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Millar K, Rodd C, Rempel G, Cohen E, Sibley KM, Garland A. The Clinical Definition of Children With Medical Complexity: A Modified Delphi Study. Pediatrics 2024; 153:e2023064556. [PMID: 38804054 DOI: 10.1542/peds.2023-064556] [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] [Received: 10/04/2023] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Children with medical complexity (CMC) comprise a subgroup of children with severe chronic diseases. A conceptual definition for CMC has been formulated, but there is no agreement on criteria to fulfill each of the 4 proposed domains: diagnostic conditions, functional limitations, health care use, and family-identified needs. Our objective with this study was to identify a standardized definition of CMC. METHODS Through a scoping review of the CMC literature, we identified potential criteria to fulfill each domain. These were incorporated into an electronic survey that was completed by a geographic and professionally varied panel of 81 American and Canadian respondents with expertise in managing CMC (response rate 70%) as part of a 4-iteration Delphi procedure. Respondents were asked to vote for the inclusion of each criterion in the definition, and for those with quantitative components (eg, hospitalization rates), to generate a consensus threshold value for meeting that criterion. The final criteria were analyzed by a committee and collapsed when situations of redundancy arose. RESULTS Of 1411 studies considered, 132 informed 55 criteria for the initial survey, which was presented to 81 respondents. Consensus for inclusion was reached on 48 criteria and for exclusion on 1 criterion. The committee collapsed those 48 criteria into 39 final criteria, 1 for diagnostic conditions, 2 for functional limitations, 13 for health care use, and 23 for family needs. CONCLUSIONS These results represent the first consensus-based, standardized definition of CMC. Standardized identification is needed to advance understanding of their epidemiology and outcomes, as well as to rigorously study treatment strategies and care models.
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Affiliation(s)
| | | | | | - Eyal Cohen
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | | | - Allan Garland
- Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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2
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Chen LP, Gerber DM, Coller RJ. Admitting what is needed: How the health system and society can reduce hospitalizations for children with medical complexity. J Hosp Med 2023; 18:90-94. [PMID: 35996947 PMCID: PMC9817383 DOI: 10.1002/jhm.12948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 01/11/2023]
Affiliation(s)
- Laura P. Chen
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health
| | - Danielle M. Gerber
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health
| | - Ryan J. Coller
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health
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3
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HarnEnz Z, Vermilion P, Foster-Barber A, Treat L. Pediatric neuropalliative care. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:157-184. [PMID: 36599507 DOI: 10.1016/b978-0-12-824535-4.00015-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Pediatric palliative care seeks to support quality of life for children and families affected by serious illness. Children with neurological disease are among the most frequent recipients of pediatric palliative care. Several important elements distinguish pediatric palliative care from adult practice, including a longer illness duration, longitudinal relationships over the span of years, diseases characterized by chronic fragility rather than progressive pathology, and the reliance on parents as proxy decision makers. This chapter will provide an overview of pediatric neuropalliative care, with emphasis on the types of disease trajectories, symptom management, and communication principles for supporting shared decision making with families. The role of neurology expertise is highlighted throughout, with special attention toward incorporating palliative care into pediatric neurology practice.
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Affiliation(s)
- Zoe HarnEnz
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - Paul Vermilion
- Department of Medicine, University of Rochester, Rochester, NY, United States
| | - Audrey Foster-Barber
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - Lauren Treat
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States.
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4
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Batson L, Donohue PK, Boss RD, Seltzer RR. Family challenges in personal transportation of children with medical complexity. J Pediatr Rehabil Med 2022; 15:655-665. [PMID: 36502348 DOI: 10.3233/prm-220015] [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: 12/13/2022] Open
Abstract
PURPOSE This study aimed to explore the family experience and associated challenges of transporting children with medical complexity (CMC) in personal vehicles. METHODS Parents/guardians of CMC in Maryland were recruited to participate in an audiotaped, semi-structured interview. Conventional content analysis was applied to transcripts. RESULTS Data from 29 participants who indicated use of personal vehicles to transport their CMC were included in the analysis. Transportation challenges were common, and analysis revealed the following themes: 1) challenges transitioning in/out of the vehicle: excess planning time, child factors (e.g., weight), equipment factors (e.g., wheelchair), physical and environmental factors, 2) safety and comfort: CMC positioning/restraints, driver distraction, 3) financial challenges: travel costs related to medical care, accessible modification costs, transportation equipment costs, insurance delays in equipment coverage, 4) adverse family repercussions: parental physical health, isolation, and 5) evolving and unpredictable transportation needs. CONCLUSION Families with CMC experience multifactorial challenges that impact all phases of travel in personal vehicles and negatively impact child and family safety, access to community and medical care, family finances, and overall well-being. Health care providers can support families by identifying transportation challenges that contribute to health inequities, tailoring solutions to the family's unique needs, and advocating at a policy level to promote change.
