1
|
McLeigh JD, Singh G, Huang R. The Impact of Health Status on Health Care Utilization of Children in Foster Care. J Dev Behav Pediatr 2024:00004703-990000000-00194. [PMID: 39023862 DOI: 10.1097/dbp.0000000000001302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/24/2024] [Indexed: 07/20/2024]
Abstract
OBJECTIVES This study sought to understand the health status of children in foster care; the relationship between their health status and health care utilization; and demographic and placement factors associated with health care utilization. METHODS To estimate relationships between health status and health care utilization, this study used electronic health records from 4976 children in foster care seen at a children's hospital in the southwestern United States, 2017 to 2020. An algorithm classified patients' health status as nonchronic, noncomplex chronic, or complex chronic. Descriptive statistics were used to describe patients and utilization. The χ2, Kruskal-Wallis, and pairwise comparison post hoc tests were used to examine relationships between health status and health care utilization. Zero-inflated negative binomial (ZINB) regression further estimated relationships between health status and health care utilization while factoring in demographic and placement characteristics. RESULTS Within the sample, 35.6% had complex chronic health status. Significant differences were found among health status groups in age, gender, ethnicity, and maltreatment exposure. Both nonparametric pairwise comparisons and the ZINB regression model showed that having complex chronic health was associated with higher utilization of all hospital resources: emergency, admission, primary and specialty care, and various therapies, relative to having noncomplex chronic and nonchronic health. CONCLUSION A high percentage of children in foster care had complex chronic health, and these patients used significantly more resources. This study suggests that hospital-based health clinics focused on children in foster care and care coordination may be warranted.
Collapse
Affiliation(s)
- Jill D McLeigh
- Rees-Jones Center for Foster Care Excellence, Children's Health, Dallas, TX
| | - Gunjan Singh
- Rees-Jones Center for Foster Care Excellence, Children's Health, Dallas, TX
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX; and
| | - Rong Huang
- Research Administration, Children's Health, Dallas, TX
| |
Collapse
|
2
|
Wells J, Shah A, Gillis H, Gustafson S, Powell C, Krasaelap A, Hanna S, Hoefert JA, Bigelow A, Sherwin J, Lewis EC, Bline KE. Tiny patients, huge impact: a call to action. Front Public Health 2024; 12:1423736. [PMID: 38952729 PMCID: PMC11215126 DOI: 10.3389/fpubh.2024.1423736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 06/06/2024] [Indexed: 07/03/2024] Open
Abstract
The continuation of high-quality care is under threat for the over 70 million children in the United States. Inequities between Medicaid and Medicare payments and the current procedural-based reimbursement model have resulted in the undervaluing of pediatric medical care and lack of prioritization of children's health by institutions. The number of pediatricians, including pediatric subspecialists, and pediatric healthcare centers are declining due to mounting financial obstacles and this crucial healthcare supply is no longer able to keep up with demand. The reasons contributing to these inequities are clear and rational: Medicaid has significantly lower rates of reimbursement compared to Medicare, yet Medicaid covers almost half of children in the United States and creates the natural incentive for medical institutions to prioritize the care of adults. Additionally, certain aspects of children's healthcare are unique from adults and are not adequately covered in the current payment model. The result of decades of devaluing children's healthcare has led to a substantial decrease in the availability of services, medications, and equipment needed to provide healthcare to children across the nation. Fortunately, the solution is just as clear as the problem: we must value the healthcare of children as much as that of adults by increasing Medicaid funding to be on par with Medicare and appreciate the complexities of care beyond procedures. If these changes are not made, the high-quality care for children in the US will continue to decline and increase strain on the overall healthcare system as these children age into adulthood.
Collapse
Affiliation(s)
- Jordee Wells
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Anita Shah
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Holly Gillis
- Department of Anesthesiology, Division of Pediatric Anesthestiology, University of Minnesota, Minneapolis, MN, United States
| | - Sarah Gustafson
- Division of Pediatric Hospital Medicine, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Carmin Powell
- Division of Pediatric Hospital Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Amornluck Krasaelap
- Department of Gastroenterology and Hepatology, SeattleChildren’s Hospital, Seattle, WA, United States
| | - Samantha Hanna
- Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, St. Louis, MO, United States
| | - Jennifer A. Hoefert
- Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, St. Louis, MO, United States
| | - Amee Bigelow
- The Heart Center, Nationwide Children’s Hospital, Columbus, OH, United States
| | - Jennifer Sherwin
- Division of Cardiovascular and Thoracic Surgery,Duke University Medical Center, Durham, NC, United States
| | - Emilee C. Lewis
- Division of Hospital Pediatrics, Department of Pediatrics,University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Katherine E. Bline
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH, United States
| |
Collapse
|
3
|
Harvey AR, Meehan E, Merrick N, D'Aprano AL, Cox GR, Williams K, Gibb SM, Mountford NJ, Connell TG, Cohen E. Comprehensive care programmes for children with medical complexity. Cochrane Database Syst Rev 2024; 5:CD013329. [PMID: 38813833 PMCID: PMC11137836 DOI: 10.1002/14651858.cd013329.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
BACKGROUND Children with medical complexity (CMC) represent a small, but growing, proportion of all children. Regardless of their underlying diagnosis, by definition, all CMC have similar functional limitations and high healthcare needs. It has been suggested that improving aspects of healthcare delivery for CMC improves health- and quality of life-related outcomes for children and their families and reduces healthcare-related expenditure. As a result, dedicated comprehensive care programmes have been established at many hospitals to meet the needs of CMC; however, it is unclear if such programmes are effective. OBJECTIVES Our main objective was to assess the effectiveness of comprehensive care programmes that aim to improve care coordination and other aspects of health care for CMC and to assess whether the effectiveness of such programmes differs according to the programme setting and structure. We aimed to assess their effectiveness in relation to child and parent health, functioning, and quality of life, quality of care, number of healthcare encounters, unmet healthcare needs, and total healthcare-related costs. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and CINAHL in May 2023. We also searched reference lists, trial registries, and the grey literature. SELECTION CRITERIA Randomised and non-randomised trials, controlled before-after studies, and interrupted time series studies were included. Studies that compared enrolment in a comprehensive care programme with non-enrolment in such a programme/treatment as usual were included. Participants were children that met the criteria for the definition of CMC, which is: having (i) a chronic condition, (ii) functional limitations, (iii) increased health and other service needs, and (iv) increased healthcare costs. Studies that included the following types of outcomes were included: health; quality of care; utilisation, coverage and access; resource use and costs; equity; and adverse outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data, assessed the risk of bias in each included study, and evaluated the certainty of evidence according to GRADE criteria. Where possible, data were represented in forest plots and pooled. We were unable to undertake a meta-analysis for comparisons and outcomes, so we used a structured synthesis approach. MAIN RESULTS We included four studies with a total of 912 CMC as participants. All included studies were randomised controlled trials conducted in hospitals in the USA or Canada. Participants varied across the included studies; however, all four studies included children with complex and chronic illness and high healthcare needs. While the primary aim of the intervention was similar across all four studies, the components of the interventions differed: in the four studies, the intervention involved some element of care coordination; in two of the studies, it involved the child receiving care from a multidisciplinary team, while in one study, the intervention was primarily centred on access to an advanced practice nurse care coordinator and another study involved nurse a practitioner-paediatrician dyad partnering with families. The risk of bias in the four studies varied across domains, with issues primarily relating to the lack of blinding of participants, personnel, and outcome assessors, inadequate allocation concealment, and incomplete outcome data. Comprehensive care for CMC compared to usual care may make little to no difference to child health, functioning, and quality of life at 12 or 24 months (three studies with 404 participants) and we assessed the evidence for the outcomes in this category (child health-related quality of life and functional status) as being of low certainty. For CMC, comprehensive care probably makes little or no difference to parent health, functioning, and quality of life compared to usual care at 12 months (one study with 117 participants) and we assessed the evidence for this outcome as being of moderate certainty. Comprehensive care for CMC compared to usual care may slightly improve child and family satisfaction with, and perceptions of, care and service delivery at 12 months (three studies with 453 participants); however, we assessed the evidence for these outcomes as being of low certainty. For CMC, comprehensive care probably makes little or no difference to the number of healthcare encounters (emergency department visits) and the number of hospitalised days (hospital admissions) compared to usual care at 12 months (three studies with 668 participants), and we assessed the evidence for these outcomes as being of moderate certainty. Three of the included studies (668 participants) reported cost outcomes and had conflicting results, with one study reporting significantly lower healthcare costs at 12 months in the intervention group compared to the control group, one reporting no differences between groups, and the other study reporting a greater increase in total healthcare costs in the intervention group compared to the control group. Overall, comprehensive care may make little or no difference to overall healthcare costs in CMC; however, the methods used to measure total healthcare costs varied across studies and the certainty of the evidence relating to this outcome is low. No studies assessed the costs to the family. AUTHORS' CONCLUSIONS The findings of this review should be treated with caution due to the limited amount and quality of the published research that was available to be included. Overall, the certainty of the evidence for the effectiveness of comprehensive care for CMC ranged from low to moderate across outcomes and there is currently insufficient evidence on which to draw strong conclusions. There is a need for more high-quality randomised trials with consistency of the target population and intervention components, methods of reporting outcomes, and follow-up periods, as well as full cost analyses, taking into account both costs to the family and costs to the healthcare system.
Collapse
Affiliation(s)
- Adrienne R Harvey
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Melbourne, Australia
| | - Elaine Meehan
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Melbourne, Australia
| | - Nicole Merrick
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Anita L D'Aprano
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Georgina R Cox
- Neurodevelopment and Disability, Royal Children's Hospital, Melbourne, Australia
| | - Katrina Williams
- Department of Paediatrics, Monash University, Melbourne, Australia
| | - Susan M Gibb
- Neurodevelopment and Disability, Royal Children's Hospital, Melbourne, Australia
| | - Nicki J Mountford
- Complex Care Hub, The Royal Children's Hospital, Melbourne, Australia
| | - Tom G Connell
- General Medicine, The Royal Children's Hospital, Melbourne, Australia
| | - Eyal Cohen
- Paediatrics and Health Policy, Management & Evaluation, University of Toronto, Toronto, Canada
| |
Collapse
|
4
|
Ram B, Rosenthal JL, Stieren E, Hamline M. Exploring Telehealth to Improve Discharge Outcomes in Children. Hosp Pediatr 2023; 13:1097-1105. [PMID: 38008989 PMCID: PMC10656430 DOI: 10.1542/hpeds.2023-007257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
OBJECTIVES The inpatient to outpatient transition is critical for patient safety but suffers from lack of standardization and communication. Expanding telehealth use allows unique opportunities to leverage secure video conferencing to streamline communication between families and hospital-based providers (HBPs) after hospital discharge. We conducted a qualitative study to evaluate HBP and caregiver beliefs regarding a proposed telehealth follow-up visit after hospital discharge (THDF). METHODS Interviews were conducted with pediatric hospitalists, senior pediatric residents, and caregivers of patients recently hospitalized on the study hospital's pediatric hospitalist service. Authors developed consensus regarding major themes to inform THDF design. These were organized into a conceptual model. RESULTS We conducted 23 interviews with 6 hospitalists, 6 senior residents, and 11 caregivers. Three primary themes were identified: (1) Caregivers and HBPs agree THDF would be beneficial for patients and families; however, evidence is not robust enough to solidify provider buy-in. (2) Telehealth should supplement and enhance current discharge practices; it should not serve as a bandage for a broken system. Although a key aspect of THDF is to have the hospitalist provide follow-up care, this should be provided in addition to primary care provider follow-up. (3) HBPs expressed concerns about challenging workflows, competing demands, and inadequate resources, which are potential barriers to widespread adoption. CONCLUSIONS THDF leverages expanding telehealth use to provide hospital-based follow-up. While HBPs shared workflow challenges in conducting telehealth, HBPs and caregivers believed potential benefits of THDF outweighed the challenges. This qualitative study will guide implementation of THDF in future studies.
Collapse
Affiliation(s)
| | | | - Emily Stieren
- Pediatrics, University of California, Davis, Davis, California
| | | |
Collapse
|
5
|
de Lange A, Alsem MW, Haspels HN, van Karnebeek CDM, van Woensel JBM, Etten-Jamaludin FS, Maaskant JM. Hospital-to-home transitions for children with medical complexity: part 1, a systematic review of reported outcomes. Eur J Pediatr 2023; 182:3805-3831. [PMID: 37318656 PMCID: PMC10570194 DOI: 10.1007/s00431-023-05050-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/19/2023] [Accepted: 05/31/2023] [Indexed: 06/16/2023]
Abstract
Outcome selection to evaluate interventions to support a successful transition from hospital to home of children with medical complexity (CMC) may be difficult due to the variety in available outcomes. To support researchers in outcome selection, this systematic review aimed to summarize and categorize outcomes currently reported in publications evaluating the effectiveness of hospital-to-home transitional care interventions for CMC. We searched the following databases: Medline, Embase, Cochrane library, CINAHL, PsychInfo, and Web of Science for studies published between 1 January 2010 and 15 March 2023. Two reviewers independently screened the articles and extracted the data with a focus on the outcomes. Our research group extensively discussed the outcome list to identify those with similar definitions, wording or meaning. Consensus meetings were organized to discuss disagreements, and to summarize and categorize the data. We identified 50 studies that reported in total 172 outcomes. Consensus was reached on 25 unique outcomes that were assigned to six outcome domains: mortality and survival, physical health, life impact (the impact on functioning, quality of life, delivery of care and personal circumstances), resource use, adverse events, and others. Most frequently studied outcomes reflected life impact and resource use. Apart from the heterogeneity in outcomes, we also found heterogeneity in designs, data sources, and measurement tools used to evaluate the outcomes. Conclusion: This systematic review provides a categorized overview of outcomes that may be used to evaluate interventions to improve hospital-to-home transition for CMC. The results can be used in the development of a core outcome set transitional care for CMC.
