Hospitalization burden among individuals with autism

In-hospital outcomes in people with autism and epilepsy - A population-based study

Autism is a common comorbid diagnosis in those with epilepsy. Understanding the health needs and outcomes in patients with this dual diagnosis is important for optimizing healthcare outcomes. We compared hospital-level variables amongst patients with co-occurring autism and epilepsy, to those with epilepsy alone. Non-elective hospital admissions amongst patients with epilepsy alone and co-occurring autism and epilepsy were identified in the 2003-14 National Inpatient Sample (NIS) using previously validated ICD-9-CM case definitions. One patient with co-occurring epilepsy and autism was matched to three epilepsy patients for age and sex. Multinomial logistic regressions were performed to examine outcomes of interest. Compared to those with epilepsy alone (n = 27,762), patients with autism and epilepsy (n = 9254) had a higher odds of transfer to another facility (OR = 1.09, p = 0.048), in-hospital mortality (OR = 1.36, p = 0.011), longer mean length of stay (5.63 days vs. 5.12 days, p < 0.0001), and septicemia (4.21 % vs. 3.08 %, p < 0.0001). Distributions of demographics, insurance type, socioeconomic status, and comorbidities significantly differed between both groups. Our findings demonstrate that patients with comorbid autism and epilepsy are a unique population with health outcomes significantly differing from those with epilepsy alone. Given the effect that dual diagnosis has on hospital trajectory, focused treatment plans must be adopted to optimize care and hospital outcomes in these patients.

Seeking Care for Children with Intellectual and/or Developmental Disabilities in the Emergency Department: A Mixed Methods Systematic Review of Parents' Experiences and Information Needs

The objective of this review was to explore parents' experiences and information needs regarding management of their child with an intellectual and/or developmental disability (IDD) in the emergency department (ED). We searched six electronic databases and grey literature to identify primary studies in English published since 2000. We synthesized quantitative and qualitative outcome data simultaneously using a convergent integrated approach and used a Mixed Methods Appraisal Tool (MMAT) to assess methodological quality of the included studies. Nine articles derived from seven studies were included (3 qualitative, 3 quantitative, 1 mixed method). Four main themes related to parents' self-reported experiences were identified: 1) appropriateness of the ED to manage and support their child; 2) acknowledgement/recognition of their child's IDD and incorporation of those considerations into overall care and management; 3) managing and navigating the ED environment; and 4) decision to disclose their child's condition when visiting the ED. Two articles provided data relevant to information needs, highlighting parents' desire to have resources supporting ED orientation and access to services within and outside of the ED setting. From the limited number of studies, it was evident that parents wanted better communication with healthcare providers and a greater understanding by ED staff around physical space settings needed to support their child. Resources supporting ED staff and parents to communicate effectively and work together can ensure that children with IDDs care needs are met. Further research into understanding parents' experiences and information needs related to managing a child with an IDD in the ED is needed to guide the development of effective resources.

Hospitalization of patients with nutritional anemia in the United States in 2020

Background

Nutritional anemia is highly prevalent and has triggered a globally recognized public health concern worldwide.

Objective

To better understand the prevalence of anemia and the state of nutritional health in developed countries to inform global nutritional health and better manage the disease.

Method

We employed the Healthcare Cost and Utilization Project (HCUP)-2020 National Inpatient Health Care Data (NIS), administered by The Agency for Healthcare Research and Quality. Nutritional anemia was diagnosed according to the International Classification of Diseases, 10th Revision (ICD-10). Matching analysis and multivariate regression were used to adjust for patient and hospital characteristics. Controls were obtained by stratifying and matching for age and sex.

Results

The 2020 HCUP-NIS database encompassed a survey over 6.4 million hospitalized patients, among which 1,745,350 patients diagnosed with anemia, representing approximately 26.97% of the hospitalized population, over 310,000 were diagnosed with nutritional anemia, and 13,150 patients were hospitalized for nutritional anemia as primary diagnosis. Hospitalization rate for nutritional anemia exhibited an increased age-dependent increase nationwide, especially among females, who displayed 1.87 times higher than males. Notably, in comparison to the control group, individuals of the Black race exhibit a higher prevalence of nutritional anemia (case group: 21.7%, control group: 13.0%, p < 0.001). In addition, hospitalization rates were higher among low-income populations, with lower rates of private insurance (case group: 18.7%, control group: 23.5%, p < 0.001) and higher rates of Medicaid insurance (case group: 15.4%, control group: 13.9%, p < 0.001). In areas characterized by larger urban centers and advanced economic conditions within the urban-rural distribution, there was an observed increase in the frequency of patient hospitalizations. Iron deficiency anemia emerged as the predominant subtype of nutritional anemia, accounting for 12,214 (92.88%). Secondary diagnosis among patients hospitalized for nutritional anemia revealed that a significant number faced concurrent major conditions like hypertension and renal failure.

Conclusion

In economically prosperous areas, greater attention should be given to the health of low-income individuals and the older adult. Our findings hold valuable insights for shaping targeted public health policies to effectively address the prevalence and consequences of nutritional anemia based on a overall population health.

Antenatal Hospital Use among Deaf and Hard of Hearing Women

OBJECTIVE

Hearing loss is increasingly prevalent among younger adults, impacting health and health care use. Deaf and hard of hearing (DHH) women have a higher risk of chronic diseases, pregnancy complications, and adverse birth outcomes compared with hearing women. Health care utilization patterns during the perinatal period remain not well understood. The objective of this study was to examine differences in antenatal emergency department and inpatient utilization among DHH and non-DHH women.

STUDY DESIGN

We conducted a retrospective cohort study design to analyze 2002 to 2013 Massachusetts Pregnancy to Early Life Longitudinal data to compare antenatal inpatient and emergency department use between DHH (N = 925) and hearing (N = 2,895) women with singleton deliveries. Matching was done based on delivery year, age at delivery, and birth parity in 1:3 case-control ratio. Demographic, socioeconomic, clinical, and hospital characteristics were first compared for DHH mothers and the matched control group using chi-squared tests and t-tests. Multivariable models were adjusted for sociodemographic and clinical characteristics.

RESULTS

Among DHH women (N = 925), 49% had at least one emergency department visit, 19% had an observational stay, and 14% had a nondelivery hospital stay compared with 26, 14, and 6%, respectively, among hearing women (N = 28,95) during the antenatal period (all ps < 0.001). The risk of nondelivery emergency department visits (risk ratio [RR] 1.58; p < 0.001) and inpatient stays (RR = 1.89; p < 0.001) remained higher among DHH women compared with hearing women even after adjustment. Having four or more antenatal emergency department visits (7 vs. 2%) and two or more nondelivery hospital stays (4 vs. 0.4%) were more common among pregnant DHH women compared with their controls (all p-values < 0.001).

CONCLUSION

The findings demonstrate that DHH women use emergency departments and inpatient services at a significantly higher rate than their hearing controls during the antenatal period. A systematic investigation of the mechanisms for these findings are needed.

KEY POINTS

· Antenatal emergency department use is significantly higher among deaf and hard of hearing women.. · Antenatal hospitalizations are significantly higher among deaf and hard of hearing women.. · Hearing loss screening may identify those at risk for adverse pregnancy and birth outcomes..

Individualized Care Delivery for Children With Autism and Related Disabilities Undergoing Overnight Video Electroencephalography (EEG): One Hospital's Experience With a Coordinated Team Approach

Background and Purpose: Children with developmental disabilities have increased risk of epilepsy and need for overnight video electroencephalographic (EEG) monitoring. However, video EEGs have historically been considered difficult to complete for this population. An autism support service at a pediatric tertiary care hospital implemented a coordinated team approach to help children with developmental disability tolerate overnight video EEGs. The project included completion of a caregiver-report preprocedure questionnaire that then was shared with the multidisciplinary team and used to create individualized care plans. The current study aims to describe rates of video EEG completion and need for lead placement under general anesthesia among children with autism and related disabilities who received these supports. Methods: Rates of video EEG completion and general anesthesia use were analyzed for children referred to the support service between April 2019 and November 2021. Results: A total of 182 children with developmental disability (mean age  = 10.3 years, 54.9% diagnosed with autism) met inclusion criteria. 92.9% (n = 169) of children successfully completed EEG (leads on ≥12 hours). Only 19.2% (n = 35) required general anesthesia for video EEG lead placement. The majority (80.2%) of parents (n = 146) completed the preprocedure questionnaire. Video EEG outcomes did not differ based on completion of the questionnaire. Parent-reported challenges with communication and cooperation were associated with shorter video EEG duration and greater use of general anesthesia. Conclusions: These findings suggest that most children with developmental disability can complete video EEG with sufficient support. Preprocedure planning can identify children who would benefit from additional accommodations. Further research is necessary to clarify which supports are most helpful.

