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Starnes LS, Hall M, Williams DJ, Katz S, Clayton DB, Antoon JW, Bell D, Carroll AR, Gastineau KAB, Wolf R, Ngo ML, Herndon A, Brown CM, Freundlich K. Intravenous antibiotics for urinary tract infections in children with neurologic impairment. J Hosp Med 2024; 19:572-580. [PMID: 38558453 PMCID: PMC11222036 DOI: 10.1002/jhm.13349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/08/2024] [Accepted: 03/17/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Children with high-intensity neurologic impairment (HINI) have an increased risk of urinary tract infection (UTI) and prolonged intravenous (IV) antibiotic exposure. OBJECTIVE To determine the association between short (≤3 days) and long (>3 days) IV antibiotic courses and UTI treatment failure in hospitalized children with HINI. METHODS We performed a retrospective cohort study examining UTI hospitalizations at 49 hospitals in the Pediatric Health Information System from 2016 to 2021 for children (1-18 years) with HINI. The primary outcome was UTI readmission within 30 days. Our secondary outcome was the association of hospital-level variation in short IV antibiotic course use with readmission. Readmission rates were compared between short and long courses using multivariable regression. RESULTS Of 5612 hospitalizations, 3840 (68.4%) had short IV antibiotic courses. In our adjusted model, children with short IV courses were less likely than with long courses to have a 30-day UTI readmission (4.0%, 95% CI [3.6%, 4.5%] vs. 6.3%, 95% CI [5.1%, 7.8%]). Despite marked hospital-level variation in short IV course use (50.0%-87.5% of hospitalizations), there was no correlation with readmissions. CONCLUSIONS Children with HINI hospitalized with UTI had low UTI readmission rates, but those who received long IV antibiotic courses were more likely to experience UTI readmission versus those receiving short courses. While residual confounding may influence our results, we did not find that short IV courses impacted readmission at the hospital level despite variation in use across institutions. Long IV antibiotic courses are associated with risks and may not confer benefit in this population.
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Affiliation(s)
- Lauren S. Starnes
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas, USA
| | - Derek J. Williams
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sophie Katz
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Douglass B. Clayton
- Division of Pediatric Urology, Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James W. Antoon
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Deanna Bell
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alison R. Carroll
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelsey A. B. Gastineau
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ryan Wolf
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - My-Linh Ngo
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alison Herndon
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Charlotte M. Brown
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Katherine Freundlich
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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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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Tchou MJ, Hall M, Markham JL, Stephens JR, Steiner MJ, McCoy E, Aronson PL, Shah SS, Molloy MJ, Cotter JM. Changing patterns of routine laboratory testing over time at children's hospitals. J Hosp Med 2024. [PMID: 38643414 DOI: 10.1002/jhm.13372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/19/2024] [Accepted: 04/09/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Research into low-value routine testing at children's hospitals has not consistently evaluated changing patterns of testing over time. OBJECTIVES To identify changes in routine laboratory testing rates at children's hospitals over ten years and the association with patient outcomes. DESIGN, SETTINGS, AND PARTICIPANTS We performed a multi-center, retrospective cohort study of children aged 0-18 hospitalized with common, lower-severity diagnoses at 28 children's hospitals in the Pediatric Health Information Systems database. MAIN OUTCOMES AND MEASURES We calculated average annual testing rates for complete blood counts, electrolytes, and inflammatory markers between 2010 and 2019 for each hospital. A > 2% average testing rate change per year was defined as clinically meaningful and used to separate hospitals into groups: increasing, decreasing, and unchanged testing rates. Groups were compared for differences in length of stay, cost, and 30-day readmission or ED revisit, adjusted for demographics and case mix index. RESULTS Our study included 576,572 encounters for common, low-severity diagnoses. Individual hospital testing rates in each year of the study varied from 0.3 to 1.4 tests per patient day. The average yearly change in hospital-specific testing rates ranged from -6% to +7%. Four hospitals remained in the lowest quartile of testing and two in the highest quartile throughout all ten years of the study. We grouped hospitals with increasing (8), decreasing (n = 5), and unchanged (n = 15) testing rates. No difference was found across subgroups in costs, length of stay, 30-day ED revisit, or readmission rates. Comparing resource utilization trends over time provides important insights into achievable rates of testing reduction.
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Affiliation(s)
- Michael J Tchou
- Department of Pediatrics, Section of Hospital Medicine, University of Colorado-Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Jessica L Markham
- Department of Pediatrics, Children's Mercy Kansas City and University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - John R Stephens
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael J Steiner
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elisha McCoy
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of General Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Paul L Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Matthew J Molloy
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Jillian M Cotter
- Department of Pediatrics, Section of Hospital Medicine, University of Colorado-Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado, USA
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4
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Bogetz JF, Oslin E, O’Donnell M, Barton KS, Yi-Frazier JP, Watson RS, Rosenberg AR. Meaning-Making Among Parents of Children With Severe Neurologic Impairment in the PICU. Pediatrics 2024; 153:e2023064361. [PMID: 38529567 PMCID: PMC10979294 DOI: 10.1542/peds.2023-064361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Parents and family caregivers of children with severe neurologic impairment (SNI) experience many stressors, especially during their child's critical illness. This study aimed to examine parent experiences around the time of their child's PICU care to explore ways parents make meaning in relation to these stressors. METHODS This qualitative study of data from a single center in the United States followed Consolidated Criteria for Reporting Qualitative Research guidelines. One to one semistructured interviews queried parents' psychosocial well-being around the time of their child's PICU care. Eligible participants had a child with an SNI condition for >3 months admitted to the PICU for >24 hours with an expected length of stay >1 week. RESULTS Data were analyzed by a research team with expertise in palliative care, psychology, critical care, and qualitative methods. Fifteen family caregivers of 15 children participated. Children were a median of 8 years old (interquartile range 4-11.5) and 80% (n = 12) had congenital/genetic conditions. Parent/family caregivers were a median age of 39 years old (interquartile range 36-42.5); 20% (n = 3) self-identified as fathers and 47% (n = 7) as having to a minority racial background. Parents discussed ongoing meaning-making that occurred through domains of comprehension and purpose, and themes of understanding of other people and the world around them. Subthemes focused on appreciation/acceptance, adaptability/accountability, valuing all lives, and learning/teaching about their child. CONCLUSIONS Meaning-making may be an opportunity for support in the PICU among parents/family caregivers of children with SNI.
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Affiliation(s)
- Jori F. Bogetz
- Divisions of Bioethics and Palliative Care
- Treuman Katz Center for Bioethics
| | | | | | - Krysta S. Barton
- Biostatistics Epidemiology and Analytics for Research (BEAR) Core, Seattle Children’s Research Institute; Seattle, Washington
| | | | - R. Scott Watson
- Division of Critical Care, Department of Pediatrics, University of Washington School of Medicine; Seattle, Washington
| | - Abby R. Rosenberg
- Division of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute; Department of Pediatrics, Boston Children’s Hospital; Department of Pediatrics, Harvard Medical School; Boston, Massachusetts
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Nelson KE, Zhu J, Thomson J, Mahant S, Widger K, Feudtner C, Cohen E, Pullenayegum E, Feinstein JA. Recurrent Intensive Care Episodes and Mortality Among Children With Severe Neurologic Impairment. JAMA Netw Open 2024; 7:e241852. [PMID: 38488795 PMCID: PMC10943411 DOI: 10.1001/jamanetworkopen.2024.1852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/05/2024] [Indexed: 03/17/2024] Open
Abstract
Importance Children requiring care in a pediatric intensive care unit (PICU) are known to have increased risk of subsequent mortality. Children with severe neurologic impairment (SNI)-who carry neurologic or genetic diagnoses with functional impairments and medical complexity-are frequently admitted to PICUs. Although recurrent PICU critical illness episodes (PICU-CIEs) are assumed to indicate a poor prognosis, the association between recurrent PICU-CIEs and mortality in this patient population is poorly understood. Objective To assess the association between number of recent PICU-CIEs and survival among children with severe neurologic impairment. Design, Setting, and Participants This population-based retrospective cohort study used health administrative data from April 1, 2002, to March 31, 2020, on 4774 children born between 2002 and 2019 with an SNI diagnosis code in an Ontario, Canada, hospital record before 16 years of age and a first PICU-CIE from 2002 to 2019. Data were analyzed from November 2021 to June 2023. Exposure Pediatric intensive care unit critical illness episodes (excluding brief postoperative PICU admissions). Main Outcome and Measures One-year survival conditioned on the number and severity (length of stay >15 days or use of invasive mechanical ventilation) of PICU-CIEs in the preceding year. Results In Ontario, 4774 children with SNI (mean [SD] age, 2.1 [3.6] months; 2636 [55.2%] <1 year of age; 2613 boys [54.7%]) were discharged alive between 2002 and 2019 after their first PICU-CIE. Ten-year survival after the initial episode was 81% (95% CI, 79%-82%) for children younger than 1 year of age and 84% (95% CI, 82%-86%) for children 1 year of age or older; the age-stratified curves converged by 15 years after the initial episode at 79% survival (95% CI, 78%-81% for children <1 year and 95% CI, 75%-84% for children ≥1 year). Adjusted for age category and demographic factors, the presence of nonneurologic complex chronic conditions (adjusted hazard ratio [AHR], 1.70 [95% CI, 1.43-2.02]) and medical technology assistance (AHR, 2.32 [95% CI, 1.92-2.81]) were associated with increased mortality. Conditional 1-year mortality was less than 20% regardless of number or severity of recent PICU-CIEs. Among children with high-risk PICU-CIEs, 1-year conditional survival decreased from 90% (95% CI, 89%-91%) after the first PICU-CIE to 81% (95% CI, 77%-86%) after the fourth PICU-CIE. Conclusions and Relevance This cohort study of children with SNI demonstrated a modest dose-dependent association between PICU-CIEs and short-term mortality. These data did not support the conventional wisdom that recurrent PICU admissions are associated with subsequent high mortality risk.