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Affiliation(s)
- Lora Batson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Pamela K Donohue
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Renee D Boss
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Berman Institute of Bioethics, Baltimore, MD, USA
| | - Rebecca R Seltzer
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Berman Institute of Bioethics, Baltimore, MD, USA
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5
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Feudtner C, Nye RT, Boyden JY, Schwartz KE, Korn ER, Dewitt AG, Waldman AT, Schwartz LA, Shen YA, Manocchia M, Xiao R, Lord BT, Hill DL. Association Between Children With Life-Threatening Conditions and Their Parents' and Siblings' Mental and Physical Health. JAMA Netw Open 2021; 4:e2137250. [PMID: 34928360 PMCID: PMC8689391 DOI: 10.1001/jamanetworkopen.2021.37250] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Despite concerns regarding the potential deleterious physical and mental health outcomes among family members of a child with a life-threatening condition (LTC), few studies have examined empirical measures of health outcomes among these family members. OBJECTIVES To examine whether mothers, fathers, sisters, and brothers of children with 1 of 4 types of pediatric LTCs have higher rates of health care encounters, diagnoses, and prescriptions compared with families of children without these conditions. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included US families with commercial insurance coverage from a single carrier. Children who had 1 of 4 LTCs (substantial prematurity, critical congenital heart disease, cancer, or a condition resulting in severe neurologic impairment) were identified by a diagnosis in their insurance claim data between July 1, 2015, and June 30, 2016. Each case child and their family was matched with up to 4 control children and their families based on the age of the case and control children. Data were analyzed between August 2020 and March 2021. EXPOSURES Having a child or sibling with substantial prematurity, critical congenital heart disease, cancer, or a condition resulting in severe and progressive neurologic impairment. MAIN OUTCOMES Rates of occurrence of health care encounters, physical and mental health diagnoses, and physical and mental health medication prescriptions, identified from insurance claims data, were compared between case and control families using a multivariable negative binomial regression model. The statistical analysis adjusted for observed differences between case and control families and accounted for clustering at the family level. RESULTS The study included 25 528 children (6909 case children [27.1%] and 18 619 control children [72.9%]; median age, 6.0 years [IQR, 1-13 years]; 13 294 [52.1%] male), 43 357 parents (11 586 case parents [26.7%] and 31 771 control parents [73.3%]; mean [SD] age, 40.4 [8.1] years; 22 318 [51.5%] female), and 25 706 siblings (7664 case siblings [29.8%] and 18 042 control siblings [70.2%]; mean [SD] age, 12.1 [6.5] years; 13 114 [51.0%] male). Overall, case mothers had higher rates of the composite outcome of health care encounters, diagnoses, and prescriptions compared with control mothers (incident rate ratio [IRR], 1.61; 95% CI, 1.54-1.68), as did case fathers compared with control fathers (IRR, 1.55; 95% CI, 1.46-1.64). Sisters of children with LTCs had higher rates of the composite outcome compared with sisters of children without LTCs (IRR, 1.68; 95% CI, 1.55-1.82), as did brothers of children with LTCs compared with brothers of children without LTCs (IRR, 1.70; 95% CI, 1.56-1.85). CONCLUSIONS AND RELEVANCE In this cohort study, mothers, fathers, sisters, and brothers who had a child or sibling with 1 of 4 types of LTCs had higher rates of health care encounters, diagnoses, and medication prescriptions compared with families who did not have a child with that condition. The findings suggest that family members of children with LTCs may experience poorer mental and physical health outcomes. Interventions for parents and siblings of children with LTCs that aim to safeguard their mental and physical well-being appear to be warranted.
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Affiliation(s)
- Chris Feudtner
- Justin Michael Ingerman Center for Palliative Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of General Pediatrics, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Russell T. Nye
- Justin Michael Ingerman Center for Palliative Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jackelyn Y. Boyden
- Justin Michael Ingerman Center for Palliative Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Katherine E. Schwartz
- Division of Neonatology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Emilie R. Korn
- Division of General Pediatrics, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Aaron G. Dewitt
- Division of Cardiology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Amy T. Waldman
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Lisa A. Schwartz
- Division of Oncology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | | | - Michael Manocchia
- Cigna, Bloomfield, Connecticut
- Department of Sociology, University of North Florida, Jacksonville
| | - Rui Xiao
- Division of General Pediatrics, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | | | - Douglas L. Hill
- Justin Michael Ingerman Center for Palliative Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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6
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Affiliation(s)
- Chris Feudtner
- Division of General Pediatrics, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Annique K Hogan
- Division of General Pediatrics, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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7
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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.
