Beth A. Tarini, MD, MS

The Institute of Medicine report linking between 48,000 and 98,000 deaths annually to medical errors1 has raised awareness about medical errors across all areas of medicine. In pediatrics, medical errors in hospitalized children are associated with significant increases in length of stay, healthcare costs, and death.2, 3 While much attention has been paid to the use of hospital systems to prevent medical errors, there has been considerably less focus on the experiences of patients and their potential role in preventing errors.

Studies have suggested that a significant majority of adult patients are concerned about medical errors during hospitalization.4, 5 However, a similar assessment of parents' concerns about medical errors in pediatrics is lacking. Admittedly, for concern to be constructive it must be linked to action. The Joint Commission and the Agency for Healthcare Research and Quality (AHRQ) currently recommend that parents help prevent errors by becoming active, involved and informed members of their healthcare team and taking part in every decision about (their) child's health care.6, 7 However, the extent to which parental concern about medical errors is related to a parent's self‐efficacy, or confidence, interacting with physicians is unknown.

Self‐efficacy is a construct used in social cognitive theory to explain behavior change.8 It refers to an individual's belief in (his/her) capabilities to organize and execute the courses of action required to produce given attainments or a desired outcome.9 Self‐efficacy is not a general concept; it must be discussed in reference to a specific activity. In healthcare it has been associated not only with willingness to adopt preventive strategies,10 but also with treatment adherence,11, 12 behavior change,13 and with greater patient participation in healthcare decision‐making.14, 15

In this study we had 2 objectives. First, we sought to assess the proportion of parents of hospitalized children who are concerned about medical errors. Second, we attempted to examine whether a parent's self‐efficacy interacting with physicians was associated with their concern about medical errors for their child. Given that parents with greater self‐efficacy interacting with physicians might feel more empowered to prevent errors and, as such, be more inclined to take an active role to do so, we hypothesized that such parents would be less concerned about medical errors during a pediatric hospitalization.

Subjects and Methods

Results

During the time period of our study, 278 parents were eligible to participate. Eighty‐five parents could not be surveyed either because they could not be reached despite multiple attempts (eg, out of the room, speaking with physicians) or because the child had already been discharged. Of the 193 parents approached, 130 agreed to take the survey. Two parents who agreed to complete the survey forgot to return it before their children were discharged. Demographics of respondents and nonparticipants are presented in Table 1. The distribution of self‐efficacy scores was skewed, with a mean score of 45 (median 46, range 5‐50) on a 50‐point scale, consistent with previous studies in adults.18

Eighty‐two parents (63% of respondents) Agreed or Strongly Agreed with the statement When my child is in the hospital I feel that I need to watch over his/her care in order to make sure that mistakes aren't made (Figure 1). In bivariate analyses, non‐white race (Table 2) and English proficiency (P = 0.002) were significantly associated with parental concern about medical errors. Notably, all respondents who were not very comfortable with English agreed that they felt the need to watch over their child's care to ensure that mistakes do not happen. The association between self‐efficacy with physician interactions and concern was nearly significant (Table 2).

Figure 1

In multivariate analysis, self‐efficacy was independently associated with parental report about the need to watch over a child's care (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.72‐0.92). In prediction models, with self‐efficacy scores of 44 (25th percentile), 46 (50th percentile), and 49 (75th percentile), about 72.2% (59.1‐82.3), 64.2% (51.8‐75.0), and 50.8% (35.3‐66.2) of parents, respectively, would feel the need to watch over their child's care to prevent medical errors.

While respondents of non‐white race had the greatest independent odds of reporting a concern for medical errors occurring while their child was hospitalized (OR, 4.9; 95% CI, 1.19‐20.4), we could not reliably determine how much of this effect was due to language instead of to race because the vast majority of parents who reported being less than very comfortable with English were also non‐white (non‐white 90.5% vs. white 9.5%, P < 0.001). In additional analyses we were unable to find a difference in concern about medical errors between white and non‐white parents who were very comfortable with English (data not shown).

Of note, while having 1 hospitalization compared to none was significantly associated with having decreased concern about medical errors (Table 2), the variable hospitalizations was not significant in the model (P = 0.07).

In post‐hoc analysis, we found no association between hospitalization for >3 days after birth, previous hospitalization for >1 week, parents' experience with the hospital system, and overall perception of child's health, previous hospitalizations for other children. While rating of care that child received was significantly associated with parents' concern about medical errors in the bivariate analysis, it did not remain significant in multivariate analysis and did not substantially change the magnitude or significance of previous associations.

Discussion

In our study, we found that nearly two‐thirds of parents of children admitted to the general pediatric service of a tertiary care children's hospital felt the need to watch over their child's care to ensure that mistakes would not be made. We also found that a parent's self‐efficacy interacting with physicians was associated with less parental concern for medical errors.

To our knowledge, this is the first study to systematically survey parents' concerns about medical errors during a child's hospitalization and to evaluate factors associated with this concern. The immediate question prompted by our findings is whether the fact that 63% of parents are concerned is alarming because it is too low or too high. Some might contend that concern about medical errors is an appropriate and desirable response because it may motivate parents to become more vigilant about the medical care that their child is receiving. However, others may challenge that such concern may indicate a feeling of powerlessness to act to prevent potential errors. In our study, the relationship between higher self‐efficacy and less parental concern raises the possibility that parents with higher levels of self‐efficacy with physician interactions may feel more comfortable communicating with physicians, which in turn may temper parents' concerns about medical errors during hospitalization.

It is equally plausible that concern about medical errors during hospitalization may motivate parents to become involved in their child's medical care and, in turn, lead them to feel empowered to prevent medical errors and so ease their concerns. It is conceivable that experience with past medical errors may fuel a parent's need to watch over their child's care to prevent additional medical errors. Future studies should address the independent effect of past medical errors on parental concern about medical errors.

