Post-Trial Sustainability and Scalability of the Benefits of a Medical Home for High-Risk Children with Medical Complexity

Randomized controlled trial of enteral vitamin D supplementation (ViDES) in infants <28 weeks gestational age or <1000 g birth weight: study protocol

BACKGROUND

Vitamin D is necessary to develop healthy lungs and other organs early in life. Most infants born before 28 weeks' gestation have low vitamin D levels at birth and a limited intake during the first month. Enteral vitamin D supplementation is inexpensive and widely used. The appropriate supplementation regimen for extremely preterm infants is controversial, and the effect of different regimens on their blood levels and outcomes is unclear.

METHODS

Randomized, blinded comparative effectiveness trial to compare two vitamin D supplementation regimens for inborn infants <28 weeks gestation or <1000 g birth weight at a large academic center in the United States. Infants are stratified by birth weight and randomized within 96 h after birth to either routine supplementation (400 IU/day with established feedings) or increased supplementation (800 IU/day with any feedings) during the first 28 days after birth. We hypothesize that the higher and early vitamin D dose (800 IU/day with early feeding) compared to placebo plus routine dose (400 IU/day with established feeding) will substantially increase total 25-hydroxyvitamin D3 levels measured as state-of-art at 1 month, reduce respiratory support at 36 weeks' postmenstrual age (on an ordinal scale predictive of later adverse outcomes), and improve or at least not worsen other important secondary outcomes. The infants in the study will follow up at 22-26 months' corrected age (~2 years) with blinded certified examiners to evaluate neurodevelopmental outcomes. The sample size of a minimum of 180 infants provides >90% power to detect a >95% posterior probability of a 33% increase in serum 25-hydroxy vitamin D3 and >80% power to detect a >80% posterior probability of a relative risk decrease of 20% of reducing respiratory support by intention-to-treat Bayesian analyses using a neutral prior probability.

DISCUSSION

Our study will help clarify the uncertain relationship of vitamin D supplementation and its associated serum metabolites to clinical outcomes of extremely preterm infants. Confirmation of our hypotheses would prompt reconsideration of the supplementation regimens used in extremely preterm infants and justify a large multicenter study to verify the generalizability of the results.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05459298. Registered on July 14, 2022.

Randomized Controlled Trial of Enteral Vitamin D Supplementation (ViDES) in Infants <28 Weeks Gestational Age or <1000 Grams Birth Weight: Study Protocol

Background

Vitamin D is necessary to develop healthy lungs and other organs early in life. Most infants born before 28 weeks' gestation have low vitamin D levels at birth and a limited intake during the first month. Enteral vitamin D supplementation is inexpensive and widely used. The appropriate supplementation regimen for extremely preterm infants is controversial, and the effect of different regimens on their blood levels and outcomes is unclear.

Methods

Randomized, blinded comparative effectiveness trial to compare two vitamin D supplementation regimens for inborn infants <28 weeks gestation or <1000 grams birth weight at a large academic center in the United States.Infants are stratified by birth weight and randomized within 96 hours after birth to either routine supplementation (400 IU/day with established feedings) or increased supplementation (800 IU/day with any feedings) during the first 28 days after birth.We hypothesize that the higher and early vitamin D dose (800 IU/d with early feeding) compared to placebo plus routine dose (400 IU/d with established feeding) will substantially increase total 25-hydroxyvitamin D3 levels measured as state-of-art at one month, reduce respiratory support at 36 weeks' postmenstrual age (on an ordinal scale predictive of later adverse outcomes) and improve or at least not worsen other important secondary outcomes. The infants in the study will follow up at 22-26 months' corrected age (~2 years) with blinded certified examiners to evaluate neurodevelopmental outcomes.The sample size of a minimum of 180 infants provides >90% power to detect a >95% posterior probability of a 33% increase in serum 25-hydroxy vitamin D3 and >80% power to detect a >80% posterior probability of a relative risk decrease of 20% of reducing respiratory support by intention-to-treat Bayesian analyses using a neutral prior probability.

Discussion

Our study will help clarify the uncertain relationship of vitamin D supplementation and its associated serum metabolites to clinical outcomes of extremely preterminfants. Confirmation of our hypotheses would prompt reconsideration of the supplementation regimens used in extremely preterm infants and justify a large multicenter study to verify the generalizability of the results.

