1
|
Leyenaar JK, Acquilano SC, Freyleue SD, Schaefer AP, McDaniel CE, Bode RS, Erdem G, Lauden S, Schmerge C, Choi SS, Felman K, Fleischer A, Houtrow AJ, Bruce ML, O'Malley AJ. Effectiveness of Direct Admission Compared to Admission Through the Emergency Department: A Stepped-Wedge Cluster-Randomized Trial. Pediatrics 2024:e2024065776. [PMID: 39301600 DOI: 10.1542/peds.2024-065776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 06/04/2024] [Accepted: 06/07/2024] [Indexed: 09/22/2024] Open
Abstract
OBJECTIVE Direct admission (DA) to hospital can reduce emergency department (ED) utilization by bypassing the ED during the admission process. We implemented a DA program across 3 health systems and compared timeliness of care, family experience of care, and post-admission clinical deterioration among children admitted via DA versus the ED after their clinic was randomized to begin the DA program. METHODS Using a stepped-wedge design, 69 primary and urgent care clinics were randomized to 1 of 4 time points to begin a voluntary DA program, February 1, 2020 to April 30, 2023. Outcomes in children <18 years admitted with 7 common medical diagnoses were compared using adjusted logistic or linear regression. RESULTS A total of 2599 children were admitted with eligible diagnoses during the study period , including 145 children admitted directly and 1852 admitted through EDs after program implementation at their clinic. Median age was 2.8 (interquartile range: 1.1-6.8) years, 994 (49.8%) were female, and 1324 (66.3%) were Medicaid-insured. Adjusted regression analyses showed that if each child was admitted via DA versus the ED, average time to initial clinical assessment was 3.1 minute (95% confidence interval: 1.7-4.5) slower, whereas time to initial therapeutic management was 49.6 minutes faster on average (95% confidence interval: 30.3.2-68.9). There were no significant differences in time to initial diagnostic testing or rates of post-admission clinical deterioration. CONCLUSIONS Compared with ED admission, DA appears equally safe and acceptable to families, and may be associated with a significantly shorter time to initial therapeutic management with modestly longer time to initial clinical assessment.
Collapse
Affiliation(s)
- JoAnna K Leyenaar
- Dartmouth Health, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Stephanie C Acquilano
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Seneca D Freyleue
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Andrew P Schaefer
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Corrie E McDaniel
- Seattle Children's Hospital, Seattle, Washington
- University of Washington, Seattle, Washington
| | - Ryan S Bode
- Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State College of Medicine, Columbus, Ohio
| | - Guliz Erdem
- Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State College of Medicine, Columbus, Ohio
| | - Stephanie Lauden
- Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State College of Medicine, Columbus, Ohio
- Department of Pediatrics, University of Colorado, Denver, Colorado
| | - Christine Schmerge
- Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State College of Medicine, Columbus, Ohio
| | - Sylvia S Choi
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Departments of Pediatrics
| | - Kristyn Felman
- Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Allison Fleischer
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Departments of Pediatrics
| | - Amy J Houtrow
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Martha L Bruce
- Dartmouth Health, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| |
Collapse
|
2
|
Barrio-Cortes J, Benito-Sánchez B, Sánchez-Ruano R, García-Hernández CA, Beca-Martínez MT, Martínez-Cuevas M, Castaño-Reguillo A, Muñoz-Lagos C. Utilization of Healthcare Services in Patients with Chronic Diseases under 18 Years Old: Differences and Contributing Factors. J Pers Med 2024; 14:956. [PMID: 39338210 DOI: 10.3390/jpm14090956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Revised: 09/02/2024] [Accepted: 09/05/2024] [Indexed: 09/30/2024] Open
Abstract
Pediatric patients with chronic conditions frequently have unmet care needs, make extensive use of healthcare services, and often encounter fragmented, non-centered care. This study aimed to analyze the differences in the utilization of primary care (PC) and hospital care (HC) services by these patients according to sex, age, and complexity and to identify associated factors. A cross-sectional study was conducted in a basic health area of Madrid, including patients under 18 years. Among these patients, 15.7% had ≥1 chronic disease, 54.1% were male, the average age was 9.5 years, 3.5% had complexity, and 11.3% had multimorbidity. The mean number of contacts/year with the healthcare system was 9.1, including 8.3 contacts/year with PC (4.9 with pediatricians and 1.9 with nurses) and 0.8 contacts/year with HC (0.8 in external consultations and 0.01 hospitalizations). The factors associated with PC utilization were complexity; female sex; European origin; and diseases like asthma, epilepsy, stroke, recurrent urinary infection, attention deficit hyperactivity disorder, and anxiety, while older age was negatively associated. Thyroid disorders were significantly associated with HC utilization. These findings could help guide the design of optimized pediatric patient-centered care approaches to coordinate care across healthcare services and reduce high healthcare utilization, therefore improving the healthcare outcomes and quality of life for these patients.
Collapse
Affiliation(s)
- Jaime Barrio-Cortes
- Foundation for Biosanitary Research and Innovation in Primary Care (FIIBAP), 28003 Madrid, Spain
- HM Faculty of Health Sciences, Camilo José Cela University, 28692 Madrid, Spain
- Gregorio Marañón Health Research Institute (IiSGM), 28009 Madrid, Spain
- Research Network on Chronicity, Primary Care and Prevention and Health Promotion (RICAPPS), Spain
| | - Beatriz Benito-Sánchez
- Foundation for Biosanitary Research and Innovation in Primary Care (FIIBAP), 28003 Madrid, Spain
| | - Raquel Sánchez-Ruano
- Foundation for Biosanitary Research and Innovation in Primary Care (FIIBAP), 28003 Madrid, Spain
- Ciudad Jardín Health Centre, Primary Care Assistance Management, 28002 Madrid, Spain
| | | | | | | | | | - Cristina Muñoz-Lagos
- Ciudad Jardín Health Centre, Primary Care Assistance Management, 28002 Madrid, Spain
| |
Collapse
|
3
|
Leyenaar JK, Freyleue SD, Arakelyan M, Schaefer AP, Moen EL, Austin AM, Goodman DC, O’Malley AJ. Rural-Urban Disparities in Hospital Services and Outcomes for Children With Medical Complexity. JAMA Netw Open 2024; 7:e2435187. [PMID: 39316395 PMCID: PMC11423179 DOI: 10.1001/jamanetworkopen.2024.35187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 07/29/2024] [Indexed: 09/25/2024] Open
Abstract
Importance Limited availability of inpatient pediatric services in rural regions has raised concerns about access, safety, and quality of hospital-based care for children. This may be particularly important for children with medical complexity (CMC). Objectives To describe differences in the availability of pediatric services at acute care hospitals where rural- and urban-residing CMC presented for hospitalization; identify rural-urban disparities in health care quality and in-hospital mortality; and determine whether the availability of pediatric services at index hospitals or the experience of interfacility transfer modified rural-urban differences in outcomes. Design, Setting, and Participants This retrospective cohort study examined all-payer claims data from Colorado, Massachusetts, and New Hampshire from 2012 to 2017. Analysis was conducted from May 2023 to July 2024. Participants included CMC younger than 18 years residing in these states and hospitalized during the study period. Exposures Rural or urban residence was determined using Rural-Urban Commuting Area codes. Hospitals were categorized as children's hospitals or general hospitals with comprehensive, limited, or no dedicated pediatric services using American Hospital Association survey data. Interfacility transfers between index and definitive care hospitals were identified using health care claims. Main Outcomes and Measures In-hospital mortality, all-cause 30-day readmission, medical-surgical safety events, and surgical safety events were operationalized using Agency for Healthcare Research and Quality measure specifications. Results Among 36 943 CMC who experienced 79 906 hospitalizations, 16 525 (44.7%) were female, 26 034 (70.5%) were Medicaid-insured, and 34 008 (92.1%) were urban-residing. Rural-residing CMC were 6.55 times more likely to present to hospitals without dedicated pediatric services (rate ratio [RR], 6.55 [95% CI, 5.86-7.33]) and 2.03 times more likely to present to hospitals without pediatric beds (RR, 2.03 [95% CI, 1.88-2.21]) than urban-residing CMC, with no significant differences in interfacility transfer rates. In unadjusted analysis, rural-residing CMC had a 44% increased risk of in-hospital mortality (RR, 1.44 [95% CI, 1.03-2.02]) with no significant differences in other outcomes. Adjusting for clinical characteristics, the difference in in-hospital mortality was no longer significant. Index hospital type was not a significant modifier of observed rural-urban outcomes, but interfacility transfer was a significant modifier of rural-urban differences in surgical safety events. Conclusions and Relevance In this cohort study, rural-residing CMC were significantly more likely to present to hospitals without dedicated pediatric services. These findings suggest that efforts are justified to ensure that all hospital types are prepared to care for CMC.
Collapse
Affiliation(s)
- JoAnna K. Leyenaar
- Department of Pediatrics, Children’s Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Seneca D. Freyleue
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Mary Arakelyan
- Department of Pediatrics, Children’s Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Andrew P. Schaefer
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Erika L. Moen
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Andrea M. Austin
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - David C. Goodman
- Department of Pediatrics, Children’s Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| |
Collapse
|
4
|
Leyenaar JK, Arakelyan M, Schaefer AP, Freyleue SD, Austin AM, Simon TD, Van Cleave J, Ahuja N, Chien AT, Moen EL, O’Malley AJ, Goodman DC. Neurodevelopmental and Mental Health Conditions in Children With Medical Complexity. Pediatrics 2024; 154:e2024065650. [PMID: 39099441 PMCID: PMC11350095 DOI: 10.1542/peds.2024-065650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/08/2024] [Accepted: 04/29/2024] [Indexed: 08/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Children with medical complexity (CMC) may be at a high risk of neurodevelopmental and mental health conditions given disease comorbidities and lived experiences. Little is known about the prevalence of these conditions at a population level. In this study, we estimated the prevalence of neurodevelopmental and mental health diagnoses in CMC relative to children without medical complexity and measured associations between these diagnoses in CMC and subsequent health care utilization and in-hospital mortality. METHODS We applied the Child and Adolescent Mental Health Disorders Classification System to identify neurodevelopmental and mental health diagnoses using all-payer claims data from three states (2012-2017). Poisson regression was used to compare outcomes in CMC with neurodevelopmental and mental health diagnoses to CMC without these diagnoses, adjusting for sociodemographic and clinical characteristics. RESULTS Among 85 581 CMC, 39 065 (45.6%) had ≥1 neurodevelopmental diagnoses, and 31 703 (37.0%) had ≥1 mental health diagnoses, reflecting adjusted relative risks of 3.46 (3.42-3.50) for neurodevelopmental diagnoses and 2.22 (2.19-2.24) for mental health diagnoses compared with children without medical complexity. CMC with both neurodevelopmental and mental health diagnoses had 3.00 (95% confidence interval [CI]: 2.98-3.01) times the number of ambulatory visits, 69% more emergency department visits (rate ratio = 1.69, 95% CI: 1.66-1.72), 58% greater risk of hospitalization (rate ratio = 1.58, 95% CI: 1.50-1.67), and 2.32 times (95% CI: 2.28-2.36) the number of hospital days than CMC without these diagnoses. CONCLUSIONS Neurodevelopmental and mental health diagnoses are prevalent among CMC and associated with increased health care utilization across the continuum of care. These findings illustrate the importance of recognizing and treating neurodevelopmental and mental health conditions in this population.
Collapse
Affiliation(s)
- JoAnna K. Leyenaar
- Department of Pediatrics, Children’s Hospital at Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice
| | - Mary Arakelyan
- Department of Pediatrics, Children’s Hospital at Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | | | | | - Tamara D. Simon
- Department of Pediatrics, Keck School of Medicine at the University of Southern California, Los Angeles, California
- The Saban Research Institute, Children’s Hospital Los Angeles, Los Angeles, California
| | - Jeanne Van Cleave
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Namrata Ahuja
- Department of Pediatrics, Keck School of Medicine at the University of Southern California, Los Angeles, California
| | - Alyna T. Chien
- Boston Children’s Hospital, Boston, Masssachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Erika L. Moen
- The Dartmouth Institute for Health Policy & Clinical Practice
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy & Clinical Practice
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - David C. Goodman
- Department of Pediatrics, Children’s Hospital at Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice
| |
Collapse
|
5
|
Studenmund C, Lyndon A, Stotts JR, Peralta-Neel C, Sharma AE, Bardach NS. What do patients and families observe about pediatric safety?: A thematic analysis of real-time narratives. J Hosp Med 2024; 19:765-776. [PMID: 38741257 DOI: 10.1002/jhm.13388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 03/04/2024] [Accepted: 04/18/2024] [Indexed: 05/16/2024]
Abstract
OBJECTIVES Data on inpatient safety are documented by hospital staff through incident reporting (IR) systems. Safety observations from families or patients are rarely captured. The Family Input for Quality and Safety (FIQS) study created a mobile health tool for pediatric patients and their families to anonymously report safety observations in real time during hospitalization. The study objectives were to describe these observations and identify domains salient to safety. METHODS In this observational study, we analyzed pediatric patient safety reports from June 2017 to April 2018. Participants were: English-speaking family members and hospitalized patients ≥13 years old. The analysis had two stages: (1) assessment of whether narratives met established safety event criteria and whether there were companion IRs; (2) thematic analysis to identify domains. RESULTS Of 248 enrolled participants, 58 submitted 120 narrative reports. Of the narratives, 68 (57%) met safety event criteria, while only 1 (0.8%) corresponded to a staff-reported IR. Twenty-five percent of narratives shared positive feedback about patient safety efforts; 75% shared constructive feedback. We identified domains particularly salient to safety: (1) patients and families as safety actors; (2) emotional safety; (3) system-centered care; and (4) shared safety domains, including medication, communication, and environment of care. Some domains capture data that is otherwise difficult to obtain (#1-3), while others fit within standard healthcare safety domains (#4). CONCLUSIONS Patients and families observe and report salient safety events that can fill gaps in IR data. Healthcare leaders should consider incorporating patient and family observations-collected with an option for anonymity and eliciting both positive and constructive comments.
Collapse
Affiliation(s)
- Christine Studenmund
- Department of Pediatrics, School of Medicine, University of California, San Francisco, California, USA
| | - Audrey Lyndon
- Rory Meyers College of Nursing, New York University, New York, New York, USA
| | - James R Stotts
- Department of Quality and Patient Safety, University of California, San Francisco, California, USA
| | - Caroline Peralta-Neel
- Department of Pediatrics, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Anjana E Sharma
- Department of Family & Community Medicine, University of California, San Francisco, California, USA
| | - Naomi S Bardach
- Department of Pediatrics, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
- Department of Pediatrics, University of California, San Francisco, California, USA
| |
Collapse
|
6
|
Kaferly J, Orsi-Hunt R, Hosokawa P, Sevick C, Creel LM, Mathieu S, Mark Gritz R. Health Differs by Foster Care Eligibility: A Nine-Year Retrospective Observational Study Among Medicaid-Enrolled Children. Acad Pediatr 2024; 24:1092-1100. [PMID: 38142889 DOI: 10.1016/j.acap.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 12/26/2023]
Abstract
OBJECTIVE This study sought to determine the prevalence and rates of physical, behavioral, and chronic health conditions among Medicaid-enrolled Colorado children by foster care eligibility codes over 9 years. METHODS This retrospective, population-based study used Colorado's Medicaid administrative data for all enrolled children, aged <19 years old, from July 2011 to August 2020 to determine the period prevalence and rates of physical, behavioral, and chronic health conditions. We identified children in foster care by Medicaid eligibility codes and used the Pediatric Medical Complexity Algorithm version 3.0 to describe health condition outcomes. We report frequencies and percentages by foster care eligibility status, birth year cohort, and sex. RESULTS Among 1,084,026 children, we identified 34,971 children in the foster cohort. Rates of physical (1105.0 per 100,000 person-months (PMs)) and behavioral health conditions (583.6 per 100,000 PMs) were two to threefold higher among the foster cohort than peers (physical 685.1 per 100,000 PMs; behavioral 212.2 per 100,000 PMs). By birth cohort, rates of behavioral health conditions among children in foster care were up to 8 times greater than peers. The foster cohort had greater prevalence of chronic conditions with (55.2%) and without (38.6%) behavioral health inclusion. CONCLUSIONS This study provides a broader health assessment among Medicaid-enrolled children and finds condition disparities concentrated among youth in foster care. A more complete understanding of health problems among children in foster care is critical for health, child welfare, and Medicaid systems to improve health outcomes through coordinated and evidence-based interventions, programs, and policies.
Collapse
Affiliation(s)
- James Kaferly
- Department of Ambulatory Care Services, Denver Health and Hospital Authority, Denver, Colo; The Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, University of Colorado School of Medicine, Aurora, Colo; Eugene Farley, Jr. Health Policy Center, University of Colorado School of Medicine, Aurora, Colo.
| | - Rebecca Orsi-Hunt
- The Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, University of Colorado School of Medicine, Aurora, Colo.
| | - Patrick Hosokawa
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), Aurora, Colo.
| | - Carter Sevick
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), Aurora, Colo.
| | - Liza Michelle Creel
- Eugene Farley, Jr. Health Policy Center, University of Colorado School of Medicine, Aurora, Colo.
| | - Susan Mathieu
- Eugene Farley, Jr. Health Policy Center, University of Colorado School of Medicine, Aurora, Colo.
| | - Robert Mark Gritz
- Eugene Farley, Jr. Health Policy Center, University of Colorado School of Medicine, Aurora, Colo.
| |
Collapse
|
7
|
Bose-Brill S, Hirabayashi K, Schwimmer E, Pajor NM, Rao S, Mejias A, Jhaveri R, Forrest CB, Bailey LC, Christakis DA, Thacker D, Hanley PC, Patel PB, Cogen JD, Block JP, Prahalad P, Lorman V, Lee GM. Pediatric Nirmatrelvir/Ritonavir Prescribing Patterns During the COVID-19 Pandemic. Hosp Pediatr 2024; 14:e341-e348. [PMID: 39076115 PMCID: PMC11287060 DOI: 10.1542/hpeds.2023-007132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 03/23/2024] [Accepted: 04/29/2024] [Indexed: 07/31/2024]
Abstract
OBJECTIVES This study seeks to identify demographic and clinical factors prompting clinician prescribing of nirmatrelvir/ritonavir to pediatric patients for management of coronavirus disease 2019 (COVID-19) infection. METHODS Patients aged 12 to 17 years with a COVID-19 infection and nirmatrelvir/ritonavir prescription during an outpatient clinical encounter within a PEDSnet-affiliated institution between January 2022 and August 2023 were identified using electronic health record data. A multivariate logistic regression analysis was used to estimate odds of nirmatrelvir/ritonavir prescription after adjusting for various factors. RESULTS A total of 20 959 patients aged 12 to 17 years were diagnosed with a COVID-19 infection on the basis of an electronic health record-documented positive polymerase chain reaction or antigen test or diagnosis during an outpatient clinical visit. Of these patients, 408 received a nirmatrelvir/ritonavir prescription within 5 days of diagnosis. Higher odds of nirmatrelvir/ritonavir treatment were associated with having chronic or complex chronic disease (chronic: odds ratio [OR] 2.50 [95% confidence interval (CI) 1.83-3.38]; complex chronic: OR 2.21 [95% CI 1.58-3.08]). Among patients with chronic disease, each additional body system conferred 1.18 times higher odds of treatment (95% CI 1.10-1.26). Compared with non-Hispanic white patients, Hispanic patients (OR 0.61 [95% CI 0.44-0.83]) had lower odds of treatment. CONCLUSIONS Children with chronic conditions are more likely than those without to receive nirmatrelvir/ritonavir prescriptions. However, nirmatrelvir/ritonavir prescribing to children with chronic conditions remains infrequent. Pediatric data concerning nirmatrelvir/ritonavir safety and effectiveness in preventing severe disease and hospitalization are critical optimizing clinical decision-making and use among children.