In this study, all parents who reported being very uncomfortable with English and parents of non‐white race felt the need to watch over their child's care to help prevent errors. A previous survey of a nationally representative sample of U.S. adults found greater proportion of non‐white adults were very concerned about errors or mistakes happening when receiving care at a hospital (blacks 62%, Hispanics 57%, whites 44%).26 However, in our study, the relationship between race and concern is likely mediated by language since many of the parents who described themselves as other than white also reported being not very comfortable with English and we could not find an effect of race on concern among parents who were very comfortable with English. Indeed, previous studies have linked decreased English proficiency to medical errors with potential clinical consequence.27

Given our previous investigation of the relationship between self‐efficacy and parent participation in medical decisions during a child's hospitalization, we conducted post‐hoc analyses exploring the association between parents' self‐report of participation in medical decisions and concern about medical errors during their child's hospitalization.16 Using a simple logistic regression we did not find any association. However, we advise caution in interpreting and generalizing these results because the study was not powered to adequately evaluate this association.

There are additional limitations in our study to be noted. First, this question has not been used previously to assess parental concern about medical errors, so future work will need to focus on assessing its reliability and validity. Second, it is also possible that parents' concern for medical errors is mitigated by the complexity of their child's healthcare.5 We attempted to address this issue by controlling for the child's number of chronic illnesses. However, it is possible that our metric did not capture the level of complexity associated with different types of chronic conditions. Moreover, additional variables such as health insurance type, parental physical and mental health, and quality of interactions with the nursing staff may confound the relationships that we observed. Future studies should examine the effect of these variables on parents' self‐efficacy and their concern about medical errors.

Third, we surveyed parents at a single institution and, as such, differences in demographics and hospital‐specific practices related to patient‐physician interactions may prevent generalization of our findings to other institutions. For example, the parents in our survey had a higher average education level than the general population and the racial makeup of our population was not nationally representative. Also, due to HIPAA constraints, we were unable to collect extensive demographic information on parents and children who were missed or those who refused to participate in the study, which also could conceivably influence the strength of our findings.

Fourth, we adapted a validated adult measure of self‐efficacy for use in pediatrics. The patient‐physician self‐efficacy scale, the PEPPI, did have a skewed distribution in our study, although this performance is consistent with adult studies18 and in post‐hoc analyses, outlier PEPPI scores did not have a significant effect on the magnitude of the relationship we observed between self‐efficacy and parental concern about medical errors. However, the reading level of this instrument is ninth grade, which may impact the generalization of our findings to populations with lower literacy levels.

Fifth, we excluded parents who were unsure about their concern from our analyses. In post‐hoc multivariate regression analyses, reassignment of unsure responses to either agree or disagree did not result in any change in odds ratio for any endpoint.

Finally, it is possible that parental concern was influenced by social desirability bias in that parents may have been less likely to report concern about medical errors during a hospitalization because of fear of the implications it might have for their child's care. We attempted to control for this effect by adjusting for social desirability bias using the Marlowe‐Crowne scale. This scale is commonly used in behavioral science research to account for such response bias and has been recommended by the NIH Consortium on Behavior Change for use in behavioral change research related to health.24

Within the context of these limitations, we feel that our study contributes an important first step toward characterizing the scope of parental concern about medical errors during pediatric hospitalizations and understanding the relationship of self‐efficacy with physician interactions to this concern. Devising a quality initiative program to improve parents' self‐efficacy interacting with physicians might help to temper parents' concerns about medical errors while also encouraging their involvement in their child's medical care. Such a program would likely prove most beneficial if it sought to improve self‐efficacy among parents with lower English proficiency given that this group had the highest concern for medical errors. Possible interventions might include more ready access to interpreters or use of visual aids.

The Institute of Medicine report linking between 48,000 and 98,000 deaths annually to medical errors1 has raised awareness about medical errors across all areas of medicine. In pediatrics, medical errors in hospitalized children are associated with significant increases in length of stay, healthcare costs, and death.2, 3 While much attention has been paid to the use of hospital systems to prevent medical errors, there has been considerably less focus on the experiences of patients and their potential role in preventing errors.

Studies have suggested that a significant majority of adult patients are concerned about medical errors during hospitalization.4, 5 However, a similar assessment of parents' concerns about medical errors in pediatrics is lacking. Admittedly, for concern to be constructive it must be linked to action. The Joint Commission and the Agency for Healthcare Research and Quality (AHRQ) currently recommend that parents help prevent errors by becoming active, involved and informed members of their healthcare team and taking part in every decision about (their) child's health care.6, 7 However, the extent to which parental concern about medical errors is related to a parent's self‐efficacy, or confidence, interacting with physicians is unknown.

Self‐efficacy is a construct used in social cognitive theory to explain behavior change.8 It refers to an individual's belief in (his/her) capabilities to organize and execute the courses of action required to produce given attainments or a desired outcome.9 Self‐efficacy is not a general concept; it must be discussed in reference to a specific activity. In healthcare it has been associated not only with willingness to adopt preventive strategies,10 but also with treatment adherence,11, 12 behavior change,13 and with greater patient participation in healthcare decision‐making.14, 15

In this study we had 2 objectives. First, we sought to assess the proportion of parents of hospitalized children who are concerned about medical errors. Second, we attempted to examine whether a parent's self‐efficacy interacting with physicians was associated with their concern about medical errors for their child. Given that parents with greater self‐efficacy interacting with physicians might feel more empowered to prevent errors and, as such, be more inclined to take an active role to do so, we hypothesized that such parents would be less concerned about medical errors during a pediatric hospitalization.