Demographic differences in access to health/therapeutic services over first year of the pandemic: a SPARK COVID-19 impact survey analysis

Introduction

This analysis examined changes in services received and service recovery one-year post-pandemic compared to pre-pandemic levels in children with ASD aged between 19 months and 17 years in various subgroups based on factors such as age, income, race/ethnicity, geographic location, and sex.

Methods

An online, parent report survey was completed by the parents of children with ASD in the SPARK study cohort (N = 6,393). Descriptive statistics, chi-square analyses, and Spearman correlations were performed to study associations between various factors and service access, pre-pandemic and one-year, post-pandemic.

Results

One year after pandemic, the lag in service recovery in children with ASD was greatest for PT/OT services followed by SLT. ABA services only recovered in half of the subgroups. In contrast, SES fully recovered and MH and MED services superseded pre-pandemic levels. Across majority of the timepoints, younger children received more SLT, PT/OT, and ABA services whereas older children received more SES, MH, and MED services. Higher income families accessed more SES, SLT, and ABA whereas lower income families received more MH services. White families received less SLT compared to non-white families. Hispanic families received more SLT services compared to non-Hispanic families. Compared to rural families, urban families received more ABA services at baseline which also recovered one year after the pandemic. Certain counterintuitive findings may be attributed to home/remote schooling leading to reduced access to related services.

Conclusions

Future research and policy changes are needed to address the American healthcare vulnerabilities when serving children with ASD by enhancing the diversity of healthcare formats for continued service access during future pandemics and other similar crises.

Optimizing Care for Autistic Patients in Health Care Settings: A Scoping Review and Call to Action

OBJECTIVE

We conducted a scoping review of interventions designed to improve the health care experiences of autistic individuals and assessed the methodology and outcomes used to evaluate them.

METHODS

Literature from January 2005 to October 2020 was searched using PubMed, Excerpta Medica dataBASE (EMBASE), Cumulated Index to Nursing and Allied Health Literature (CINAHL), PsycINFO as well as hand searching. Studies included described an intervention for autistic individuals in inpatient or outpatient settings and evaluated the intervention using standardized methodology. Results were exported to Covidence software. Ten reviewers completed abstract screening, full text review, and then systematic data extraction of the remaining articles. Two reviewers evaluated each article at each stage, with a third reviewer arbitrating differences.

RESULTS

A total of 38 studies, including three randomized controlled trials (RCTs) were included. Twenty-six (68%) took place in dental, psychiatric, or procedural settings. Interventions primarily focused on visit preparation and comprehensive care plans or pathways (N = 29, 76%). The most frequent outcome was procedural compliance (N = 15), followed by intervention acceptability (N = 7) and parent satisfaction (N = 6). Two studies involved autistic individuals and caregivers in study design, and no studies assessed racial/ethnic diversity on intervention impact.

CONCLUSIONS

Well-designed evaluations of interventions to support autistic individuals in pediatric health care settings are limited. There is a need to conduct large multi-site intervention implementation studies.

The Development and Acceptability of a Comprehensive Crisis Prevention Program for Implementation in Health Care Settings

INTRODUCTION

Behavioral crises are increasingly prevalent in health care settings. Existing programs, however, include procedures that lack adaptability, omit critical components, and deviate from clinical best-practice recommendations. Health care employees also continue to report lacking confidence for safely managing behavioral crises.

AIMS

We described the development and acceptability of a comprehensive crisis prevention program and its modification for a large pediatric health care system to help remediate the limitations of existing programs.

METHOD

Chi-square analyses evaluated the acceptability of the crisis prevention program pre- versus post-training and at 3- and 6-month follow-up times. For insignificant outcomes, logistical regressions identify whether responses differed between emergency-department and nonemergency-department employees.

RESULTS

Chi-square analyses were significant for 10 of 15 questions suggesting that employees were more confident in managing and communicating during behavioral crises post-training, and that this confidence was maintained. Logistic regressions found that emergency-department employees differed in some responses to the acceptability questionnaire than nonemergency-department employees over time.

CONCLUSION

The present crisis prevention program is adaptable to various settings and patients, and it is well received overall by employees. The safety of patients and employees is integral to the delivery of quality care and improving patient-provider relations.

Multiple Chronic Condition Emergency Department Visits Among U.S. Adults: Disparities at the Intersection of Intellectual and Developmental Disabilities Status and Race or Ethnicity

Background

The study aims to examine the risk of multiple chronic condition (MCC)-related emergency department (ED) visits, MCC-related hospitalization following the ED visit, and mortality after MCC-related ED visits among adults with intellectual and developmental disabilities (IDD), adults compared with nondisabled adults by race and ethnicity, using the 2020 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample.

Methods

We identified IDD adults using ICD-10-CM codes, extracting 296,394 nondisabled adults and 99,538 IDD adults, of which 67,771 are white, 19,164 are black, 10,667 are Latinx, and 1936 are other race or multiple race. The control group of nondisabled adults was age-matched and sex-matched in a 1:3 case-control ratio. We conducted multilevel Poisson regression models for the binary-dependent variables and adjusted for covariates, including sociodemographic and hospital characteristics.

Results

The results show that across all racial/ethnic groups, individuals with IDD have significantly higher rates of MCC-related ED visits, hospitalizations, and deaths compared with nondisabled. Moreover, the disparities are more pronounced for individuals from racial/ethnic minority groups. Black and Latinx individuals with IDD have significantly higher rates of MCC-related ED visits and poor outcomes than their white counterparts with and without IDD.

Conclusions

The findings from this study highlight significant racial and ethnic disparities in the risk of MCC-related ED visits, hospitalization following the ED visit, and mortality through the ED among IDD adults. This underscores the importance of adopting a multifaceted approach that addresses the social determinants of health, enhances access to health care, improves quality of care, and enhances care coordination.

Hospitalizations Among Children and Youth With Autism in the United States: Frequency, Characteristics, and Costs

National estimates of hospitalization diagnoses and costs were determined using the 2016 HCUP Kids' Inpatient Database. Children and youth with autism were hospitalized over 45,000 times at over $560 million in costs and 260,000 inpatient days. The most frequent principal diagnoses for hospitalizations of children and youth with autism were epilepsy, mental health conditions, pneumonia, asthma, and gastrointestinal disorders, which resulted in almost $200 million in costs and 150,000 inpatient days. Mental health diagnoses accounted for 24.8% of hospitalizations, an estimated $82 million in costs, and approximately 94,000 inpatient days. Children and youth with autism were more likely hospitalized for epilepsy, mental health diagnoses, and gastrointestinal disorders, and less likely for pneumonia and asthma compared to other children and youth.

A systematic review of in-patient psychiatric care for people with intellectual disabilities and/or autism: effectiveness, patient safety and experience

BACKGROUND

An increasing number of children, adolescents and adults with intellectual disabilities and/or autism are being admitted to general psychiatric wards and cared for by general psychiatrists.

AIMS

The aim of this systematic review was to consider the likely effectiveness of in-patient treatment for this population, and compare and contrast differing models of in-patient care.

METHOD

A systematic search was completed to identify papers where authors had reported data about the effectiveness of in-patient admissions with reference to one of three domains: treatment effect (e.g. length of stay, clinical outcome, readmission), patient safety (e.g. restrictive practices) and patient experience (e.g. patient or family satisfaction). Where possible, outcomes associated with admission were considered further within the context of differing models of in-patient care (e.g. specialist in-patient services versus general mental health in-patient services).

RESULTS

A total of 106 studies were included and there was evidence that improvements in mental health, social functioning, behaviour and forensic risk were associated with in-patient admission. There were two main models of in-patient psychiatric care described within the literature: admission to a specialist intellectual disability or general mental health in-patient service. Patients admitted to specialist intellectual disability in-patient services had greater complexity, but there were additional benefits, including fewer out-of-area discharges and lower seclusion rates.