Collapse
Affiliation(s)
- Seuli Bose-Brill
- Combined Internal Medicine and Pediatrics Section, Division of General Internal Medicine, Department of Internal Medicine, Ohio State University College of Medicine, Columbus, Ohio
| | - Kathryn Hirabayashi
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Emmanuel Schwimmer
- Combined Internal Medicine and Pediatrics Section, Division of General Internal Medicine, Department of Internal Medicine, Ohio State University College of Medicine, Columbus, Ohio
| | - Nathan M. Pajor
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Suchitra Rao
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado
| | - Asuncion Mejias
- Division of Infectious Diseases, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Ravi Jhaveri
- Division of Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Christopher B. Forrest
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - L. Charles Bailey
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Dimitri A. Christakis
- Center for Child Health, Behavior, and Development, Seattle Children’s Hospital, Seattle, Washington
| | | | | | - Payal B. Patel
- Center for Child Health, Behavior, and Development, Seattle Children’s Hospital, Seattle, Washington
| | - Jonathan D. Cogen
- Center for Child Health, Behavior, and Development, Seattle Children’s Hospital, Seattle, Washington
| | - Jason P. Block
- Division of Chronic Disease Research Across the Lifecourse, Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
| | | | - Vitaly Lorman
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Grace M. Lee
- Pediatrics (Infectious Diseases), Stanford University School of Medicine, Stanford, California
| | | |
Collapse
|
8
|
Robinson CH, Hussain J, Jeyakumar N, Smith G, Birken CS, Dart A, Dionne J, Garg A, Kandasamy S, Karam S, Marjerrison S, South AM, Thabane L, Wahi G, Zappitelli M, Chanchlani R. Long-Term Cardiovascular Outcomes in Children and Adolescents With Hypertension. JAMA Pediatr 2024; 178:688-698. [PMID: 38709137 PMCID: PMC11217870 DOI: 10.1001/jamapediatrics.2024.1543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 04/15/2024] [Indexed: 05/07/2024]
Abstract
Importance Hypertension affects 6% of all children, and its prevalence is increasing. Childhood hypertension tracks into adulthood and is associated with subclinical cardiovascular disease; however, there is a lack of evidence linking childhood hypertension to cardiovascular outcomes, which may contribute to underdiagnosis and undertreatment. Objective To determine the long-term associated risk of major adverse cardiac events (MACE) among children diagnosed with hypertension. Design, Setting, and Participants This was a population-based, retrospective, matched cohort study conducted from 1996 to 2022. The study included all children (aged 3-18 years) alive in Ontario, Canada, from 1996 to 2021, who were identified using provincial administrative health databases. Children with prior kidney replacement therapy were excluded. Exposure Incident hypertension diagnosis, identified by validated case definitions using diagnostic and physician billing claims. Each case was matched with 5 controls without hypertension by age, sex, birth weight, maternal gestational hypertension, prior comorbidities (chronic kidney disease, diabetes, cardiovascular surgery), and a propensity score for hypertension. Main Outcomes and Measures The primary outcome was MACE (a composite of cardiovascular death, stroke, hospitalization for myocardial infarction or unstable angina, or coronary intervention). Time to MACE was evaluated using the Kaplan-Meier method and Cox proportional hazards regression. Results A total of 25 605 children (median [IQR] age, 15 [11-17] years; 14 743 male [57.6%]) with hypertension were matched to 128 025 controls without hypertension. Baseline covariates were balanced after propensity score matching, and prior comorbidities were uncommon (hypertension vs control cohort: malignancy, 1451 [5.7%] vs 7908 [6.2%]; congenital heart disease, 1089 [4.3%] vs 5408 [4.2%]; diabetes, 482 [1.9%] vs 2410 [1.9%]). During a median (IQR) of 13.6 (7.8-19.5) years of follow-up, incidence of MACE was 4.6 per 1000 person-years in children with hypertension vs 2.2 per 1000 person-years in controls (hazard ratio, 2.1; 95% CI, 1.9-2.2). Children with hypertension were at higher associated risk of stroke, hospitalization for myocardial infarction or unstable angina, coronary intervention, and congestive heart failure, but not cardiovascular death, compared with nonhypertensive controls. Conclusions and Relevance Children diagnosed with hypertension had a higher associated long-term risk of MACE compared with controls without hypertension. Improved detection, follow-up, and control of pediatric hypertension may reduce the risk of adult cardiovascular disease.
Collapse
Affiliation(s)
- Cal H. Robinson
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Junayd Hussain
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nivethika Jeyakumar
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
| | - Graham Smith
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Catherine S. Birken
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Allison Dart
- Department of Pediatrics and Child Health, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Janis Dionne
- Department of Pediatrics, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anika Garg
- Infant, Child, and Youth Health Lab, Brock University, St Catharine’s, Ontario, Canada
| | - Sujane Kandasamy
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Sabine Karam
- Department of Medicine, Division of Nephrology and Hypertension, University of Minnesota, Minneapolis
| | - Stacey Marjerrison
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Andrew M. South
- Department of Pediatrics, Brenner Children’s, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, St Joseph’s Healthcare, Hamilton, Ontario, Canada
- Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Gita Wahi
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Michael Zappitelli
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rahul Chanchlani
- ICES, Toronto, Ontario, Canada
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
9
|
Bhimraj A, Morgan RL, Shumaker AH, Baden L, Cheng VCC, Edwards KM, Gallagher JC, Gandhi RT, Muller WJ, Nakamura MM, O’Horo JC, Shafer RW, Shoham S, Murad MH, Mustafa RA, Sultan S, Falck-Ytter Y. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients With COVID-19 (September 2022). Clin Infect Dis 2024; 78:e250-e349. [PMID: 36063397 PMCID: PMC9494372 DOI: 10.1093/cid/ciac724] [Citation(s) in RCA: 61] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 08/30/2022] [Indexed: 02/07/2023] Open
Abstract
There are many pharmacologic therapies that are being used or considered for treatment of coronavirus disease 2019 (COVID-19), with rapidly changing efficacy and safety evidence from trials. The objective was to develop evidence-based, rapid, living guidelines intended to support patients, clinicians, and other healthcare professionals in their decisions about treatment and management of patients with COVID-19. In March 2020, the Infectious Diseases Society of America (IDSA) formed a multidisciplinary guideline panel of infectious disease clinicians, pharmacists, and methodologists with varied areas of expertise to regularly review the evidence and make recommendations about the treatment and management of persons with COVID-19. The process used a living guideline approach and followed a rapid recommendation development checklist. The panel prioritized questions and outcomes. A systematic review of the peer-reviewed and grey literature was conducted at regular intervals. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the certainty of evidence and make recommendations. Based on the most recent search conducted on 31 May 2022, the IDSA guideline panel has made 32 recommendations for the treatment and management of the following groups/populations: pre- and postexposure prophylaxis, ambulatory with mild-to-moderate disease, and hospitalized with mild-to-moderate, severe but not critical, and critical disease. As these are living guidelines, the most recent recommendations can be found online at: https://idsociety.org/COVID19guidelines. At the inception of its work, the panel has expressed the overarching goal that patients be recruited into ongoing trials. Since then, many trials were conducted that provided much-needed evidence for COVID-19 therapies. There still remain many unanswered questions as the pandemic evolved, which we hope future trials can answer.
Collapse
Affiliation(s)
- Adarsh Bhimraj
- Division of Infectious Diseases, Houston Methodist Hospital, Houston, Texas
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Case Western Reserve University, School of Medicine, Cleveland, Ohio
| | - Amy Hirsch Shumaker
- Department of Medicine, Case Western Reserve University, School of Medicine, Cleveland, Ohio
- VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | | | - Vincent Chi Chung Cheng
- Queen Mary Hospital, Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Kathryn M Edwards
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center,Nashville, Tennessee
| | - Jason C Gallagher
- Department of Pharmacy Practice, Temple University, Philadelphia, Pennsylvania
| | - Rajesh T Gandhi
- Infectious Diseases Division, Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
| | - William J Muller
- Division of Pediatric Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University, Chicago, Illinois
| | - Mari M Nakamura
- Antimicrobial Stewardship Program and Division of Infectious Diseases, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - John C O’Horo
- Division of Infectious Diseases, Joint Appointment Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Robert W Shafer
- Division of Infectious Diseases, Department of Medicine, Stanford University, Palo Alto, California
| | - Shmuel Shoham
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - M Hassan Murad
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota
| | - Reem A Mustafa
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Shahnaz Sultan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis VA Healthcare System, Minneapolis, Minnesota
| | - Yngve Falck-Ytter
- Department of Medicine, Case Western Reserve University, School of Medicine, Cleveland, Ohio
- VA Northeast Ohio Healthcare System, Cleveland, Ohio
| |
Collapse
|
10
|
Li L, Zhou T, Lu Y, Chen J, Lei Y, Wu Q, Arnold J, Becich MJ, Bisyuk Y, Blecker S, Chrischilles E, Christakis DA, Geary CR, Jhaveri R, Lenert L, Liu M, Mirhaji P, Morizono H, Mosa ASM, Onder AM, Patel R, Smoyer WE, Taylor BW, Williams DA, Dixon BP, Flynn JT, Gluck C, Harshman LA, Mitsnefes MM, Modi ZJ, Pan CG, Patel HP, Verghese PS, Forrest CB, Denburg MR, Chen Y. Post-acute and Chronic Kidney Function Outcomes of COVID-19 in Children and Adolescents: An EHR Cohort Study from the RECOVER Initiative. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.25.24309488. [PMID: 38978683 PMCID: PMC11230320 DOI: 10.1101/2024.06.25.24309488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
We investigated the risks of post-acute and chronic adverse kidney outcomes of SARS-CoV-2 infection in the pediatric population via a retrospective cohort study using data from the RECOVER program. We included 1,864,637 children and adolescents under 21 from 19 children's hospitals and health institutions in the US with at least six months of follow-up time between March 2020 and May 2023. We divided the patients into three strata: patients with pre-existing chronic kidney disease (CKD), patients with acute kidney injury (AKI) during the acute phase (within 28 days) of SARS-CoV-2 infection, and patients without pre-existing CKD or AKI. We defined a set of adverse kidney outcomes for each stratum and examined the outcomes within the post-acute and chronic phases after SARS-CoV-2 infection. In each stratum, compared with the non-infected group, patients with COVID-19 had a higher risk of adverse kidney outcomes. For patients without pre-existing CKD, there were increased risks of CKD stage 2+ (HR 1.20; 95% CI: 1.13-1.28) and CKD stage 3+ (HR 1.35; 95% CI: 1.15-1.59) during the post-acute phase (28 days to 365 days) after SARS-CoV-2 infection. Within the post-acute phase of SARS-CoV-2 infection, children and adolescents with pre-existing CKD and those who experienced AKI were at increased risk of progression to a composite outcome defined by at least 50% decline in estimated glomerular filtration rate (eGFR), eGFR <15 mL/min/1.73m2, End Stage Kidney Disease diagnosis, dialysis, or transplant.
Collapse
Affiliation(s)
- Lu Li
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
- The Graduate Group in Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Ting Zhou
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
| | - Yiwen Lu
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
- The Graduate Group in Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Jiajie Chen
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
| | - Yuqing Lei
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
| | - Qiong Wu
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan Arnold
- Division of General Internal Medicine, University of Pittsburgh School of Medicine
| | - Michael J. Becich
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Yuriy Bisyuk
- Office of Research, University Medical Center New Orleans, New Orleans, LA
| | - Saul Blecker
- Department of Population Health, NYU Grossman School of Medicine
| | | | - Dimitri A Christakis
- Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, WA 98105, USA
| | - Carol Reynolds Geary
- Department of Pathology, Microbiology, and Immunology, University of Nebraska Medical Center, Omaha, NE
| | - Ravi Jhaveri
- Division of Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Leslie Lenert
- Biomedical Informatics Center, Medical University of South Carolina
| | - Mei Liu
- Department of Health Outcomes and Biomedical Informatics, University of Florida, College of Medicine
| | - Parsa Mirhaji
- Albert Einstein College of Medicine, Bronx, NY 10461
| | - Hiroki Morizono
- Center for Genetic Medicine Research, Children’s National Hospital, Washington DC
| | | | - Ali Mirza Onder
- Division of Pediatric Nephrology, Nemours Children’s Hospital, Wilmington, DE
| | - Ruby Patel
- Division of Pediatric Nephrology, Stanford Medicine Children’s Health, Palo Alto, CA
| | - William E. Smoyer
- Center for Clinical and Translational Research, Nationwide Children’s Hospital, Department of Pediatrics, The Ohio State University
| | - Bradley W. Taylor
- Clinical and Translational Science Institute, The Medical College of Wisconsin, Milwaukee, WI 53226
| | | | - Bradley P. Dixon
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | | | - Caroline Gluck
- Nemours Children’s Health, Division of Pediatric Nephrology, Wilmington, DE
| | | | - Mark M Mitsnefes
- Cincinnati Children’s Hospital medical Center and University of Cincinnati
| | - Zubin J. Modi
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor
- Division of Pediatric Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Cynthia G. Pan
- Department of Pediatrics, Section of Nephrology, Medical College of Wisconsin
| | - Hiren P. Patel
- Nationwide Children’s Hospital
- Ohio State University College of Medicine
| | - Priya S. Verghese
- Ann & Robert H Lurie Children’s Hospital
- Northwestern University, Feinberg School of Medicine
| | - Christopher B. Forrest
- Applied Clinical Research Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michelle R. Denburg
- Division of Pediatric Nephrology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics and Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Yong Chen
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
- The Graduate Group in Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
11
|
Daley MF, Reifler LM, Sterrett AT, Poole NM, Winn DB, Steiner JF, Arnold Rehring SM. Improving Antibiotic Prescribing for Children with Community-acquired Pneumonia in Outpatient Settings. J Pediatr 2024; 274:114155. [PMID: 38897380 DOI: 10.1016/j.jpeds.2024.114155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 05/24/2024] [Accepted: 06/11/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVE To assess whether a two-phase intervention was associated with improvements in antibiotic prescribing among nonhospitalized children with community-acquired pneumonia. STUDY DESIGN In a large health care organization, a first intervention phase was implemented in September 2020 directed at antibiotic choice and duration for children 2 months through 17 years of age with pneumonia. Activities included clinician education and implementation of a pneumonia-specific order set in the electronic health record. In October 2021, a second phase comprised additional education and order set revisions. A narrow spectrum antibiotic (eg, amoxicillin) was recommended in most circumstances. Electronic health record data were used to identify pneumonia cases and antibiotics ordered. Using interrupted time series analyses, antibiotic choice and duration after phase one (September 2020-September 2021) and after phase two (October 2021-October 2022) were compared with a preintervention prepandemic period (January 2016-early March 2020). RESULTS Overall, 3570 cases of community-acquired pneumonia were identified: 3246 cases preintervention, 98 post-phase one, and 226 post-phase two. The proportion receiving narrow spectrum monotherapy increased from 40.6% preintervention to 68.4% post-phase one to 69.0% post-phase two (P < .001). For children with an initial narrow spectrum antibiotic, duration decreased from preintervention (mean duration 9.9 days, SD 0.5 days) to post-phase one (mean 8.2, SD 1.9) to post-phase two (mean 6.8, SD 2.3) periods (P < .001). CONCLUSIONS A two-phase intervention with educational sessions combined with clinical decision support was associated with sustained improvements in antibiotic choice and duration among children with community-acquired pneumonia.
Collapse
Affiliation(s)
- Matthew F Daley
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Liza M Reifler
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Andrew T Sterrett
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Nicole M Poole
- Department of Pediatrics, Division of Pediatric Infectious Diseases and Epidemiology, University of Colorado School of Medicine, Aurora, CO
| | - D Brian Winn
- Department of Medicine, Colorado Permanente Medical Group, Denver, CO; Department of Medical Informatics, Colorado Permanente Medical Group, Denver, CO
| | - John F Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO; Department of Medical Education, Colorado Permanente Medical Group, Denver, CO; Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Sharisse M Arnold Rehring
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Department of Medical Education, Colorado Permanente Medical Group, Denver, CO
| |
Collapse
|
12
|
Peng J, Gorham TJ, Meyer BD. Predicting Dental General Anesthesia Use among Children with Behavioral Health Conditions. JDR Clin Trans Res 2024:23800844241252817. [PMID: 38877718 DOI: 10.1177/23800844241252817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024] Open
Abstract
OBJECTIVES To evaluate how different data sources affect the performance of machine learning algorithms that predict dental general anesthesia use among children with behavioral health conditions. STUDY DESIGN Observational study using claims data. METHODS Using Medicaid claims from Partners For Kids (2013-2019), electronic medical record data, and the Ohio Child Opportunity Index, we conducted a retrospective cohort study of 12,410 children with behavioral health diagnoses. Four lasso-regularized logistic regression models were developed to predict dental general anesthesia use, each incorporating different data sources. Lift scores, or the ratio of positive predictive value to base case prevalence, were used to compare models, and a lift score of 2.5 was considered minimally acceptable for risk prediction. RESULTS Dental general anesthesia use ranged from 3.2% to 3.9% across models, which made it difficult for the machine learning models to achieve high positive predictive value. Model performance was best when either the electronic medical record (lift = 2.59) or Ohio Child Opportunity Index (lift = 2.56), but not both (lift = 2.34) or neither (lift = 1.87), was used. CONCLUSIONS Incorporating additional data sources improved machine learning model performance, and 2 models achieved satisfactory performance. The model using electronic medical record data could be applied in hospital-based settings, and the model using the Ohio Child Opportunity Index could be more valuable in community-based settings. KNOWLEDGE TRANSFER STATEMENT Machine learning was applied to satisfactorily predict which children with behavioral health diagnoses would require dental treatment under general anesthesia. Incorporating electronic medical record data or area-level social determinants of health data, but not both, improved the performance of the machine learning predictions. The 2 highest performing models could be applied by hospitals using medical record data or by organizations using area-level social determinants of health data to risk stratify the pediatric behavioral health population.
