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Chen S, Anderson MP. Considerations in Complex Survey Data Sampling, Weighting, and Analysis for Pediatric Research. J Pediatr 2024; 273:114142. [PMID: 38871076 DOI: 10.1016/j.jpeds.2024.114142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 06/10/2024] [Indexed: 06/15/2024]
Affiliation(s)
- Sixia Chen
- Department of Biostatistics and Epidemiology, College of Public Health, The University of Oklahoma, Health Sciences Center, Oklahoma City, OK.
| | - Michael P Anderson
- Department of Biostatistics and Epidemiology, College of Public Health, The University of Oklahoma, Health Sciences Center, Oklahoma City, OK
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2
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Dewan T, Avinashi V, Beaudry P, Doré-Bergeron MJ, Gaucher N, Nelson K. Antireflux Procedures in Children With Neurologic Impairment: A National Survey of Physician Perspectives. Hosp Pediatr 2024; 14:413-420. [PMID: 38738287 DOI: 10.1542/hpeds.2023-007643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/22/2024] [Accepted: 02/01/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVE Decision-making about antireflux procedures (ARPs) to treat gastroesophageal reflux disease in children with neurologic impairment and gastrostomy tubes is challenging and likely influenced by physicians' experience and perspectives. This study will explore physician attitudes about ARPs and determine if there are relationships to clinical practice and personal characteristics. METHODS This is a national observational cross-sectional study that used an electronic questionnaire addressing reported practice, attitudes regarding the ARPs, and responses to clinical vignettes. Participants were physicians in Canadian tertiary-care pediatric settings. Descriptive statistics were used to analyze physician attitudes. Multivariable logistic regression modeling was used to determine associations between physician and practice characteristics and likelihood to consider ARP. RESULTS Eighty three respondents represented 12 institutions, with a majority from general or complex care pediatrics. There was a wide disparity between likelihood to consider ARP in each clinical scenario. Likelihood to consider ARP ranged from to 19% to 78% depending on the scenario. Two scenarios were equally split in whether the respondent would offer an ARP. None of the demographic characteristics were significantly associated with likelihood to consider ARP. Often, gastrojejunostomy tubes alone were considered (56% to 68%). CONCLUSIONS There is considerable variability in physician attitudes toward and recommendations regarding ARPs to treat gastroesophageal reflux disease. We did not find a significant association with clinical experience or location of practice. More research is needed to define indications and outcomes for ARPs. This is a scenario where shared decision-making, bringing together physician and family knowledge and expertise, is likely the best course of action.
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Affiliation(s)
| | - Vishal Avinashi
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Nathalie Gaucher
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Kate Nelson
- Department of Paediatrics, University of Toronto, Toronto, Ontario
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3
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Narayanan AM, Dabbous H, St John R, Kou YF, Johnson RF, Chorney SR. Pediatric tracheostomy audiometric outcomes - A quality improvement initiative. Int J Pediatr Otorhinolaryngol 2023; 173:111694. [PMID: 37625278 DOI: 10.1016/j.ijporl.2023.111694] [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: 05/05/2023] [Revised: 06/29/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVE Pediatric tracheostomy patients disproportionately experience hearing loss and are at risk for delayed identification due to their medical complexity. Nonetheless, protocols to monitor hearing in these children are lacking. This quality improvement (QI) initiative aimed to increase the rates of audiometric testing within 12 months of pediatric tracheostomy placement. METHODS A retrospective cohort study included children who underwent tracheostomy under 18 months of age between 2012 and 2020. Rates of audiometric assessments before and after QI project implementation (2015) were reported along with hearing loss characteristics. RESULTS A total of 253 children met inclusion. Before project initiation (2012-2014), 32% of children (28/87) obtained audiometric testing within 12 months after tracheostomy. During the first three years of implementation (2015-2017), 39% (38/97) were tested, while 55% (38/69) were tested during the subsequent three years (2018-2020) (P = .01). A passing newborn hearing screen was obtained for 70% of the 210 children with a recorded result, and 198 survived at least 12 months to receive audiometric testing at a median of 11.3 months (IQR: 6.2-22.8) after tracheostomy. Hearing loss was identified for 44% of children (N = 88), of which 42 children initially passed newborn hearing screen. A second assessment was obtained for 62% of children (123/198) at a median of 11.3 months (IQR: 4.5-17.5) after the initial test. In this group, 23% with a previously normal audiometric exam were found to have hearing loss (15/66). CONCLUSIONS QI initiatives designed to monitor hearing loss in children with a tracheostomy can result in improved rates of audiometric assessments. This population has disproportionately high rates of hearing loss, including delayed onset hearing loss making audiometric protocols valuable to address speech and language development delays.
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Affiliation(s)
- Ajay M Narayanan
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Helene Dabbous
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rachel St John
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, TX, USA
| | - Yann-Fuu Kou
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, TX, USA
| | - Romaine F Johnson
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, TX, USA
| | - Stephen R Chorney
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, TX, USA.
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4
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Elgen I, Lygre RB, Årli Å, Heggestad T. An interdisciplinary intervention for children with complex health complaints; a feasibility study of selection criteria. Front Pediatr 2023; 11:1167528. [PMID: 37780046 PMCID: PMC10536176 DOI: 10.3389/fped.2023.1167528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 09/01/2023] [Indexed: 10/03/2023] Open
Abstract
Background There is a need for re-designing the health service for children suffering from complex and compound health complaints. Based on a previous register study, we have developed criteria to select patients with complex health complaints eligible for an Intervention with an interdisciplinary professional team. The team consists of a pediatrician, a psychologist and a physiotherapist. Method To identify children with complex health complaints who would benefit from this intervention, we have selected a group of patients by using a set of criteria consisting of the following criteria: multi-referred young school age children referred to both mental health service and pediatric service. This study focuses on the feasibility of these criteria by measuring participation and compliance and by gathering feedback from the team members in the interdisciplinary team. Results Among 677 children aged 6-12 years referred to a regional hospital, we found 32 (5%) children eligible for the interdisciplinary Intervention according to the applied criteria. Only 6% of the invited parents declined to participate in the intervention. According to the interdisciplinary team, the intervention was found suitable for 88% of the children. Conclusion The suggested criteria seemed feasible, in terms of identifying eligible patients for this interdisciplinary Intervention for children with complex health complaints. Clinical Trial Registration Retrospectively registered on www.clinicaltrials.gov, ID NCT04652154, on the 3rd of December 2020.