Subjects and Methods

Results

During the time period of our study, 278 parents were eligible to participate. Eighty‐five parents could not be surveyed either because they could not be reached despite multiple attempts (eg, out of the room, speaking with physicians) or because the child had already been discharged. Of the 193 parents approached, 130 agreed to take the survey. Two parents who agreed to complete the survey forgot to return it before their children were discharged. Demographics of respondents and nonparticipants are presented in Table 1. The distribution of self‐efficacy scores was skewed, with a mean score of 45 (median 46, range 5‐50) on a 50‐point scale, consistent with previous studies in adults.18

Eighty‐two parents (63% of respondents) Agreed or Strongly Agreed with the statement When my child is in the hospital I feel that I need to watch over his/her care in order to make sure that mistakes aren't made (Figure 1). In bivariate analyses, non‐white race (Table 2) and English proficiency (P = 0.002) were significantly associated with parental concern about medical errors. Notably, all respondents who were not very comfortable with English agreed that they felt the need to watch over their child's care to ensure that mistakes do not happen. The association between self‐efficacy with physician interactions and concern was nearly significant (Table 2).

Figure 1

In multivariate analysis, self‐efficacy was independently associated with parental report about the need to watch over a child's care (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.72‐0.92). In prediction models, with self‐efficacy scores of 44 (25th percentile), 46 (50th percentile), and 49 (75th percentile), about 72.2% (59.1‐82.3), 64.2% (51.8‐75.0), and 50.8% (35.3‐66.2) of parents, respectively, would feel the need to watch over their child's care to prevent medical errors.

While respondents of non‐white race had the greatest independent odds of reporting a concern for medical errors occurring while their child was hospitalized (OR, 4.9; 95% CI, 1.19‐20.4), we could not reliably determine how much of this effect was due to language instead of to race because the vast majority of parents who reported being less than very comfortable with English were also non‐white (non‐white 90.5% vs. white 9.5%, P < 0.001). In additional analyses we were unable to find a difference in concern about medical errors between white and non‐white parents who were very comfortable with English (data not shown).

Of note, while having 1 hospitalization compared to none was significantly associated with having decreased concern about medical errors (Table 2), the variable hospitalizations was not significant in the model (P = 0.07).

In post‐hoc analysis, we found no association between hospitalization for >3 days after birth, previous hospitalization for >1 week, parents' experience with the hospital system, and overall perception of child's health, previous hospitalizations for other children. While rating of care that child received was significantly associated with parents' concern about medical errors in the bivariate analysis, it did not remain significant in multivariate analysis and did not substantially change the magnitude or significance of previous associations.

Discussion

In our study, we found that nearly two‐thirds of parents of children admitted to the general pediatric service of a tertiary care children's hospital felt the need to watch over their child's care to ensure that mistakes would not be made. We also found that a parent's self‐efficacy interacting with physicians was associated with less parental concern for medical errors.

To our knowledge, this is the first study to systematically survey parents' concerns about medical errors during a child's hospitalization and to evaluate factors associated with this concern. The immediate question prompted by our findings is whether the fact that 63% of parents are concerned is alarming because it is too low or too high. Some might contend that concern about medical errors is an appropriate and desirable response because it may motivate parents to become more vigilant about the medical care that their child is receiving. However, others may challenge that such concern may indicate a feeling of powerlessness to act to prevent potential errors. In our study, the relationship between higher self‐efficacy and less parental concern raises the possibility that parents with higher levels of self‐efficacy with physician interactions may feel more comfortable communicating with physicians, which in turn may temper parents' concerns about medical errors during hospitalization.

It is equally plausible that concern about medical errors during hospitalization may motivate parents to become involved in their child's medical care and, in turn, lead them to feel empowered to prevent medical errors and so ease their concerns. It is conceivable that experience with past medical errors may fuel a parent's need to watch over their child's care to prevent additional medical errors. Future studies should address the independent effect of past medical errors on parental concern about medical errors.

In this study, all parents who reported being very uncomfortable with English and parents of non‐white race felt the need to watch over their child's care to help prevent errors. A previous survey of a nationally representative sample of U.S. adults found greater proportion of non‐white adults were very concerned about errors or mistakes happening when receiving care at a hospital (blacks 62%, Hispanics 57%, whites 44%).26 However, in our study, the relationship between race and concern is likely mediated by language since many of the parents who described themselves as other than white also reported being not very comfortable with English and we could not find an effect of race on concern among parents who were very comfortable with English. Indeed, previous studies have linked decreased English proficiency to medical errors with potential clinical consequence.27

Given our previous investigation of the relationship between self‐efficacy and parent participation in medical decisions during a child's hospitalization, we conducted post‐hoc analyses exploring the association between parents' self‐report of participation in medical decisions and concern about medical errors during their child's hospitalization.16 Using a simple logistic regression we did not find any association. However, we advise caution in interpreting and generalizing these results because the study was not powered to adequately evaluate this association.

There are additional limitations in our study to be noted. First, this question has not been used previously to assess parental concern about medical errors, so future work will need to focus on assessing its reliability and validity. Second, it is also possible that parents' concern for medical errors is mitigated by the complexity of their child's healthcare.5 We attempted to address this issue by controlling for the child's number of chronic illnesses. However, it is possible that our metric did not capture the level of complexity associated with different types of chronic conditions. Moreover, additional variables such as health insurance type, parental physical and mental health, and quality of interactions with the nursing staff may confound the relationships that we observed. Future studies should examine the effect of these variables on parents' self‐efficacy and their concern about medical errors.

Third, we surveyed parents at a single institution and, as such, differences in demographics and hospital‐specific practices related to patient‐physician interactions may prevent generalization of our findings to other institutions. For example, the parents in our survey had a higher average education level than the general population and the racial makeup of our population was not nationally representative. Also, due to HIPAA constraints, we were unable to collect extensive demographic information on parents and children who were missed or those who refused to participate in the study, which also could conceivably influence the strength of our findings.

Fourth, we adapted a validated adult measure of self‐efficacy for use in pediatrics. The patient‐physician self‐efficacy scale, the PEPPI, did have a skewed distribution in our study, although this performance is consistent with adult studies18 and in post‐hoc analyses, outlier PEPPI scores did not have a significant effect on the magnitude of the relationship we observed between self‐efficacy and parental concern about medical errors. However, the reading level of this instrument is ninth grade, which may impact the generalization of our findings to populations with lower literacy levels.