Collapse
Affiliation(s)
- J Peng
- IT Research & Innovation, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - T J Gorham
- IT Research & Innovation, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - B D Meyer
- Division of Pediatric Dentistry, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, USA
| |
Collapse
|
13
|
Gerber DM, Coller RJ. Standardizing Medical Complexity: Fruitful, Formidable, or Futile? Pediatrics 2024; 153:e2023065014. [PMID: 38804060 DOI: 10.1542/peds.2023-065014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 03/14/2024] [Accepted: 03/27/2024] [Indexed: 05/29/2024] Open
Affiliation(s)
- Danielle M Gerber
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ryan J Coller
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| |
Collapse
|
14
|
Nielsen VML, Søvsø MB, Skals RG, Bender L, Corfield AR, Lossius HM, Mikkelsen S, Christensen EF. Mortality after paediatric emergency calls for patients with or without pre-existing comorbidity: a nationwide population based cohort study. Scand J Trauma Resusc Emerg Med 2024; 32:48. [PMID: 38807153 PMCID: PMC11134704 DOI: 10.1186/s13049-024-01212-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 04/24/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Life-threatening conditions are infrequent in children. Current literature in paediatric prehospital research is centred around trauma and paediatric out-of-hospital cardiac arrests (POHCA). The aims of this study were to (1) outline the distribution of trauma, POHCA or other medical symptoms among survivors and non-survivors after paediatric emergency calls, and (2) to investigate these clinical presentations' association with mortality in children with and without pre-existing comorbidity, respectively. METHODS Nationwide population-based cohort study including ground and helicopter emergency medical services in Denmark for six consecutive years (2016-2021). The study included all calls to the emergency number 1-1-2 regarding children ≤ 15 years (N = 121,230). Interhospital transfers were excluded, and 1,143 patients were lost to follow-up. Cox regressions were performed with trauma or medical symptoms as exposure and 7-day mortality as the outcome, stratified by 'Comorbidity', 'Severe chronic comorbidity' and 'None' based on previous healthcare visits. RESULTS Mortality analysis included 76,956 unique patients (median age 5 (1-12) years). Annual all-cause mortality rate was 7 per 100,000 children ≤ 15 years. For non-survivors without any pre-existing comorbidity (n = 121), reasons for emergency calls were trauma 18.2%, POHCA 46.3% or other medical symptoms 28.9%, whereas the distribution among the 134 non-survivors with any comorbidity was 7.5%, 27.6% and 55.2%, respectively. Compared to trauma patients, age- and sex-adjusted hazard ratio for patients with calls regarding medical symptoms besides POHCA was 0.8 [0.4;1.3] for patients without comorbidity, 1.1 [0.5;2.2] for patients with comorbidity and 6.1 [0.8;44.7] for patients with severe chronic comorbidity. CONCLUSION In both non-survivors with and without comorbidity, a considerable proportion of emergency calls had been made because of various medical symptoms, not because of trauma or POHCA. This outline of diagnoses and mortality following paediatric emergency calls can be used for directing paediatric in-service training in emergency medical services.
Collapse
Affiliation(s)
- Vibe Maria Laden Nielsen
- Centre for Prehospital and Emergency Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Selma Lagerløfs Vej 249, Gistrup, 9260, Denmark.
- Emergency Medical Services, North Denmark Region, Hjulmagervej 20, Aalborg, 9000, Denmark.
| | - Morten Breinholt Søvsø
- Centre for Prehospital and Emergency Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Selma Lagerløfs Vej 249, Gistrup, 9260, Denmark
| | - Regitze Gyldenholm Skals
- Unit of Clinical Biostatistics, Aalborg University Hospital, Søndre Skovvej 15, Aalborg, 9000, Denmark
| | - Lars Bender
- Paediatric Department, Aalborg University Hospital, Reberbansgade 15, Aalborg, 9000, Denmark
| | | | - Hans Morten Lossius
- Norwegian Air Ambulance Foundation, Postboks 414 Sentrum Oslo 0103, Norway, United Kingdom
| | - Søren Mikkelsen
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, , J. B. Winsløws Vej 4, Odense C 5000, Denmark
| | - Erika Frischknecht Christensen
- Centre for Prehospital and Emergency Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Selma Lagerløfs Vej 249, Gistrup, 9260, Denmark
- Emergency Medical Services, North Denmark Region, Hjulmagervej 20, Aalborg, 9000, Denmark
| |
Collapse
|
15
|
Zhang B, Thacker D, Zhou T, Zhang D, Lei Y, Chen J, Chrischilles E, Christakis DA, Fernandez S, Garg V, Kim S, Mosa ASM, Sills MR, Taylor BW, Williams DA, Wu Q, Forrest CB, Chen Y. Post-Acute Cardiovascular Outcomes of COVID-19 in Children and Adolescents: An EHR Cohort Study from the RECOVER Project. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.14.24307380. [PMID: 38798448 PMCID: PMC11118642 DOI: 10.1101/2024.05.14.24307380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Background The risk of cardiovascular outcomes in the post-acute phase of SARS-CoV-2 infection has been quantified among adults and children. This paper aimed to assess a multitude of cardiac signs, symptoms, and conditions, as well as focused on patients with and without congenital heart defects (CHDs), to provide a more comprehensive assessment of the post-acute cardiovascular outcomes among children and adolescents after COVID-19. Methods This retrospective cohort study used data from the RECOVER consortium comprising 19 US children's hospitals and health institutions between March 2020 and September 2023. Every participant had at least a six-month follow-up after cohort entry. Absolute risks of incident post-acute COVID-19 sequelae were reported. Relative risks (RRs) were calculated by contrasting COVID-19-positive with COVID-19-negative groups using a Poisson regression model, adjusting for demographic, clinical, and healthcare utilization factors through propensity scoring stratification. Results A total of 1,213,322 individuals under 21 years old (mean[SD] age, 7.75[6.11] years; 623,806 male [51.4%]) were included. The absolute rate of any post-acute cardiovascular outcome in this study was 2.32% in COVID-19 positive and 1.38% in negative groups. Patients with CHD post-SARS-CoV-2 infection showed increased risks of any cardiovascular outcome (RR, 1.63; 95% confidence interval (CI), 1.47-1.80), including increased risks of 11 of 18 post-acute sequelae in hypertension, arrhythmias (atrial fibrillation and ventricular arrhythmias), myocarditis, other cardiac disorders (heart failure, cardiomyopathy, and cardiac arrest), thrombotic disorders (thrombophlebitis and thromboembolism), and cardiovascular-related symptoms (chest pain and palpitations). Those without CHDs also experienced heightened cardiovascular risks after SARS-CoV-2 infection (RR, 1.63; 95% CI, 1.57-1.69), covering 14 of 18 conditions in hypertension, arrhythmias (ventricular arrhythmias and premature atrial or ventricular contractions), inflammatory heart disease (pericarditis and myocarditis), other cardiac disorders (heart failure, cardiomyopathy, cardiac arrest, and cardiogenic shock), thrombotic disorders (pulmonary embolism and thromboembolism), and cardiovascular-related symptoms (chest pain, palpitations, and syncope). Conclusions Both children with and without CHDs showed increased risks for a variety of cardiovascular outcomes after SARS-CoV-2 infection, underscoring the need for targeted monitoring and management in the post-acute phase.
Collapse
Affiliation(s)
- Bingyu Zhang
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
- The Graduate Group in Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Deepika Thacker
- Nemours Cardiac Center, Nemours Children’s Health System, Wilmington, DE, USA
| | - Ting Zhou
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Dazheng Zhang
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Yuqing Lei
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jiajie Chen
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Elizabeth Chrischilles
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, IA, USA
| | - Dimitri A. Christakis
- Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, WA, USA
| | - Soledad Fernandez
- Department of Biomedical Informatics and Center for Biostatistics, Ohio State University, Columbus, OH, USA
| | - Vidu Garg
- Heart Center and Center for Cardiovascular Research, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Susan Kim
- Division of Pediatric Rheumatology, Benioff Children’s Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Abu S. M. Mosa
- Department of Biomedical Informatics, Biostatistics and Medical Epidemiology, University of Missouri School of Medicine, Columbia, MO, USA
| | - Marion R. Sills
- Department of Research, OCHIN, Inc., Portland, OR, USA
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Bradley W. Taylor
- Clinical and Translational Science Institute, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David A. Williams
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Qiong Wu
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Christopher B. Forrest
- Applied Clinical Research Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yong Chen
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, USA
- The Graduate Group in Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
- Penn Medicine Center for Evidence-based Practice (CEP), Philadelphia, PA, USA
- Penn Institute for Biomedical Informatics (IBI), Philadelphia, PA, USA
| |
Collapse
|
16
|
Swietek K, Jones KA, Bettger JP, French A, Maslow G, Norman KS, Lake AD, Carvalho M, Cholera R, Freed SS, Tchuisseu YP, Repka S, Whitaker RG. What Explains Inequalities in Telehealth Utilization Among North Carolina Medicaid Beneficiaries? Telemed J E Health 2024. [PMID: 38728091 DOI: 10.1089/tmj.2023.0563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
Background: Increased availability of telehealth can improve access to health care. However, there is evidence of persistent disparities in telehealth usage, as well as among people from minoritized racial and ethnic groups and rural residents. The objective of our work was to explore the degree to which disparities in telehealth use for behavioral health (BH) and musculoskeletal (MSK) related services during the COVID-19 pandemic are explained by observed beneficiary- and area-level characteristics. Methods: Using North Carolina Medicaid claims data of Medicaid beneficiaries with BH or MSK conditions, we apply nonlinear regression-based decomposition analysis-based models developed by Kitagawa, Oaxaca, and Blinder to determine which observed variables are associated with racial, ethnic, and rural inequalities in telehealth usage. Results: In the BH cohort, we found statistically significant differences in telehealth usage by race in the adult population, and by race, Hispanic ethnicity, and rurality in the pediatric population. In the MSK cohort, we found significant inequities by Hispanic ethnicity and rurality among adults, and by race and rurality among children. Inequalities in telehealth use between groups were small, ranging from 0.7 percentage points between urban and rural adults with MSK conditions to 3.8 percentage points between white adults and people of color among those with BH conditions. Overall, we found that racial and ethnic inequalities in telehealth use are not well explained by the observed variables in our data. Rural disparities in telehealth use are better explained by observed variables, particularly area-level broadband internet use. Conclusions: For inequalities between rural and urban residents, our analysis provides observational evidence that infrastructure such as broadband internet access is an important driver of differences in telehealth use. For racial and ethnic inequalities, the pathways may be more complex and difficult to measure, particularly when relying on administrative data sources in place of more detailed data on individual-level socioeconomic factors.
Collapse
Affiliation(s)
- Karen Swietek
- Health Care Evaluation Department, NORC at the University of Chicago, Cambridge, Massachusetts, USA
| | - Kelley A Jones
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Janet Prvu Bettger
- Duke-Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
| | - Alexis French
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gary Maslow
- Duke-Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
- Department of Psychiatry, Duke University School of Medicine, Durham, North Carolina, USA
| | - Katherine S Norman
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ashley D Lake
- Duke Physical Therapy Sports Medicine at the Center for Living, Duke Health, Durham, North Carolina, USA
| | - Marissa Carvalho
- Department of Physical Therapy and Occupational Therapy, Duke University Health System, Durham, North Carolina, USA
| | - Rushina Cholera
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke-Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Salama S Freed
- Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, USA
| | | | - Samantha Repka
- Duke-Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
| | - Rebecca G Whitaker
- Duke-Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
| |
Collapse
|
17
|
Fowler CA, Roddy M, Havlicek E, Sochet AA. Vitamin K Prescribing Trends Among Critically Ill Children Hospitalized for Sepsis: A Multicenter Observational Cohort Study. J Intensive Care Med 2024:8850666241252419. [PMID: 38711324 DOI: 10.1177/08850666241252419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Objective: Vitamin K (VK) is commonly prescribed for pediatric sepsis-induced coagulopathy without trial-derived evidence to support its use for this indication. The purpose of this study was to characterize national prescribing trends for VK in this population. Patients and Methods: This is a multicenter retrospective cohort study using the Pediatric Health Information System registry including children 0 to 17 years of age hospitalized for sepsis in the pediatric intensive care unit from January 2016 through December 2022. The primary outcome was overall, annual, and center-specific VK prescribing rates. Descriptive data included demographics, length of stay, and rates of VK deficiency, hepatic insufficiency, red blood cell (RBC) transfusion, venous thromboembolism (VTE), and mortality. VK prescribing trends were assessed using Joinpoint regression. Descriptive statistics employed included Wilcoxon rank-sum, student's t, and chi-square tests. Results: Of the 31 221 encounters studied, 4539 (14.6%) were prescribed VK (median center-specific rate: 14.2%; interquartile range [IQR]: 8.8-21%) with a linear annual trend decreasing from 17.3% in 2016 to 13.3% in 2022 (-0.6%/year, r2 = .661). Those prescribed VK had greater rates of hepatic dysfunction (20.5% vs 3.1%), RBC transfusion (26.5% vs 11.2%), VTE (12.5% vs 4.6%), mortality (17.1% vs 4.4%), and median length of stay (16 [IQR: 8-33] vs 8 [4-15] days) (all P < .001). VK deficiency was diagnosed in 0.2% of encounters. Conclusions: In this multicenter retrospective cohort, VK prescribing was common among critically ill children diagnosed with sepsis. Phased trials are needed to demonstrate clinical efficacy and safety for VK in this population.
Collapse
Affiliation(s)
- Corey A Fowler
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Meghan Roddy
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Elizabeth Havlicek
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Anthony A Sochet
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, FL, USA
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
- Department of Medicine, Division of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
18
|
Maddux AB, Miller KR, Sierra YL, Bennett TD, Watson RS, Spear M, Pyle LL, Mourani PM. Recovery Trajectories in Children Requiring 3 or More Days of Invasive Ventilation. Crit Care Med 2024; 52:798-810. [PMID: 38193769 PMCID: PMC11018493 DOI: 10.1097/ccm.0000000000006187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
OBJECTIVES To characterize health-related quality of life (HRQL) and functional recovery trajectories and risk factors for prolonged impairments among critically ill children receiving greater than or equal to 3 days of invasive ventilation. DESIGN Prospective cohort study. SETTING Quaternary children's hospital PICU. PATIENTS Children without a preexisting tracheostomy who received greater than or equal to 3 days of invasive ventilation, survived hospitalization, and completed greater than or equal to 1 postdischarge data collection. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We evaluated 144 children measuring HRQL using proxy-report Pediatric Quality of Life Inventory and functional status using the Functional Status Scale (FSS) reflecting preillness baseline, PICU and hospital discharge, and 1, 3, 6, and 12 months after hospital discharge. They had a median age of 5.3 years (interquartile range, 1.1-13.0 yr), 58 (40%) were female, 45 (31%) had a complex chronic condition, and 110 (76%) had normal preillness FSS scores. Respiratory failure etiologies included lung disease ( n = 49; 34%), neurologic failure ( n = 23; 16%), and septic shock ( n = 22; 15%). At 1-month postdischarge, 68 of 122 (56%) reported worsened HRQL and 35 (29%) had a new functional impairment compared with preillness baseline. This improved at 3 months to 54 (46%) and 24 (20%), respectively, and remained stable through the remaining 9 months of follow-up. We used interaction forests to evaluate relative variable importance including pairwise interactions and found that therapy consultation within 3 days of intubation was associated with better HRQL recovery in older patients and those with better preillness physical HRQL. During the postdischarge year, 76 patients (53%) had an emergency department visit or hospitalization, and 62 (43%) newly received physical, occupational, or speech therapy. CONCLUSIONS Impairments in HRQL and functional status as well as health resource use were common among children with acute respiratory failure. Early therapy consultation was a modifiable characteristic associated with shorter duration of worsened HRQL in older patients.
Collapse
Affiliation(s)
- Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
- Children’s Hospital Colorado, Aurora, CO
| | - Kristen R. Miller
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Yamila L. Sierra
- Research Institute, Pediatric Critical Care, Children’s Hospital Colorado, Aurora, CO
| | - Tellen D. Bennett
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
- Children’s Hospital Colorado, Aurora, CO
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora, CO
| | - R. Scott Watson
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington School of Medicine and Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA
| | - Matthew Spear
- Department of Pediatrics, Dell Children’s Medical Center, The University of Texas at Austin Dell Medical School, Austin, TX
| | - Laura L. Pyle
- Children’s Hospital Colorado, Aurora, CO
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Peter M. Mourani
- Department of Pediatrics, Section of Critical Care, University of Arkansas for Medical Sciences and Arkansas Children’s, Little Rock, AR
| |
Collapse
|
19
|
Alotaibi F, Alkhalaf H, Alshalawi H, Almijlad H, Ureeg A, Alghnam S. Unplanned Readmissions in Children with Medical Complexity in Saudi Arabia: A Large Multicenter Study. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2024; 12:134-144. [PMID: 38764560 PMCID: PMC11098271 DOI: 10.4103/sjmms.sjmms_352_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 01/26/2024] [Accepted: 02/07/2024] [Indexed: 05/21/2024]
Abstract
Background Children with medical complexity (CMC) account for a substantial proportion of healthcare spending, and one-third of their expenditures are due to readmissions. However, knowledge regarding the healthcare-resource utilization and characteristics of CMC in Saudi Arabia is limited. Objectives To describe hospitalization patterns and characteristics of Saudi CMC with an unplanned 30-day readmission. Methodology This retrospective study included Saudi CMC (aged 0-14 years) who had an unplanned 30-day readmission at six tertiary centers in Riyadh, Jeddah, Dammam, Alahsa, and Almadina between January 2016 and December 2020. Hospital-based inclusion criteria focused on CMC with multiple complex chronic conditions (CCCs) and technology assistance (TA) device use. CMC were compared across demographics, clinical characteristics, and hospital-resource utilization. Results A total of 9139 pediatric patients had unplanned 30-day readmission during the study period, of which 680 (7.4%) met the inclusion criteria. Genetic conditions were the most predominant primary pathology (66.3%), with one-third of cases (33.7%) involving the neuromuscular system. During the index admission, pneumonia was the most common diagnosis (33.1%). Approximately 35.1% of the readmissions were after 2 weeks. Pneumonia accounted for 32.5% of the readmissions. After readmission, 16.9% of patients were diagnosed with another CCC or received a new TA device, and the in-hospital mortality rate was 6.6%. Conclusion The rate of unplanned 30-day readmissions in children with medical complexity in Saudi Arabia is 7.4%, which is lower than those reported from developed countries. Saudi children with CCCs and TA devices were readmitted approximately within similar post-discharge time and showed distinct hospitalization patterns associated with specific diagnoses. To effectively reduce the risk of 30-day readmissions, targeted measures must be introduced both during the hospitalization period and after discharge.
Collapse
Affiliation(s)
- Futoon Alotaibi
- Department of Pediatrics, King Abdullah Specialist Children’s Hospital, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Hamad Alkhalaf
- Department of Pediatrics, King Abdullah Specialist Children’s Hospital, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Hissah Alshalawi
- Department of Pediatrics, King Abdullah Specialist Children’s Hospital, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Hadeel Almijlad
- Department of Pediatrics, King Abdullah Specialist Children’s Hospital, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abdulaziz Ureeg
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Suliman Alghnam
- Public Health Intelligence, Saudi Public Health Authority, Riyadh, Saudi Arabia
| |
Collapse
|
20
|
Razzaghi H, Forrest CB, Hirabayashi K, Wu Q, Allen AJ, Rao S, Chen Y, Bunnell HT, Chrischilles EA, Cowell LG, Cummins MR, Hanauer DA, Higginbotham M, Horne BD, Horowitz CR, Jhaveri R, Kim S, Mishkin A, Muszynski JA, Naggie S, Pajor NM, Paranjape A, Schwenk HT, Sills MR, Tedla YG, Williams DA, Bailey LC. Vaccine Effectiveness Against Long COVID in Children. Pediatrics 2024; 153:e2023064446. [PMID: 38225804 PMCID: PMC10979300 DOI: 10.1542/peds.2023-064446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2023] [Indexed: 01/17/2024] Open
Abstract
OBJECTIVES Vaccination reduces the risk of acute coronavirus disease 2019 (COVID-19) in children, but it is less clear whether it protects against long COVID. We estimated vaccine effectiveness (VE) against long COVID in children aged 5 to 17 years. METHODS This retrospective cohort study used data from 17 health systems in the RECOVER PCORnet electronic health record program for visits after vaccine availability. We examined both probable (symptom-based) and diagnosed long COVID after vaccination. RESULTS The vaccination rate was 67% in the cohort of 1 037 936 children. The incidence of probable long COVID was 4.5% among patients with COVID-19, whereas diagnosed long COVID was 0.8%. Adjusted vaccine effectiveness within 12 months was 35.4% (95 CI 24.5-44.7) against probable long COVID and 41.7% (15.0-60.0) against diagnosed long COVID. VE was higher for adolescents (50.3% [36.6-61.0]) than children aged 5 to 11 (23.8% [4.9-39.0]). VE was higher at 6 months (61.4% [51.0-69.6]) but decreased to 10.6% (-26.8% to 37.0%) at 18-months. CONCLUSIONS This large retrospective study shows moderate protective effect of severe acute respiratory coronavirus 2 vaccination against long COVID. The effect is stronger in adolescents, who have higher risk of long COVID, and wanes over time. Understanding VE mechanism against long COVID requires more study, including electronic health record sources and prospective data.
