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Rajan M, Abramson EL, Pinheiro LC, Kern LM. Association between Gaps in Care Coordination and Emergency Department Visits Among Children without Chronic Conditions or Special Needs. Matern Child Health J 2024; 28:1551-1558. [PMID: 38904902 DOI: 10.1007/s10995-024-03942-2] [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] [Accepted: 05/14/2024] [Indexed: 06/22/2024]
Abstract
OBJECTIVE Prior studies and have shown that gaps in care coordination (CC) increase the risk of emergency department (ED) visits among children with special healthcare needs. This study aims to determine if gaps in CC are associated with an increased risk of ED visits among children without special needs (non-CSHCN). STUDY DESIGN We conducted a cross-sectional study using the National Survey of Children's Health (2018-2019), representing children up to age 17. A "gap" in CC occurs if the adult proxy reported dissatisfaction with communication between providers or difficulty getting the help needed to coordinate care for the child. Using logistic regression models adjusting for age and sex, we measured the association between a gap in CC and 1 or more ED visits during the past 12 months overall and stratified by any special needs. Adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) were calculated. RESULTS Between 2018 and 2019, 15% of respondents reported a gap in CC and 19.4% of children had at least one ED visit. Among non-CSHCN, these rates were 11% and 17%. In this population, a gap in CC was independently associated with an increased odds of ED use (AOR: 2.14; 95% CI 1.82, 2.52). CONCLUSIONS FOR PRACTICE Self-reported gaps in ambulatory CC were associated with increased odds of ED visits even among non-CSHCN children with minor illnesses, suggesting that providers need to be aware of potential pitfalls in CC for all children, and ensure that pertinent information is available where needed.
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Affiliation(s)
- Mangala Rajan
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, Room LH-348, New York, NY, 10021, USA.
| | - Erika L Abramson
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, Room LH-348, New York, NY, 10021, USA
| | - Laura C Pinheiro
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, Room LH-348, New York, NY, 10021, USA
| | - Lisa M Kern
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, Room LH-348, New York, NY, 10021, USA
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Porterfield L, Yu X, Warren V, Bowen ME, Smith-Morris C, Vaughan EM. A community health worker led diabetes self-management education program: Reducing patient and system burden. J Diabetes Complications 2024; 38:108794. [PMID: 38878424 DOI: 10.1016/j.jdiacomp.2024.108794] [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: 04/01/2024] [Revised: 05/02/2024] [Accepted: 06/09/2024] [Indexed: 07/12/2024]
Abstract
AIMS Conduct a secondary analysis of the TIME (Telehealth-supported, Integrated Community Health Workers (CHWs), Medication access, diabetes Education) made simple trial (SIMPLE) to evaluate healthcare utilization and explore variables that may have influenced HbA1c. METHODS Participants (N = 134 [67/group]) were low-income, uninsured Hispanics with or at risk for type 2 diabetes mellitus. We included in-person and telehealth clinician visits, other visits, missed visits, orders placed, and guideline-adherence (e.g., vaccinations, quarterly HbA1c for uncontrolled diabetes). Using multivariable models, we explored for associations between HbA1c changes and these measures. RESULTS The control arm had higher missed visits rates (intervention: 45 %; control: 56 %; p = 0.007) and missed telehealth appointments (intervention: 10 %; control: 27.4 %; p = 0.04). The intervention group received more COVID vaccinations than the control (p = 0.005). Other health measures were non-significant between groups. Intervention individuals' HbA1c improved with more missed visits (-0.60 %; p < 0.01) and worsened with improved guideline-adherent HbA1c measurements (HbA1c: 1.2 %; p = 0.057). The control group had non-significant HbA1c associations. CONCLUSIONS Findings suggest that the SIMPLE trial's improved HbA1c levels stemmed from a CHW-driven intervention and not additional healthcare contact. Exploratory outcomes resulted in seemingly counterintuitive HbA1c associations with missed visits and guideline-adherent measurements; these may suggest that an intervention that enhances communication provides support to reduce the amount of follow-up needed by participants without sacrificing clinical improvements.
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Affiliation(s)
- Laura Porterfield
- Department of Family Medicine, University of Texas Medical Branch, Galveston, TX, United States; Sealy Institute for Vaccine Scienes, University of Texas Medical Branch, Galveston, TX, United States
| | - Xiaoying Yu
- Department of Biostatistics, University of Texas Medical Branch, Galveston, TX, United States
| | - Victoria Warren
- Department of Health and Human Services; University of Houston, Houston, TX, United States
| | - Michael E Bowen
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, United States; Peter O'Donnell Jr. School of Public Health, Univeristy of Texas Southwestern, Dallas, TX, United States
| | - Carolyn Smith-Morris
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, United States
| | - Elizabeth M Vaughan
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States; Department of Medicine, Baylor College of Medicine, Houston, TX, United States.
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3
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Nummedal MA, King S, Uleberg O, Pedersen SA, Bjørnsen LP. Non-emergency department (ED) interventions to reduce ED utilization: a scoping review. BMC Emerg Med 2024; 24:117. [PMID: 38997631 PMCID: PMC11242019 DOI: 10.1186/s12873-024-01028-4] [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: 08/25/2023] [Accepted: 06/20/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Emergency department (ED) crowding is a global burden. Interventions to reduce ED utilization have been widely discussed in the literature, but previous reviews have mainly focused on specific interventions or patient groups within the EDs. The purpose of this scoping review was to identify, summarize, and categorize the various types of non-ED-based interventions designed to reduce unnecessary visits to EDs. METHODS This scoping review followed the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive structured literature search was performed in the databases MEDLINE and Embase from 2008 to March 2024. The inclusion criteria covered studies reporting on interventions outside the ED that aimed to reduce ED visits. Two reviewers independently screened the records and categorized the included articles by intervention type, location, and population. RESULTS Among the 15,324 screened records, we included 210 studies, comprising 183 intervention studies and 27 systematic reviews. In the primary studies, care coordination/case management or other care programs were the most commonly examined out of 15 different intervention categories. The majority of interventions took place in clinics or medical centers, in patients' homes, followed by hospitals and primary care settings - and targeted patients with specific medical conditions. CONCLUSION A large number of studies have been published investigating interventions to mitigate the influx of patients to EDs. Many of these targeted patients with specific medical conditions, frequent users and high-risk patients. Further research is needed to address other high prevalent groups in the ED - including older adults and mental health patients (who are ill but may not need the ED). There is also room for further research on new interventions to reduce ED utilization in low-acuity patients and in the general patient population.
