Comparing emergency department presentations among children with cerebral palsy with general childhood presentations: a data linkage study

Cerebral palsy in African paediatric populations: A scoping review

AIM

To review the epidemiology and outcomes of African children with cerebral palsy (CP) over a 21-year period.

METHOD

The PubMed, Scopus, and Web of Science online databases were searched for original research on African children with CP aged 18 years and younger published from 2000 to 2021.

RESULTS

A total of 1811 articles underwent review against explicit criteria; 93 articles were selected for inclusion in the scoping review. The reported prevalence of CP ranged from 0.8 to 10 per 1000 children. Almost half had perinatal risk factors, but up to 26% had no identifiable risk factor. At least one-third of children with CP had one or more comorbidities, most commonly epilepsy, intellectual disability, and malnutrition. African children with CP demonstrated excess premature mortality approximately 25 times that of the general population, predominantly from infections. Hospital-based and younger populations had larger proportions of children with severe impairments. African children with CP had inadequate access to care and education, yet showed functional improvements compared to controls for all evaluated interventions.

INTERPRETATION

The prevalence of CP in Africa remains uncertain. African children with CP have different risk profiles, greater premature mortality, and more severe functional impairments and comorbidities compared to the Global North. Several barriers prevent access to optimal care. Larger African studies on validated and effective interventions are needed.

'There was nothing, just absolute darkness': Understanding the needs of those caring for children and young people with complex neurodisability in a diverse UK context: A qualitative exploration in the ENCOMPASS study

BACKGROUND

Children and young people (CYP) with complex neurodisability experience multiple physical, communication, educational and social challenges, which require complex packages of multidisciplinary care. Part of the holistic care required includes supporting the families and parents/caregivers. The aim of the wider study was to introduce a new programme ('Ubuntu') to parents/caregivers and healthcare professionals (HCPs) in order to test the feasibility and acceptability of the concept and content, with the goal of potential adaptation for the UK in mind. Data collection and analysis uncovered rich data on caregiving journeys, navigation of health services, and perceived service gaps. This paper focuses solely on these topics. Further papers will report on the feasibility and adaptation data.

METHODS

Two rounds of semi-structured interviews were conducted with 12 caregivers of CYP with complex neurodisability and six HCPs from a variety of disciplines, recruited from a community child health service in London Borough of Newham, UK in 2020. The interviews included open-ended questions to explore caregiving journeys, experiences of navigating health services and perceived service gaps. Transcripts were analysed using a data-driven inductive thematic analysis.

RESULTS

Three themes were identified that related to the aim of understanding caregivers' experiences and unmet needs relating to current service provision. These were (1) Caregiver Mental Health, (2) The Information Gap and (3) The Need for Holistic Support. Mental health difficulties were reported, particularly around the period of diagnosis. Priority needs included the provision of clear information about the diagnosis and services offered, opportunities to forge peer support networks and for services across the community to collaborate.

CONCLUSIONS

The delivery of health services for CYP with neurodisability should encompass the broad needs of the family as well as meeting the clinical needs of the CYP.

Outpatient encounters, continuity of care, and unplanned hospital care for children and young people with cerebral palsy

AIM

To describe the relationships between outpatient encounters, continuity of care, and unplanned hospital care in children/young people with cerebral palsy (CP).

METHOD

In this population-based data-linkage cohort study we included children/young people with CP identified in the New South Wales/Australian Capital Territory CP Register (birth years 1994-2018). We measured the frequency of outpatient encounters and unplanned hospital care, defined as presentations to emergency departments and/or urgent hospital admissions (2015-2020). Continuity of outpatient care was measured using the Usual Provider of Care Index (UPCI).

RESULTS

Of 3267 children/young people with CP, most (n = 2738, 83.8%, 57.6% male) had one or more outpatient encounters (123 463 total encounters, median six outpatient encounters per year during childhood). High UPCI was more common in children/young people with mild CP (Gross Motor Function Classification System levels I-III, with no epilepsy or no intellectual disability), residing in metropolitan and areas of least socioeconomic disadvantage. Low UPCI was associated with four or more emergency department presentations (adjusted odds ratio [aOR] 2.34; 95% confidence interval [CI] 1.71-3.19) and one or more urgent hospital admissions (aOR 2.02; 95% CI 1.57-2.61).