CONCLUSIONS

There was evidence that admission to in-patient services was associated with improvements in mental health for this population. There was some evidence indicating better outcomes for those admitted to specialist services.

Hospital Inpatient Stays for Autistic Youth and Youth With Other Disabilities

BACKGROUND

Addressing health care needs is complex in autistic youth for many reasons. Increased inpatient care that has been noted in this population, particularly for ambulatory care sensitive conditions (ACSCs), may be a marker of inadequate primary and outpatient care.

METHODS

This study used data from hospital inpatient discharges from the National Inpatient Sample 2017. The prevalence, average length of stay, and the average cost per day of the 10 most common principal diagnoses for index stay were calculated for autistic youth and youth with mental, behavioral, and other neurodevelopmental disabilities (MBND), ages 0 to 17.

RESULTS

Of every 1000 inpatient stays, 7.3 were for autistic youth and 65.2 for youth with MBND. The rate varied by US region and zip code-level household income. The most common diagnosis associated with stays in autistic youth was mood disorders, as in youth with MBND. Nearly all top 10 principal diagnoses for autistic youth were for ACSCs. The highest average cost per day for autistic youth was for physical injuries ($4320 per day), and the longest stays were for schizophrenia (14 days).

CONCLUSIONS

High occurrence of ACSCs in autistic youth suggests that primary care may not adequately address health and mental health needs. Clinical complexity and autism characteristics may be impacting care received in the hospital. Additional considerations need to explore and examine care complexity, racial and ethnic disparities, and the large portion of Medicaid-covered youth. Strategies for the provision of care to these vulnerable populations are of great concern.

Severe Maternal Morbidity and Maternal Mortality in Women With Intellectual and Developmental Disabilities

INTRODUCTION

Despite increased attention on severe maternal morbidity and maternal mortality, scant research exists on adverse maternal outcomes in women with disabilities. This study compares the rates of severe maternal morbidity and maternal mortality in women with and without intellectual and developmental disabilities.

METHODS

This study used 2004-2017 Healthcare Cost and Utilization Project Nationwide Inpatient Sample data. Analyses were conducted in 2019‒2020. The risk of severe maternal morbidity with and without blood transfusion and maternal mortality during delivery among women with and without intellectual and developmental disabilities were compared using modified Poisson regression analysis.

RESULTS

This study identified 32,324 deliveries to women with intellectual and developmental disabilities. Per 10,000 deliveries, 566 deliveries with severe maternal morbidity occurred in women with intellectual and developmental disabilities compared with 239 in women without intellectual and developmental disabilities. Women with intellectual and developmental disabilities had greater risk of both severe maternal morbidity (risk ratio=2.36, 95% CI=2.06, 2.69) and nontransfusion severe maternal morbidity (risk ratio=2.95, 95% CI=2.42, 3.61) in unadjusted analyses, which was mitigated in adjusted analyses for sociodemographic characteristics (risk ratio=1.74, 95% CI=1.47, 2.06; risk ratio=1.85, 95% CI=1.42, 2.41) and the expanded obstetric comorbidity index (risk ratio=1.23, 95% CI=1.04, 1.44; risk ratio=1.31, 95% CI=1.02, 1.68). The unadjusted incidence of maternal mortality in women with intellectual and developmental disabilities was 284 per 100,000 deliveries, nearly 4-fold higher than in women without intellectual and developmental disabilities (69 per 100,000 deliveries; risk ratio=4.07, 95% CI=2.04, 8.12), and the risk remained almost 3-fold higher after adjustment for sociodemographic characteristics (risk ratio=2.86, 95% CI=1.30, 6.29) and the expanded obstetric comorbidity index (risk ratio=2.30, 95% CI=1.05, 5.29).

CONCLUSIONS

Women with intellectual and developmental disabilities are at increased risk of severe maternal morbidity and maternal mortality. These findings underscore the need for enhanced monitoring of the needs and maternal outcomes of women with intellectual and developmental disabilities in efforts to improve maternal health.

Health Care Utilization for Privately and Publicly Insured Children During Autism Insurance Reform

We examined the effects of insurance type on health service utilization among children with autism spectrum disorder (ASD) following autism insurance reform by analyzing the most recent data from the 2019 National Survey of Children's Health. Families with private insurance were less likely to report that their health insurance covered needed services compared to families with public insurance. Privately versus publicly insured children were not significantly different in receiving behavioral or medication treatment, or in parental frustration in efforts to obtain services. However, parents' frustration escalated with increased ASD severity. Findings from this study suggest the need for continuing to improve implementation of health insurance reform legislation and providing adequate ASD-related services for children with private insurance.

The role of the host microbiome in autism and neurodegenerative disorders and effect of epigenetic procedures in the brain functions

Autism Spectrum Disorder (ASD) is a severe neurological/neurodegenerative syndrome that results in cognitive and communication disorders. The degree of dysbiosis is related to the severity of ASD signs. The gut is conferred with a variety of sensory receptors that cooperate with effector systems including the endocrine, nervous and gut immune systems of the intestine. Gut dysbiosis causes amplified inflammation, the launch of the HPA axis, changed levels of neurotransmitters and bacterial metabolites; these may donate to abnormal signaling throughout the Vagus nerve in ASD. Decreased integrity of the gastrointestinal barrier led to extreme leakage of substances as of the intestine in early life and inflammation followed by disruption of BBB integrity maybe increase the risk of ASD. Microbiota, by controlling the barrier permeability, regulate the quantity and types of bioactive materials that are transferred from the intestine to the brain. Exposure to metabolites and microbial products regulate significant procedures in the CNS, including glial cell role, myelination, synaptic pruning, and play a role in neurobehavioral, neurodegenerative, psychiatric, and metabolic syndrome.

Physician Perspectives on Severe Behavior and Restraint Use in a Hospital Setting for Patients with Autism Spectrum Disorder

Hospitals, with many features that can evoke severe behavior in patients with autism spectrum disorder (ASD), often use restraint as a behavior management strategy. Prior research on restraint in patients with ASD has primarily focused on children or specific departments. Twenty-five physicians and medical trainees from an urban teaching hospital participated in discussions about experiences managing severe behavior in patients with ASD across the lifespan. Twenty themes emerged from thematic analysis of participant transcripts. The five most salient themes included: lack of procedural knowledge with restraint implemented by other hospital professionals; alternative strategies to manage severe behavior; negative perceptions of restraint; helpful role of caregivers; and limited experience treating patients with ASD, and critical need for training in function-based management.

Development and preliminary evaluation of a novel physician-report tool for assessing barriers to providing care to autistic patients

BACKGROUND

Individuals on the autism spectrum face significant disparities in health and physicians often report difficulties in providing care to autistic patients. In order to improve the quality of care autistic individuals receive, it is important to identify the barriers that physicians experience in providing care so that these may be addressed. This paper reports the initial development and preliminary evaluation of a physician-report 'Barriers to Providing Healthcare' measurement tool.

METHOD

An established taxonomy of healthcare barriers for autistic individuals informed the initial draft of a 22-item measurement tool. This measurement tool was distributed to physicians working in various healthcare specialties and settings. Exploratory factor analysis (EFA) was conducted to determine the construct validity of the tool; discriminant validity between, and internal consistency of, the resultant factors were assessed. Multiple regressions were used to explore variables potentially associated with barriers endorsed by physicians.

RESULTS

A total of 203 physicians were included in the analyses. The EFA resulted in a 17-item tool with three distinct factors which explained 37.6% of the variance: 1) Patient-related barriers (Cronbach's α = 0.83; e.g., the patient's reactivity to the healthcare environment); 2) Healthcare provider (HCP)/family-related barriers (Cronbach's α = 0.81; e.g., a lack of providers willing to work with autistic patients); and 3) System-related barriers (Cronbach's α = 0.84; e.g., there is a lack of support for patients and families). Discriminant validity between the factors was adequate (r < .8). The barriers that were most frequently endorsed as occurring 'often' or 'very often' included a lack of support for patients and families (endorsed by 79.9% of physicians); communication difficulties (73.4%); and a lack of coordination between services (69.9%). The regression analyses identified no significant associated variables.