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Affiliation(s)
- Målfrid A Nummedal
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Sarah King
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Oddvar Uleberg
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Sindre A Pedersen
- The Medicine and Health Library, Library Section for Research Support, Data and Analysis, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Lars Petter Bjørnsen
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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deJong N, Zhang X, Kappelman M. Prevalence of Preceding and Follow-up Outpatient Care Surrounding Emergency Department Visits for Pediatric Inflammatory Bowel Disease: Identifying Opportunities for Quality Improvement. Am J Gastroenterol 2024:00000434-990000000-01228. [PMID: 39051825 DOI: 10.14309/ajg.0000000000002936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 06/12/2024] [Indexed: 07/27/2024]
Abstract
INTRODUCTION To assess prevalence of outpatient care received before and after emergency department (ED) visits for pediatric patients with inflammatory bowel disease (IBD). METHODS Using commercial claims, we identified patients 2-18 years old with IBD and a related ED visit (2015-2018). We identified outpatient visits in 2 weeks before and after ED visits, then used logistic regression to assess relationships between care received and patient characteristics. RESULTS Forty-one percent received care in 2 weeks before an IBD-related ED visit and 51% in 2 weeks after. High-risk medications and outpatient continuity were associated with higher odds of outpatient care. DISCUSSION Gaps in preceding and follow-up care signal opportunities to improve care quality.
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Affiliation(s)
- Neal deJong
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Xian Zhang
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael Kappelman
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Porterfield L, Ram M, Kuo YF, Gaither ZM, O'Connell KP, Roy K, Bhardwaj N, Fingado E. Disparities in the Timeliness of Addressing Patient-Initiated Telephone Calls in a Primary Care Clinic: The Impact of Quality Improvement Interventions. HEALTH COMMUNICATION 2024:1-9. [PMID: 38567512 DOI: 10.1080/10410236.2024.2335056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
A timely response to patient-initiated telephone calls can affect many aspects of patient health, including quality of care and health equity. Historically, at a family medicine residency clinic, at least 1 out of 4 patient calls remained unresolved three days after the call was placed. We sought to explore whether there were differential delays in resolution of patient concerns for certain groups and how these were affected by quality improvement interventions to increase responsiveness to patient calls. A multidisciplinary team at a primary care residency clinic applied Lean education and tools to improve the timeliness of addressing telephone encounters. Telephone encounter data were obtained for one year before and nine months after the intervention. Data were stratified by race, ethnicity, preferred language, sex, online portal activation status, age category, zip code, patient risk category, and reason for call. Stratified data revealed consistently worse performance on telephone encounter closure by 72 hours for Black/African American patients compared to Hispanic and non-Hispanic White patients pre-intervention. Interventions resulted in statistically significant overall improvement, with an OR of 2.9 (95% CI: 2.62 to 3.21). Though interventions did not target a specific population, pre-intervention differences based on race and ethnicity resolved post-intervention. Telephone calls serve as an important means of patient communication with care teams. General interventions to improve the timeliness of addressing telephone encounters can lead to sustainable improvement in a primary care academic clinic and may also alleviate disparities.
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Affiliation(s)
| | - Mythili Ram
- System Optimization & Performance, University of Texas Medical Branch
| | - Yong Fang Kuo
- Department of Biostatistics and Data Science, University of Texas Medical Branch
| | - Zanita M Gaither
- Department of Family Medicine, University of Texas Medical Branch
| | | | - Khushali Roy
- School of Medicine, University of Texas Medical Branch
| | - Namita Bhardwaj
- Department of Family Medicine, University of Texas Medical Branch
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch
| | - Elizabeth Fingado
- System Optimization & Performance, University of Texas Medical Branch
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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.
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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
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Sidra M, Pietrosanu M, Ohinmaa A, Zwicker J, Round J, Johnson DW. Clinical and Socioeconomic Associations With Hospital Days and Emergency Department Visits Among Medically Complex Children: A Retrospective Cohort Study. Hosp Pediatr 2024; 14:93-101. [PMID: 38204352 DOI: 10.1542/hpeds.2023-007457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
OBJECTIVES To estimate associations between clinical and socioeconomic variables and hospital days and emergency department (ED) visits for children with medical complexity (CMCs) for 5 years after index admission. METHODS Retrospective, longitudinal, population-based cohort study of CMCs in Alberta (n = 12 621) diagnosed between 2010 and 2013 using administrative data linked to socioeconomic data. The primary outcomes were annual cumulative numbers of hospital days and ED visits for 5 years after index admission. Data were analyzed using mixed-effect hurdle regression. RESULTS Among CMCs utilizing resources, those with more chronic medications had more hospital days (relative difference [RD] 3.331 for ≥5 vs 0 medications in year 1, SE 0.347, P value < .001) and ED visits (RD 1.836 for 0 vs ≥5 medications in year 1, SE 0.133, P value < .001). Among these CMCs, initial length of stay had significant, positive associations with hospital days (RD 1.960-5.097, SE 0.161-0.610, P value < .001 outside of the gastrointestinal and hematology and immunodeficiency groups). Those residing in rural or remote areas had more ED visits than those in urban or metropolitan locations (RD 1.727 for rural versus urban, SE 0.075, P < .001). Material and social deprivation had significant, positive associations with number of ED visits. CONCLUSIONS Clinical factors are more strongly associated with hospitalizations and socioeconomic factors with ED visits. Policy administrators and researchers aiming to optimize resource use and improve outcomes for CMCs should consider interventions that include both clinical care and socioeconomic support.