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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
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8
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Feudtner C, Schall T, Nathanson P, Berry J. Ethical Framework for Risk Stratification and Mitigation Programs for Children With Medical Complexity. Pediatrics 2018; 141:S250-S258. [PMID: 29496976 DOI: 10.1542/peds.2017-1284j] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2017] [Indexed: 11/24/2022] Open
Abstract
Those in hospitals and health care systems, when designing clinical programs for children with medical complexity, often talk about needing to develop and implement a system of risk stratification. In this article, we use the framework of an ethical evaluation of a health care program to examine what this task of risk stratification might entail by identifying specific and detailed issues that require particular attention and making a series of recommendations to help ensure that programs for children with medical complexity avoid potentially ethically problematic situations and practices.
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Affiliation(s)
- Chris Feudtner
- Department of Medical Ethics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; .,Departments of Pediatrics and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Theodore Schall
- Department of Medical Ethics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Pamela Nathanson
- Department of Medical Ethics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jay Berry
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
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9
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Hind D, Parkin J, Whitworth V, Rex S, Young T, Hampson L, Sheehan J, Maguire C, Cantrill H, Scott E, Epps H, Main M, Geary M, McMurchie H, Pallant L, Woods D, Freeman J, Lee E, Eagle M, Willis T, Muntoni F, Baxter P. Aquatic therapy for children with Duchenne muscular dystrophy: a pilot feasibility randomised controlled trial and mixed-methods process evaluation. Health Technol Assess 2018. [PMID: 28627356 DOI: 10.3310/hta21270] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Duchenne muscular dystrophy (DMD) is a rare disease that causes the progressive loss of motor abilities such as walking. Standard treatment includes physiotherapy. No trial has evaluated whether or not adding aquatic therapy (AT) to land-based therapy (LBT) exercises helps to keep muscles strong and children independent. OBJECTIVES To assess the feasibility of recruiting boys with DMD to a randomised trial evaluating AT (primary objective) and to collect data from them; to assess how, and how well, the intervention and trial procedures work. DESIGN Parallel-group, single-blind, randomised pilot trial with nested qualitative research. SETTING Six paediatric neuromuscular units. PARTICIPANTS Children with DMD aged 7-16 years, established on corticosteroids, with a North Star Ambulatory Assessment (NSAA) score of 8-34 and able to complete a 10-m walk without aids/assistance. Exclusions: > 20% variation between baseline screens 4 weeks apart and contraindications. INTERVENTIONS Participants were allocated on a 1 : 1 ratio to (1) optimised, manualised LBT (prescribed by specialist neuromuscular physiotherapists) or (2) the same plus manualised AT (30 minutes, twice weekly for 6 months: active assisted and/or passive stretching regime; simulated or real functional activities; submaximal exercise). Semistructured interviews with participants, parents (n = 8) and professionals (n = 8) were analysed using Framework analysis. An independent rater reviewed patient records to determine the extent to which treatment was optimised. A cost-impact analysis was performed. Quantitative and qualitative data were mixed using a triangulation exercise. MAIN OUTCOME MEASURES Feasibility of recruiting 40 participants in 6 months, participant and therapist views on the acceptability of the intervention and research protocols, clinical outcomes including NSAA, independent assessment of treatment optimisation and intervention costs. RESULTS Over 6 months, 348 children were screened - most lived too far from centres or were enrolled in other trials. Twelve (30% of target) were randomised to AT (n = 8) or control (n = 4). People in the AT (n = 8) and control (n = 2: attrition because of parental report) arms contributed outcome data. The mean change in NSAA score at 6 months was -5.5 [standard deviation (SD) 7.8] for LBT and -2.8 (SD 4.1) in the AT arm. One boy suffered pain and fatigue after AT, which resolved the same day. Physiotherapists and parents valued AT and believed that it should be delivered in community settings. The independent rater considered AT optimised for three out of eight children, with other children given programmes that were too extensive and insufficiently focused. The estimated NHS costs of 6-month service were between £1970 and £2734 per patient. LIMITATIONS The focus on delivery in hospitals limits generalisability. CONCLUSIONS Neither a full-scale frequentist randomised controlled trial (RCT) recruiting in the UK alone nor a twice-weekly open-ended AT course delivered at tertiary centres is feasible. Further intervention development research is needed to identify how community-based pools can be accessed, and how families can link with each other and community physiotherapists to access tailored AT programmes guided by highly specialised physiotherapists. Bayesian RCTs may be feasible; otherwise, time series designs are recommended. TRIAL REGISTRATION Current Controlled Trials ISRCTN41002956. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 27. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Daniel Hind
- Sheffield Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - James Parkin
