January 21, 2020
In This Issue

Research Spotlight:
CPCE Faculty Seminar: Dr. Brian Fisher Discusses Research and Career Trajectory

Upcoming Events

Recent Publications
CPCE Faculty Seminar: Dr. Brian Fisher Discusses Research and Career Trajectory
I never learn anything by talking. I only learn things when I ask questions. – Lou Holtz

That’s how Brian Fisher, DO, MSCE started his January 10 th talk for the CPCE and PolicyLab Faculty Seminar Series. Aside from asking good questions, Dr. Fisher's talk highlighted the importance of listening to the advice of mentors, taking advantage of opportunities, and pursuing your passions both in and out of the workplace. More on that later.

Early in his career, one of the first questions he asked himself was, "Do we need to concern ourselves with improving supportive care for infections in children with leukemia?" Though there had been impressive strides in leukemia care at the time, available data indicated a high rate of infection, and that infection was a major source of treatment related mortality. The next question was, "Are there studies to guide us in reducing the risk of infection in pediatric leukemia patients?" The answer was yes, but few, small, and decades old.

Along with his mentors, including CPCE members Richard Aplenc, MD, PhD, Theo Zaoutis, MD, MSCE, and Susan Coffin, MD, MPH, Dr. Fisher turned to the Pediatric Health Information Systems (PHIS) database to build and validate cohorts of patients being treated for acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML).

These enabled Dr. Fisher and his team to answer comparative supportive care questions. One study showed that antifungal prophylaxis reduced induction mortality in children being treated for new-onset AML and reduced downstream resource utilization.

These successes led to an invitation to join the Infectious Diseases Committee of the Children’s Oncology Group (COG), and later a promotion to Chair of the Committee. He highlighted COG projects that reduced risk of bacteremia in children with acute leukemia or undergoing stem cell transplant, and compared preventive treatments for invasive fungal infections in children and young adults with AML.

Dr. Fisher pointed out that collaborative work can lead to additional collaborations, and in his case, it was the establishment of the International Pediatric Fungal Network, which he co-directs and has several ongoing studies. Mentoring others also takes on a larger role.
Those out of the workplace activities? Dr. Fisher's examples primarily involved family, including making birthday cakes for his kids, and recently, building a backyard ice hockey rink.

Don't miss invited speakers Dr. Lauri Hicks later this month, Dr. Russell Localio on February 7, and our next CPCE/PolicyLab Faculty seminar by Dr. Jim Guevara on February 21. Details under Upcoming Events below.
Upcoming Events

2020 Martin Luther King, Jr. Health Equity Symposium
Date: January 22, 2020
Time: 12:00 - 1:00 pm
Location: Smilow Center for Translational Research, Arthur H. Rubenstein Auditorium
The Penn Medicine Office of Inclusion and Diversity present the annual Martin Luther King Jr. Health Equity Symposium. Keynote Address by Dr. Leandris Liburd, Director of the Office of Minority Health and Health Equity at the Centers for Disease Control. Register here.

Toward Scaling Twitter Data Analysis for Digital Epidemiology
Date: January 23, 2020
Time: 12:00 - 1:00 pm
Location: Colket Translational Research Building 6040
The Mobile Health (mHealth) Research Affinity Group hosts Gracciela Gonzalez-Hernandez, MS, PhD, who will discuss her research about mining social media data for health concerns. She is associate professor of Informatics in the Department of Biostatistics, Epidemiology, and Informatics of the Perelman School of Medicine at the University of Pennsylvania. Please RSVP to mhealth@email.chop.edu.

Intersecting Implementation Science and Economics: Applying Theory
Date: January 24, 2020
Time: 12:00 - 1:20 pm
Location: Colonial Penn Center Auditorium, 3641 Locust Walk
Penn's Leonard Davis Institute of Health Economics and the Penn Implementation Science Center (PISCE@LDI) will co-host Anne Sales, PhD, RN, a Professor in the Department of Learning Health Sciences, School of Medicine, University of Michigan, and Research Scientist at the Center for Clinical Management Research at the VA Ann Arbor Healthcare System. Learn more and please register here.