Collapse
Affiliation(s)
- Hanieh Razzaghi
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christopher B. Forrest
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics
| | - Kathryn Hirabayashi
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Qiong Wu
- Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrea J. Allen
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Suchitra Rao
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado
| | - Yong Chen
- Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - H. Timothy Bunnell
- Biomedical Research Informatics Center, Nemours Children’s Health, Wilmington, Delaware
| | | | - Lindsay G. Cowell
- Peter O’Donnell Jr School of Public Health; Department of Immunology, School of Biomedical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - David A. Hanauer
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan
| | - Miranda Higginbotham
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Benjamin D. Horne
- Intermountain Heart Institute, Intermountain Health, Salt Lake City, Utah
| | - Carol R. Horowitz
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Ravi Jhaveri
- Division of Infectious Diseases, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Susan Kim
- Division of Rheumatology, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, California
| | - Aaron Mishkin
- Section of Infectious Diseases, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Jennifer A. Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Susanna Naggie
- Division of Infectious Diseases, Duke University School of Medicine, Duke Clinical Research Institute, Durham, North Carolina
| | - Nathan M. Pajor
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Anuradha Paranjape
- Section of Infectious Diseases, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Hayden T. Schwenk
- Division of Pediatric Infectious Diseases, Stanford School of Medicine, Palo Alto, California
| | | | - Yacob G. Tedla
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David A. Williams
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - L. Charles Bailey
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics
| | | |
Collapse
|
21
|
Tan CD, Vermont CL, Zachariasse JM, von Both U, Carrol ED, Eleftheriou I, Emonts M, van der Flier M, Herberg J, Kohlmaier B, Levin M, Lim E, Maconochie IK, Martinon-Torres F, Nijman RG, Pokorn M, Rivero-Calle I, Rudzāte A, Tsolia M, Zenz W, Zavadska D, Moll HA. Which low urgent triaged febrile children are suitable for a fast track? An observational European study. Emerg Med J 2024; 41:236-241. [PMID: 38238066 PMCID: PMC10982627 DOI: 10.1136/emermed-2023-213375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 01/07/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND The number of paediatric patients visiting the ED with non-urgent problems is increasing, leading to poor patient flow and ED crowding. Fast track aims to improve the efficiency of evaluation and discharge of low acuity patients. We aimed to identify which febrile children are suitable for a fast track based on presenting symptoms and management. METHODS This study is part of the Management and Outcome of Fever in children in Europe study, which is an observational study including routine data of febrile children <18 years attending 12 European EDs. We included febrile, low urgent children (those assigned a triage acuity of either 'standard' or 'non-urgent' using the Manchester Triage System) and defined children as suitable for fast track when they have minimal resource use and are discharged home. Presenting symptoms consisted of neurological (n=237), respiratory (n=8476), gastrointestinal (n=1953) and others (n=3473, reference group). Multivariable logistic regression analyses regarding presenting symptoms and management (laboratory blood testing, imaging and admission) were performed with adjustment for covariates: patient characteristics, referral status, previous medical care, previous antibiotic use, visiting hours and ED setting. RESULTS We included 14 139 children with a median age of 2.7 years (IQR 1.3-5.2). The majority had respiratory symptoms (60%), viral infections (50%) and consisted of self-referrals (69%). The neurological group received imaging more often (adjusted OR (aOR) 1.8, 95% CI 1.1 to 2.9) and were admitted more frequently (aOR 1.9, 95% CI 1.4 to 2.7). The respiratory group had fewer laboratory blood tests performed (aOR 0.6, 95% CI 0.5 to 0.7), were less frequently admitted (aOR 0.6, 95% CI 0.5 to 0.7), but received imaging more often (aOR 1.8, 95% CI 1.6 to 2.0). Lastly, the gastrointestinal group had more laboratory blood tests performed (aOR 1.2. 95% CI 1.1 to 1.4) and were admitted more frequently (aOR 1.4, 95% CI 1.2 to 1.6). CONCLUSION We determined that febrile children triaged as low urgent with respiratory symptoms were most suitable for a fast track. This study provides evidence for which children could be triaged to a fast track, potentially improving overall patient flow at the ED.
Collapse
Affiliation(s)
- Chantal D Tan
- General Paediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Clementien L Vermont
- Section of Paediatric Infectious Diseases and Immunology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Joany M Zachariasse
- General Paediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ulrich von Both
- Paediatric Infectious Diseases, University Children's Hospital at Dr. von Haunersches Kinderspital, LMU Munich, Munich, Germany
| | - Enitan D Carrol
- Section of Paediatric Infectious Diseases and Immunology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool Institute of Infection Veterinary and Ecological Sciences, Liverpool, UK
| | | | - Marieke Emonts
- Paediatric Immunology, Infectious Diseases & Allergy, Great North Children's Hospital, Newcastle upon Tyne, UK
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Michiel van der Flier
- Paediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital University Medical Centre, Utrecht, The Netherlands
- Paediatric Infectious Diseases and Immunology, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Jethro Herberg
- Section of Paediatric Infectious Diseases, Imperial College London, London, UK
| | - Benno Kohlmaier
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | | | - Emma Lim
- Paediatric Immunology, Infectious Diseases & Allergy, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Ian K Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Federico Martinon-Torres
- Genetics, Vaccines, Infections and Paediatrics Research group, Hospital de Clinico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Ruud G Nijman
- Section of Paediatric Infectious Diseases, Imperial College London, London, UK
- Paediatric Emergency Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Marko Pokorn
- Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Irene Rivero-Calle
- Genetics, Vaccines, Infections and Paediatrics Research group, Hospital de Clinico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Maria Tsolia
- Paediatrics, P and A Kyriakou Children's Hospital, Athens, Greece
| | - Werner Zenz
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | - Dace Zavadska
- Paediatrics, Children's Clinical University Hospital, Riga, Latvia
| | - Henriette A Moll
- Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| |
Collapse
|
22
|
Wittman SR, Hoberman A, Mehrotra A, Sabik LM, Yabes JG, Ray KN. Antibiotic Receipt for Pediatric Telemedicine Visits With Primary Care vs Direct-to-Consumer Vendors. JAMA Netw Open 2024; 7:e242359. [PMID: 38483387 PMCID: PMC10940962 DOI: 10.1001/jamanetworkopen.2024.2359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 01/23/2024] [Indexed: 03/17/2024] Open
Abstract
Importance Prior research found that pediatric direct-to-consumer (DTC) telemedicine visits are associated with more antibiotic prescribing than in-person primary care visits. It is unclear whether this difference is associated with modality of care (telemedicine vs in-person) or with the context of telemedicine care (primary care vs not primary care). Objective To compare antibiotic management during telemedicine visits with primary care practitioners (PCPs) vs commercial direct-to-consumer (DTC) telemedicine companies for pediatric acute respiratory tract infections (ARTIs). Design, Setting, and Participants This retrospective, cross-sectional study of visits for ARTIs by commercially insured children 17 years of age or younger analyzed deidentified medical and pharmacy claims in OptumLabs Data Warehouse data, a national sample of commercial enrollees, between January 1 and December 31, 2022. Exposure Setting of telemedicine visit as PCP vs DTC. Main Outcomes and Measures The primary outcome was percentage of visits with antibiotic receipt. Secondary outcomes were the percentages of visits with diagnoses for which prescription of an antibiotic was potentially appropriate, guideline-concordant antibiotic management, and follow-up ARTI visits within the ensuing 1 to 2 days and 3 to 14 days. The ARTI telemedicine visits with PCP vs DTC telemedicine companies were matched on child demographic characteristics. Generalized estimated equation log-binomial regression models were used to compute marginal outcomes. Results In total, data from 27 686 children (mean [SD] age, 8.9 [5.0] years; 13 893 [50.2%] male) were included in this study. There were 14 202 PCP telemedicine index visits matched to 14 627 DTC telemedicine index visits. The percentage of visits involving receipt of an antibiotic was lower for PCP (28.9% [95% CI, 28.1%-29.7%]) than for DTC (37.2% [95% CI, 36.0%-38.5%]) telemedicine visits. Additionally, fewer PCP telemedicine visits involved receipt of a diagnosis in which the use of antibiotics may be appropriate (19.0% [95% CI, 18.4%-19.7%] vs 28.4% [95% CI, 27.3%-29.6%]), but no differences were observed in receipt of nonguideline-concordant antibiotic management based on a given diagnosis between PCP (20.2% [95% CI, 19.5%-20.9%]) and DTC (20.1% [95% CI, 19.1%-21.0%]) telemedicine visits. Fewer PCP telemedicine visits involved a follow-up visit within the ensuing 1 to 2 days (5.0% [95% CI, 4.7%-5.4%] vs 8.0% [95% CI, 7.3%-8.7%]) and 3 to 14 days (8.2% [95% CI, 7.8%-8.7%] vs 9.6% [95% CI, 8.8%-10.3%]). Conclusions and Relevance Compared with virtual-only DTC telemedicine companies, telemedicine integrated within primary care was associated with lower rates of antibiotic receipt and follow-up care. Supporting use of telemedicine integrated within pediatric primary care may be one strategy to reduce antibiotic receipt through telemedicine visits.
Collapse
Affiliation(s)
- Samuel R. Wittman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Jonathan G. Yabes
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
23
|
Arakelyan M, Freyleue SD, Schaefer AP, Austin AM, Moen EL, O'Malley AJ, Goodman DC, Leyenaar JK. Rural-urban disparities in health care delivery for children with medical complexity and moderating effects of payer, disability, and community poverty. J Rural Health 2024; 40:326-337. [PMID: 38379187 PMCID: PMC10954394 DOI: 10.1111/jrh.12827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 11/22/2023] [Accepted: 02/02/2024] [Indexed: 02/22/2024]
Abstract
PURPOSE Children with medical complexity (CMC) may be at increased risk of rural-urban disparities in health care delivery given their multifaceted health care needs, but these disparities are poorly understood. This study evaluated rural-urban disparities in health care delivery to CMC and determined whether Medicaid coverage, co-occurring disability, and community poverty modified the effects of rurality on care delivery. METHODS This retrospective cohort study of 2012-2017 all-payer claims data from Colorado, Massachusetts, and New Hampshire included CMC <18 years. Health care delivery measures (ambulatory clinic visits, emergency department visits, acute care hospitalizations, total hospital days, and receipt of post-acute care) were compared for rural- versus urban-residing CMC in multivariable regression models, following established methods to evaluate effect modification. FINDINGS Of 112,475 CMC, 7307 (6.5%) were rural residing and 105,168 (93.5%) were urban residing. A total of 68.9% had Medicaid coverage, 33.9% had a disability, and 39.7% lived in communities with >20% child poverty. In adjusted analyses, rural-residing CMC received significantly fewer ambulatory visits (risk ratio [RR] = 0.95, 95% confidence interval [CI]: 0.94-0.96), more emergency visits (RR = 1.12, 95% CI: 1.08-1.16), and fewer hospitalization days (RR = 0.90, 95% CI = 0.85-0.96). The estimated modification effects of rural residence by Medicaid coverage, disability, and community poverty were each statistically significant. Differences in the odds of having a hospitalization and receiving post-acute care did not persist after incorporating sociodemographic and clinical characteristics and interaction effects. CONCLUSIONS Rural- and urban-residing CMC differed in their receipt of health care, and Medicaid coverage, co-occurring disabilities, and community poverty modified several of these effects. These modifying effects should be considered in clinical and policy initiatives to ensure that such initiatives do not widen rural-urban disparities.
Collapse
Affiliation(s)
- Mary Arakelyan
- Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Seneca D Freyleue
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - Andrew P Schaefer
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - Andrea M Austin
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - Erika L Moen
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - A James O'Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - David C Goodman
- Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - JoAnna K Leyenaar
- Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| |
Collapse
|
24
|
Wisk LE, Garvey KC, Fu C, Landrum MB, Beaulieu ND, Chien AT. Diabetes-Focused Health Care Utilization Among Adolescents and Young Adults With Type 1 Diabetes. Acad Pediatr 2024; 24:59-67. [PMID: 37148967 DOI: 10.1016/j.acap.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/27/2023] [Accepted: 05/01/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVE To describe the current rates of health services use with various types of providers among adolescents and young adults (AYA) with type 1 diabetes (T1D) and evaluate which patient factors are associated with rates of service use from different provider types. METHODS Using 2012-16 claims data from a national commercial insurer, we identified 18,927 person-years of AYA with T1D aged 13 to 26 years and evaluated the frequency at which: 1) AYA skipped diabetes care for a year despite being insured; 2) received care from pediatric or non-pediatric generalists or endocrinologists if care was sought; and 3) received annual hemoglobin A1c (HbA1c) testing as recommended for AYA. We used descriptive statistics and multivariable regression to examine patient, insurance, and physician characteristics associated with utilization and quality outcomes. RESULTS Between ages 13 and 26, the percentage of AYA with: any diabetes-focused visits declined from 95.3% to 90.3%; the mean annual number of diabetes-focused visits, if any, decreased from 3.5 to 3.0; receipt of ≥2 HbA1c tests annually decreased from 82.3% to 60.6%. Endocrinologists were the majority providers of diabetes care across ages, yet the relative proportion of AYA whose diabetes care was endocrinologist-dominated decreased from 67.3% to 52.7% while diabetes care dominated by primary care providers increased from 19.9% to 38.2%. The strongest predictors of diabetes care utilization were younger age and use of diabetes technology (pumps and continuous glucose monitors). CONCLUSIONS Several provider types are involved in the care of AYA with T1D, though predominate provider type and care quality changes substantially across age in a commercially-insured population.
Collapse
Affiliation(s)
- Lauren E Wisk
- Division of General Internal Medicine and Health Services Research (LE Wisk), David Geffen School of Medicine at the University of California, Los Angeles (UCLA); Department of Health Policy and Management (LE Wisk), Fielding School of Public Health at UCLA, Los Angeles, Calif.
| | | | - Christina Fu
- Department of Health Care Policy (C Fu, MB Landrum, and ND Beaulieu), Harvard Medical School, Boston, Mass
| | - Mary Beth Landrum
- Department of Health Care Policy (C Fu, MB Landrum, and ND Beaulieu), Harvard Medical School, Boston, Mass
| | - Nancy D Beaulieu
- Department of Health Care Policy (C Fu, MB Landrum, and ND Beaulieu), Harvard Medical School, Boston, Mass
| | - Alyna T Chien
- Department of Pediatrics (AT Chien), Harvard Medical School, Boston, Mass; Division of General Pediatrics (AT Chien), Boston Children's Hospital, Mass
| |
Collapse
|
25
|
Lion KC, Arthur KC, Frías García M, Hsu C, Sotelo Guerra LJ, Chisholm H, Griego E, Ebel BE, Penfold RB, Rafton S, Zhou C, Mangione-Smith R. Pilot Evaluation of the Family Bridge Program: A Communication- and Culture-Focused Inpatient Patient Navigation Program. Acad Pediatr 2024; 24:33-42. [PMID: 37354947 DOI: 10.1016/j.acap.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 06/17/2023] [Accepted: 06/18/2023] [Indexed: 06/26/2023]
Abstract
OBJECTIVE Children with low income and minority race and ethnicity have worse hospital outcomes due partly to systemic and interpersonal racism causing communication and system barriers. We tested the feasibility and acceptability of a novel inpatient communication-focused navigation program. METHODS Multilingual design workshops with parents, providers, and staff created the Family Bridge Program. Delivered by a trained navigator, it included 1) hospital orientation; 2) social needs screening and response; 3) communication preference assessment; 4) communication coaching; 5) emotional support; and 6) a post-discharge phone call. We enrolled families of hospitalized children with public or no insurance, minority race or ethnicity, and preferred language of English, Spanish, or Somali in a single-arm trial. We surveyed parents at enrollment and 2 to 4 weeks post-discharge, and providers 2 to 3 days post-discharge. Survey measures were analyzed with paired t tests. RESULTS Of 60 families enrolled, 57 (95%) completed the follow-up survey. Most parents were born outside the United States (60%) with a high school degree or less (60%). Also, 63% preferred English, 33% Spanish, and 3% Somali. The program was feasible: families received an average of 5.3 of 6 components; all received >2. Most caregivers (92%) and providers (81% [30/37]) were "very satisfied." Parent-reported system navigation improved from enrollment to follow-up (+8.2 [95% confidence interval 2.9, 13.6], P = .003; scale 0-100). Spanish-speaking parents reported decreased skills-related barriers (-18.4 [95% confidence interval -1.8, -34.9], P = .03; scale 0-100). CONCLUSIONS The Family Bridge Program was feasible, acceptable, and may have potential for overcoming barriers for hospitalized children at risk for disparities.