- Sheffield Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Victoria Whitworth
- Sheffield Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Saleema Rex
- Sheffield Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Tracey Young
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Lisa Hampson
- Department of Mathematics and Statistics, University of Lancaster, Lancaster, UK
| | - Jennie Sheehan
- Evelina London Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Chin Maguire
- Sheffield Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Hannah Cantrill
- Sheffield Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Elaine Scott
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Marion Main
- Dubowitz Neuromuscular Centre (DNC), Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Michelle Geary
- Children's Therapy Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Heather McMurchie
- Paediatric Physiotherapy, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Lindsey Pallant
- Regional Paediatric Neuromuscular Team, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Jennifer Freeman
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ellen Lee
- Sheffield Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | | | - Tracey Willis
- The Oswestry Inherited Neuromuscular Service, The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, UK
| | - Francesco Muntoni
- Dubowitz Neuromuscular Centre (DNC), Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Peter Baxter
- Paediatric Neurology, Sheffield Children's Hospital, Sheffield, UK
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10
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Nightingale R, Wirz L, Cook W, Swallow V. Collaborating With Parents of Children With Chronic Conditions and Professionals to Design, Develop and Pre-pilot PLAnT (the Parent Learning Needs and Preferences Assessment Tool). J Pediatr Nurs 2017; 35:90-97. [PMID: 28728776 DOI: 10.1016/j.pedn.2017.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 02/17/2017] [Accepted: 03/22/2017] [Indexed: 11/16/2022]
Abstract
PURPOSE This study aimed to design, develop and pre-pilot an assessment tool (PLAnT) to identify parents' learning needs and preferences when carrying out home-based clinical care for their child with a chronic condition. DESIGN AND METHODS A mixed methods, two-phased design was used. Phase 1: a total of 10 parents/carers and 13 professionals from six UK's children's kidney units participated in qualitative interviews. Interview data were used to develop the PLAnT. Eight of these participants subsequently took part in an online survey to refine the PLAnT. Phase 2: thirteen parents were paired with one of nine professionals to undertake a pre-pilot evaluation of PLAnT. Data were analyzed using the Framework approach. RESULTS A key emergent theme identifying parents' learning needs and preferences was identified. The importance of professionals being aware of parents' learning needs and preferences was recognised. Participants discussed how parents' learning needs and preferences should be identified, including: the purpose for doing this, the process for doing this, and what would the outcome be of identifying parents' needs. CONCLUSIONS The evidence suggests that asking parents directly about their learning needs and preferences may be the most reliable way for professionals to ascertain how to support individual parents' learning when sharing management of their child's chronic condition. PRACTICE IMPLICATIONS With the increasing emphasis on parent-professional shared management of childhood chronic conditions, professionals can be guided by PLAnT in their assessment of parents' learning needs and preferences, based on identified barriers and facilitators to parental learning.
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Affiliation(s)
- Ruth Nightingale
- NIHR Clinical Research Network: North Thames, c/o Somers Clinical Research Facility, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
| | - Lucy Wirz
- Great North Children's Hospital Kidney Team, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, UK.
| | - Wendy Cook
- Nephrotic Syndrome Trust (NeST), Yeovil, Somerset, UK.
| | - Veronica Swallow
- School of Healthcare, Baines Wing, Woodhouse Lane, University of Leeds, UK.
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11
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Mother-caregiver expectations for function among survivors of childhood brain tumors. Support Care Cancer 2015; 24:2147-2154. [PMID: 26556212 DOI: 10.1007/s00520-015-3013-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 11/01/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Children diagnosed with brain tumors increasingly survive to adulthood, although they do so with needs often requiring continued parental caregiving. We sought to describe the nature of caregivers' expectations about survivors' function and how expectations connect to ongoing management and decision-making. METHODS Forty-five qualitative interviews with mother-caregivers were conducted and coded for themes related to expectations for their adolescent/young adult children living post-childhood brain tumors. RESULTS Five main themes emerged as integral to mother-caregiver expectations: realizing a difference in the survivor, noticing limitations to independence in the survivor, memories of learning about clinical prognoses as understood from consent meetings and education, managing these realizations, and acknowledging unresolved challenges. CONCLUSIONS Caregiver expectations are influenced by both initial clinical interactions and contemporary family dynamics and require individual- and family-specific survivorship planning. As caregiver expectations can influence management behaviors that impact outcomes and possibly independence, implications for clinician-caregiver shared decision-making are substantial.