CONCLUSION

A preliminary version of a novel physician-report tool to assess barriers to providing care to autistic patients has been developed although further validation work is required. The use of this tool will help physicians to identify issues specific to different medical specialities and healthcare settings. This information may help identify the supports physicians require to recognise and implement the required accommodations. Future research which elucidates barriers to healthcare provision for autistic patients is required to support systemic change in healthcare so as to improve care experiences and health outcomes for people on the autism spectrum.

States' use of Medicaid to meet the needs of autistic individuals

OBJECTIVE

To assess the use of Medicaid programs, including waivers, to address the needs of aging autistic individuals.

DATA SOURCES

We gathered data on Medicaid programs in place between 2004 and 2015 for 50 states and the District of Columbia from the Centers for Medicare and Medicaid Services website, by contacting state Medicaid administrators and advocacy groups, and by reviewing the Medicaid Analytic eXtract Waiver Crosswalk.

STUDY DESIGN

This retrospective analysis classified each Medicaid program and documented state changes over time in eligibility criteria: those serving autism spectrum disorder only, autism spectrum disorder or intellectual disability, and intellectual disability only.

DATA COLLECTION/EXTRACTION METHODS

We captured age and diagnosis eligibility criteria for Medicaid programs serving any of the three target groups.

PRINCIPAL FINDINGS

A total of 269 Medicaid programs met our criteria and most programs (51%) were 1915(c) waivers. The number of autism-specific 1915(c) waivers grew more than fivefold during the study period, outpacing increases in waivers serving individuals with intellectual disability.

CONCLUSIONS

States varied in their use of Medicaid to address the needs of the aging autism population. Further study of characteristics of states that changed their Medicaid programs, and of the health care use and outcomes associated with these changes, are needed to identify opportunities to replicate effective approaches to meeting the needs of this population.

Implementation of a Protocol: Dexmedetomidine for Use in Long-Term Procedural Sedation in Non-Intubated Pediatric Patients

The objective of this quality initiative was to evaluate the process of implementing a new protocol using the Iowa model and evidence-base interventions. The first aim included deploying a protocol guiding sedation with dexmedetomidine for up to 24 h; the procedure involved non-intubated pediatric patients in the pediatric intensive care unit (PICU) while monitored by certified registered nurses. Dexmedetomidine is supported within the literature to be a safe and effective medication for pediatric patients, exceeding 24 h, without the adverse event of respiratory depression. The second aim was to then evaluate the implementation process. A pre-post educational approach was used, over a five-month period. Thirty-two nurses were educated and surveyed on their knowledge and attitudes regarding the use and administration of dexmedetomidine. The evaluation of pre and post knowledge surrounding dexmedetomidine was concluded following the post-survey. The evaluation of pre-post education showed, greater than 90% of the attending nurses, had an increase in their knowledge and understanding of safe use and monitoring for dexmedetomidine sedations in children. This quality initiative further supports effective application of evidence-based interventions. Moreover, using the Iowa model allowed for the effective execution in driving change, promoting sustainability, and improving safety in the delivery of care for pediatric patients receiving dexmedetomidine for long-term sedation.

Estimating Components and Costs of Standard Care for Children with Autism Spectrum Disorder in Europe from a Large International Sample

(1) Background: European guidelines provide recommendations for services and care for people with autism spectrum disorder (ASD), but not all interventions are generally available. Knowledge of service use and costs and wider societal costs in Europe is limited; (2) Method: Using an international sample, we analysed services and costs in 357 children (4-6.99 years) with ASD based on parent reports. Costs were transformed into EU-28 average using purchasing power parity; (3) Results: 122 children (34%) received specialist autism services; 149 (42%) received sensory/motor therapy; 205 (57%) received speech/language therapy; 35 (10%) received play therapy; 55 (15%) received behavioural interventions; 31 (9%) received social skills training; 47 (13%) participated in therapeutic recreational activities; and 59 (17%) received other services. The total number of hours for these services combined over two months was M = 34 (SD = 63; range: 0 -372). Estimated total costs of health-related services were M = 1210 EUR (SD = 2160 EUR); indirect societal costs were M = 1624 EUR (SD = 1317 EUR). Regression analyses suggested that costs rise with age and presence of intellectual disabilities, but not with severity of autism; (4) Conclusions: The high extent of community-based services indicates good accessibility but also considerable variation in the receipt of services. The costs of autism services are considerable. Further research is needed to investigate whether services received match individual needs.

Providing Inpatient Medical Care to Children With Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a common neurodevelopmental disorder, affecting an estimated 1 in 40 children. Children with ASD have high rates of medical comorbidity and often experience high levels of distress during medical admissions, increasing the risk of agitation. Pediatric hospitalists receive minimal formal training on the inpatient care of children with ASD. In this article, we review strategies that pediatric hospitalists can use to optimize the care of children with ASD during inpatient admissions. These include gathering an ASD-related history early in the admission to understand the child's baseline core ASD symptoms, including social and communication ability, sensory needs, and restricted or repetitive behaviors. This information can be used to tailor the hospitalist's approach in each of these 3 domains. We conclude by reviewing procedure-related considerations, an approach to managing agitation, and quality improvement interventions.

Simulation-based education for teaching aggression management skills to health care providers in the acute health care setting: a systematic review protocol

BACKGROUND

Clinical aggression episodes, that is aggression and externalising behaviours that create risk, in acute care hospitals are increasing. Acute care staff are often not confident or trained in the management of aggression. Various aggression management training formats have been described in practice including face to face training, written learning resources, web- and media-based training resources, and simulation training. The aim of this systematic review is to assess whether simulation-based training is effective in increasing de-escalation knowledge, skills, and behaviour of staff working in the acute care setting.

METHODS

We designed and registered a study protocol for a systematic review of studies evaluating simulation-based training for the management of patients with aggression. We will include randomised controlled trials, non-randomised controlled trials, quasi-experimental studies, and observational studies including health care professionals and trainees in acute health care settings. Comprehensive searches will be conducted in the following databases (from January 1980 onwards): PubMed, MEDLINE, PsycINFO, CINAHL, and the Cochrane Library. The reference lists of selected studies, trial registers, and leading journals will also be searched. Two reviewers will independently screen all citations, full-text articles, and abstract data. Potential discrepancies will be resolved through discussion. The primary outcomes will include patient outcomes (e.g. frequency of clinical aggression), quality of care (e.g. frequency of emergency situations, physical/chemical/mechanical restraint), and adverse effects (e.g. patient/family complaints, patient harms, staff harms). Secondary outcomes will include workplace resource use, health care provider-related outcomes, knowledge (de-escalation techniques), performance, attitudes, and satisfaction. The study methodological risk of bias will be appraised using appropriate tools. A narrative synthesis will be performed for included studies. If feasible, we will conduct random-effects meta-analysis of data. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g. participant characteristics, interventions, and follow-up).

DISCUSSION

This systematic review will identify, evaluate, and integrate the evidence on simulation-based training programmes for acute care health professionals on managing clinical aggression. The results of this study will inform the implementation of effective training strategies. Implications for future research will be discussed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42020151002.

Simulation-Based Education for Staff Managing Aggression and Externalizing Behaviors in Children With Autism Spectrum Disorder in the Hospital Setting: Pilot and Feasibility Study Protocol for a Cluster Randomized Controlled Trial

Background

Children with autism spectrum disorder (ASD) frequently demonstrate aggression and externalizing behaviors in the acute care hospital environment. Pediatric acute care nursing staff are often not trained in managing aggression and, in particular, lack confidence in preventing and managing externalizing behaviors in children with ASD. High-fidelity simulation exercises will be used in this study to provide deliberate practice for acute care pediatric nursing staff in the management of aggressive and externalizing behaviors.

Objective

The purpose of this study is to conduct a pilot and feasibility cluster randomized controlled trial (RCT) to evaluate the effectiveness of simulation-based education for staff in managing aggression and externalizing behaviors of children with ASD in the hospital setting.