Collapse
Affiliation(s)
- K Casey Lion
- Center for Child Health, Behavior and Development (K Casey Lion, KC Arthur, MF García, LJ Sotelo Guerra, H Chisholm, BE Ebel, C Zhou, and R Mangione-Smith), Seattle Children's Research Institute, Seattle, Wash; Department of Pediatrics (K Casey Lion, E Griego, BE Ebel, C Zhou, and R Mangione-Smith), University of Washington School of Medicine, Seattle, Wash.
| | - Kimberly C Arthur
- Center for Child Health, Behavior and Development (K Casey Lion, KC Arthur, MF García, LJ Sotelo Guerra, H Chisholm, BE Ebel, C Zhou, and R Mangione-Smith), Seattle Children's Research Institute, Seattle, Wash
| | - Mariana Frías García
- Center for Child Health, Behavior and Development (K Casey Lion, KC Arthur, MF García, LJ Sotelo Guerra, H Chisholm, BE Ebel, C Zhou, and R Mangione-Smith), Seattle Children's Research Institute, Seattle, Wash
| | - Clarissa Hsu
- Kaiser Permanente Washington Health Research Institute (C Hsu and RB Penfold), Seattle, Wash
| | - Laura J Sotelo Guerra
- Center for Child Health, Behavior and Development (K Casey Lion, KC Arthur, MF García, LJ Sotelo Guerra, H Chisholm, BE Ebel, C Zhou, and R Mangione-Smith), Seattle Children's Research Institute, Seattle, Wash
| | - Hillary Chisholm
- Center for Child Health, Behavior and Development (K Casey Lion, KC Arthur, MF García, LJ Sotelo Guerra, H Chisholm, BE Ebel, C Zhou, and R Mangione-Smith), Seattle Children's Research Institute, Seattle, Wash
| | - Elena Griego
- Department of Pediatrics (K Casey Lion, E Griego, BE Ebel, C Zhou, and R Mangione-Smith), University of Washington School of Medicine, Seattle, Wash
| | - Beth E Ebel
- Center for Child Health, Behavior and Development (K Casey Lion, KC Arthur, MF García, LJ Sotelo Guerra, H Chisholm, BE Ebel, C Zhou, and R Mangione-Smith), Seattle Children's Research Institute, Seattle, Wash; Department of Pediatrics (K Casey Lion, E Griego, BE Ebel, C Zhou, and R Mangione-Smith), University of Washington School of Medicine, Seattle, Wash
| | - Robert B Penfold
- Kaiser Permanente Washington Health Research Institute (C Hsu and RB Penfold), Seattle, Wash
| | - Sarah Rafton
- Center for Diversity and Health Equity, Seattle Children's Hospital (S Rafton), Seattle, Wash
| | - Chuan Zhou
- Center for Child Health, Behavior and Development (K Casey Lion, KC Arthur, MF García, LJ Sotelo Guerra, H Chisholm, BE Ebel, C Zhou, and R Mangione-Smith), Seattle Children's Research Institute, Seattle, Wash; Department of Pediatrics (K Casey Lion, E Griego, BE Ebel, C Zhou, and R Mangione-Smith), University of Washington School of Medicine, Seattle, Wash
| | - Rita Mangione-Smith
- Center for Child Health, Behavior and Development (K Casey Lion, KC Arthur, MF García, LJ Sotelo Guerra, H Chisholm, BE Ebel, C Zhou, and R Mangione-Smith), Seattle Children's Research Institute, Seattle, Wash; Department of Pediatrics (K Casey Lion, E Griego, BE Ebel, C Zhou, and R Mangione-Smith), University of Washington School of Medicine, Seattle, Wash
| |
Collapse
|
26
|
Chung J, Pecora PJ, Sinha A, Prichett L, Lin FY, Seltzer RR. A gap in the data: Defining, identifying, and tracking children with medical complexity in the child welfare system. CHILD ABUSE & NEGLECT 2024; 147:106600. [PMID: 38118290 DOI: 10.1016/j.chiabu.2023.106600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/30/2023] [Accepted: 12/06/2023] [Indexed: 12/22/2023]
Abstract
BACKGROUND Among nearly 400,000 children in US foster care, an estimated 10 % are medically complex. Yet, population-level data about children with medical complexity (CMC) served by the child welfare system, both for prevention and foster care services, are largely unavailable. OBJECTIVE To understand how US child welfare agencies define, identify, and track CMC. PARTICIPANTS AND SETTING Child welfare agencies across the US. METHODS Agencies were recruited to complete a survey as part of a larger study exploring how CMC are served by the child welfare system. Survey responses related to defining, identifying, and tracking CMC were included in analysis. Descriptive statistical analysis was conducted with Stata. Qualitative content and thematic analysis were applied to free text responses. RESULTS Surveys were completed by agencies from 28 states and 2 major cities. Nearly half of the agencies did not have a clear definition to identify CMC; those that did have a definition often lacked standardization. The majority of agencies could not easily identify CMC or access CMC-related data within data systems. Agencies described lack of a clear definition as a barrier to collecting population level data. CONCLUSIONS Many US child welfare agencies lack a clear definition to identify and track CMC, impacting the ability to tailor care and service delivery to meet their unique needs. To address this, a clear definition for CMC should be developed and consistently applied within child welfare data systems. Once CMC are identifiable, future research can collect population-level data and provide recommendations for best practices and policies.
Collapse
Affiliation(s)
- Joyce Chung
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Peter J Pecora
- University of Washington School of Social Work, Seattle, WA, United States of America; Casey Family Programs, Seattle, WA, United States of America
| | - Aakanksha Sinha
- Casey Family Programs, Seattle, WA, United States of America
| | - Laura Prichett
- Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Fang-Yi Lin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America; Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Rebecca R Seltzer
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America; Johns Hopkins University School of Medicine, Baltimore, MD, United States of America; Berman Institute of Bioethics, Baltimore, MD, United States of America.
| |
Collapse
|
27
|
Alabbadi S, Rowe G, Gill G, Chikwe J, Egorova N. Racial Disparities in Failure to Rescue after Pediatric Heart Surgeries in the US. J Pediatr 2024; 264:113734. [PMID: 37739060 DOI: 10.1016/j.jpeds.2023.113734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/07/2023] [Accepted: 09/13/2023] [Indexed: 09/24/2023]
Abstract
OBJECTIVE To identify the trend in failure to rescue (FTR) and risk factors contributing to racial disparities in FTR after pediatric heart surgery using contemporary nationwide data. STUDY DESIGN We identified 85 267 congenital heart surgeries in patients <18 years of age from 2009 to 2019 using the Kid's Inpatient Database. The primary outcome was FTR. A mixed-effect logistic regression model with hospital random intercept was used to identify independent predictors of FTR. RESULTS Among 36 753 surgeries with postoperative complications, the FTR was 7.3%. The FTR decreased from 7.4% in 2009 to 6.3% in 2019 (P = .02). FTR was higher among Black than White children for all years. The FTR was higher among girls (7.2%) vs boys (6.6%), children aged <1 (9.6%) vs 12-17 years (2.4%), and those of Black (8.5%) vs White race (5.9%) (all P < .05). Black race was associated with a higher FTR odds (OR, 1.40; 95% CI, 1.20-1.65) after adjusting for demographics, medical complexity, nonelective admission, and hospital surgical volume. Higher hospital volume was associated with a lower odds of FTR for all racial groups, but fewer Black (19.7%) vs White (31%) children underwent surgery at high surgical volume hospitals (P < .001). If Black children were operated on in the same hospitals as White children, the racial differences in FTR would decrease by 47.3%. CONCLUSIONS Racial disparities exist in FTR after pediatric heart surgery in the US. The racial differences in the location of care may account for almost half the disparities in FTR.
Collapse
Affiliation(s)
- Sundos Alabbadi
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Georgina Rowe
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - George Gill
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Joanna Chikwe
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Natalia Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
| |
Collapse
|
28
|
Smith MB, Dervan LA, Watson RS, Ohman RT, Albert JEM, Rhee EJ, Vavilala MS, Rivara FP, Killien EY. Family Presence at the PICU Bedside: A Single-Center Retrospective Cohort Study. Pediatr Crit Care Med 2023; 24:1053-1062. [PMID: 38055001 DOI: 10.1097/pcc.0000000000003334] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
OBJECTIVES To determine factors associated with bedside family presence in the PICU and to understand how individual factors interact as barriers to family presence. DESIGN Mixed methods study. SETTING Tertiary children's hospital PICU. SUBJECTS Five hundred twenty-three children of less than 18 years enrolled in the Seattle Children's Hospital Outcomes Assessment Program from 2011 to 2017. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Quantitative: Family was documented every 2 hours. Exposures included patient and illness characteristics and family demographic and socioeconomic characteristics. We used multivariable logistic regression to identify factors associated with presence of less than 80% and stratified results by self-reported race. Longer PICU length of stay (LOS), public insurance, and complex chronic conditions (C-CD) were associated with family presence of less than 80%. Self-reported race modified these associations; no factors were associated with lower bedside presence for White families, in contrast with multiple associations for non-White families including public insurance, C-CD, and longer LOS. Qualitative: Thematic analysis of social work notes for the 48 patients with family presence of less than 80% matched on age, LOS, and diagnosis to 48 patients with greater than or equal to 95% family presence. Three themes emerged: the primary caregiver's prior experiences with the hospital, relationships outside of the hospital, and additional stressors during the hospitalization affected bedside presence. CONCLUSIONS We identified sociodemographic and illness factors associated with family bedside presence in the PICU. Self-reported race modified these associations, representing racism within healthcare. Family presence at the bedside may help identify families facing greater disparities in healthcare access.
Collapse
Affiliation(s)
- Mallory B Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Leslie A Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA
| | - R Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA
| | - Robert T Ohman
- Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, WA
| | - J Elaine-Marie Albert
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
| | - Eileen J Rhee
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington, Seattle, WA
| | - Monica S Vavilala
- Department of Anesthesiology, University of Washington, Seattle, WA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Frederick P Rivara
- Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, WA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| | - Elizabeth Y Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA
| |
Collapse
|
29
|
Larson IA, Zaniletti I, Gupta R, Wright SM, Winterer C, Toburen C, Williams K, Goodwin EJ, Northup RM, Roderick E, Hall M, Colvin JD. Accuracy of the Exeter Hospitalizations-Office Visits-Medical Conditions-Extra Care-Social Concerns Index for Identifying Children With Complex Chronic Medical Conditions in the Clinical Setting. Acad Pediatr 2023; 23:1553-1560. [PMID: 37516350 DOI: 10.1016/j.acap.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 07/20/2023] [Accepted: 07/22/2023] [Indexed: 07/31/2023]
Abstract
OBJECTIVE Our objective was to determine the accuracy of a point-of-care instrument, the Hospitalizations-Office Visits-Medical Conditions-Extra Care-Social Concerns (HOMES) instrument, in identifying patients with complex chronic conditions (CCCs) compared to an algorithm used to identify patients with CCCs within large administrative data sets. METHODS We compared the HOMES to Feudtner's CCCs classification system. Using administrative algorithms, we categorized primary care patients at a children's hospital into 3 categories: no chronic conditions, non-complex chronic conditions, and CCCs. We randomly selected 100 patients from each category. HOMES scoring was completed for each patient. We performed an optimal cut-point analysis on 80% of the sample to determine which total HOMES score best identified children with ≥1 CCC and ≥2 CCCs. Using the optimal cut points and the remaining 20% of the study population, we determined the odds and area under the curve (AUC) of having ≥1 CCC and ≥2 CCCs. RESULTS The median (interquartile range [IQR]) age was 4 (IQR: 0, 8). Using optimal cut points of ≥7 for ≥1 CCC and ≥11 for ≥2 CCCs, the odds of having ≥1 CCC was 19 times higher than lower scores (odds ratio [OR] 19.1 [95% confidence interval [CI]: 9.75, 37.5]) and of having ≥2 CCCs was 32 times higher (OR 32.3 [95% CI: 12.9, 50.6]). The AUCs were 0.76 for ≥1 CCC (sensitivity 0.82, specificity 0.80) and 0.74 for ≥2 CCCs (sensitivity 0.92, specificity 0.74). CONCLUSIONS The HOMES accurately identified patients with CCCs.
Collapse
Affiliation(s)
- Ingrid A Larson
- Administration (IA Larson), Children's Mercy Hospital Kansas, Overland Park
| | - Isabella Zaniletti
- Analytics, Children's Hospital Association (I Zaniletti and M Hall), Kansas City, Kans
| | - Rupal Gupta
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - S Margaret Wright
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Courtney Winterer
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Cristy Toburen
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Kristi Williams
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Emily J Goodwin
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Ryan M Northup
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Edie Roderick
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Matt Hall
- Analytics, Children's Hospital Association (I Zaniletti and M Hall), Kansas City, Kans; Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Jeffrey D Colvin
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo.
| |
Collapse
|
30
|
Austin AM, Schaefer AP, Arakelyan M, Freyleue SD, Goodman DC, Leyenaar JK. Specialties Providing Ambulatory Care and Associated Health Care Utilization and Quality for Children With Medical Complexity. Acad Pediatr 2023; 23:1542-1552. [PMID: 37468062 PMCID: PMC10792122 DOI: 10.1016/j.acap.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/30/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE Although children with medical complexity (CMC) have substantial health care needs, the extent to which they receive ambulatory care from primary care versus specialist clinicians is unknown. We aimed to determine the predominant specialty providing ambulatory care to CMC (primary care or specialty discipline), the extent to which specialists deliver well-child care, and associations between having a specialty predominant provider and health care utilization and quality. METHODS In a retrospective cohort analysis of 2012-17 all-payer claims data from Colorado, New Hampshire, and Massachusetts, we identified the predominant specialty providing ambulatory care for CMC <18 years. Propensity score weighting was used to create a balanced sample of CMC and assess differences in outcomes, including adequate well-child care, continuity of care, emergency visits, and hospitalizations, between CMC with a primary care versus specialty predominant provider. RESULTS Among 67,218 CMC, 75.3% (n = 50,584) received the plurality of care from a primary care discipline. Body system involvement, age > 2 years, urban residence, and cooccurring disabilities were associated with predominantly receiving care from specialists. After propensity score weighting, there were no significant differences between CMC with a primary care or specialist "predominant specialty seen" (PSS) in ambulatory visit counts, adequate well-child care, hospitalizations, or overall continuity of care. Specialists were the sole providers of well-child care and vaccines for 49.9% and 53.1% of CMC with a specialist PSS. CONCLUSIONS Most CMC received the plurality of care from primary care disciplines, and there were no substantial differences in overall utilization or quality based on the PSS.
Collapse
Affiliation(s)
- Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice (AM Austin, AP Schaefer, SD Freyleue, D Goodman, and JK Leyenaar), Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Andrew P Schaefer
- The Dartmouth Institute for Health Policy and Clinical Practice (AM Austin, AP Schaefer, SD Freyleue, D Goodman, and JK Leyenaar), Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Mary Arakelyan
- Department of Pediatrics (M Arakelyan and JK Leyenaar), Dartmouth Health Children's, Lebanon, NH
| | - Seneca D Freyleue
- The Dartmouth Institute for Health Policy and Clinical Practice (AM Austin, AP Schaefer, SD Freyleue, D Goodman, and JK Leyenaar), Geisel School of Medicine at Dartmouth, Hanover, NH
| | - David C Goodman
- The Dartmouth Institute for Health Policy and Clinical Practice (AM Austin, AP Schaefer, SD Freyleue, D Goodman, and JK Leyenaar), Geisel School of Medicine at Dartmouth, Hanover, NH
| | - JoAnna K Leyenaar
- The Dartmouth Institute for Health Policy and Clinical Practice (AM Austin, AP Schaefer, SD Freyleue, D Goodman, and JK Leyenaar), Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Pediatrics (M Arakelyan and JK Leyenaar), Dartmouth Health Children's, Lebanon, NH.
| |
Collapse
|
31
|
Freed SS, Jones KA, Whitaker RG, Norman K, Carvalho M, Giri A, Lake A, Tchuisseu YP, Repka S, Vasudeva K, Bey N, Bettger JP. Evaluating Telehealth Uptake Among North Carolina Medicaid Beneficiaries With Musculoskeletal Conditions: Insights From the COVID-19 Pandemic. Med Care 2023; 61:750-759. [PMID: 37733405 DOI: 10.1097/mlr.0000000000001915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
BACKGROUND The shift from in-person to virtual visits, known as telehealth (TH), during the COVID-19 pandemic was a significant change for North Carolina (NC) Medicaid beneficiaries seeking treatment for musculoskeletal (MSK) conditions, as remote care for these conditions was previously unavailable. We used this policy change to investigate factors associated with TH uptake and whether TH availability mitigated disparities in access to care or affected emergency department (ED) visits among these beneficiaries. RESEARCH DESIGN Using 2019-2021 NC Medicaid claims, we identified beneficiaries receiving treatment for MSK conditions before COVID-19 (March 2019-February 2020) and analyzed uptake of newly available TH during COVID-19 (April 2020-March 2021). We used descriptive analysis and Poisson generalized estimating equations to quantify TH uptake, factors associated with TH uptake, and the association with ED visits during COVID-19. RESULTS Black and Hispanic beneficiaries were less likely to use TH compared with White and non-Hispanic counterparts (10%, P <0.001 and 20%, P =0.03, respectively). Adults eligible for Tailored Plans, specialized NC Medicaid plans for those with significant behavioral health needs or intellectual/developmental disabilities, were less likely to use TH [adjusted risk ratio (ARR):0.83, 95% CI (0.78, 0.87)]; youth eligible for Tailored Plans were more likely to use TH [ARR:1.28, 95% CI (1.16, 1.42)]. Lower county-level internet access was associated with lower TH use [ARR: 0.85, 95% CI (0.82, 0.99)]. No statistical difference in ED utilization was observed between TH users and non-users. CONCLUSIONS TH has the potential to deliver convenient care to beneficiaries with MSK conditions who can access it. Further research and policy changes should explore and address underlying factors driving disparities and improve equitable access to care for this population.
Collapse
Affiliation(s)
- Salama S Freed
- Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - Kelley A Jones
- Department of Population Health Sciences, Duke University School of Medicine
| | | | - Katherine Norman
- Department of Population Health Sciences, Duke University School of Medicine
| | - Marissa Carvalho
- Department of Physical Therapy and Occupational Therapy, Duke Health, Durham NC
| | - Abhigya Giri
- Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - Ashley Lake
- Duke Physical Therapy Sports Medicine at Center for Living, Duke University, Durham
| | | | | | - Karina Vasudeva
- Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Nadia Bey
- Duke Margolis Center for Health Policy, Duke University
| | - Janet Prvu Bettger
- Department of Health and Rehabilitation Sciences, Temple University, Philadelphia, PA
| |
Collapse
|
32
|
Gorsky KG, Butala S, House M, Moon C, Calvetti S, Khando T, Kipke M, Lakshmanan A. Uncertainty and the NICU Experience: A Qualitative Evaluation of Family and Provider Perspectives. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1745. [PMID: 38002836 PMCID: PMC10670907 DOI: 10.3390/children10111745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/13/2023] [Accepted: 10/25/2023] [Indexed: 11/26/2023]
Abstract
There is limited information regarding caregiver and provider perspectives on uncertainty across the continuum of the neonatal intensive care unit (NICU) experience. Open-ended semi-structured interviews were conducted with providers and English- and Spanish-speaking caregivers of infants with a history of admission to a quaternary safety-net NICU. Major themes were generated using inductive-deductive thematic analysis. Seventy-six individuals participated in the study: 47 caregivers and 29 providers. The median gestational age of the infants was 29 weeks and 85% were classified as having chronic complex disease per the Pediatric Medical Complexity Algorithm. Most providers were neonatologists (37%) and nurses (27%) and more than half had over ten years of experience. A conceptual model of caregiver uncertainty was developed and key domains included drivers of uncertainty and its impact, and factors influencing coping and adaptation. Our analysis found a positive association between caregiver information gathering, clinical continuity, support systems, maternal mental health supports, and witnessing a child's progress and the development of adjustment to chronic uncertainty. These results suggest key areas for intervention that can promote parental adaptation to the uncertainty inherent in the NICU experience.
Collapse
Affiliation(s)
- Katharine Griffin Gorsky
- Division of Neonatology, San Francisco School of Medicine, University of California, San Francisco, CA 94158, USA;
| | - Saloni Butala
- Fetal and Neonatal Medicine Institute, Division of Neonatal Medicine, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA; (S.B.); (M.H.)
- School of Medicine, WesternU College of Osteopathic Medicine of the Pacific, Pomona, CA 91766, USA
| | - Madison House
- Fetal and Neonatal Medicine Institute, Division of Neonatal Medicine, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA; (S.B.); (M.H.)