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Affiliation(s)
- Irene Elgen
- Department of Child and Adolescent Psychiatry, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ragnhild B Lygre
- Department of Child and Adolescent Psychiatry, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ånen Årli
- Department of Child and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Torhild Heggestad
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
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5
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Jacobs S, Davies N, Butterick KL, Oswell JL, Siapka K, Smith CH. Shared decision-making for children with medical complexity in community health services: a scoping review. BMJ Paediatr Open 2023; 7:10.1136/bmjpo-2023-001866. [PMID: 37012004 PMCID: PMC10083859 DOI: 10.1136/bmjpo-2023-001866] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/02/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Children with medical complexity is an increasing population whose parents and healthcare providers face multiple decisions. Shared decision-making is a process where patients, their families and healthcare providers collaborate to make decisions based on clinical evidence and informed preferences of the family. Shared decision-making has benefits for the child, family and healthcare providers, including improved parental understanding of the child's difficulties, increased participation, improved coping skills and more efficient healthcare use. It is, however, poorly implemented. AIMS AND METHODS A scoping review was conducted to explore shared decision-making for children with medical complexity in community health services, including how shared decision-making is defined in research, how it is implemented, including barriers and facilitators and recommendations for research. Six databases were systematically searched for papers published in English up to May 2022: Medline, CINAHL, EMBASE, PsycINFO, PubMed, Cochrane Database of Systematic Reviews and sources of grey literature. The review is reported according to the Preferred Reporting Items for Scoping Reviews. RESULTS Thirty sources met the inclusion criteria. Most factors can either be a facilitator or barrier to shared decision-making depending on the context. Two significant barriers to shared decision-making in this population include uncertainty about the child's diagnosis, prognosis, and treatment options and the presence of hierarchy and power imbalance during clinical encounters with healthcare providers. Further influencing factors include continuity of care, the availability of accurate, accessible, adequate, and balanced information and the interpersonal and communication skills of parents and healthcare providers. CONCLUSION Uncertainty about diagnosis, prognosis and treatment outcomes for children with medical complexity are additional challenges to the known barriers and facilitators to shared decision-making in community health services. Effective implementation of shared decision-making requires advancement of the evidence base for children with medical complexity, reducing power imbalance in clinical encounters, improving continuity of care, and improving the availability and accessibility of information resources.
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Affiliation(s)
- Sonja Jacobs
- Community Children's Therapies, Barts Health NHS Trust, London, UK
| | - Nathan Davies
- Research Department of Primary Care & Population Health, University College London, London, UK
| | | | - Jane L Oswell
- Community Children's Therapies, Barts Health NHS Trust, London, UK
| | | | - Christina H Smith
- Division of Psychology and Language Sciences, University College London, London, UK
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6
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Tschamper MK, Systad S. Rare, epilepsy-related disorder including intellectual disability - A scoping review of caregivers' identified information needs. JOURNAL OF INTELLECTUAL DISABILITIES : JOID 2022; 26:704-717. [PMID: 33998344 PMCID: PMC9442773 DOI: 10.1177/17446295211002348] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/17/2021] [Indexed: 06/12/2023]
Abstract
AIMS The aims of this review were: (1) to obtain an overview of caregiver-reported information needs; and (2) to investigate if there are information needs that are unique for caregivers of persons with rare epilepsies. METHOD We followed the scoping review framework outlined by Arksey and O'Malley and the preferred reporting items outlined by PRISMA. RESULTS Among the 17 articles that met the inclusion criteria, 5 included caregivers of persons with rare epilepsies. Categories of information needs: (1) Medical information; (2) Information on how to cope with emotional distress; (3) Experiential information from peers; and (4) Interdisciplinary information exchange. The need for disorder-specific information seemed particularly important for caregivers of persons with rare epilepsies. CONCLUSION There is a need for further studies, particularly on formal caregivers' information needs.
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Affiliation(s)
- Merete Kristin Tschamper
- Merete Kristin Tschamper, National Center for Rare
Epilepsy-Related Disorders, Department of Rare Disorders, Oslo University Hospital, 0316
Oslo, Norway.
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7
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Buchanan F, Lai C, Cohen E, Milo-Manson G, Shachak A. Decision-making for Parents of Children With Medical Complexities: Activity Theory Analysis. J Particip Med 2022; 14:e31699. [PMID: 35037890 PMCID: PMC8804956 DOI: 10.2196/31699] [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: 06/30/2021] [Revised: 10/28/2021] [Accepted: 12/09/2021] [Indexed: 11/28/2022] Open
Abstract
Background Shared decision-making (SDM), a collaborative approach to reach decisional agreement, has been advocated as an ideal model of decision-making in the medical encounter. Frameworks for SDM have been developed largely from the clinical context of a competent adult patient facing a single medical problem, presented with multiple treatment options informed by a solid base of evidence. It is difficult to apply this model to the pediatric setting and children with medical complexity (CMC), specifically since parents of CMC often face a myriad of interconnected decisions with minimal evidence available on the multiple complex and co-existing chronic conditions. Thus, solutions that are developed based on the traditional model of SDM may not improve SDM practices for CMCs and may be a factor contributing to the low rate of SDM practiced with CMCs. Objective The goal of our study was to address the gaps in the current approach to SDM for CMC by better understanding the decision-making activity among parents of CMCs and exploring what comprises their decision-making activity. Methods We interviewed 12 participants using semistructured interviews based on activity theory. Participants identified as either a parent of a CMC or a CMC over the age of 18 years. Qualitative framework analysis and an activity theory framework were employed to understand the complexity of the decision-making process in context. Results Parents of CMCs in our study made decisions based on a mental model of their child’s illness, informed by the activities of problem-solving, seeking understanding, obtaining tests and treatment, and caregiving. These findings suggest that the basis for parental choice and values, which are used in the decision-making activity, was developed by including activities that build concrete understanding and capture evidence to support their decisions. Conclusions Our interviews with parents of CMCs suggest that we can address both the aims of each individual activity and the related outcomes (both intended and unintended) by viewing the decision-making activity as a combination of caregiving, problem-solving, and seeking activities. Clinicians could consider using this lens to focus decision-making discussions on integrating the child’s unique situation, the insights parents gain through their decision-making activity, and their clinical knowledge to enhance the understanding between parents and health care providers, beyond the narrow concept of parental values.
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Affiliation(s)
- Francine Buchanan
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Claudia Lai
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Eyal Cohen
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Golda Milo-Manson
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Division of Developmental Pediatrics, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
| | - Aviv Shachak
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,Faculty of Information, University of Toronto, Toronto, ON, Canada
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8
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Yu J, Cook S, Imming C, Knezevich L, Ray K, Houtrow A, Rosenberg AR, Schenker Y. A Qualitative Study of Family Caregiver Perceptions of High-Quality Care at a Pediatric Complex Care Center. Acad Pediatr 2022; 22:107-115. [PMID: 34020106 PMCID: PMC9979253 DOI: 10.1016/j.acap.2021.05.012] [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: 10/27/2020] [Revised: 05/10/2021] [Accepted: 05/12/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Pediatric complex care centers are an increasingly common approach to address the needs of children with medical complexity (CMC). We sought to better understand CMC caregivers' perceptions of what constitutes high-quality care at a complex care center. METHODS We conducted a cross-sectional qualitative study of family caregivers of CMC receiving care at a pediatric complex care center situated within a tertiary-care children's hospital. In-depth, semistructured interviews focused on caregivers' general experiences at the clinic, positive and negative experiences related to core components of the pediatric medical home, and recommendations for improvements. We thematically analyzed transcripts through a mixed inductive and deductive approach, using constant comparative methodology, with the pediatric medical home model as an organizing framework. RESULTS We conducted interviews with 20 participants (18 [90%] biological parents; 19 [95%] female; mean age 39 years) in outpatient settings. Caregivers described 2 major themes: 1) the value of having a clinician "quarterback" who is in-charge of their child's care and caregivers' go-to for questions and concerns, and 2) wanting clinicians who are personally invested in and willing to "go above and beyond" for their child. Participants discussed how and which components of the medical home model enable CMC clinicians to meet these needs. CONCLUSIONS Family caregivers of CMC want clinicians who take responsibility for managing their child's overall care and demonstrate personal commitment to ensuring their child's well-being. Multiple aspects of the medical home framework, rather than care coordination alone, help meet caregivers' perceptions of high-quality complex care.
