Reflux related hospital admissions after fundoplication in children with neurological impairment: retrospective cohort study

Well-being of children with neurologic impairment after fundoplication and gastrojejunostomy tube feeding

BACKGROUND

There is limited understanding on the impact of fundoplication or gastrojejunostomy tube (GJT) feeding in children with neurologic impairment who have swallowing dysfunction, gastroesophageal reflux disease, and/or dysmotility.

OBJECTIVE

To explore and understand the well-being of families and their children with neurologic impairment who had either a fundoplication or GJT.

METHODS

This was a qualitative study using in-depth, individual interviews with parents of children with severe neurologic impairment who had either a fundoplication with gastrostomy or GJT. Parents' perceptions of daily life and QoL were explored in the context of the interventions. Interviews were transcribed, and data were analyzed using qualitative content analysis.

RESULTS

Children and their parents are profoundly impacted by the health condition of the children. QoL effects were similar across spheres of individual and family experience and well-being. Themes related to QoL were: physical health of the child and the future, intense caregiving needs, social isolation and stigma, pervasive impact on the family, financial strain, and the process of finding meaning. Fundoplication and GJT affected feeding tolerance and times, caregiving, and health care utilization. Parents identified how changes in these factors influenced child, parental, and family QoL.

CONCLUSIONS

The diverse influences of the underlying condition and the interventions should be addressed in the delivery of health services. Future studies of the effectiveness of fundoplication and GJT feeding should address the well-being of the child and family, the impact on family caregiving, and health care utilization.

Survival of children following Nissen fundoplication

BACKGROUND

Analyses of survival after fundoplication in childhood are often restricted to 30-day mortality, or to the neurologically impaired. The objective of this study was to report actuarial survival and variables associated with mortality for all children undergoing fundoplication.

METHODS

This was a prospective observational study of fundoplication surgery by one surgeon; the endpoint was survival. Using a Cox proportional hazards model, gastrostomy, neurological status, tracheostomy, congenital cardiac disease, syndromic status, presence of congenital anomaly, other chronic disease, weight z-score at time of surgery, need for revisional fundoplication, use of laparoscopic surgery, gastric drainage procedures, age and sex were assessed for their influence on survival.

RESULTS

Two-hundred and thirty children underwent 255 fundoplications at a median age of 3·6 years. Forty-six children (20·0 per cent) died during a median follow-up of 2·8 (range 0·5-11·2) years. Statistical modelling showed gastrostomy (relative risk of death 11·04, P < 0·001), cerebral palsy (relative risk 6·58, P = 0·021) and female sex (relative risk 2·12, P = 0·015) to be associated with reduced survival. Revisional fundoplication was associated with improved survival (relative risk of death 0·37, P = 0·037). Survivors had significantly higher weight z-scores (-1·4 versus - 2·9 for those who died; P = 0·001). The 5-year survival rate after fundoplication for children with cerebral palsy and gastrostomy was 59 per cent.

CONCLUSION

Survival of children following fundoplication is related principally to the presence of a gastrostomy and neurological status. Estimates of children's life expectancy should take account of the poorer survival of neurologically impaired children who undergo fundoplication, presumably due to the related co-morbidities that lead to a gastrostomy.

Hospital utilization and characteristics of patients experiencing recurrent readmissions within children's hospitals

CONTEXT

Early hospital readmission is emerging as an indicator of care quality. Some children with chronic illnesses may be readmitted on a recurrent basis, but there are limited data describing their rehospitalization patterns and impact.

OBJECTIVES

To describe the inpatient resource utilization, clinical characteristics, and admission reasons of patients recurrently readmitted to children's hospitals.

DESIGN, SETTING, AND PATIENTS

Retrospective cohort analysis of 317,643 patients (n = 579,504 admissions) admitted to 37 US children's hospitals in 2003 with follow-up through 2008.

MAIN OUTCOME MEASURE

Maximum number of readmissions experienced by each child within any 365-day interval during the 5-year follow-up period.

RESULTS

In the sample, 69,294 patients (21.8%) experienced at least 1 readmission within 365 days of a prior admission. Within a 365-day interval, 9237 patients (2.9%) experienced 4 or more readmissions; time between admissions was a median 37 days (interquartile range [IQR], 21-63). These patients accounted for 18.8% (109,155 admissions) of all admissions and 23.2% ($3.4 billion) of total inpatient charges for the study cohort during the entire follow-up period. Tests for trend indicated that as the number of readmissions increased from 0 to 4 or more, the prevalences increased for a complex chronic condition (from 22.3% [n = 55,382/248,349] to 89.0% [n = 8225/9237]; P < .001), technology assistance (from 5.3% [n = 13,163] to 52.6% [n = 4859]; P < .001), public insurance use (from 40.9% [n = 101,575] to 56.3% [n = 5202]; P < .001), and non-Hispanic black race (from 21.8% [n = 54,140] to 34.4% [n = 3181]; P < .001); and the prevalence decreased for readmissions associated with an ambulatory care-sensitive condition (from 23.1% [62,847/272,065] to 14.0% [15,282/109,155], P < .001). Of patients readmitted 4 or more times in a 365-day interval, 2633 (28.5%) were rehospitalized for a problem in the same organ system across all admissions during the interval.