Collapse
Affiliation(s)
- Annemieke de Lange
- Department of Pediatrics, Amsterdam UMC location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, the Netherlands
| | - Mattijs W Alsem
- Department of Rehabilitation, Amsterdam UMC location University of Amsterdam, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, the Netherlands
| | - Heleen N Haspels
- Department of Pediatrics, Amsterdam UMC location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, the Netherlands
- Department of Pediatric and Neonatal Intensive Care, Division of Pediatric Intensive Care, ErasmusMC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Clara D M van Karnebeek
- Department of Pediatrics and Human Genetics, Emma Center for Personalized Medicine, Amsterdam UMC location University of Amsterdam, Emma Children's Hospital, Amsterdam Reproduction and Development, Meibergdreef 9, Amsterdam, the Netherlands
| | - Job B M van Woensel
- Department of Pediatrics, Amsterdam UMC location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, the Netherlands
| | - Faridi S Etten-Jamaludin
- Medical Library, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Jolanda M Maaskant
- Department of Pediatrics, Amsterdam UMC location University of Amsterdam, Emma Children's Hospital, Meibergdreef 9, Amsterdam, the Netherlands.
| |
Collapse
|
6
|
Cohen E, Quartarone S, Orkin J, Moretti ME, Emdin A, Guttmann A, Willan AR, Major N, Lim A, Diaz S, Osqui L, Soscia J, Fu L, Gandhi S, Heath A, Fayed N. Effectiveness of Structured Care Coordination for Children With Medical Complexity: The Complex Care for Kids Ontario (CCKO) Randomized Clinical Trial. JAMA Pediatr 2023; 177:461-471. [PMID: 36939728 PMCID: PMC10028546 DOI: 10.1001/jamapediatrics.2023.0115] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Importance Children with medical complexity (CMC) have chronic conditions and high health needs and may experience fragmented care. Objective To compare the effectiveness of a structured complex care program, Complex Care for Kids Ontario (CCKO), with usual care. Design, Setting, and Participants This randomized clinical trial used a waitlist variation for randomizing patients from 12 complex care clinics in Ontario, Canada, over 2 years. The study was conducted from December 2016 to June 2021. Participants were identified based on complex care clinic referral and randomly allocated into an intervention group, seen at the next available clinic appointment, or a control group that was placed on a waitlist to receive the intervention after 12 months. Intervention Assignment of a nurse practitioner-pediatrician dyad partnering with families in a structured complex care clinic to provide intensive care coordination and comprehensive plans of care. Main Outcomes and Measures Co-primary outcomes, assessed at baseline and at 6, 12, and 24 months postrandomization, were service delivery indicators from the Family Experiences With Coordination of Care that scored (1) coordination of care among health care professionals, (2) coordination of care between health care professionals and families, and (3) utility of care planning tools. Secondary outcomes included child and parent health outcomes and child health care system utilization and cost. Results Of 144 participants randomized, 141 had complete health administrative data, and 139 had complete baseline surveys. The median (IQR) age of the participants was 29 months (9-102); 83 (60%) were male. At 12 months, scores for utility of care planning tools improved in the intervention group compared with the waitlist group (adjusted odds ratio, 9.3; 95% CI, 3.9-21.9; P < .001), with no difference between groups for the other 2 co-primary outcomes. There were no group differences for secondary outcomes of child outcomes, parent outcomes, and health care system utilization and cost. At 24 months, when both groups were receiving the intervention, no primary outcome differences were observed. Total health care costs in the second year were lower for the intervention group (median, CAD$17 891; IQR, 6098-61 346; vs CAD$37 524; IQR, 9338-119 547 [US $13 415; IQR, 4572-45 998; vs US $28 136; IQR, 7002-89 637]; P = .01). Conclusions and Relevance The CCKO program improved the perceived utility of care planning tools but not other outcomes at 1 year. Extended evaluation periods may be helpful in assessing pediatric complex care interventions. Trial Registration ClinicalTrials.gov Identifier: NCT02928757.
Collapse
Affiliation(s)
- Eyal Cohen
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada
| | - Samantha Quartarone
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Julia Orkin
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Myla E Moretti
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Clinical Trials Unit, Ontario Child Health Support Unit, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Abby Emdin
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Hospital, Toronto, Ontario, Canada
| | - Astrid Guttmann
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada
| | - Andrew R Willan
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Nathalie Major
- Department of Paediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Audrey Lim
- Department of Pediatrics, Hamilton Health Sciences Centre, McMaster University, Hamilton, Ontario, Canada
| | - Sanober Diaz
- Provincial Council for Maternal and Child Health, Toronto, Ontario, Canada
| | - Lisa Osqui
- Provincial Council for Maternal and Child Health, Toronto, Ontario, Canada
| | - Joanna Soscia
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Lawrence M. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Anna Heath
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Statistical Science, University College London, London, United Kingdom
| | - Nora Fayed
- School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada
| |
Collapse
|
7
|
Pygott N, Hartley A, Seregni F, Ford TJ, Goodyer IM, Necula A, Banu A, Anderson JK. Research Review: Integrated healthcare for children and young people in secondary/tertiary care - a systematic review. J Child Psychol Psychiatry 2023. [PMID: 36941107 DOI: 10.1111/jcpp.13786] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Children and young people (CYP) with comorbid physical and/or mental health conditions often struggle to receive a timely diagnosis, access specialist mental health care, and more likely to report unmet healthcare needs. Integrated healthcare is an increasingly explored model to support timely access, quality of care and better outcomes for CYP with comorbid conditions. Yet, studies evaluating the effectiveness of integrated care for paediatric populations are scarce. AIM AND METHODS This systematic review synthesises and evaluates the evidence for effectiveness and cost-effectiveness of integrated care for CYP in secondary and tertiary healthcare settings. Studies were identified through systematic searches of electronic databases: Medline, Embase, PsychINFO, Child Development and Adolescent Studies, ERIC, ASSIA and British Education Index. FINDINGS A total of 77 papers describing 67 unique studies met inclusion criteria. The findings suggest that integrated care models, particularly system of care and care coordination, improve access and user experience of care. The results on improving clinical outcomes and acute resource utilisation are mixed, largely due to the heterogeneity of studied interventions and outcome measures used. No definitive conclusion can be drawn on cost-effectiveness since studies focused mainly on costs of service delivery. The majority of studies were rated as weak by the quality appraisal tool used. CONCLUSIONS The evidence of on clinical effectiveness of integrated healthcare models for paediatric populations is limited and of moderate quality. Available evidence is tentatively encouraging, particularly in regard to access and user experience of care. Given the lack of specificity by medical groups, however, the precise model of integration should be undertaken on a best-practice basis taking the specific parameters and contexts of the health and care environment into account. Agreed practical definitions of integrated care and associated key terms, and cost-effectiveness evaluations are a priority for future research.
Collapse
Affiliation(s)
- Naomi Pygott
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Alex Hartley
- Department of Psychiatry, University of Cambridge, Cambridge, UK
- Department of Psychology, University of Bath, Bath, UK
| | - Francesca Seregni
- Department of Paediatrics, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Tamsin J Ford
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Ian M Goodyer
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Andreea Necula
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania
| | - Arina Banu
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania
| | | |
Collapse
|
8
|
Esser K, Moore C, Hounsell KG, Davis A, Sunderji A, Shulman R, Maguire B, Cohen E, Orkin J. Housing Need Among Children With Medical Complexity: A Cross-Sectional Descriptive Study of Three Populations. Acad Pediatr 2022; 22:900-909. [PMID: 34607051 DOI: 10.1016/j.acap.2021.09.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 09/20/2021] [Accepted: 09/26/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Children with medical complexity (CMC) are hypothesized to have unique housing and accessibility needs due to their medical fragility and medical technology dependency; however, research on prevalence and types of housing need in CMC is limited. The objective was to describe housing need in families of CMC, and to compare housing need across CMC, children with one chronic condition (Type 1 diabetes; CT1D) and healthy children (HC). METHODS This cross-sectional descriptive study assessed housing suitability, adequacy, affordability, stress, stability, and accessibility using survey methodology. Participants were caregivers of CMC, CT1D and HC at a tertiary-care pediatric hospital. The association of housing need outcomes across groups was analyzed using logistic and ordinal logistic regression models, adjusting for income, educational attainment, employment status, community type, immigration status, child age, and number of people in household. RESULTS Four hundred ninety caregivers participated. Caregivers of CMC reported increased risk of housing-related safety concerns (aOR 3.1 [1.3-7.5]), using a common area as a sleeping area (5.6 [2.0-16.8]), reducing spending (4.6 [2.3-9.5]) or borrowing money to afford rent (2.9 [1.2-6.7]), experiencing housing stress (3.3 [1.8-6.0]), and moving or considering moving to access health/community services (15.0 [6.4-37.6]) compared to HC. CONCLUSIONS CMC were more likely to experience multiple indicators of housing need compared to CT1D and HC even after adjusting for sociodemographic factors, suggesting an association between complexity of child health conditions and housing need. Further research and practise should consider screening for and supporting housing need in CMC.
Collapse
Affiliation(s)
- Kayla Esser
- Child Health Evaluative Sciences, The Hospital for Sick Children (K Esser, C Moore, KG Hounsell, R Shulman, E Cohen, and J Orkin), Toronto, Canada
| | - Clara Moore
- Child Health Evaluative Sciences, The Hospital for Sick Children (K Esser, C Moore, KG Hounsell, R Shulman, E Cohen, and J Orkin), Toronto, Canada
| | - Kara Grace Hounsell
- Child Health Evaluative Sciences, The Hospital for Sick Children (K Esser, C Moore, KG Hounsell, R Shulman, E Cohen, and J Orkin), Toronto, Canada
| | - Adrienne Davis
- Division of Paediatric Emergency Medicine, The Hospital for Sick Children (A Davis and A Sunderji), Toronto, Canada
| | - Alia Sunderji
- Division of Paediatric Emergency Medicine, The Hospital for Sick Children (A Davis and A Sunderji), Toronto, Canada
| | - Rayzel Shulman
- Child Health Evaluative Sciences, The Hospital for Sick Children (K Esser, C Moore, KG Hounsell, R Shulman, E Cohen, and J Orkin), Toronto, Canada; Division of Endocrinology, The Hospital for Sick Children (R Shulman), Toronto, Canada; Department of Paediatrics, University of Toronto (R Shulman), Toronto, Canada
| | - Bryan Maguire
- Biostatistics, Design and Analysis, Research Institute, The Hospital for Sick Children (B Maguire), Toronto, Canada
| | - Eyal Cohen
- Child Health Evaluative Sciences, The Hospital for Sick Children (K Esser, C Moore, KG Hounsell, R Shulman, E Cohen, and J Orkin), Toronto, Canada; Department of Paediatrics, University of Toronto (R Shulman), Toronto, Canada; Division of Paediatric Medicine, The Hospital for Sick Children (E Cohen and J Orkin), Toronto, Canada; Edwin S.H. Leong Centre for Healthy Children, University of Toronto (E Cohen), Toronto, Canada
| | - Julia Orkin
- Child Health Evaluative Sciences, The Hospital for Sick Children (K Esser, C Moore, KG Hounsell, R Shulman, E Cohen, and J Orkin), Toronto, Canada; Department of Paediatrics, University of Toronto (R Shulman), Toronto, Canada; Division of Paediatric Medicine, The Hospital for Sick Children (E Cohen and J Orkin), Toronto, Canada.
| |
Collapse
|
9
|
Azzopardi C, Cohen E, Pépin K, Netten K, Birken C, Madigan S. Child Welfare System Involvement Among Children With Medical Complexity. CHILD MALTREATMENT 2022; 27:257-266. [PMID: 34219484 PMCID: PMC9003756 DOI: 10.1177/10775595211029713] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Children with medical complexity may be at elevated risk of experiencing child maltreatment and child welfare system involvement, though empirical data are limited. This study examined the extent of child welfare system involvement among children with medical complexity and investigated associated health and social factors. A retrospective chart review of children with medical complexity (N = 208) followed at a pediatric hospital-based complex care program in Canada was conducted. Descriptive statistics and odds ratios using logistic regression were computed. Results showed that nearly one-quarter (23.6%) had documented contact with the child welfare system, most commonly for neglect; of those, more than one-third (38.8%) were placed in care. Caregiver reported history of mental health problems (aOR = 3.19, 95%CI = 1.55-6.56), chronic medical conditions (aOR = 2.86, 95%CI = 1.09-7.47), and interpersonal violence or trauma (aOR = 17.58, 95%CI = 5.43-56.98) were associated with increased likelihood of child welfare system involvement, while caregiver married/common-law relationship status (aOR = 0.35, 95%CI = 0.16-0.74) and higher number of medical technology supports (aOR = 0.75, 95%CI = 0.57-0.99) were associated with decreased likelihood. Implications for intervention and prevention of maltreatment in children with high healthcare needs are discussed.