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Affiliation(s)
- Justin Yu
- Department of Pediatrics, Division of Pediatric Hospital Medicine; University of Pittsburgh School of Medicine, Pittsburgh, PA,Palliative Research Center (PaRC), University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Stacey Cook
- Department of General Pediatrics, Division of Complex Care, Boston Children’s Hospital, Boston MA
| | - Christina Imming
- Department of Pediatrics, Division of Pediatric Hospital Medicine; University of Pittsburgh School of Medicine, Pittsburgh, PA,Complex Care Center of UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA,Department of Pediatrics, Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Liana Knezevich
- Complex Care Center of UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Kristin Ray
- Department of Pediatrics, Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Amy Houtrow
- Department of Physical Medicine and Rehabilitation, Division of Pediatric Rehabilitation Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Abby R. Rosenberg
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA,Palliative Care and Resilience Lab, Seattle Children’s Research Institute, Seattle, WA
| | - Yael Schenker
- Palliative Research Center (PaRC), University of Pittsburgh School of Medicine, Pittsburgh, PA,Division of General Internal Medicine, Section of Palliative Care and Medical Ethics; University of Pittsburgh School of Medicine, Pittsburgh, PA
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9
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Lin JL, Tawfik DS, Gupta R, Imrie M, Bendavid E, Owens DK. Health and Economic Outcomes of Posterior Spinal Fusion for Children With Neuromuscular Scoliosis. Hosp Pediatr 2021; 10:257-265. [PMID: 32079619 DOI: 10.1542/hpeds.2019-0153] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Neuromuscular scoliosis (NMS) can result in severe disability. Nonoperative management minimally slows scoliosis progression, but operative management with posterior spinal fusion (PSF) carries high risks of morbidity and mortality. In this study, we compare health and economic outcomes of PSF to nonoperative management for children with NMS to identify opportunities to improve care. METHODS We performed a cost-effectiveness analysis. Our decision analytic model included patients aged 5 to 20 years with NMS and a Cobb angle ≥50°, with a base case of 15-year-old patients. We estimated costs, life expectancy, quality-adjusted life-years (QALYs), and incremental cost-effectiveness from published literature and conducted sensitivity analyses on all model inputs. RESULTS We estimated that PSF resulted in modestly decreased discounted life expectancy (10.8 years) but longer quality-adjusted life expectancy (4.84 QALYs) than nonoperative management (11.2 years; 3.21 QALYs). PSF costs $75 400 per patient. Under base-case assumptions, PSF costs $50 100 per QALY gained. Our findings were sensitive to quality of life (QoL) and life expectancy, with PSF favored if it significantly increased QoL. CONCLUSIONS In patients with NMS, whether PSF is cost-effective depends strongly on the degree to which QoL improved, with larger improvements when NMS is the primary cause of debility, but limited data on QoL and life expectancy preclude a definitive assessment. Improved patient-centered outcome assessments are essential to understanding the effectiveness of NMS treatment alternatives. Because the degree to which PSF influences QoL substantially impacts health outcomes and varies by patient, clinicians should consider shared decision-making during PSF-related consultations.
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Affiliation(s)
- Jody L Lin
- Divisions of Pediatric Hospital Medicine and .,Clinical Excellence Research Center, Stanford University, Stanford, California.,Division of Inpatient Medicine, Department of Pediatrics, School of Medicine, The University of Utah, Salt Lake City, Utah; and
| | | | - Ribhav Gupta
- Division of Biomechanical Engineering, School of Engineering.,Divisions of Infectious Diseases and Geographic Medicine, and
| | | | - Eran Bendavid
- Primary Care and Population Health, Departments of Medicine and
| | - Douglas K Owens
- VA Palo Alto Health Care System, Palo Alto, California.,Stanford Health Policy, Freeman Spogli Institute for International Studies, School of Medicine, and
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10
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Edwards JD, Panitch HB, George M, Cirrilla AM, Grunstein E, Wolfe J, Nelson JE, Miller RL. Development and validation of a novel informational booklet for pediatric long-term ventilation decision support. Pediatr Pulmonol 2021; 56:1198-1204. [PMID: 33305899 PMCID: PMC8035285 DOI: 10.1002/ppul.25221] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/30/2020] [Accepted: 12/05/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To provide accessible, uniform, comprehensive, and balanced information to families deciding whether to initiate long-term ventilation (LTV) for their child, we sought to develop and validate a novel informational resource. METHODS The Ottawa Decision Support Framework was followed. Previous interviews with 44 lay and 15 professional stakeholders and published literature provided content for a booklet. Iterative versions were cognitive tested with six parents facing decisions and five pediatric intensivists. Ten parents facing decisions evaluated the booklet using the Preparation for Decision Making Scale and reported their decisional conflict, which was juxtaposed to the conflict of 21 parents who did not read it, using the Decisional Conflict Scale. Twelve home ventilation program directors evaluated the booklet's clinical sensibility and sensitivity, using a self-designed six-item questionnaire. Data presented using summary statistics. RESULTS The illustrated booklet (6th-grade reading level) has nine topical sections on chronic respiratory failure and invasive and noninvasive LTV, including the option to forgo LTV. Ten parents who read the booklet rated it as helping "Quite a bit" or more on all items of the Preparation for Decision Making Scale and had seemingly less decisional conflict than 21 parents who did not. Twelve directors rated it highly for clinical sensibility and sensitivity. CONCLUSIONS The LTV booklet was rigorously developed and favorably evaluated. It offers a resource to improve patient/family knowledge, supplement shared decision-making, and reduce decisional conflict around LTV decisions. Future studies should validate it in other settings and further study its effectiveness.
