Development and Validation of the Pediatric Medical Complexity Algorithm (PMCA) Version 3.0

OBJECTIVE

To modify the Pediatric Medical Complexity Algorithm (PMCA) to include both International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification (ICD-9/10-CM) codes for classifying children with chronic disease (CD) by level of medical complexity and to assess the sensitivity and specificity of the new PMCA version 3.0 for correctly identifying level of medical complexity.

METHODS

To create version 3.0, PMCA version 2.0 was modified to include ICD-10-CM codes. We applied PMCA version 3.0 to Seattle Children's Hospital data for children with ≥1 emergency department (ED), day surgery, and/or inpatient encounter from January 1, 2016, to June 30, 2017. Starting with the encounter date, up to 3 years of retrospective discharge data were used to classify children as having complex chronic disease (C-CD), noncomplex chronic disease (NC-CD), and no CD. We then selected a random sample of 300 children (100 per CD group). Blinded medical record review was conducted to ascertain the levels of medical complexity for these 300 children. The sensitivity and specificity of PMCA version 3.0 was assessed.

RESULTS

PMCA version 3.0 identified children with C-CD with 86% sensitivity and 86% specificity, children with NC-CD with 65% sensitivity and 84% specificity, and children without CD with 77% sensitivity and 93% specificity.

CONCLUSIONS

PMCA version 3.0 is an updated publicly available algorithm that identifies children with C-CD, who have accessed tertiary hospital emergency department, day surgery, or inpatient care, with very good sensitivity and specificity when applied to hospital discharge data and with performance to earlier versions of PMCA.

Caregiver and Health Care Provider Perspectives on Cloud-Based Shared Care Plans for Children With Medical Complexity

OBJECTIVES

Shared care plans play an essential role in coordinating care across health care providers and settings for children with medical complexity (CMC). However, existing care plans often lack shared ownership, are out-of-date, and lack universal accessibility. In this study, we aimed to establish requirements for shared care plans to meet the information needs of caregivers and providers and to mitigate current information barriers when caring for CMC.

METHODS

We followed a user-centered design methodology and conducted in-depth semistructured interviews with caregivers and providers of CMC who receive care at a tertiary care children's hospital. We applied inductive, thematic analysis to identify salient themes. Analysis occurred concurrently with data collection; therefore, the interview guide was iteratively revised as new questions and themes emerged.

RESULTS

Interviews were conducted with 17 caregivers and 22 providers. On the basis of participant perspectives, we identified 4 requirements for shared care plans that would help meet information needs and mitigate current information barriers when caring for CMC. These requirements included the following: (1) supporting the accessibility of care plans from multiple locations (eg, cloud-based) and from multiple devices, with alert and search features; (2) ensuring the organization is tailored to the specific user; (3) including collaborative functionality such as real-time, multiuser content management and secure messaging; and (4) storing care plans on a secure platform with caregiver-controlled permission settings.

CONCLUSIONS

Although further studies are needed to understand the optimal design and implementation strategies, shared care plans that meet these specified requirements could mitigate perceived information barriers and improve care for CMC.

Hospital-Based Quality Measures for Pediatric Mental Health Care

BACKGROUND AND OBJECTIVES

Patients with a primary mental health condition account for nearly 10% of pediatric hospitalizations nationally, but little is known about the quality of care provided for them in hospital settings. Our objective was to develop and test medical record-based measures used to assess quality of pediatric mental health care in the emergency department (ED) and inpatient settings.

METHODS

We drafted an evidence-based set of pediatric mental health care quality measures for the ED and inpatient settings. We used the modified Delphi method to prioritize measures; 2 ED and 6 inpatient measures were operationalized and field-tested in 2 community and 3 children's hospitals. Eligible patients were 5 to 19 years old and diagnosed with psychosis, suicidality, or substance use from January 2012 to December 2013. We used bivariate and multivariate models to examine measure performance by patient characteristics and by hospital.

RESULTS

Eight hundred and seventeen records were abstracted with primary diagnoses of suicidality (n = 446), psychosis (n = 321), and substance use (n = 50). Performance varied across measures. Among patients with suicidality, male patients (adjusted odds ratio: 0.27, P < .001) and African American patients (adjusted odds ratio: 0.31, P = .02) were less likely to have documentation of caregiver counseling on lethal means restriction. Among admitted suicidal patients, 27% had documentation of communication with an outside provider, with variation across hospitals (0%-38%; P < .001). There was low overall performance on screening for comorbid substance abuse in ED patients with psychosis (mean: 30.3).