- School of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Chelsea Moon
- Fetal and Neonatal Medicine Institute, Division of Neonatal Medicine, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA; (S.B.); (M.H.)
- School of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA
| | - Sam Calvetti
- Community Health Outcome Intervention Research, Children’s Hospital, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA;
| | - Tenzin Khando
- Life Course Intervention Research Network, University of California, Los Angeles, CA 94158, USA;
| | - Michele Kipke
- School of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA
| | - Ashwini Lakshmanan
- Fetal and Neonatal Medicine Institute, Division of Neonatal Medicine, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA; (S.B.); (M.H.)
- Department of Health Systems Science, Bernard J. Tyson School of Medicine, Pasadena, CA 91101, USA
| |
Collapse
|
33
|
Freyleue SD, Arakelyan M, Leyenaar JK. Epidemiology of pediatric hospitalizations at general hospitals and freestanding children's hospitals in the United States: 2019 update. J Hosp Med 2023; 18:908-917. [PMID: 37661338 DOI: 10.1002/jhm.13194] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 08/01/2023] [Accepted: 08/11/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND General hospitals (GH) provide inpatient care for the majority of hospitalized children in the United States, yet the majority of hospital pediatrics research is conducted at freestanding children's hospitals. OBJECTIVE Updating a prior 2012 analysis, this study used 2019 data to describe characteristics of pediatric hospitalizations at general and freestanding hospitals in the United States and identify the most common and costly reasons for hospitalization in these settings. DESIGNS, SETTING, AND PARTICIPANTS This study examined hospitalizations in children <18 years using the Healthcare Cost and Utilization Project's 2019 Kids' Inpatient Database, stratifying neonatal and nonneonatal hospital stays. INTERVENTION Not applicable. MAIN OUTCOME AND MEASURES Sociodemographic and clinical differences between hospitalizations at general and freestanding children's hospitals were examined, applying survey weights to generate national estimates. RESULTS There were an estimated 5,263,218 pediatric hospitalizations in 2019, including 3,757,601 neonatal and 1,505,617 nonneonatal hospital stays. Overall, 88.6% (n = 4,661,288) of hospitalizations occurred at GH, including 97.6% of neonatal hospitalizations and 65.9% of nonneonatal hospitalizations. 11.4% (n = 601,930) of hospitalizations occurred at freestanding children's hospitals, including 2.4% (n = 88,313) of neonatal hospitalizations and 34.1% (n = 513,616) of nonneonatal hospitalizations. In total, 98.9% of complicated birth hospitalizations and 66.0% of neonatal nonbirth hospitalizations occurred at GH. Among nonneonatal stays, 85.2% of mental health hospitalizations, 63.5% of medical hospitalizations, and 61.3% of surgical hospitalizations occurred at GH.
Collapse
Affiliation(s)
- Seneca D Freyleue
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
| | - Mary Arakelyan
- Department of Pediatrics, Dartmouth Health Children's, Lebanon, New Hampshire, USA
| | - JoAnna K Leyenaar
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
- Department of Pediatrics, Dartmouth Health Children's, Lebanon, New Hampshire, USA
| |
Collapse
|
34
|
Oliveira PV, Enes CC, Nucci LB. How are children with medical complexity being identified in epidemiological studies? A systematic review. World J Pediatr 2023; 19:928-938. [PMID: 36574212 DOI: 10.1007/s12519-022-00672-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 12/05/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND There are different definitions to identify/classify children with medical complexity (CMC). We aimed to investigate and describe the definitions used to classify CMC in epidemiological studies. METHODS PubMed, SciELO, LILACS, and EMBASE were searched from 2015 to 2020 (last updated September 15th, 2020) for original studies that presented the definition used to classify/identify CMC in the scientific research method. We applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. From the included studies, the following were identified: first author, year of publication, design, population, study period, the definition of CMC used, limitations, and strengths. RESULTS Nine hundred and sixty-seven records were identified in the searched databases, and 42 met the inclusion criteria. Of the 42 studies included, the four most frequent definitions used in the articles included in this review were classification of CMC into nine diagnostic categories based on the International Classification of Diseases, Ninth Revision (ICD-9) (35.7%, 15 articles); update of the previous classification for ICD-10 codes with the inclusion of other conditions in the definition (21.4%, nine articles); definition based on a medical complexity algorithm for classification (16.7%, seven articles); and a risk rating system (7.1%, three articles). CONCLUSIONS CMC definitions using diagnostic codes were more frequent. However, several limitations were found in its uses. Our research highlighted the need to improve health information systems to accurately characterize the CMC population and promote the provision of comprehensive care.
Collapse
Affiliation(s)
- Patrícia Vicente Oliveira
- Postgraduate Program in Health Sciences, Center for Life Sciences, Pontifical Catholic University of Campinas, Av. John Boyd Dunlop s/n, Campinas, CEP 13060-904, Brazil.
| | - Carla C Enes
- Postgraduate Program in Health Sciences, School of Nutrition, Pontifical Catholic University of Campinas, São Paulo, Brazil
| | - Luciana B Nucci
- Postgraduate Program in Health Sciences, School of Medicine, Pontifical Catholic University of Campinas, São Paulo, Brazil
| |
Collapse
|
35
|
Discepolo K, Melvin P, Ghazarians M, Tennermann N, Ward VL. Socioeconomic and Clinical Demography of Dental Missed Care Opportunities. JDR Clin Trans Res 2023; 8:356-366. [PMID: 35722931 DOI: 10.1177/23800844221104790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Missed care opportunities (MCOs) contribute to poor health outcomes, and pediatric dental patients are particularly vulnerable; identifying associated patient characteristics will help inform development of targeted interventional programs. OBJECTIVE To assess socioeconomic and demographic disparities associated with MCOs among children in an urban pediatric hospital's dental clinic. MCOs lead to a lack of continuous care and increased emergent needs, so understanding MCOs is required to achieve equitable pediatric dental health. METHODS A retrospective 2-y (2019-2020) cohort of MCOs in children 1 to 17 y old, with scheduled dental visits. MCOs were defined as appointments not attended or canceled and not rescheduled prior to initial scheduled visit. Multivariable mixed-effects logistic regression models with patient-level clustering assessed the associations of demographics, neighborhood-level socioeconomic factors (using social vulnerability index [SVI]), and clinic characteristics with MCOs. RESULTS Of 30,095 visits, 30.9% were MCOs. Multivariable logistic regression estimated increased likelihood of MCOs in Black/non-Hispanic (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.09-1.32) and Hispanic (OR, 1.18; 95% CI, 1.06-1.31) patients, patients with public insurance (OR, 1.25; 95% CI, 1.15-1.36) or no insurance (OR, 1.46; 95% CI, 1.15-1.85), patients with complex chronic conditions (OR, 1.11; 95% CI, 1.03-1.19), visits scheduled during the COVID-19 pandemic (OR, 9.48; 95% CI, 8.89-10.11), appointments with wait days over 21 d (OR, 4.07; 95% CI, 3.49-4.74), and children from neighborhoods of high social vulnerability (75th percentile SVI) (OR, 1.08; 95% CI, 1.01-1.16). CONCLUSIONS Children with highest dental MCOs were from neighborhoods with high SVI, had public insurance, and were from marginalized populations. MCOs contribute to inequities in overall health; hence, interventions that address barriers related to characteristics associated with pediatric dental MCOs are needed. KNOWLEDGE TRANSFER STATEMENT Missed care opportunities contribute to poor health outcomes; identifying associated patient characteristics will help inform development of targeted interventional programs. Providing these findings to stakeholders will better impart understanding access barriers and drive research and program development. Dissemination of this information in the form of altering appointment practices will better accommodate specific patient population needs.
Collapse
Affiliation(s)
- K Discepolo
- Department of Dentistry, Boston Children's Hospital, Boston, MA, USA
| | - P Melvin
- Office of Health Equity and Inclusion, Boston Children's Hospital, Boston, MA, USA
- Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion, Boston Children's Hospital, Boston, MA, USA
| | - M Ghazarians
- Department of Dentistry, Boston Children's Hospital, Boston, MA, USA
| | - N Tennermann
- Office of Health Equity and Inclusion, Boston Children's Hospital, Boston, MA, USA
| | - V L Ward
- Office of Health Equity and Inclusion, Boston Children's Hospital, Boston, MA, USA
- Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion, Boston Children's Hospital, Boston, MA, USA
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| |
Collapse
|
36
|
Warniment A, Sauers-Ford H, Brady PW, Beck AF, Callahan SR, Giambra BK, Herzog D, Huang B, Loechtenfeldt A, Loechtenfeldt L, Miller CL, Perez E, Riddle SW, Shah SS, Shepard M, Sucharew HJ, Tegtmeyer K, Thomson JE, Auger KA. Garnering effective telehealth to help optimize multidisciplinary team engagement (GET2HOME) for children with medical complexity: Protocol for a pragmatic randomized control trial. J Hosp Med 2023; 18:877-887. [PMID: 37602537 DOI: 10.1002/jhm.13192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023]
Abstract
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.
Collapse
Affiliation(s)
- Amanda Warniment
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Hadley Sauers-Ford
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Patrick W Brady
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Andrew F Beck
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Cincinnati Children's HealthVine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Michael Fisher Child Health Equity Center Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Scott R Callahan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Barbara K Giambra
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- College of Nursing, University of Cincinnati, Cincinnati, Ohio, USA
| | - Diane Herzog
- Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Bin Huang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Allison Loechtenfeldt
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Chelsey L Miller
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Combined Pediatrics/Medicine House Staff, Cincinnati Children's Hospital Medical Center and University of Cincinnati Hospital, Cincinnati, Ohio, USA
| | | | - Sarah W Riddle
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Heidi J Sucharew
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ken Tegtmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Center for Telehealth, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Joanna E Thomson
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Katherine A Auger
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| |
Collapse
|
37
|
Leyenaar JK, Freyleue SD, Arakelyan M, Goodman DC, O’Malley AJ. Pediatric Hospitalizations at Rural and Urban Teaching and Nonteaching Hospitals in the US, 2009-2019. JAMA Netw Open 2023; 6:e2331807. [PMID: 37656457 PMCID: PMC10474556 DOI: 10.1001/jamanetworkopen.2023.31807] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/07/2023] [Indexed: 09/02/2023] Open
Abstract
Importance National analyses suggest that approximately 1 in 5 US hospitals closed their pediatric units between 2008 and 2018. The extent to which pediatric hospitalizations at general hospitals in rural and urban communities decreased during this period is not well understood. Objective To describe changes in the number and proportion of pediatric hospitalizations and costs at urban teaching, urban nonteaching, and rural hospitals vs freestanding children's hospitals from 2009 to 2019; to estimate the number and proportion of hospitals providing inpatient pediatric care; and to characterize changes in clinical complexity. Design, Setting, and Participants This study is a retrospective cross-sectional analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative data set of US pediatric hospitalizations among children younger than 18 years. Data were analyzed from February to June 2023. Exposures Pediatric hospitalizations were grouped as birth or nonbirth hospitalizations. Hospitals were categorized as freestanding children's hospitals or as rural, urban nonteaching, or urban teaching general hospitals. Main Outcomes and Measures The primary outcomes were annual number and proportion of birth and nonbirth hospitalizations and health care costs, changes in the proportion of hospitalizations with complex diagnoses, and estimated number and proportion of hospitals providing pediatric care and associated hospital volumes. Regression analyses were used to compare health care utilization in 2019 vs that in 2009. Results The data included 23.2 million (95% CI, 22.7-23.6 million) weighted hospitalizations. From 2009 to 2019, estimated national annual pediatric hospitalizations decreased from 6 425 858 to 5 297 882, as birth hospitalizations decreased by 10.6% (95% CI, 6.1%-15.1%) and nonbirth hospitalizations decreased by 28.9% (95% CI, 21.3%-36.5%). Concurrently, hospitalizations with complex chronic disease diagnoses increased by 45.5% (95% CI, 34.6%-56.4%), and hospitalizations with mental health diagnoses increased by 78.0% (95% CI, 61.6%-94.4%). During this period, the most substantial decreases were in nonbirth hospitalizations at rural hospitals (4-fold decrease from 229 263 to 62 729) and urban nonteaching hospitals (6-fold decrease from 581 320 to 92 118). In 2019, birth hospitalizations occurred at 2666 hospitals. Nonbirth pediatric hospitalizations occurred at 3507 hospitals, including 1256 rural hospitals and 843 urban nonteaching hospitals where the median nonbirth hospitalization volumes were fewer than 25 per year. Conclusions and Relevance Between 2009 and 2019, the largest decreases in pediatric hospitalizations occurred at rural and urban nonteaching hospitals. Clinical and policy initiatives to support hospitals with low pediatric volumes may be needed to maintain hospital access and pediatric readiness, particularly in rural communities.
Collapse
Affiliation(s)
- JoAnna K. Leyenaar
- Department of Pediatrics, Dartmouth Health Children’s, Lebanon, New Hampshire
| | - Seneca D. Freyleue
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Mary Arakelyan
- Department of Pediatrics, Dartmouth Health Children’s, Lebanon, New Hampshire
| | - David C. Goodman
- Department of Pediatrics, Dartmouth Health Children’s, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| |
Collapse
|
38
|
McDaniel CE, Lowry SJ, Ziniel SI, Freyleue S, Acquilano SC, Leyenaar JK. Development of the Pediatric Hospitalization Admission Survey of Experience (PHASE) Measure. Pediatrics 2023; 152:e2023061522. [PMID: 37584105 DOI: 10.1542/peds.2023-061522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND Although significant research is devoted to transitions of care at discharge, few measures assess the quality of transitions into the hospital. Our objective was to develop a caregiver-reported quality measure to evaluate the pediatric hospital admission experience. METHODS Measure development included: (1) adapting items from existing instruments; (2) an expert-consensus process to prioritize survey items; (3) cognitive pretesting with caregivers (n = 16); and (4) pilot testing revised items (n = 27). Subsequently, the survey was administered to caregivers at 2 children's hospitals and 1 general hospital from February 2020 through November 2021. Item reduction statistics and exploratory factor analysis were performed followed by confirmatory factor analysis. Domain scores were calculated using a top-box approach. Known-group validity and indices of model fit were evaluated. RESULTS The initial survey included 25 items completed by 910 caregivers. Following item reduction and the exploratory factor analysis, 14 items were mapped to 4 domains: (1) Patient and Family Engagement, (2) Information Sharing, (3) Effectiveness of Care Delivery, and (4) Timeliness of Care. The confirmatory factor analysis and validity testing supported the factor structure. Domain scores ranged from 49% (95% confidence interval, 46-53) for Timelines of Care to 81% (95% confidence interval, 65-84) for Patient and Family Engagement, with significant differences between general and children's hospitals in Information Sharing and Effectiveness of Care Delivery. CONCLUSIONS A 4-domain caregiver-reported hospital admission experience measure demonstrated acceptable validity and psychometric properties across children's and general hospitals. This measure can be used to evaluate the quality of transitions into the hospital and to focus quality improvement efforts.
Collapse
Affiliation(s)
- Corrie E McDaniel
- Seattle Children's Hospital, Seattle, Washington
- University of Washington, Seattle, Washington
| | - Sarah J Lowry
- Seattle Children's Hospital, Seattle, Washington
- University of Washington, Seattle, Washington
- Center for Biostatistics Epidemiology and Analytics, Seattle Children's Research Institute, Seattle, Washington
| | - Sonja I Ziniel
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado
| | - Seneca Freyleue
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Stephanie C Acquilano
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - JoAnna K Leyenaar
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Dartmouth Health Children's, Lebanon, New Hampshire
| |
Collapse
|
39
|
Holland JE, Rettew DC, Varni SE, Harder VS. Associations Between Mental and Physical Illness Comorbidity and Hospital Utilization. Hosp Pediatr 2023; 13:841-848. [PMID: 37555263 DOI: 10.1542/hpeds.2022-006984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
OBJECTIVE Characterize the prevalence of chronic physical illness types and mental illness and their comorbidity among adolescents and young adults (AYA) and assess the association of comorbidity on hospital utilization. METHODS This study features a population-level sample of 61 339 insurance-eligible AYA with an analytic sample of 49 089 AYA (aged 12-21) in Vermont's 2018 all-payer database. We used multiple logistic regressions to examine the associations between physical illness types and comorbid mental illness and emergency department (ED) use and inpatient hospitalization. RESULTS The analytic sample was 50% female, 63% Medicaid, and 43% had ≥1 chronic illness. Mental illness was common (31%) and highly comorbid with multiple physical illnesses. Among AYA with pulmonary illness, those with comorbid mental illness had 1.74-times greater odds (95% confidence interval [CI]: 1.49-2.05, P ≤.0005) of ED use and 2.9-times greater odds (95% CI: 2.05-4.00, P ≤.0005) of hospitalization than those without mental illness. Similarly, comorbid endocrine and mental illness had 1.84-times greater odds of ED use (95% CI: 1.39-2.44, P ≤.0005) and 2.1-times greater odds of hospitalization (95% CI: 1.28-3.46, P = .003), comorbid neurologic and mental illness had 1.36-times greater odds of ED use (95% CI: 1.18-1.56, P ≤.0005) and 2.4-times greater odds of hospitalization (95% CI: 1.73-3.29, P ≤.0005), and comorbid musculoskeletal and mental illness had 1.38-times greater odds of ED use (95% CI: 1.02-1.86, P = .04) and 2.1-times greater odds of hospitalization (95% CI: 1.20-3.52, P = .01). CONCLUSIONS Comorbid physical and mental illness was common. Having a comorbid mental illness was associated with greater ED and inpatient hospital utilization across multiple physical illness types.