Trial registration

ClinicalTrials.gov registered on July 14, 2022 (NCT05459298).

Reported costs of children with medical complexity-A systematic review

Examining reported costs for Children with Medical Complexity (CMCs) is essential because costing and resource utilization studies influence policy and operational decisions. Our objectives were to (1) examine how authors identified CMCs in administrative databases, (2) compare reported costs for the CMC population in different study settings, and (3) analyze author recommendations related to reported costs. We undertook a systematic search of the following databases: Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library with a focus on CMCs as a heterogeneous group. The most common method used n = 11 (41%) to identify the CMC population in administrative data was the Complex Chronic Conditions methodology. The majority of included studies reported on health care service costs n = 24 (89%). Only n = 3 (11%) of the studies included costs from the family perspective. Author recommendations included standardizing how costs are reported and including the family perspective when making care delivery or policy decisions. Health system administrators and policymakers must consider the limitations of reported costs when assessing local costing studies or comparing costs across jurisdictions.

Developing a Sustainable Care Delivery Payment Model for Children With Medical Complexity

Children with medical complexity (CMC) are a small but growing population representing <1% of all children while accounting for >30% of childhood health care expenditure. Complex care is a relatively new discipline that has emerged with goals of improving CMC care, optimizing CMC family function, and reducing health care costs. The provision of care coordination services is a major function of most complex care programs. Unfortunately, most complex care programs struggle to achieve financial sustainability in a predominately fee-for-service environment. The article describes how 2 programs in Wisconsin worked with their state Medicaid payer through a Centers for Medicare and Medicaid Services Health Care Innovation Award to develop a sustainable complex care payment model, and the value the payment model is currently bringing to stakeholders. Key elements of the process included: Developing a relationship between payer and clinicians that allowed for an understanding of each's viewpoint, use of an accepted clinical service model, and an effort to measure cost of care for the service provided supported by time-study methodology.

Financing Policy Considerations From Texas to Optimize Care for Children With Medical Complexity

Texas has a tremendous opportunity and momentum to build a more effective system of care for children with medical complexity (CMC) and their families. This is evidenced by growing collaboration among many committed partners since implementation of the Medicaid STAR Kids managed care program in 2016 and Texas' participation in a US Health Resources and Services Administration-funded, 10-state Collaborative Improvement and Innovation Network to Advance Care for CMC from 2017 to 2022. Texas has several comprehensive health homes for CMC that position the state to serve as a national model of integrated, family-centered care for CMC and ensure high-quality care to an exceedingly vulnerable population. Further, Texas' elected leaders demonstrated their interest in system innovation in 2019 and 2021 by enacting state legislation to explore alternative care models and conduct a health home pilot for CMC. Much more must be done to sustain the work underway and bring the promise of care transformation to reality. To this point, we recommend that care planning and coordination be delegated to provider-led, integrated health homes for CMC with alternative payment structures that appropriately reimburse and align incentives with optimal care delivery. To realize the policy aspirations of an effective system of care for CMC, regulatory oversight, payment models, and outcome measures need to be improved to align with the vision articulated in Texas legislation and agency guidance. Although each state's Medicaid program is different, we believe each state can take away policy lessons from those learned by Texas.

Implementation and Evaluation of a Wraparound Virtual Care Program for Children with Medical Complexity

Objectives: Children and adolescents with medical complexity benefit from care coordination and specialized pediatric care, but many access barriers exist. We implemented a virtual wraparound model to support patients with medical complexity and their families and used an economic framework to measure outcomes. Methods: Children with medical complexity were identified and enrolled in a virtual complex care program with a dedicated multidisciplinary team, which provided care coordination, education, parental support, acute care triage, and virtual visits. A retrospective pre- and postanalysis of data obtained from the Hospital Industry Data Institute (HIDI) database measured inpatient, outpatient, and emergency department (ED) utilization and charges before implementation and during the 2-year program. Results: Eighty (n = 80) children were included in the economic evaluation, and 75 had sufficient data for analysis. Compared to the 12 months before enrollment, patients had a 35.3% reduction in hospitalizations (p = 0.0268), a 43.9% reduction in emergency visits (p = 0.0005), and a 16.9% reduction in overall charges (p = 0.1449). Parents expressed a high degree of satisfaction, with a 70% response rate and 90% satisfaction rate. Conclusions: We implemented a virtual care model to provide in-home support and care coordination for medically complex children and adolescents and used an economic framework to assess changes in utilization and cost. The program had high engagement rates and parent satisfaction, and a pre/postanalysis demonstrated statistically significant reduction in hospitalizations and ED visits for this high-cost population. Further economic evaluation is needed to determine sustainability of this model in a value-based payment system.