CONCLUSIONS

These new pediatric mental health care quality measures were used to identify sex and race disparities and substantial hospital variation. These measures may be useful for assessing and improving hospital-based pediatric mental health care quality.

Development of a Caregiver-Reported Experience Measure for Pediatric Hospital-to-Home Transitions

OBJECTIVE

To develop and test a caregiver-reported experience measure for pediatric hospital-to-home transitions.

DATA SOURCES/STUDY SETTING

Primary data were collected between 07/2014 and 05/2015 from caregivers within 2-8 weeks of their child's discharge from a tertiary care children's hospital.

STUDY DESIGN/DATA COLLECTION

We used a step-wise approach to developing the measure that included drafting de novo survey items based on caregiver interviews (n = 18), pretesting items using cognitive interviews (n = 18), and pilot testing revised items among an independent sample of caregivers (n = 500). Item reduction statistics and confirmatory factor analysis (CFA) were performed on a test sample of the pilot data to refine the measure, followed by CFA on the validation sample to test the final measure model fit.

PRINCIPAL FINDINGS

Of 46 initial survey items, 19 were removed after pretesting and 19 were removed after conducting item statistics and CFA. This resulted in an eight-item measure with two domains: transition preparation (four items) and transition support (four items). Survey items assess the quality of discharge instructions, access to needed support and resources, care coordination, and follow-up care. Practical fit indices demonstrated an acceptable model fit: χ²  = 28.3 (df = 19); root-mean-square error of approximation = 0.04; comparative fit index = 0.99; and Tucker-Lewis index = 0.98.

CONCLUSIONS

An eight-item caregiver-reported experience measure to evaluate hospital-to-home transition outcomes in pediatric populations demonstrated acceptable content validity and psychometric properties.

Impact of Childhood Vaccine Discussion Format Over Time on Immunization Status

OBJECTIVE

Presumptive formats to initiate childhood vaccine discussions (eg, "Well, we have to do some shots") have been associated with increased vaccine acceptance after one visit compared to participatory formats (eg, "How do you feel about vaccines?"). We characterize discussion format patterns over time and the impact of their repeated use on vaccine acceptance.

METHODS

We conducted a longitudinal prospective cohort study of children of vaccine-hesitant parents enrolled in a Seattle-based integrated health system. After the child's 2-, 4-, and 6-month visits, parents reported the format their child's provider used to begin the vaccine discussion (presumptive, participatory, or other). Our outcome was the percentage of days underimmunized of the child at 8 months old for 6 recommended vaccines. We used linear regression and generalized estimating equations to test the association of discussion format and immunization status.

RESULTS

We enrolled 73 parent-child dyads and obtained data from 82%, 73%, and 53% after the 2-, 4-, and 6-month visits, respectively. Overall, 65% of parents received presumptive formats at ≥1 visit and 42% received participatory formats at ≥1 visit. Parental receipt of presumptive formats at 1 and ≥2 visits (vs no receipt) was associated with significantly less underimmunization of the child, while receipt of participatory formats at ≥2 visits was associated with significantly more underimmunization. Visit-specific use of participatory (vs presumptive) formats was associated with a child being 10.1% (95% confidence interval, 0.3, 19.8; P = .04) more days underimmunized (amounting to, on average, 98 more days underimmunized for all 6 vaccines combined).

CONCLUSIONS

Presumptive (vs participatory) discussion formats are associated with increased immunization.

Development of New Quality Measures for Hospital-Based Care of Suicidal Youth

OBJECTIVES

To develop, validate, and test the feasibility of implementation of 4 new quality measures assessing emergency department (ED) and inpatient care for suicidal youth.

METHODS

Four quality measures were developed to assess hospital-based care for suicidal youth. These measures, focused on counseling caregivers about restricting access to lethal means of self-harm and benefits and risks of antidepressant medications, were operationalized into 2 caregiver surveys that assessed ED and inpatient quality, respectively. Survey field tests included caregivers of youth who received inpatient and/or ED care for suicidality at 1 of 2 children's hospitals between July 2013 and June 2014. We examined the feasibility of obtaining measure scores and variation in scores. Multivariate models examined associations between quality measure scores and 4 validation metrics: modified Child Hospital Consumer Assessments of Health Care Providers and Systems, communication composites, hospital readmissions, and ED return visits.