Fifth, we excluded parents who were unsure about their concern from our analyses. In post‐hoc multivariate regression analyses, reassignment of unsure responses to either agree or disagree did not result in any change in odds ratio for any endpoint.

Finally, it is possible that parental concern was influenced by social desirability bias in that parents may have been less likely to report concern about medical errors during a hospitalization because of fear of the implications it might have for their child's care. We attempted to control for this effect by adjusting for social desirability bias using the Marlowe‐Crowne scale. This scale is commonly used in behavioral science research to account for such response bias and has been recommended by the NIH Consortium on Behavior Change for use in behavioral change research related to health.24

Within the context of these limitations, we feel that our study contributes an important first step toward characterizing the scope of parental concern about medical errors during pediatric hospitalizations and understanding the relationship of self‐efficacy with physician interactions to this concern. Devising a quality initiative program to improve parents' self‐efficacy interacting with physicians might help to temper parents' concerns about medical errors while also encouraging their involvement in their child's medical care. Such a program would likely prove most beneficial if it sought to improve self‐efficacy among parents with lower English proficiency given that this group had the highest concern for medical errors. Possible interventions might include more ready access to interpreters or use of visual aids.

The Institute of Medicine report linking between 48,000 and 98,000 deaths annually to medical errors1 has raised awareness about medical errors across all areas of medicine. In pediatrics, medical errors in hospitalized children are associated with significant increases in length of stay, healthcare costs, and death.2, 3 While much attention has been paid to the use of hospital systems to prevent medical errors, there has been considerably less focus on the experiences of patients and their potential role in preventing errors.

Studies have suggested that a significant majority of adult patients are concerned about medical errors during hospitalization.4, 5 However, a similar assessment of parents' concerns about medical errors in pediatrics is lacking. Admittedly, for concern to be constructive it must be linked to action. The Joint Commission and the Agency for Healthcare Research and Quality (AHRQ) currently recommend that parents help prevent errors by becoming active, involved and informed members of their healthcare team and taking part in every decision about (their) child's health care.6, 7 However, the extent to which parental concern about medical errors is related to a parent's self‐efficacy, or confidence, interacting with physicians is unknown.

Self‐efficacy is a construct used in social cognitive theory to explain behavior change.8 It refers to an individual's belief in (his/her) capabilities to organize and execute the courses of action required to produce given attainments or a desired outcome.9 Self‐efficacy is not a general concept; it must be discussed in reference to a specific activity. In healthcare it has been associated not only with willingness to adopt preventive strategies,10 but also with treatment adherence,11, 12 behavior change,13 and with greater patient participation in healthcare decision‐making.14, 15

In this study we had 2 objectives. First, we sought to assess the proportion of parents of hospitalized children who are concerned about medical errors. Second, we attempted to examine whether a parent's self‐efficacy interacting with physicians was associated with their concern about medical errors for their child. Given that parents with greater self‐efficacy interacting with physicians might feel more empowered to prevent errors and, as such, be more inclined to take an active role to do so, we hypothesized that such parents would be less concerned about medical errors during a pediatric hospitalization.

Subjects and Methods

Results

During the time period of our study, 278 parents were eligible to participate. Eighty‐five parents could not be surveyed either because they could not be reached despite multiple attempts (eg, out of the room, speaking with physicians) or because the child had already been discharged. Of the 193 parents approached, 130 agreed to take the survey. Two parents who agreed to complete the survey forgot to return it before their children were discharged. Demographics of respondents and nonparticipants are presented in Table 1. The distribution of self‐efficacy scores was skewed, with a mean score of 45 (median 46, range 5‐50) on a 50‐point scale, consistent with previous studies in adults.18

Eighty‐two parents (63% of respondents) Agreed or Strongly Agreed with the statement When my child is in the hospital I feel that I need to watch over his/her care in order to make sure that mistakes aren't made (Figure 1). In bivariate analyses, non‐white race (Table 2) and English proficiency (P = 0.002) were significantly associated with parental concern about medical errors. Notably, all respondents who were not very comfortable with English agreed that they felt the need to watch over their child's care to ensure that mistakes do not happen. The association between self‐efficacy with physician interactions and concern was nearly significant (Table 2).

Figure 1

In multivariate analysis, self‐efficacy was independently associated with parental report about the need to watch over a child's care (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.72‐0.92). In prediction models, with self‐efficacy scores of 44 (25th percentile), 46 (50th percentile), and 49 (75th percentile), about 72.2% (59.1‐82.3), 64.2% (51.8‐75.0), and 50.8% (35.3‐66.2) of parents, respectively, would feel the need to watch over their child's care to prevent medical errors.

While respondents of non‐white race had the greatest independent odds of reporting a concern for medical errors occurring while their child was hospitalized (OR, 4.9; 95% CI, 1.19‐20.4), we could not reliably determine how much of this effect was due to language instead of to race because the vast majority of parents who reported being less than very comfortable with English were also non‐white (non‐white 90.5% vs. white 9.5%, P < 0.001). In additional analyses we were unable to find a difference in concern about medical errors between white and non‐white parents who were very comfortable with English (data not shown).

Of note, while having 1 hospitalization compared to none was significantly associated with having decreased concern about medical errors (Table 2), the variable hospitalizations was not significant in the model (P = 0.07).

In post‐hoc analysis, we found no association between hospitalization for >3 days after birth, previous hospitalization for >1 week, parents' experience with the hospital system, and overall perception of child's health, previous hospitalizations for other children. While rating of care that child received was significantly associated with parents' concern about medical errors in the bivariate analysis, it did not remain significant in multivariate analysis and did not substantially change the magnitude or significance of previous associations.

Discussion

In our study, we found that nearly two‐thirds of parents of children admitted to the general pediatric service of a tertiary care children's hospital felt the need to watch over their child's care to ensure that mistakes would not be made. We also found that a parent's self‐efficacy interacting with physicians was associated with less parental concern for medical errors.