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12
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Nightingale R, Friedl S, Swallow V. Parents' learning needs and preferences when sharing management of their child's long-term/chronic condition: A systematic review. PATIENT EDUCATION AND COUNSELING 2015; 98:1329-1338. [PMID: 26054454 DOI: 10.1016/j.pec.2015.05.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 05/08/2015] [Accepted: 05/12/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE This review aimed to (1) identify parents' learning needs and preferences when sharing the management of their child's long-term/chronic (long-term) condition and (2) inform healthcare professional support provided to parents across the trajectory. METHODS We conducted a literature search in seven health databases from 1990 to 2013. The quality of included studies was assessed using a critical appraisal tool developed for reviewing the strengths and weaknesses of qualitative, quantitative and mixed methods studies. RESULTS Twenty-three studies met our criteria and were included in the review. Three themes emerged from synthesis of the included studies: (1) parents' learning needs and preferences (2) facilitators to parents' learning, and (3) barriers to parents' learning. CONCLUSION Asking parents directly about their learning needs and preferences may be the most reliable way for healthcare professionals to ascertain how to support and promote individual parents' learning when sharing management of their child's long-term condition. PRACTICE IMPLICATIONS With the current emphasis on parent-healthcare professional shared management of childhood long-term conditions, it is recommended that professionals base their assessment of parents' learning needs and preferences on identified barriers and facilitators to parental learning. This should optimise delivery of home-based care, thereby contributing to improved clinical outcomes for the child.
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Affiliation(s)
- Ruth Nightingale
- NIHR Clinical Research Network: North Thames, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK.
| | - Simone Friedl
- Department of Clinical and Health Psychology, St. James's University Hospital, Leeds LS9 7TF, UK.
| | - Veronica Swallow
- School of Healthcare, Baines Wing, Woodhouse Lane, University of Leeds, Leeds LS2 9JT, UK.
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13
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Nightingale R, Sinha MD, Swallow V. Using focused ethnography in paediatric settings to explore professionals' and parents' attitudes towards expertise in managing chronic kidney disease stage 3-5. BMC Health Serv Res 2014; 14:403. [PMID: 25234741 PMCID: PMC4176584 DOI: 10.1186/1472-6963-14-403] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 09/15/2014] [Indexed: 11/26/2022] Open
Abstract
Background Interactions between parents and healthcare professionals are essential when parents of children with chronic conditions are learning to share expertise about clinical care, but limited evidence exists on how they actually interact. This paper discusses the use of focused ethnography in paediatric settings as an effective means of exploring attitudes towards expertise. Methods The paper draws on repeated observations, interviews and field-notes involving the parents of six children with chronic kidney disease, and 28 healthcare professionals at two, tertiary, children’s hospital-based units. Data were analysed using the Framework approach and the concepts of expertise and self-management. Results Our study highlighted rewards and challenges associated with focused ethnography in this context. Rewards included the ability to gain a richer understanding of the complex phenomena of mutual acknowledgement of expertise that occurs during parent/ healthcare professional interactions. Challenges related to gaining informed consent and ensuring potential participants had an adequate understanding of the purpose of the study. Two dimensions of parental expertise around their child (personal and clinical) were evident in our data. Parents’ and professionals’ expertise about the child and their condition was acknowledged and exchanged as parents learnt to share clinical-care with the multi-disciplinary team. Healthcare professionals acknowledged parents’ need to understand aspects of each of the eight disciplinary knowledge bases relating to their child’s management and recognised parents’ expert knowledge of their child, found ways to mobilise this knowledge, and wove parents’ expertise into the management plan. Parents spoke of the degree to which their own expert knowledge of their child complemented healthcare professionals’ clinical knowledge. However, ambivalence around expertise was evident as both parents and healthcare professionals questioned what the expertise was, and who the expert was. Our discussion focuses on the ways healthcare professionals and parents share expertise around the child’s condition as parents take on responsibility for home-based clinical care. Conclusions Our findings point to focused ethnography being an effective way of capturing new insights into parent and professional interactions in a paediatric setting and mutual acknowledgement of expertise; these insights may help redress the reported limitations of previous, retrospective studies.
