The increasing proportion of adult discharges at children's hospitals, 2004-2019

Systematic review and meta-analysis of interventions to promote medication adherence among children, adolescents, and young adults with medical conditions

OBJECTIVE

This meta-analysis examined the efficacy of adherence-promotion interventions for children, adolescents, and young adults prescribed a medication for > 90 days as part of a treatment regimen for a medical condition.

METHODS

A systematic literature review was conducted to identify randomized controlled trials of adherence-promotion interventions published between 2013 and 2023 and including children, adolescents, and/or young adults with a medical condition. A total of 38 articles representing 39 trials met inclusion criteria. A narrative synthesis was conducted to summarize included trials and a random-effects model was used to compute an overall intervention effect. Effect sizes by adherence outcome assessment methodology, participant age, and technology use were also computed.

RESULTS

Pediatric adherence-promotion interventions demonstrate a medium effect with those randomized to an intervention displaying greater improvements in medication adherence than those randomized to a comparator condition (SMD = 0.46, 95% CI: 0.31, 0.60, n = 37; 95% Prediction Interval: -0.32, 1.23).

CONCLUSIONS

Adherence interventions for children, adolescents, and young adults with medical conditions increase adherence.

Disparities in pediatric hospital use during transition to adult healthcare for young adults with childhood-onset chronic conditions

BACKGROUND

Young adults (YA) with childhood-onset chronic conditions-particularly YA with cystic fibrosis (CF), congenital heart disease (CHD), and sickle cell disease (SCD)-continue to have pediatric hospital admissions. Factors associated with this continued pediatric hospital use remain underexplored.

OBJECTIVE

To determine if pediatric hospital use by YA differed (1) across condition and (2) within each condition by sociodemographic factors.

METHODS

Conducted a cross-sectional analysis of admissions for YA 22-35 years with CF, CHD, and SCD from 2016 to 2020 in the National Inpatient Sample. Admissions for YA with CF, CHD, and SCD were identified by international classification of diseases, 10th revision-clinical modification diagnosis codes. To determine if conditions or sociodemographic factors were associated with YA pediatric hospital use, we used multivariable logistic regression with separate models for the different objectives.

RESULTS

YA with SCD had lower odds of pediatric hospital use compared to YA with CF. Relationships between sociodemographic factors and pediatric hospital use varied. Black YA with both CF and CHD had lower odds of pediatric hospital use than white YA with CF and CHD. For YA with SCD, despite 17,810 (6.5%) having rural residence, zero (0) had pediatric hospital use; whereas YA with CF living in a rural area had greater odds of pediatric hospital use compared to urban residents.

CONCLUSION

YA with SCD used pediatric hospitals less than YA with either CF or CHD. Coupled with our findings that Black YA with CF and CHD had less pediatric hospital use, these data may reflect systematic racial differences within pediatric to adult healthcare transition programs.

Giving Voice to Cardiovocal Syndrome: A 26-Year-Old Woman With Hypophonia and Dysphagia

Are children's hospitals only for children? Practically speaking, they and their associated specialty clinics often provide necessary medical and surgical care for patients older than 18 years, especially those with medical complexity. For this reason, pediatric practitioners must be familiar with both childhood-onset conditions and problems common in older and larger individuals. This case report describes a 26-year-old woman with CHARGE syndrome (coloboma/cranial nerve palsy, heart defects, atresia of the choanae, restricted development/growth, genitourinary abnormalities, ear abnormalities) who presented to a children's hospital with hypophonia and dysphagia and was ultimately diagnosed with left recurrent laryngeal nerve palsy due to untreated sleep apnea and uncontrolled congestive heart failure leading to pulmonary hypertension that exacerbated her congenital cardiovascular abnormalities. Her hospitalization, during which she was cared for by two Internal Medicine-Pediatrics physicians (among others), exemplifies common themes in Med-Peds practice, such as a potential mismatch of expectations, experience, equipment, and policies when adults are admitted to children's hospital, as well as an all-too-familiar lag in transitioning from pediatric to adult care for children and youth with special healthcare needs (CYSHCN).