RESULTS

Response rates were 35% (ED) and 31% (inpatient). Most caregivers reported receiving counseling to restrict their child's access to lethal means of self-harm (90% in the ED and 96% in the inpatient setting). In the inpatient setting, caregivers reported higher rates of counseling on benefits (95%) of newly prescribed antidepressants than risks (physical adverse effects 85%, increased suicidality 72%). Higher scores on the latter measure were associated with higher nurse (P < .001) and doctor (P < .01) communication composite scores. Measure scores were not associated with readmissions or ED return visits.

CONCLUSIONS

These new quality measures evaluate key aspects of care for suicidal youth, and they may facilitate assessing quality of care for this vulnerable population.

Using State Administrative Data to Identify Social Complexity Risk Factors for Children

PURPOSE

Screening for social determinants of health is challenging but critically important for optimizing child health outcomes. We aimed to test the feasibility of using an integrated state agency administrative database to identify social complexity risk factors and examined their relationship to emergency department (ED) use.

METHODS

We conducted a retrospective cohort study among children younger than 18 years with Washington State Medicaid insurance coverage (N = 505,367). We linked child and parent administrative data for this cohort to identify a set of social complexity risk factors, such as poverty and parent mental illness, that have either a known or hypothesized association with suboptimal health care use. Using multivariate analyses, we examined associations of each risk factor and of number of risk factors with the rate of ED use.

RESULTS

Nine of 11 identifiable social complexity risk factors were associated with a higher rate of ED use. Additionally, the rate increased as the number of risk factors increased from 0 to 5 or more, reaching approximately twice the rate when 5 or more risk factors were present in children aged younger than 5 years (incidence rate ratio = 1.92; 95% CI, 1.85-2.00) and in children aged 5 to 17 years (incidence rate ratio = 2.06; 95% CI, 1.99-2.14).

CONCLUSIONS

State administrative data can be used to identify social complexity risk factors associated with higher rates of ED use among Medicaid-insured children. State agencies could give primary care medical homes a social risk flag or score to facilitate targeted screening and identification of needed resources, potentially preventing future unnecessary ED use in this vulnerable population of children.

Agreement Between Parent Proxy Report and Child Self-Report of Pain Intensity and Health-Related Quality of Life After Surgery

OBJECTIVES

Monitoring patient-centered health outcomes after hospital discharge is important for identifying patients experiencing poor recovery after surgery. Utilizing parent reports may improve the feasibility of monitoring recovery when children are not available to provide self-report. We therefore aimed to examine agreement between parent and child reports of child pain and health-related quality of life (HRQOL) in children after hospital discharge from inpatient surgery.

METHODS

A total of 295 children aged 8 to 18 years and their parents reported on child pain intensity using an 11-point numerical rating scale and on HRQOL using the 0- to 100-point Pediatric Quality of Life Inventory Version 4.0 Generic Core Scales by phone or online, 4 to 8 weeks after surgery. Agreement between parent and child ratings was assessed by absolute discrepancy scores, Pearson product-moment correlations, 2-way mixed effects intraclass correlation coefficient models, and linear regression models.

RESULTS

We found good to excellent agreement between child and parent reports of pain intensity and HRQOL. Average absolute discrepancy scores of pain intensity and HRQOL were 0.6 and 7.8 points, respectively. Pearson product-moment correlation coefficients were 0.74 and 0.80, and intraclass correlation coefficients were 0.72 and 0.79, for pain intensity and HRQOL, respectively. Regression coefficients for models examining pain intensity and HRQOL were 0.93 to 0.98 and 1.0, respectively.

CONCLUSIONS

Although child and parent reports may both contribute important information, parent report is a valid proxy for child self-reported pain intensity and HRQOL after discharge from inpatient pediatric surgery, which may prove important for better understanding pain experiences and intervention needs.

Importance and Feasibility of Transitional Care for Children With Medical Complexity: Results of a Multistakeholder Delphi Process

BACKGROUND

Children with medical complexity (CMC) account for disproportionate hospital utilization and adverse outcomes after discharge, and several gaps exist regarding the quality of hospital to home transitional care for this population. We conducted an expert elicitation process to identify important and feasible hospital to home transitional care interventions for CMC from the perspectives of parents and health care professionals.