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Affiliation(s)
- Jeffrey D Edwards
- Division of Critical Care and Hospital Medicine, Department of Pediatrics, Columbia University Valegos College of Physicians and Surgeons, New York, New York, USA
| | - Howard B Panitch
- Division of Pulmonary Medicine, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maureen George
- Columbia University School of Nursing, New York, New York, USA
| | - Anne-Marie Cirrilla
- Department of Care Coordination/Social Work, New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
| | - Eli Grunstein
- Division of Pediatric Otolaryngology, Columbia University Valegos College of Physicians and Surgeons, New York, New York, USA
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Judith E Nelson
- Critical Care Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York, USA.,Palliative Medicine Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York, USA
| | - Rachel L Miller
- Division of Clinical Immunology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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11
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Adams S, Beatty M, Moore C, Desai A, Bartlett L, Culbert E, Cohen E, Stinson J, Orkin J. Perspectives on team communication challenges in caring for children with medical complexity. BMC Health Serv Res 2021; 21:300. [PMID: 33794885 PMCID: PMC8015748 DOI: 10.1186/s12913-021-06304-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 03/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Children with medical complexity (CMC) require the expertise of many care providers spanning different disciplines, institutions, and settings of care. This leads to duplicate health records, breakdowns in communication, and limited opportunities to provide comprehensive, collaborative care. The objectives of this study were to explore communication challenges and solutions/recommendations from multiple perspectives including (i) parents, (ii) HCPs - hospital and community providers, and (iii) teachers of CMC with a goal of informing patient care. METHODS This qualitative study utilized an interpretive description methodology. In-depth semi-structured interviews were conducted with parents and care team members of CMC. The interview guides targeted questions surrounding communication, coordination, access to information and roles in the health system. Interviews were conducted until thematic saturation was reached. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed using thematic analysis. RESULTS Thirty-two individual interviews were conducted involving parents (n = 16) and care team members (n = 16). Interviews revealed 2 main themes and several associated subthemes (in parentheses): (1) Communication challenges in the care of CMC (organizational policy and technology systems barriers, inadequate access to health information, and lack of partnership in care) (2) Communication solutions (shared systems that can be accessed in real-time, universal access to health information, and partnered contribution to care). CONCLUSION Parents, HCPs, and teachers face multiple barriers to communication and information accessibility in their efforts to care for CMC. Parents and care providers in this study suggested potential strategies to improve communication including facilitating communication in real-time, universal access to health information and meaningful partnerships.
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Affiliation(s)
- Sherri Adams
- Division of Pediatric Medicine, SickKids, The Hospital for Sick Children, Toronto, Canada. .,SickKids Research Institute, Toronto, Canada. .,Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.
| | | | - Clara Moore
- SickKids Research Institute, Toronto, Canada
| | - Arti Desai
- Department of Pediatrics, University of Washington, Seattle, USA
| | | | | | - Eyal Cohen
- Division of Pediatric Medicine, SickKids, The Hospital for Sick Children, Toronto, Canada.,SickKids Research Institute, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Jennifer Stinson
- SickKids Research Institute, Toronto, Canada.,Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.,Department of Anesthesia and Pain Medicine, Toronto, Canada
| | - Julia Orkin
- Division of Pediatric Medicine, SickKids, The Hospital for Sick Children, Toronto, Canada.,SickKids Research Institute, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
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12
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Rogers J, Reed MP, Blaine K, Manning H. Children with medical complexity: A concept analysis. Nurs Forum 2021; 56:676-683. [PMID: 33625740 DOI: 10.1111/nuf.12559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 01/01/2021] [Accepted: 01/29/2021] [Indexed: 11/27/2022]
Abstract
AIM The aim of this paper is to conduct a concept analysis on the term, "children with medical complexity." BACKGROUND Children with medical complexity (CMC) describes pediatric patients with chronic, sustained acuity; however, there is a lack of consensus in the literature regarding its exact meaning, characteristics, and implications. DESIGN This analysis relied upon the framework described by Walker and Avant. DATA SOURCE The CINAHL, MEDLINE, and PubMed databases were queried from April 2020 to December 2020 with an initial search of the literature for the keyword, "children with medical complexity" and other associated terms, such as "pediatric medical complexity" and "nursing care of children with medical complexity." REVIEW METHODS This analysis will explore the concept of CMC and its significance, attributes, antecedents, and consequences. RESULTS This investigation revealed that CMC are a growing population of pediatric patients who have one or more complex chronic conditions that affect multiple body systems, experience functional limitations, require extensive care coordination from multiple providers, and are dependent upon life-sustaining medical technology. CONCLUSIONS The findings can serve as a foundation for future work advancing the understanding of the topic of CMC.
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Affiliation(s)
- Jayne Rogers
- Medical Nursing Service, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mary P Reed
- Medical Nursing Service, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kevin Blaine
- Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Haylee Manning
- Medical Nursing Service, Boston Children's Hospital, Boston, Massachusetts, USA
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Yu JA, McKernan G, Hagerman T, Schenker Y, Houtrow A. Most Children With Medical Complexity Do Not Receive Care in Well-Functioning Health Care Systems. Hosp Pediatr 2021; 11:183-191. [PMID: 33408158 PMCID: PMC7831373 DOI: 10.1542/hpeds.2020-0182] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe the access of children with medical complexity (CMC) to well-functioning health care systems. To examine the relationships between medical complexity status and this outcome and its component indicators. PATIENTS AND METHODS Secondary analysis of children in the National Survey of Children's Health combined 2016-2017 data set who received care in well-functioning health systems. Secondary outcomes included this measure's component indicators. The χ2 analyses were used to examine associations between child and family characteristics and the primary outcome. Adjusted multivariable logistic regression was used to examine relationships between medical complexity status and primary and secondary outcomes. Using these regression models, we examined the interaction between medical complexity status and household income. RESULTS CMC accounted for 1.6% of the weighted sample (n = 1.2 million children). Few CMC (7.6%) received care in a well-functioning health care system. CMC were significantly less likely than children with special health care needs (CSHCN) (odds ratio, 0.3) of meeting criteria for this primary outcome. Attainment rates for secondary outcomes (families feeling like partners in care; receives care within a medical home; received needed health care) were significantly lower among CMC than CSHCN. Family income was significantly associated with likelihood of meeting criteria for primary and secondary outcomes; however, the relationships between medical complexity status and our outcomes did not differ by income level. CONCLUSIONS CMC are less likely than other CSHCN to report receiving care in well-functioning health care systems at all income levels. Further efforts are necessary to better adapt current health care systems to meet the unique needs of CMC.