INTERPRETATION

Children/young people with CP require frequent outpatient services. Improving continuity of care, particularly for those residing in regional/remote areas, may decrease need for unplanned hospital care.

WHAT THIS PAPER ADDS

Many children with cerebral palsy use multiple and frequent outpatient services. Better continuity of care is associated with living in metropolitan and less socioeconomically disadvantaged areas. Outpatient service utilization reduces at the time of transition to adult services. High outpatient utilization is associated with unplanned hospital care. Decreased continuity of care is associated with unplanned hospital care.

The cost of respiratory hospitalizations in children with cerebral palsy

AIM

To establish the burden of respiratory illness in cerebral palsy (CP) on the Western Australian health care system by quantifying the costs of respiratory hospitalizations in children with CP, compared with non-respiratory hospitalizations.

METHOD

A 2-year (2014-2015) retrospective study using linked hospital data (excluding emergency department visits), in a population of children with CP in Western Australia aged 18 years and under (median age at hospitalization 7 years; interquartile range 5-12 years).

RESULTS

In 671 individuals (57% male) there were 726 emergency hospitalizations, and 1631 elective hospitalizations. Although there were more elective hospitalizations, emergency hospitalizations were associated with longer stays in hospital, and more days in an intensive care unit, resulting in a higher total cost of emergency hospitalizations than elective hospitalizations (total costs: emergency AU$7 748 718 vs elective AU$6 738 187). 'Respiratory' was the leading cause of emergency hospitalizations, contributing to 36% of all emergency admission costs. For a group of high-cost inpatient users (top 5% of individuals with the highest total inpatient costs) the most common reason for hospitalization was 'respiratory'. Where non-respiratory admissions were complicated by an additional respiratory diagnosis, length of stay was greater.

INTERPRETATION

Respiratory hospitalizations in CP are a significant driver of health care costs. In the paediatric group, they are a burden for a subgroup of children with CP.

WHAT THIS PAPER ADDS

Respiratory illness is the most costly area for unplanned, emergency hospitalizations for children and young people with cerebral palsy. The top 5% of individuals with the highest total inpatient costs account for a disproportionate amount of health care costs.

An analysis of the diagnoses and costs of pediatric emergency care visits: a single center study

BACKGROUND

Children's emergency care visits are common, although the costs and reasons for visits vary. This register-based study examines the costs of pediatric emergency care and the diagnoses related to visits made to the Pediatric Emergency Unit at Tampere University Hospital (Tays), Tampere, Finland.

METHODS

This retrospective study described pediatric emergency care visits made between September 2018 and December 2019 to a single center in Tampere, Finland. The data were gathered from medical files and from cost-per-patient software and analyzed in groups by age, season, level of treatment in the ED (primary or secondary), and hospitalization, as well as by diagnosis groups.

RESULTS

During the study period, 11,454 visits were made. The total costs were over €3,380,000 ($2,837,758), with a median cost per visit was €260 ($217.90). Higher costs were associated with hospitalization and treatment in secondary care. The most common diagnoses were respiratory tract infections, counseling, other infections, GI symptoms, and other reasons.

CONCLUSION

Seriously ill children incur the highest costs per visit in pediatric emergency care. Respiratory tract infections are common reasons for emergency care visits, and the reasons why children come to emergency care in Finland are similar to those in other countries.

Using Communication Assistants in Qualitative Health Research

Qualitative health research is hampered by narrow constructs of human communication that privilege participants with access to spoken and written (normative) language. With limited awareness of such things as augmentative and alternative communication (AAC) or the rights of people with complex communication access needs, qualitative research becomes a 'picker and chooser' of whose voices are included in studies and whose are not. In order for 'voices' to be heard, adaptations are required which include the acknowledgement and support of communication assistants (informal and formal) who can help provide a communication bridge between people with complex communication access needs and researcher(s). Yet little is known of who qualifies as a communication assistant nor the scope and limitations of this role in health research. Beginning with communication diversity arguments the article compares communication assistants with language interpreters before discussing practice and implications for health research.