CHOP Health and Behavior Research Affinity Group Biannual Retreat
Date: January 29, 2020
Time: 8:00 am - 3:00 pm
Location: Inn at Penn, 3600 Sansom Street, Philadelphia
The retreat is built around the idea of using science to drive innovative research and quality improvement initiatives, and is structured to give faculty and near faculty and research scientists an opportunity to develop research questions and cultivate collaboration.  Dr. Flaura Winston will give the keynote. Please RSVP to Shelby Brizzolara-Dove by January 22, 2020.

Update on antibiotic stewardship in the United States
Date: January 30, 2020
Time: 12:00 - 1:00 pm
Location: CHOP Main Hospital, Stokes Auditorium
Lauri Hicks, DO will present for the CPCE and PolicyLab Seminar Series. Dr. Hicks is a medical epidemiologist in the Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC). She is also a Captain in the US Public Health Service. For more information or to RSVP, e-mail CPCE@email.chop.edu .

To P or not to P. That is the question. Life and death beyond statistical significance
Date: February 7, 2020
Time: 12:00 - 1:00 pm
Location: Roberts Center for Pediatric Research, 1st floor, Room 1-120A
A. Russell Localio, PhD will present for the CPCE and PolicyLab Seminar Series. Dr. Localio is Emeritus Associate Professor of Biostatistics at the University of Pennsylvania. For more information or to RSVP, e-mail CPCE@email.chop.edu.

CPCE/PolicyLab Faculty Seminar Series featuring Jim Guevara, MD, MPH
Date: February 21, 2020
Time: 12:00 - 1:00 pm
Location: Roberts Center for Pediatric Research, 2nd floor, Room 2-180
James Guevara, MD, MPH is a core faculty member of CPCE and PolicyLab, professor of pediatrics and epidemiology at the University of Pennsylvania, and a primary care pediatrician at CHOP. Dr. Guevara will discuss community-based participatory research. To RSVP, e-mail CPCE@email.chop.edu.

Emerging Therapies in a New Era of Care
Date: March 3, 2020
Time: 6:00 - 7:30 pm
Location: The Franklin Institute, 222 North 20th Street, Philadelphia
Penn Medicine bioethicist and pediatric oncologist Dr. Steven Joffe joins Franklin Institute’s Dr. Jayatri Das for a dynamic discussion exploring the promise and the realities of newer breakthrough therapies. Free, advanced registration required.
Recent Publications

Many clinicians delay referral for pediatric palliative care until the end of life, despite evidence that such care reduces suffering and improves quality of life. Jennifer Walter, MD, PhD, MS, Doug Hill, PhD, Chris Feudtner, MD, PhD, MPH and their team argue for a conceptual model of the challenges and facilitators a clinical team might face in shifting from a restorative-focused treatment plan to one that includes palliative aspects, a transition they call “clinician regoaling.” Recognizing such barriers to transitioning to palliative care at the team level can help clinicians develop strategies for transitioning more effectively when appropriate for their patients.

Infections due to carbapenem-resistant Enterobacteriaceae (CRE) are increasingly prevalent in children and are associated with poor clinical outcomes. Optimal treatment strategies are evolving and there remains a lack of pediatric-specific comparative effectiveness data. Kathleen Chiotos, MD, MSCE and Jeffrey Gerber, MD, PhD, MSCE and their colleagues provide a review, including a framework for antibiotic treatment of CRE infections in children, highlighting relevant microbiologic considerations and summarizing available data related to the evaluation of FDA-approved antibiotics with CRE activity.