Collapse
Affiliation(s)
- Corry Azzopardi
- Suspected Child Abuse and Neglect Program, Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eyal Cohen
- Child Health Evaluative Sciences, The Hospital for Sick Children, Department of Paediatrics and Institute of Health Policy, Management & Evaluation, Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Ontario, Canada
| | - Karine Pépin
- Department of Paediatric, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Quebec, Canada
| | - Kathy Netten
- Department of Social Work, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Catherine Birken
- Department of Paediatrics, University of Toronto, Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Sheri Madigan
- Department of Psychology, University of Calgary, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| |
Collapse
|
10
|
Implementing a Care Coordination Strategy for Children with Medical Complexity in Ontario, Canada: A Process Evaluation. Int J Integr Care 2022; 22:9. [PMID: 35582499 PMCID: PMC9053529 DOI: 10.5334/ijic.6073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 04/11/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction: A provincial strategy to expand care coordination and integration of care for children with medical complexity (CMC) was launched in Ontario, Canada in 2015. A process evaluation of the roll-out examined the processes, mechanisms of impact, and contextual factors affecting the implementation of the Complex Care for Kids Ontario (CCKO) intervention strategy. Methods: This process evaluation was conducted and analyzed according to the United Kingdom Medical Research Council (UK-MRC) process evaluation framework. To evaluate the implementation of the CCKO intervention, a multi-method study design was used, including semi-structured interviews with 38 key informants and 10 families of CMC involved in CCKO. To further understand implementation details across regional sites, provincial-level implementation plans, and process documents were reviewed. Discussion: Strengths of CCKO included novel collaborations and partnerships between complex care teams, community partners and regional sites. Issues relating to communication and coordination across care sectors created challenges to holistic care coordination objectives. Provincial system fragmentation limited the ability of CCKO to provide seamless care coordination due to the multiple care sectors involved. Conclusion: This study adds to the understanding of the processes involved in a population-level care coordination intervention for CMC. Lessons learned through CCKO can help facilitate reproducibility and necessary adjustments of the intervention in different settings.
Collapse
|
11
|
Thomson J, Butts B, Camara S, Rasnick E, Brokamp C, Heyd C, Steuart R, Callahan S, Taylor S, Beck AF. Neighborhood Socioeconomic Deprivation and Health Care Utilization of Medically Complex Children. Pediatrics 2022; 149:185376. [PMID: 35253047 DOI: 10.1542/peds.2021-052592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To assess the association between neighborhood socioeconomic deprivation and health care utilization in a cohort of children with medical complexity (CMC). METHODS Cross-sectional study of children aged <18 years receiving care in our institution's patient-centered medical home (PCMH) for CMC in 2016 to 2017. Home addresses were assigned to census tracts and a tract-level measure of socioeconomic deprivation (Deprivation Index with range 0-1, higher numbers represent greater deprivation). Health care utilization outcomes included emergency department visits, hospitalizations, inpatient bed days, and missed PCMH clinic appointments. To evaluate the independent association between area-level socioeconomic deprivation and utilization outcomes, multivariable Poisson and linear regression models were used to control for demographic and clinical covariates. RESULTS The 512 included CMC lived in neighborhoods with varying degrees of socioeconomic deprivation (median 0.32, interquartile range 0.26-0.42, full range 0.12-0.82). There was no association between area-level deprivation and emergency department visits (adjusted risk ratio [aRR] 0.98; 95% confidence interval [CI]: 0.93 to 1.04), hospitalizations (aRR 0.97; 95% CI: 0.92 to 1.01), or inpatient bed-days (aRR 1.00, 95% CI: 0.80 to 1.27). However, there was a 13% relative increase in the missed clinic visit rate for every 0.1 unit increase in Deprivation Index (95% CI: 8%-18%). CONCLUSIONS A child's socioeconomic context is associated with their adherence to PCMH visits. Our PCMH for CMC includes children living in neighborhoods with a range of socioeconomic deprivation and may blunt effects from harmful social determinants. Incorporating knowledge of the socioeconomic context of where CMC and their families live is crucial to ensure equitable health outcomes.
Collapse
Affiliation(s)
- Joanna Thomson
- Divisions of Hospital Medicine.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics.,University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Breann Butts
- General and Community Pediatrics.,Department of Pediatrics.,University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Saige Camara
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Cole Brokamp
- Biostatistics and Epidemiology.,Department of Pediatrics.,University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Caroline Heyd
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Scott Callahan
- General and Community Pediatrics.,Department of Pediatrics.,University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Stuart Taylor
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Andrew F Beck
- Divisions of Hospital Medicine.,General and Community Pediatrics.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics.,University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
12
|
Gill PJ, Thavam T, Anwar MR, Zhu J, Parkin PC, Cohen E, To T, Mahant S. Prevalence, Cost, and Variation in Cost of Pediatric Hospitalizations in Ontario, Canada. JAMA Netw Open 2022; 5:e2147447. [PMID: 35138399 PMCID: PMC8829658 DOI: 10.1001/jamanetworkopen.2021.47447] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
IMPORTANCE Identifying conditions that could be prioritized for research based on health care system burden is important for developing a research agenda for the care of hospitalized children. However, existing prioritization studies are decades old or do not include data from both pediatric and general hospitals. OBJECTIVE To assess the prevalence, cost, and variation in cost of pediatric hospitalizations at all general and pediatric hospitals in Ontario, Canada, with the aim of identifying conditions that could be prioritized for future research. DESIGN, SETTING, AND PARTICIPANTS This population-based cross-sectional study used health administrative data from 165 general and pediatric hospitals in Ontario, Canada. Children younger than 18 years with an inpatient hospital encounter between April 1, 2014, and March 31, 2019, were included. MAIN OUTCOMES AND MEASURES Condition-specific prevalence, cost of pediatric hospitalizations, and condition-specific variation in cost per inpatient encounter across hospitals. Variation in cost was evaluated using (1) intraclass correlation coefficient (ICC) and (2) number of outlier hospitals. Costs were adjusted for inflation to 2018 US dollars. RESULTS Overall, 627 314 inpatient hospital encounters (44.8% among children younger than 30 days and 53.0% among boys) at 165 hospitals (157 general and 8 pediatric) costing $3.3 billion were identified. A total of 408 003 hospitalizations (65.0%) and $1.4 billion (43.8%) in total costs occurred at general hospitals. Among the 50 most prevalent and 50 most costly conditions (of 68 total conditions), the top 10 highest-cost conditions accounted for 55.5% of all costs and 48.6% of all encounters. The conditions with highest prevalence and cost included low birth weight (86.2 per 1000 encounters; $676.3 million), preterm newborn (38.0 per 1000 encounters; $137.4 million), major depressive disorder (20.7 per 1000 encounters; $78.3 million), pneumonia (27.3 per 1000 encounters; $71.6 million), other perinatal conditions (68.0 per 1000 encounters; $65.8 million), bronchiolitis (25.4 per 1000 encounters; $54.6 million), and neonatal hyperbilirubinemia (47.9 per 1000 encounters; $46.7 million). The highest variation in cost per encounter among the most costly medical conditions was observed for 2 mental health conditions (other mental health disorders [ICC, 0.28] and anxiety disorders [ICC, 0.19]) and 3 newborn conditions (intrauterine hypoxia and birth asphyxia [ICC, 0.27], other perinatal conditions [ICC, 0.17], and surfactant deficiency disorder [ICC, 0.17]). CONCLUSIONS AND RELEVANCE This population-based cross-sectional study of hospitalized children identified several newborn and mental health conditions as having the highest prevalence, cost, and variation in cost across hospitals. Findings of this study can be used to develop a research agenda for the care of hospitalized children that includes general hospitals and to ultimately build a more substantial evidence base and improve patient outcomes.
Collapse
Affiliation(s)
- Peter J. Gill
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
| | - Thaksha Thavam
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | | | - Jingqin Zhu
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Patricia C. Parkin
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
| | - Eyal Cohen
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
| | - Teresa To
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
| | - Sanjay Mahant
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
13
|
Emdin A, Strzelecki M, Seto W, Feinstein J, Bogler O, Cohen E, Roth DE. Medications Reconciled at Discharge Versus Admission Among Inpatients at a Children's Hospital. Hosp Pediatr 2021:hpeds.2021-006080. [PMID: 34807980 PMCID: PMC9156657 DOI: 10.1542/hpeds.2021-006080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Discharge prescription practices may contribute to medication overuse and polypharmacy. We aimed to estimate changes in the number and types of medications reported at inpatient discharge (versus admission) at a tertiary care pediatric hospital. METHODS Electronic medication reconciliation data were extracted for inpatient admissions at The Hospital for Sick Children from January 1, 2016, to December 31, 2017 (n = 22 058). Relative changes in the number of medications and relative risks (RRs) of specific types and subclasses of medications at discharge (versus admission) were estimated overall and stratified by the following: sex, age group, diagnosis of a complex chronic condition, surgery, or ICU (PICU) admission. Micronutrient supplements, nonopioid analgesics, cathartics, laxatives, and antibiotics were excluded in primary analyses. RESULTS Medication counts at discharge were 1.27-fold (95% confidence interval [CI]: 1.25-1.29) greater than admission. The change in medications at discharge (versus admission) was increased by younger age, absence of a complex chronic condition, surgery, PICU admission, and discharge from a surgical service. The most common drug subclasses at discharge were opioids (22% of discharges), proton pump inhibitors (18%), bronchodilators (10%), antiemetics (9%), and corticosteroids (9%). Postsurgical patients had higher RRs of opioid prescriptions at discharge (versus admission; RR: 13.3 [95% CI: 11.5-15.3]) compared with nonsurgical patients (RR: 2.38 [95% CI: 2.22-2.56]). CONCLUSIONS Pediatric inpatients were discharged from the hospital with more medications than admission, frequently with drugs that may be discretionary rather than essential. The high frequency of opioid prescriptions in postsurgical patients is a priority target for educational and clinical decision support interventions.
Collapse
Affiliation(s)
- Abby Emdin
- Child Health Evaluative Sciences and SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health
| | - Marina Strzelecki
- Department of Pharmacy, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Winnie Seto
- Child Health Evaluative Sciences and SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pharmacy, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - James Feinstein
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Children's Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | | | - Eyal Cohen
- Child Health Evaluative Sciences and SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation
| | - Daniel E Roth
- Child Health Evaluative Sciences and SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health
- Institute of Health Policy, Management and Evaluation
| |
Collapse
|
14
|
Pulcini CD, Coller RJ, Houtrow AJ, Belardo Z, Zorc JJ. Preventing Emergency Department Visits for Children With Medical Complexity Through Ambulatory Care: A Systematic Review. Acad Pediatr 2021; 21:605-616. [PMID: 33486099 DOI: 10.1016/j.acap.2021.01.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/09/2020] [Accepted: 01/17/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Children with medical complexity (CMC) represent a growing population with high emergency department (ED) utilization. How to reduce preventable ED visits is poorly understood. OBJECTIVE We sought to determine what components of ambulatory care programs focused on CMC were most effective in preventing ED visits. DATA SOURCES PubMed Plus, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and Cumulative Index to Nursing and Allied Health Literature databases through October 2019, and hand search of bibliographies. STUDY ELIGIBILITY CRITERIA Two independent reviewers used a structured screening protocol to include English language articles summarizing studies that included CMC, emergency care, or ED utilization. Data on ED utilization were extracted. RESULTS Sixteen included studies described outpatient interventions to prevent ED utilization. Of these, studies that included 24/7 access to knowledgeable providers for acute care needs by phone (telehealth) or expedited or next-day appointments were the most consistently successful in reducing ED visits. LIMITATIONS Risk of bias was mixed across studies. The evidence base is currently small and observational nature of interventions and their evaluations limit definitive, generalizable recommendations. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Current research suggests that real-time access to knowledgeable providers and expedited appointments can prevent ED visits. Further study is needed to generalize these findings as well as investigate novel strategies such as telehealth to improve quality of care, decrease utilization, and provide cost-effective care for this vulnerable population.
Collapse
Affiliation(s)
- Christian D Pulcini
- Division of Emergency Medicine, Department of Surgery, University of Vermont (CD Pulcini), Burlington, Vt.
| | - Ryan J Coller
- Department of Pediatrics, University of Wisconsin-Madison (RJ Coller), Madison, Wis
| | - Amy J Houtrow
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh (AJ Houtrow), Pittsburgh, Pa
| | - Zoe Belardo
- University of Pennsylvania (Z Belardo), Philadelphia, Pa
| | - Joseph J Zorc
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia (JJ Zorc), Philadelphia, Pa
| |
Collapse
|
15
|
Nkoy F, Stone B, Hofmann M, Fassl B, Zhu A, Mahtta N, Murphy N. Home-Monitoring Application for Children With Medical Complexity: A Feasibility Trial. Hosp Pediatr 2021; 11:492-502. [PMID: 33827786 DOI: 10.1542/hpeds.2020-002097] [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 Mobile apps are suggested for supporting home monitoring and reducing emergency department (ED) visits and hospitalizations for children with medical complexity (CMC). None have been implemented. We sought to assess the MyChildCMC app (1) feasibility for CMC home monitoring, (2) ability to detect early deteriorations before ED and hospital admissions, and (3) preliminary impact. METHODS Parents of CMC (aged 1-21 years) admitted to a children's hospital were randomly assigned to MyChildCMC or usual care. MyChildCMC subjects recorded their child's vital signs and symptoms daily for 3 months postdischarge and received real-time feedback. Feasibility measures included parent's enrollment, retention, and engagement. The preliminary impact was determined by using quality of life, parent satisfaction with care, and subsequent ED and hospital admissions and hospital days. RESULTS A total of 62 parents and CMC were invited to participate: 50 enrolled (80.6% enrollment rate) and were randomly assigned to MyChildCMC (n = 24) or usual care (n = 26). Retention at 1 and 3 months was 80% and 74%, and engagement was 68.3% and 62.6%. Run-chart shifts in vital signs were common findings preceding admissions. The satisfaction score was 26.9 in the MyChildCMC group and 24.1 in the control group (P = .035). No quality of life or subsequent admission differences occurred between groups. The 3-month hospital days (pre-post enrollment) decreased from 9.25 to 4.54 days (rate ratio = 0.49; 95% confidence interval = 0.39-0.62; P < .001) in the MyChildCMC group and increased from 1.08 to 2.46 days (rate ratio = 2.29; 95% confidence interval = 1.47-3.56; P < .001) in the control group. CONCLUSIONS MyChildCMC was feasible and appears effective, with the potential to detect early deteriorations in health for timely interventions that might avoid ED and hospitalizations. A larger and definitive study of MyChildCMC's impact and sustainability is needed.