Methods

This study has a mixed design, with between-group and within-participant comparisons to explore the acceptability and feasibility of delivering a large-scale cluster RCT. The trial process, including recruitment, completion rates, contamination, and completion of outcome measures, will be assessed and reported as percentages. This study will assess the acceptability of the simulation-based training format for two scenarios involving an adolescent with autism, with or without intellectual disability, who displays aggressive and externalizing behaviors and the resulting change in confidence in managing clinical aggression. Two pediatric wards of similar size and patient complexity will be selected to participate in the study; they will be randomized to receive either simulation-based education plus web-based educational materials or the web-based educational materials only. Change in confidence will be assessed using pre- and posttraining surveys for bedside nursing staff exposed to the training and the control group who will receive the web-based training materials. Knowledge retention 3 months posttraining, as well as continued confidence and exposure to clinical aggression, will be assessed via surveys. Changes in confidence and competence will be compared statistically with the chi-square test using before-and-after data to compare the proportion of those who have high confidence between the two arms at baseline and at follow-up. The simulation-based education will be recorded with trained assessors reviewing participants’ abilities to de-escalate aggressive behaviors using a validated tool. This data will be analyzed using mean values and SDs to understand the variation in performance of individuals who undertake the training. Data from each participating ward will be collected during each shift for the duration of the study to assess the number of aggressive incidents and successful de-escalation for patients with ASD. Total change in Code Grey activations will also be assessed, with both datasets analyzed using descriptive statistics.

Results

This study gained ethical approval from The Royal Children's Hospital Melbourne Human Research Ethics Committee (HREC) on November 1, 2019 (HREC reference number: 56684). Data collection was completed in February 2020. Data analysis is due to commence with results anticipated by August 2020.

Conclusions

We hypothesize that this study is feasible to be conducted as a cluster RCT and that simulation-based training will be acceptable for acute care pediatric nurses. We anticipate that the intervention ward will have increased confidence in managing clinical aggression in children with ASD immediately and up to 3 months posttraining.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000139976; http://www.ANZCTR.org.au/ACTRN12620000139976.aspx

International Registered Report Identifier (IRRID)

DERR1-10.2196/18105

Objective Estimates of Direct-Medical Costs Among Persons Aged 3 to 38 Years With and Without Research-Defined Autism Spectrum Disorder Ascertained During Childhood: A Population-Based Birth-Cohort Study

OBJECTIVES

Accurate estimates of autism spectrum disorder (ASD)-associated medical costs are essential for predicting future care needs, allocating resources, identifying best practices, and modeling cost-effectiveness. Most existing studies have either employed subjective cost data or ascertained ASD using self-reported or International Classification of Diseases-coded diagnoses. Such ascertainment is especially problematic for identifying milder ASD among older individuals never diagnosed with ASD.

METHODS

This 1976 through 2000 population-based birth-cohort study was set in Olmsted County, Minnesota. ASD cases and age- and sex-matched unaffected controls were identified by applying uniform operational research criteria for ASD (using the guidelines of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision) after rigorous review of provider-linked medical and public, private, or home school records available for all members from birth to a maximum age of 21 years. Medical cost estimates for the 901 case-control pairs used line-item provider-linked billing data (including all payers) from 2003 through 2014 (ages 3-38 years). Outpatient pharmaceutical costs were unavailable. Temporal changes in diagnostic criteria, clinical practice, public awareness, and access were addressed by separating analyses into 5-year age group and 4-year calendar period cells. Unadjusted and adjusted (age and age plus co-occurring conditions) cost estimates were provided for cases, controls, and case-control differences. Additional factors (co-occurring conditions, percentage hospitalized, intellectual disability) were investigated using unadjusted descriptive analyses.

RESULTS

Cell sample sizes ranged from 93 to 402 for age groups 3 through 19 years and from 45 to 395 for age groups 20 through 38 years. Unadjusted, age-adjusted, and fully adjusted medical costs were significantly higher for cases versus controls in 100% of cells for age groups 3 through 19 years and in 50% (unadjusted), 38% (age adjusted), and 12% (fully adjusted) of cells for age groups 20 through 38 years.

CONCLUSIONS

These unique estimates can help inform the construction of cost-effectiveness models; decisions by payers, providers, and policy makers; and predictions of lifetime costs.

Pediatric Consultation-Liaison Psychiatry: An Update and Review

Background

In recent years, there has been an increasing burden of child and adolescent mental illness recognized in the United States, and the need for pediatric mental health care is growing. Pediatric consultation-liaison (C-L) psychiatrists are increasingly playing a role in the management of medical and psychiatric disease for pediatric patients. The field is a fast-moving one, with understanding of new neuropsychiatric disease entities; reformulation of prior disease entities; and new interdisciplinary treatments and models of care.

Methods

In this study, we aim to review recent advances in the field of pediatric C-L psychiatry, including new diagnostic entities, updated management of frequently encountered clinical presentations, and developments in systems of care.

Conclusion

The advances in pediatric C-L psychiatry are broad and serve to promote more streamlined, evidence-based care for the vulnerable population of psychiatrically ill pediatric medical patients. More work remains to determine the most effective interventions for the wide array of presentations seen by pediatric C-L psychiatrists.

Do Demographics and Comorbidities Act as Predictors of Co-diagnosis of Attention-deficit/Hyperactivity Disorder in Autism Spectrum Disorder?

Objective

The study aims to determine the demographic predictors of attention-deficit/hyperactivity disorder (ADHD) in hospitalized children with autism spectrum disorder (ASD) and the impact of comorbidities on the length of stay (LOS).

Methods

A retrospective study was performed using a nationwide inpatient sample from US hospitals. All patients were ≤18 years in age with a primary diagnosis of ASD (n = 3,095) and grouped by co-diagnosis of ADHD based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes. Logistic regression was used to calculate the odds ratio (OR) and linear regression for estimated LOS.

Results

Male patients had a higher odds of comorbid ADHD (OR: 2.2). Age and race were not significant predictors of ADHD though the condition was found to be prevalent in adolescents and Caucasians. These children were mainly from the South (30.8%) and the Midwest (29.9%) regions of the US. Psychosis was seen in 37.3% of patients with ADHD and was more likely to be comorbid psychosis (OR: 1.8). Depression and ADHD increased the LOS in hospitals for ASD by 2.1 days and 0.9 days, respectively.

Conclusion

Our study led us to determine the demographic predictors of comorbid ADHD in patients with autism, and we believe that our findings can help to better serve these patients and their families. Comorbid ADHD and depression can prolong the length of hospitalization and they necessitate the need for acute inpatient care in such patients.

Disparities in Service Use Among Children With Autism: A Systematic Review

CONTEXT

Research reveals racial, ethnic, and socioeconomic disparities in autism diagnosis; there is limited information on potential disparities related to other dimensions of services.

OBJECTIVE

We reviewed evidence related to disparities in service use, intervention effectiveness, and quality of care provided to children with autism by race, ethnicity, and/or socioeconomic status.

DATA SOURCES

Medline, PsychInfo, Educational Resources Informational Clearinghouse, and the Cumulative Index to Nursing and Allied Health Literature were searched by using a combination of Medical Subject Headings terms and keywords related to autism, disparities, treatment, and services.

STUDY SELECTION

Included studies addressed at least one key question and met eligibility criteria.

DATA EXTRACTION

Two authors reviewed the titles and abstracts of articles and reviewed the full text of potentially relevant articles. Authors extracted information from articles that were deemed appropriate.

RESULTS

Treatment disparities exist for access to care, referral frequency, number of service hours, and proportion of unmet service needs. Evidence revealed that racial and ethnic minority groups and children from low-income families have less access to acute care, specialized services, educational services, and community services compared with higher-income and white families. We found no studies in which differences in intervention effectiveness were examined. Several studies revealed disparities such that African American and Hispanic families and those from low-income households reported lower quality of care.

LIMITATIONS

The body of literature on this topic is small; hence it served as a limitation to this review.

CONCLUSIONS

The documented disparities in access and quality of care may further identify groups in need of outreach, care coordination, and/or other interventions.

The Economic Costs of Autism Spectrum Disorder: A Literature Review

Autism is associated with a range of costs. This paper reviews the literature on estimating the economic costs of autism spectrum disorder (ASD). More or less 50 papers covering multiple countries (US, UK, Australia, Canada, Sweden, the Netherlands, etc.) were analysed. Six types of costs are discussed in depth: (i) medical and healthcare service costs, (ii) therapeutic costs, (iii) (special) education costs, (iv) costs of production loss for adults with ASD, (v) costs of informal care and lost productivity for family/caregivers, and (vi) costs of accommodation, respite care, and out-of-pocket expenses. A general finding is that individuals with ASD and families with children with ASD have higher costs. Education costs appear to be a major cost component for parents with children with ASD.