METHODS

We conducted a 2-round electronic Delphi process to identify important and feasible transitional care interventions. Panelists included parents of CMC and multidisciplinary health care professionals. In the first round, panelists rated the importance and feasibility of 39 transitional care interventions on a 9-point Likert scale; agreement between panelists was defined according to RAND/UCLA Appropriateness Methods. The second round of data collection evaluated 16 interventions that panelists did not agree on in the first round and 8 new or revised interventions, accompanied by quantitative and qualitative data summaries.

RESULTS

A total of 29 parents of CMC and 37 health care professionals participated in the Delphi process (response rate 75%). Both stakeholder panels endorsed most interventions as important; health care professionals were less likely to rate several interventions as feasible compared with the parent panel. Over 2 rounds of data collection, the 2 stakeholder panels endorsed 25 interventions as important as well as feasible. These interventions related to family engagement during the hospitalization, care coordination and social support assessment, predischarge education, and written materials.

CONCLUSIONS

Parents and health care professionals considered several transitional care interventions important as well as feasible. This research might inform hospitals' transitional care programs and policies.

Effectiveness of a Comprehensive Case Management Service for Children With Medical Complexity

OBJECTIVES

To assess whether children with medical complexity (CMC) exposed to a hospital-based comprehensive case management service (CCMS) experience improved health care quality, improved functional status, reduced hospital-based utilization, and/or reduced overall health care costs.

METHODS

Eligible CMC at Seattle Children's Hospital were enrolled in a cluster randomized controlled trial between December 1, 2010, and September 29, 2014. Participating primary care providers (PCPs) were randomly assigned, and CMC either had access to an outpatient hospital-based CCMS or usual care directed by their PCP. The CCMS included visits to a multidisciplinary clinic ≥ every 6 months for 1.5 years, an individualized shared care plan, and access to CCMS providers. Differences between control and intervention groups in change from baseline to 12 months and baseline to 18 months (difference of differences) were tested.

RESULTS

Two hundred PCPs caring for 331 CMC were randomly assigned. Intervention group (n = 181) parents reported more improvement in the Consumer Assessment of Healthcare Providers and Systems version 4.0 Child Health Plan Survey global health care quality ratings than control group parents (6.7 [95% confidence interval (CI): 3.5-9.8] vs 1.3 [95% CI: 1.9-4.6] at 12 months). We did not detect significant differences in child functional status and most hospital-based utilization between groups. The difference in change of overall health care costs was higher in the intervention group (+$8233 [95% CI: $1701-$16 937]) at 18 months). CCMS clinic costs averaged $3847 per child-year.

CONCLUSIONS

Access to a CCMS generally improved health care quality, but was not associated with changes in child functional status or hospital-based utilization, and increased overall health care costs among CMC.

Development and Implementation of the Family Experiences With Coordination of Care Survey Quality Measures

OBJECTIVE

Ensuring high-quality care coordination for children with medical complexity (CMC) could yield significant health and economic benefits because they account for one-third of pediatric health care expenditures. The objective of this study was to develop and field test the Family Experiences with Coordination of Care (FECC) survey, which facilitates assessment of 20 new caregiver-reported quality measures for CMC.

METHODS

We identified caregivers of Medicaid-insured CMC aged 0 to 17 years in Minnesota and Washington state, categorized by the Pediatric Medical Complexity Algorithm as having complex chronic disease. Eligible caregivers had CMC with at least 4 visits to health care providers participating in Medicaid in 2012. Caregivers were randomized to telephone or mixed mode (mail with telephone follow-up). Survey administration and data were collected in 2013.

RESULTS

Twelve hundred nine caregivers responded to the FECC survey (response rate, 41%; 36% via telephone only, 46% via mixed mode; P < .001). Among CMC with a hospitalization, caregivers were invited to join hospital rounds in 51% of cases. Seventy-two percent of caregivers reported their child had a care coordinator; among these, 96% reported knowing how to access the care coordinator. Few children had written shared care plans (44%) or emergency care plans (20%). Only 10% of adolescents had a written transition care plan. Scores were lower from mixed mode respondents than from telephone-only respondents for some measures.

CONCLUSIONS

The FECC survey enables the evaluation of care coordination quality for CMC. Both survey modes were feasible to implement, but mixed mode administration produced a higher response rate.