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Affiliation(s)
- Michael Sidra
- School of Public Health, University of Alberta, Edmonton, Alberta
| | - Matthew Pietrosanu
- Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, Canada
| | - Arto Ohinmaa
- School of Public Health, University of Alberta, Edmonton, Alberta
| | | | - Jeff Round
- School of Public Health, University of Alberta, Edmonton, Alberta
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Rajan M, Pinheiro LC, Abramson EL, Kern LM. Adverse Social Determinants of Health and Gaps in Care Coordination Among Children. J Ambul Care Manage 2024; 47:3-13. [PMID: 37994509 DOI: 10.1097/jac.0000000000000481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
Gaps in care coordination (CC) can have detrimental impacts on children's health. It is unclear how much adverse social determinants of health (SDoH) may affect CC gaps. We determined whether exposure to adverse SDoH is associated with experiencing more gaps in CC using a representative national sample of children. Children with inadequate or no health insurance (adjusted odds ratio [aOR] = 2.41; 95% confidence interval [CI], 2.19-2.66) and living in disadvantaged neighborhoods (aOR = 1.53; 95% CI, 1.33-1.75) have a higher likelihood of having gaps in CC, as do those with higher counts of adverse SDoH (aOR = 2.17; 95% CI, 1.85-2.53). Thus, interventions to improve CC for children should consider adverse SDoH.
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Pulcini CD, Coller RJ, Houtrow AJ, Belardo Z, Zorc JJ. Further Developments in Preventing Emergency Department Visits for Children with Medical Complexity. Acad Pediatr 2024; 24:10-12. [PMID: 37714426 PMCID: PMC10843297 DOI: 10.1016/j.acap.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/28/2023] [Accepted: 09/08/2023] [Indexed: 09/17/2023]
Affiliation(s)
- Christian D Pulcini
- University of Vermont (CD Pulcini), Department of Emergency Medicine & Pediatrics, Burlington, Vt.
| | - Ryan J Coller
- Department of Pediatrics (RJ Coller), University of Wisconsin-Madison
| | - Amy J Houtrow
- Department of Physical Medicine and Rehabilitation (AJ Houtrow), University of Pittsburgh, Pittsburgh, Pa
| | - Zoe Belardo
- University of Pennsylvania (Z Belardo), Philadelphia, Pa
| | - Joseph J Zorc
- Children's Hospital of Philadelphia (JJ Zorc), Division of Emergency Medicine, Philadelphia, Pa
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Babayan K, Keilty K, Esufali J, Grajales Iii FJ. An After-Hours Virtual Care Service for Children With Medical Complexity and New Medical Technology: Mixed Methods Feasibility Study. JMIR Pediatr Parent 2023; 6:e41393. [PMID: 37938869 PMCID: PMC10666005 DOI: 10.2196/41393] [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: 07/24/2022] [Revised: 01/11/2023] [Accepted: 03/04/2023] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND Family caregivers (FCs) of children with medical complexity require specialized support to promote the safe management of new medical technologies (eg, gastrostomy tubes) during hospital-to-home transitions. With limited after-hours services available to families in home and community care, medical device complications that arise often lead to increased FC stress and unplanned emergency department (ED) visits. To improve FC experiences, enable safer patient discharge, and reduce after-hours ED visits, this study explores the feasibility of piloting a 24/7 virtual care service (Connected Care Live) with families to provide real-time support by clinicians expert in the use of pediatric home care technologies. OBJECTIVE This study aims to establish the economic, operational, and technical feasibility of piloting the expansion of an existing nurse-led after-hours virtual care service offered to home and community care providers to FCs of children with newly inserted medical devices after hospital discharge at Toronto's Hospital for Sick Children (SickKids). METHODS This exploratory study, conducted from October 2020 to August 2021, used mixed data sources to inform service expansion feasibility. Semistructured interviews were conducted with FCs, nurses, and hospital leadership to assess the risks, benefits, and technical and operational requirements for sustainable and cost-effective future service operations. Time and travel savings were estimated using ED visit data in SickKids' electronic medical records (Epic) with a chief complaint of "medical device problems," after-hours medical device inquiries from clinician emails and voicemails, and existing service operational data. RESULTS A total of 30 stakeholders were interviewed and voiced the need for the proposed service. Safer and more timely management of medical device complications, improved caregiver and provider experiences, and strengthened partnerships were identified as expected benefits, while service demand, nursing practice, and privacy and security were identified as potential risks. A total of 47 inquiries were recorded over 2 weeks from March 26, 2021, to April 8, 2021, with 51% (24/47) assessed as manageable via service expansion. This study forecasted annual time and travel savings of 558 hours for SickKids and 904 hours and 22,740 km for families. Minimal technical and operational requirements were needed to support service expansion by leveraging an existing platform and clinical staff. Of the 212 ED visits related to "medical device problems" over 6 months from September 1, 2020, to February 28, 2021, enteral feeding tubes accounted for nearly two-thirds (n=137, 64.6%), with 41.6% (57/137) assessed as virtually manageable. CONCLUSIONS Our findings indicate that it is feasible to pilot the expansion of Connected Care Live to FCs of children with newly inserted enteral feeding tubes. This nurse-led virtual caregiver service is a promising tool to promote safe hospital-to-home transitions, improve FC experiences, and reduce after-hours ED visits.