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Affiliation(s)
- Katherine E. Nelson
- Pediatric Advanced Care Team, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Jingqin Zhu
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Joanna Thomson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Sanjay Mahant
- Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada
| | - Kimberley Widger
- Pediatric Advanced Care Team, Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Chris Feudtner
- The Justin Michael Ingerman Center for Palliative Care, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Eyal Cohen
- Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada
| | - Eleanor Pullenayegum
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - James A. Feinstein
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado and Children’s Hospital Colorado
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Mauritz MD, von Both U, Dohna-Schwake C, Gille C, Hasan C, Huebner J, Hufnagel M, Knuf M, Liese JG, Renk H, Rudolph H, Schulze-Sturm U, Simon A, Stehling F, Tenenbaum T, Zernikow B. Clinical recommendations for the inpatient management of lower respiratory tract infections in children and adolescents with severe neurological impairment in Germany. Eur J Pediatr 2024; 183:987-999. [PMID: 38172444 PMCID: PMC10951000 DOI: 10.1007/s00431-023-05401-6] [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: 10/23/2023] [Revised: 12/06/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024]
Abstract
Children and adolescents with severe neurological impairment (SNI) require specialized care due to their complex medical needs. In particular, these patients are often affected by severe and recurrent lower respiratory tract infections (LRTIs). These infections, including viral and bacterial etiology, pose a significant risk to these patients, often resulting in respiratory insufficiency and long-term impairments. Using expert consensus, we developed clinical recommendations on the management of LRTIs in children and adolescents with SNI. These recommendations emphasize comprehensive multidisciplinary care and antibiotic stewardship. Initial treatment should involve symptomatic care, including hydration, antipyretics, oxygen therapy, and respiratory support. In bacterial LRTIs, antibiotic therapy is initiated based on the severity of the infection, with aminopenicillin plus a beta-lactamase inhibitor recommended for community-acquired LRTIs and piperacillin-tazobactam for patients with chronic lung disease or tracheostomy. Ongoing management includes regular evaluations, adjustments to antibiotic therapy based on pathogen identification, and optimization of supportive care. Implementation of these recommendations aims to improve the diagnosis and treatment of LRTIs in children and adolescents with SNI. What is Known: • Children and adolescents with severe neurological impairment are particularly affected by severe and recurrent lower respiratory tract infections (LRTIs). • The indication and choice of antibiotic therapy for bacterial LRTI is often difficult because there are no evidence-based treatment recommendations for this heterogeneous but vulnerable patient population; the frequent overuse of broad-spectrum or reserve antibiotics in this patient population increases selection pressure for multidrug-resistant pathogens. What is New: • The proposed recommendations provide a crucial framework for focused diagnostics and treatment of LRTIs in children and adolescents with severe neurological impairment. • Along with recommendations for comprehensive and multidisciplinary therapy and antibiotic stewardship, ethical and palliative care aspects are taken into account.
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Affiliation(s)
- Maximilian David Mauritz
- Paediatric Palliative Care Centre, Children's and Adolescents' Hospital, 45711, Datteln, Germany.
- Department of Children's, Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine , Herdecke University, 58448, WittenWitten, Germany.
| | - Ulrich von Both
- Department of Infectious Diseases, Dr von Hauner Children's Hospital, LMU University Hospital, 80337, Munich, Germany
| | - Christian Dohna-Schwake
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, 45147, Essen, Germany
| | - Christian Gille
- Department of Neonatology, Heidelberg University Children's Hospital, 69120, Heidelberg, Germany
| | - Carola Hasan
- Paediatric Palliative Care Centre, Children's and Adolescents' Hospital, 45711, Datteln, Germany
- Department of Children's, Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine , Herdecke University, 58448, WittenWitten, Germany
| | - Johannes Huebner
- Department of Infectious Diseases, Dr von Hauner Children's Hospital, LMU University Hospital, 80337, Munich, Germany
| | - Markus Hufnagel
- Department of Paediatrics and Adolescent Medicine, Medical Faculty, University Medical Centre, University of Freiburg, 79106, Freiburg, Germany
| | - Markus Knuf
- Department for Pediatric and Adolescent Medicine, Worms Clinic, 67550, Worms, Germany
| | - Johannes G Liese
- Department of Paediatrics, Division of Paediatric Infectious Diseases, University Hospital of Wuerzburg, 97080, Würzburg, Germany
| | - Hanna Renk
- University Children's Hospital Tuebingen, 72076, Tuebingen, Germany
| | - Henriette Rudolph
- Department of Pediatrics, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany
| | - Ulf Schulze-Sturm
- University Children's Hospital, University Medical Centre Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Arne Simon
- Pediatric Oncology and Hematology, University Hospital Homburg Saar, 66421, Homburg/Saar, Germany
| | - Florian Stehling
- Department of Pediatric Pulmonology and Sleep Medicine, University Children's Hospital Essen, 45147, Essen, Germany
| | - Tobias Tenenbaum
- Clinic for Child and Adolescent Medicine, Sana Klinikum Lichtenberg, Academic Teaching Hospital, Charité-Universitätsmedizin, 10365, Berlin, Germany
| | - Boris Zernikow
- Paediatric Palliative Care Centre, Children's and Adolescents' Hospital, 45711, Datteln, Germany
- Department of Children's, Pain Therapy and Pediatric Palliative Care, Faculty of Health, School of Medicine , Herdecke University, 58448, WittenWitten, Germany
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7
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Jafari K, Carlin K, Caglar D, Klein EJ, Simon TD. National Characteristics of Emergency Care for Children with Neurologic Complex Chronic Conditions. West J Emerg Med 2024; 25:237-245. [PMID: 38596925 PMCID: PMC11000559 DOI: 10.5811/westjem.17834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 11/16/2023] [Accepted: 11/21/2023] [Indexed: 04/11/2024] Open
Abstract
Introduction Most pediatric emergency care occurs in general emergency departments (GED), where less pediatric experience and lower pediatric emergency readiness may compromise care. Medically vulnerable pediatric patients, such as those with chronic, severe, neurologic conditions, are likely to be disproportionately affected by suboptimal care in GEDs; however, little is known about characteristics of their care in either the general or pediatric emergency setting. In this study our objective was to compare the frequency, characteristics, and outcomes of ED visits made by children with chronic neurologic diseases between general and pediatric EDs (PED). Methods We conducted a retrospective analysis of the 2011-2014 Nationwide Emergency Department Sample (NEDS) for ED visits made by patients 0-21 years with neurologic complex chronic conditions (neuro CCC). We compared patient, hospital, and ED visits characteristics between GEDs and PEDs using descriptive statistics. We assessed outcomes of admission, transfer, critical procedure performance, and mortality using multivariable logistic regression. Results There were 387,813 neuro CCC ED visits (0.3% of 0-21-year-old ED visits) in our sample. Care occurred predominantly in GEDs, and visits were associated with a high severity of illness (30.1% highest severity classification score). Compared to GED visits, PED neuro CCC visits were comprised of individuals who were younger, more likely to have comorbid conditions (32.9% vs 21%, P < 0.001), and technology assistance (65.4% vs. 45.9%) but underwent fewer procedures and had lower ED charges ($2,200 vs $1,520, P < 0.001). Visits to PEDs had lower adjusted odds of critical procedures (adjusted odds ratio [aOR] 0.74, 95% confidence interval [CI] 0.62-0.87), transfers (aOR 0.14, 95% CI 0.04-0.56), and mortality (aOR 0.38, 95% CI 0.19-0.75) compared to GEDs. Conclusion Care for children with neuro CCCs in a pediatric ED is associated with less resource utilization and lower rates of transfer and mortality. Identifying features of PED care for neuro CCCs could lead to lower costs and mortality for this population.
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Affiliation(s)
- Kaileen Jafari
- University of Washington, Department of Pediatrics, Seattle, Washington
- Seattle Children’s Research Institute, Center for Clinical and Translational Research, Seattle, Washington
| | - Kristen Carlin
- Seattle Children’s Research Institute, Center for Clinical and Translational Research, Seattle, Washington
| | - Derya Caglar
- University of Washington, Department of Pediatrics, Seattle, Washington
- Seattle Children’s Research Institute, Center for Clinical and Translational Research, Seattle, Washington
| | - Eileen J. Klein
- University of Washington, Department of Pediatrics, Seattle, Washington
- Seattle Children’s Research Institute, Center for Clinical and Translational Research, Seattle, Washington
| | - Tamara D. Simon
- University of Southern California, Keck School of Medicine, Department of Pediatrics, Los Angeles, California
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8
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LaCoursiere CM, Ullmann JFP, Koh HY, Turner L, Baker CM, Robens B, Shao W, Rotenberg A, McGraw CM, Poduri A. Zebrafish models of candidate human epilepsy-associated genes provide evidence of hyperexcitability. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.02.07.579190. [PMID: 38370728 PMCID: PMC10871320 DOI: 10.1101/2024.02.07.579190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
Hundreds of novel candidate human epilepsy-associated genes have been identified thanks to advancements in next-generation sequencing and large genome-wide association studies, but establishing genetic etiology requires functional validation. We generated a list of >2200 candidate epilepsy-associated genes, of which 81 were determined suitable for the generation of loss-of-function zebrafish models via CRISPR/Cas9 gene editing. Of those 81 crispants, 48 were successfully established as stable mutant lines and assessed for seizure-like swim patterns in a primary F2 screen. Evidence of seizure-like behavior was present in 5 (arfgef1, kcnd2, kcnv1, ubr5, wnt8b) of the 48 mutant lines assessed. Further characterization of those 5 lines provided evidence for epileptiform activity via electrophysiology in kcnd2 and wnt8b mutants. Additionally, arfgef1 and wnt8b mutants showed a decrease in the number of inhibitory interneurons in the optic tectum of larval animals. Furthermore, RNAseq revealed convergent transcriptional abnormalities between mutant lines, consistent with their developmental defects and hyperexcitable phenotypes. These zebrafish models provide strongest experimental evidence supporting the role of ARFGEF1, KCND2, and WNT8B in human epilepsy and further demonstrate the utility of this model system for evaluating candidate human epilepsy genes.