Provider Perspectives of High-Quality Pediatric Hospital-to-Home Transitions for Children and Youth With Chronic Disease

OBJECTIVE

The objective of this study was to describe health care providers' and hospital administrators' perspectives on how to improve pediatric hospital-to-home transitions for children and youth with chronic disease (CYCD).

METHODS

Focus groups and key informant interviews of inpatient attending physicians, primary care physicians, pediatric residents, nurses, care coordinators, and social workers were conducted at a tertiary care children's hospital. Key informant interviews were performed with hospital administrators. Semistructured questions were used to elicit perceptions of transitional care quality and to identify key structures and processes needed to improve transitional care outcomes. Transcripts of discussions were coded to identify emergent themes.

RESULTS

Participants (N = 22) reported that key structures needed to enhance transitional care were a multidisciplinary team, inpatient provider-patient continuity, hospital resource availability, an interoperative electronic health record, and availability of community resources. Key processes needed to achieve high-quality transitional care included setting individualized transition goals, involving parents in care planning, establishing parental competency with home care tasks, and consistently communicating with primary care physicians. Providers identified a lack of reliable roles and processes, insufficient assessment of patient and/or family psychosocial factors, and consistent 2-way communication with community providers as elements to target to improve transitional care outcomes for CYCD.

CONCLUSIONS

Many key structures and processes of care perceived as important to achieving high-quality transitional care outcomes for CYCD have the opportunity for improvement at the institution studied. Engaging key stakeholders in designing quality improvement interventions to address these deficits in the current care model may improve transitional care outcomes for this vulnerable population.

Development and Validation of the Pediatric Medical Complexity Algorithm (PMCA) Version 2.0

BACKGROUND AND OBJECTIVES

The Pediatric Medical Complexity Algorithm (PMCA) was developed to stratify children by level of medical complexity. We sought to refine PMCA and evaluate its performance based on the duration of eligibility and completeness of Medicaid data.

METHODS

PMCA version 1.0 was applied to a cohort of 299 children insured by Washington State Medicaid with ≥1 Seattle Children's Hospital outpatient, emergency department, and/or inpatient encounter in 2012. Blinded assessment of the validation cohort's PMCA category was performed by using medical records. In-depth review of discrepant cases was performed and informed the development of PMCA version 2.0. The sensitivity and specificity of PMCA version 2.0 were assessed.

RESULTS

Using Medicaid data, the sensitivity of PMCA version 2.0 was 74% for complex chronic disease (C-CD), 60% for noncomplex chronic disease (NC-CD), and 87% for those without chronic disease (CD). Specificity was 84% to 91% in Medicaid data for all 3 groups. Medicaid data were most complete for children that had primarily fee-for-service claims and were less complete for those with some managed care encounter data. PMCA version 2.0 performed optimally when children had a longer duration of coverage (25 to 36 months) with fee-for-service reimbursement, identifying children with C-CD with 85% sensitivity and 75% specificity, children with NC-CD with 55% sensitivity and 88% specificity, and children without CD with 100% sensitivity and 97% specificity.

CONCLUSIONS

PMCA version 2.0 identifies children with C-CD with good sensitivity and very good specificity when applied to Medicaid data. Data quality is a critical consideration when using PMCA.

Validation of New Quality Measures for Transitions Between Sites of Care

BACKGROUND AND OBJECTIVE

Assessing and improving the quality of transitions to home from the emergency department (ED) or hospital is critical for patient safety. Our objective was to validate 8 newly developed caregiver-reported measures of transition quality.

METHODS

This prospective observational study included 1086 caregiver survey respondents whose children had an ED visit (n = 523) or hospitalization (n = 563) at Seattle Children's Hospital in 2014. Caregivers were contacted to complete 2 surveys. The first survey included the newly developed transition quality measures and multiple validation measures including modified versions of Child Hospital Consumer Assessments of Healthcare Providers and Systems (HCAHPS) composites, assessing communication and discharge planning. The second survey (administered 30 days later) included questions about follow-up appointments and ED return visits and readmissions. Using multivariate regression, we examined associations between the newly developed transition quality measures and each validation measure.

RESULTS

All transition quality measures were significantly associated with ≥1 validation measures. The hospital-to-home transition measure assessing whether discharge instructions were easy to understand, were useful, and contained necessary follow-up information had the largest association with the Child HCAHPS nurse-parent and doctor-parent communication composites (β = 55.6; 95% confidence interval, 43 to 68.3; and β = 48.3; 95% confidence interval, 36.3 to 60.3, respectively, scaled to reflect change associated with a 0 to 100 change in the transition measure score).