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Affiliation(s)
- Katherine Babayan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Krista Keilty
- Connected Care Program, Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Studies, SickKids Research Institute, Toronto, ON, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Jessica Esufali
- Connected Care Program, Hospital for Sick Children, Toronto, ON, Canada
| | - Francisco J Grajales Iii
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Glick AF, Farkas JS, Magro J, Shah AV, Taye M, Zavodovsky V, Rodriguez RH, Modi AC, Dreyer BP, Famiglietti H, Yin HS. Management of Discharge Instructions for Children With Medical Complexity: A Systematic Review. Pediatrics 2023; 152:e2023061572. [PMID: 37846504 PMCID: PMC10598634 DOI: 10.1542/peds.2023-061572] [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: 07/25/2023] [Indexed: 10/18/2023] Open
Abstract
CONTEXT Children with medical complexity (CMC) are at risk for adverse outcomes after discharge. Difficulties with comprehension of and adherence to discharge instructions contribute to these errors. Comprehensive reviews of patient-, caregiver-, provider-, and system-level characteristics and interventions associated with discharge instruction comprehension and adherence for CMC are lacking. OBJECTIVE To systematically review the literature related to factors associated with comprehension of and adherence to discharge instructions for CMC. DATA SOURCES PubMed/Medline, Embase, Cochrane Central Register of Controlled Trials, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, Web of Science (database initiation until March 2023), and OAIster (gray literature) were searched. STUDY SELECTION Original studies examining caregiver comprehension of and adherence to discharge instructions for CMC (Patient Medical Complexity Algorithm) were evaluated. DATA EXTRACTION Two authors independently screened titles/abstracts and reviewed full-text articles. Two authors extracted data related to study characteristics, methodology, subjects, and results. RESULTS Fifty-one studies were included. More than half were qualitative or mixed methods studies. Few interventional studies examined objective outcomes. More than half of studies examined instructions for equipment (eg, tracheostomies). Common issues related to access, care coordination, and stress/anxiety. Facilitators included accounting for family context and using health literacy-informed strategies. LIMITATIONS No randomized trials met inclusion criteria. Several groups (eg, oncologic diagnoses, NICU patients) were not examined in this review. CONCLUSIONS Multiple factors affect comprehension of and adherence to discharge instructions for CMC. Several areas (eg, appointments, feeding tubes) were understudied. Future work should focus on design of interventions to optimize transitions.
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Affiliation(s)
| | | | - Juliana Magro
- Health Sciences Libraries, NYU Langone Health, New York, New York
| | | | | | | | | | - Avani C. Modi
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | | | - H. Shonna Yin
- Department of Pediatrics
- Department of Population Health, NYU Langone Health, New York, New York
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Huth K, Hotz A, Emara N, Robertson B, Leaversuch M, Mercer AN, Khan A, Campos ML, Liss I, Hahn PD, Graham DA, Rossi L, Thomas MV, Elias N, Morris M, Glader L, Pinkham A, Bardsley KM, Wells S, Rogers J, Berry JG, Mauskar S, Starmer AJ. Reduced Postdischarge Incidents After Implementation of a Hospital-to-Home Transition Intervention for Children With Medical Complexity. J Patient Saf 2023; 19:493-500. [PMID: 37729645 DOI: 10.1097/pts.0000000000001155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
OBJECTIVES Prior research suggests that errors occur frequently for patients with medical complexity during the hospital-to-home transition. Less is known about effective postdischarge communication strategies for this population. We aimed to assess rates of 30-day (1) postdischarge incidents and (2) readmissions and emergency department (ED) visits before and after implementing a hospital-to-home intervention. METHODS We conducted a prospective intervention study of children with medical complexity discharged at a children's hospital from April 2018 to March 2020. A multistakeholder team developed a bundled intervention incorporating the I-PASS handoff framework including a postdischarge telephone call, restructured discharge summary, and handoff communication to outpatient providers. The primary outcome measure was rate of postdischarge incidents collected via electronic medical record review and family surveys. Secondary outcomes were 30-day readmissions and ED visits. RESULTS There were 199 total incidents and the most common were medication related (60%), equipment issues (15%), and delays in scheduling/provision of services (11%). The I-PASS intervention was associated with a 36.4% decrease in the rate of incidents per discharge (1.51 versus 0.95, P = 0.003). There were fewer nonharmful errors and quality issues after intervention (1.27 versus 0.85 per discharge, P = 0.02). The 30-day ED visit rate was significantly lower after intervention (12.6% versus 3.4%, per 100 discharges, P = 0.05). Thirty-day readmissions were 15.8% versus 10.2% postintervention (P = 0.32). CONCLUSIONS A postdischarge communication intervention for patients with medical complexity was associated with fewer postdischarge incidents and reduced 30-day ED visits. Standardized postdischarge communication may play an important role in improving quality and safety in the transition from hospital-to-home for vulnerable populations.
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Affiliation(s)
| | | | - Norah Emara
- From the Department of Pediatrics, Boston Children's Hospital
| | | | | | | | | | | | - Isabella Liss
- From the Department of Pediatrics, Boston Children's Hospital
| | - Phillip D Hahn
- Program for Patient Safety and Quality, Boston Children's Hospital
| | | | | | - Margaret V Thomas
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Nahel Elias
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Marie Morris
- From the Department of Pediatrics, Boston Children's Hospital
| | - Laurie Glader
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Amy Pinkham
- From the Department of Pediatrics, Boston Children's Hospital
| | | | - Sarah Wells
- From the Department of Pediatrics, Boston Children's Hospital
| | - Jayne Rogers
- From the Department of Pediatrics, Boston Children's Hospital
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13
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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.