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Affiliation(s)
- Christopher Mark LaCoursiere
- F.M. Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Jeremy F P Ullmann
- F.M. Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Hyun Yong Koh
- F.M. Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Departments of Neuroscience and Pediatrics, Division of Neurology and Developmental Neuroscience, BCM, Houston, Texas, USA
| | - Laura Turner
- F.M. Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Cristina M Baker
- F.M. Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Kavli Institute for Systems Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
| | - Barbara Robens
- F.M. Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Wanqing Shao
- Research Computing, Department of Information Technology, Boston Children's Hospital, Boston, MA, USA
| | - Alexander Rotenberg
- F.M. Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Department of Neurology, Harvard Medical School, Boston, MA, USA
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher M McGraw
- F.M. Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Department of Neurology, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Annapurna Poduri
- F.M. Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Department of Neurology, Harvard Medical School, Boston, MA, USA
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
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9
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Jones MN, Simpson SL, Beck AF, Cortezzo DE, Thienprayoon R, Corley AMS, Thomson J. Racial Inequities in Palliative Referral for Children with High-Intensity Neurologic Impairment. J Pediatr 2024; 268:113930. [PMID: 38309525 DOI: 10.1016/j.jpeds.2024.113930] [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] [Received: 08/17/2023] [Revised: 12/05/2023] [Accepted: 01/28/2024] [Indexed: 02/05/2024]
Abstract
OBJECTIVE To evaluate whether racial and socioeconomic inequities in pediatric palliative care utilization extend to children with high-intensity neurologic impairment (HI-NI), which is a chronic neurological diagnosis resulting in substantial functional morbidity and mortality. STUDY DESIGN We conducted a retrospective study of patients with HI-NI who received primary care services at a tertiary care center from 2014 through 2019. HI-NI diagnoses that warranted a palliative care referral were identified by consensus of a multidisciplinary team. The outcome was referral to palliative care. The primary exposure was race, categorized as Black or non-Black to represent the impact of anti-Black racism. Additional exposures included ethnicity (Hispanic/non-Hispanic) and insurance status (Medicaid/non-Medicaid). Descriptive statistics, bivariate analyses, and multivariable logistic regression models were performed to assess associations between exposures and palliative care referral. RESULTS A total of 801 patients with HI-NI were included; 7.5% received a palliative referral. There were no differences in gestational age, sex, or ethnicity between patients who received a referral and those who did not. In multivariable analysis, adjusting for ethnicity, sex, gestational age, and presence of complex chronic conditions, Black children (aOR 0.47, 95% CI 0.26, 0.84) and children with Medicaid insurance (aOR 0.40, 95% CI 0.23, 0.70) each had significantly lower odds of palliative referral compared with their non-Black and non-Medicaid-insured peers, respectively. CONCLUSIONS We identified inequities in pediatric palliative care referral among children with HI-NI by race and insurance status. Future work is needed to develop interventions, with families, aimed at promoting more equitable, antiracist systems of palliative care.
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Affiliation(s)
- Margaret N Jones
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Samantha L Simpson
- Division of Neonatal and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Andrew F Beck
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - DonnaMaria E Cortezzo
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Neonatal and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Palliative Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Rachel Thienprayoon
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Palliative Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alexandra M S Corley
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Joanna Thomson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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10
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Bogetz JF, Yu J, Oslin E, Barton KS, Yi-Frazier JP, Watson RS, Rosenberg AR. Navigating Stress in the Pediatric Intensive Care Unit Among Parents of Children with Severe Neurological Impairment. J Pain Symptom Manage 2023; 66:647-655. [PMID: 37666370 PMCID: PMC10841251 DOI: 10.1016/j.jpainsymman.2023.08.025] [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: 07/05/2023] [Revised: 08/23/2023] [Accepted: 08/29/2023] [Indexed: 09/06/2023]
Abstract
CONTEXT Children with severe neurological impairment (SNI) make up nearly 50% of pediatric intensive care unit (PICU) admissions, yet little is known about their family caregiver experiences. OBJECTIVE To examine how parents and family caregivers of children with SNI navigate stress during PICU admissions. METHODS This qualitative single-center study used content and thematic networks analysis to evaluate data from 1:1 semistructured interviews conducted around the time of PICU discharge with parents and family caregivers of children with SNI to examine ways they navigate stress. Proportions of participants reporting each theme and subtheme were calculated. RESULTS Fifteen parents/family caregivers of 15 children with SNI participated. Children were a median of 8 years old (range 1-21 years) and the majority had congenital/chromosomal conditions leading to their neurologic condition (80%, n = 12). 20% of participants were fathers (n = 3) and 45% (n = 7) reported identifying as having a minority racial background. Themes included 1) self-activation, and 2) letting go and the majority (80%, n = 12) of parents reported using both self-activation and letting go strategies. Within each of these themes, 5 subthemes illustrated ways parents navigate stress. The most reported subthemes were advocating and showing up (53%, n = 8) and being supported by compassionate clinicians (67%, n = 10). Themes/subthemes were used to create recommended language to guide clinicians in supporting parents. CONCLUSION Parents and family caregivers of children with SNI employ various ways to navigate stress in the PICU. Themes from this study can be used to develop interventions that meet the psychosocial needs of parents and family caregivers of children with SNI during highly stressful times.
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Affiliation(s)
- Jori F Bogetz
- Division of Bioethics and Palliative Care, Department of Pediatrics (J.B.), University of Washington School of Medicine; Treuman Katz Center for Bioethics, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA.
| | - Justin Yu
- Divisions of Pediatric Palliative and Supportive Care and Hospital Medicine (J.Y.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ellie Oslin
- Treuman Katz Center for Bioethics, Center for Clinical and Translational Research (E.O.), Seattle Children's Research Institute, Seattle, Washington, USA
| | - Krysta S Barton
- Palliative Care and Resilience Lab, Biostatistics Epidemiology and Analytics for Research (BEAR) Core, Seattle Children's Research Institute (K. S. B.), Seattle, Washington, USA
| | - Joyce P Yi-Frazier
- Center for Clinical and Translational Research (J.P.Y-.F.), Seattle Children's Research Institute, Seattle, Washington, USA
| | - Robert Scott Watson
- Division of Critical Care, Department of Pediatrics (R.S.W.), University of Washington School of Medicine, Seattle, Washington, USA
| | - Abby R Rosenberg
- Division of Psychosocial Oncology and Palliative Care(A.R.S.), Dana Farber Cancer Institute; Palliative Care and Resilience Lab, Boston Children's Hospital, Boston, Massachusetts, USA
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11
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Oliveira PV, Enes CC, Nucci LB. How are children with medical complexity being identified in epidemiological studies? A systematic review. World J Pediatr 2023; 19:928-938. [PMID: 36574212 DOI: 10.1007/s12519-022-00672-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 12/05/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND There are different definitions to identify/classify children with medical complexity (CMC). We aimed to investigate and describe the definitions used to classify CMC in epidemiological studies. METHODS PubMed, SciELO, LILACS, and EMBASE were searched from 2015 to 2020 (last updated September 15th, 2020) for original studies that presented the definition used to classify/identify CMC in the scientific research method. We applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. From the included studies, the following were identified: first author, year of publication, design, population, study period, the definition of CMC used, limitations, and strengths. RESULTS Nine hundred and sixty-seven records were identified in the searched databases, and 42 met the inclusion criteria. Of the 42 studies included, the four most frequent definitions used in the articles included in this review were classification of CMC into nine diagnostic categories based on the International Classification of Diseases, Ninth Revision (ICD-9) (35.7%, 15 articles); update of the previous classification for ICD-10 codes with the inclusion of other conditions in the definition (21.4%, nine articles); definition based on a medical complexity algorithm for classification (16.7%, seven articles); and a risk rating system (7.1%, three articles). CONCLUSIONS CMC definitions using diagnostic codes were more frequent. However, several limitations were found in its uses. Our research highlighted the need to improve health information systems to accurately characterize the CMC population and promote the provision of comprehensive care.