Evaluation of Factors Related to Prolonged Lengths of Stay for Patients With Autism With or Without Intellectual Disability

Patients with autism spectrum disorder and/or intellectual disability (ASD/ID) face unique health care challenges. In addition to hospital experiences characterized by fear and insufficient staff training, these patients have 1.5-times longer lengths of stay (LOS) than patients without ASD/ID, and 3.4% of patients with ASD/ID have prolonged LOS (i.e., ≥30 days). Little research exists on factors related to prolonged LOS of patients with ASD/ID, hindering efforts to develop and implement evidence-based practices to improve care and reduce prolonged LOS. The purpose of the current study was to describe factors related to prolonged LOS of adult patients with ASD/ID in acute care settings using a retrospective chart review of 10 patients discharged from one academic medical center. Findings indicate that health care institutions should evaluate performance with this patient population and identify evidence-based strategies to provide a safe environment for care and reduce LOS that is due to non-health care needs. [Journal of Psychosocial Nursing and Mental Health Services, 57(7), 17-22.].

In-hospital mortality among adults with autism spectrum disorder in the United States: A retrospective analysis of US hospital discharge data

A retrospective data analysis using 2004-2014 Healthcare Cost and Utilization Project Nationwide Inpatient Sample was conducted to examine in-hospital mortality among adults with autism spectrum disorders in the United States compared to individuals in the general population. We modeled logistic regressions to compare inpatient hospital mortality between adults with autism spectrum disorders (n = 34,237) and age-matched and sex-matched controls (n = 102,711) in a 1:3 ratio. Adults with autism spectrum disorders had higher odds for inpatient hospital mortality than controls (odds ratio = 1.44, 95% confidence interval: 1.29-1.61, p < 0.001). This risk remained high even after adjustment for age, sex, race/ethnicity, income, number of comorbidities, epilepsy and psychiatric comorbidities, hospital bed size, hospital region, and hospitalization year (odds ratio = 1.51, 95% confidence interval: 1.33-1.72, p < 0.001). Adults with autism spectrum disorders who experienced in-hospital mortality had a higher risk for having 10 out of 27 observed Elixhauser-based medical comorbidities at the time of death, including psychoses, other neurological disorders, diabetes, hypothyroidism, rheumatoid arthritis collagen vascular disease, obesity, weight loss, fluid and electrolyte disorders, deficiency anemias, and paralysis. The results from the interaction of sex and autism spectrum disorders status suggest that women with autism spectrum disorders have almost two times higher odds for in-hospital mortality (odds ratio = 1.95, p < 0.001) than men with autism spectrum disorders. The results from the stratified analysis also showed that women with autism spectrum disorders had 3.17 times higher odds (95% confidence interval: 2.50-4.01, p < 0.001) of in-hospital mortality compared to women from the non-autism spectrum disorders matched control group; this difference persisted even after adjusting for socioeconomic, clinical, and hospital characteristics (odds ratio = 2.75, 95% confidence interval: 2.09-3.64, p < 0.001). Our findings underscore the need for more research to develop better strategies for healthcare and service delivery to people with autism spectrum disorders.

Health Care Service Utilization and Cost Among Adults with Autism Spectrum Disorders in a U.S. Integrated Health Care System

Objectives

To compare health care utilization patterns and cost among insured adults with autism spectrum disorder (ASD), adults with attention-deficit and hyperactivity disorder (ADHD), and adults with neither condition (general population [GP] controls).

Method

We conducted a case-control study among adults (≥18 years) who were members of Kaiser Permanente Northern California (KPNC) for at least 9 months each year from 2008 to 2012. Cases (N = 1507) were adults with an ASD diagnosis (ICD-9-CM 299.0-299.8) recorded in the electronic medical record on at least two separate occasions by December 31, 2012. Two control groups, adults with ADHD (N = 9042) defined by ICD-9-CM code 314 and GP (N = 15,070), were randomly selected and frequency matched to cases on gender and age. Health care utilization and cost data were obtained from KPNC databases for the year 2012.

Results

Compared with adults with ADHD, adults with ASD had significantly higher utilization of outpatient visits for primary care (74.2% vs. 66.6%), mental health (43.3% vs. 33.2%), and laboratory services (60.9% vs. 54.4%). Hospitalizations for ambulatory care sensitive diagnoses (5.4% vs. 2.3%) were less frequent overall but more common among adults with ASD than with ADHD. Group differences were larger comparing adults with ASD with GP controls. Gynecology visits and screening for cervical cancer were significantly less common among women with ASD than among women with ADHD (35% vs. 50%) or GP (35% vs. 49%). Total annual mean healthcare costs for adults with ASD were 20% higher than costs for adults with ADHD and double costs for GP.

Conclusion

Adults with ASD had significantly higher rates of utilization across most health care service areas compared with adults with ADHD or GP; however, women with ASD were significantly less likely to have gynecology visits and have screening for cervical cancer.

Lay Summary

We conducted a study among adults (≥18 years) who were members of Kaiser Permanente Northern California (KPNC) from 2008 to 2012. We compared how often people attended different types of health care and costs of health care among adults with autism spectrum disorder (ASD), adults with attention-deficit and hyperactivity disorder (ADHD), and adults with neither condition (general population [GP] controls). The study included 1507 adults with ASD, 9042 with ADHD but not ASD, and 15,070 GP controls with no ASD or ADHD. Health care and cost data were obtained from KPNC databases for the year 2012. The study found that adults with ASD used more outpatient visits for primary care, mental health, and laboratory services than adults with ADHD. Gynecology visits and screening for cervical cancer were less common among women with ASD than among women with ADHD or GP. Health care costs for adults with ASD were higher than costs for adults with ADHD and costs for GP. In conclusion, adults with ASD had higher rates of use of most health care service areas than adults with ADHD or GP; however, women with ASD were less likely to have gynecology visits and have screening for cervical cancer.

Geographic Disparities in Treatment for Children with Autism Spectrum Disorder

OBJECTIVE

Geographic differences may provide insight into what factors influence the likelihood that a child is diagnosed with autism spectrum disorder (ASD) in the United States; yet, there have been few nationally representative surveys that have explored this topic. The current study expands the limited literature by analyzing regional differences in ASD prevalence, service utilization, and the presence of unmet needs within a nationally representative sample of children.

METHODS

Data were drawn from the 2014-2016 National Health Interview Survey (NHIS), a nationally representative household survey of the noninstitutionalized US population. Children 3 to 17 years of age were included in the analytic sample. Prevalence estimates accounted for the complex survey design of the NHIS, and differences between geographic regions were compared using logistic/linear regressions with and without adjustment for child/family characteristics.

RESULTS

The prevalence of ASD was highest in the Northeast (3.0%), followed by the Midwest (2.4%), South (2.4%), and West (2.3%). A significant difference was found between the Northeast and West (P < .05); however, after accounting for child and family characteristics, this difference was no longer significant. Children with ASD in the Northeast were the most likely to have seen a specialist in the past year. Approximately 1 in 8 children with ASD experienced at least 1 unmet need, but there were no differences found by geographic region.

CONCLUSIONS

Although differences in prevalence were not significant after adjustment, service utilization differences remained. It appears that children with ASD in the Northeast utilize the greatest number of specialty services when compared to children with ASD from other parts of the country.

Predictors of Inpatient Psychiatric Hospitalization for Children and Adolescents with Autism Spectrum Disorder

Autism Spectrum Disorder (ASD) is associated with significant healthcare expenditures and a greater utilization of psychiatric health services. High utilization may not be evenly distributed across individuals with ASD. The objective of this study was to identify individual and family characteristics that increase the risk of psychiatric hospitalization. Naturalistic study of two age- and gender-matched ASD cohorts, inpatients enrolled in the Autism Inpatient Collection (AIC) and outpatients enrolled in the Rhode Island Consortium of Autism Research and Treatment (RI-CART), revealed a number of factors associated with hospitalization. Multiple logistic regression analyses revealed that adaptive functioning, ASD symptom severity, primary caregiver's marital status, the presence of mood disorders, and the presence of sleep problems independently increased the risk of psychiatric hospitalization.