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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
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14
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Variations in Emergency Service Utilization among Cancer Survivors: Results from the Pan-Canadian Experiences of Cancer Patients in Transition Study Survey. JOURNAL OF ONCOLOGY 2023; 2023:5056408. [PMID: 36968642 PMCID: PMC10036192 DOI: 10.1155/2023/5056408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/04/2023] [Accepted: 03/07/2023] [Indexed: 03/18/2023]
Abstract
Purpose. The objective of this study was to examine variations in emergency service utilization (ESU) among cancer survivors during the first year after completing primary cancer treatment. Methods. In 2016, the Canadian Partnership Against Cancer collected survey responses from cancer survivors across Canada about self-reported ESU after completing primary cancer treatment. We included survey respondents diagnosed with nonmetastatic breast, hematologic, colorectal, melanoma, or prostate cancer. Multivariable, multinomial logistic regression analysis was used to examine factors associated with cancer survivors’ ESU. Results. Of the 5,774 cancer survivors included in our analysis, 22% reported ESU during the first year after completing their primary cancer treatment, 16% reported ESU one to three times, and 6% reported ESU more than three times. Factors significantly associated with frequent ESU included younger age, colorectal and hematologic cancers, more frequent primary care provider and oncology specialist visits, single or retired status, lower income, and self-reported lower quality of life. Conclusion. Our study identified factors associated with more frequent ESU among cancer survivors in the first year after completing primary cancer treatment. These factors highlight differences in cancer survivors’ demographics, their ability to access and need for healthcare services, and the complexity of using ESU as a metric for quality improvement in survivorship care. These variations must be considered in quality improvement initiatives.
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15
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Garrity BM, Perrin JM, Rodean J, Houtrow AJ, Shelton C, Stille C, McLellan S, Coleman C, Mann M, Kuhlthau K, Desmarais A, Berry JG. Annual Days With a Health Care Encounter for Children and Youth Enrolled in Medicaid: A Multistate Analysis. Acad Pediatr 2023; 23:441-447. [PMID: 35863733 DOI: 10.1016/j.acap.2022.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 07/03/2022] [Accepted: 07/07/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To assess the number of days that children experienced a health care encounter and associations between chronic condition types and health care encounters. METHODS Retrospective analysis of data from 5,082,231 children ages 0 to 18 years enrolled in Medicaid during 2017 in 12 US states contained in the IBM Watson Marketscan Medicaid Database. We counted and categorized enrollees' encounter days, defined as unique days a child had a health care visit, by type of health service. We used International Classification of Disease-10 diagnosis code categories from Agency for Healthcare Research and Quality's Chronic Condition Indicator System to identify chronic mental and physical health conditions. RESULTS Median (interquartile range [IQR]) annual encounter days was 6 (2-13). Children in the 91st to 98th and ≥99th percentiles for encounter days experienced a median of 49 (IQR 38-70) and 229 (IQR 181, 309) days, respectively; these children accounted for 52.6% of days for the cohort. As encounter days increased from the 25th to >90th percentile, the percentage of children with co-existing mental and physical health conditions increased from <0.1% to 47.4% (P < .001). Outpatient visits accounted for a total of 68.3% and 62.2% of days for children the 91st to 98th and ≥99th percentiles. CONCLUSION Ten percent of children enrolled in Medicaid averaged health care encounters at least 1 day per week; 1% experienced health care encounters on most weekdays. Further investigation is needed to understand how families perceive frequent health care encounters, including how to facilitate their children's care in the most feasible way.
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Affiliation(s)
- Brigid M Garrity
- Division of General Pediatrics, Boston Children's Hospital (BM Garrity, A Desmarais, and JG Berry), Boston, Mass.
| | - James M Perrin
- Division of General Academic Pediatrics, MassGeneral Hospital for Children (JM Perrin), Boston, Mass; Department of Pediatrics, Harvard Medical School (JM Perrin and JG Berry), Boston, Mass
| | | | - Amy J Houtrow
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh (AJ Houtrow), Pittsburgh, Pa
| | - Charlene Shelton
- School of Medicine, University of Colorado Anschutz Medical Campus (C Shelton and C Stille), Aurora, Colo
| | - Christopher Stille
- School of Medicine, University of Colorado Anschutz Medical Campus (C Shelton and C Stille), Aurora, Colo; General Academic Pediatrics, Children's Hospital Colorado (C Stille), Denver, Colo
| | - Sarah McLellan
- Health Resources and Services Administration, Maternal and Child Health Bureau (S McLellan), Rockville, Md
| | - Cara Coleman
- Family Voices National (C Coleman), Washington, DC
| | - Marie Mann
- Health Resources and Services Administration (M Mann), Rockville, Md
| | - Karen Kuhlthau
- Division of General Academic Pediatrics, Department of Pediatrics, MassGeneral Hospital for Children, Harvard Medical School (K Kuhlthau), Boston, Mass
| | - Anna Desmarais
- Division of General Pediatrics, Boston Children's Hospital (BM Garrity, A Desmarais, and JG Berry), Boston, Mass
| | - Jay G Berry
- Division of General Pediatrics, Boston Children's Hospital (BM Garrity, A Desmarais, and JG Berry), Boston, Mass; Department of Pediatrics, Harvard Medical School (JM Perrin and JG Berry), Boston, Mass
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16
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Nkoy F, Stone B, Sheng X, Murphy N. High Parental Concern in Children With Medical Complexity: An Early Indicator of Illness. Hosp Pediatr 2023; 13:250-257. [PMID: 36720703 DOI: 10.1542/hpeds.2022-006876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES High concern about child's health is a common reason parents of children with medical complexity (CMC) seek care in emergency departments and hospitals. Factors driving parental concern are unknown. This study explores associations of parent's sociodemographic and child's clinical factors with high parental concern. PATIENT AND METHODS Secondary analysis of a pilot study of CMC and parents who used daily for 3 months MyChildCMC, a home monitoring app. Parents recorded their child's vital signs (temperature, heart rate, respiratory rate, oximetry), symptoms (pain, seizures, fluid intake/feeding, mental status), and oxygen use, and received immediate feedback. Parents rated their child's health concern on a 4-point Likert scale. Concern scores were dichotomized (3-4 = high, 1-2 = low) and modeled in a mixed-effects logistic regression to explore important associations. RESULTS We analyzed 1223 measurements from 24 CMC/parents, with 113 (9.24%) instances of high concern. Child factors associated with high parental concern were increased pain (odds ratio [OR], 5.10; 95% confidence interval [CI], 2.53-10.29; P < .01), increased oxygen requirement (OR, 28.91; 95% CI, 10.07-82.96; P < .01), reduced nutrition/fluid intake (OR, 71.58; 95% CI, 13.01-393.80; P < .01), and worsened mental status (OR, 2.15; 95% CI, 1.10-4.17, P = .02). No other associations existed. CONCLUSIONS Changes in CMC's clinical parameters were associated with high concern, which may be an early indicator of acute illness in CMC when it is the primary complaint. Monitoring and responding to high parental concerns may support CMC care at home.