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Affiliation(s)
- Patrícia Vicente Oliveira
- Postgraduate Program in Health Sciences, Center for Life Sciences, Pontifical Catholic University of Campinas, Av. John Boyd Dunlop s/n, Campinas, CEP 13060-904, Brazil.
| | - Carla C Enes
- Postgraduate Program in Health Sciences, School of Nutrition, Pontifical Catholic University of Campinas, São Paulo, Brazil
| | - Luciana B Nucci
- Postgraduate Program in Health Sciences, School of Medicine, Pontifical Catholic University of Campinas, São Paulo, Brazil
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12
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Abuhamdah SM, Naser AY. Hospitalisations related to nervous-system diseases in Australia, 1998-2019: a secular trend analysis. BMJ Open 2023; 13:e074553. [PMID: 37758673 PMCID: PMC10537858 DOI: 10.1136/bmjopen-2023-074553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
OBJECTIVE The burden of neurological disease-related disabilities and deaths is one of the most serious issues globally. We aimed to examine the hospitalisation profile related to nervous system diseases in Australia for the duration between 1998 and 2019. DESIGN A secular trend analysis using a population-based dataset. SETTING This analysis used a population-based study of hospitalised patients in Australia. Hospitalisation data were extracted from the National Hospital Morbidity Database, which collects sets of episode-level information for Australian patients admitted to all private and public hospitals. PARTICIPANTS All patients who were hospitalised in all private and public hospitalisations. PRIMARY OUTCOME MEASURE Hospitalisation rates related to nervous system diseases. RESULTS Hospitalisation rates increased by 1.04 times (from 650.36 (95% CI 646.73 to 654.00) in 1998 to 1328.90 (95% CI 1324.44 to 1333.35) in 2019 per 100 000 persons, p<0.01). Overnight-stay episodes accounted for 57.0% of the total number of hospitalisations. Rates of the same-day hospitalisation for diseases of the nervous system increased by 2.10-fold (from 219.74 (95% CI 217.63 to 221.86) in 1998 to 680.23 (95% CI 677.03 to 683.43) in 2019 per 100 000 persons). Rates of overnight-stay hospital admission increased by 42.7% (from 430.62 (95% CI 427.66 to 433.58) in 1998 to 614.70 (95% CI 611.66 to 617.75) in 2019 per 100 000 persons). 'Episodic and paroxysmal disorders' were the most prevalent reason for hospitalisation, which accounted for 49.0% of the total number of episodes. Female hospitalisation rates increased by 1.13-fold (from 618.23 (95% CI 613.24 to 623.22) in 1998 to 1316.33 (95% CI 1310.07 to 1322.58) in 2019 per 100 000 persons). Male hospitalisation rates increased by 86.4% (from 682.95 (95% CI 677.67 to 688.23) in 1998 to 1273.18 (95% CI 1266.98 to 1279.37) in 2019 per 100 000 persons). CONCLUSION Hospitalisation rates for neurological disorders in Australia are high, potentially owing to the ageing of the population. Males had greater rates of hospitalisation than females.
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Affiliation(s)
- Sawsan Ma Abuhamdah
- Department of Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, The University of Jordan, Amman, Jordan
- Department of Pharmaceutical Sciences, Al Ain University College of Pharmacy, Abu Dhabi, UAE
| | - Abdallah Y Naser
- Department of Applied Pharmaceutical Sciences and Clinical Pharmacy, Isra University, Amman, Jordan
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13
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Lillvis DF, Sheehan KM, Yu J, Noyes K, Harmon C, Kuo DZ. Comparing Pediatric Physical Trauma Outcomes by Special Health Care Needs Status. Hosp Pediatr 2023; 13:849-856. [PMID: 37584151 PMCID: PMC10468415 DOI: 10.1542/hpeds.2023-007226] [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: 08/17/2023]
Abstract
BACKGROUND AND OBJECTIVES Children and Youth with Special Health Care Needs (CYSHCN) have differing risk factors and injury characteristics compared with peers without special health care needs (SHCN). We examined the association between SHCN status and complications, mortality, and length of stay (LOS) after trauma hospitalization. METHODS We conducted a cross-sectional study using 2018 data from the National Trauma Data Bank for patients aged 1 to 18 years (n = 108 062). We examined the following hospital outcomes: any complication reported, unplanned admission to the ICU, in-hospital mortality, and hospital and ICU LOS. Multivariate regression models estimated the effect of SHCN status on hospital outcomes after controlling for patient demographics, injury severity score, and Glasgow Coma Score. Subanalyses examined outcomes by age, SHCN, and injury severity score. RESULTS CYSHCN encounters had a greater adjusted relative risk (ARR) of any hospital complications (ARR = 2.980) and unplanned admission to the ICU (ARR = 1.996) than encounters that did not report a SHCN (P < .001). CYSHCN had longer hospital (incidence rate ratio = 1.119) and ICU LOS (incidence rate ratio = 1.319, both P < .001). There were no statistically significant in-hospital mortality differences between CYSHCN and those without. Lower severity trauma was associated with a greater ARR of hospital complications for CYSHCN encounters versus non-CYSHCN encounters. CONCLUSIONS CYSHCN, particularly those with lower-acuity injuries, are at greater risk for developing complications and requiring more care after trauma hospitalization. Future studies may examine mechanisms of hospital complications for traumatic injuries among CYSHCN to develop prevention and risk-minimization strategies.
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Affiliation(s)
- Denise F. Lillvis
- John R. Oishei Children’s Hospital, Buffalo, New York
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions
| | - Karen M. Sheehan
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Jihnhee Yu
- Department of Biostatistics, University at Buffalo, Buffalo, New York
| | - Katia Noyes
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions
| | - Carroll Harmon
- John R. Oishei Children’s Hospital, Buffalo, New York
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences
| | - Dennis Z. Kuo
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
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14
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Brandon E, Green P, Palozzi L, Kassam-Lallani D, Lauzon A, Nenadovic V, Puthen R, Rudden L, Ballantyne M. Nurse Practitioners in a Canadian Pediatric Rehabilitation Hospital: A Description of Roles and Scope of Practice. J Pediatr Health Care 2023; 37:e1-e10. [PMID: 37245130 DOI: 10.1016/j.pedhc.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 03/13/2023] [Accepted: 04/23/2023] [Indexed: 05/29/2023]
Abstract
The nurse practitioner role is strongly suited to meet the needs of children with complex developmental conditions in pediatric rehabilitation settings as they have a unique combination of clinical expertise. To meet the increasing demands in a large Canadian pediatric rehabilitation hospital, the NP role was implemented in several clinical program settings to improve access to care. This paper describes the contributions of NPs to nine specialized inpatient and outpatient programs in NP-led, collaborative NP and physician or interagency care team models of practice. The initial challenges of role implementation and implications for NP practice, research and leadership are discussed.
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15
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Chen Y, Gutierrez V, Morris L, Marti JL. Diagnostic Scrutiny and Patterns of Elevated Cancer Risk: Uncovering Overdiagnosis Through Standardized Incidence Ratios. Cureus 2023; 15:e42439. [PMID: 37637595 PMCID: PMC10447997 DOI: 10.7759/cureus.42439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 08/29/2023] Open
Abstract
Certain medical diagnoses and environmental or occupational exposures may be associated with elevated risk of cancer diagnosis, either through causal mechanisms or via increased detection of a subclinical reservoir through increased diagnostic scrutiny (overdiagnosis). The present study aimed to investigate the distribution of elevated cancer risks associated with different diagnoses and exposures. A systematic literature search was conducted to identify studies published in the last 30 years that examined the standardized incidence ratio (SIR) associated with exposures and risk factors. Meta-SIRs for each cancer type were calculated. The distribution of elevated cancer risks was then compared between cancer types previously reported to be susceptible to overdiagnosis and those that have not been associated with overdiagnosis. The review of 108 studies identified four patterns: SIR generally elevated for 1) only overdiagnosis-susceptible cancer types, 2) both overdiagnosed and non-overdiagnosed cancer types, 3) select cancers in accordance with risk factor or exposure, and 4) SIRs that did not exhibit a distinct increase in any cancer type. The distribution of elevated cancer risks may serve as a signature of whether the underlying risk factor or exposure is a carcinogenic process or a mechanism of increased diagnostic scrutiny uncovering clinically occult diseases. The identification of increased cancer risk should be viewed with caution, and analyzing the pattern of elevated cancer risk distribution can potentially reveal conditions that appear to be cancer risk factors but are in fact the result of exposure to medical surveillance or other healthcare activities that lead to the detection of indolent tumors.
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Affiliation(s)
- Yunchan Chen
- Department of Surgery, Weill Cornell Medicine, New York, USA
| | | | - Luc Morris
- Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Jennifer L Marti
- Division of Breast Surgical Oncology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, USA
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16
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The post-diagnostics world: charting a path for pediatric genomic medicine in the twenty-first century. Pediatr Res 2023; 93:457-459. [PMID: 35690684 PMCID: PMC9187847 DOI: 10.1038/s41390-022-02144-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 05/11/2022] [Accepted: 05/20/2022] [Indexed: 11/08/2022]
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17
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Difazio RL, Shore BJ, Melvin P, Mauskar S, Berry JG. Pneumonia after hip surgery in children with neurological complex chronic conditions. Dev Med Child Neurol 2023; 65:232-242. [PMID: 35811335 DOI: 10.1111/dmcn.15339] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 06/14/2022] [Accepted: 06/17/2022] [Indexed: 01/04/2023]
Abstract
AIM In children with neurological complex chronic conditions (CCC) undergoing hip surgery we aimed to: estimate the rate of postoperative pneumonia, determine the effect of pneumonia on postoperative hospital resource use, and identify predictors of postoperative pneumonia. METHOD A retrospective cohort study was conducted utilizing the Pediatric Health Information System database for 2609 children (1081 females, 1528 males) aged 4 years and older with a neurological CCC who underwent hip surgery (i.e. reconstruction surgery or salvage procedure) between 2016 and 2018 in 41 US children's hospitals. Multivariable, mixed-effects logistic regression was used to assess patient characteristics and risk of pneumonia. RESULTS Mean age at hip surgery was 10 years 1 month (SD 4y 8mo). The postoperative pneumonia rate was 1.6% (n=42). Median length of stay (LOS) was longer for children with pneumonia and the 30-day all-cause unplanned readmission rate and costs were higher. Variability in rates of pneumonia ranged from 1.1% to 2.8% across hospitals. Significant predictors of postoperative pneumonia were osteotomy type (p=0.005) and number of chronic conditions (p≤0.001). INTERPRETATION Postoperative pneumonia after hip surgery in children with a neurological CCC is associated with longer LOS, readmissions, and higher costs. Children undergoing pelvic osteotomies and who have multimorbidity need additional clinical support to prevent postoperative pneumonia and decrease resource utilization. WHAT THIS PAPER ADDS Pneumonia is a major postoperative complication in children with neurological complex chronic conditions (CCC). Forty-two (1.6%) children with neurological CCC developed pneumonia after hip surgery. Length of stay, readmissions, and costs were significantly higher in the group with pneumonia. Variability in pneumonia rates existed across hospitals. Predictors of developing pneumonia include osteotomy type and number of CCC.