Epilepsy in children with cerebral palsy: a data linkage study

AIM

To compare the prevalence of epilepsy in children with cerebral palsy (CP) to peer controls and their differences in healthcare utilization.

METHOD

The Quebec CP registry was linked to the provincial administrative health database. Two CP cohorts were identified from the registry (n=302, 168 males, 1y 2mo-14y) and administrative data (n=370, 221 males, 2y 2mo-14y). A control cohort (n=6040, 3340 males, 10-14y) was matched by age, sex, and region to the CP registry cohort. Administrative data algorithms were used to define epilepsy cases. Data on hospitalizations and emergency department presentations were obtained.

RESULTS

Using the most sensitive epilepsy definition, prevalence was 42.05% in the CP registry, 43.24% in the CP administrative data, and 1.39% in controls. Prevalence rose with increasing Gross Motor Function Classification System level. Children with CP and epilepsy had increased number and length of hospitalizations and emergency department presentations compared to children with CP or epilepsy alone. Epilepsy accounted for approximately 5% of emergency department presentations and 10% of hospitalizations in children with epilepsy, with and without CP.

INTERPRETATION

Children with CP have an increased risk of epilepsy compared to their peers. Children with CP and coexisting epilepsy represent a unique subset with complex developmental disability and increased healthcare service utilization.

Determinants of hospital-based health service utilisation in cerebral palsy: a systematic review

OBJECTIVE

To systematically review and synthesize evidence of determinants associated with hospital-based health service utilisation among individuals with cerebral palsy (CP).

DATA SOURCES

Electronic databases MEDLINE, Embase, APA Psycinfo were searched from January 2000 to April 2020.

STUDY SELECTION

Observational studies were included that described people with CP, reported quantitative measures of hospital-based health service utilisation (inpatient, outpatient, emergency department), and based in high-income countries. We excluded studies that included only subsets of people with CP, or those that only reported therapy service utilisation.

DATA EXTRACTION

After initial screen, two reviewers reviewed full texts for inclusion and performed data extraction and risk of bias assessment using the Newcastle Ottawa scale. Determinants of health service utilisation were identified and categorised using the Andersen Behavioural Model.

DATA SYNTHESIS

Seventeen studies met inclusion criteria. Study quality was high. Twenty-six determinants were reported across eight Andersen Model characteristics. Individual predisposing factors such as sex showed no difference in health service utilisation; inpatient admissions decreased with increasing age during childhood and was lower in adults. Increased health service utilisation was associated with "individual need" including severe gross motor disability, epilepsy, developmental/ intellectual disability and gastrostomy-use across inpatient, outpatient and emergency department settings. There was little information reported on socio-demographic and health system contextual determinants.

CONCLUSIONS

CP health service utilisation was associated with age, severity and comorbidities. Improved understanding of determinants of health service utilisation can support health service access for people with CP.

Emergency department usage by adults with cerebral palsy: A retrospective cohort study

OBJECTIVE

To retrospectively profile the ED usage for a cohort of adults with cerebral palsy (CP).

METHODS

Five years of ED data from a Victorian hospital network was analysed to identify participants with CP using the Victorian Emergency Minimum Dataset supplemented with scrutiny of inpatient admission data to identify cases because of limited ED coding of CP. Presentation frequency, emergency diagnoses (International Classification of Diseases, 10th Revision codes) and presentation sequelae were calculated and described. An investigation into rates of low urgency presentations was conducted. Differences between adult and paediatric cohorts were described.

RESULTS

Participants with CP constituted 1586 ED presentations. Adults represented 43% (n = 689) of these. Thirty percent of adults presented more than five times over the study period, with respiratory (25%), gastrointestinal (17%) and epilepsy/convulsion diagnoses (11%) being the most common presentations. Rates of inpatient hospital admissions from the ED increased with age in adults (P < 0.001). Low urgency presentations made up 8.9% of total adult presentations.