To our knowledge, this is the first study to systematically survey parents' concerns about medical errors during a child's hospitalization and to evaluate factors associated with this concern. The immediate question prompted by our findings is whether the fact that 63% of parents are concerned is alarming because it is too low or too high. Some might contend that concern about medical errors is an appropriate and desirable response because it may motivate parents to become more vigilant about the medical care that their child is receiving. However, others may challenge that such concern may indicate a feeling of powerlessness to act to prevent potential errors. In our study, the relationship between higher self‐efficacy and less parental concern raises the possibility that parents with higher levels of self‐efficacy with physician interactions may feel more comfortable communicating with physicians, which in turn may temper parents' concerns about medical errors during hospitalization.

It is equally plausible that concern about medical errors during hospitalization may motivate parents to become involved in their child's medical care and, in turn, lead them to feel empowered to prevent medical errors and so ease their concerns. It is conceivable that experience with past medical errors may fuel a parent's need to watch over their child's care to prevent additional medical errors. Future studies should address the independent effect of past medical errors on parental concern about medical errors.

In this study, all parents who reported being very uncomfortable with English and parents of non‐white race felt the need to watch over their child's care to help prevent errors. A previous survey of a nationally representative sample of U.S. adults found greater proportion of non‐white adults were very concerned about errors or mistakes happening when receiving care at a hospital (blacks 62%, Hispanics 57%, whites 44%).26 However, in our study, the relationship between race and concern is likely mediated by language since many of the parents who described themselves as other than white also reported being not very comfortable with English and we could not find an effect of race on concern among parents who were very comfortable with English. Indeed, previous studies have linked decreased English proficiency to medical errors with potential clinical consequence.27

Given our previous investigation of the relationship between self‐efficacy and parent participation in medical decisions during a child's hospitalization, we conducted post‐hoc analyses exploring the association between parents' self‐report of participation in medical decisions and concern about medical errors during their child's hospitalization.16 Using a simple logistic regression we did not find any association. However, we advise caution in interpreting and generalizing these results because the study was not powered to adequately evaluate this association.

There are additional limitations in our study to be noted. First, this question has not been used previously to assess parental concern about medical errors, so future work will need to focus on assessing its reliability and validity. Second, it is also possible that parents' concern for medical errors is mitigated by the complexity of their child's healthcare.5 We attempted to address this issue by controlling for the child's number of chronic illnesses. However, it is possible that our metric did not capture the level of complexity associated with different types of chronic conditions. Moreover, additional variables such as health insurance type, parental physical and mental health, and quality of interactions with the nursing staff may confound the relationships that we observed. Future studies should examine the effect of these variables on parents' self‐efficacy and their concern about medical errors.

Third, we surveyed parents at a single institution and, as such, differences in demographics and hospital‐specific practices related to patient‐physician interactions may prevent generalization of our findings to other institutions. For example, the parents in our survey had a higher average education level than the general population and the racial makeup of our population was not nationally representative. Also, due to HIPAA constraints, we were unable to collect extensive demographic information on parents and children who were missed or those who refused to participate in the study, which also could conceivably influence the strength of our findings.

Fourth, we adapted a validated adult measure of self‐efficacy for use in pediatrics. The patient‐physician self‐efficacy scale, the PEPPI, did have a skewed distribution in our study, although this performance is consistent with adult studies18 and in post‐hoc analyses, outlier PEPPI scores did not have a significant effect on the magnitude of the relationship we observed between self‐efficacy and parental concern about medical errors. However, the reading level of this instrument is ninth grade, which may impact the generalization of our findings to populations with lower literacy levels.

Fifth, we excluded parents who were unsure about their concern from our analyses. In post‐hoc multivariate regression analyses, reassignment of unsure responses to either agree or disagree did not result in any change in odds ratio for any endpoint.

Finally, it is possible that parental concern was influenced by social desirability bias in that parents may have been less likely to report concern about medical errors during a hospitalization because of fear of the implications it might have for their child's care. We attempted to control for this effect by adjusting for social desirability bias using the Marlowe‐Crowne scale. This scale is commonly used in behavioral science research to account for such response bias and has been recommended by the NIH Consortium on Behavior Change for use in behavioral change research related to health.24

Within the context of these limitations, we feel that our study contributes an important first step toward characterizing the scope of parental concern about medical errors during pediatric hospitalizations and understanding the relationship of self‐efficacy with physician interactions to this concern. Devising a quality initiative program to improve parents' self‐efficacy interacting with physicians might help to temper parents' concerns about medical errors while also encouraging their involvement in their child's medical care. Such a program would likely prove most beneficial if it sought to improve self‐efficacy among parents with lower English proficiency given that this group had the highest concern for medical errors. Possible interventions might include more ready access to interpreters or use of visual aids.

Bronchiolitis was the most common primary diagnosis of infants hospitalized in the United States from 2000 to 2001.1 Consequently, much research has focused on the effectiveness of management24 and variation in care, especially the use of unproven diagnostic tests such as chest x‐rays.5 Such variation may have substantial financial and medical impact and has been shown to correlate significantly with hospital costs and length of stay.6

Because bronchiolitis is primarily a clinical diagnosis,7 there is no strong evidence to support the role of diagnostic testing, particularly that of complete blood counts (CBCs).8 Moreover, given the limited diagnostic utility of a single CBC, the benefit of obtaining a second CBC, especially with its associated physical discomfort and additional financial costs, is questionable. Yet despite the lack of evidence and rationale to support initial and repeated ordering of CBCs, we suspect that this practice may be more widespread and variable than currently appreciated.

Using a national database of children's hospitals, we sought to determine the frequency with which CBCs are ordered and repeated during hospitalizations for bronchiolitis, the extent to which these practices vary across institutions, and the relationship of these practices to average charges for a hospital stay.