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Affiliation(s)
- Rachel L Difazio
- Division of Orthopedic Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Benjamin J Shore
- Division of Orthopedic Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Patrice Melvin
- Program for Patients Safety and Quality, Boston Children's Hospital, Boston, MA, USA
| | - Sangeeta Mauskar
- Harvard Medical School, Boston, MA, USA.,Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Jay G Berry
- Harvard Medical School, Boston, MA, USA.,Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
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18
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Nelson KE, Finlay M, Huang E, Chakravarti V, Feinstein JA, Diskin C, Thomson J, Mahant S, Widger K, Feudtner C, Cohen E. Clinical characteristics of children with severe neurologic impairment: A scoping review. J Hosp Med 2023; 18:65-77. [PMID: 36484088 PMCID: PMC9829450 DOI: 10.1002/jhm.13019] [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: 07/11/2022] [Revised: 10/21/2022] [Accepted: 11/16/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of this study is to extrapolate the clinical features of children with severe neurologic impairment (SNI) based on the functional characteristics and comorbidities described in published studies. METHODS Four databases were searched. We included studies that describe clinical features of a group of children with SNI (≥20 subjects <19 years of age with >1 neurologic diagnosis and severe functional limitation) using data from caregivers, medical charts, or prospective collection. Studies that were not written in English were excluded. We extracted data about functional characteristics, comorbidities, and study topics. RESULTS We included 102 studies, spanning 5 continents over 43 years, using 41 distinct terms for SNI. The terms SNI and neurologic impairment (NI) were used in 59 studies (58%). Most studies (n = 81, 79%) described ≥3 types of functional characteristics, such as technology assistance and motor impairment. Studies noted 59 comorbidities and surgeries across 10 categories. The most common comorbidities were related to feeding, nutrition, and the gastrointestinal system, which were described in 79 studies (77%). Most comorbidities (76%) were noted in <10 studies. Studies investigated seven clinical topics, with "Gastrointestinal reflux and feeding tubes" as the most common research focus (n = 57, 56%). The next most common topic, "Aspiration and respiratory issues," included 13 studies (13%). Most studies (n = 54, 53%) were retrospective cohorts or case series; there were no clinical trials. CONCLUSIONS Despite the breadth of described comorbidities, studies focused on a narrow set of clinical topics. Further research is required to understand the prevalence, clinical impact, and interaction of the multiple comorbidities that are common in children with SNI.
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Affiliation(s)
- Katherine E Nelson
- Pediatric Advanced Care Team, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Melissa Finlay
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Emma Huang
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Vishakha Chakravarti
- Pediatric Advanced Care Team, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - James A Feinstein
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Catherine Diskin
- Department of Paediatrics, Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joanna Thomson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sanjay Mahant
- Department of Paediatrics, Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada
| | - Kimberley Widger
- Pediatric Advanced Care Team, Hospital for Sick Children, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Chris Feudtner
- The Justin Michael Ingerman Center for Palliative Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Departments of Pediatrics and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eyal Cohen
- Department of Paediatrics, Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, USA
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada
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19
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Thomson J, Richardson T, Auger KA, Brady PW, Hall M, Hartley D, Schondelmeyer AC, Shah SS. Impact of the COVID-19 pandemic on hospitalizations of children with neurologic impairment. J Hosp Med 2023; 18:33-42. [PMID: 36504483 PMCID: PMC9877577 DOI: 10.1002/jhm.13021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 10/20/2022] [Accepted: 10/27/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Children with neurologic impairment (NI) are frequently hospitalized for infectious and noninfectious illnesses. The early period of the COVID-19 pandemic was associated with overall lower pediatric hospitalization rates, particularly for respiratory infections, but the effect on utilization for children with NI is unknown. METHOD This multicenter retrospective cohort study included hospitalizations of children 1-18 years of age with NI diagnosis codes from 49 children's hospitals. We calculated the percent change in the median weekly hospitalization volumes and the hospitalization resource intensity score (H-RISK), comparing the early-COVID era (March 15, 2020 to December 31, 2020) with the pre-COVID era (same timeframe of 2017-2019). Percent change was calculated over the entire study period as well as within three seasonal time periods (spring, summer, and fall/winter). Differences between infectious and noninfectious admission diagnoses were also examined. RESULTS Compared with the pre-COVID era, there was a 14.4% decrease (interquartile range [IQR]: -33.8, -11.7) in the weekly median number of hospitalizations in the early-COVID era; the weekly median H-RISK score was 11.7% greater (IQR: 8.9, 14.9). Hospitalizations decreased for both noninfectious (-11.6%, IQR: -30.0, -8.0) and infectious (-35.5%, IQR: -51.1, -31.3) illnesses in the early-COVID era. This decrease was the largest in spring 2020 and continued throughout 2020. CONCLUSIONS For children with NI, there was a substantial and significant decrease in hospitalizations for infectious and noninfectious diagnoses but an increase in illness severity during the early-COVID era compared with the pre-COVID era. Our data suggest a need to reconsider current thresholds for hospitalization and identify opportunities to support and guide families through certain illnesses without hospitalization.
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Affiliation(s)
- Joanna Thomson
- Cincinnati Children's Hospital Medical CenterDivision of Hospital MedicineCincinnatiOhioUSA
- James M. Anderson Center for Health Systems ExcellenceCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | | | - Katherine A. Auger
- Cincinnati Children's Hospital Medical CenterDivision of Hospital MedicineCincinnatiOhioUSA
- James M. Anderson Center for Health Systems ExcellenceCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Patrick W. Brady
- Cincinnati Children's Hospital Medical CenterDivision of Hospital MedicineCincinnatiOhioUSA
- James M. Anderson Center for Health Systems ExcellenceCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Matt Hall
- Children's Hospital AssociationLenexaKansasUSA
| | - David Hartley
- James M. Anderson Center for Health Systems ExcellenceCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Amanda C. Schondelmeyer
- Cincinnati Children's Hospital Medical CenterDivision of Hospital MedicineCincinnatiOhioUSA
- James M. Anderson Center for Health Systems ExcellenceCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Samir S. Shah
- Cincinnati Children's Hospital Medical CenterDivision of Hospital MedicineCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Cincinnati Children's Hospital Medical CenterDivision of Infectious DiseasesCincinnatiOhioUSA
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20
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Perioperative Care of Children with Severe Neurological Impairment and Neuromuscular Scoliosis- A Practical Pathway to Optimize Peri-Operative Health and Guide Decision Making. J Clin Med 2022; 11:jcm11226769. [PMID: 36431246 PMCID: PMC9696380 DOI: 10.3390/jcm11226769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/07/2022] [Accepted: 11/14/2022] [Indexed: 11/17/2022] Open
Abstract
Neuromuscular scoliosis is a common feature in children with severe neurological impairment (SNI), including those with severe cerebral palsy. Surgical correction of scoliosis is the mainstay of treatment. This group of patients also have associated medical complexity. The complication rates post-surgery are high, although, for many, they are worth the risk. There are currently no published practice guidelines or care pathways for children with SNI who are undergoing scoliosis corrective surgery. In response to the high uptake of this surgery, coupled with the expected complication rates, our hospital established a perioperative clinic. The purpose of this paper is to describe our perioperative approach. This clinic has developed into a service beyond perioperative care and, with the collaborative meeting, enables shared decision-making to identify the right candidate for surgery. The process involves surgical expertise, understanding the family and child at the centre, and optimisation of medical care pre- and post-surgery. In this paper, we describe the process in a step-by-step manner. We provide clinical vignettes, as well as the proformas that we use, and we highlight the benefits of the team-based process.
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21
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Abuga J, Mwangi L, Ndolo J, Kariuki S, Newton C. Healthcare utilization by children with neurological impairments and disabilities in rural Kenya: a retrospective cohort study combined with secondary analysis of audit data. Wellcome Open Res 2022. [DOI: 10.12688/wellcomeopenres.18405.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background: There is a paucity of data on healthcare utilization by children with neurological impairments (NI) in sub-Saharan Africa. We determined the rate, risk factors, causes, and outcomes of hospital admission and utilization patterns for rehabilitative care among children with NI in a defined rural area in Kenya. Methods: We designed two sub-studies to address the primary objectives. Firstly, we retrospectively observed 251 children aged 6–9 years with NI and 2162 age-matched controls to determine the rate, causes and outcomes of hospitalization in a local referral hospital. The two cohorts were identified from an epidemiological survey conducted in 2015 in a defined geographical area. Secondly, we reviewed hospital records to characterize utilization patterns for rehabilitative care. Results: Thirty-four in-patient admissions occurred in 8503 person-years of observation (PYO), yielding a crude rate of 400 admissions per 100 000 PYO (95% confidence interval (Cl): 286–560). The risk of admission was similar between cases and controls (rate ratio=0.70, 95%CI: 0.10–2.30, p = 0.31). The presence of electricity in the household was associated with reduced odds of admission (odds ratio=0.32, 95% Cl: 0.10–0.90, p < 0.01). Seizures and malaria were the main causes of admission. We confirmed six (0.3%) deaths during the follow-up period. Over 93% of outpatient paediatric visits for rehabilitative care were related to cerebral palsy and intellectual developmental delay. Health education (87%), rehabilitative exercises (79%) and assistive technology (64%) were the most common interventions. Conclusions: Surprisingly, the risk of hospitalization was not different between children with NI and those without, possibly because those with severe NI who died before this follow-up were under seclusion and restraint in the community. Evidence-based and tailored rehabilitative interventions are urgently required based on the existing secondary data.