CONCLUSIONS

The high rates of respiratory diagnoses and epilepsy/convulsions, both ambulatory care-sensitive conditions, may be indicative of transitional challenges between paediatric and adult healthcare, potentially highlighting difficulties in accessing primary care services. Relatively low rates of 'low urgency' presentations may suggest perceived medical fragility in this vulnerable population. People with CP who present to ED and were not admitted may be underrepresented in this data. National expansion of this research will aid the development of an evidence-based model of care for CP in Australia.

Patterns of Health Service Use Among Young People With Cerebral Palsy in England

Background: Although the provision of healthcare for people with cerebral palsy (CP) is typically focussed on childhood, many people with CP require access to services periodically throughout their life. Few studies have examined patterns of health service use among young people with CP in England. Understanding patterns of use may inform future service development.

Objective: To describe patterns of visits to rehabilitation and medical professionals among ambulatory young people with CP living in England, and identify factors associated with service use.

Methods: Sixty-two young people with CP aged 10–19 years [mean (SD) age 13.7 (2.5) years] in Gross Motor Function Classification System (GMFCS) levels I-III reported visits to a range of health professionals, hospital admissions and visits to the emergency department over a median duration of 34 weeks (min–max: 12–34 weeks). Negative binomial models were used to examine factors associated with number of visits.

Results: Physiotherapists were the most commonly used professional, with 67.7% of participants visiting a physiotherapist at least once, followed by dentists (66.1%), general practitioners (48.4%), occupational therapists (40.3%) and orthopaedic surgeons (40.3%). Physiotherapists were also the most frequently visited professional with a total of 473 visits (13.3 visits per person-year). Speech and language therapists (5.0 visits per person-year), occupational therapists (4.5 visits per person-year) and nurses (4.3 per person-year) were the next most frequently visited professionals. Age, GMFCS level, and speech impairment were associated with rate of visits to a physiotherapist.

Conclusions: The proportion of young people who visited medical and rehabilitation professionals during the study period varied considerably depending on the profession. Generally, the proportion of young people using services was low. In the context of limited resources, data on service use in combination with data on unmet need, may support the reorganisation of services to maximise benefits to young people with CP.

Predicting waiting and treatment times in emergency departments using ordinal logistic regression models

BACKGROUND

Since providing timely care is the primary concern of emergency departments (EDs), long waiting times increase patient dissatisfaction and adverse outcomes. Especially in overcrowded ED environments, emergency care quality can be significantly improved by developing predictive models of patients' waiting and treatment times to use in ED operations planning.

METHODS

Retrospective data on 37,711 patients arriving at the ED of a large urban hospital were examined. Ordinal logistic regression models were proposed to identify factors causing increased waiting and treatment times and classify patients with longer waiting and treatment times.

RESULTS

According to the proposed ordinal logistic regression model for waiting time prediction, age, arrival mode, and ICD-10 encoded diagnoses are all significant predictors. The model had 52.247% accuracy. The model for treatment time showed that in addition to age, arrival mode, and diagnosis, triage level was also a significant predictor. The model had 66.365% accuracy. The model coefficients had negative signs in the corresponding models, indicating that waiting times are negatively related to treatment times.

CONCLUSION

By predicting patients' waiting and treatment times, ED workloads can be assessed instantly. This enables ED personnel to be scheduled to better manage demand supply deficiencies, increase patient satisfaction by informing patients and relatives about expected waiting times, and evaluate performances to improve ED operations and emergency care quality.

Disability, Hospital Care, and Cost: Utilization of Emergency and Inpatient Care by a Cohort of Children with Intellectual and Developmental Disabilities

OBJECTIVE

To use medical claims data to determine patterns of healthcare utilization in children with intellectual and developmental disabilities, including frequency of service utilization, conditions that require hospital care, and costs.

STUDY DESIGN

Medicaid administrative claims from 4 states (Iowa, Massachusetts, New York, and South Carolina) from years 2008-2013 were analyzed, including 108 789 children (75 417 male; 33 372 female) under age 18 years with intellectual and developmental disabilities. Diagnoses included cerebral palsy, autism, fetal alcohol syndrome, Down syndrome/trisomy/autosomal deletions, other genetic conditions, and intellectual disability. Utilization of emergency department (ED) and inpatient hospital services were analyzed for 2012.