Collapse
Affiliation(s)
- Flory Nkoy
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Bryan Stone
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Michelle Hofmann
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Bernhard Fassl
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Angela Zhu
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Namita Mahtta
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Nancy Murphy
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| |
Collapse
|
16
|
Braun L, Steurer M, Henry D. Healthcare Utilization of Complex Chronically Ill Children Managed by a Telehealth-Based Team. Front Pediatr 2021; 9:689572. [PMID: 34222153 PMCID: PMC8242159 DOI: 10.3389/fped.2021.689572] [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: 04/01/2021] [Accepted: 05/13/2021] [Indexed: 11/29/2022] Open
Abstract
Objectives: Medical advances have improved survival of critically ill children, increasing the number that have substantial ongoing care needs. The first aim of this study was to compare healthcare utilization of children with complex chronic conditions across an extensive geographic area managed by a predominantly telehealth-based team (FamiLy InteGrated Healthcare Transitions-FLIGHT) compared to matched historical controls. The second aim was to identify risk factors for healthcare utilization within the FLIGHT population. Methods: We performed a retrospective cohort study of all patients enrolled in the care management team. First, we compared them to age- and technology-based matched historic controls across medical resource-utilization outcomes. Second, we used univariable and multivariable linear regression models to identify risk factors for resource utilization within the FLIGHT population. Results: Sixty-four FLIGHT patients were included, with 34 able to be matched with historic controls. FLIGHT patients had significantly fewer hospital days per year (13.6 vs. 30.3 days, p = 0.02) and shorter admissions (6.0 vs. 17.3 days, p = 0.02) compared to controls. Within the telehealth managed population, increased number of technologies was associated with more admissions per year (coefficient 0.90, CI 0.05 - 1.75) and hospital days per year (16.83, CI 1.76 - 31.90), although increased number of complex chronic conditions was not associated with an increase in utilization. Conclusion: A telehealth-based care coordination team was able to significantly decrease some metrics of healthcare utilization in a complex pediatric population. Future study is warranted into utilization of telemedicine for care coordination programs caring for children with medical complexity.
Collapse
Affiliation(s)
- Lindsay Braun
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States.,University of California, Benioff Children's Hospital, San Francisco, San Francisco, CA, United States
| | - Martina Steurer
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States.,University of California, Benioff Children's Hospital, San Francisco, San Francisco, CA, United States
| | - Duncan Henry
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States.,University of California, Benioff Children's Hospital, San Francisco, San Francisco, CA, United States
| |
Collapse
|
17
|
Lushaj EB, Hermsen J, Leverson G, MacLellan-Tobert SG, Nelson K, Amond K, Anagnostopoulos PV. Beyond 30 Days: Analysis of Unplanned Readmissions During the First Year Following Congenital Heart Surgery. World J Pediatr Congenit Heart Surg 2020; 11:177-182. [PMID: 32093562 DOI: 10.1177/2150135119895212] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We investigated the incidence and etiologies for unplanned hospital readmissions during the first year following congenital heart surgery (CHS) at our institution and the potential association of readmissions with longer term survival. METHODS We retrospectively reviewed 263 patients undergoing CHS at our institution from August 2011 to June 2015. Scheduled readmissions were excluded. RESULTS Seventy patients accrued a total of 120 readmissions (1.7 readmission/patient) within one year after surgery. The first readmission for 57% of the patients was within 30 days postdischarge. Twenty-two patients were first readmitted between 31 and 90 days postdischarge. Eight patients were first readmitted between 90 days and 1 year postdischarge. Median time-to-first readmission was 21 days. Median hospital length of stay at readmission was two days. Causes of 30-day readmissions included viral illness (25%), wound infections (15%), and cardiac causes (15%). Readmissions between 30 and 90 days included viral illness (27%), gastrointestinal (27%), and cardiac causes (9%). Age, STAT category, length of surgery, intubation, intensive care unit, and hospital stay were risk factors associated with readmissions based on logistic regression. Distance to hospital had a significant effect on readmissions (P < .001). Patients with higher family income were less likely to be readmitted (P < .001). There was no difference in survival between readmitted and non-readmitted patients (P = .68). CONCLUSIONS The first 90 days is a high-risk period for unplanned hospital readmissions after CHS. Complicated postoperative course, higher surgical complexity, and lower socioeconomic status are risk factors for unplanned readmissions the first 90 days after surgery. Efforts to improve the incidence or readmission after CHS should extend to the first 3 months after surgery and target these high-risk patient populations.
Collapse
Affiliation(s)
- Entela B Lushaj
- Department of Surgery-Cardiothoracic, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Joshua Hermsen
- Department of Surgery-Cardiothoracic, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Glen Leverson
- Department of Surgery-Cardiothoracic, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Susan G MacLellan-Tobert
- Department of Surgery-Cardiothoracic, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Kari Nelson
- Department of Surgery-Cardiothoracic, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Kate Amond
- Department of Surgery-Cardiothoracic, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Petros V Anagnostopoulos
- Department of Surgery-Cardiothoracic, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| |
Collapse
|
18
|
Understanding Young People and Their Care Providers' Perceptions and Experiences of Integrated Care Within a Tertiary Paediatric Hospital Setting, Using Interpretive Phenomenological Analysis. Int J Integr Care 2020; 20:7. [PMID: 33177966 PMCID: PMC7597574 DOI: 10.5334/ijic.5545] [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] [Indexed: 11/30/2022] Open
Abstract
Introduction: Benefits of integrated care include improved health outcomes and more satisfaction with experiences of care for consumers. For children and young people with chronic and complex health conditions, their care may be fragmented due to the multitude of healthcare providers involved. This paper describes the experiences of integrated care in a paediatric tertiary hospital. Theory and methods: Using an Interpretive Phenomenological Analysis approach, semi-structured interviews were conducted with children and young people, their parents and healthcare providers to explore stakeholders’ integrated care experiences. Results: Nineteen interviews were completed (6 children and young people, 7 parents and 6 healthcare providers) and transcribed verbatim. Two recurrent themes were applicable across the three cohorts: ‘agency and empowerment’ and ‘impact of organisational systems, supports and structures’. Discussion and conclusion: Stakeholders’ experiences of integrated care highlighted the need to examine the discrepancies between healthcare strategies, policies and service delivery within a complex, and often inflexible organisational structure. Power imbalance and family agency (including directly with children and young people) needs to be addressed to support the implementation of integrated care.
Collapse
|
19
|
Noyek S, Vowles C, Batorowicz B, Davies C, Fayed N. Direct assessment of emotional well-being from children with severe motor and communication impairment: a systematic review. Disabil Rehabil Assist Technol 2020; 17:501-514. [PMID: 32878502 DOI: 10.1080/17483107.2020.1810334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE Explore methods used in peer-reviewed literature for obtaining self-expression of well-being information from children with severe motor and communication impairment (SMCI). MATERIALS AND METHODS A comprehensive search was conducted on 22 August 2019 through academic databases: CINAHL; Embase; MEDLINE; PsycINFO; InSpec; Compendex. Search strategies were informed by keywords under the following areas: (1) population: children with SMCI, (2) assessment methods: alternative to natural speech, paper and pencil report or standardized keyboard use (e.g., eye gaze) and (3) target information: well-being (e.g., quality of life). Studies were excluded if they focused on individuals over 25-years old, exclusively autism or typically developing children. RESULTS Non-duplicate studies of 10,986 were screened; 49 studies met inclusion criteria. Most studies used high-tech methods of self-expression in a single context (n = 17). Familiar partners play a significant role in self-expression; 18 studies required a familiar partner for children with SMCI to self-express. Thirty-five studies involved children self-expressing to solely adults, in comparison to 14 studies which involved peers. CONCLUSION Findings highlight the advancement of high-tech communication devices restricted to application in single contexts. Familiar partner knowledge of children with SMCI has the potential to be shared with others (e.g., respite care providers), enhancing both caregiver and child well-being. Future research that would enhance the literature could explore the assessment of emotional well-being for application in various contexts using multimodal methods. Opportunities for children with SMCI to express their emotional well-being can further influence the understanding and enhancement of participation, social connections, and experiences.IMPLICATIONS FOR REHABILITATIONUse of lower tech methods of self-expression to obtain information directly from children with severe motor and communication impairment (SMCI) remain more feasible in home and school contexts.By utilizing familiar partners' experiences and knowledge of the child, respite care providers, novel support workers, and others involved in the lives of children with SMCI can become further informed.Current high-tech methods for obtaining the emotional expressions of children with SMCI may benefit from incorporating multimodal approaches including lower tech methods, to be feasibly applied in real world contexts where well-being takes place.Further research on this topic is imperative to enable children with SMCI to self-express their emotional well-being which can enhance participation, activities, social connections, and experiences.
Collapse
Affiliation(s)
- Samantha Noyek
- School of Rehabilitation Therapy, Queen's University, Kingston, Canada
| | - Caryn Vowles
- Department of Mechanical and Materials Engineering, Queen's University, Kingston, Canada
| | - Beata Batorowicz
- School of Rehabilitation Therapy, Queen's University, Kingston, Canada
| | - Claire Davies
- Department of Mechanical and Materials Engineering, Queen's University, Kingston, Canada
| | - Nora Fayed
- School of Rehabilitation Therapy, Queen's University, Kingston, Canada
| |
Collapse
|
20
|
Ehlenbach ML, Coller RJ. Growing Evidence for Successful Care Management in Children With Medical Complexity. Pediatrics 2020; 145:peds.2019-3982. [PMID: 32229618 DOI: 10.1542/peds.2019-3982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2019] [Indexed: 11/24/2022] Open
Affiliation(s)
- Mary L Ehlenbach
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Ryan J Coller
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| |
Collapse
|
21
|
D'Aprano A, Gibb S, Riess S, Cooper M, Mountford N, Meehan E. Important components of a programme for children with medical complexity: An Australian perspective. Child Care Health Dev 2020; 46:90-103. [PMID: 31782538 DOI: 10.1111/cch.12721] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 11/23/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Children with medical complexity (CMC) have high care needs, often unmet by traditional healthcare models. In response to this need, the Complex Care Service (CCS) at The Royal Children's Hospital (RCH), Melbourne was created. Although preliminary parent satisfaction data were available, we lacked knowledge of how the various components of the expanded service were valued and contributed to overall caregiver satisfaction. AIM The aims of this study were to (a) determine what caregivers value most about the CCS and (b) explore caregiver perceptions of care. METHODS All caregivers of children enrolled in the RCH CCS in April 2017 were invited to participate. A purposefully designed survey explored caregiver perceptions of care, including patient quality of care; the extent to which the CCS components added value and satisfaction; and frequency of contact. Participants were also invited to answer open-ended questions and provide general comments. RESULTS Responses were received from 53 families (51%). We found that 24-hr phone advice, coordination of appointments, a key contact, and access to timely information were the most important components of the service. More than 90% of caregivers indicated that they were satisfied with care and that the CCS improved their child's quality of care. Coordination, communication, family-centred care, quality care, and access were emergent themes within comments. CONCLUSION This study provides important information regarding the design and operation of services for CMC throughout Australia and further afield. Our findings highlight the importance of the key contact and family-centred care. This has implications for practice, as maintaining service quality, as the CCS expands and is implemented more widely, is a major sustainability challenge. It is crucial that we have a detailed understanding of what elements are required to support effective care coordination, to achieve successful implementation on a larger scale.
Collapse
Affiliation(s)
- Anita D'Aprano
- Department of General Medicine, The Royal Children's Hospital, Melbourne, Melbourne, Victoria, Australia.,Population Health Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Susie Gibb
- Department of General Medicine, The Royal Children's Hospital, Melbourne, Melbourne, Victoria, Australia.,Department of Neurodevelopment & Disability, The Royal Children's Hospital, Melbourne, Melbourne, Victoria, Australia.,Infection and Immunity Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Suzi Riess
- Population Health Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Neurodevelopment & Disability, The Royal Children's Hospital, Melbourne, Melbourne, Victoria, Australia
| | - Monica Cooper
- Department of Neurodevelopment & Disability, The Royal Children's Hospital, Melbourne, Melbourne, Victoria, Australia.,Clinical Sciences Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Nicki Mountford
- Quality and Improvement, The Royal Children's Hospital, Melbourne, Melbourne, Victoria, Australia
| | - Elaine Meehan
- Clinical Sciences Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| |
Collapse
|
22
|
Looman WS, Park YS, Gallagher TT, Weinfurter EV. Outcomes research on children with medical complexity: A scoping review of gaps and opportunities. Child Care Health Dev 2020; 46:121-131. [PMID: 31782818 DOI: 10.1111/cch.12725] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 10/09/2019] [Accepted: 11/23/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND There has been a recent, rapid increase in the number of studies of children with medical complexity (CMC) and their families. There is a need for attention to gaps and patterns in this emerging field of study. OBJECTIVES The purpose of this scoping review was to identify patterns and gaps in the evidence related to classification systems, data, and outcomes in studies of CMC. DATA SOURCES We searched peer-reviewed journals for reports of quantitative studies focused on CMC outcomes published between 2008 and 2018. On the basis of a structured screening process, we selected 63 reports that met our inclusion criteria. STUDY APPRAISAL AND SYNTHESIS We used the methodological framework for scoping studies described by Arskey and O'Malley to map relevant literature in the field and the ECHO model to categorize studies according to three health outcome domains (economic, clinical, and humanistic). RESULTS The terminology used to describe and classify CMC differed across studies depending on outcome domain. Two thirds of the reports focused on economic outcomes; fewer than a quarter included child or family quality of life as an outcome. A majority of studies used a single source of data, with robust analyses of administrative, payer, and publicly available data. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Research on CMC and their families would benefit from standardization of terms and classification systems, the use of measurement strategies that map humanistic outcomes as trajectories, and more attention to outcomes identified as most meaningful to CMC and their families.