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Affiliation(s)
- Justin A Yu
- Divisions of Pediatric Hospital Medicine and Palliative and Supportive Care,
- Departments of Pediatrics and
| | - Gina McKernan
- Physical Medicine and Rehabilitation
- Department of Physical Medicine and Rehabilitation, Human Engineering Research Laboratories, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, Pennsylvania
| | - Thomas Hagerman
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Yael Schenker
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, and
| | - Amy Houtrow
- Division of Pediatric Rehabilitation Medicine, Department of Physical Medicine and Rehabilitation
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Yu JA, McKernan G, Hagerman T, Schenker Y, Houtrow A. Identifying Children With Medical Complexity From the National Survey of Children's Health Combined 2016-17 Data Set. Hosp Pediatr 2021; 11:192-197. [PMID: 33414223 DOI: 10.1542/hpeds.2020-0180] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To develop a method of identifying children with medical complexity (CMC) from the National Survey of Children's Health (NSCH) 2016-2017 combined data set, to compare this approach to existing CMC identification strategies, and to describe sociodemographic characteristics of our CMC sample. METHODS Using survey items pertinent to the medical complexity domains in the style by Cohen et al (chronic health conditions, health service needs, health care use, and functional limitations), we created a schema to categorize children as CMC by applying a 95th percentile cutoff for survey item positivity. We applied existing CMC identification techniques to the NSCH. We used 2-proportion z tests to compare the classification output of our CMC identification method to those of existing approaches. We used χ2 analyses to examine relationships between child and family characteristics, comparing CMC with children with special health care needs (CSHCN) and children with no special health care needs. RESULTS Among the 71 811 children in the sample, 1.5% were classified as CMC by our method, representing almost 1.2 million children (weighted) in the United States in 2016-2017. CSHCN and children with no special health care needs represented 17.2% (weighted n = 12.6 million) and 81.2% (weighted n = 59.6 million) of the sample, respectively. Our approach classified a significantly smaller number of CSHCN as CMC than existing CMC identification methods, which classified 3.9% to 13.2% of the 2016-2017 NSCH sample as more complex (P < .001). CMC status was significantly associated with male sex, minority race or ethnicity, and experiencing socioeconomic adversity (all P < .001). CONCLUSIONS This method enables standardized identification of CMC from NSCH data sets, thus allowing for an examination of CMC health outcomes, pertinent to pediatric hospitalist medicine, contained in the survey.
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Affiliation(s)
- Justin A Yu
- Divisions of Pediatric Hospital Medicine and Palliative Care Medicine, .,Departments of Pediatrics and
| | - Gina McKernan
- Physical Medicine and Rehabilitation.,Human Engineering Research Laboratories, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, Pennsylvania
| | - Thomas Hagerman
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine and
| | - Amy Houtrow
- Division of Pediatric Rehabilitation Medicine.,Physical Medicine and Rehabilitation
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15
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Elgen I, Lygre R, Greve G, Griffiths S, Heggestad T. Interdisciplinary Approaches Suggested for Children With Multiple Hospital Referrals Presenting With Non-specific Conditions. Front Pediatr 2021; 9:656939. [PMID: 33898364 PMCID: PMC8058187 DOI: 10.3389/fped.2021.656939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/11/2021] [Indexed: 11/13/2022] Open
Abstract
Aims: To describe the care patterns of patients with repeated referrals to both mental and somatic specialist healthcare, and to study their diagnostic processes. Methods: In a previous register study patients aged 6-12 years referred to Haukeland University Hospital from 2013 to 2015, we found 922 children with at least three referrals including both somatic and mental health services. Of these, more than one in four (250) were randomly selected and observed from their first hospital episode ever and further after inclusion followed during their next three referrals or until July 2017. Data on referral patterns and diagnostics were collected from patient hospital records. Results: Mean number of referrals was 6.5 prior to inclusion and 4.2 in the follow-up period. At the end of the study period 15% of patients still had a non-specific diagnosis. During the follow-up period, more than half of the children were again referred across the border between somatic and mental healthcare. Conclusion: Very complex care patterns were found for these patients, who were repeatedly being referred and "crossing over" between mental and somatic healthcare. This indicates a need for more interdisciplinary-based approaches both within specialist care and between different care levels to broaden the perspective and achieve shorter time lag before reaching a diagnostic conclusion. Trial Registration: Data was obtained from Haukeland university hospital the patient registry system No. 2017/12470. Start of registration was April 1th 2017 and patients included was from 2013 to 15.
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Affiliation(s)
- Irene Elgen
- Division of Psychiatry, Department of Child and Adolescent Psychiatry, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ragnhild Lygre
- Division of Psychiatry, Department of Child and Adolescent Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Gottfried Greve
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Silja Griffiths
- Department of Child and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Torhild Heggestad
- Department of Research & Development, Haukeland University Hospital, Bergen, Norway
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16
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Buchanan F, Cohen E, Milo-Manson G, Shachak A. What makes difficult decisions so difficult?: An activity theory analysis of decision making for physicians treating children with medical complexity. PATIENT EDUCATION AND COUNSELING 2020; 103:2260-2268. [PMID: 32409096 DOI: 10.1016/j.pec.2020.04.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 04/23/2020] [Accepted: 04/25/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Shared Decision-Making (SDM) has been advocated as an ideal model of decision-making in the medical encounter. Much of the research into SDM has focused on measuring if SDM is happening, or facilitating SDM by developing specific models and tools. Understanding SDM as an activity in context, has remained mostly absent from the research. This study sought to garner details on the actions, judgements and motives that comprise the activity of making a decision, in the context of a shared process between physicians and families of Children with Medical Complexity (CMC). METHODS 11 physicians who treat CMC were interviewed. Activity Theory framework was employed to understand the complexity of the decision-making process in context. RESULTS Ambiguous information, conflicting rules, and beliefs on roles all contribute to the difficulty of decision-making. A decision is achieved by allocating the decision to one party. CONCLUSION Lack of tools, rules or beliefs that would assist sharing the decision between the physician and patient/family, contributes to the need to allocate the decision to one party. PRACTICE IMPLICATION In developing SDM policies and tools, one must consider all aspects of the SDM activity system, and how they influence each other and the activity as a whole.
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Affiliation(s)
- Francine Buchanan
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Eyal Cohen
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Golda Milo-Manson
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada; Division of Developmental Pediatrics, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Aviv Shachak
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Faculty of Information, University of Toronto, Toronto, Ontario, Canada
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17
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Gower WA, Golden SL, King NMP, Nageswaran S. Decision-Making About Tracheostomy for Children With Medical Complexity: Caregiver and Health Care Provider Perspectives. Acad Pediatr 2020; 20:1094-1100. [PMID: 32540425 DOI: 10.1016/j.acap.2020.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/29/2020] [Accepted: 06/06/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Caregivers of children with medical complexity (CMC) face decisions about tracheostomy. The objectives of this paper are to identify facilitators and barriers to tracheostomy decision-making (TDM) process for CMC. METHODS Using phenomenology as its methodologic orientation, this qualitative study conducted in North Carolina between 2013 and 2015 consists of semistructured interviews with 56 caregivers of 41 CMC who received tracheostomies, and 5 focus groups of 33 health care providers (HCP) at a tertiary care children's hospital involved in TDM for CMC. Participants were asked to share their experiences and perspectives on the TDM process. Qualitative data were transcribed, coded, and organized into themes as is consistent with thematic content analysis. RESULTS Five themes were identified. 1) Caregivers perceived decision about tracheostomy for their children was theirs to make. 2) Strategies that increased caregivers' active participation in the TDM process facilitated the TDM process. 3) Caregiver emotional stress and lack of understanding about tracheostomy were barriers. 4) Good HCP communication during the TDM process was valued; poor communication was a barrier. 5) Collaboration among HCP-facilitated TDM, especially when nurses were involved, whereas fragmentation in care was a barrier. CONCLUSIONS Caregivers take a primary role in the TDM process. Many caregiver and HCP-level facilitators and barriers for TDM exist. Augmenting the facilitators and reducing the barriers identified in this study could improve the TDM process for CMC.