CONCLUSIONS

Among a group of pediatric hospitals, 18.8% of admissions and 23.2% of inpatient charges were accounted for by the 2.9% of patients with frequent recurrent admissions. Many of these patients were rehospitalized recurrently for a problem in the same organ system.

The hospitalist movement in general pediatrics

PURPOSE OF REVIEW

The present review focuses on the latest evidence from the past 18 months related to pediatric hospitalist medicine.

RECENT FINDINGS

The number of hospitalists continues to increase despite many programs not being financially self-supporting. Reports in the past have shown decreased length of stay, resource utilization, and costs with the hospitalist model. There are an increasing number of studies examining patient safety, quality initiatives, and communication issues such as 'handoffs' and family-centered rounds. The teaching role continues to broaden in scope and is highly valued by trainees. Pediatric hospitalist fellowship training programs are in an early stage of development. A list of core competencies as a framework for a pediatric hospital medicine curriculum has recently been published and should help to facilitate and standardize training. Recent publications suggest that there is still significant variation in the approach to and management of many common inpatient illnesses.

SUMMARY

In general, there continue to be reports of positive outcomes as a result of the introduction of the hospitalist model in pediatrics. Much of the current literature is geared toward reporting on alternative models of care, inpatient quality and safety initiatives, and hospitalist teaching. What is still somewhat lacking is multicenter collaborative prospective clinical trials for common inpatient general pediatric conditions. The variation reported in the management of common conditions presents an opportunity for improving the quality, safety, resource utilization, and appropriateness of care.

Children with complex chronic conditions in inpatient hospital settings in the United States

OBJECTIVES

Hospitalized children are perceived to be increasingly medically complex, but no such trend has been documented. The objective of this study was to determine whether the proportion of pediatric inpatient use that is attributable to patients with a diagnosis of one or more complex chronic condition (CCC) has increased over time and to assess the degree to which CCC hospitalizations are associated with attributes that are consistent with heightened medical complexity.

METHODS

A retrospective observational study that used the 1997, 2000, 2003, and 2006 Kids Inpatient Databases examined US hospitalizations for children. Attributes of medical complexity included hospital admissions, length of stay, total charges, technology-assistance procedures, and mortality risk.

RESULTS

The proportion of inpatient pediatric admissions, days, and charges increased from 1997 to 2006 for any CCC and for every CCC group except hematology. CCCs accounted for 8.9% of US pediatric admissions in 1997 and 10.1% of admissions in 2006. These admissions used 22.7% to 26.1% of pediatric hospital days, used 37.1% to 40.6% of pediatric hospital charges, accounted for 41.9% to 43.2% of deaths, and (for 2006) used 73% to 92% of different forms of technology-assistance procedures. As the number of CCCs for a given admission increased, all markers of use increased.

CONCLUSIONS

CCC-associated hospitalizations compose an increasing proportion of inpatient care and resource use. Future research should seek to improve methods to identify the population of medically complex children, monitor their increasing inpatient use, and assess whether current systems of care are meeting their needs.

Pediatric palliative care

Palliative care has always been a part of the care of children. It includes any intervention that focuses on relieving suffering, slowing the progression of disease, and improving quality of life at any stage of disease. In addition, for even the child with the most unpredictable disease, there are predictable times in this child's life when the child, family, and care team will be suffering in ways that can be mitigated by specific interventions. Rather than defining pediatric palliative care in terms of a patient base, severity of disease, or even a general philosophy of care, palliative care can best be understood as a specific set of tasks directed at mitigating suffering. By understanding these tasks; learning to identify predictable times and settings of suffering; and learning to collaborate with multidisciplinary specialists, use communication skills, and identify clinical resources, the pediatrician can more effectively support children with life-threatening illnesses and their families. In this article, we define palliative care as a focus of care integrated in all phases of life and as a set of interventions aimed at easing suffering associated with life-threatening conditions. We detail an approach to these interventions and discuss how they can be implemented by the pediatrician with the support of specialists in hospice and palliative medicine. We discuss common and predictable times of suffering when these interventions become effective ways to treat suffering and improve quality of life. Finally, we discuss those situations that pediatricians most commonly and intensely interface with palliative care-the care of the child with complex, chronic conditions and severe neurologic impairment (SNI).