METHODS

RESULTS

A total of 17,397 children met the inclusion criteria. Children under 3 months were more likely to be covered by Medicaid, be admitted to the ICU, have a longer length of stay, and have at least 1 CBC (Table 1). Of all children hospitalized, 48.2% had at least 1 CBC, and 7.8% had more than 1 CBC performed during their hospital stay. Notably, the proportion of all admissions with at least 1 CBC varied from 23.2% to 79.2% (Fig. 1), and those with repeat CBCs varied from 0% to 18.6% across hospitals (Fig. 2). This variation was significant when stratified by age and adjusted for covariates, which included length of stay and severity of illness (P < .001). In additional post hoc analyses we found differences in ordering pattern by disease severity that should be noted. The proportion of admissions with repeat CBCs varied significantly across severity groups (mild 3.9%, moderate 10.3%, and severe 21.3%, P < .001) and ICU admission status (ICU admission 5.5%, no ICU admission 23%, P <.001). Stratified analyses indicated an interaction between ICU utilization and disease severity, but neither covariate showed significant interactions with other variables in the model (data not shown).

Figure 1

Figure 2

With respect to repeat CBCs, for children at least 3 months old, the strongest predictor was ICU admission (odds ratio [OR] 2.53, 95% CI: 1.69‐3.77), followed by a severe or extreme APR‐DRG severity score (OR 1.75, 95% CI: 1.23‐2.49) and LOS (OR 1.22, 95% CI: 1.15‐1.28). For children less than 3 months old, some of these associations strengthened ICU admission (OR 2.58, 95% CI: 1.84‐3.61), followed by a severe or extreme APR‐DRG severity score (OR 2.31, 95% CI: 1.64‐3.24) and LOS (OR 1.24, 95% CI: 1.16‐1.32). Additional predictors for this age group were a moderate severity score (OR 1.67, 95% CI: 1.29‐2.16) and Medicaid status (OR 1.20, 95% CI: 1.0‐1.43) (Table 2).

Compared with hospitals that had the lowest proportion of admissions in which CBCs were ordered, hospitals with higher proportions of CBCs ordered had significantly higher mean charges per hospital stay (Table 3).

DISCUSSION

We found that in a nationwide sample of children hospitalized with bronchiolitis, 48% had at least 1 CBC and nearly 8% had a repeat CBC ordered during their hospital stay. Moreover, even after adjusting for covariates, the proportion of children with initial and repeat CBCs during a single admission varied widely and significantly across a nationwide sample of children's hospitals.

We can only speculate on the reasons for institutional variation. Although it is not unusual for some cases of illness to vary from a standard course and so trigger initial or repeat evaluations with a CBC, we do not have any a priori reason to expect the proportion of unusual cases to vary by institution in a national cohort of children's hospitals. One compelling explanation for this variation is differing institutional patterns of practice. For example, it may be that some institutions have protocols that require the ordering of a CBC on admission. This practice could prompt a costly and unnecessary testing cascade14 generated by an initially abnormal CBC and so could trigger additional testing and/or procedures, such as x‐rays and parental antibiotics. Such a cascade of testing and intervention could conceivably lead to additional, and dependent, costs not captured by a simple tally of the costs of individual CBCs. Indeed, in our analysis we found that those hospitals with higher proportion of admissions in which CBCs were ordered also had significantly higher admission charges that exceeded the cost of a CBC. Previous studies support the finding that institutional variation in care for viral respiratory illness is significantly correlated with hospital costs.6

Limitations of this study should be noted. First, the PHIS database does not provide indications for, results of, or hospital location of tests, so we cannot determine whether clinical condition or results prompted initial and/or repeat testing. However, because children with complicated courses or atypical disease presentations likely have longer hospital stays, severe disease, or additional diagnoses, we attempted to control for these factors in our analysis. Second, although we selected cases based on a discharge diagnosis of bronchiolitis, it is possible that admitting physicians obtained an initial CBC to rule out alternative diagnoses, such as bacteremia, which can occur but is rare in this population.12, 13 It is plausible that bacteremia is most likely in children with other comorbidities or higher disease severity. In additional stratified analyses we did find that the proportion of repeat CBCs increased with higher disease severity and that there was an interaction between severe disease status and ICU admission. However, all participating institutions are children's hospitals and so are likely to treat children with a range of severity of illness and comorbidities. Finally, as with other analyses of the PHIS database, we used charges to identify diagnostic tests.5

Given that more than 120,000 U.S. infants are hospitalized annually with bronchiolitis,15 the cost and discomfort associated with unnecessary testing warrants attention. The issue of cost is particularly relevant in light of recent research findings of increased costs for admissions at freestanding children's hospitals.16 We found that mean charges per hospital stay were significantly higher for hospitals that had a higher proportion of admissions during which multiple CBCs were ordered. Although we cannot exclude illness severity and age as explanations for the higher charges, we have no reason to believe that one freestanding children's hospital would have a sicker and younger population than another. An alternative and compelling explanation is that a variation in the standard of care exists across these hospitals.

The institutional variation in and the limited evidence for the utility of the ordering of CBCs in the evaluation of bronchiolitis call into question the necessity of this testing strategy. Exploration of the reasons for this institutional variation will help to create quality initiatives and directed interventions to improve and standardize care in bronchiolitis.

Bronchiolitis was the most common primary diagnosis of infants hospitalized in the United States from 2000 to 2001.1 Consequently, much research has focused on the effectiveness of management24 and variation in care, especially the use of unproven diagnostic tests such as chest x‐rays.5 Such variation may have substantial financial and medical impact and has been shown to correlate significantly with hospital costs and length of stay.6

Because bronchiolitis is primarily a clinical diagnosis,7 there is no strong evidence to support the role of diagnostic testing, particularly that of complete blood counts (CBCs).8 Moreover, given the limited diagnostic utility of a single CBC, the benefit of obtaining a second CBC, especially with its associated physical discomfort and additional financial costs, is questionable. Yet despite the lack of evidence and rationale to support initial and repeated ordering of CBCs, we suspect that this practice may be more widespread and variable than currently appreciated.