Brief Report: Regional Variations in Characteristics of ASD Hospitalizations in the U.S

Regional differences in ASD inpatient care remain understudied. We used the Nationwide Inpatient Sample to examine contributory causes and potential determinants associated with regional variations in ASD hospitalizations. We performed univariate and multivariate analyses to identify differences in ASD hospitalizations across four U.S. Census Bureau-defined regions. Our results revealed considerable variations in ASD hospitalizations across U.S. regions. Compared with patients in the Northeast, those in the Midwest, South, and West were less likely to be hospitalized for ASD. Significant differences were observed among regions with regard to the effect of health insurance type, hospital length of stay, hospital bed size, hospital location and teaching status on ASD hospitalizations. The region-specific analysis provides direction for further investigation.

Medical care experiences of children with autism and their parents: A scoping review

Children with autism spectrum disorder (ASD) and their families may benefit from the provision of additional supports in health care settings, particularly when preparing for and attending medical appointments. This review examined literature that describes experiences in medical care settings from the perspective of patients under age 18 with ASD and their caregivers. A scoping review was conducted to examine the experiences of children with ASD and their families in medical care settings. Twenty-nine studies meeting inclusion criteria were identified and reviewed. The review indicated a number of challenges (e.g., parent-reported problems in parent-provider communication and overwhelming environments) as well as factors that facilitate positive experiences (e.g., providing positive reinforcement and explaining exam steps) during medical appointments. Children with ASD and their families are faced with many challenges while receiving care in medical settings. The present review identified many challenges families face, as well as facilitators of positive experiences. Understanding the unique experiences of patients with ASD and their parents will help to improve experiences in medical care settings for children, caregivers, and health care providers.

Development and Evaluation of an Educational Initiative to Improve Hospital Personnel Preparedness to Care for Children with Autism Spectrum Disorder

OBJECTIVE

To evaluate the effectiveness of a multimodal educational curriculum on increasing hospital personnel's awareness of successful strategies and comfort in caring for children with autism spectrum disorder (ASD).

METHODS

We developed a 3-part training for front-line staff (i.e., front desk, clinical assistants, and phlebotomists) in 8 outpatient hospital departments frequented by patients with ASD. Following a needs assessment, participants completed an online educational module and then attended an in-person seminar tailored to each department. To evaluate training effectiveness, we administered pre-, immediate post-, and 1 month post-training surveys assessing personnel attitudes, comfort, perceived knowledge, and behaviors around caring for patients with ASD.

RESULTS

We trained 168 staff members from 8 departments. On the needs assessment, participants (N = 129) reported a mean 2.5 behavioral incidents involving patients with ASD over the previous 3 months; 92% believed that the training would be helpful for their work. Across pre-, immediate- and 1-month post-training surveys, scores improved on all questions related to personnel attitudes about the importance of ASD-friendly care, comfort interacting with patients with ASD, perceived knowledge about ASD, and self-reported frequency of behaviors intended to help children with ASD adjust to the hospital setting (p < 0.05). There was no difference in baseline scores or change in scores between clinical and nonclinical personnel. On a program evaluation (N = 57), 81% rated the training as "very good" or "excellent," and 87% reported that they would be able to apply training material immediately to their role.

CONCLUSION

This training initiative led to improvement in attitudes, comfort level, perceived knowledge, and self-reported behaviors of hospital personnel working with patients with ASD, which was maintained over 1 month.

'How deep are your pockets?' Autoethnographic reflections on the cost of raising a child with autism

Background

In this article, we reflected on our experience of the cost of parenting a child with autism, including our ongoing search for educational and therapeutic intervention.

Objectives

We aimed to give an academic insight into the state of autism education and care in South Africa as seen by us, with special attention to its cost and sustainability.

Methods

Using evocative autoethnography as storied scholarship together with critical autism studies, we reflected on stories of the past 5 years since our son’s diagnosis.

Results

Our experiences agree with international studies that establish autism as the most expensive disability. In addition to the high costs of diagnosis, existing intervention and support approaches are unaffordable for the majority of South Africans. We recommend that teachers should be trained to participate in early screening and diagnosis, as well as co-therapists, to strengthen the implementation of inclusive education.

Conclusion

The kind of autism intervention currently offered in South Africa is financially and socially unsustainable. Instead of positioning autism as an individual or family dilemma, it should be addressed as an educational and societal issue. Future research should explore cost-effective options for a developing country context, while promoting best practice within inclusive settings.

A Profile on Emergency Department Utilization in Adolescents and Young Adults with Autism Spectrum Disorders

There has been an increase in utilization of the Emergency Department (ED) in individuals with autism spectrum disorder (ASD) which may reflect a deficit of services (Green et al., Journal of the American Academy of Child and Adolescent Psychiatry 40(3):325-332, 2001; Gurney et al., Archives of Pediatric and Adolescent Medicine 160:825-830, 2006; Leichtman et al., American Journal of Orthopsyhciatry 72(2):227-235, 2001). The current study examined the rates of ED utilization between 2005 and 2013 in ASD youth 12- to 21-years-old. Adolescents with ASD accessed ED services four times as often as adolescents without ASD. Older adolescents and those living in rural areas showed a significant increase in ED visits over time. Post hoc analysis revealed increased ED utilization for females and behavioral health ED services over time. Better access to and greater understanding of services for adolescents with ASD is a critical need.

ECHO Autism

Children with autism spectrum disorder (ASD) have complex medical problems, yet they are at high risk for unmet health care needs. Primary care providers are perfectly positioned to meet these needs; however, they often lack training in ASD. This pilot project developed and tested a new model for training primary care providers in best-practice care for ASD using the Extension for Community Healthcare Outcomes (ECHO) framework. The 6-month ECHO Autism pilot project consisted of 12 biweekly clinics focused on screening and identification of ASD symptoms and management of medical and psychiatric comorbidities. Participants completed measures of practice behavior and self-efficacy in screening and management of children with ASD at baseline (pretest) and after 6 months of ECHO Autism (posttest). Statistically significant improvements were observed in self-efficacy, in adherence to ASD screening guidelines, and in use of ASD-specific resources. Participants also reported high satisfaction with the program.

Safety Profile of Children in an Enclosure Bed

PURPOSE

Pediatric nurses care for many children in the hospital setting whose behavioral challenges can impact safety. One intervention utilized to prevent injury and improve safety when caring for this population of children has been the enclosure bed. Scant information was found in the literature that discusses the use of the enclosure bed in the pediatric setting. The purpose of this article is to examine the use of the enclosure bed in the pediatric setting. A secondary aim is to identify the population of children where an enclosure bed was implemented and the safety factors associated with use of the enclosure bed.

METHODS

An exploratory retrospective chart review was conducted of 208 pediatric enclosure bed encounters in an acute care setting over a 2-year period. Variables included demographics, length of stay and bed use, behavioral medications, restraint and sitter usage, skin breakdown, fall risk, and falls.

RESULTS

Three categories of children based on cognitive function, no cognitive impairment, new cognitive impairment, and congenital cognitive impairment, were extracted from the chart review. Significant differences were found between groups of children and between safety variables observed with enclosure bed use. Children with new-onset cognitive impairment were more likely to incur falls, skin breakdown, and injury during use of the enclosure bed.

CONCLUSION

Use of the enclosure bed is a reasonable intervention in certain children to ensure their safety in the hospital setting. This information will enhance nursing knowledge related to providing safe and optimal care of this challenging population of children.

Mental Health Conditions and Medical and Surgical Hospital Utilization

OBJECTIVE

Mental health conditions are prevalent among children hospitalized for medical conditions and surgical procedures, but little is known about their influence on hospital resource use. The objectives of this study were to examine how hospitalization characteristics vary by presence of a comorbid mental health condition and estimate the association of a comorbid mental health condition with hospital length of stay (LOS) and costs.

METHODS

Using the 2012 Kids' Inpatient Database, we conducted a retrospective, nationally representative, cross-sectional study of 670 161 hospitalizations for 10 common medical and 10 common surgical conditions among 3- to 20-year-old patients. Associations between mental health conditions and hospital LOS were examined using adjusted generalized linear models. Costs of additional hospital days associated with mental health conditions were estimated using hospital cost-to-charge ratios.

RESULTS

A comorbid mental health condition was present in 13.2% of hospitalizations. A comorbid mental health condition was associated with a LOS increase of 8.8% (from 2.5 to 2.7 days, P < .001) for medical hospitalizations and a 16.9% increase (from 3.6 to 4.2 days, P < .001) for surgical hospitalizations. For hospitalizations in this sample, comorbid mental health conditions were associated with an additional 31 729 (95% confidence interval: 29 085 to 33 492) hospital days and $90 million (95% confidence interval: $81 to $101 million) in hospital costs.