Garnering effective telehealth to help optimize multidisciplinary team engagement (GET2HOME) for children with medical complexity: Protocol for a pragmatic randomized control trial

BACKGROUND

Children and young adults with medical complexity (CMC) experience high rates of healthcare reutilization following hospital discharge. Prior studies have identified common hospital-to-home transition failures that may increase the risk for reutilization, including medication, technology and equipment issues, financial concerns, and confusion about which providers can help with posthospitalization needs. Few interventions have been developed and evaluated for CMC during this transition period.

OBJECTIVE

We will compare the effectiveness of the garnering effective telehealth 2 help optimize multidisciplinary team engagement (GET2HOME) transition bundle intervention to the standard hospital-based care coordination discharge process by assessing healthcare reutilization and patient- and family-centered outcomes.

DESIGNS, SETTINGS, AND PARTICIPANTS

We will conduct a pragmatic 2-arm randomized controlled trial (RCT) comparing the GET2HOME bundle intervention to the standard hospital-based care discharge process on CMC hospitalized and discharged from hospital medicine at two sites of our pediatric medical center between November 2022 and February 2025. CMC of any age will be identified as having complex chronic disease using the Pediatric Medical Complexity Algorithm tool. We will exclude CMC who live independently, live in skilled nursing facilities, are in custody of the county, or are hospitalized for suicidal ideation or end-of-life care.

INTERVENTION

We will randomize participants to the bundle intervention or standard hospital-based care coordination discharge process. The bundle intervention includes (1) predischarge telehealth huddle with inpatient providers, outpatient providers, patients, and their families; (2) care management discharge task tracker; and (3) postdischarge telehealth huddle with similar participants within 7 days of discharge. As part of the pragmatic design, families will choose if they want to complete the postdischarge huddle. The standard hospital-based discharge process includes a pharmacist, social worker, and care management support when consulted by the inpatient team but does not include huddles between providers and families.

MAIN OUTCOME AND MEASURES

Primary outcome will be 30-day urgent healthcare reutilization (unplanned readmission, emergency department, and urgent care visits). Secondary outcomes include 7-day urgent healthcare reutilization, patient- and family-reported transition quality, quality of life, and time to return to baseline using electronic health record and surveys at 7, 30, 60, and 90 days following discharge. We will also evaluate heterogeneity of treatment effect for the intervention across levels of financial strain and for CMC with high-intensity neurologic impairment. The primary analysis will follow the intention-to-treat principle with logistic regression used to study reutilization outcomes and generalized linear mixed modeling to study repeated measures of patient- and family-reported outcomes over time.

RESULTS

This pragmatic RCT is designed to evaluate the effectiveness of enhanced discharge transition support, including telehealth huddles and a care management discharge tool, for CMC and their families. Enrollment began in November 2022 and is projected to complete in February 2025. Primary analysis completion is anticipated in July 2025 with reporting of results following.

Adult Inpatient Services in Pediatric Hospitals: A National Mixed Methods Study

OBJECTIVES

Some pediatric institutions have developed adult inpatient services to enable quality care of hospitalized adults. Our objectives were to understand the characteristics of these adult inpatient services in pediatric hospitals, barriers and facilitators to their creation and sustainability, and patient and system needs they addressed.

METHODS

An explanatory mixed methods study was conducted using a distribution of an electronic survey followed by targeted semi-structured interviews of directors (or designates) of adult inpatient services in US pediatric hospitals. The survey identified institutional demographics, service line characteristics, and patient populations. An interview guide was created to explore survey findings and facilitators and barriers in the creation of adult inpatient services. Interviews were conducted after survey completion. A codebook was created using an inductive thematic approach and iteratively refined. Final themes were condensed, and illustrative quotes selected.

RESULTS

Ten institutions identified as having an adult inpatient service. Service staffing models varied, but all had dually trained internal medicine and pediatrics physicians. All participants voiced their respective pediatric institutions valued that these services filled a clinical care gap for hospitalized adults adding to whole-person care, patient safety, and health system navigation.

CONCLUSIONS

Adult inpatient services in pediatric institutions have been present for >15 years. These services address clinical care gaps for adults hospitalized in pediatric institutions and use specialized internal medicine and pediatrics knowledge. Demonstrating return on investment of these services using a traditional fee for service model is a barrier to creation and sustainability.