A Theory for Understanding Parental Workload and Capacity to Care for Children With Medical Complexity

BACKGROUND AND PURPOSE

Children with medical complexity (CMC) experience poor health outcomes despite the high cost of care, and their parents face challenges in providing complex care. Poor health outcomes may be related to an imbalance between parental demands to manage care and their ability to meet the demands needed to provide complex care. However, this phenomenon has not been explored. In addition, much of the existing research focused on CMC lacks an overarching theoretical framework. The purpose of this article is to outline factors that impact families of CMC described in the literature. This article proposes a modified framework using theory derivation, which highlights the concepts of parental workload and capacity and demonstrates how they are related to CMC health.

METHODS

A revised theoretical framework using theory derivation by Walker and Avant is presented using findings from the CMC literature that most affect the parents of these children.

RESULTS

Applying content from two existing theories using concepts of relevance results in a framework that provides richer insight into the relationship between parental workload and parental capacity, particularly when parental workload outweighs parental capacity. This framework allows for the examination of how an imbalance between workload and capacity impacts CMC health outcomes.

IMPLICATIONS FOR PRACTICE

Although further study is needed to test the proposed theory, the framework can be used to examine these relationships with hopes of developing interventions to decrease parental workload and enhance parental ability.

Optimizing the multidisciplinary team to enhance care coordination across the continuum for children with medical complexity

The number of individual patients needing the support of complex care coordination to help manage chronic illness and functional disability and to negotiate systemic barriers to care continues to grow. Children with medical complexity (CMC) require a multidisciplinary team approach to address their complex health care needs.  CMC may have multiple health conditions affecting numerous body systems, increased use of the health care system, and technology dependence.  A cohesive team approach to care for CMC is necessary to ensure that there are clearly defined roles for each member of the care team and the individualized plan of care is implemented with the unique needs of the patient and family at the center of the care. This article will outline the roles of the essential providers that support these children.

Intervention research to improve care and outcomes for children with medical complexity and their families

Healthcare and outcomes for children with medical complexity (CMC) and their families can be improved by conducting well-conceived, designed, implemented, and analyzed research studies of clinical interventions. This article presents a framework for how to approach the study of clinical interventions for CMC, including 7 key questions and example answers to each: (1) What intervention questions should be our focus? (2) What barriers to intervention research exist? (3) How do we design and optimize interventions? (4) How do we characterize and select patients to enroll? (5) How can we enhance data collection and integration? (6) How can we improve enrollment and participation? And (7) which intervention experimental designs should we choose? By exploring each of these key aspects of intervention-based research, we hope to expand thinking about and spark ideas for specific research projects focused on clinical interventions for CMC.

Telemedicine for Children With Medical Complexity: A Randomized Clinical Trial

BACKGROUND

Telemedicine is widely used but has uncertain value. We assessed telemedicine to further improve outcomes and reduce costs of comprehensive care (CC) for medically complex children.

METHODS

We conducted a single-center randomized clinical trial comparing telemedicine with CC relative to CC alone for medically complex children in reducing care days outside the home (clinic, emergency department, or hospital; primary outcome), rate of children developing serious illnesses (causing death, ICU admission, or hospital stay >7 days), and health system costs. We used intent-to-treat Bayesian analyses with neutral prior assuming no benefit. All participants received CC, which included 24/7 phone access to primary care providers (PCPs), low patient-to-PCP ratio, and hospital consultation from PCPs. The telemedicine group also received remote audiovisual communication with the PCPs.