Using a national database of children's hospitals, we sought to determine the frequency with which CBCs are ordered and repeated during hospitalizations for bronchiolitis, the extent to which these practices vary across institutions, and the relationship of these practices to average charges for a hospital stay.

METHODS

RESULTS

A total of 17,397 children met the inclusion criteria. Children under 3 months were more likely to be covered by Medicaid, be admitted to the ICU, have a longer length of stay, and have at least 1 CBC (Table 1). Of all children hospitalized, 48.2% had at least 1 CBC, and 7.8% had more than 1 CBC performed during their hospital stay. Notably, the proportion of all admissions with at least 1 CBC varied from 23.2% to 79.2% (Fig. 1), and those with repeat CBCs varied from 0% to 18.6% across hospitals (Fig. 2). This variation was significant when stratified by age and adjusted for covariates, which included length of stay and severity of illness (P < .001). In additional post hoc analyses we found differences in ordering pattern by disease severity that should be noted. The proportion of admissions with repeat CBCs varied significantly across severity groups (mild 3.9%, moderate 10.3%, and severe 21.3%, P < .001) and ICU admission status (ICU admission 5.5%, no ICU admission 23%, P <.001). Stratified analyses indicated an interaction between ICU utilization and disease severity, but neither covariate showed significant interactions with other variables in the model (data not shown).

Figure 1

Figure 2

With respect to repeat CBCs, for children at least 3 months old, the strongest predictor was ICU admission (odds ratio [OR] 2.53, 95% CI: 1.69‐3.77), followed by a severe or extreme APR‐DRG severity score (OR 1.75, 95% CI: 1.23‐2.49) and LOS (OR 1.22, 95% CI: 1.15‐1.28). For children less than 3 months old, some of these associations strengthened ICU admission (OR 2.58, 95% CI: 1.84‐3.61), followed by a severe or extreme APR‐DRG severity score (OR 2.31, 95% CI: 1.64‐3.24) and LOS (OR 1.24, 95% CI: 1.16‐1.32). Additional predictors for this age group were a moderate severity score (OR 1.67, 95% CI: 1.29‐2.16) and Medicaid status (OR 1.20, 95% CI: 1.0‐1.43) (Table 2).

Compared with hospitals that had the lowest proportion of admissions in which CBCs were ordered, hospitals with higher proportions of CBCs ordered had significantly higher mean charges per hospital stay (Table 3).

DISCUSSION

We found that in a nationwide sample of children hospitalized with bronchiolitis, 48% had at least 1 CBC and nearly 8% had a repeat CBC ordered during their hospital stay. Moreover, even after adjusting for covariates, the proportion of children with initial and repeat CBCs during a single admission varied widely and significantly across a nationwide sample of children's hospitals.

We can only speculate on the reasons for institutional variation. Although it is not unusual for some cases of illness to vary from a standard course and so trigger initial or repeat evaluations with a CBC, we do not have any a priori reason to expect the proportion of unusual cases to vary by institution in a national cohort of children's hospitals. One compelling explanation for this variation is differing institutional patterns of practice. For example, it may be that some institutions have protocols that require the ordering of a CBC on admission. This practice could prompt a costly and unnecessary testing cascade14 generated by an initially abnormal CBC and so could trigger additional testing and/or procedures, such as x‐rays and parental antibiotics. Such a cascade of testing and intervention could conceivably lead to additional, and dependent, costs not captured by a simple tally of the costs of individual CBCs. Indeed, in our analysis we found that those hospitals with higher proportion of admissions in which CBCs were ordered also had significantly higher admission charges that exceeded the cost of a CBC. Previous studies support the finding that institutional variation in care for viral respiratory illness is significantly correlated with hospital costs.6

Limitations of this study should be noted. First, the PHIS database does not provide indications for, results of, or hospital location of tests, so we cannot determine whether clinical condition or results prompted initial and/or repeat testing. However, because children with complicated courses or atypical disease presentations likely have longer hospital stays, severe disease, or additional diagnoses, we attempted to control for these factors in our analysis. Second, although we selected cases based on a discharge diagnosis of bronchiolitis, it is possible that admitting physicians obtained an initial CBC to rule out alternative diagnoses, such as bacteremia, which can occur but is rare in this population.12, 13 It is plausible that bacteremia is most likely in children with other comorbidities or higher disease severity. In additional stratified analyses we did find that the proportion of repeat CBCs increased with higher disease severity and that there was an interaction between severe disease status and ICU admission. However, all participating institutions are children's hospitals and so are likely to treat children with a range of severity of illness and comorbidities. Finally, as with other analyses of the PHIS database, we used charges to identify diagnostic tests.5

Given that more than 120,000 U.S. infants are hospitalized annually with bronchiolitis,15 the cost and discomfort associated with unnecessary testing warrants attention. The issue of cost is particularly relevant in light of recent research findings of increased costs for admissions at freestanding children's hospitals.16 We found that mean charges per hospital stay were significantly higher for hospitals that had a higher proportion of admissions during which multiple CBCs were ordered. Although we cannot exclude illness severity and age as explanations for the higher charges, we have no reason to believe that one freestanding children's hospital would have a sicker and younger population than another. An alternative and compelling explanation is that a variation in the standard of care exists across these hospitals.

The institutional variation in and the limited evidence for the utility of the ordering of CBCs in the evaluation of bronchiolitis call into question the necessity of this testing strategy. Exploration of the reasons for this institutional variation will help to create quality initiatives and directed interventions to improve and standardize care in bronchiolitis.