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22
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Mattiello RMA, Pazin-Filho A, Aragon DC, Cupo P, Carlotti APDCP. Impact of children with complex chronic conditions on costs in a tertiary referral hospital. Rev Saude Publica 2022; 56:89. [PMID: 36259914 PMCID: PMC9550162 DOI: 10.11606/s1518-8787.2022056004656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/23/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To investigate the impact of complex chronic conditions on the use of healthcare resources and hospitalization costs in a pediatric ward of a public tertiary referral university hospital in Brazil. METHODS This is a longitudinal study with retrospective data collection. Overall, three one-year periods, separated by five-year intervals (2006, 2011, and 2016), were evaluated. Hospital costs were calculated in three systematic samples of 100 patients each, consisting of patients with and without complex chronic conditions in proportion to their participation in the studied year. RESULTS Over the studied period, the hospital received 2,372 admissions from 2,172 patients. The proportion of hospitalized patients with complex chronic conditions increased from 13.3% in 2006 to 16.9% in 2016 as a result of a greater proportion of neurologically impaired children, which rose from 6.6% to 11.6% of the total number of patients in the same period. Patients’ complexity also progressively increased, which greatly impacted the use of healthcare resources and costs, increasing by 11.6% from 2006 (R$1,300,879.20) to 2011 (R$1,452,359.71) and 9.4% from 2011 to 2016 (R$1,589,457.95). CONCLUSIONS Hospitalizations of pediatric patients with complex chronic conditions increased from 2006 to 2016 in a Brazilian tertiary referral university hospital, associated with an important impact on hospital costs. Policies to reduce these costs in Brazil are greatly needed.
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Affiliation(s)
- Regina Maria Antunes Mattiello
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoDepartamento de Puericultura e PediatriaRibeirão PretoSPBrasilUniversidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Departamento de Puericultura e Pediatria. Ribeirão Preto, SP, Brasil
| | - Antonio Pazin-Filho
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoDepartamento de Clínica MédicaRibeirão PretoSPBrasilUniversidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Departamento de Clínica Médica. Ribeirão Preto, SP, Brasil
| | - Davi Casale Aragon
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoDepartamento de Puericultura e PediatriaRibeirão PretoSPBrasilUniversidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Departamento de Puericultura e Pediatria. Ribeirão Preto, SP, Brasil
| | - Palmira Cupo
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoDepartamento de Puericultura e PediatriaRibeirão PretoSPBrasilUniversidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Departamento de Puericultura e Pediatria. Ribeirão Preto, SP, Brasil
| | - Ana Paula de Carvalho Panzeri Carlotti
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoDepartamento de Puericultura e PediatriaRibeirão PretoSPBrasilUniversidade de São Paulo. Faculdade de Medicina de Ribeirão Preto. Departamento de Puericultura e Pediatria. Ribeirão Preto, SP, Brasil
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23
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Bogetz JF, Trowbridge A, Jonas D, Root MC, Mullin J, Hauer J. The Impact of Caring for Children With Severe Neurological Impairment on Clinicians. Clin Pediatr (Phila) 2022; 61:707-716. [PMID: 35610773 DOI: 10.1177/00099228221099135] [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: 11/16/2022]
Abstract
Clinicians face many challenges in caring for children with severe neurological impairment (SNI). This study aimed to understand expert clinician perspectives on the personal impact of caring for children with SNI to highlight the challenges and potential solutions by underscoring the aspects of care that can be sustaining. Twenty-five clinicians participated including physicians (n = 8, 32%), social workers (n = 5, 20%), nurses/nurse practitioners (n = 5, 20%), case managers (n = 3, 12%), developmental therapists (n = 2, 8%), and other psychosocial clinicians (n = 2, 8%). Clinicians represented a variety of specialties including complex care/hospitalists (n = 10, 19%), palliative care (n = 7, 13%), and critical care (n = 6, 12%). Thematic content analysis revealed 3 major themes: (1) worries and challenges; (2) positive impact from being present; and (3) personal growth and meaning-making. Many clinicians described the ways listening, examining biases, learning about family perspectives, and normalizing the need for emotional processing helped them to understand their patients, families, and themselves more deeply.
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Affiliation(s)
- Jori F Bogetz
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Palliative Care and Resilience Lab, Center for Clinical and Translational Research, Seattle Children's Hospital and Research Institute, Seattle, WA, USA
| | - Amy Trowbridge
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Palliative Care and Resilience Lab, Center for Clinical and Translational Research, Seattle Children's Hospital and Research Institute, Seattle, WA, USA
| | - Danielle Jonas
- Silver School of Social Work, New York University, New York, NY, USA
| | - Maggie C Root
- Vanderbilt University School of Nursing, Nashville, TN, USA
| | - Jonathan Mullin
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, Saint Louis, MO, USA
| | - Julie Hauer
- Seven Hills Pediatric Center, Division of General Pediatrics, Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
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24
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Lewis H, Trowbridge A, Jonas D, Rosenberg AR, Bogetz JF. A Qualitative Study of Clinicians and Parents of Children with Severe Neurological Impairment on Tools to Support Family-Centered Care. J Palliat Med 2022; 25:1338-1344. [PMID: 35593900 PMCID: PMC9639233 DOI: 10.1089/jpm.2021.0579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 11/12/2022] Open
Abstract
Background: Children with severe neurological impairment (SNI) have complex conditions and require family-centered care, yet, this is challenging in the hospital. Objectives: To describe themes related to building parent-clinician rapport and to examine ways to promote family-centered care for children with SNI. Design: Post hoc secondary analysis of data from a qualitative cross-sectional study. Setting/Subjects: Semistructured interviews conducted between August 2019 and February 2020 with parents of children with SNI and interprofessional clinicians at a single tertiary children's hospital in the United States. Measurement: Data from codes pertaining to strategies to promote therapeutic alliance were extracted for inductive thematic analysis and to collate ideas for tools suggested by participants. The research team iteratively discussed each proposed tool, developed an example representative depiction, and expanded upon potential opportunities and limitations of the tools' practical implementation. Results: Twenty-five parents/legal guardians and 25 interprofessional clinicians participated. The median age of parents/legal guardians was 38 [interquartile range 35,48]. Sixty-eight percent (n = 17) identified as mothers and 68% (n = 17) identified as white. Clinicians were predominantly female (84%, n = 21) and represented 8 professions and 15 specialties. Themes and suggested tools included (1) continuity of previous decision-making conversations and the decision roadmap tool, (2) maintaining family communication preferences and the relational handoff tool, and (3) recognizing the abilities of each individual child and the developmental inventory tool. Conclusions: Family-centered care for parents of children with SNI may be bolstered by continuity in decision making, maintaining parents' communication preferences, and appreciating the child's individual abilities. Clinical tools may provide opportunities to promote these concepts.
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Affiliation(s)
- Hannah Lewis
- Treuman Katz Center for Bioethics, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Amy Trowbridge
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Palliative Care and Resilience Lab, Center for Clinical and Translational Research, Seattle Children's Hospital and Research Institute, Seattle, Washington, USA
| | - Danielle Jonas
- Silver School of Social Work, New York University, New York, New York, USA
| | - Abby R. Rosenberg
- Palliative Care and Resilience Lab, Center for Clinical and Translational Research, Seattle Children's Hospital and Research Institute, Seattle, Washington, USA
- Division of Hematology/Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jori F. Bogetz
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Palliative Care and Resilience Lab, Center for Clinical and Translational Research, Seattle Children's Hospital and Research Institute, Seattle, Washington, USA
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25
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Bogetz JF, Munjapara V, Henderson CM, Raisanen JC, Jabre NA, Shipman KJ, Wilfond BS, Boss RD. Home mechanical ventilation for children with severe neurological impairment: Parents' perspectives on clinician counselling. Dev Med Child Neurol 2022; 64:840-846. [PMID: 35080259 DOI: 10.1111/dmcn.15151] [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] [Received: 08/17/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 11/26/2022]
Abstract
AIM To retrospectively explore the perspectives of parents of children with severe neurological impairment (SNI), such as those with severe cerebral palsy, epilepsy syndromes, and structural brain differences, on clinician counseling regarding home mechanical ventilation (HMV). METHOD Inductive thematic analysis was performed on data from telephone interviews with parents who chose for and against HMV for their child with SNI at three academic children's hospitals across the USA. RESULTS Twenty-six parents/legal guardians of 24 children were interviewed. Fourteen children had static encephalopathy, 11 received HMV, and 20 were alive at the time of parent interviews. Themes included how HMV related to the child's prognosis, risk of death, and integration with goals of care. Although clinicians voiced uncertainty about how HMV would impact their child, parents felt this was coupled with prescriptive/intimidating examples about the child's end of life and judgments about the child's quality of life. INTERPRETATION While prognositc uncertainty exists, this study suggests that parents of children with SNI seek clinician counseling about HMV that considers their goals of care and views on their child's quality of life.