Collapse
Affiliation(s)
- Wendy S Looman
- School of Nursing, University of Minnesota, Minneapolis, MN
| | | | | | | |
Collapse
|
23
|
Orkin J, Chan CY, Fayed N, Lin JLL, Major N, Lim A, Peebles ER, Moretti ME, Soscia J, Sultan R, Willan AR, Offringa M, Guttmann A, Bartlett L, Kanani R, Culbert E, Hardy-Brown K, Gordon M, Perlmutar M, Cohen E. Complex care for kids Ontario: protocol for a mixed-methods randomised controlled trial of a population-level care coordination initiative for children with medical complexity. BMJ Open 2019; 9:e028121. [PMID: 31375613 PMCID: PMC6688698 DOI: 10.1136/bmjopen-2018-028121] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Technological and medical advances have led to a growing population of children with medical complexity (CMC) defined by substantial medical needs, healthcare utilisation and morbidity. These children are at a high risk of missed, fragmented and/or inappropriate care, and families bear extraordinary financial burden and stress. While small in number (<1% of children), this group uses ~1/3 of all child healthcare resources, and need coordinated care to optimise their health. Complex care for kids Ontario (CCKO) brings researchers, families and healthcare providers together to develop, implement and evaluate a population-level roll-out of care for CMC in Ontario, Canada through a randomised controlled trial (RCT) design. The intervention includes dedicated key workers and the utilisation of coordinated shared care plans. METHODS AND ANALYSIS Our primary objective is to evaluate the CCKO intervention using a randomised waitlist control design. The waitlist approach involves rolling out an intervention over time, whereby all participants are randomised into two groups (A and B) to receive the intervention at different time points determined at random. Baseline measurements are collected at month 0, and groups A and B are compared at months 6 and 12. The primary outcome is the family-prioritized Family Experiences with Coordination of Care (FECC) survey at 12 months. The FECC will be compared between groups using an analysis of covariance with the corresponding baseline score as the covariate. Secondary outcomes include reports of child and parent health outcomes, health system utilisation and process outcomes. ETHICS AND DISSEMINATION Research ethics approval has been obtained for this multicentre RCT. This trial will assess the effect of a large population-level complex care intervention to determine whether dedicated key workers and coordinated care plans have an impact on improving service delivery and quality of life for CMC and their families. TRIAL REGISTRATION NUMBER NCT02928757.
Collapse
Affiliation(s)
- Julia Orkin
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Carol Y Chan
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nora Fayed
- School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada
| | - Jia Lu Lilian Lin
- Institute of Health Policy, Management and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Nathalie Major
- Department of Paediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Audrey Lim
- Department of Pediatrics, Hamilton Health Sciences Center, McMaster University, Hamilton, Ontario, Canada
| | - Erin R Peebles
- Department of Pediatrics, Western University, London, Ontario, Canada
| | - Myla E Moretti
- Clinical Trials Unit, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Joanna Soscia
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Roxana Sultan
- The Provincial Council for Maternal and Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andrew R Willan
- Clinical Trials Unit, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Astrid Guttmann
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Leah Bartlett
- Department of Pediatrics, Royal Victoria Regional Health Centre, Barrie, Ontario, Canada
| | - Ronik Kanani
- Department of Pediatrics, North York General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Erin Culbert
- The Credit Valley Hospital, Trillium Health Partners, Mississauga, Ontario, Canada
| | | | - Michelle Gordon
- Department of Pediatrics, Orillia Soldier's Memorial Hospital, Orillia, Ontario, Canada
| | - Marty Perlmutar
- Department of Pediatrics, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Eyal Cohen
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
24
|
Gafni Lachter LR, Josman N, Ben-Sasson A. Evaluating change: Using the Measure of Processes of Care-Service Provider as an outcome measure for performance and confidence in family-centred care. Child Care Health Dev 2019; 45:592-599. [PMID: 30983005 DOI: 10.1111/cch.12668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 03/20/2019] [Accepted: 04/09/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Family-centred care (FCC) is considered the best practice in paediatric care but it is not always implemented sufficiently. Effective training programmes that enhance health care providers' knowledge and self-efficacy have the potential to improve FCC implementation in their daily practice. The goal of the study was to evaluate the sensitivity of the measure of processes of care (MPOC)-service provider (MPOC-SP) version and MPOC confidence (MPOC-Con) in detecting changes following an FCC training. METHODS The MPOC-Con was developed for this study as a sequel to MPOC-SP to measure self-efficacy related to specific FCC practices. Twenty-four health care providers (occupational and physical therapists, speech pathologist, and special education teacher) participated in a 6-month FCC provider training. The training included 30 contact hours on FCC principles and techniques through experiential learning, reflective exercises, peer mentoring, and case-study analyses. The MPOC-SP and MPOC-Con were administered preparticipation and postparticipation. RESULTS Repeated multivariate analysis of variance and reliable change index (RCI) analyses indicated a significant group increase in performance and confidence following the training in two of the four MPOC-SP factors and in all MPOC-Con factors, F(1, 7) = 5.17, P = .003, η2 = .68; RCI > 1.96. Individual change patterns in FCC performance indicated patterns of increased, decreased, or stable performance, with the highest increased performances reported for treating people respectfully (79%) and communicating specific information (71%), mostly stable performance in providing general information (75%) and similar levels of increase and stability (41% and 39%, respectively) for interpersonal sensitivity. The Pearson's correlation between MPOC-SP and MPOC-Con were significant, moderate-strong, and positive (r = .42-.69, P < .05). CONCLUSIONS The MPOC-SP and the MPOC-Con are sensitive measures suitable for evaluating individual and group changes following training. When designing professional development programmes, managers and educators should consider the interrelation between self-efficacy and implementing acquired knowledge and skills in FCC.
Collapse
Affiliation(s)
- Liat R Gafni Lachter
- Faculty of Social Welfare and Health Sciences, Department of Occupational Therapy, University of Haifa, Haifa, Israel.,College of Health and rehabilitation Science: Sargent College, Department of Occupational Therapy, Boston University, Boston, MA, USA
| | - Naomi Josman
- Faculty of Social Welfare and Health Sciences, Department of Occupational Therapy, University of Haifa, Haifa, Israel
| | - Ayelet Ben-Sasson
- Faculty of Social Welfare and Health Sciences, Department of Occupational Therapy, University of Haifa, Haifa, Israel
| |
Collapse
|
25
|
Meehan E, D’Aprano AL, Gibb SM, Mountford NJ, Williams K, Harvey AR, Connell TG, Cohen E. Comprehensive care programmes for children with medical complexity. Hippokratia 2019. [DOI: 10.1002/14651858.cd013329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Elaine Meehan
- Murdoch Children's Research Institute; Neurodisability and Rehabilitation; 50 Flemington Road Melbourne Victoria Australia 3052
| | - Anita L D’Aprano
- The Royal Children's Hospital; General Medicine; Melbourne Australia
| | - Susan M Gibb
- The Royal Children's Hospital; Neurodevelopment and Disability; Melbourne Australia
| | - Nicki J Mountford
- The Royal Children's Hospital; Complex Care Hub; Melbourne Australia
| | - Katrina Williams
- The University of Melbourne; Department of Paediatrics; Melbourne Australia
| | - Adrienne R Harvey
- Murdoch Children's Research Institute; Neurodisability and Rehabilitation; 50 Flemington Road Melbourne Victoria Australia 3052
| | - Tom G Connell
- The Royal Children's Hospital; General Medicine; Melbourne Australia
| | - Eyal Cohen
- University of Toronto; Pediatrics and Health Policy, Management & Evaluation; The Hospital for Sick Children 555 University Avenue Toronto ON Canada M5G 1X8
| |
Collapse
|
26
|
Plews-Ogan J, Babbar A, Keim-Malpass J. Compassion and connectedness as motivational drivers in the care of children with medical complexity. J Pediatr Rehabil Med 2019; 12:279-284. [PMID: 31476186 DOI: 10.3233/prm-190611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Employing a cross-sectional qualitative descriptive design, using individual, semi-structured interviews collected from primary care and specialty clinicians who routinely care for children with medical complexity (CMC) in a largely rural area in central Virginia, this study aimed to better understand the current state of care, the motivations, and barriers for expansion of care for CMC in a semi-rural academic hospital center. Five themes emerged describing the current practice of the participants: (1) complexities of care, (2) compassion and empathy for families, (3) limited resources, (4) essential nature of coordination and teamwork, and (5) proximity to care. Each of the five themes that emerged from our interviews present both challenges and rewards. The theme of compassion for families of CMC is seen as a key potential motivational driver for expansion and reorganization of clinical care for CMC.
Collapse
Affiliation(s)
- James Plews-Ogan
- Department of Pediatrics, The University of Virginia Medical School, Charlottesville, VA, USA
| | - Ambika Babbar
- Department of Internal Medicine, New York University Langone Health, New York, NY, USA
| | | |
Collapse
|
27
|
Nkoy FL, Hofmann MG, Stone BL, Poll J, Clark L, Fassl BA, Murphy NA. Information needs for designing a home monitoring system for children with medical complexity. Int J Med Inform 2018; 122:7-12. [PMID: 30623786 DOI: 10.1016/j.ijmedinf.2018.11.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/08/2018] [Accepted: 11/25/2018] [Indexed: 10/27/2022]
Abstract
Background Children with medical complexity (CMC) are a growing population of medically fragile children with unique healthcare needs, who have recurrent emergency department (ED) and hospital admissions due to frequent acute escalations of their chronic conditions. Mobile health (mHealth) tools have been suggested to support CMC home monitoring and prevent admissions. No mHealth tool has ever been developed for CMC and challenges exist. Objective To: 1) assess information needs for operationalizing CMC home monitoring, and 2) determine technology design functionalities needed for building a mHealth application for CMC. Methods Qualitative descriptive study conducted at a tertiary care children's hospital with a purposive sample of English-speaking caregivers of CMC. We conducted 3 focus group sessions, using semi-structured, open-ended questions. We assessed caregiver's perceptions of early symptoms that commonly precede acute escalations of their child conditions, and explored caregiver's preferences on the design functionalities of a novel mHealth tool to support home monitoring of CMC. We used content analysis to assess caregivers' experience concerning CMC symptoms, their responses, effects on caregivers, and functionalities of a home monitoring tool. Results Overall, 13 caregivers of CMC (ages 18 months to 19 years, mean = 9 years) participated. Caregivers identified key symptoms in their children that commonly presented 1-3 days prior to an ED visit or hospitalization, including low oxygen saturations, fevers, rapid heart rates, seizures, agitation, feeding intolerance, pain, and a general feeling of uneasiness about their child's condition. They believed a home monitoring system for tracking these symptoms would be beneficial, providing a way to identify early changes in their child's health that could prompt a timely and appropriate intervention. Caregivers also reported their own symptoms and stress related to caregiving activities, but opposed monitoring them. They suggested an mHealth tool for CMC to include the following functionalities: 1) symptom tracking, targeting commonly reported drivers (symptoms) of ED/hospital admissions; 2) user friendly (ease of data entry), using voice, radio buttons, and drop down menus; 3) a free-text field for reporting child's other symptoms and interventions attempted at home; 4) ability to directly access a health care provider (HCP) via text/email messaging, and to allow real-time sharing of child data to facilitate care, and 5) option to upload and post a photo or video of the child to allow a visual recall by the HCP. Conclusions Caregivers deemed a mHealth tool beneficial and offered a set of key functionalities to meet information needs for monitoring CMC's symptoms. Our future efforts will consist of creating a prototype of the mHealth tool and testing it for usability among CMC caregivers.
Collapse
Affiliation(s)
- Flory L Nkoy
- University of Utah, Pediatric Department, SLC, Utah, United States.
| | | | - Bryan L Stone
- University of Utah, Pediatric Department, SLC, Utah, United States
| | - Justin Poll
- Intermountain Healthcare, SLC, Utah, United States
| | - Lauren Clark
- University of Utah, Pediatric Department, SLC, Utah, United States
| | - Bernhard A Fassl
- University of Utah, Pediatric Department, SLC, Utah, United States
| | - Nancy A Murphy
- University of Utah, Pediatric Department, SLC, Utah, United States
| |
Collapse
|
28
|
Hamline MY, Speier RL, Vu PD, Tancredi D, Broman AR, Rasmussen LN, Tullius BP, Shaikh U, Li STT. Hospital-to-Home Interventions, Use, and Satisfaction: A Meta-analysis. Pediatrics 2018; 142:e20180442. [PMID: 30352792 PMCID: PMC6317574 DOI: 10.1542/peds.2018-0442] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2018] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Hospital-to-home transitions are critical opportunities to promote patient safety and high-quality care. However, such transitions are often fraught with difficulties associated with increased health care use and poor patient satisfaction. OBJECTIVE In this review, we determine which pediatric hospital discharge interventions affect subsequent health care use or parental satisfaction compared with usual care. DATA SOURCES We searched 7 bibliographic databases and 5 pediatric journals. STUDY SELECTION Inclusion criteria were: (1) available in English, (2) focused on children <18 years of age, (3) pediatric data reported separately from adult data, (4) not focused on normal newborns or pregnancy, (5) discharge intervention implemented in the inpatient setting, and (6) outcomes of health care use or caregiver satisfaction. Reviews, case studies, and commentaries were excluded. DATA EXTRACTION Two reviewers independently abstracted data using modified Cochrane data collection forms and assessed quality using modified Downs and Black checklists. RESULTS Seventy one articles met inclusion criteria. Although most interventions improved satisfaction, interventions variably reduced use. Interventions focused on follow-up care, discharge planning, teach back-based parental education, and contingency planning were associated with reduced use across patient groups. Bundled care coordination and family engagement interventions were associated with lower use in patients with chronic illnesses and neonates. LIMITATIONS Variability limited findings and reduced generalizability. CONCLUSIONS In this review, we highlight the utility of a pediatric discharge bundle in reducing health care use. Coordinating follow-up, discharge planning, teach back-based parental education, and contingency planning are potential foci for future efforts to improve hospital-to-home transitions.