Bronchiolitis was the most common primary diagnosis of infants hospitalized in the United States from 2000 to 2001.1 Consequently, much research has focused on the effectiveness of management24 and variation in care, especially the use of unproven diagnostic tests such as chest x‐rays.5 Such variation may have substantial financial and medical impact and has been shown to correlate significantly with hospital costs and length of stay.6

Because bronchiolitis is primarily a clinical diagnosis,7 there is no strong evidence to support the role of diagnostic testing, particularly that of complete blood counts (CBCs).8 Moreover, given the limited diagnostic utility of a single CBC, the benefit of obtaining a second CBC, especially with its associated physical discomfort and additional financial costs, is questionable. Yet despite the lack of evidence and rationale to support initial and repeated ordering of CBCs, we suspect that this practice may be more widespread and variable than currently appreciated.

Using a national database of children's hospitals, we sought to determine the frequency with which CBCs are ordered and repeated during hospitalizations for bronchiolitis, the extent to which these practices vary across institutions, and the relationship of these practices to average charges for a hospital stay.

METHODS

RESULTS

A total of 17,397 children met the inclusion criteria. Children under 3 months were more likely to be covered by Medicaid, be admitted to the ICU, have a longer length of stay, and have at least 1 CBC (Table 1). Of all children hospitalized, 48.2% had at least 1 CBC, and 7.8% had more than 1 CBC performed during their hospital stay. Notably, the proportion of all admissions with at least 1 CBC varied from 23.2% to 79.2% (Fig. 1), and those with repeat CBCs varied from 0% to 18.6% across hospitals (Fig. 2). This variation was significant when stratified by age and adjusted for covariates, which included length of stay and severity of illness (P < .001). In additional post hoc analyses we found differences in ordering pattern by disease severity that should be noted. The proportion of admissions with repeat CBCs varied significantly across severity groups (mild 3.9%, moderate 10.3%, and severe 21.3%, P < .001) and ICU admission status (ICU admission 5.5%, no ICU admission 23%, P <.001). Stratified analyses indicated an interaction between ICU utilization and disease severity, but neither covariate showed significant interactions with other variables in the model (data not shown).

Figure 1

Figure 2

With respect to repeat CBCs, for children at least 3 months old, the strongest predictor was ICU admission (odds ratio [OR] 2.53, 95% CI: 1.69‐3.77), followed by a severe or extreme APR‐DRG severity score (OR 1.75, 95% CI: 1.23‐2.49) and LOS (OR 1.22, 95% CI: 1.15‐1.28). For children less than 3 months old, some of these associations strengthened ICU admission (OR 2.58, 95% CI: 1.84‐3.61), followed by a severe or extreme APR‐DRG severity score (OR 2.31, 95% CI: 1.64‐3.24) and LOS (OR 1.24, 95% CI: 1.16‐1.32). Additional predictors for this age group were a moderate severity score (OR 1.67, 95% CI: 1.29‐2.16) and Medicaid status (OR 1.20, 95% CI: 1.0‐1.43) (Table 2).

Compared with hospitals that had the lowest proportion of admissions in which CBCs were ordered, hospitals with higher proportions of CBCs ordered had significantly higher mean charges per hospital stay (Table 3).

DISCUSSION

We found that in a nationwide sample of children hospitalized with bronchiolitis, 48% had at least 1 CBC and nearly 8% had a repeat CBC ordered during their hospital stay. Moreover, even after adjusting for covariates, the proportion of children with initial and repeat CBCs during a single admission varied widely and significantly across a nationwide sample of children's hospitals.

We can only speculate on the reasons for institutional variation. Although it is not unusual for some cases of illness to vary from a standard course and so trigger initial or repeat evaluations with a CBC, we do not have any a priori reason to expect the proportion of unusual cases to vary by institution in a national cohort of children's hospitals. One compelling explanation for this variation is differing institutional patterns of practice. For example, it may be that some institutions have protocols that require the ordering of a CBC on admission. This practice could prompt a costly and unnecessary testing cascade14 generated by an initially abnormal CBC and so could trigger additional testing and/or procedures, such as x‐rays and parental antibiotics. Such a cascade of testing and intervention could conceivably lead to additional, and dependent, costs not captured by a simple tally of the costs of individual CBCs. Indeed, in our analysis we found that those hospitals with higher proportion of admissions in which CBCs were ordered also had significantly higher admission charges that exceeded the cost of a CBC. Previous studies support the finding that institutional variation in care for viral respiratory illness is significantly correlated with hospital costs.6

Limitations of this study should be noted. First, the PHIS database does not provide indications for, results of, or hospital location of tests, so we cannot determine whether clinical condition or results prompted initial and/or repeat testing. However, because children with complicated courses or atypical disease presentations likely have longer hospital stays, severe disease, or additional diagnoses, we attempted to control for these factors in our analysis. Second, although we selected cases based on a discharge diagnosis of bronchiolitis, it is possible that admitting physicians obtained an initial CBC to rule out alternative diagnoses, such as bacteremia, which can occur but is rare in this population.12, 13 It is plausible that bacteremia is most likely in children with other comorbidities or higher disease severity. In additional stratified analyses we did find that the proportion of repeat CBCs increased with higher disease severity and that there was an interaction between severe disease status and ICU admission. However, all participating institutions are children's hospitals and so are likely to treat children with a range of severity of illness and comorbidities. Finally, as with other analyses of the PHIS database, we used charges to identify diagnostic tests.5

Given that more than 120,000 U.S. infants are hospitalized annually with bronchiolitis,15 the cost and discomfort associated with unnecessary testing warrants attention. The issue of cost is particularly relevant in light of recent research findings of increased costs for admissions at freestanding children's hospitals.16 We found that mean charges per hospital stay were significantly higher for hospitals that had a higher proportion of admissions during which multiple CBCs were ordered. Although we cannot exclude illness severity and age as explanations for the higher charges, we have no reason to believe that one freestanding children's hospital would have a sicker and younger population than another. An alternative and compelling explanation is that a variation in the standard of care exists across these hospitals.

The institutional variation in and the limited evidence for the utility of the ordering of CBCs in the evaluation of bronchiolitis call into question the necessity of this testing strategy. Exploration of the reasons for this institutional variation will help to create quality initiatives and directed interventions to improve and standardize care in bronchiolitis.