Francisco Alvarez

All Publications

• Healthcare utilization in children across the care continuum during the COVID-19 pandemic. PloS one Schroeder, A. R., Dahlen, A., Purington, N., Alvarez, F., Brooks, R., Destino, L., Madduri, G., Wang, M., Coon, E. R. 2022; 17 (10): e0276461

  Abstract

  OBJECTIVES: Healthcare utilization decreased during the COVID-19 pandemic, likely due to reduced transmission of infections and healthcare avoidance. Though various investigations have described these changing patterns in children, most have analyzed specific care settings. We compared healthcare utilization, prescriptions, and diagnosis patterns in children across the care continuum during the first year of the pandemic with preceding years.STUDY DESIGN: Using national claims data, we compared enrollees under 18 years during the pre-pandemic (January 2016 -mid-March 2020) and pandemic (mid-March 2020 through March 2021) periods. The pandemic was further divided into early (mid-March through mid-June 2020) and middle (mid-June 2020 through March 2021) periods. Utilization was compared using interrupted time series.RESULTS: The mean number of pediatric enrollees/month was 2,519,755 in the pre-pandemic and 2,428,912 in the pandemic period. Utilization decreased across all settings in the early pandemic, with the greatest decrease (76.9%, 95% confidence interval [CI] 72.6-80.5%) seen for urgent care visits. Only well visits returned to pre-pandemic rates during the mid-pandemic. Hospitalizations decreased by 43% (95% CI 37.4-48.1) during the early pandemic and were still 26.6% (17.7-34.6) lower mid-pandemic. However, hospitalizations in non-psychiatric facilities for various mental health disorders increased substantially mid-pandemic.CONCLUSION: Healthcare utilization in children dropped substantially during the first year of the pandemic, with a shift away from infectious diseases and a spike in mental health hospitalizations. These findings are important to characterize as we monitor the health of children, can be used to inform healthcare strategies during subsequent COVID-19 surges and/or future pandemics, and may help identify training gaps for pediatric trainees. Subsequent investigations should examine how changes in healthcare utilization impacted the incidence and outcomes of specific diseases.

  View details for DOI 10.1371/journal.pone.0276461

  View details for PubMedID 36301947

• Choosing Wisely in Pediatric Hospital Medicine: 5 New Recommendations to Improve Value. Hospital pediatrics Tchou, M. J., Schondelmeyer, A. C., Alvarez, F., Holmes, A. V., Lee, V., Lossius, M. N., O'Callaghan, J., Rajbhandari, P., Soung, P. J., Quinonez, R. 2021

  Abstract

  OBJECTIVES: The health care system faces ongoing challenges due to low-value care. Building on the first pediatric hospital medicine contribution to the American Board of Internal Medicine Foundation Choosing Wisely Campaign, a working group was convened to identify additional priorities for improving health care value for hospitalized children.METHODS: A study team composed of nominees from national pediatric medical professional societies was convened, including pediatric hospitalists with expertise in clinical care, hospital leadership, and research. The study team surveyed national pediatric hospitalist LISTSERVs for suggestions, condensed similar responses, and performed a literature search of articles published in the previous 10 years. Using a modified Delphi process, the team completed a series of structured ratings of feasibility and validity and facilitated group discussion. The sum of final mean validity and feasibility scores was used to identify the 5 highest priority recommendations.RESULTS: Two hundred seven respondents suggested 397 preliminary recommendations, yielding 74 unique recommendations that underwent evidence review and rating. The 5 highest-scoring recommendations had a focus on the following aspects of hospital care: (1) length of intravenous antibiotic therapy before transition to oral antibiotics, (2) length of stay for febrile infants evaluated for serious bacterial infection, (3) phototherapy for neonatal hyperbilirubinemia, (4) antibiotic therapy for community-acquired pneumonia, and (5) initiation of intravenous antibiotics in infants with maternal risk factors for sepsis.CONCLUSIONS: We propose that pediatric hospitalists can use this list to prioritize quality improvement and scholarly work focused on improving the value and quality of patient care for hospitalized children.

  View details for DOI 10.1542/hpeds.2021-006037

  View details for PubMedID 34667087

• Choosing Wisely: Five Things Physicians and Patients Should Question Alvarez, F., Holmes, A., Lee, V., O'Callaghan, J., Quinonez, R., Rajbhandari, P., Schondelmeyer , A., Soung, P., Tchou, M. Society of Hospital Medicine. 2021
• Lessons Learned From the Pediatric Overflow Planning Contingency Response Network: A Transdisciplinary Virtual Collaboration Addressing Health System Fragmentation and Disparity During the COVID-19 Pandemic. Journal of hospital medicine El-Hage, L., Ratner, L., Sridhar, S., Jenkins, A. 2021