RESULTS

Children with intellectual and developmental disabilities used both inpatient and ED care at 1.8 times that of the general population. Epilepsy/convulsions was the most frequent reason for hospitalization at 20 times the relative risk of the general population. Other frequent diagnoses requiring hospitalization were mood disorders, pneumonia, paralysis, and asthma. Annual per capita expenses for hospitalization and ED care were 100% higher for children with intellectual and developmental disabilities, compared with the general population ($153 348 562 and $76 654 361, respectively).

CONCLUSIONS

Children with intellectual and developmental disabilities utilize significantly more ED and inpatient care than other children, which results in higher annual costs. Recognizing chronic conditions that increase risk for hospital care can provide guidance for developing outpatient care strategies that anticipate common clinical problems in intellectual and developmental disabilities and ensure responsive management before hospital care is needed.

Risk of hospital-treated injury in children with cerebral palsy: a population-based cohort study

AIM

To study whether cerebral palsy (CP) increases the risk of hospital-treated injuries in children up to 13 years of age.

METHODS

A Finnish population-based cohort (n=328 903) of children born during 2001 to 2006 was followed up for hospital-treated injuries until the end of 2014 via linkage of nation-wide registers. The rate of first injury was compared in children with and without CP. The effect of CP type, gender, severe comorbidities (intellectual disability, epilepsy, hearing or visual impairment), and the type of injury was evaluated.

RESULTS

Children with CP had an increased risk of injury compared with children without CP (unadjusted HR: 1.2, 95% CI: 1.0 - 1.4, p=0.40). Girls with CP (n = 191) had a higher risk of injury compared with girls without CP (29% vs 22%, HR: 1.4, 95% CI: 1.1 to 1.8, p = 0.01). Any comorbidity increased the risk of injury (HR: 1.5, 95% CI: 1.1 to 2.2, p = 0.015) among children with CP. Children with CP had a higher risk of traumatic brain injury (HR: 1.7, 95% CI 1.2 to 2.4, p = 0.002) than children without CP.

CONCLUSION

Girls with CP had the highest risk of hospital-treated injury. Children with CP are particularly prone to traumatic brain injuries.

Longitudinal trajectories and reference centiles for the impact of health conditions on daily activities of children with cerebral palsy

AIM

First, to describe the impact of health conditions on daily activities over time in children with cerebral palsy (CP) and to create age-specific reference centiles. Second, to determine the amount of change typical over a 1-year period, across Gross Motor Function Classification System (GMFCS) levels.

METHOD

A prospective, cohort design, with five assessments over 2 years, involved 708 children with a confirmed diagnosis of CP participating in the On Track Study (396 males, 312 females; mean age 6y [SD 2y 7mo]; range 18mo-12y at first assessment; 32.1% in GMFCS level I, 22.7% in GMFCS level II, 11.2% in GMFCS level III, 18.2% in GMFCS level IV, 15.7% in GMFCS level V). The impact of health conditions on daily activities was assessed using the Child Health Conditions Questionnaire. Data were analyzed using mixed-effects models and quantile regression.

RESULTS

Linear longitudinal trajectories describe the relatively stable impact of health conditions over time for each functional level for children aged 2 years to 12 years, with the lowest scores (least impact) in GMFCS level I and the highest scores (highest impact) in GMFCS level V. Centiles were created for children in each GMFCS level. A system to interpret the magnitude of change over time in centiles was developed.

INTERPRETATION

Longitudinal trajectories of co-occurring health conditions assist with understanding children's prognoses. Centiles assist in understanding a child's experience relative to children in similar GMFCS levels. Guidelines are provided to determine if children are progressing 'as expected', 'better than expected' or 'more poorly than expected' in regard to the impact of health conditions on daily activities.

WHAT THIS PAPER ADDS

For children with cerebral palsy, the mean impact of health conditions on daily activities is relatively stable. Significant intraindividual and interindividual variability for the impact of health conditions exists, which complicates prognosis. Centiles enable interpretation of the impact of health conditions relative to Gross Motor Function Classification System level.