Collapse
Affiliation(s)
| | | | - Paul Dai Vu
- School of Aerospace Medicine, Wright-Patterson Air Force Base, United States Air Force, Dayton, Ohio
| | | | - Alia R Broman
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon; and
| | | | - Brian P Tullius
- Department of Pediatric Hematology, Oncology, and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio
| | - Ulfat Shaikh
- Department of Pediatrics
- School of Medicine, University of California, Davis, Sacramento, California
| | | |
Collapse
|
29
|
Cohen E, Berry JG, Sanders L, Schor EL, Wise PH. Status Complexicus? The Emergence of Pediatric Complex Care. Pediatrics 2018; 141:S202-S211. [PMID: 29496971 DOI: 10.1542/peds.2017-1284e] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2017] [Indexed: 11/24/2022] Open
Abstract
Discourse about childhood chronic conditions has transitioned in the last decade from focusing primarily on broad groups of children with special health care needs to concentrating in large part on smaller groups of children with medical complexity (CMC). Although a variety of definitions have been applied, the term CMC has most commonly been defined as children and youth with serious chronic conditions, substantial functional limitations, increased health and other service needs, and increased health care costs. The increasing attention paid to CMC has occurred because these children are growing in impact, represent a disproportionate share of health system costs, and require policy and programmatic interventions that differ in many ways from broader groups of children with special health care needs. But will this change in focus lead to meaningful changes in outcomes for children with serious chronic diseases, or is the pediatric community simply adopting terminology with resonance in adult-focused health systems? In this article, we will explore the implications of the rapid emergence of pediatric complex care in child health services practice and research. As an emerging field, pediatric care systems should thoughtfully and rapidly develop evidence-based solutions to the new challenges of caring for CMC, including (1) clearer definitions of the target population, (2) a more appropriate incorporation of components of care that occur outside of hospitals, and (3) a more comprehensive outcomes measurement framework, including the recognition of potential limitations of cost containment as a target for improved care for CMC.
Collapse
Affiliation(s)
- Eyal Cohen
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada; .,Department of Pediatrics and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Jay G Berry
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Lee Sanders
- Center for Policy, Outcomes and Prevention (CPOP) and.,Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
| | - Edward L Schor
- Lucile Packard Foundation for Children's Health, Palo Alto, California
| | - Paul H Wise
- Center for Policy, Outcomes and Prevention (CPOP) and.,Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
| |
Collapse
|
30
|
White CM, Thomson JE, Statile AM, Auger KA, Unaka N, Carroll M, Tucker K, Fletcher D, Hall DE, Simmons JM, Brady PW. Development of a New Care Model for Hospitalized Children With Medical Complexity. Hosp Pediatr 2017; 7:410-414. [PMID: 28596445 DOI: 10.1542/hpeds.2016-0149] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Children with medical complexity are a rapidly growing inpatient population with frequent, lengthy, and costly hospitalizations. During hospitalization, these patients require care coordination among multiple subspecialties and their outpatient medical homes. At a large freestanding children's hospital, a new inpatient model of care was developed in an effort to consistently provide coordinated, family-centered, and efficient care. In addition to expanding the multidisciplinary team to include a pharmacist, dietician, and social worker, the team redesign included: (1) medication reconciliation rounds, (2) care coordination rounds, and (3) multidisciplinary weekly handoff with outpatient providers. During weekly medication reconciliation rounds, the team pharmacist reviews each patient's current medications with the team. In care coordination rounds, the team collaborates with unit care managers to identify discharge needs and complete discharge tasks. Finally, at the end of the week, the outgoing hospital medicine attending physician hands off patient care to the incoming attending with input from the team's pharmacist, dietician, and social worker. Families and providers noted improvements in care coordination with the new care model. Remaining challenges include balancing resident autonomy and attending supervision, as well as supporting providers in delivering care that can be emotionally challenging. Aspects of this care model could be tested and adapted at other hospitals that care for children with medical complexity. Additionally, future work should study the impact of inpatient complex care models on patient health outcomes and experience.
Collapse
Affiliation(s)
- Christine M White
- Division of Hospital Medicine, .,James M. Anderson Center for Health Systems Excellence, and.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Joanna E Thomson
- Division of Hospital Medicine.,James M. Anderson Center for Health Systems Excellence, and.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Angela M Statile
- Division of Hospital Medicine.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Katherine A Auger
- Division of Hospital Medicine.,James M. Anderson Center for Health Systems Excellence, and.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ndidi Unaka
- Division of Hospital Medicine.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Matthew Carroll
- Hospitalist Group, Cook Children's, Fort Worth, Texas.,Department of Pediatrics, Texas A&M Health Science Center College of Medicine, Fort Worth, Texas
| | - Karen Tucker
- Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Derek Fletcher
- Complex Healthcare Program, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University, Columbus, Ohio; and
| | - David E Hall
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jeffrey M Simmons
- Division of Hospital Medicine.,James M. Anderson Center for Health Systems Excellence, and.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Patrick W Brady
- Division of Hospital Medicine.,James M. Anderson Center for Health Systems Excellence, and.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
31
|
Strategies to support transitions from hospital to home for children with medical complexity: A scoping review. Int J Nurs Stud 2017; 72:91-104. [PMID: 28521207 DOI: 10.1016/j.ijnurstu.2017.04.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 04/15/2017] [Accepted: 04/28/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Children with medical complexity constitute a small but resource-intensive subgroup of children with special health care needs. Their medical fragility and resource-intensive needs put them at greater risk for inadequate transitions from hospital to home-based care, and subsequent adverse outcomes and hospital re-admissions. OBJECTIVE This scoping literature review was conducted to map empirically researched interventions, frameworks, programs or models that could inform or support the transition from hospital to home for children with medical complexity. DESIGN We conducted a scoping review using the methodology outlined by the Joanna Briggs Institute. DATA SOURCES In consultation with an experienced librarian, we searched PubMed, EMBASE and CINAHL for English-language articles published from the date of origin to February 2016. We also hand-searched four high impact journals and searched the reference lists of relevant articles. REVIEW METHODS Two reviewers independently screened the literature results according to inclusion criteria. Empirically designed studies that targeted children <18years old who were specifically defined as medically complex or fragile and transitioning from acute care to home were included. Data were extracted using a predefined tool. Quality appraisal of the articles was conducted using the mixed methods appraisal tool (MMAT). Thematic analysis was carried out to identify existing patterns or trends in the included studies. RESULTS Of the 2088 abstracts retrieved, 14 studies met the inclusion criteria. Following analysis, we identified three major categories of interventions: Comprehensive care plans (n=3), Complex Care Programs (n=8) and Integrated delivery models (n=3). The overall quality of included studies was moderate, with 21% (n=3) scoring 0.25, 29% (n=4) scoring 0.50, 43% (n=6) scoring 0.75, and 7% (n=1) scoring 1.0. CONCLUSIONS In the absence of evidence-based guidelines to ensure adequate transitions from hospital to home for children with medical complexity, identification of potential models to support this transition is imperative. We identified interventions, frameworks, models and programs in the literature that might inform the development of such guidelines; however, there is a need for consensus around the definition for children with medical complexity and the limited number of these studies and lack of high quality of evidence signals the need for further research to improve the transition from hospital to home and ultimately, improve patient and family outcomes.
Collapse
|
32
|
King G, Williams L, Hahn Goldberg S. Family-oriented services in pediatric rehabilitation: a scoping review and framework to promote parent and family wellness. Child Care Health Dev 2017; 43:334-347. [PMID: 28083952 DOI: 10.1111/cch.12435] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 11/02/2016] [Accepted: 11/17/2016] [Indexed: 11/26/2022]
Abstract
Family-oriented services are not as common as one would expect, given the widespread endorsement of family-centred care, the role of parents in supporting optimal child outcomes, and legislation and literature indicating that parent outcomes are important in their own right. There are no published service delivery frameworks describing the scope of services that could be delivered to promote parent and family wellness. A scoping review was conducted to identify types of family-oriented services for parents of children with physical disabilities and/or intellectual impairments. This information was then synthesized into a conceptual framework of services to inform service selection and design. A scoping review of the recent literature was performed to capture descriptions of services targeting parents/families of children with physical disabilities and/or intellectual impairments, published in a six-year period (2009 to 2014). Six databases were searched and 557 retrieved articles were screened using inclusion and exclusion criteria. Thirty six relevant articles were identified. Based on descriptions of services in these articles, along with seminal articles describing the nature of desirable services, we propose a needs-based and capacity-enhancing framework outlining a continuum of family-oriented services for parents of children with disabilities. The framework includes six types of services to meet parent/family needs, organized as a continuum from fundamental information/education services, to those supporting parents to deliver services to meet their child's needs, to a variety of services addressing parents' own needs (support groups, psychosocial services and service coordination). The framework provides pediatric rehabilitation service organizations with a way to consider different possible family-oriented services. Implications include the particular importance of providing information resources, support groups and psychosocial services to meet parents' needs, enhance capacity and promote family wellness. There is also an opportunity to provide composite parent-child services to address the needs of both parents and children.
Collapse
Affiliation(s)
- G King
- Senior Scientist, Bloorview Research Institute and Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada
| | - L Williams
- Director, Client and Family Integrated Care, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
| | - S Hahn Goldberg
- Bloorview Research Institute and OpenLab, University Health Network, Toronto, Canada
| |
Collapse
|
33
|
Health Services and Health Care Needs Fulfilled by Structured Clinical Programs for Children with Medical Complexity. J Pediatr 2016; 169:291-6.e1. [PMID: 26526361 PMCID: PMC4729644 DOI: 10.1016/j.jpeds.2015.10.010] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 08/24/2015] [Accepted: 10/02/2015] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To describe family-reported health service needs of children with medical complexity (CMC) and to assess which needs are more often addressed in a tertiary care center-based structured clinical program for CMC. STUDY DESIGN Mailed survey to families of CMC enrolled in a structured-care program providing care coordination and oversight at 1 of 3 children's hospitals. Outcomes included receipt of 14 specific health service needs. Paired t tests compared unmet health care needs prior to and following program enrollment. RESULTS Four hundred forty-one of 968 (46%) surveys were returned and analyzed. Respondents reported their children had a mean age of 7 (SD 5) years. A majority of respondents reported the child had developmental delay (79%) and feeding difficulties (64%). Of the respondents, 56% regarded the primary care provider as the primary point of contact for medical issues. Respondents reported an increase in meeting all 14 health services needs after enrollment in a tertiary care center-based structured clinical program, including primary care checkups (82% vs 96%), therapies (78% vs 91%), mental health care (34% vs 58%), respite care (56% vs 75%), and referrals (51% vs 83%) (all P < .001). CONCLUSIONS Tertiary care center-based structured clinical care programs for CMC may address and fulfill a broad range of health service needs that are not met in the primary care setting.
Collapse
|
34
|
Affiliation(s)
- Sanjay Mahant
- Division of Paediatric Medicine, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Michael Weinstein
- Division of Paediatric Medicine, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| |
Collapse
|
35
|
Abstract
PURPOSE The purpose of this report was to determine the feasibility of short-term modified ride-on car (ROC) use for exploration and enjoyment by children with complex medical needs. METHODS A single-subject research design was used (n = 3; age, 6 months to 5 years). Children were video-recorded using their modified ROC. RESULTS All children successfully learned how to independently drive a modified ROC. Two of the 3 children demonstrated high levels of enjoyment during use of a modified ROC. CONCLUSIONS Modified ROC use is a feasible and enjoyable powered mobility device for children with complex medical needs.
Collapse
|
36
|
Ralston SL, Harrison W, Wasserman J, Goodman DC. Hospital Variation in Health Care Utilization by Children With Medical Complexity. Pediatrics 2015; 136:860-7. [PMID: 26438701 DOI: 10.1542/peds.2014-3920] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Although children with medical complexity have high health care needs, little is known about the variation in care provided between centers. This information may be particularly useful in identifying opportunities to improve quality and reduce costs. METHODS We conducted a retrospective population-based observational cohort study using all payer claims databases for children aged 30 days to <18 years residing in Maine, New Hampshire, and Vermont from 2007 to 2010. We identified hospital-affiliated cohorts (n = 6) of patients (n = 8216) with medical complexity by using diagnostic codes from both inpatient and outpatient claims. Children were assigned to the hospital where they received the most inpatient days, or their outpatient visits if no hospitalization occurred. Outcomes of interest included patient encounters, medical imaging, and diagnostic testing. Adjusted relative rates were calculated with overdispersed Poisson regression models. RESULTS Adjusting for patient characteristics, the number of inpatient (relative rate 0.84 vs 2.28) and intensive care days (relative rate 0.45 vs 1.28) varied by more than twofold, whereas office (relative rate 0.77 vs 1.12) and emergency department visits (relative rate 0.71 vs 1.37) varied to a lesser extent. There was also marked variation in the use of imaging, and other diagnostic tests, with particularly high variation in electrocardiography (relative rate 0.35 vs 2.81) and head MRI (relative rate 0.72 vs 2.12). CONCLUSIONS Depending on where they receive care, children with medical complexity experience widely different patterns of utilization. These findings indicate the need for identifying best practices for this growing patient population.