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Affiliation(s)
- Flory Nkoy
- University of Utah, Department of Pediatrics, Salt Lake City, Utah
| | - Bryan Stone
- University of Utah, Department of Pediatrics, Salt Lake City, Utah
| | - Xiaoming Sheng
- University of Utah, Department of Pediatrics, Salt Lake City, Utah
| | - Nancy Murphy
- University of Utah, Department of Pediatrics, Salt Lake City, Utah
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17
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Gould MJ, Marcon MA, Nguyen GC, Benchimol EI, Moineddin R, Swayze S, Kopp A, Ratcliffe EM, Merritt N, Davidson J, Langer JC, Mistry N, Lorenzo AJ, Temple M, Walsh CM. Impact of antegrade enema initiation on healthcare utilization in pediatric patients: A population-based cohort study. Neurogastroenterol Motil 2023; 35:e14495. [PMID: 36377812 DOI: 10.1111/nmo.14495] [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: 04/30/2022] [Revised: 10/24/2022] [Accepted: 11/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND When constipation is refractory to first-line interventions, antegrade enema use may be considered. We aimed to assess the impact of this intervention on healthcare utilization. METHODS We conducted a population-based, quasi-experimental study with pre-post comparison of the intervention group and a non-equivalent control group using linked clinical and health administrative data from Ontario, Canada. Subjects included children (0-18 years) who underwent antegrade enema initiation from 2007 to 2020 and matched controls (4:1) from the general population. To assess the change in healthcare utilization following antegrade enema initiation, we used negative binomial generalized estimating equations with covariates selected a priori. KEY RESULTS One hundred thirty-eight subjects met eligibility criteria (appendicostomy = 55 (39.9%); cecostomy tube = 83 (60.1%)) and were matched to 550 controls. There was no significant difference in the change in the rate of hospitalizations (rate ratio (RR) 1.05, 95% confidence interval (CI) 0.35-1.75), outpatient visits (RR 1.05, 95% CI 0.91-1.18), or same-day surgical procedures (RR 1.51, 95% CI 0.60-2.43) across cases in 2 years following antegrade enema initiation compared with controls. Cases had an increased rate of emergency department (ED) visits, which was not observed in controls (RR 1.52, 95% CI 1.11-1.79), driven in part by device-related complications. CONCLUSIONS AND INFERENCES Understanding healthcare utilization patterns following antegrade enema initiation allows for effective health system planning and aids medical decision-making. The observed increase in ED visits for device-related complications speaks to the need to improve preventive management to help mitigate emergency care after initiation of antegrade enemas.
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Affiliation(s)
- Michelle J Gould
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Margaret A Marcon
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Geoffrey C Nguyen
- Division of Gastroenterology, Mount Sinai Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,ICES, Toronto, Canada
| | - Eric I Benchimol
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,ICES, Toronto, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, Division of Biostatistics, University of Toronto, Toronto, Canada
| | | | | | - Elyanne M Ratcliffe
- Division of Pediatric Gastroenterology and Nutrition, McMaster Children's Hospital, Hamilton, Canada.,Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Neil Merritt
- Division of Pediatric Surgery, London Health Sciences Center, London, Canada
| | - Jacob Davidson
- Division of Pediatric Surgery, London Health Sciences Center, London, Canada
| | - Jacob C Langer
- Division of General and Thoracic Surgery, Hospital for Sick Children, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Niraj Mistry
- Department of Paediatrics, University of Toronto, Toronto, Canada.,Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Canada
| | - Armando J Lorenzo
- Department of Surgery, University of Toronto, Toronto, Canada.,Division of Urology, Hospital for Sick Children, Toronto, Canada
| | - Michael Temple
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Catharine M Walsh
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,SickKids Research and Learning Institutes, Toronto, Canada
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18
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Hall JE, Pham PK, Liberman DB. Describing the Patient Population of a Pediatric Emergency Department Based on Visit Frequency. Pediatr Emerg Care 2022; 38:e1620-e1625. [PMID: 36173434 DOI: 10.1097/pec.0000000000002615] [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] [Indexed: 11/25/2022]
Abstract
OBJECTIVE A small number of children in the United States use a disproportionate share of emergency healthcare services. Our study objective was to examine characteristics associated with frequent pediatric emergency department (PED) utilization. METHODS A retrospective cohort-sequential study of patients seen in the PED of an urban children's hospital was conducted. Patients were categorized into 2 groups: infrequent users (<4 visits during index year 2017) and frequent users (≥4 visits in 2017). Frequent PED users were further divided into persistent frequent (≥4 visits in the year before and after 2017) and incidental frequent (≥4 visits in 2017). Patient- and visit-level characteristics were analyzed for associations with PED utilization. RESULTS In 2017, there were 82,361 visits by 56,767 patients to our PED. Frequent users comprised 4% of the total patient volume but accounted for 13% of visits. Compared with infrequent users, frequent users were younger, more likely publicly insured, and English speaking. Frequent user visits were more likely to occur outside clinic hours, be triaged as emergent, and involve subspecialists. Compared with visits by incidental frequent users, visits by persistent frequent users were more likely to be emergent or urgent, and involve subspecialists, diagnostic imaging, laboratory testing, and medication administration. CONCLUSIONS Although the percentage of frequent users to a PED in 2017 was low, they made up a disproportionate share of total visits. Differences between persistent and incidental frequent PED users suggest that these subgroups may benefit from tailored interventions to reduce frequent PED utilization.