RESULTS

Between August 22, 2018, and March 23, 2020, we randomly assigned 422 medically complex children (209 to CC with telemedicine and 213 to CC alone) before meeting predefined stopping rules. The probability of a reduction with CC with telemedicine versus CC alone was 99% for care days outside the home (12.94 vs 16.94 per child-year; Bayesian rate ratio, 0.80 [95% credible interval, 0.66-0.98]), 95% for rate of children with a serious illness (0.29 vs 0.62 per child-year; rate ratio, 0.68 [0.43-1.07]) and 91% for mean total health system costs (US$33 718 vs US$41 281 per child-year; Bayesian cost ratio, 0.85 [0.67-1.08]).

CONCLUSION

The addition of telemedicine to CC likely reduced care days outside the home, serious illnesses, other adverse outcomes, and health care costs for medically complex children.

The Relationship of Parental Health Literacy to Health Outcomes of Children with Medical Complexity

THEORETICAL PRINCIPLES

Children with medical complexity experience negative health outcomes despite the high costs associated with their care. There is growing evidence that low parental health literacy is associated with a number of poor child health outcomes, including medication errors. However, less is known about the relationship between parental health literacy and the health outcomes of children with medical complexity, whose care is known to be more complex and demanding of parents.

PHENOMENA ADDRESSED

The challenges faced by parents of children with medical complexity are presented, including those related to communication, care coordination, and medication administration. The historical and theoretical perspectives of health literacy are discussed, and the relationship of parental health literacy to pediatric health outcomes for children with medical complexity is explored.

RESEARCH LINKAGES

Remaining knowledge gaps about parental health literacy and its influence on the health of children with medical complexity are outlined. Future research and clinical practice implications of health literacy and its importance to family-centered care are discussed.

Discharging Medically Complex Infants with Supplemental Nasogastric Tube Feeds: Impact on Neonatal Intensive Care Unit Length of Stay and Prevention of Gastrostomy Tubes

OBJECTIVE

The aim of this study is to evaluate the feasibility, safety, and efficacy of discharge with supplemental nasogastric tube (NGT) feeds in medically complex infants.

STUDY DESIGN

Cohort study of 400 infants enrolled in the Transitional Medical Home (TMH) program at Duke University Level IV neonatal intensive care unit from January 2013 to 2017.

RESULTS

Among 400 infants enrolled in the TMH, 57 infants were discharged with an NGT. A total of 45 infants with a variety of diagnoses and comorbidities were included in final analysis. Among 45 infants, 5 obtained a gastrostomy tube (GT) postdischarge. Median (25-75th percentile) length of use of NGT in 40 infants was 12 days (4-37). Excluding four outliers who used NGT for ≥140 days, the median length of use was 8 days (3-24). This extrapolates to a median of 288 hospital days saved for the remaining 36 infants. There were only three emergency room visits related to parental concern for incorrect NGT placement. There was no statistically significant difference in percent oral feeding predischarge or growth in first month postdischarge between infants who orally fed versus those who obtained GTs.

CONCLUSION

Discharge with supplemental NGT feeds is safe and feasible utilizing a standardized protocol and close postdischarge follow-up. This practice can decrease length of stay and prevent need for GT.

KEY POINTS

· Discharge with nasogastric tube (NGT) supplementation is safe.. · Discharge with NGT supplementation decreases cost.. · Discharge with NGT can decrease neonatal intensive care unit length of stay.. · Medical home model facilitates safe discharge..

Families' perspectives on monitoring infants' health and development after discharge from NICUs

Based on a survey of families of very preterm infants, Seppanen et al report that: 1) parents rated post-discharge (post-NICU) care as poor or fair for 14.2% of children; 2) parents of one-third of children with health or developmental disorders rated their child’s post-hospital care as poor or fair, as compared to 12–13% of parents of typically developing and healthy children; and 3) parents’ suggestions for ways to improve post-hospital care focused primarily on better communication between the health care team and parents and better coordination of the child’s care. These findings point to a large opportunity for improving post-NICU services for infants born very preterm, especially for children with health or developmental disorders. In addition to gathering more information about families’ perspectives, vigorous quality improvement methods should be applied to improve the effectiveness of post-NICU clinics and the health and development outcomes of the infants and families served by these clinics.