Collapse
Affiliation(s)
- Shawn L Ralston
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Section of Pediatric Hospital Medicine, Children's Hospital at Dartmouth, Lebanon, New Hampshire; and
| | - Wade Harrison
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Jared Wasserman
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - David C Goodman
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Section of Pediatric Hospital Medicine, Children's Hospital at Dartmouth, Lebanon, New Hampshire; and The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| |
Collapse
|
37
|
Thomson J, Shah SS. Interpreting Variability in the Health Care Utilization of Children With Medical Complexity. Pediatrics 2015; 136:974-6. [PMID: 26438706 DOI: 10.1542/peds.2015-0440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2015] [Indexed: 11/24/2022] Open
Affiliation(s)
- Joanna Thomson
- Divisions of Hospital Medicine and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Samir S Shah
- Divisions of Hospital Medicine and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
| |
Collapse
|
38
|
Groleger Sršen K, Vidmar G, Zupan A. Validity, internal consistency reliability and one-year stability of the Slovene translation of the Measure of Processes of Care (20-item version). Child Care Health Dev 2015; 41:569-80. [PMID: 25297060 DOI: 10.1111/cch.12198] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Measure of Processes of Care (MPOC) was developed as a self-administered questionnaire for parents to report on behaviours of healthcare providers. The original (MPOC-56) and the 20-item version (MPOC-20) have established reliability and validity, but the instrument must be rechecked whenever translated and applied in a different social and cultural setting. The aim of our study was to evaluate validity, internal consistency reliability and 1-year stability of the Slovene translation of MPOC-20. METHODS Parents of children who were admitted as inpatients or outpatients of several hospitals and health centres were invited to participate. MPOC-20, the Client Satisfaction Questionnaire (CSQ-8) and a separate question on stress and worries were sent by mail. Descriptive item analysis was performed. Cronbach's alpha coefficient and corrected item-total correlations were used to assess internal consistency for each of the five MPOC-20 subscales. To evaluate validity, we correlated the MPOC-20 subscale scores with CSQ-8 scores and a stress alleviation rating. Assessment with MPOC-20 was performed again 1 year later and we used paired-samples tests to compare mean scores of both assessments. RESULTS Parents of 235 children participated in the study (80% mothers). They reported high general satisfaction as 15 out of the 20 MPOC-20 mean item scores were above 5 (out of 7) and none was below 4. The mean MPOC-20 mean subscale scores were 5.83 (SD 1.10) for Coordinated and Comprehensive Care for Child and Family, 5.62 (SD 1.12) for Respectful and Supportive Care, 5.45 (SD 1.23) for Enabling and Partnership, 5.33 (SD 1.61) for Providing Specific Information about the Child and 4.59 (SD 1.65) for Providing General Information. The ranking order of the mean rating of the MPOC-20 subscales was similar to previous studies. The parents reported that they felt their stress and worries had been notably or slightly reduced through the process of care in the last year in more than two-thirds of the cases. All the MPOC-20 subscales (as well as the CSQ-8 scale) showed high internal consistency: the corrected item-total correlations were far above the lower limit for item's acceptance of 0.3. After 1 year (66 returned questionnaires) none of the mean subscale scores changed statistically significantly (P-values 0.159-0.910). CONCLUSION The Slovene translation of the MPOC-20 can be considered as a valid and reliable instrument that shows good stability over a period of 1 year, and as such it can be adopted in clinical practice.
Collapse
Affiliation(s)
- K Groleger Sršen
- Department for Children Rehabilitation, University Rehabilitation Institute, Ljubljana, Republic of Slovenia
| | - G Vidmar
- Biostatistics and Scientific Informatics, University Rehabilitation Institute, Ljubljana, Republic of Slovenia
| | - A Zupan
- University Rehabilitation Institute, Ljubljana, Republic of Slovenia
| |
Collapse
|
39
|
Abstract
Children with medical complexity are a subset of patients with special health care needs whose "health and quality of life depend on integrating health care between a primary care medical home, tertiary care services, and other important loci of care such as transitional care facilities, rehabilitation units, the home, the school, and other community based settings," according to Cohen et al. These children are characterized by (1) substantial health care service needs, (2) one or more severe chronic clinical condition(s), (3) severe functional limitations, and (4) high projected use of health resources that may include frequent or prolonged hospitalization, multiple surgeries, or the ongoing involvement of multiple subspecialty services and providers. Children with medical complexity are an important population for pediatric hospitalists, particularly those practicing in tertiary care settings. Recent studies describe the increasing prevalence of complex chronic conditions among all pediatric hospitalizations in the United States. This article reviews the definitions of children with medical complexity and recent studies describing the changes in hospital utilization for this group. We discuss issues in their inpatient care, including (1) intensive care coordination needs, (2) critical decision-making that occurs in the inpatient setting, (3) common clinical issues that occur with technology dependence (tracheostomies, feeding tubes, and cerebrospinal fluid shunts), and (4) common reasons for admission (eg, perioperative care, aspiration pneumonia, seizures, and feeding intolerance). Finally, we present a few important clinical questions regarding inpatient care for children with medical complexity that will require research in the coming years.
Collapse
|
40
|
Cunningham BJ, Rosenbaum PL. Measure of processes of care: a review of 20 years of research. Dev Med Child Neurol 2014; 56:445-52. [PMID: 24283936 DOI: 10.1111/dmcn.12347] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2013] [Indexed: 01/18/2023]
Abstract
AIM This article reviews literature on findings from the Measure of Processes of Care (MPOC) to assess family-centred services. METHOD Systematic searches for papers citing MPOC in both PubMed and Web of Science identified 107 articles. Fifty-five met the criterion for inclusion in this review in that they reported MPOC data. RESULTS Over the past 20 years MPOC has been used in settings additional to the children's treatment centres for which it was designed; used in 11 countries and translated into 14 languages; and used to measure change in respondents' perceptions over time. MPOC findings have also informed our understanding of the provision of family-centred services. Overall, parents report that service providers do a good job of providing respectful, comprehensive services in partnership with families, but that there remain limitations in the provision of general information, an area for improvement. Finally, MPOC has been shown to correlate with various other measures related to the provision of family-centred services. INTERPRETATION The MPOC 'family' of measures can be used to assess both families' and service providers' experiences and perceptions of the family-centredness of services received/provided. Opportunities abound for further research enquiries.
Collapse
Affiliation(s)
- Barbara J Cunningham
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, ON, Canada
| | | |
Collapse
|
41
|
Higdon R, Stewart E, Roach JC, Dombrowski C, Stanberry L, Clifton H, Kolker N, van Belle G, Del Beccaro MA, Kolker E. Predictive Analytics In Healthcare: Medications as a Predictor of Medical Complexity. BIG DATA 2013; 1:237-244. [PMID: 27447256 DOI: 10.1089/big.2013.0024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Children with special healthcare needs (CSHCN) require health and related services that exceed those required by most hospitalized children. A small but growing and important subset of the CSHCN group includes medically complex children (MCCs). MCCs typically have comorbidities and disproportionately consume healthcare resources. To enable strategic planning for the needs of MCCs, simple screens to identify potential MCCs rapidly in a hospital setting are needed. We assessed whether the number of medications used and the class of those medications correlated with MCC status. Retrospective analysis of medication data from the inpatients at Seattle Children's Hospital found that the numbers of inpatient and outpatient medications significantly correlated with MCC status. Numerous variables based on counts of medications, use of individual medications, and use of combinations of medications were considered, resulting in a simple model based on three different counts of medications: outpatient and inpatient drug classes and individual inpatient drug names. The combined model was used to rank the patient population for medical complexity. As a result, simple, objective admission screens for predicting the complexity of patients based on the number and type of medications were implemented.
Collapse
Affiliation(s)
- Roger Higdon
- 1 Bioinformatics and High-Throughput Data Analysis Laboratory, Seattle Children's Research Institute , Seattle, Washington
- 2 Predictive Analytics, Seattle Children's Hospital , Seattle, Washington
- 3 Data Enabled Life Sciences Alliance (DELSA Global) , Seattle, Washington
| | - Elizabeth Stewart
- 1 Bioinformatics and High-Throughput Data Analysis Laboratory, Seattle Children's Research Institute , Seattle, Washington
- 3 Data Enabled Life Sciences Alliance (DELSA Global) , Seattle, Washington
| | - Jared C Roach
- 4 Institute for Systems Biology , Seattle, Washington
| | | | - Larissa Stanberry
- 1 Bioinformatics and High-Throughput Data Analysis Laboratory, Seattle Children's Research Institute , Seattle, Washington
- 2 Predictive Analytics, Seattle Children's Hospital , Seattle, Washington
- 3 Data Enabled Life Sciences Alliance (DELSA Global) , Seattle, Washington
| | - Holly Clifton
- 6 Center for Children with Special Needs , Seattle Children's Research Institute, Seattle, Washington
| | - Natali Kolker
- 2 Predictive Analytics, Seattle Children's Hospital , Seattle, Washington
- 3 Data Enabled Life Sciences Alliance (DELSA Global) , Seattle, Washington
| | - Gerald van Belle
- 7 Departments of Biostatistics and Environmental and Occupational Health Sciences, University of Washington , Seattle, Washington
| | - Mark A Del Beccaro
- 8 Department of Pediatrics, University of Washington , Seattle, Washington
- 9 Medical Affairs, Seattle Children's Hospital , Seattle, Washington
- 10 Department of Biomedical Informatics & Medical Education, University of Washington , Seattle, Washington
| | - Eugene Kolker
- 1 Bioinformatics and High-Throughput Data Analysis Laboratory, Seattle Children's Research Institute , Seattle, Washington
- 2 Predictive Analytics, Seattle Children's Hospital , Seattle, Washington
- 3 Data Enabled Life Sciences Alliance (DELSA Global) , Seattle, Washington
- 8 Department of Pediatrics, University of Washington , Seattle, Washington
- 10 Department of Biomedical Informatics & Medical Education, University of Washington , Seattle, Washington
| |
Collapse
|
42
|
Willits KA, Platonova EA, Nies MA, Racine EF, Troutman ML, Harris HL. Medical home and pediatric primary care utilization among children with special health care needs. J Pediatr Health Care 2013; 27:202-8. [PMID: 22243921 DOI: 10.1016/j.pedhc.2011.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 11/11/2011] [Accepted: 11/17/2011] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The medical home model seeks to improve health care delivery by enhancing primary care. This study examined the relationship between the presence of a medical home and pediatric primary care office visits by children with special health care needs (CSHCN) using the data from 2005-2006 National Survey of Children with Special Healthcare Needs. METHOD Survey logistic regression was used to analyze the relationship. RESULTS When CSHCN age, gender, ethnicity/race, functional status, insurance status, household education, residence, and income were included in the model, CSHCN with a medical home were 1.6 times more likely to have six or more annual pediatric primary care office visits than were children without a medical home [odds ratio = 1.60, 95% confidence interval = (1.47, 1.75)]. Female CSHCN, younger CSHCN, children with public health insurance, children with severe functional limitations, and CSHCN living in rural areas also were more likely to have a larger number of visits. DISCUSSION By controlling for child sociodemographic characteristics, this study provides empirical evidence about how medical home availability affects primary care utilization by CSHCN.
Collapse
|
43
|
Adams S, Cohen E, Mahant S, Friedman JN, MacCulloch R, Nicholas DB. Exploring the usefulness of comprehensive care plans for children with medical complexity (CMC): a qualitative study. BMC Pediatr 2013; 13:10. [PMID: 23331710 PMCID: PMC3570291 DOI: 10.1186/1471-2431-13-10] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 01/04/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Medical Home model recommends that Children with Special Health Care Needs (CSHCN) receive a medical care plan, outlining the child's major medical issues and care needs to assist with care coordination. While care plans are a primary component of effective care coordination, the creation and maintenance of care plans is time, labor, and cost intensive, and the desired content of the care plan has not been studied. The purpose of this qualitative study was to understand the usefulness and desired content of comprehensive care plans by exploring the perceptions of parents and health care providers (HCPs) of children with medical complexity (CMC). METHODS This qualitative study utilized in-depth semi-structured interviews and focus groups. HCPs (n = 15) and parents (n = 15) of CMC who had all used a comprehensive care plan were recruited from a tertiary pediatric academic health sciences center. Themes were identified through grounded theory analysis of interview and focus group data. RESULTS A multi-dimensional model of perceived care plan usefulness emerged. The model highlights three integral aspects of the care plan: care plan characteristics, activating factors and perceived outcomes of using a care plan. Care plans were perceived as a useful tool that centralized and focused the care of the child. Care plans were reported to flatten the hierarchical relationship between HCPs and parents, resulting in enhanced reciprocal information exchange and strengthened relationships. Participants expressed that a standardized template that is family-centered and includes content relevant to both the medical and social needs of the child is beneficial when integrated into overall care planning and delivery for CMC. CONCLUSIONS Care plans are perceived to be a useful tool to both health care providers and parents of CMC. These findings inform the utility and development of a comprehensive care plan template as well as a model of how and when to best utilize care plans within family-centered models of care.