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Affiliation(s)
- Ruth Nightingale
- NIHR Clinical Research Network: North Thames, c/o Somers Clinical Research Facility, Frontage Building, Level 1, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK.
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Schwantes S, O'Brien HW. Pediatric palliative care for children with complex chronic medical conditions. Pediatr Clin North Am 2014; 61:797-821. [PMID: 25084725 DOI: 10.1016/j.pcl.2014.04.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Children with complex chronic medical conditions are at risk for significant distress during multiple points in their life. Pediatric palliative care can meaningfully assist in providing support to the child and family throughout their complex care, managing distressing symptoms, anticipating future decision points, and helping the child and family to thrive in their local community.
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Affiliation(s)
- Scott Schwantes
- Department of Pediatrics, Gillette Children's Specialty Healthcare, Regions Hospital, 200 University Avenue East, St Paul, MN 55101, USA.
| | - Helen Wells O'Brien
- Department of Pediatrics, Gillette Children's Specialty Healthcare, Regions Hospital, 200 University Avenue East, St Paul, MN 55101, USA
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Moreira MCN, Gomes R, Sá MRCD. Doenças crônicas em crianças e adolescentes: uma revisão bibliográfica. CIENCIA & SAUDE COLETIVA 2014; 19:2083-94. [DOI: 10.1590/1413-81232014197.20122013] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Accepted: 11/22/2013] [Indexed: 11/22/2022] Open
Abstract
O artigo analisa artigos publicados entre 2003 e 2011 enfocando discussões sobre condições crônicas ou doenças crônicas de crianças e adolescentes. Metodologicamente conjuga a revisão de literatura a uma análise de conteúdo temática com vistas a identificar quais os elementos que caracterizam doenças crônicas em crianças e adolescentes e as especificidades geradas por essas condições. A revisão resultou na descrição do conjunto dos artigos, caracterizando-os quanto ano de publicação, país, tipo de estudo, população e condição de cronicidade abordada. A análise de conteúdo temática gerou dois temas: Definição de Doença Crônica e Formas de se lidar com as doenças crônicas em crianças e adolescentes. Destaca-se como conclusão que as transições etárias quando uma doença é diagnosticada e tratada desde a infância, vai passar por transformações que incluem a maneira como se dá o seu fluxo entre os serviços e as mudanças que envolvem processos de alta, de tomada de decisão e de construção de rede que inclua família, hospital, escola e sistema de garantia de direitos.
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Renjilian CB, Womer JW, Carroll KW, Kang TI, Feudtner C. Parental explicit heuristics in decision-making for children with life-threatening illnesses. Pediatrics 2013; 131:e566-72. [PMID: 23319524 PMCID: PMC3557409 DOI: 10.1542/peds.2012-1957] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To identify and illustrate common explicit heuristics (decision-making aids or shortcuts expressed verbally as terse rules of thumb, aphorisms, maxims, or mantras and intended to convey a compelling truth or guiding principle) used by parents of children with life-threatening illnesses when confronting and making medical decisions. METHODS Prospective cross-sectional observational study of 69 parents of 46 children who participated in the Decision-making in Pediatric Palliative Care Study between 2006 and 2008 at the Children's Hospital of Philadelphia. Parents were guided individually through a semistructured in-depth interview about their experiences and thoughts regarding making medical decisions on behalf of their ill children, and the transcribed interviews were qualitatively analyzed. RESULTS All parents in our study employed explicit heuristics in interviews about decision-making for their children, with the number of identified explicit heuristics used by an individual parent ranging from tens to hundreds. The heuristics served 5 general functions: (1) to depict or facilitate understanding of a complex situation; (2) to clarify, organize, and focus pertinent information and values; (3) to serve as a decision-making compass; (4) to communicate with others about a complex topic; and (5) to justify a choice. CONCLUSIONS Explicit heuristics played an important role in decision-making and communication about decision-making in our population of parents. Recognizing explicit heuristics in parent interactions and understanding their content and functions can aid clinicians in their efforts to partner with parents in the decision-making process.
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Affiliation(s)
| | - James W. Womer
- Pediatric Advanced Care Team,,Department of Medical Ethics
| | | | - Tammy I. Kang
- Pediatric Advanced Care Team,,Division of Oncology, and
| | - Chris Feudtner
- Pediatric Advanced Care Team,,Department of Medical Ethics,,PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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