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19
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Pulcini CD, Dubuque A, Lamberson M, Macy ML, Mistry RD, Pruitt CM, Schnadower D, Zorc JJ, Stevens MW. Pediatric Emergency Medicine Physicians' Perspectives on Emergency Care of Children With Medical Complexity: A Multi-institution Mixed-Methods Assessment. Pediatr Emerg Care 2022; 38:e1423-e1427. [PMID: 35436769 DOI: 10.1097/pec.0000000000002712] [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] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Children with medical complexity (CMC) compose 1% of the pediatric population but account for 20% of pediatric emergency department (ED) visits. Previous descriptions of challenges and interventions to ensure quality of care are limited. Our objective was to elicit pediatric emergency medicine (PEM) physicians' perspectives on challenges and opportunities for improvement of emergency care of CMC, with a focus on emergency information forms (EIFs). METHODS We conducted a web-based survey of PEM physicians participating the American Academy of Pediatrics Section on Emergency Medicine Survey listserv. The survey was designed using an expert panel, and subsequently piloted and revised to an 18-item survey. Data were analyzed with descriptive statistics. RESULTS One hundred fifty-one of 495 respondents (30%) completed the survey. Most respondents (62.9%) reported caring for >10 CMC per month. Whereas overall medical fragility and time constraints were major contributors to the challenges of caring for CMC in the ED, communication with known providers and shared care plans were identified as particularly helpful. Most respondents did not report routine use of EIFs. Anticipated emergencies/action plan was deemed the most important component of EIFs. CONCLUSIONS Most PEM physicians view the care for CMC in the ED as challenging despite practicing in high-resource environments. Further research is needed to develop and implement strategies to improve care of CMC in the ED. Understanding experiences of providers in general ED settings is also an important next step given that 80% of CMC present for emergency care outside of major children's hospitals.
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Affiliation(s)
- Christian D Pulcini
- From the Division of Emergency Medicine, Department of Surgery and Pediatrics
| | - Amy Dubuque
- Division of Emergency Medicine, Department of Surgery, University of Vermont Larner College of Medicine, Burlington, VT
| | - Miles Lamberson
- Division of Emergency Medicine, Department of Surgery, University of Vermont Larner College of Medicine, Burlington, VT
| | - Michelle L Macy
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | - David Schnadower
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Joseph J Zorc
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Martha W Stevens
- From the Division of Emergency Medicine, Department of Surgery and Pediatrics
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20
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Murphy Salem S, Chase B, Newman LR, Cohen AP, Cheston C, Huth K. Perspectives on Complex Care Training in a Large Academic Pediatric Training Program. Acad Pediatr 2022; 22:867-872. [PMID: 35306188 DOI: 10.1016/j.acap.2022.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/23/2022] [Accepted: 03/14/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To identify gaps and opportunities in complex care training for pediatric residents. METHODS Residents in an academic pediatric residency program were surveyed about: training experiences in complex care; self-entrustment in key clinical activities in complex care; educational strategies that would increase preparedness; and recommendations for curriculum development. We used descriptive statistics for quantitative data and content analysis for free-text responses. RESULTS Of the 160 residents surveyed, 110 (69%) participated. Most participants reported prior clinical exposure to children with medical complexity (CMC; 106, 96%) during both inpatient (82, 75%) and outpatient (88, 80%) clinical rotations. Mean self-entrustment was at or below "somewhat confident" for all clinical activities in complex care, for residents in all postgraduate years. Clinical activities with highest reported self-entrustment included evaluating aspiration into the airway, nutritional issues, care coordination, and evaluating pain. Lowest self-entrustment was reported for facilitating transition to adult care, managing medical technologies, and safety/emergency planning. In terms of educational strategies, participants recommended inpatient encounters with an expert preceptor teaching about evaluating aspiration, pain/irritability and dysmotility (>50%); discussions with patients/families for advocacy, difficult discussions, and transition to adult care (>40%); and hands-on practice for medical technology care (>40%). CONCLUSIONS Pediatric residents report limited self-entrustment in performing key clinical activities in complex care, including for residents at the end of their last postgraduate year. Future curriculum development should prioritize direct observation of clinical encounters with CMC by expert preceptors, partnership with patients and families of CMC, and hands-on simulation.
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Affiliation(s)
- Sinead Murphy Salem
- Department of Pediatrics (S Murphy Salem, B Chase, and Kathleen Huth), Boston Children's Hospital, Boston, Mass; Department of Pediatrics (S Murphy Salem, B Chase, and C Cheston), Boston Medical Center, Boston, Mass.