Collapse
Affiliation(s)
| | - David C Rettew
- The Robert Larner, M.D. College of Medicine
- Department of Pediatrics
- Department of Psychiatry, The University of Vermont, Burlington, Vermont
- Lane County Behavioral Health, Eugene, Oregon
| | - Susan E Varni
- The Robert Larner, M.D. College of Medicine
- Department of Pediatrics
| | - Valerie S Harder
- The Robert Larner, M.D. College of Medicine
- Department of Pediatrics
- Department of Psychiatry, The University of Vermont, Burlington, Vermont
| |
Collapse
|
40
|
Tan CD, Vermont CL, Zachariasse JM, von Both U, Eleftheriou I, Emonts M, van der Flier M, Herberg J, Kohlmaier B, Levin M, Lim E, Maconochie IK, Martinon-Torres F, Nijman RG, Pokorn M, Rivero-Calle I, Tsolia M, Zenz W, Zavadska D, Moll HA, Carrol ED. Emergency medical services utilisation among febrile children attending emergency departments across Europe: an observational multicentre study. Eur J Pediatr 2023; 182:3939-3947. [PMID: 37354239 PMCID: PMC10570223 DOI: 10.1007/s00431-023-05056-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/24/2023] [Accepted: 06/04/2023] [Indexed: 06/26/2023]
Abstract
Children constitute 6-10% of all patients attending the emergency department (ED) by emergency medical services (EMS). However, discordant EMS use in children occurs in 37-61% with fever as an important risk factor. We aimed to describe EMS utilisation among febrile children attending European EDs. This study is part of an observational multicentre study assessing management and outcome in febrile children up to 18 years (MOFICHE) attending twelve EDs in eight European countries. Discordant EMS use was defined as the absence of markers of urgency including intermediate/high triage urgency, advanced diagnostics, treatment, and admission in children transferred by EMS. Multivariable logistic regression analyses were performed for the association between (1) EMS use and markers of urgency, and (2) patient characteristics and discordant EMS use after adjusting all analyses for the covariates age, gender, visiting hours, presenting symptoms, and ED setting. A total of 5464 (15%, range 0.1-42%) children attended the ED by EMS. Markers of urgency were more frequently present in the EMS group compared with the non-EMS group. Discordant EMS use occurred in 1601 children (29%, range 1-59%). Age and gender were not associated with discordant EMS use, whereas neurological symptoms were associated with less discordant EMS use (aOR 0.2, 95%CI 0.1-0.2), and attendance out of office hours was associated with more discordant EMS use (aOR 1.6, 95%CI 1.4-1.9). Settings with higher percentage of self-referrals to the ED had more discordant EMS use (p < 0.05). Conclusion: There is large practice variation in EMS use in febrile children attending European EDs. Markers of urgency were more frequently present in children in the EMS group. However, discordant EMS use occurred in 29%. Further research is needed on non-medical factors influencing discordant EMS use in febrile children across Europe, so that pre-emptive strategies can be implemented. What is Known: •Children constitute around 6-10% of all patients attending the emergency department by emergency medical services. •Discordant EMS use occurs in 37-61% of all children, with fever as most common presenting symptom for discordant EMS use in children. What is New: •There is large practice variation in EMS use among febrile children across Europe with discordance EMS use occurring in 29% (range 1-59%), which was associated with attendance during out of office hours and with settings with higher percentage of self-referrals to the ED. •Future research is needed focusing on non-medical factors (socioeconomic status, parental preferences and past experience, healthcare systems, referral pathways, out of hours services provision) that influence discordant EMS use in febrile children across Europe.
Collapse
Affiliation(s)
- Chantal D. Tan
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Clementien L. Vermont
- Department of Paediatric Infectious Diseases and Immunology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Joany M. Zachariasse
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Ulrich von Both
- Division of Paediatric Infectious Diseases, Dr. Von Hauner Children’s Hospital, University Hospital, Ludwig-Maximilians University, Munich, Germany
- German Centre for Infection Research, DZIF, Partner Site, Munich, Germany
| | - Irini Eleftheriou
- Second Department of Paediatrics, P. and A. Kyriakou Children’s Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marieke Emonts
- Paediatric Immunology, Infectious Diseases & Allergy, Great North Children’s Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle Upon Tyne Hospitals NHS Trust, Westgate Rd, Newcastle Upon Tyne, NE4 5PL UK
| | - Michiel van der Flier
- Section of Paediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Center for Infectious Diseases, Radboud Institute for Molecular Life Sciences, RadboudUMC, Nijmegen, the Netherlands
- Paediatric Infectious Diseases and Immunology, Amalia Children’s Hospital, RadboudUMC, Nijmegen, the Netherlands
- Paediatric Infectious Diseases and Immunology, Wilhelmina Children’s Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jethro Herberg
- Section of Paediatric Infectious Diseases, Imperial College, London, UK
| | - Benno Kohlmaier
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | - Michael Levin
- Section of Paediatric Infectious Diseases, Imperial College, London, UK
| | - Emma Lim
- Paediatric Immunology, Infectious Diseases & Allergy, Great North Children’s Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Department of Medicine, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Ian K. Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, London, UK
| | - Federico Martinon-Torres
- Genetics, Vaccines, Infections and Paediatrics Research Group (GENVIP), Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Ruud G. Nijman
- Section of Paediatric Infectious Diseases, Imperial College, London, UK
| | - Marko Pokorn
- Department of Infectious Diseases and Faculty of Medicine, University Medical Centre Ljubljana, University of Ljubljana, Ljubljana, Slovenia
| | - Irene Rivero-Calle
- Genetics, Vaccines, Infections and Paediatrics Research Group (GENVIP), Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Maria Tsolia
- Second Department of Paediatrics, P. and A. Kyriakou Children’s Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Werner Zenz
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | - Dace Zavadska
- Department of Paediatrics, Children Clinical University Hospital, Rīgas Stradiņa Universitāte, Riga, Latvia
| | - Henriëtte A. Moll
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Enitan D. Carrol
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
- Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| |
Collapse
|
41
|
Chavez LJ, Tyson DP, Davenport MA, Kelleher KJ, Chisolm DJ. Social Needs as a Risk Factor for Positive Postpartum Depression Screens in Pediatric Primary Care. Acad Pediatr 2023; 23:1411-1416. [PMID: 36958532 DOI: 10.1016/j.acap.2023.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 03/25/2023]
Abstract
OBJECTIVE The goal of this study was to examine the association between self-reported social needs and postpartum depression (PPD) symptoms of mothers screened in pediatric primary care clinics. METHODS This retrospective cohort study used electronic health record data from 3616 pediatric patients (age 0-6 months), whose mothers completed the Edinburgh Postpartum Depression Scale (EPDS) and a social needs screening in a large pediatric primary care network between April 2021 and February 2022. Mothers were screened for four self-reported social needs (food, housing, transportation, and utilities). Logistic regression evaluated the association between the report of any social need and a positive EPDS screen (≥ 10), adjusting for demographic and clinical characteristics and ZIP code-level poverty. RESULTS Overall, 8.6% of mothers screened positive for PPD and 10.0% reported any social needs. The odds of a positive depression screen were significantly higher among mothers who reported any social need compared to those not reporting a social need (OR 4.18, 95% CI 3.11-5.61). The prevalence of all depressive symptoms on the EPDS was significantly higher among those who reported any social need, relative to those reporting no needs. Mothers reporting any social needs were significantly more likely to report thoughts of self-harm (6.9% vs 1.5%, P < .005). CONCLUSIONS Self-report of social need was significantly associated with positive PPD screens during infant well-child visits. Social needs may be a target of future interventions addressing PPD in pediatric settings. Improving care for social needs may have added benefit of alleviating the risk of PPD.
Collapse
Affiliation(s)
- Laura J Chavez
- Center for Child Health Equity and Outcomes Research (LJ Chavez, MA Davenport, KJ Kelleher, and DJ Chisolm), The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio.
| | - Danielle P Tyson
- Division of Epidemiology (DP Tyson), College of Public Health, The Ohio State University, Columbus, Ohio.
| | - Mattina A Davenport
- Center for Child Health Equity and Outcomes Research (LJ Chavez, MA Davenport, KJ Kelleher, and DJ Chisolm), The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio.
| | - Kelly J Kelleher
- Center for Child Health Equity and Outcomes Research (LJ Chavez, MA Davenport, KJ Kelleher, and DJ Chisolm), The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Division of Health Behavior and Health Promotion (KJ Kelleher), College of Public Health, The Ohio State University, Columbus, Ohio; Department of Pediatrics (KJ Kelleher and DJ Chisolm), College of Medicine, The Ohio State University, Columbus, Ohio.
| | - Deena J Chisolm
- Center for Child Health Equity and Outcomes Research (LJ Chavez, MA Davenport, KJ Kelleher, and DJ Chisolm), The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics (KJ Kelleher and DJ Chisolm), College of Medicine, The Ohio State University, Columbus, Ohio.
| |
Collapse
|
42
|
Lo CB, Conrad B, Debs A, Herbst J, Kulkarni N, Nelson DM, Wentzel E, Cohen DM, Patel AD. Counseling on the Need for Folic Acid in Adolescents With Epilepsy. Neurol Clin Pract 2023; 13:e200177. [PMID: 37529297 PMCID: PMC10389172 DOI: 10.1212/cpj.0000000000200177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 05/09/2023] [Indexed: 08/03/2023]
Abstract
Background and Objectives Folic acid is an important supplement to take for women with epilepsy on antiseizure medications (ASMs). Determination of baseline counseling given to women with epilepsy and the association with folic acid being recommended were evaluated. Factors surrounding the association were reviewed. Methods An exploratory retrospective review of women with epilepsy seen at a large Midwestern pediatric institution was performed between January 2018 and January 2020. Results Patients who received preconception counseling were more likely to be given a recommendation to take folic acid. Patients on more than 1 ASM were likely to receive counseling. Patient age and race were associated with having folic acid recommended. Discussion Providing preconception counseling for women with epilepsy is associated with an increased recommendation and prescription of folic acid. Further evaluation into possible disparities to receiving a folic acid recommendation is needed.
Collapse
Affiliation(s)
- Charmaine B Lo
- Division of Emergency Medicine (CBL, DMN, DMC), Nationwide Children's Hospital; Pediatric Emergency Medicine (CBL), Abigail Wexner Research Institute at Nationwide Children's Hospital; The Ohio State University College of Medicine (BC); Division of Neurology (AD, NK, EW, ADP), Nationwide Children's Hospital; Endocrinology and Metabolism Institute (AD), Cleveland Clinic; Department of Pharmacy (JH), Nationwide Children's Hospital, Columbus, OH; Lincoln Memorial University (DMN), Debusk College of Osteopathic Medicine, Knoxville, TN; Department of Pediatrics (DMC, ADP), The Ohio State University College of Medicine; and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Bailey Conrad
- Division of Emergency Medicine (CBL, DMN, DMC), Nationwide Children's Hospital; Pediatric Emergency Medicine (CBL), Abigail Wexner Research Institute at Nationwide Children's Hospital; The Ohio State University College of Medicine (BC); Division of Neurology (AD, NK, EW, ADP), Nationwide Children's Hospital; Endocrinology and Metabolism Institute (AD), Cleveland Clinic; Department of Pharmacy (JH), Nationwide Children's Hospital, Columbus, OH; Lincoln Memorial University (DMN), Debusk College of Osteopathic Medicine, Knoxville, TN; Department of Pediatrics (DMC, ADP), The Ohio State University College of Medicine; and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Andrea Debs
- Division of Emergency Medicine (CBL, DMN, DMC), Nationwide Children's Hospital; Pediatric Emergency Medicine (CBL), Abigail Wexner Research Institute at Nationwide Children's Hospital; The Ohio State University College of Medicine (BC); Division of Neurology (AD, NK, EW, ADP), Nationwide Children's Hospital; Endocrinology and Metabolism Institute (AD), Cleveland Clinic; Department of Pharmacy (JH), Nationwide Children's Hospital, Columbus, OH; Lincoln Memorial University (DMN), Debusk College of Osteopathic Medicine, Knoxville, TN; Department of Pediatrics (DMC, ADP), The Ohio State University College of Medicine; and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - James Herbst
- Division of Emergency Medicine (CBL, DMN, DMC), Nationwide Children's Hospital; Pediatric Emergency Medicine (CBL), Abigail Wexner Research Institute at Nationwide Children's Hospital; The Ohio State University College of Medicine (BC); Division of Neurology (AD, NK, EW, ADP), Nationwide Children's Hospital; Endocrinology and Metabolism Institute (AD), Cleveland Clinic; Department of Pharmacy (JH), Nationwide Children's Hospital, Columbus, OH; Lincoln Memorial University (DMN), Debusk College of Osteopathic Medicine, Knoxville, TN; Department of Pediatrics (DMC, ADP), The Ohio State University College of Medicine; and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Neil Kulkarni
- Division of Emergency Medicine (CBL, DMN, DMC), Nationwide Children's Hospital; Pediatric Emergency Medicine (CBL), Abigail Wexner Research Institute at Nationwide Children's Hospital; The Ohio State University College of Medicine (BC); Division of Neurology (AD, NK, EW, ADP), Nationwide Children's Hospital; Endocrinology and Metabolism Institute (AD), Cleveland Clinic; Department of Pharmacy (JH), Nationwide Children's Hospital, Columbus, OH; Lincoln Memorial University (DMN), Debusk College of Osteopathic Medicine, Knoxville, TN; Department of Pediatrics (DMC, ADP), The Ohio State University College of Medicine; and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Dustin Mark Nelson
- Division of Emergency Medicine (CBL, DMN, DMC), Nationwide Children's Hospital; Pediatric Emergency Medicine (CBL), Abigail Wexner Research Institute at Nationwide Children's Hospital; The Ohio State University College of Medicine (BC); Division of Neurology (AD, NK, EW, ADP), Nationwide Children's Hospital; Endocrinology and Metabolism Institute (AD), Cleveland Clinic; Department of Pharmacy (JH), Nationwide Children's Hospital, Columbus, OH; Lincoln Memorial University (DMN), Debusk College of Osteopathic Medicine, Knoxville, TN; Department of Pediatrics (DMC, ADP), The Ohio State University College of Medicine; and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Evelynne Wentzel
- Division of Emergency Medicine (CBL, DMN, DMC), Nationwide Children's Hospital; Pediatric Emergency Medicine (CBL), Abigail Wexner Research Institute at Nationwide Children's Hospital; The Ohio State University College of Medicine (BC); Division of Neurology (AD, NK, EW, ADP), Nationwide Children's Hospital; Endocrinology and Metabolism Institute (AD), Cleveland Clinic; Department of Pharmacy (JH), Nationwide Children's Hospital, Columbus, OH; Lincoln Memorial University (DMN), Debusk College of Osteopathic Medicine, Knoxville, TN; Department of Pediatrics (DMC, ADP), The Ohio State University College of Medicine; and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Daniel M Cohen
- Division of Emergency Medicine (CBL, DMN, DMC), Nationwide Children's Hospital; Pediatric Emergency Medicine (CBL), Abigail Wexner Research Institute at Nationwide Children's Hospital; The Ohio State University College of Medicine (BC); Division of Neurology (AD, NK, EW, ADP), Nationwide Children's Hospital; Endocrinology and Metabolism Institute (AD), Cleveland Clinic; Department of Pharmacy (JH), Nationwide Children's Hospital, Columbus, OH; Lincoln Memorial University (DMN), Debusk College of Osteopathic Medicine, Knoxville, TN; Department of Pediatrics (DMC, ADP), The Ohio State University College of Medicine; and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Anup D Patel
- Division of Emergency Medicine (CBL, DMN, DMC), Nationwide Children's Hospital; Pediatric Emergency Medicine (CBL), Abigail Wexner Research Institute at Nationwide Children's Hospital; The Ohio State University College of Medicine (BC); Division of Neurology (AD, NK, EW, ADP), Nationwide Children's Hospital; Endocrinology and Metabolism Institute (AD), Cleveland Clinic; Department of Pharmacy (JH), Nationwide Children's Hospital, Columbus, OH; Lincoln Memorial University (DMN), Debusk College of Osteopathic Medicine, Knoxville, TN; Department of Pediatrics (DMC, ADP), The Ohio State University College of Medicine; and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| |
Collapse
|
43
|
McDaniel CE, Leyenaar JK, Bryan MA, Test M, Sullivan E. Urban-rural disparities in interfacility transfers for children during COVID-19. J Rural Health 2023; 39:611-616. [PMID: 36710077 PMCID: PMC11132630 DOI: 10.1111/jrh.12746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE We aimed to identify temporal trends and differences in urban and rural pediatric interfacility transfers (IFTs) before and during the COVID-19 pandemic. METHODS We conducted a cross-sectional analysis of IFT among children <18 years from January 2019 to June 2022 using the Pediatric Health Information System. The primary outcome was IFTs from general hospitals to referral children's hospitals. The primary exposure was patient rurality, defined by Rural-Urban Commuting Area codes. We categorized IFTs into medical, surgical, and mental health diagnoses and analyzed trends by month. We calculated observed-to-expected (O-E) ratios of pre-pandemic (March 2019-Feb 2020) transfers compared to pandemic year 1 (March 2020-Feb 2021) and year 2 (March 2021-February 2022) using Poisson modeling. FINDINGS Of 419,250 IFTs, 18.8% (n = 78,751) were experienced by rural-residing children. The O-E ratio of IFT in year 1 for urban children was 14.0% (95% confidence interval [CI] 13.8, 14.2) and 14.8% (95% CI 14.4, 15.3) for rural children compared to pre-pandemic (P = .0001). In year 2, transfers rebounded with IFTs for rural-residing children increasing more than urban-residing children (101.7% [95% CI 100.1, 103.4] compared to 90.7% [95% CI 89.0, 90.4], P < .0001). For mental-health indications in year 2, rural transfer ratios were higher than urban, 126.8% (95% CI, 116.7, 137.6) compared to 113.7% (95% CI 109.9, 117.6), P = .0168. CONCLUSIONS Pediatric IFTs decreased dramatically during pandemic year 1. In year 2, while medical and surgical transfers continued to lag pre-pandemic volumes, transfers for mental health indications significantly exceeded pre-pandemic levels, particularly among rural-residing children.
Collapse
Affiliation(s)
- Corrie E. McDaniel
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Seattle Children’s Research Institute, Seattle, Washington, USA
| | - JoAnna K. Leyenaar
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Mersine A. Bryan
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Matthew Test
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Erin Sullivan
- Seattle Children’s Research Institute, Seattle, Washington, USA
| |
Collapse
|
44
|
Ramgopal S, Heneghan JA. Comparing two definitions of pediatric complexity among children cared for in general and pediatric emergency departments in a statewide sample. J Am Coll Emerg Physicians Open 2023; 4:e12950. [PMID: 37124473 PMCID: PMC10132184 DOI: 10.1002/emp2.12950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/20/2023] [Accepted: 03/30/2023] [Indexed: 05/02/2023] Open
Abstract
Objective The number of children cared for in emergency departments (EDs) with medical complexity continues to rise. We sought to identify the concordance between 2 commonly used criteria of medical complexity among children presenting to a statewide sample of EDs. Methods We conducted a retrospective cross-sectional study of children presenting to a statewide sample of Illinois EDs between 2016 and 2021. We classified patients as having medical complexity when using 2 definitions (≥1 pediatric Complex Chronic Condition [CCC] or complex chronic disease using the Pediatric Medical Complexity Algorithm [PMCA]) and compared their overlap and clinical outcomes. Results Of 6,550,296 pediatric ED encounters, CCC criteria and PMCA criteria were met in 217,609 (3.3%) and 175,708 (2.7%) encounters, respectively. Among patients with complexity, 100,015 (34.1%) met both criteria, with moderate agreement (κ = 0.49). Children with complexity by CCC had similar rates of presentation to a pediatric hospital (16.3% vs 14.8%), admission (28.5% vs 33.7%), ICU stay (10.0% vs 10.1%), and in-hospital mortality (0.5% vs 0.5%) compared to children with complexity by PMCA. The most common visit diagnoses for children with CCCs were related to sickle cell disease with crisis (3.9%), abdominal pain (3.6%), and non-specific chest pain (2.7%). The most common diagnoses by PMCA were related to depressive disorders (4.9%), sickle cell disease with crisis (4.8%), and seizures (3.2%). Conclusions and Relevance The CCC and PMCA criteria of multisystem complexity identified different populations, with moderate agreement. Careful selection of operational definitions is required for proper application and interpretation in clinical and health services research.