CONCLUSIONS

Newly developed quality measures for pediatric ED- and hospital-to-home transitions were significantly and positively associated with previously validated measures of caregiver experience. These new measures may be useful for assessing and improving on the quality of ED- and hospital-to-home transitions.

Caring for Children with Medical Complexity: Perspectives of Primary Care Providers

OBJECTIVE

To describe typical care experiences and key barriers and facilitators to caring for children with medical complexity (CMC) from the perspective of community primary care providers (PCPs).

STUDY DESIGN

PCPs participating in a randomized controlled trial of a care-coordination intervention for CMC were sent a 1-time cross-sectional survey that asked PCPs to (1) describe their experiences with caring for CMC; (2) identify key barriers affecting their ability to care for CMC; and (3) prioritize facilitators enhancing their ability to provide care coordination for CMC. PCP and practice demographics also were collected.

RESULTS

One hundred thirteen of 155 PCPs sent the survey responded fully (completion rate = 73%). PCPs endorsed that medical characteristics such as polypharmacy (88%), multiorgan system involvement (84%), and rare/unfamiliar diagnoses (83%) negatively affected care. Caregivers with high needs (88%), limited time with patients and caregivers (81%), and having a large number of specialists involved in care (79%) were also frequently cited. Most commonly endorsed strategies to improve care coordination included more time with patients/caregivers (84%), summative action plans (83%), and facilitated communication (eg, e-mail, phone meetings) with specialists (83%).

CONCLUSIONS

Community PCPs prioritized more time with patients and their families, better communication with specialists, and summative action plans to improve care coordination for this vulnerable population. Although this study evaluated perceptions rather than actual performance, it provides insights to improve understanding of which barriers and facilitators ideally might be targeted first for care delivery redesign.

Association of Bronchiolitis Clinical Pathway Adherence With Length of Stay and Costs

OBJECTIVES

To examine the associations between the level of adherence to bronchiolitis clinical pathway recommendations, health care use, and costs.

METHODS

We conducted a retrospective cohort study of 267 patients ≤24 months old diagnosed with bronchiolitis from 12/2009 to 7/2012. Clinical pathway adherence was assessed by using a standardized scoring system (0-100) for 18 quality measures obtained by medical record review. Level of adherence was categorized into low, middle, and high tertiles. Generalized linear models were used to examine relationships between adherence tertile and (1) length of stay (LOS) and (2) costs. Logistic regression was used to examine the associations between adherence tertile and probability of inpatient admission and 7-day readmissions.

RESULTS

Mean adherence scores were: ED, 78.8 (SD, 18.1; n = 264), inpatient, 95.0 (SD, 6.3; n = 216), and combined ED/inpatient, 89.1 (SD, 8.1; n = 213). LOS was significantly shorter for cases in the highest versus the lowest adherence tertile (ED, 90 vs 140 minutes, adjusted difference, -51 [95% confidence interval (CI), -73 to -29; P <.05]; inpatient, 3.1 vs 3.8 days, adjusted difference, -0.7 [95% CI, -1.4 to 0.0; P <.05]). Costs were less for cases in the highest adherence tertile (ED, -$84, [95% CI, -$7 to -$161; P <.05], total, -$1296 [95% CI, -126.43 to -2466.03; P <.05]). ED cases in the highest tertile had a lower odds of admission (odds ratio, 0.38 [95% CI, 0.15-0.97; P < .05]). Readmissions did not differ by tertile.

CONCLUSIONS

High adherence to bronchiolitis clinical pathway recommendations across care settings was associated with shorter LOS and lower cost.

Development and Testing of the Pediatric Respiratory Illness Measurement System (PRIMES) Quality Indicators

OBJECTIVES

To develop and test quality indicators for assessing care in pediatric hospital settings for common respiratory illnesses.

PATIENTS

A sample of 2796 children discharged from the emergency department or inpatient setting at 1 of the 3 participating hospitals with a primary diagnosis of asthma, bronchiolitis, croup, or community-acquired pneumonia (CAP) between January 1, 2010, and December 31, 2011.

SETTING

Three tertiary care children's hospitals in the United States.