Researchers including Theoklis Zaoutis, MD, MSCE ran a systematic review and meta-analysis to estimate the attributable mortality, length of stay (LOS), and healthcare cost of pediatric and neonatal healthcare-acquired bloodstream infections (HA-BSIs). They found that attributable mean LOS ranged between 4 and 27.8 days, healthcare cost ranged between $1,642.16 and $160,804 per patient, and mortality rate ranged between 1.43% and 24%. The pooled mean attributable hospital LOS was 16.91 (95% confidence interval, 13.70-20.11) and the pooled attributable mortality rate was 8% (95% confidence interval, 6-9). These findings highlight the need for implementation of HA-BSI prevention strategies.

Medical errors in blood product orders and administration are common, especially for pediatric patients. A failure modes and effects analysis indicated high risk from the electronic blood ordering process. A team including Naveen Muthu, MD ran formative usability testing with 27 providers from seven specialties, which led to 18 changes made to the order sets designed by expert committee (DEC) to produce the user-centered design (UCD). UCD led to substantially different blood product orders and order sets than DEC. Users made fewer errors when ordering blood products for pediatric patients in simulated scenarios when using the UCD orders and order sets compared with the original design.

Naveen Muthu, MD and his colleagues aimed to reduce the proportion of pediatric patients with bronchiolitis receiving albuterol from 43% to <35% in the emergency department and from 18% to 10% in inpatient care, in accordance with 2014 American Academy of Pediatrics guidelines recommending against the use of bronchodilators. The team identified key drivers of albuterol use and potential interventions, and implemented changes to the pathway and the associated order set. The team monitored albuterol use and reported back to clinicians. Their efforts reduced albuterol use at the hospital level without impacting other outcome measures.

Little is known about how the interest of practicing pediatricians in global health (GH) experiences has changed over the past 30 years. Katherine Yun, MD, MHS and her colleagues ran descriptive analyses to look at changes in experience and interest in GH, comparing data from American Academy of Pediatrics Periodic Surveys from 1989 and 2017. They found that practicing pediatricians have increased their involvement in GH, and are more interested in future GH experiences with a focus on short-term opportunities. They mirror medical trainees in their growing interest and participation in GH.

Child-Adult Relationship Enhancement in Primary Care (PriCARE) is a 6-session group training designed to teach positive parenting skills. Joanne Wood, MD, MSHP and her team examined the impact of having a peer mentor attend PriCARE sessions and measured PriCARE’s impact on child behavior and parenting practice’s. They found that adapting PriCARE to include a peer mentor may decrease stigma but does not improve attendance. PriCARE nevertheless shows promise in improving the behavior of preschool-aged children and increasing positive parenting practices.

Researchers including Joyce Chang, MD, MSCE, Rosemary Peterson, MD, and Lindsay Waqar, MPH, CCRC applied quality improvement methods to increase the frequency and timeliness of identification of eligible patients with new paediatric rheumatic diagnoses to approach for research studies. Improvement methodology was used to standardize communication between clinicians and the research team, to leverage social feedback, and to measure change in response to interventions. The number of eligible patients identified between missed recruitment opportunities increased from every 0-1 patient to every 14 patients, corresponding to an increase in the identification rate from 32% to 91% of all eligible patients.

Although medication needs for children born preterm during infancy and their need for asthma medication during childhood had been described, little was known regarding other medication needs for children born preterm. A research team including Molly Passarella, Ashley Martin, MPH, and Scott Lorch, MD, MSCE explored this other medication use by children born preterm at 5-8 years of age. Compared with children born at full term, those born preterm had higher medication use that included most therapeutic classifications. Although asthma and chronic lung disease influenced use, prematurity remained an independent risk factor.

About CPCE

We are a pediatric research center dedicated to discovering and sharing knowledge about best practices in pediatric care by facilitating, organizing and centralizing the performance of clinical effectiveness research -- research aimed at understanding the best ways to prevent, diagnose and treat diseases in children. CPCE’s multidisciplinary team conducts research on a diverse range of clinical effectiveness topics.

CPCE E-News is edited by Holly Burnside. Please feel free to contact us with questions or feedback.