Collapse
Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of PediatricsNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Julia A. Heneghan
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's HospitalUniversity of MinnesotaMinneapolisMinnesotaUSA
| |
Collapse
|
45
|
Boyden JY, Bogetz JF, Johnston EE, Thienprayoon R, Williams CSP, McNeil MJ, Patneaude A, Widger KA, Rosenberg AR, Ananth P. Measuring Pediatric Palliative Care Quality: Challenges and Opportunities. J Pain Symptom Manage 2023; 65:e483-e495. [PMID: 36736860 PMCID: PMC10106436 DOI: 10.1016/j.jpainsymman.2023.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023]
Abstract
Pediatric palliative care (PPC) programs vary widely in structure, staffing, funding, and patient census, resulting in inconsistency in service provision. Improving the quality of palliative care for children living with serious illness and their families requires measuring care quality, ensuring that quality measurement is embedded into day-to-day clinical practice, and aligning quality measurement with healthcare policy priorities. Yet, numerous challenges exist in measuring PPC quality. This paper provides an overview of PPC quality measurement, including challenges, current initiatives, and future opportunities. While important strides toward addressing quality measurement challenges in PPC have been made, including ongoing quality measurement initiatives like the Cambia Metrics Project, the PPC What Matters Most study, and collaborative learning networks, more work remains. Providing high-quality PPC to all children and families will require a multi-pronged approach. In this paper, we suggest several strategies for advancing high-quality PPC, which includes 1) considering how and by whom success is defined, 2) evaluating, adapting, and developing PPC measures, including those that address care disparities within PPC for historically marginalized and excluded communities, 3) improving the infrastructure with which to routinely and prospectively measure, monitor, and report clinical and administrative quality measures, 4) increasing endorsement of PPC quality measures by prominent quality organizations to facilitate accountability and possible reimbursement, and 5) integrating PPC-specific quality measures into the administrative, funding, and policy landscape of pediatric healthcare.
Collapse
Affiliation(s)
- Jackelyn Y Boyden
- Department of Family and Community Health, School of Nursing (J.Y.B.), University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Jori F Bogetz
- Department of Pediatrics, Division of Bioethics and Palliative Care (J.F.B.), University of Washington School of Medicine, Seattle, Washington, USA; Center for Clinical and Translational Research (J.F.B.), Seattle Children's Research Institute, Seattle, Washington, USA
| | - Emily E Johnston
- Department of Pediatrics, Division of Hematology and Oncology (E.E.J.), University of Alabama at Birmingham, Birmingham, Alabama, USA; Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham (E.E.J.), Birmingham, Alabama, USA
| | - Rachel Thienprayoon
- Department of Anesthesia, Division of Palliative Care, Cincinnati Children's Hospital Medical Center (R.T.), Cincinnati, Ohio, USA; Department of Pediatrics, Cincinnati Children's Hospital Medical Center (R.T.), Cincinnati, Ohio, USA
| | - Conrad S P Williams
- Palliative Care Program and Department of Pediatrics (C.S.P.W.), Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael J McNeil
- St. Jude Children's Research Hospital, Department of Global Pediatric Medicine (M.J.M.), Memphis, Tennessee, USA; St. Jude Children's Research Hospital, Division of Quality and Life and Palliative Care, Department of Oncology (M.J.M.), Memphis, Tennessee, USA
| | - Arika Patneaude
- Bioethics and Palliative Care, Seattle Children's Hospital (A.P.), Seattle, Washington, USA; University of Washington School of Social Work (A.P.), Seattle, Washington, USA; Treuman Katz Center for Pediatric Bioethics (A.P.), Seattle, Washington, USA
| | - Kimberley A Widger
- Lawrence S. Bloomberg Faculty of Nursing (K.A.W.), University of Toronto, Toronto, Ontario, Canada; Hospital for Sick Children (K.A.W.), Toronto, Ontario, Canada
| | - Abby R Rosenberg
- Department of Psychosocial Oncology and Palliative Care (A.R.S.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School (A.R.S.), Boston, Massachusetts, USA
| | - Prasanna Ananth
- Department of Pediatrics, Yale School of Medicine (P.A.), New Haven, Connecticut, USA; Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center (P.A.), New Haven, Connecticut, USA
| |
Collapse
|
46
|
Mick E, Tsitsiklis A, Kamm J, Kalantar KL, Caldera S, Lyden A, Tan M, Detweiler AM, Neff N, Osborne CM, Williamson KM, Soesanto V, Leroue M, Maddux AB, Simões EA, Carpenter TC, Wagner BD, DeRisi JL, Ambroggio L, Mourani PM, Langelier CR. Integrated host/microbe metagenomics enables accurate lower respiratory tract infection diagnosis in critically ill children. J Clin Invest 2023; 133:e165904. [PMID: 37009900 PMCID: PMC10065066 DOI: 10.1172/jci165904] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/02/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUNDLower respiratory tract infection (LRTI) is a leading cause of death in children worldwide. LRTI diagnosis is challenging because noninfectious respiratory illnesses appear clinically similar and because existing microbiologic tests are often falsely negative or detect incidentally carried microbes, resulting in antimicrobial overuse and adverse outcomes. Lower airway metagenomics has the potential to detect host and microbial signatures of LRTI. Whether it can be applied at scale and in a pediatric population to enable improved diagnosis and treatment remains unclear.METHODSWe used tracheal aspirate RNA-Seq to profile host gene expression and respiratory microbiota in 261 children with acute respiratory failure. We developed a gene expression classifier for LRTI by training on patients with an established diagnosis of LRTI (n = 117) or of noninfectious respiratory failure (n = 50). We then developed a classifier that integrates the host LRTI probability, abundance of respiratory viruses, and dominance in the lung microbiome of bacteria/fungi considered pathogenic by a rules-based algorithm.RESULTSThe host classifier achieved a median AUC of 0.967 by cross-validation, driven by activation markers of T cells, alveolar macrophages, and the interferon response. The integrated classifier achieved a median AUC of 0.986 and increased the confidence of patient classifications. When applied to patients with an uncertain diagnosis (n = 94), the integrated classifier indicated LRTI in 52% of cases and nominated likely causal pathogens in 98% of those.CONCLUSIONLower airway metagenomics enables accurate LRTI diagnosis and pathogen identification in a heterogeneous cohort of critically ill children through integration of host, pathogen, and microbiome features.FUNDINGSupport for this study was provided by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Heart, Lung, and Blood Institute (UG1HD083171, 1R01HL124103, UG1HD049983, UG01HD049934, UG1HD083170, UG1HD050096, UG1HD63108, UG1HD083116, UG1HD083166, UG1HD049981, K23HL138461, and 5R01HL155418) as well as by the Chan Zuckerberg Biohub.
Collapse
Affiliation(s)
- Eran Mick
- Chan Zuckerberg Biohub, San Francisco, California, USA
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, and
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Alexandra Tsitsiklis
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Jack Kamm
- Chan Zuckerberg Biohub, San Francisco, California, USA
| | | | - Saharai Caldera
- Chan Zuckerberg Biohub, San Francisco, California, USA
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Amy Lyden
- Chan Zuckerberg Biohub, San Francisco, California, USA
| | - Michelle Tan
- Chan Zuckerberg Biohub, San Francisco, California, USA
| | | | - Norma Neff
- Chan Zuckerberg Biohub, San Francisco, California, USA
| | - Christina M. Osborne
- Department of Pediatrics, University of Colorado and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Kayla M. Williamson
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Victoria Soesanto
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Matthew Leroue
- Department of Pediatrics, University of Colorado and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Aline B. Maddux
- Department of Pediatrics, University of Colorado and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Eric A.F. Simões
- Department of Pediatrics, University of Colorado and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Todd C. Carpenter
- Department of Pediatrics, University of Colorado and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Brandie D. Wagner
- Department of Pediatrics, University of Colorado and Children’s Hospital Colorado, Aurora, Colorado, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Joseph L. DeRisi
- Chan Zuckerberg Biohub, San Francisco, California, USA
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, California, USA
| | - Lilliam Ambroggio
- Department of Pediatrics, University of Colorado and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Peter M. Mourani
- Department of Pediatrics, University of Colorado and Children’s Hospital Colorado, Aurora, Colorado, USA
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children’s Research Institute, Little Rock, Arkansas, USA
| | - Charles R. Langelier
- Chan Zuckerberg Biohub, San Francisco, California, USA
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
47
|
Bohnhoff JC, Xue L, Hollander MAG, Burgette JM, Cole ES, Ray KN, Donohue J, Roberts ET. Healthcare Utilization Among Children Receiving Permanent Supportive Housing. Pediatrics 2023; 151:e2022059833. [PMID: 36974602 PMCID: PMC10071430 DOI: 10.1542/peds.2022-059833] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Permanent supportive housing (PSH) integrates long-term housing and supports for families and individuals experiencing homelessness. Although PSH is frequently provided to families with children, little is known about the impacts of PSH among children. We examined changes in health care visits among children receiving PSH compared with similar children who did not receive PSH. METHODS We analyzed Pennsylvania Medicaid administrative data for children entering PSH between 2011 and 2016, matching to a comparison cohort with similar demographic and clinical characteristics who received non-PSH housing services. We conducted propensity score-weighted difference-in-differences (DID) analyses to compare changes in health care visits 3 years before and after children entered PSH versus changes in the comparison cohort. RESULTS We matched 705 children receiving PSH to 3141 in the comparison cohort. Over 3 years following PSH entry, dental visits among children entering PSH increased differentially relative to the comparison cohort (DID: 12.70 visits per 1000 person-months, 95% confidence interval: 3.72 to 21.67). We did not find differential changes in preventive medicine visits, hospitalizations, or emergency department (ED) visits overall. When stratified by age, children ≤5 years old at PSH entry experienced a greater decrease in ED visits relative to the comparison cohort (DID: -13.16 visits per 1000 person-months, 95% confidence interval: -26.23 to -0.10). However, emergency visit trends before PSH entry differed between the cohorts. CONCLUSIONS Children in PSH had relatively greater increases in dental visits, and younger children entering PSH may have experienced relative reductions in ED visits. Policymakers should consider benefits to children when evaluating the overall value of PSH.
Collapse
Affiliation(s)
- James C. Bohnhoff
- Schools of Medicine
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lingshu Xue
- Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Evan S. Cole
- Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kristin N. Ray
- Schools of Medicine
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Julie Donohue
- Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eric T. Roberts
- Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
48
|
Robinson C, Chanchlani R, Gayowsky A, Brar S, Darling E, Demers C, Mondal T, Parekh R, Seow H, Batthish M. Cardiovascular outcomes in children with Kawasaki disease: a population-based cohort study. Pediatr Res 2023; 93:1267-1275. [PMID: 36380069 DOI: 10.1038/s41390-022-02391-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 10/05/2022] [Accepted: 10/26/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND The risk of cardiovascular events after Kawasaki disease (KD) remains uncertain. Our objective was to determine the risk of cardiovascular events and mortality after KD. METHODS Population-based retrospective cohort study using Ontario health administrative databases (0-18 years; 1995-2018). EXPOSURE pediatric KD hospitalizations. Each case was matched to 100 non-exposed controls. PRIMARY OUTCOME major adverse cardiac events (MACE; cardiovascular death, myocardial infarction, or stroke composite). SECONDARY OUTCOMES composite cardiovascular events and mortality. We determined incidence rates and adjusted hazard ratios (aHR) using multivariable Cox models. RESULTS Among 4597 KD survivors, 79 (1.7%) experienced MACE, 632 (13.8%) composite cardiovascular events, and 9 (0.2%) died during 11-year median follow-up. The most frequent cardiovascular events among KD survivors were ischemic heart disease (4.6 events/1000 person-years) and arrhythmias (4.5/1000 person-years). KD survivors were at increased risk of MACE between 0-1 and 5-10 years, and composite cardiovascular events at all time periods post-discharge. KD survivors had a lower mortality risk throughout follow-up (aHR 0.36, 95% CI 0.19-0.70). CONCLUSION KD survivors are at increased risk of post-discharge cardiovascular events but have a lower risk of death, which justifies enhanced cardiovascular disease surveillance in these patients. IMPACT Among 4597 Kawasaki disease (KD) survivors, 79 (1.7%) experienced major adverse cardiac events (MACE) and 632 (13.8%) had composite cardiovascular events during 11-year median follow-up. KD survivors had significantly higher risks of post-discharge MACE and cardiovascular events versus non-exposed children. Only nine KD survivors (0.2%) died during follow-up, and the risk of mortality was significantly lower among KD survivors versus non-exposed children. Childhood KD survivors should receive preventative counseling and cardiovascular surveillance, aiming to mitigate adult cardiovascular disease.
Collapse
Affiliation(s)
- Cal Robinson
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Division of Nephrology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Rahul Chanchlani
- Division of Nephrology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- ICES McMaster, Hamilton, ON, Canada
| | | | - Sandeep Brar
- Department of Epidemiology & Biostatistics, University of California, San Francisco, CA, USA
| | - Elizabeth Darling
- McMaster Midwifery Research Centre, McMaster University, Hamilton, ON, Canada
| | - Catherine Demers
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Tapas Mondal
- Division of Cardiology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Rulan Parekh
- Division of Nephrology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Michelle Batthish
- Division of Rheumatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada.
| |
Collapse
|
49
|
Lion KC, Zhou C, Fishman P, Senturia K, Cole A, Sherr K, Opel DJ, Stout J, Hazim CE, Warren L, Rains BH, Lewis CC. A sequential, multiple assignment randomized trial comparing web-based education to mobile video interpreter access for improving provider interpreter use in primary care clinics: the mVOCAL hybrid type 3 study protocol. Implement Sci 2023; 18:8. [PMID: 36915138 PMCID: PMC10012737 DOI: 10.1186/s13012-023-01263-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 02/12/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Individuals who use a language other than English for medical care are at risk for disparities related to healthcare safety, patient-centered care, and quality. Professional interpreter use decreases these disparities but remains underutilized, despite widespread access and legal mandates. In this study, we compare two discrete implementation strategies for improving interpreter use: (1) enhanced education targeting intrapersonal barriers to use delivered in a scalable format (interactive web-based educational modules) and (2) a strategy targeting system barriers to use in which mobile video interpreting is enabled on providers' own mobile devices. METHODS We will conduct a type 3 hybrid implementation-effectiveness study in 3-5 primary care organizations, using a sequential multiple assignment randomized trial (SMART) design. Our primary implementation outcome is interpreter use, calculated by matching clinic visits to interpreter invoices. Our secondary effectiveness outcome is patient comprehension, determined by comparing patient-reported to provider-documented visit diagnosis. Enrolled providers (n = 55) will be randomized to mobile video interpreting or educational modules, plus standard interpreter access. After 9 months, providers with high interpreter use will continue as assigned; those with lower use will be randomized to continue as before or add the alternative strategy. After another 9 months, both strategies will be available to enrolled providers for 9 more months. Providers will complete 2 surveys (beginning and end) and 3 in-depth interviews (beginning, middle, and end) to understand barriers to interpreter use, based on the Theoretical Domains Framework. Patients who use a language other than English will be surveyed (n = 648) and interviewed (n = 75) following visits with enrolled providers to understand their experiences with communication. Visits will be video recorded (n = 100) to assess fidelity to assigned strategies. We will explore strategy mechanism activation to refine causal pathway models using a quantitative plus qualitative approach. We will also determine the incremental cost-effectiveness of each implementation strategy from a healthcare organization perspective, using administrative and provider survey data. DISCUSSION Determining how these two scalable strategies, alone and in sequence, perform for improving interpreter use, the mechanisms by which they do so, and at what cost, will provide critical insights for addressing a persistent cause of healthcare disparities. TRIAL REGISTRATION NCT05591586.
Collapse
Affiliation(s)
- K Casey Lion
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, 98145-5005, USA.
| | - Chuan Zhou
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, 98145-5005, USA
| | - Paul Fishman
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Kirsten Senturia
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Allison Cole
- Department of Family Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Kenneth Sherr
- Department of Global Health, University of Washington Schools of Medicine and Public Health, Seattle, WA, USA
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA
- Department of Industrial & Systems Engineering, University of Washington, Seattle, WA, USA
| | - Douglas J Opel
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - James Stout
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Carmen E Hazim
- Department of Global Health, University of Washington Schools of Medicine and Public Health, Seattle, WA, USA
| | - Louise Warren
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Bonnie H Rains
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Cara C Lewis
- Department of Global Health, University of Washington Schools of Medicine and Public Health, Seattle, WA, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| |
Collapse
|
50
|
Choi SH, Choi JH, Lee JK, Eun BW, Song SH, Ahn B, Kim YK, Yun KW. Clinical Characteristics and Outcomes of Children With SARS-CoV-2 Infection During the Delta and Omicron Variant-Dominant Periods in Korea. J Korean Med Sci 2023; 38:e65. [PMID: 36880106 PMCID: PMC9988433 DOI: 10.3346/jkms.2023.38.e65] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/06/2022] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Data on the clinical characteristics of pediatric patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant infection are limited. We aimed to evaluate the clinical features and outcomes of children with SARS-CoV-2 infection before and after omicron variant dominance in Korea. METHODS A multicenter retrospective cohort study was conducted in hospitalized patients aged ≤ 18 years with laboratory-confirmed SARS-CoV-2 infection at five university hospitals in South Korea. The study periods were divided into the delta (from August 23, 2021 to January 2, 2022) and omicron (from January 30 to March 31, 2022). RESULTS In total, 612 hospitalized patients were identified (211, delta; 401, omicron). During the omicron and delta periods, the proportions of individuals with serious illness (moderate, severe, and critical severity) were 21.2% and 11.8%, respectively (P = 0.034). Compared with the delta period, the proportions of patients with moderate illness increased significantly in the age groups of 0-4 years (14.2% vs. 3.4%) and 5-11 years (18.6% vs. 4.2%) during the omicron period. During the two periods, the proportions of patients with complex chronic diseases (delta, 16.0% vs. 4.3%, P = 0.040; omicron, 27.1% vs. 12.7%; P = 0.002), respiratory diseases except for asthma (delta, 8.0% vs. 0.0%, P = 0.013; omicron, 9.4% vs. 1.6%; P = 0.001), and neurologic diseases (delta, 28.0% vs. 3.2%, P < 0.001; omicron, 40.0% vs. 5.1%, P < 0.001) were significantly higher in patients with serious illness than in those with non-serious illness. During the delta period, the risk for serious illness was higher among patients with obesity (adjusted odds ratio [aOR], 8.18; 95% confidence interval [CI], 2.80-27.36) and neurologic diseases (aOR, 39.43; 95% CI, 6.90-268.3) and aged 12-18 years (aOR, 3.92; 95% CI, 1.46-10.85). However, the presence of neurologic disease (aOR, 9.80; 95% CI, 4.50-22.57) was the only risk factor for serious illness during the omicron period. During the omicron period, the proportions of patients with croup (11.0% vs. 0.5%) and seizures (13.2% vs. 2.8%) increased significantly compared with the delta period. CONCLUSION Compared with the delta period, the proportions of young children and patients with complex comorbidities were higher during the omicron period in Korea. Patients with complex chronic diseases, especially neurologic diseases, had a high risk of severe coronavirus disease 2019 in the two distinct variant-dominant periods.
Collapse
Affiliation(s)
- Soo-Han Choi
- Department of Pediatrics, Pusan National University School of Medicine, Busan, Korea
| | - Jae Hong Choi
- Department of Pediatrics, Jeju National University School of Medicine, Jeju, Korea
| | - Joon Kee Lee
- Department of Pediatrics, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Byung-Wook Eun
- Department of Pediatrics, Nowon Eulji University Hospital, Seoul, Korea
| | - Seung Ha Song
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Bin Ahn
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Ye Kyung Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Ki Wook Yun
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea.
| |
Collapse
|