METHODS

We developed evidence-based quality indicators for asthma, bronchiolitis, croup, and CAP. Expert panel-endorsed indicators were included in the Pediatric Respiratory Illness Measurement System (PRIMES). This new set of pediatric quality measures was tested to assess feasibility of implementation and sensitivity to variations in care. Medical records data were extracted by trained abstractors. Quality measure scores (0-100 scale) were calculated by dividing the number of times indicated care was received by the number of eligible cases. Score differences within and between hospitals were determined by using the Student's t-test or analysis of variance.

RESULTS

CAP and croup condition-level PRIMES scores demonstrated significant between-hospital variations (P < .001). Asthma and bronchiolitis condition-level PRIMES scores demonstrated significant within-hospital variation with emergency department scores (means [SD] 82.2(6.1)-100.0 (14.4)] exceeding inpatient scores (means [SD] 71.1 (2.0)-90.8 (1.3); P < .001).

CONCLUSIONS

PRIMES is a new set of measures available for assessing the quality of hospital-based care for common pediatric respiratory illnesses.

Costs of Care for Hospitalized Children Associated With Preferred Language and Insurance Type

OBJECTIVE

The study goal was to determine whether preferred language for care and insurance type are associated with cost among hospitalized children.

METHODS

A retrospective cohort study was conducted of inpatients at a freestanding children's hospital from January 2011 to December 2012. Patient information and hospital costs were obtained from administrative data. Cost differences according to language and insurance were calculated using multivariate generalized linear model estimates, allowing for language/insurance interaction effects. Models were also stratified according to medical complexity and length of stay (LOS) ≥3 days.

RESULTS

Of 19 249 admissions, 8% of caregivers preferred Spanish and 6% preferred another language; 47% of admissions were covered by public insurance. Models controlled for LOS, medical complexity, home-to-hospital distance, age, asthma diagnosis, and race/ethnicity. Total hospital costs were significantly higher for publicly insured Spanish speakers ($20 211 [95% confidence interval (CI), 7781 to 32 641]) and lower for privately insured Spanish speakers (-$16 730 [95% CI, -28 265 to -5195]) and publicly insured English speakers (-$4841 [95% CI, -6781 to -2902]) compared with privately insured English speakers. Differences were most pronounced among children with medical complexity and LOS ≥3 days.

CONCLUSIONS

Hospital costs varied significantly according to preferred language and insurance type, even adjusting for LOS and medical complexity. These differences in the amount of billable care provided to medically similar patients may represent either underprovision or overprovision of care on the basis of sociodemographic factors and communication, suggesting problems with care efficiency and equity. Further investigation may inform development of effective interventions.

Effectiveness of the Spirometry 360 Quality Improvement Program for Improving Asthma Care: A Cluster Randomized Trial

OBJECTIVE

To determine the effectiveness of the Spirometry 360 distance learning quality improvement (QI) program for enhancing the processes and outcomes of care for children with asthma.

METHODS

Cluster randomized controlled trial involving 25 matched pairs of pediatric primary care practices. Practices were recruited from 2 practice-based research networks: the Slone Center Office-based Research Network at Boston University, Boston, Mass, and the Puget Sound Pediatric Research Network, Seattle, Wash. Study participants included providers from one of the 50 enrolled pediatric practices and 626 of their patients with asthma. Process measures assessed included spirometry test quality and appropriate prescription of asthma controller medications. Outcome measures included asthma-specific health-related quality of life, and outpatient, emergency department, and inpatient utilization for asthma.

RESULTS

At baseline, 25.4% of spirometry tests performed in control practices and 50.4% of tests performed in intervention practices were of high quality. During the 6-month postintervention period, 28.7% of spirometry tests performed in control practices and 49.9% of tests performed in intervention practices were of high quality. The adjusted difference-of-differences analysis revealed no intervention effect on spirometry test quality. Adjusted differences-of-differences analysis also revealed no intervention effect on appropriate use of controller medications or any of the parent- or patient-reported outcomes examined.

CONCLUSIONS

In this study, the Spirometry 360 distance learning QI program was ineffective in improving spirometry test quality or parent- or patient-reported outcomes. QI programs like the one assessed here may need to focus on practices with lower baseline performance levels or may need to be tailored for those with higher baseline performance.

Modification of an Established Pediatric Asthma Pathway Improves Evidence-Based, Efficient Care

OBJECTIVE

In September 2011, an established pediatric asthma pathway at a tertiary care children's hospital underwent significant revision. Modifications included simplification of the visual layout, addition of evidence-based recommendations regarding medication use, and implementation of standardized admission criteria. The objective of this study was to determine the impact of the modified asthma pathway on pathway adherence, percentage of patients receiving evidence-based care, length of stay, and cost.