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Affiliation(s)
- Jori F Bogetz
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA.,Palliative Care Resilience Research Lab, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Vasu Munjapara
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carrie M Henderson
- Center for Bioethics and Medical Humanities, University of Mississippi Medical Center, Jackson, Mississippi, USA.,Division of Critical Care Medicine, Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Jessica C Raisanen
- Johns Hopkins Berman Institute of Bioethics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicholas A Jabre
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly J Shipman
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA.,Palliative Care Resilience Research Lab, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA.,Palliative Care Resilience Research Lab, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Renee D Boss
- Johns Hopkins Berman Institute of Bioethics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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26
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Nelson KE, Chakravarti V, Diskin C, Thomson J, Cohen E, Mahant S, Feudtner C, Widger K, Pullenayegum E, Berry JG, Feinstein JA. Validation of Neurologic Impairment Diagnosis Codes as Signifying Documented Functional Impairment in Hospitalized Children. Acad Pediatr 2022; 22:782-788. [PMID: 34320414 PMCID: PMC8786975 DOI: 10.1016/j.acap.2021.07.014] [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: 02/19/2021] [Revised: 07/15/2021] [Accepted: 07/20/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the performance of previously published high-intensity neurologic impairment (NI) diagnosis codes in identification of hospitalized children with clinical NI. METHODS Retrospective study of 500 randomly selected discharges in 2019 from a freestanding children's hospital. All charts were reviewed for 1) NI discharge diagnosis codes and 2) documentation of clinical NI (a neurologic diagnosis and indication of functional impairment like medical technology). Test statistics of clinical NI were calculated for discharges with and without an NI diagnosis code. A sensitivity analysis varied the threshold for "substantial functional impairment." Secondary analyses evaluated misclassified discharges and a more stringent definition for NI. RESULTS Diagnosis codes identified clinically documented NI with 88.1% (95% confidence interval [CI]: 84.7, 91) specificity, and 79.4% (95% CI: 67.3, 88.5) sensitivity; negative predictive value (NPV) was 96.7% (95% CI: 94.8, 98.0), and positive predictive value (PPV) was 49% (95% CI: 42, 56.1). Including children with milder functional impairment (lower threshold) resulted in NPV of 95.7% and PPV of 77.5%. Restricting to children with more severe functional impairment (higher threshold) resulted in NPV of 98.2% and PPV of 44.1%. Misclassification was primarily due to inclusion of children without functional impairments. A more stringent NI definition including diagnosis codes for NI and feeding tubes had a specificity of 98.4% (95% CI: 96.7-99.3) and sensitivity of 28.6% (19.4-41.3). CONCLUSIONS All scenarios evaluated demonstrated high NPV and low-to-moderate PPV of the diagnostic code list. To maximize clinical utility, NI diagnosis codes should be used with strategies to mitigate the risk of misclassification.
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Affiliation(s)
- Katherine E. Nelson
- Pediatric Advanced Care Team, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada,Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada,Child Health Evaluative Sciences, SickKids Research Institute, 686 Bay St, Toronto, Ontario M5G 0A4, Canada,Institute for Clinical Evaluative Sciences, G1 06, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada,Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, Ontario M5T 3M7, Canada
| | - Vishakha Chakravarti
- Pediatric Advanced Care Team, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada,Child Health Evaluative Sciences, SickKids Research Institute, 686 Bay St, Toronto, Ontario M5G 0A4, Canada
| | - Catherine Diskin
- Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joanna Thomson
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave Cincinnati, Ohio 45267, USA,Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio 45267, USA
| | - Eyal Cohen
- Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada,Child Health Evaluative Sciences, SickKids Research Institute, 686 Bay St, Toronto, Ontario M5G 0A4, Canada,Institute for Clinical Evaluative Sciences, G1 06, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada,Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, Ontario M5T 3M7, Canada,CanChild Centre for Childhood Disability Research, Room 408, McMaster University, 1400 Main St W, Hamilton, Ontario L8S 1C7, Canada,Edwin S.H. Leong Centre for Healthy Children, University of Toronto, 27 King’s College Cir, Toronto, Ontario M5S 3K1, Canada
| | - Sanjay Mahant
- Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada,Child Health Evaluative Sciences, SickKids Research Institute, 686 Bay St, Toronto, Ontario M5G 0A4, Canada,Institute for Clinical Evaluative Sciences, G1 06, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada,Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, Ontario M5T 3M7, Canada,CanChild Centre for Childhood Disability Research, Room 408, McMaster University, 1400 Main St W, Hamilton, Ontario L8S 1C7, Canada
| | - Chris Feudtner
- The Justin Michael Ingerman Center for Palliative Care, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, Pennsylvania 19104, USA,Departments of Pediatrics and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania 19104, USA
| | - Kimberley Widger
- Pediatric Advanced Care Team, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, Ontario M5T 1P8, Canada
| | - Eleanor Pullenayegum
- Child Health Evaluative Sciences, SickKids Research Institute, 686 Bay St, Toronto, Ontario M5G 0A4, Canada,Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, Ontario M5T 3M7, Canada
| | - Jay G. Berry
- Complex Care, Division of General Pediatrics, Children’s Hospital Boston, 300 Longwood Avenue, Boston, Massachusetts 02115, USA,Department of Pediatrics, Harvard Medical School, 25 Shattuck St, Boston, Massachusetts 02115, USA
| | - James A. Feinstein
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado and Children’s Hospital Colorado, 13199 East Montview Boulevard, Suite 300, Aurora, Colorado 80045, USA
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27
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Lower Respiratory Tract Infections in Pediatric Patients with Severe Neurological Impairments: Clinical Observations and Perspectives in a Palliative Care Unit. CHILDREN 2022; 9:children9060852. [PMID: 35740789 PMCID: PMC9221664 DOI: 10.3390/children9060852] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/02/2022] [Accepted: 06/06/2022] [Indexed: 11/29/2022]
Abstract
Pediatric palliative care (PPC) patients with a severe neurologic impairment (SNI) suffer considerable morbidity and increased mortality from lower respiratory tract infections (LRTIs). The indication and choice of antibiotic therapy for bacterial LRTIs are often challenging given the lack of evidence-based treatment recommendations for this vulnerable patient population. We conducted an observational study before the SARS-CoV-2 pandemic in an eight-bed pediatric palliative care inpatient unit. During two years of surveillance, we diagnosed and treated 33 cases of a bacterial LRTI in patients with an SNI; 5 patients were hospitalized with an LRTI more than once. Two patients died from complications due to LRTIs during hospitalization. Three patients (15%) were colonized with multidrug-resistant organisms. An initial antibiotic treatment failed in one-third of the cases; a successful therapy of the LRTI was achieved with broad-spectrum and extended-spectrum penicillins (n = 13; in combination with β-lactamase inhibitors for n = 5 cases), cephalosporins (n = 13: n = 4 second-generation and n = 9 third-generation cephalosporins; in combination with other substances for n = 5 cases), ciprofloxacin (n = 3), and meropenem plus vancomycin (n = 2) or meropenem (n = 1). A respiratory specimen was obtained in 66.7% of cases with P. aeruginosa, E. coli, and K. pneumoniae accounting for the majority of the detected species. In most cases, there was no definite confirmation that the LRTI was caused by the species detected. The diagnostics and treatment of bacterial LRTIs in PPC patients with an SNI are challenging. The lack of controlled studies and the heterogeneity of this population often necessitate an individual approach. This lack of controlled studies may partly be compensated by a set of diagnostic and antibiotic stewardship criteria.
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28
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Fritz CQ, Hall M, Bettenhausen JL, Beck AF, Krager MK, Freundlich KL, Ibrahim D, Thomson JE, Gay JC, Carroll AR, Neeley M, Frost PA, Herndon AC, Kehring AL, Williams DJ. Child Opportunity Index 2.0 and acute care utilization among children with medical complexity. J Hosp Med 2022; 17:243-251. [PMID: 35535923 PMCID: PMC9254633 DOI: 10.1002/jhm.12810] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/24/2022] [Accepted: 01/28/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Disproportionately high acute care utilization among children with medical complexity (CMC) is influenced by patient-level social complexity. OBJECTIVE The objective of this study was to determine associations between ZIP code-level opportunity and acute care utilization among CMC. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional, multicenter study used the Pediatric Health Information Systems database, identifying encounters between 2016-2019. CMC aged 28 days to <16 years with an initial emergency department (ED) encounter or inpatient/observation admission in 2016 were included in primary analyses. MAIN OUTCOME AND MEASURES We assessed associations between the nationally-normed, multi-dimensional, ZIP code-level Child Opportunity Index 2.0 (COI) (high COI = greater opportunity), and total utilization days (hospital bed-days + ED discharge encounters). Analyses were conducted using negative binomial generalized estimating equations, adjusting for age and distance from hospital and clustered by hospital. Secondary outcomes included intensive care unit (ICU) days and cost of care. RESULTS A total of 23,197 CMC were included in primary analyses. In unadjusted analyses, utilization days decreased in a stepwise fashion from 47.1 (95% confidence interval: 45.5, 48.7) days in the lowest COI quintile to 38.6 (36.9, 40.4) days in the highest quintile (p < .001). The same trend was present across all outcome measures, though was not significant for ICU days. In adjusted analyses, patients from the lowest COI quintile utilized care at 1.22-times the rate of those from the highest COI quintile (1.17, 1.27). CONCLUSIONS CMC from low opportunity ZIP codes utilize more acute care. They may benefit from hospital and community-based interventions aimed at equitably improving child health outcomes.
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Affiliation(s)
- Cristin Q. Fritz
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matt Hall
- Children’s Hospital Association, Lenexa, KS
| | - Jessica L Bettenhausen
- Department of Pediatrics, Children’s Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Andrew F Beck
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Molly K Krager
- Department of Pediatrics, Children’s Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Katherine L Freundlich
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dena Ibrahim
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joanna E Thomson
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - James C Gay
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alison R Carroll
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Maya Neeley
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Patricia A Frost
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alison C Herndon
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Allysa L Kehring
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Derek J Williams
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
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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.