  View details for DOI 10.12788/jhm.3668

  View details for PubMedID 34424187

• The Silent Crisis of Pediatric Clinical Practice Guidelines. JAMA pediatrics Rea, C. J., Alvarez, F. J., Tieder, J. S. 2021

  View details for DOI 10.1001/jamapediatrics.2021.2435

  View details for PubMedID 34424270

• SECTION 1. COMMON CLINICAL DIAGNOSES AND CONDITIONS. Journal of hospital medicine 2020; 15 (S1): 18–67

  View details for DOI 10.12788/jhm.3397

  View details for PubMedID 32716285

• Community Pediatric Hospitalist Workload: Results from a National Survey. Journal of hospital medicine Alvarez, F., McDaniel, C. E., Birnie, K., Gosdin, C., Mariani, A., Paciorkowski, N., Mendez, S. S., Weng, Y., Fromme, H. B. 2019; 14: E1–E4

  Abstract

  As a newly recognized subspecialty, understanding programmatic models for pediatric hospital medicine (PHM) programs is vital to lay the groundwork for a sustainable field. Although variability has been described within university-based PHM programs, there remains no national benchmark for community-based PHM programs. In this report, we describe the workload, clinical services, employment, and perception of sustainability of 70 community-based PHM programs in 29 states through a survey of community site leaders. The median hours for a full-time hospitalist was 1,882 hours/year with those employed by community hospitals working 8% more hours/year and viewing appropriate morning pediatric census as 20% higher than those employed by university institutions. Forty-three out of 70 (63%) site leaders perceived their programs as sustainable, with no significant difference by employer structure. Future studies should further explore root causes for workload discrepancies between community and academic employed programs along with establishing potential standards for PHM program development.

  View details for DOI 10.12788/jhm.3263

  View details for PubMedID 31433774

• The Value of Pediatricians on Pharmacy and Therapeutics Committees. P & T : a peer-reviewed journal for formulary management Austin, J. P., Gunden, S. n., Hoffner, W. n., Ismail, L. n., Mendez, S. n., Alvarez, F. n. 2019; 44 (1): 2–4

  View details for PubMedID 30675084

  View details for PubMedCentralID PMC6336204

• Pediatric Medication Safety in Adult Community Hospital Settings: A Glimpse Into Nationwide Practice. Hospital pediatrics Alvarez, F. n., Ismail, L. n., Markowsky, A. n. 2016; 6 (12): 744–49

  Abstract

  Most children in the United States are treated in adult settings. Studies show that the pediatric population is vulnerable to medication errors. It can be extrapolated that children cared for in adult settings are at equal or higher risk for errors. The goal of this study was to assess the existing pediatric medication safety infrastructure within adult hospitals.Questionnaire developed through Research Electronic Data Capture (REDCap) and distributed to pediatric hospitalist programs listed on the American Academy of Pediatrics, Section on Hospital Medicine web site and members of the American Academy of Pediatrics Quality Improvement Innovation Networks listserv. There were >20 questions regarding the use of various safety measures and characteristics of the hospital.Thirty-eight program staff and 26 Quality Improvement Innovation Networks listserv members completed the survey (total = 64). Of these, 90.6% use order sets or computerized provider order entry with pediatric weight-based dosing, 79.7% review pediatric medication safety events or concerns, 58.7% were aware that their hospital had defined or documented maximum doses on orders, and 50.0% had milligram-per-kilogram dosing required to be in the order. A majority of respondents document weights only in the metric system (kilograms or grams) in both the emergency department and the pediatric unit (84.4% and 92.1%, respectively). A total of 57.8% of hospitals had pharmacists trained in pediatrics, with hospitals with >300 beds more likely to have a pediatric pharmacist than those with <300 beds (75% vs 44%, P ≤ .05).Pediatric medication safety infrastructure shows variations within the sites surveyed. Our results indicate that certain deficiencies are more widespread than others, providing opportunities for targeted, but hospital-specific interventions.

  View details for DOI 10.1542/hpeds.2016-0068

  View details for PubMedID 27811162

• The Effect of Implementation of Standardized, Evidence-Based Order Sets on Efficiency and Quality Measures for Pediatric Respiratory Illnesses in a Community Hospital. Hospital pediatrics Dayal, A. n., Alvarez, F. n. 2015; 5 (12): 624–29