METHODS

Cases were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Data were analyzed for 24 months before and after pathway modification. Statistical process control was used to examine changes in processes of care, and interrupted time series was used to examine outcome measures, including length of stay and cost in the premodification and postmodification periods.

RESULTS

A total of 5584 patients were included (2928 premodification; 2656 postmodification). Pathway adherence was high (79%-88%) throughout the study period. The percentage of patients receiving evidence-based care improved after pathway modification, and the results were sustained for 2 years. There was also improved efficiency, with a 30-minute (10%) decrease in emergency department length of stay for patients admitted with asthma (P = .006). There was a nominal (<10%) increase in costs of asthma care for patients in the emergency department (P = .04) and no change for those admitted to the hospital.

CONCLUSIONS

Modification of an existing pediatric asthma pathway led to sustained improvement in provision of evidence-based care and patient flow without adversely affecting costs. Our results suggest that continuous re-evaluation of established clinical pathways can lead to changes in provider practices and improvements in patient care.

Epidemiology of pediatric hospitalizations at general hospitals and freestanding children's hospitals in the United States

BACKGROUND

Children may be hospitalized at general hospitals or freestanding children's hospitals. Knowledge about how inpatient care differs at these hospitals is important to inform national research and quality efforts.

OBJECTIVE

To describe the volume and characteristics of pediatric hospitalizations at acute care general and freestanding children's hospitals in the United States.

DESIGN, PATIENTS, AND SETTING

Cross-sectional study of hospitalizations in the United States among children <18 years, excluding in-hospital births, using the Healthcare Cost and Utilization Project's 2012 Kids' Inpatient Database.

MEASUREMENT

We examined differences between hospitalizations at general and freestanding children's hospitals, applying weights to generate national estimates. Reasons for hospitalization were categorized using a pediatric grouper, and differences in hospital volumes were assessed for common diagnoses.

RESULTS

A total of 1,407,822 (standard deviation 50,456) hospitalizations occurred at general hospitals, representing 71.7% of pediatric hospitalizations. Hospitalizations at general hospitals accounted for 63.6% of hospital days and 50.0% of pediatric inpatient healthcare costs. Median volumes of pediatric hospitalizations, per hospital, were significantly lower at general hospitals than freestanding children's hospitals for common medical and surgical diagnoses. Although the most common reasons for hospitalization were similar, the most costly conditions differed.

CONCLUSIONS

In 2012, more than 70% of pediatric hospitalizations occurred at general hospitals in the United States. Differences in patterns of care at general hospitals and freestanding children's hospitals may inform clinical programs, research, and quality improvement efforts. Journal of Hospital Medicine 2016;11:743-749. © 2016 Society of Hospital Medicine.

Development and Validation of a Method to Identify Children With Social Complexity Risk Factors

OBJECTIVES

We sought to develop and validate a method to identify social complexity risk factors (eg, limited English proficiency) using Minnesota state administrative data. A secondary objective was to examine the relationship between social complexity and caregiver-reported need for care coordination.

METHODS

A total of 460 caregivers of children with noncomplex chronic conditions enrolled in a Minnesota public health care program were surveyed and administrative data on these caregivers and children were obtained. We validated the administrative measures by examining their concordance with caregiver-reported indicators of social complexity risk factors using tetrachoric correlations. Logistic regression analyses subsequently assessed the association between social complexity risk factors identified using Minnesota's state administrative data and caregiver-reported need for care coordination, adjusting for child demographics.

RESULTS

Concordance between administrative and caregiver-reported data was moderate to high (correlation range 0.31-0.94, all P values <.01), with only current homelessness (r = -0.01, P = .95) failing to align significantly between the data sources. The presence of any social complexity risk factor was significantly associated with need for care coordination before (unadjusted odds ratio = 1.65; 95% confidence interval, 1.07-2.53) but not after adjusting for child demographic factors (adjusted odds ratio = 1.53; 95% confidence interval, 0.98-2.37).

CONCLUSIONS

Social complexity risk factors may be accurately obtained from state administrative data. The presence of these risk factors may heighten a family's need for care coordination and/or other services for children with chronic illness, even those not considered medically complex.