback. We followed Standards for Quality Improvement Reporting Excellence guidelines.Results: Registry eligibility is patients aged 0-17 years. QI tools include prompts to register eligible patients; decision support tools grounded in evidence-based guidelines; and performance dashboard reports delivered at the provider and aggregated levels at regular intervals. The registry was successfully piloted in two practices with documented caries risk assessment increasing from 57 percent to 92 percent and positive feedback regarding the potential to improve dental practice patient centeredness, patient engagement and education, and quality of care.Conclusions: The caries risk assessment registry demonstrates how dental registries may be used in QI efforts to promote joint patient and provider engagement, foster shared decision making, and systematically collect patient information to generate timely and actionable data to improve care quality and patient outcomes at the individual and population levels. [ABSTRACT FROM AUTHOR]

Objective: To describe the stakeholder-engaged processes used to develop, specify, and validate 2 oral health care electronic clinical quality measures.Materials and Methods: A broad range of stakeholders were engaged from conception through testing to develop measures and test feasibility, reliability, and validity following National Quality Forum guidance. We assessed data element feasibility through semistructured interviews with key stakeholders using a National Quality Forum-recommended scorecard. We created test datasets of synthetic patients to test measure implementation feasibility and reliability within and across electronic health record (EHR) systems. We validated implementation with automated reporting of EHR clinical data against manual record reviews, using the kappa statistic.Results: A stakeholder workgroup was formed and guided all development and testing processes. All critical data elements passed feasibility testing. Four test datasets, representing 577 synthetic patients, were developed and implemented within EHR vendors' software, demonstrating measure implementation feasibility. Measure reliability and validity were established through implementation at clinical practice sites, with kappa statistic values in the "almost perfect" agreement range of 0.80-0.99 for all but 1 measure component, which demonstrated "substantial" agreement. The 2 validated measures were published in the United States Health Information Knowledgebase.Conclusion: The stakeholder-engaged processes used in this study facilitated a successful measure development and testing cycle. Engaging stakeholders early and throughout development and testing promotes early identification of and attention to potential threats to feasibility, reliability, and validity, thereby averting significant resource investments that are unlikely to be fruitful. [ABSTRACT FROM AUTHOR]