  Abstract

  Standardization of evidence-based care, resource utilization, and cost efficiency are commonly used metrics to measure inpatient clinical care delivery. The aim of our project was to evaluate the effect of pediatric respiratory order sets and an asthma pathway on the efficiency and quality measures of pediatric patients treated with respiratory illnesses in an adult community hospital setting.We used a pre-post study to review pediatric patients admitted to the inpatient setting with the primary diagnoses of asthma, bronchiolitis, or pneumonia. Patients with concomitant chronic respiratory illnesses were excluded. After implementation of order sets and asthma pathway, we examined changes in respiratory medication use, hospital utilization cost, length of stay (LOS), and 30-day readmission rate. Statistical significance was measured via 2-tailed t-test and Fisher test.After implementation of evidence-based order sets and asthma pathway, utilization of bronchodilators decreased and the hospital utilization cost of patients with asthma was reduced from $2010 per patient in 2009 to $1174 per patient in 2011 (P < .05). Asthma LOS decreased from 1.90 days to 1.45 days (P < .05), bronchiolitis LOS decreased from 2.37 days to 2.04 days (P < .05), and pneumonia LOS decreased from 2.3 days to 2.1 days (P = .083). Readmission rates were unchanged.The use of order sets and an asthma pathway was associated with a reduction in respiratory treatment use as well as hospitalization utilization costs. Statistically significant decrease in LOS was achieved within the asthma and bronchiolitis populations but not in the pneumonia population. No statistically significant effect was found on the 30-day readmission rates.

  View details for DOI 10.1542/hpeds.2015-0140

  View details for PubMedID 26596964

• Prioritization of Randomized Clinical Trial Questions for Children Hospitalized With Common Conditions: A Consensus Statement. JAMA network open Coon, E. R., McDaniel, C. E., Paciorkowski, N., Grimshaw, M., Frakes, E., Ambroggio, L., Auger, K. A., Cohen, E., Garber, M., Gill, P. J., Jennings, R., Joshi, N. S., Leyenaar, J. K., McCulloh, R., Pantell, M. S., Sauers-Ford, H. S., Schroeder, A. R., Srivastava, R., Wang, M. E., Wilson, K. M., Kaiser, S. V., RCT conference series group, Kemper, A. R., Heath, A., Fromme, H. B., Jennings, B. N., Wainscott, C. E., Russell, C. J., McCulloch, C. E., Snow, C. H., Alvarez, F. J., Percelay, J. M., Nicholson, K. S., Morton, K. M., Dias, M., Marek, R. L., Wilcox, R. A., Hyde, S. A., Mahant, S., Edwards, Y. R. 2024; 7 (5): e2411259

  Abstract

  Importance: There is a lack of randomized clinical trial (RCT) data to guide many routine decisions in the care of children hospitalized for common conditions. A first step in addressing the shortage of RCTs for this population is to identify the most pressing RCT questions for children hospitalized with common conditions.Objective: To identify the most important and feasible RCT questions for children hospitalized with common conditions.Design, Setting, and Participants: For this consensus statement, a 3-stage modified Delphi process was used in a virtual conference series spanning January 1 to September 29, 2022. Forty-six individuals from 30 different institutions participated in the process. Stage 1 involved construction of RCT questions for the 10 most common pediatric conditions leading to hospitalization. Participants used condition-specific guidelines and reviews from a structured literature search to inform their development of RCT questions. During stage 2, RCT questions were refined and scored according to importance. Stage 3 incorporated public comment and feasibility with the prioritization of RCT questions.Main Outcomes and Measures: The main outcome was RCT questions framed in a PICO (population, intervention, control, and outcome) format and ranked according to importance and feasibility; score choices ranged from 1 to 9, with higher scores indicating greater importance and feasibility.Results: Forty-six individuals (38 who shared demographic data; 24 women [63%]) from 30 different institutions participated in our modified Delphi process. Participants included children's hospital (n=14) and community hospital (n=13) pediatricians, parents of hospitalized children (n=4), other clinicians (n=2), biostatisticians (n=2), and other researchers (n=11). The process yielded 62 unique RCT questions, most of which are pragmatic, comparing interventions in widespread use for which definitive effectiveness data are lacking. Overall scores for importance and feasibility of the RCT questions ranged from 1 to 9, with a median of 5 (IQR, 4-7). Six of the top 10 selected questions focused on determining optimal antibiotic regimens for 3 common infections (pneumonia, urinary tract infection, and cellulitis).Conclusions and Relevance: This consensus statementhas identified the most important and feasible RCT questions for children hospitalized with common conditions. This list of RCT questions can guide investigators and funders in conducting impactful trials to improve care and outcomes for hospitalized children.

  View details for DOI 10.1001/jamanetworkopen.2024.11259

  View details for PubMedID 38748429

• PHM16: How to Design, Improve Educational Programs at Community Hospitals Alvarez, F. The Hospitalist. 2016
• PHM15: A Closer Look at Quality Indicators, Evaluation Tools Alvarez, F. The Hospitalist. 2015
• PHM15: New Quality Measures for Children with Medical Complexity Alvarez, F. The Hospitalist. 2015
• Albuterol MDI versus Nebulizer for Acute Asthma Exacerbation Alvarez, F. Hospital Pediatrics . Online Newsletter. 2008