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Affiliation(s)
- William A Gower
- Department of Pediatrics, Wake Forest School of Medicine (WA Gower and S Nageswaran), Winston-Salem, NC; Department of Pediatrics, University of North Carolina School of Medicine (WA Gower), Chapel Hill, NC
| | - Shannon L Golden
- Department of Social Science and Health Policy, Wake Forest University (SL Golden, NMP King, and S Nageswaran), Winston-Salem, NC
| | - Nancy M P King
- Department of Social Science and Health Policy, Wake Forest University (SL Golden, NMP King, and S Nageswaran), Winston-Salem, NC
| | - Savithri Nageswaran
- Department of Pediatrics, Wake Forest School of Medicine (WA Gower and S Nageswaran), Winston-Salem, NC; Department of Social Science and Health Policy, Wake Forest University (SL Golden, NMP King, and S Nageswaran), Winston-Salem, NC.
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18
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Schnell JL, Johaningsmeir S, Bartelt T, Bergman DA. Partnering with Parents of Children with Medical Complexity: A Framework for Engaging Families for Practice Improvement. Pediatr Ann 2020; 49:e467-e472. [PMID: 33170294 DOI: 10.3928/19382359-20201012-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The role of patients and families has evolved over the years, from being viewed as entities who were told what to do, to consumers of health services, to being central to health system design and clinical decision-making. When designing health care practices and programs to be patient- and family-centered, we believe that parents of children with medical complexity (CMC) bring valuable viewpoints and experiences to the table. Good health and functional outcomes for CMC and their families are dependent on active family engagement with their health care partners. We apply the Patient Engagement in Redesigning Care Toolkit (PERCT) model to describe the experience of complex care programs with engaging families at various levels of program design and function, including strengths and pitfalls experienced with each PERCT category. Operationalizing the health care system to treat patients and families as equal stakeholders is necessary if we want to succeed in a patient-centered, value-based environment. [Pediatr Ann. 2020;49(11):e467-e472.].
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19
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Lygre RB, Thuen VM, Gjestad R, Norekvål TM, Greve G, Mildestvedt T, Elgen IB. How can we improve specialist health services for children with multi-referrals? Parent reported experience. BMC Health Serv Res 2020; 20:786. [PMID: 32831078 PMCID: PMC7446114 DOI: 10.1186/s12913-020-05666-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 08/18/2020] [Indexed: 12/02/2022] Open
Abstract
Background Children with combined mental and somatic conditions pose a challenge to specialized health services. These cases are often characterized by multi-referrals, frequent use of health services, poor clinical and cost effectiveness, and a lack of coordination and consistency in the care. Reorganizing the health services offered to these children seems warranted. Patient reported experiences give important evidence for evaluating and developing health services. The aim of the present descriptive study was to explore how to improve specialist health services for children with multiple referrals for somatic and mental health conditions. Based on parent reported experiences of health services, we attempted to identify key areas of improvement. Methods As part of a larger, ongoing project; “Transitioning patients’ Trajectories”, we asked parents of children with multiple referrals to both somatic and mental health departments to provide their experiences with the services their children received. Parents/guardians of 250 children aged 6–12 years with multi-referrals to the Departments of Pediatrics and Child and Adolescent Mental Health at Haukeland University Hospital between 2013 and 2015 were invited. Their experience was collected through a 14 items questionnaire based on a generic questionnaire supplied with questions from parents and health personnel. Possible associations between overall experience and possible predictors were analyzed using bivariate regression. Results Of the 250 parents invited, 148 (59%) responded. Mean scores on single items ranged from 3.18 to 4.42 on a 1–5 scale, where five is the best possible experience. In the multiple regression model, perception of wait time (r = .56, CI = .44–.69 / β = 0.16, CI = .05–.28), accommodation of consultations (r = .71, CI = .62–.80 / β = 0.25, CI = .06–.45 / β = 0.27, CI = .09–.44), providing adequate information about the following treatment (r = .66, CI = .55–.77 / β = 0.26, CI = .09–.43), and collaboration between different departments at the hospital (r = .68, CI = .57–.78 / β = 0.20, CI = -.01–.40) were all statistically significantly associated with parents overall experience of care. Conclusions The study support tailored interdisciplinary innovations targeting wait time, accommodation of consultations, communication regarding the following treatment and collaboration within specialist health services for children with multi-referrals to somatic and mental specialist health care services.
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Affiliation(s)
- Ragnhild B Lygre
- Department of Child and Adolescent Mental Health Services, Haukeland University Hospital, Bergen, Norway.
| | | | - Rolf Gjestad
- Research Department, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway.,Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Tone M Norekvål
- Centre on Patient-reported Outcomes Data, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Gottfried Greve
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Thomas Mildestvedt
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Irene Bircow Elgen
- Department of Child and Adolescent Mental Health Services, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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20
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Egholm GJ, Bjerknes M, Illum NO. Parents' Assessment of Disability in Their Children With Down Syndrome. Child Neurol Open 2020; 7:2329048X20934248. [PMID: 32596412 PMCID: PMC7303779 DOI: 10.1177/2329048x20934248] [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: 11/16/2019] [Revised: 04/15/2020] [Accepted: 04/27/2020] [Indexed: 11/23/2022] Open
Abstract
Aim: To describe a population of children with Down syndrome and evaluate their
parents’ assessment of disability. Methods: Medical records of a population of 80 children with Down syndrome aged 5 to
17 years were analyzed for genetic background and associated diagnoses. And
27 parents to their children agreed to assess disability by employing a set
of 26 International Classification of Functioning, Disability and Health
body function (b) codes and activity and participation (d) codes. Clinical
data were gathered and analysis of parents’ assessment of disability using
psychometric and Rasch analysis was performed. Results: Clinical data on 27 children assessed by their parents and 53 children not
assessed had identical associated diagnoses. The 26 International
Classification of Functioning, Disability and Health codes and qualifiers
had a mean score of 2.67 (range 1.26-4.11) and corrected code-total
correlations mean of 0.55 (range −1.17 to 0.82). Rasch analysis showed
proper code MNSQ infit and outfit values with mean 1.03 and 1.06. Conclusion: Clinical data on 27 children assessed were similar to 53 children that were
not evaluated. Parents’ assessment of the 27 children showed good
psychometric and Rasch analysis properties. Similar results might be
expected in the total population of 80 children.