Collapse
Affiliation(s)
- Sherri Adams
- Division of Paediatric Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, Ontario, M5T 1P8, Canada
| | - Eyal Cohen
- Division of Paediatric Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Paediatrics, University of Toronto, 1 King’s College Circle, Toronto, Ontario, M5S 1A8, Canada
- Department of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, Ontario, M5T 3M6, Canada
- CanChild Center for Childhood Disability Research, 1400 Main Street West, Room 408, Hamilton, Ontario, L8S 1C7, Canada
| | - Sanjay Mahant
- Division of Paediatric Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Paediatrics, University of Toronto, 1 King’s College Circle, Toronto, Ontario, M5S 1A8, Canada
| | - Jeremy N Friedman
- Division of Paediatric Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Paediatrics, University of Toronto, 1 King’s College Circle, Toronto, Ontario, M5S 1A8, Canada
| | - Radha MacCulloch
- School of Social Work, McGill, University of Montreal, 3506 University Street, Montreal, Quebec, H3A 2A7, Canada
| | - David B Nicholas
- Faculty of Social Work, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada
| |
Collapse
|
44
|
Cohen E, Berry JG, Camacho X, Anderson G, Wodchis W, Guttmann A. Patterns and costs of health care use of children with medical complexity. Pediatrics 2012; 130. [PMID: 23184117 PMCID: PMC4528341 DOI: 10.1542/peds.2012-0175] [Citation(s) in RCA: 457] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Health care use of children with medical complexity (CMC), such as those with neurologic impairment or other complex chronic conditions (CCCs) and those with technology assistance (TA), is not well understood. The objective of the study was to evaluate health care utilization and costs in a population-based sample of CMC in Ontario, Canada. METHODS Hospital discharge data from 2005 through 2007 identified CMC. Complete health system use and costs were analyzed over the subsequent 2-year period. RESULTS The study identified 15 771 hospitalized CMC (0.67% of children in Ontario); 10 340 (65.6%) had single-organ CCC, 1063 (6.7%) multiorgan CCC, 4368 (27.6%) neurologic impairment, and 1863 (11.8%) had TA. CMC saw a median of 13 outpatient physicians and 6 distinct subspecialists. Thirty-six percent received home care services. Thirty-day readmission varied from 12.6% (single CCC without TA) to 23.7% (multiple CCC with TA). CMC accounted for almost one-third of child health spending. Rehospitalization accounted for the largest proportion of subsequent costs (27.2%), followed by home care (11.3%) and physician services (6.0%). Home care costs were a much larger proportion of costs in children with TA. Children with multiple CCC with TA had costs 3.5 times higher than children with a single CCC without TA. CONCLUSIONS Although a small proportion of the population, CMC account for a substantial proportion of health care costs. CMC make multiple transitions across providers and care settings and CMC with TA have higher costs and home care use. Initiatives to improve their health outcomes and decrease costs need to focus on the entire continuum of care.
Collapse
Affiliation(s)
- Eyal Cohen
- Department of Pediatrics, Hospital for Sick Children, and,Institute for Health Policy, Management and Evaluation, University of Toronto
| | - Jay G. Berry
- Division of General Pediatrics, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts; and
| | - Ximena Camacho
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Geoff Anderson
- Institute for Health Policy, Management and Evaluation, University of Toronto;,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Walter Wodchis
- Institute for Health Policy, Management and Evaluation, University of Toronto;,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada;,Toronto Rehabilitation Institute, Toronto, Ontario, Canada
| | - Astrid Guttmann
- Department of Pediatrics, Hospital for Sick Children, and,Institute for Health Policy, Management and Evaluation, University of Toronto;,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| |
Collapse
|
45
|
Cohen E, Lacombe-Duncan A, Spalding K, MacInnis J, Nicholas D, Narayanan UG, Gordon M, Margolis I, Friedman JN. Integrated complex care coordination for children with medical complexity: a mixed-methods evaluation of tertiary care-community collaboration. BMC Health Serv Res 2012; 12:366. [PMID: 23088792 PMCID: PMC3529108 DOI: 10.1186/1472-6963-12-366] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 10/16/2012] [Indexed: 11/25/2022] Open
Abstract
Background Primary care medical homes may improve health outcomes for children with special healthcare needs (CSHCN), by improving care coordination. However, community-based primary care practices may be challenged to deliver comprehensive care coordination to complex subsets of CSHCN such as children with medical complexity (CMC). Linking a tertiary care center with the community may achieve cost effective and high quality care for CMC. The objective of this study was to evaluate the outcomes of community-based complex care clinics integrated with a tertiary care center. Methods A before- and after-intervention study design with mixed (quantitative/qualitative) methods was utilized. Clinics at two community hospitals distant from tertiary care were staffed by local community pediatricians with the tertiary care center nurse practitioner and linked with primary care providers. Eighty-one children with underlying chronic conditions, fragility, requirement for high intensity care and/or technology assistance, and involvement of multiple providers participated. Main outcome measures included health care utilization and expenditures, parent reports of parent- and child-quality of life [QOL (SF-36®, CPCHILD©, PedsQL™)], and family-centered care (MPOC-20®). Comparisons were made in equal (up to 1 year) pre- and post-periods supplemented by qualitative perspectives of families and pediatricians. Results Total health care system costs decreased from median (IQR) $244 (981) per patient per month (PPPM) pre-enrolment to $131 (355) PPPM post-enrolment (p=.007), driven primarily by fewer inpatient days in the tertiary care center (p=.006). Parents reported decreased out of pocket expenses (p<.0001). Parental QOL did not significantly change over the course of the study. Child QOL improved between baseline and 6 months in two PedsQL™ domains [Social (p=.01); Emotional (p=.003)], and between baseline and 1 year in two CPCHILD© domains [Health Standardization Section (p=.04); Comfort and Emotions (p=.03)], while total CPCHILD© score decreased between baseline and 1 year (p=.003). Parents and providers reported the ability to receive care close to home as a key benefit. Conclusions Complex care can be provided in community-based settings with less direct tertiary care involvement through an integrated clinic. Improvements in health care utilization and family-centeredness of care can be achieved despite minimal changes in parental perceptions of child health.
Collapse
Affiliation(s)
- Eyal Cohen
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto M5G 1X8, ON, Canada.
| | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Kuo DZ, Cohen E, Agrawal R, Berry JG, Casey PH. A national profile of caregiver challenges among more medically complex children with special health care needs. ACTA ACUST UNITED AC 2011; 165:1020-6. [PMID: 22065182 DOI: 10.1001/archpediatrics.2011.172] [Citation(s) in RCA: 365] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES To profile the national prevalence of more medically complex children with special health care needs (CSHCN) and the diversity of caregiver challenges that their families confront. DESIGN Secondary analysis of the 2005-2006 National Survey of Children With Special Health Care Needs (unweighted n = 40 723). SETTING United States-based population. PARTICIPANTS National sample of CSHCN. MAIN EXPOSURE More complex CSHCN were defined by incorporating components of child health and family need, including medical technology dependence and care by 2 or more subspecialists. MAIN OUTCOME MEASURES Caregiver challenges were defined by family-reported care burden (including hours providing care coordination and home care), medical care use (on the basis of health care encounters in the last 12 months), and unmet needs (defined by 15 individual medical care needs and a single nonmedical service need). RESULTS Among CSHCN, 3.2% (weighted n = 324 323) met criteria for more complex children, representing 0.4% of all children in the United States. Caregivers of more complex CSHCN reported a median of 2 (interquartile range, 1-6) hours per week on care coordination and 11 to 20 (interquartile range, 3->21) hours per week on direct home care. More than half (56.8%) reported financial problems, 54.1% reported that a family member stopped working because of the child's health, 48.8% reported at least 1 unmet medical service need, and 33.1% reported difficulty in accessing nonmedical services. CONCLUSIONS Extraordinary and diverse needs are common among family caregivers of more complex CSHCN. Enhanced care coordination support, respite care, and direct home care may begin to address the substantial economic burden and the multiple unmet needs that many of these families face.
Collapse
Affiliation(s)
- Dennis Z Kuo
- Center for Applied Research and Evaluation, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR 72202, USA.
| | | | | | | | | |
Collapse
|
47
|
Kuo DZ, Cohen E, Agrawal R, Berry JG, Casey PH. A national profile of caregiver challenges among more medically complex children with special health care needs. ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE 2011. [PMID: 22065182 DOI: 10.1001/archpediatrics.2011.172.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES To profile the national prevalence of more medically complex children with special health care needs (CSHCN) and the diversity of caregiver challenges that their families confront. DESIGN Secondary analysis of the 2005-2006 National Survey of Children With Special Health Care Needs (unweighted n = 40 723). SETTING United States-based population. PARTICIPANTS National sample of CSHCN. MAIN EXPOSURE More complex CSHCN were defined by incorporating components of child health and family need, including medical technology dependence and care by 2 or more subspecialists. MAIN OUTCOME MEASURES Caregiver challenges were defined by family-reported care burden (including hours providing care coordination and home care), medical care use (on the basis of health care encounters in the last 12 months), and unmet needs (defined by 15 individual medical care needs and a single nonmedical service need). RESULTS Among CSHCN, 3.2% (weighted n = 324 323) met criteria for more complex children, representing 0.4% of all children in the United States. Caregivers of more complex CSHCN reported a median of 2 (interquartile range, 1-6) hours per week on care coordination and 11 to 20 (interquartile range, 3->21) hours per week on direct home care. More than half (56.8%) reported financial problems, 54.1% reported that a family member stopped working because of the child's health, 48.8% reported at least 1 unmet medical service need, and 33.1% reported difficulty in accessing nonmedical services. CONCLUSIONS Extraordinary and diverse needs are common among family caregivers of more complex CSHCN. Enhanced care coordination support, respite care, and direct home care may begin to address the substantial economic burden and the multiple unmet needs that many of these families face.
Collapse
Affiliation(s)
- Dennis Z Kuo
- Center for Applied Research and Evaluation, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR 72202, USA.
| | | | | | | | | |
Collapse
|
48
|
Cohen E, Jovcevska V, Kuo DZ, Mahant S. Hospital-based comprehensive care programs for children with special health care needs: a systematic review. ACTA ACUST UNITED AC 2011; 165:554-61. [PMID: 21646589 DOI: 10.1001/archpediatrics.2011.74] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To examine the effectiveness of hospital-based comprehensive care programs in improving the quality of care for children with special health care needs. DATA SOURCES A systematic review was conducted using Ovid MEDLINE, CINAHL, EMBASE, PsycINFO, Sociological Abstracts SocioFile, and Web of Science. STUDY SELECTION Evaluations of comprehensive care programs for categorical (those with single disease) and noncategorical groups of children with special health care needs were included. Selected articles were reviewed independently by 2 raters. DATA EXTRACTION Models of care focused on comprehensive care based at least partially in a hospital setting. The main outcome measures were the proportions of studies demonstrating improvement in the Institute of Medicine's quality-of-care domains (effectiveness of care, efficiency of care, patient or family centeredness, patient safety, timeliness of care, and equity of care). DATA SYNTHESIS Thirty-three unique programs were included, 13 (39%) of which were randomized controlled trials. Improved outcomes most commonly reported were efficiency of care (64% [49 of 76 outcomes]), effectiveness of care (60% [57 of 95 outcomes]), and patient or family centeredness (53% [10 of 19 outcomes). Outcomes less commonly evaluated were patient safety (9% [3 of 33 programs]), timeliness of care (6% [2 of 33 programs]), and equity of care (0%). Randomized controlled trials occurred more frequently in studies evaluating categorical vs noncategorical disease populations (11 of 17 [65%] vs 2 of 16 [17%], P = .008). CONCLUSIONS Although positive, the evidence supporting comprehensive hospital-based programs for children with special health care needs is restricted primarily to nonexperimental studies of children with categorical diseases and is limited by inadequate outcome measures. Additional high-quality evidence with appropriate comparative groups and broad outcomes is necessary to justify continued development and growth of programs for broad groups of children with special health care needs.
Collapse
Affiliation(s)
- Eyal Cohen
- Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada.
| | | | | | | |
Collapse
|
49
|
Cohen E, Kuo DZ, Agrawal R, Berry JG, Bhagat SKM, Simon TD, Srivastava R. Children with medical complexity: an emerging population for clinical and research initiatives. Pediatrics 2011; 127:529-38. [PMID: 21339266 PMCID: PMC3387912 DOI: 10.1542/peds.2010-0910] [Citation(s) in RCA: 798] [Impact Index Per Article: 61.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Children with medical complexity (CMC) have medical fragility and intensive care needs that are not easily met by existing health care models. CMC may have a congenital or acquired multisystem disease, a severe neurologic condition with marked functional impairment, and/or technology dependence for activities of daily living. Although these children are at risk of poor health and family outcomes, there are few well-characterized clinical initiatives and research efforts devoted to improving their care. In this article, we present a definitional framework of CMC that consists of substantial family-identified service needs, characteristic chronic and severe conditions, functional limitations, and high health care use. We explore the diversity of existing care models and apply the principles of the chronic care model to address the clinical needs of CMC. Finally, we suggest a research agenda that uses a uniform definition to accurately describe the population and to evaluate outcomes from the perspectives of the child, the family, and the broader health care system.
Collapse
Affiliation(s)
- Eyal Cohen
- Division of Pediatric Medicine, Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8.
| | - Dennis Z. Kuo
- Center for Applied Research and Evaluation, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Rishi Agrawal
- Division of Hospital Based Medicine, Department of Pediatrics, Children's Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois; ,Section of Chronic Disease, La Rabida Children's Hospital, Chicago, Illinois
| | - Jay G. Berry
- Division of General Pediatrics, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts
| | | | - Tamara D. Simon
- Division of Hospital Medicine, Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Washington; and
| | - Rajendu Srivastava
- Division of Inpatient Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| |
Collapse
|
50
|
Abstract
PURPOSE OF REVIEW The present review focuses on the latest evidence from the past 18 months related to pediatric hospitalist medicine. RECENT FINDINGS The number of hospitalists continues to increase despite many programs not being financially self-supporting. Reports in the past have shown decreased length of stay, resource utilization, and costs with the hospitalist model. There are an increasing number of studies examining patient safety, quality initiatives, and communication issues such as 'handoffs' and family-centered rounds. The teaching role continues to broaden in scope and is highly valued by trainees. Pediatric hospitalist fellowship training programs are in an early stage of development. A list of core competencies as a framework for a pediatric hospital medicine curriculum has recently been published and should help to facilitate and standardize training. Recent publications suggest that there is still significant variation in the approach to and management of many common inpatient illnesses. SUMMARY In general, there continue to be reports of positive outcomes as a result of the introduction of the hospitalist model in pediatrics. Much of the current literature is geared toward reporting on alternative models of care, inpatient quality and safety initiatives, and hospitalist teaching. What is still somewhat lacking is multicenter collaborative prospective clinical trials for common inpatient general pediatric conditions. The variation reported in the management of common conditions presents an opportunity for improving the quality, safety, resource utilization, and appropriateness of care.
Collapse
|