CONCLUSIONS

Medical and surgical hospitalizations with comorbid mental health conditions were associated with longer hospital stay and higher hospital costs. Knowledge about the influence of mental health conditions on pediatric hospital utilization can inform clinical innovation and case-mix adjustment.

Emergency Department Use Among Adults with Autism Spectrum Disorders (ASD)

A cross-sectional analyses using Nationwide Emergency Department Sample (2006-2011) was conducted to examine the trends, type of ED visits, and mean total ED charges for adults aged 22-64 years with and without ASD (matched 1:3). Around 0.4% ED visits (n = 25,527) were associated with any ASD and rates of such visits more than doubled from 2006 to 2011 (2549-6087 per 100,000 admissions). Adults with ASD visited ED for: primary psychiatric disorder (15%ASD vs. 4.2%noASD), primary non-psychiatric disorder (16%ASD vs. 14%noASD), and any injury (24%ASD vs. 28%noASD). Mean total ED charges for adults with ASD were 2.3 times higher than for adults without ASD. Findings emphasize the need to examine the extent of frequent ED use in this population.

Comorbidity prevalence, healthcare utilization, and expenditures of Medicaid enrolled adults with autism spectrum disorders

A retrospective data analysis using 2000-2008 three state Medicaid Analytic eXtract was conducted to examine the prevalence and association of comorbidities (psychiatric and non-psychiatric) with healthcare utilization and expenditures of fee-for-service enrolled adults (22-64 years) with and without autism spectrum disorders (International Classification of Diseases, Ninth Revision-clinical modification code: 299.xx). Autism spectrum disorder cases were 1:3 matched to no autism spectrum disorder controls by age, gender, and race using propensity scores. Study outcomes were all-cause healthcare utilization (outpatient office visits, inpatient hospitalizations, emergency room, and prescription drug use) and associated healthcare expenditures. Bivariate analyses (chi-square tests and t-tests), multinomial logistic regressions (healthcare utilization), and generalized linear models with gamma distribution (expenditures) were used. Adults with autism spectrum disorders (n = 1772) had significantly higher rates of psychiatric comorbidity (81%), epilepsy (22%), infections (22%), skin disorders (21%), and hearing impairments (18%). Adults with autism spectrum disorders had higher mean annual outpatient office visits (32_ASD vs 8_noASD) and prescription drug use claims (51_ASD vs 24_noASD) as well as higher mean annual outpatient office visits (US$4375_ASD vs US$824_noASD), emergency room (US$15,929_ASD vs US$2598_noASD), prescription drug use (US$6067_ASD vs US$3144_noASD), and total expenditures (US$13,700_ASD vs US$8560_noASD). The presence of a psychiatric and a non-psychiatric comorbidity among adults with autism spectrum disorders increased the annual total expenditures by US$4952 and US$5084, respectively.

Traumatic Childhood Events and Autism Spectrum Disorder

Traumatic childhood events are associated with a wide range of negative physical, psychological and adaptive outcomes over the life course and are one of the few identifiable causes of psychiatric illness. Children with autism spectrum disorder (ASD) may be at increased risk for both encountering traumatic events and developing traumatic sequelae; however, this topic has been understudied. This review considers the rationale for examining traumatic events and related symptomology in individuals with ASD and summarizes the limited research on this topic. A conceptual framework for understanding the interplay of ASD, trauma and traumatic sequelae is proposed and recommendations for future research presented.

Utilization due to chronic obstructive pulmonary disease and its predictors: a study using the U.S. National Emergency Department Sample (NEDS)

Background

Previous studies of healthcare utilization for chronic obstructive pulmonary disease (COPD) have focused on time-trends in COPD visits or COPD treatments, or the effect of hospital volume on mortality. Few data are available regarding outcomes after an ED visit (and subsequent hospitalization) for COPD, which are both very common in patients with COPD. Our objective was to assess time-trends and predictors of emergency department and subsequent inpatient health care utilization and charges associated with COPD in the U.S.

Method

We used the 2009-12 U.S. Nationwide Emergency Department Sample (NEDS) to study the incidence of ED visits and subsequent hospitalizations with COPD as the primary diagnosis. We used the 2012 NEDS data to study key patient/hospital factors associated with outcomes, including charges, hospitalization and dischage from hospital to home.

Results

ED visits for COPD as the primary diagnosis increased from 1.02 million in 2009 to 1.04 in 2010 to 1.10 million in 2012 (0.79–0.82 % of all ED visits); respective charges were $2.13, $2.32, and $3.09 billion. In 2012, mean ED charges/visit were $2,812, hospitalization charges/visit were $29,043 and the length of hospital stay was 4.3 days. 49 % were hospitalized after an ED visit. Older age, higher median income, metropolitan residence and comorbidities (diabetes, hypertension, HF, hyperlipidemia, CHD, renal failure and osteoarthritis) were associated with higher risk whereas male sex, Medicaid or self pay insurance status, hospital location in Midwest, South or West U.S. were associated with lower risk of hospitalization. 65.4 % of all patients hospitalized for COPD from ED were discharged home. Older age, comorbidities (diabetes, HF, CHD, renal failure, osteoarthritis) and metropolitan residence were associated with lower odds of discharge to home, whereas male sex, payer other than Medicare, Midwest, South or West U.S. hospital location were associated with higher odds.

Conclusion

Health care utilization and costs in patients with COPD are significant and increasing. COPD constitutes a major public health burden in the U.S. We identified risk factors for hospitalization, costs, and home discharge in patients with COPD that will allow future studies to investigate interventions to potentially reduce COPD-associated utilization.

Electronic supplementary material

The online version of this article (doi:10.1186/s12931-015-0319-y) contains supplementary material, which is available to authorized users.

Non-traumatic Dental Condition-Related Emergency Department Visits and Associated Costs for Children and Adults with Autism Spectrum Disorders

We analyzed 2010 US National Emergency Department Sample data and ran regression models to test the hypotheses that individuals with ASD are more likely to have non-traumatic dental condition (NTDC)-related emergency department (ED) visits and to incur greater costs for these visits than those without ASD. There were nearly 2.3 million NTDC-related ED visits in 2010. Less than 1.0% (children) and 2.1% (adults) of all ED visits were for NTDC. There was no significant difference in NTDC-related ED visits or costs for children by ASD status. Adults with ASD had significantly lower odds of NTDC-related ED visits (OR 0.39; 95% CI 0.29, 0.52; p < 0.001) but incurred significantly greater mean costs for NTDC-related ED visits (p < 0.006) than did adults without ASD.

A Comparison of Ambulatory Care Sensitive Hospitalizations Among Children With and Without Autism Spectrum Disorder

OBJECTIVE

To compare the prevalence of hospitalizations for ambulatory care sensitive conditions (ACSC) in children with and without autism spectrum disorder (ASD) and to compare inpatient health care utilization (total charges and length of stay) for the same conditions in children with and without ASD.

METHODS

The 2009 Kids' Inpatient Database was used to examine hospitalizations for ACSC in children within 3 cohorts: those with ASD, those with chronic conditions (CC) without ASD, and those with no CC.

RESULTS

The proportion of hospitalizations for ACSC in the ASD cohort was 55.9%, compared with 28.2% in the CC cohort and 22.9% in the no-CC cohort (P < .001). Hospitalized children with ASD were more likely to be admitted for a mental health condition, epilepsy, constipation, pneumonia, dehydration, vaccine-preventable diseases, underweight, and nutritional deficiencies compared with the no-CC cohort. Compared with the CC cohort, the ASD cohort was more likely to be admitted for mental health conditions, epilepsy, constipation, dehydration, and underweight. Hospitalized children with ASD admitted for mental health conditions had significantly higher total charges and longer LOS compared with the other 2 cohorts.

CONCLUSIONS

The proportion of potentially preventable hospitalizations is higher in hospitalized children with ASD compared with children without ASD. These data underscore the need to improve outpatient care of children with ASD, especially in the areas of mental health care and seizure management. Future research should focus on understanding the reasons for increased inpatient health care utilization in children with ASD admitted for mental health conditions.