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Affiliation(s)
- Guðrun Jákupsdóttir Egholm
- Division of Child Neurology, Hans Christian Andersen Hospital for Children and Adolescents, Odense University Hospital, Odense, Denmark
| | - Margrethe Bjerknes
- Division of Child Neurology, Hans Christian Andersen Hospital for Children and Adolescents, Odense University Hospital, Odense, Denmark
| | - Niels Ove Illum
- Division of Child Neurology, Hans Christian Andersen Hospital for Children and Adolescents, Odense University Hospital, Odense, Denmark
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“The Whole Game is Changing and You’ve Got Hope”: Australian Perspectives on Treatment Decision Making in Spinal Muscular Atrophy. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2020; 13:389-400. [DOI: 10.1007/s40271-020-00415-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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22
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Antolick MM, Looman WS, Cady RG, Kubiatowicz K. Identifying and Communicating Postdischarge Goals for Hospitalized Children With Medical Complexity: A Process Improvement Pilot in a Specialty Pediatric Setting. J Pediatr Health Care 2020; 34:90-98. [PMID: 31548138 DOI: 10.1016/j.pedhc.2019.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 07/04/2019] [Accepted: 07/13/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Family-centered communication at transitions of care can decrease readmissions and costs for children with medical complexity (CMC). The purpose of this quality improvement project was to improve the communication of postdischarge goals for CMC in a pediatric specialty setting. METHODS We used process improvement strategies to implement a Post-Hospitalization Action Grid (PHAG) and a standardized discharge handoff process. Families of hospitalized CMC at high risk for readmission received the pilot intervention over 3 months. Indicators of successful implementation included rates of use of the PHAG, perceptions of integrated care, and usability of the tool. RESULTS The PHAG was implemented with 11 of 40 eligible CMC families. Most staff agreed that the new process could improve the communication of postdischarge goals; however, perceptions of integrated care in the organization changed only minimally. DISCUSSION The PHAG facilitates family engagement in discharge transitions but requires organizational investment of resources to implement.
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Lin JL, Clark CL, Halpern-Felsher B, Bennett PN, Assis-Hassid S, Amir O, Castaneda Nunez Y, Cleary NM, Gehrmann S, Grosz BJ, Sanders LM. Parent Perspectives in Shared Decision-Making for Children With Medical Complexity. Acad Pediatr 2020; 20:1101-1108. [PMID: 32540424 PMCID: PMC7655593 DOI: 10.1016/j.acap.2020.06.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 06/05/2020] [Accepted: 06/07/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Shared decision-making (SDM) may improve outcomes for children with medical complexity (CMC). CMC have lower rates of SDM than other children, but little is known about how to improve SDM for CMC. The objective of this study is to describe parent perspectives of SDM for CMC and identify opportunities to improve elements of SDM specific to this vulnerable population. METHODS Interviews with parents of CMC explored SDM preferences and experiences. Eligible parents were ≥18 years old, English- or Spanish-speaking, with a CMC <12 years old. Interviews were recorded, transcribed, and analyzed by independent coders for shared themes using modified grounded theory. Codes were developed using an iterative process, beginning with open-coding of a subset of transcripts followed by discussion with all team members, and distillation into preliminary codes. Subsequent coding reviews were conducted until no new themes emerged and existing themes were fully explored. RESULTS We conducted interviews with 32 parents (27 in English, mean parent age 34 years, standard deviation = 7; mean child age 4 years, standard deviation = 4; 50% with household income <$50,000, 47% with low health literacy) in inpatient and outpatient settings. Three categories of themes emerged: participant, knowledge, and context. Key opportunities to improve SDM included: providing a shared decision timeline, purposefully integrating patient preferences and values, and addressing uncertainty in decisions. CONCLUSION Our results provide insight into parent experiences with SDM for CMC. We identified unique opportunities to improve SDM for CMC that will inform future research and interventions to improve SDM for CMC.
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Affiliation(s)
- Jody L. Lin
- Division of Pediatric Hospital Medicine, Department of Pediatrics; Stanford University School of Medicine, Stanford, CA 94305,Division of Pediatric Hospital Medicine, Department of Pediatrics; University of Utah, Salt Lake City, UT 84113 (Present address)
| | - Catherine L. Clark
- Division of General Pediatrics, Department of Pediatrics; Stanford University School of Medicine, Stanford, CA 94305
| | - Bonnie Halpern-Felsher
- Division of Adolescent Medicine, Department of Pediatrics; Stanford University School of Medicine, Stanford, CA 94305
| | - Paul N. Bennett
- Medical and Clinical Affairs, Satellite Healthcare, San Jose, CA 95128,Deakin University, Geelong, VIC, Australia, 3125
| | - Shiri Assis-Hassid
- Center for Research on Computation and Society, John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138
| | - Ofra Amir
- Technion – Israel Institute of Technology, Haifa, Israel
| | - Yadira Castaneda Nunez
- Division of General Pediatrics, Department of Pediatrics; Stanford University School of Medicine, Stanford, CA 94305
| | - Nancy Miles Cleary
- Division of General Pediatrics, Department of Pediatrics; Stanford University School of Medicine, Stanford, CA 94305
| | - Sebastian Gehrmann
- John A. Paulson School of Engineering and Applied Sciences (Computer Science), Harvard University, Cambridge, MA 02138
| | - Barbara J. Grosz
- John A. Paulson School of Engineering and Applied Sciences (Computer Science), Harvard University, Cambridge, MA 02138
| | - Lee M. Sanders
- Division of General Pediatrics, Department of Pediatrics; Stanford University School of Medicine, Stanford, CA 94305
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Creating a Pharmacotherapy Collaborative Practice Network to Manage Medications for Children and Youth: A Population Health Perspective. CHILDREN-BASEL 2019; 6:children6040058. [PMID: 30970616 PMCID: PMC6518168 DOI: 10.3390/children6040058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 02/07/2023]
Abstract
Children with special health care needs (CSHCN) use relatively high quantities of healthcare resources and have overall higher morbidity than the general pediatric population. Embedding clinical pharmacists into the Patient-Centered Medical Home (PCMH) to provide comprehensive medication management (CMM) through collaborative practice agreements (CPAs) for children, especially for CSHCN, can improve outcomes, enhance the experience of care for families, and reduce the cost of care. Potential network infrastructures for collaborative practice focused on CSHCN populations, common language and terminology for CMM, and clinical pharmacist workforce estimates are provided. Applying the results from the CMM in Primary Care grant, this paper outlines the following: (1) setting up collaborative practices for CMM between clinical pharmacists and pediatricians (primary care pediatricians and sub-specialties, such as pediatric clinical pharmacology); (2) proposing various models, organizational structures, design requirements, and shared electronic health record (EHR) needs; and (3) outlining consistent documentation of CMM by clinical pharmacists in CSHCN populations.