Hospital Consultation From Outpatient Clinicians for Medically Complex Children: A Randomized Clinical Trial

IMPORTANCE

Children with medical complexity (CMC) frequently experience fragmented care. We have demonstrated that outpatient comprehensive care (CC) reduces serious illnesses, hospitalizations, and costs for high-risk CMC. Yet continuity of care for CMC is often disrupted with emergency department (ED) visits and hospitalizations.

OBJECTIVE

To evaluate a hospital consultation (HC) service for CMC from their outpatient CC clinicians.

DESIGN, SETTING, AND PARTICIPANTS

Randomized quality improvement trial at the University of Texas Health Science Center at Houston with an outpatient CC clinic and tertiary pediatric hospital (Children's Memorial Hermann Hospital). Participants included high-risk CMC (≥2 hospitalizations or ≥1 pediatric intensive care unit [PICU] admission in the year before enrolling in our clinic) receiving CC. Data were analyzed between January 11, 2018, and December 20, 2019.

INTERVENTIONS

The HC included serial discussions between CC clinicians, ED physicians, and hospitalists addressing need for admission, inpatient treatment, and transition back to outpatient care. Usual hospital care (UHC) involved routine pediatric hospitalist care.

MAIN OUTCOMES AND MEASURES

Total hospital days (primary outcome), PICU days, hospitalizations, and health system costs in skeptical bayesian analyses (using a prior probability assuming no benefit).

RESULTS

From October 3, 2016, through October 2, 2017, 342 CMC were randomized to either HC (n = 167) or UHC (n = 175) before meeting the predefined bayesian stopping guideline (>80% probability of reduced hospital days). In intention-to-treat analyses, the probability that HC reduced total hospital days was 91% (2.72 vs 6.01 per child-year; bayesian rate ratio [RR], 0.61; 95% credible interval [CrI], 0.30-1.26). The probability of a reduction with HC vs UHC was 98% for hospitalizations (0.60 vs 0.93 per child-year; RR, 0.68; 95% CrI, 0.48-0.97), 89% for PICU days (0.77 vs 1.89 per child-year; RR, 0.59; 95% CrI, 0.26-1.38), and 94% for mean total health system costs ($24 928 vs $42 276 per child-year; cost ratio, 0.67; 95% CrI, 0.41-1.10). In secondary analysis using a bayesian prior centered at RR of 0.78, reflecting the opinion of 7 experts knowledgeable about CMC, the probability that HC reduced hospital days was 96%.

CONCLUSIONS AND RELEVANCE

Among CMC receiving comprehensive outpatient care, an HC service from outpatient clinicians likely reduced total hospital days, hospitalizations, PICU days, other outcomes, and health system costs. Additional trials of an HC service from outpatient CC clinicians are needed for CMC in other centers.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02870387.

Unexpected results of a randomized quality improvement program for children with severe asthma

Objective: To assess whether an asthma intervention program reduces treatment days outside the home among children with severe asthma receiving comprehensive care (CC) in our center.Methods: Between October 21, 2014 and September 28, 2016, children with severe asthma were randomized to receive CC alone (n = 29) or CC plus the asthma intervention program (n = 34) which involved collaboration with pharmacists and school nurses, motivational interviewing, and tracking the one-second forced expiratory volume at home. All patients were followed through March 31, 2017. Frequentist and Bayesian intent-to-treat analyses were performed.Results: The asthma intervention program doubled the telephone calls between the staff and families (753 vs 356 per 100 child years for the intervention group vs. control group; Rate Ratio [RR], 2.11 [95% confidence interval, 1.29-3.45]). Yet, we found no evidence that it reduced the composite number of days of healthcare outside home which includes: clinic visits, ED visits, and hospital admissions (1179 vs 958 per 100 child-years in the intervention group vs. control group; [RR], 1.23 [95% CI, 0.82-1.84]) or secondary outcomes which are individual components (clinic visits, ED visits, hospitalizations, PICU admissions and school absences; RR 1.15 - 2.30; p > 0.05). Bayesian analysis indicated a 67% probability that the intervention program increases total treatment days outside the home and only a 14% probability of a true decrease of >20% as originally hypothesized.Conclusion: A multi-component intervention program provided to children with severe asthma failed to reduce and may have increased days of healthcare outside home and school absenteeism.