| | - Brenna Chase
- Department of Pediatrics (S Murphy Salem, B Chase, and Kathleen Huth), Boston Children's Hospital, Boston, Mass; Department of Pediatrics (S Murphy Salem, B Chase, and C Cheston), Boston Medical Center, Boston, Mass
| | - Lori R Newman
- Department of Education (LR Newman), Boston Children's Hospital, Boston, Mass
| | - Amy P Cohen
- Department of Health Policy and Management (AP Cohen), Harvard Chan School of Public Health, Boston, Mass
| | - Christine Cheston
- Department of Pediatrics (S Murphy Salem, B Chase, and C Cheston), Boston Medical Center, Boston, Mass
| | - Kathleen Huth
- Department of Pediatrics (S Murphy Salem, B Chase, and Kathleen Huth), Boston Children's Hospital, Boston, Mass
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21
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Heneghan JA, Goodman DM, Ramgopal S. Demographic and Clinical Differences Between Applied Definitions of Medical Complexity. Hosp Pediatr 2022; 12:654-663. [PMID: 35652303 DOI: 10.1542/hpeds.2021-006432] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To identify the degree of concordance and characterize demographic and clinical differences between commonly used definitions of multisystem medical complexity in children hospitalized in children's hospitals. METHODS We conducted a retrospective, cross-sectional cohort study of children <21 years of age hospitalized at 47 US Pediatric Health Information System-participating children's hospitals between January 2017 to December 2019. We classified patients as having multisystem complexity when using 3 definitions of medical complexity (pediatric complex chronic conditions, pediatric medical complexity algorithm, and pediatric chronic critical illness) and assessed their overlap. We compared demographic, clinical, outcome, cost characteristics, and longitudinal healthcare utilization for each grouping. RESULTS Nearly one-fourth (23.5%) of children hospitalized at Pediatric Health Information System-participating institutions were identified as meeting at least 1 definition of multisystem complexity. Children with multisystem complexity ranged from 1.0% to 22.1% of hospitalized children, depending on the definition, with 31.2% to 95.9% requiring an ICU stay during their index admission. Differences were seen in demographic, clinical, and resource utilization patterns across the definitions. Definitions of multisystem complexity demonstrated poor agreement (Fleiss' κ 0.21), with 3.5% of identified children meeting all 3. CONCLUSIONS Three definitions of multisystem complexity identified varied populations of children with complex medical needs, with poor overall agreement. Careful consideration is required when applying definitions of medical complexity in health services research, and their lack of concordance should result in caution in the interpretation of research using differing definitions of medical complexity.
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Affiliation(s)
- Julia A Heneghan
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
| | | | - Sriram Ramgopal
- Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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22
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Agreement of the Neonatal Pain, Agitation, and Sedation Scale (N-PASS) With NICU Nurses' Assessments. Adv Neonatal Care 2022; 23:173-181. [PMID: 35362716 DOI: 10.1097/anc.0000000000000968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Objective assessment tools should standardize and reflect nurses' expert assessments. The Neonatal Pain, Agitation, and Sedation Scale (N-PASS) and the Neonatal Infant Pain Scale (NIPS) are valid measures of pain. The N-PASS also provides a sedation subscale. PURPOSE The objective of this study was to determine N-PASS clinical validity and utility by evaluating agreement of N-PASS scores with bedside nurses' assessments of pain/agitation and sedation in a 64-bed tertiary neonatal intensive care unit. METHODS Fifteen bedside nurses trained to use the N-PASS and the NIPS prospectively completed 202 pain/agitation and sedation assessments from a convenience sample of 88 infants, including chronically ventilated, medically fragile infants. N-PASS and NIPS scores were obtained simultaneously but independently of nurse investigators. Bedside nurses also made recommendations about infants' pain and sedation management. RESULTS There was moderate agreement between N-PASS pain scores and nurses' recommendations (κ= 0.52), very strong agreement between N-PASS sedation scores and nurses' recommendations (κ= 0.99), and very strong associations between N-PASS pain and NIPS scores (P< .001). Bedside nurse and independent investigator interrater reliability was good for N-PASS pain and NIPS scores (intraclass correlation coefficient [ICC] = 0.83, ICC = 0.85) and excellent for N-PASS sedation (ICC = 0.94). During 93% of assessments, bedside nurses reported that the N-PASS reflected the level of infant sedation well or very well. IMPLICATIONS FOR PRACTICE AND RESEARCH The N-PASS provides an easy-to-use, valid, and reliable objective measure of pain and sedation that reflects nurses' assessments. Additional studies using the N-PASS are needed to verify results and the influence of the N-PASS on pain and sedation management for medically fragile infants with chronic medical conditions.
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The Association of the Childhood Opportunity Index on Pediatric Readmissions and Emergency Department Revisits. Acad Pediatr 2022; 22:614-621. [PMID: 34929386 PMCID: PMC9169565 DOI: 10.1016/j.acap.2021.12.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 12/07/2021] [Accepted: 12/13/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Reutilization following discharge is costly to families and the health care system. Singular measures of the social determinants of health (SDOH) have been shown to impact utilization; however, the SDOH are multifactorial. The Childhood Opportunity Index (COI) is a validated approach for comprehensive estimation of the SDOH. Using the COI, we aimed to describe the association between SDOH and 30-day revisit rates. METHODS This retrospective study included children 0 to 17 years within 48 children's hospitals using the Pediatric Health Information System from 1/1/2019 to 12/31/2019. The main exposure was a child's ZIP code level COI. The primary outcome was unplanned readmissions and emergency department (ED) revisits within 30 days of discharge. Primary outcomes were summarized by COI category and compared using chi-square or Kruskal-Wallis tests. Adjusted analysis used generalized linear mixed effects models with adjustments for demographics, clinical characteristics, and hospital clustering. RESULTS Of 728,997 hospitalizations meeting inclusion criteria, 30-day unplanned returns occurred for 96,007 children (13.2%). After adjustment, the patterns of returns were significantly associated with COI. For example, 30-day returns occurred for 19.1% (95% confidence interval [CI]: 18.2, 20.0) of children living within very low opportunity areas, with a gradient-like decrease as opportunity increased (15.5%, 95% CI: 14.5, 16.5 for very high). The relative decrease in utilization as COI increased was more pronounced for ED revisits. CONCLUSIONS Children living in low opportunity areas had greater 30-day readmissions and ED revisits. Our results suggest that a broader approach, including policy and system-level change, is needed to effectively reduce readmissions and ED revisits.
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