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25
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Lee KJ, Corden TE. Feeding Tubes in Children With Neurologic Impairment: An Opportunity for Shared Decision-making. Pediatrics 2019; 143:peds.2018-3623. [PMID: 30679377 DOI: 10.1542/peds.2018-3623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
- K Jane Lee
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Timothy E Corden
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
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Illum NO, Bonderup M, Gradel KO. Parents' Expressions of Concerns and Hopes for the Future and Their Concomitant Assessments of Disability in Their Children. CLINICAL MEDICINE INSIGHTS-PEDIATRICS 2018; 12:1179556518784948. [PMID: 30046263 PMCID: PMC6055242 DOI: 10.1177/1179556518784948] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 05/30/2018] [Indexed: 12/13/2022]
Abstract
Aim To assess parents' ability to express their concerns and hopes for the future in their children with disability and assess their children's disability as well as to analyse these data for consistency. Method Parents of 162 children with spina bifida, spinal muscular atrophy, muscular disorders, cerebral palsy, visual impairment, hearing impairment, mental disability, or disability following brain tumours were asked to freely express their concerns and hopes for the future and to assess disability in their own children by employing a set of 26 International Classification of Functioning, Disability and Health, Children and Youth Version (ICF-CY) body function (b) codes and activity and participation (d) codes. A grounded theory approach was employed to systematize parents' expressions of concerns and hopes; then, parents scored qualifiers on a 5-step qualitative Likert scale. Parents assessed their children's disability in the same way using the ICF-CY 5-step qualifier scale. Results Altogether, 119 parents freely expressed their concerns and hopes, and 101 of them also assessed their children's disability using the 26 ICF-CY codes. A total of 475 expressions of concern and hopes (issues) were expressed and categorized into 34 areas of concern and hopes (subsections). The most frequently mentioned issues were education; understanding, goodwill, and communication between parents; and community support. Qualitative data on both 5-step qualifier scales showed good reliability. Rasch analysis maps on concerns and hopes for children as well as on the ICF-CY assessment demonstrated good alignment and a clinically relevant progression from the least to the most disabled children. Conclusion Parents can express valid and reliable data on their concerns and hopes for the future and can reliably assess disability in their own children.
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Affiliation(s)
- Niels Ove Illum
- Hans Christian Andersen Children's Hospital, Division of Child Neurology, Odense University Hospital, Odense, Denmark
| | - Mette Bonderup
- Odense Municipality, Special Counselling Unit, Odense, Denmark
| | - Kim Oren Gradel
- Center for Clinical Epidemiology, Research Unit of Clinical Epidemiology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Arnold CM, Bixenstine PJ, Cheng TL, Tschudy MM. Concordance among children, caregivers, and clinicians on barriers to controller medication use. J Asthma 2018; 55:1352-1361. [PMID: 29420091 DOI: 10.1080/02770903.2018.1424188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE While much research has addressed asthma medication adherence, few have combined quantitative and qualitative data, and none has addressed the triad of child, caregiver, and clinician simultaneously. This study assessed, with mixed methods, barriers to medication adherence within this triad. METHODS We conducted interviews with publicly-insured children with asthma, their caregivers, and their primary-care clinicians. Children (7-17 years) had been prescribed daily inhaled corticosteroids and visited the ED for asthma (past year). Participants answered open-ended and survey questions, rating suggested barriers to medication use (never vs. ever a barrier). McNemar's tests compared report of barriers by each group (children, caregivers, clinicians), and assessed concordance within triads. RESULTS Fifty child-caregiver dyads participated (34 clinicians). Children (40% female; median age 10 years) had mostly non-Hispanic black (90%) caregivers with less than or equal to high-school education (68%). For barriers, children and clinicians were more likely than caregivers to report medications running out. Clinicians were also more likely to cite controllers being a "pain to take" (vs. children) and forgetfulness (vs. caregivers) (all p < .05). There was a lack of within-triad concordance regarding barriers to adherence, especially regarding medication running out, worrying about taking a daily medication, and medication being a pain to take. Qualitative data revealed themes of competing priorities, home routines, and division of responsibility as prominent contributors to medication adherence. CONCLUSIONS There was significant disagreement among children, caregivers, and clinicians regarding barriers to daily use of asthma medications. To tailor asthma management conversations, clinicians should understand family-specific barriers and child-caregiver disagreements.
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Affiliation(s)
- Carolyn M Arnold
- a Department of Pediatrics , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Paul J Bixenstine
- b Departments of Pediatrics & Internal Medicine , University of California Los Angeles School of Medicine , Los Angeles , CA , USA
| | - Tina L Cheng
- a Department of Pediatrics , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Megan M Tschudy
- a Department of Pediatrics , Johns Hopkins University School of Medicine , Baltimore , MD , USA
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Acerini CL, Segal D, Criseno S, Takasawa K, Nedjatian N, Röhrich S, Maghnie M. Shared Decision-Making in Growth Hormone Therapy-Implications for Patient Care. Front Endocrinol (Lausanne) 2018; 9:688. [PMID: 30524377 PMCID: PMC6262035 DOI: 10.3389/fendo.2018.00688] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 11/02/2018] [Indexed: 12/19/2022] Open
Abstract
Several studies have shown that adherence to growth hormone therapy (GHT) is not optimal. There are several reasons why patients may not fully adhere to their treatment regimen and this may have implications on treatment success, patient outcomes and healthcare spending and resourcing. A change in healthcare practices, from a physician paternalistic to a more patient autonomous approach to healthcare, has encouraged a greater onus on a shared decision-making (SDM) process whereby patients are actively encouraged to participate in their own healthcare decisions. There is growing evidence to suggest that SDM may facilitate patient adherence to GHT. Improved adherence to therapy in this way may consequently positively impact treatment outcomes for patients. Whilst SDM is widely regarded as a healthcare imperative, there is little guidance on how it should be best implemented. Despite this, there are many opportunities for the implementation of SDM during the treatment journey of a patient with a GH-related disorder. Barriers to the successful practice of SDM within the clinic may include poor patient education surrounding their condition and treatment options, limited healthcare professional time, lack of support from clinics to use SDM, and healthcare resourcing restrictions. Here we discuss the opportunities for the implementation of SDM and the barriers that challenge its effective use within the clinic. We also review some of the potential solutions to overcome these challenges that may prove key to effective patient participation in treatment decisions. Encouraging a sense of empowerment for patients will ultimately enhance treatment adherence and improve clinical outcomes in GHT.
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Affiliation(s)
- Carlo L. Acerini
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
- *Correspondence: Carlo L. Acerini
| | - David Segal
- Department of Paediatrics, University of the Witwatersrand, Johannesburg, South Africa
| | - Sherwin Criseno
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Kei Takasawa
- Department of Paediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | | | | | - Mohamad Maghnie
- Department of Paediatrics, IRCCS Istituto Giannina Gaslini, University of Genova, Genova, Italy
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Adams RC, Levy SE. Shared Decision-Making and Children With Disabilities: Pathways to Consensus. Pediatrics 2017; 139:peds.2017-0956. [PMID: 28562298 DOI: 10.1542/peds.2017-0956] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Shared decision-making (SDM) promotes family and clinician collaboration, with ultimate goals of improved health and satisfaction. This clinical report provides a basis for a systematic approach to the implementation of SDM by clinicians for children with disabilities. Often in the discussion of treatment plans, there are gaps between the child's/family's values, priorities, and understanding of perceived "best choices" and those of the clinician. When conducted well, SDM affords an appropriate balance incorporating voices of all stakeholders, ultimately supporting both the child/family and clinician. With increasing knowledge of and functional use of SDM skills, the clinician will become an effective partner in the decision-making process with families, providing family-centered care. The outcome of the process will support the beneficence of the physician, the authority of the family, and the autonomy and well-being of the child.
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Affiliation(s)
- Richard C. Adams
- aUniversity of Texas Southwestern Medical Center, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Susan E. Levy
- bCenter for Autism Research, Division Developmental and Behavioral Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- cPerelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
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