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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
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30
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Spees LP, Hicklin K, Adams MC, Farnan L, Bensen JT, Gilleskie DB, Berg JS, Powell BC, Lich KH. Testing and extending strategies for identifying genetic disease-related encounters in pediatric patients. Genet Med 2022; 24:831-838. [PMID: 35034852 PMCID: PMC8995346 DOI: 10.1016/j.gim.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 12/03/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To better understand health care utilization and develop decision support tools, methods for identifying patients with suspected genetic diseases (GDs) are needed. Previous studies had identified inpatient-relevant International Classification of Diseases (ICD) codes that were possibly, probably, or definitely indicative of GDs. We assessed whether these codes identified GD-related inpatient, outpatient, and emergency department encounters among pediatric patients with suspected GDs from a previous study (the North Carolina Clinical Genomic Evaluation by Next-Generation Exome Sequencing [NCGENES] study). METHODS Using the electronic medical records of 140 pediatric patients from the NCGENES study, we characterized the presence of ICD codes representing possible, probable, or definite GD-related diagnoses across encounter types. In addition, we examined codes from encounters for which initially no GD-related codes had been found and determined whether these codes were indicative of a GD. RESULTS Among NCGENES patients with visits between 2014 and 2017, 92% of inpatient, 75% of emergency department, and 63% of outpatient encounters included ≥1 GD-related code. Encounters with highly specific (ie, definite) GD codes had fewer low-specificity GD codes than encounters with only low-specificity GD codes. We identified an additional 32 ICD-9 and 56 ICD-10 codes possibly indicative of a GD. CONCLUSION Code-based strategies can be refined to assess health care utilization among pediatric patients and may contribute to a systematic approach to identify patients with suspected GDs.
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Affiliation(s)
- Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Karen Hicklin
- Department of Industrial & Systems Engineering, Herbert Wertheim College of Engineering, University of Florida, Gainesville, FL
| | - Michael C Adams
- Division of Pediatric Genetics & Metabolism, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Laura Farnan
- Lineberger Comprehensive Cancer Center, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jeannette T Bensen
- Lineberger Comprehensive Cancer Center, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Donna B Gilleskie
- Department of Economics, College of Arts and Sciences, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jonathan S Berg
- Department of Genetics, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Bradford C Powell
- Department of Genetics, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Abstract
OBJECTIVES Children with severe chronic illness are a prevalent, impactful, vulnerable group in PICUs, whose needs are insufficiently met by transitory care models and a narrow focus on acute care needs. Thus, we sought to provide a concise synthetic review of published literature relevant to them and a compilation of strategies to address their distinctive needs. DATA SOURCES English language articles were identified in MEDLINE using a variety of phrases related to children with chronic conditions, prolonged admissions, resource utilization, mortality, morbidity, continuity of care, palliative care, and other critical care topics. Bibliographies were also reviewed. STUDY SELECTION Original articles, review articles, and commentaries were considered. DATA EXTRACTION Data from relevant articles were reviewed, summarized, and integrated into a narrative synthetic review. DATA SYNTHESIS Children with serious chronic conditions are a heterogeneous group who are growing in numbers and complexity, partly due to successes of critical care. Because of their prevalence, prolonged stays, readmissions, and other resource use, they disproportionately impact PICUs. Often more than other patients, critical illness can substantially negatively affect these children and their families, physically and psychosocially. Critical care approaches narrowly focused on acute care and transitory/rotating care models exacerbate these problems and contribute to ineffective communication and information sharing, impaired relationships, subpar and untimely decision-making, patient/family dissatisfaction, and moral distress in providers. Strategies to mitigate these effects and address these patients' distinctive needs include improving continuity and communication, primary and secondary palliative care, and involvement of families. However, there are limited outcome data for most of these strategies and little consensus on which outcomes should be measured. CONCLUSIONS The future of pediatric critical care medicine is intertwined with that of children with serious chronic illness. More concerted efforts are needed to address their distinctive needs and study the effectiveness of strategies to do so.
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Bogetz JF, Trowbridge A, Lewis H, Jonas D, Hauer J, Rosenberg AR. Forming Clinician-Parent Therapeutic Alliance for Children With Severe Neurologic Impairment. Hosp Pediatr 2022; 12:282-292. [PMID: 35141756 DOI: 10.1542/hpeds.2021-006316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Care for children with severe neurologic impairment (SNI) often involves complex medical decision-making where therapeutic alliance between clinicians and families is essential. Yet, existing data suggest that communication and alliance are often lacking. This study aimed to examine aspects important to developing therapeutic alliance between clinicians and parents of children with SNI. METHODS A purposive sample of expert clinicians and parents of children with SNI completed brief demographic surveys and 1:1 semistructured interviews between July 2019 and August 2020 at a single tertiary pediatric academic center. Interviews focused on the inpatient experience and transcriptions underwent thematic analysis by a study team of qualitative researchers with expertise in palliative care and communication science. RESULTS Twenty-five parents and 25 clinicians participated (total n = 50). Many parents were mothers (n = 17, 68%) of school-aged children with congenital/chromosomal conditions (n = 15, 65%). Clinicians represented 8 professions and 15 specialties. Responses from participants suggested 3 major themes that build and sustain therapeutic alliance including: (1) foundational factors that must exist to establish rapport; (2) structural factors that provide awareness of the parent/child experience; and (3) weathering factors that comprise the protection, security, and additional support during hard or uncertain times. Participants also shared concrete actions that promote these factors in clinical practice. CONCLUSION Therapeutic alliance between clinicians and parents of children with SNI consists of at least 3 factors that support communication and medical decision-making. These factors are facilitated by concrete actions and practices, which enhance communication about the care for children with SNI.
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Affiliation(s)
- Jori F Bogetz
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
- Treuman Katz Center for Bioethics, Center for Clinical and Translational Research
- Palliative Care Resilience Research Laboratory, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Amy Trowbridge
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
- Treuman Katz Center for Bioethics, Center for Clinical and Translational Research
- Palliative Care Resilience Research Laboratory, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Hannah Lewis
- Treuman Katz Center for Bioethics, Center for Clinical and Translational Research
| | - Danielle Jonas
- Silver School of Social Work, New York University, New York, New York
| | - Julie Hauer
- Seven Hills Pediatric Center, Groton, Massachusetts
| | - Abby R Rosenberg
- Palliative Care Resilience Research Laboratory, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
- Division of Hematology Oncology, Department of Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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Szpindel A, Myers KA, Ng P, Dorais M, Koclas L, Pigeon N, Shevell M, Oskoui M. Epilepsy in children with cerebral palsy: a data linkage study. Dev Med Child Neurol 2022; 64:259-265. [PMID: 34423432 DOI: 10.1111/dmcn.15028] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 06/29/2021] [Accepted: 07/22/2021] [Indexed: 11/28/2022]
Abstract
AIM To compare the prevalence of epilepsy in children with cerebral palsy (CP) to peer controls and their differences in healthcare utilization. METHOD The Quebec CP registry was linked to the provincial administrative health database. Two CP cohorts were identified from the registry (n=302, 168 males, 1y 2mo-14y) and administrative data (n=370, 221 males, 2y 2mo-14y). A control cohort (n=6040, 3340 males, 10-14y) was matched by age, sex, and region to the CP registry cohort. Administrative data algorithms were used to define epilepsy cases. Data on hospitalizations and emergency department presentations were obtained. RESULTS Using the most sensitive epilepsy definition, prevalence was 42.05% in the CP registry, 43.24% in the CP administrative data, and 1.39% in controls. Prevalence rose with increasing Gross Motor Function Classification System level. Children with CP and epilepsy had increased number and length of hospitalizations and emergency department presentations compared to children with CP or epilepsy alone. Epilepsy accounted for approximately 5% of emergency department presentations and 10% of hospitalizations in children with epilepsy, with and without CP. INTERPRETATION Children with CP have an increased risk of epilepsy compared to their peers. Children with CP and coexisting epilepsy represent a unique subset with complex developmental disability and increased healthcare service utilization.
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Affiliation(s)
- Aliya Szpindel
- Faculty of Medicine, McGill University, Montréal, Quebec, Canada
| | - Kenneth A Myers
- Departments of Pediatrics and Neurology/Neurosurgery, McGill University, Montréal, Quebec, Canada.,Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
| | - Pamela Ng
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
| | - Marc Dorais
- StatSciences, Notre-Dame-de-l'Île-Perrot, Quebec, Canada
| | - Louise Koclas
- Centre de Réadaptation Marie Enfant du Centre Hospitalier Universitaire Sainte-Justine, Montréal, Quebec, Canada
| | - Nicole Pigeon
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Michael Shevell
- Departments of Pediatrics and Neurology/Neurosurgery, McGill University, Montréal, Quebec, Canada
| | - Maryam Oskoui
- Departments of Pediatrics and Neurology/Neurosurgery, McGill University, Montréal, Quebec, Canada.,Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
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Diskin C, Malik K, Gill PJ, Rashid N, Chan CY, Nelson KE, Thomson J, Berry J, Agrawal R, Orkin J, Cohen E. Research priorities for children with neurological impairment and medical complexity in high-income countries. Dev Med Child Neurol 2022; 64:200-208. [PMID: 34462917 PMCID: PMC9291325 DOI: 10.1111/dmcn.15037] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 07/16/2021] [Accepted: 08/03/2021] [Indexed: 02/05/2023]
Abstract
AIM To identify the highest-priority clinical research areas related to children with neurological impairment and medical complexity among clinicians and caregivers. METHOD A modified, three-stage Delphi study using online surveys and guided by a steering committee was completed. In round 1, clinicians and family caregivers suggested clinical topics and related questions that require research to support this subgroup of children. After refinement of the suggestions by the steering committee, participants contributed to 1 (family caregivers) or 2 (clinicians) subsequent rounds to develop a prioritized list. RESULTS A diverse international expert panel consisting of 49 clinicians and 12 family caregivers provided 601 responses. Responses were distilled into 26 clinical topics comprising 126 related questions. The top clinical topics prioritized for research were irritability and pain, child mental health, disorders of tone, polypharmacy, sleep, aspiration, behavior, dysautonomia, and feeding intolerance. The clinician expert panel also prioritized 10 specific research questions. INTERPRETATION Study findings support a research agenda for children with neurological impairment and medical complexity focused on addressing clinical questions, prioritized by an international group of clinicians and caregivers.
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Affiliation(s)
- Catherine Diskin
- Division of Paediatric MedicineDepartment of PaediatricsThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Kristina Malik
- Department of PediatricsUniversity of Colorado School of MedicineAuroraCOUSA,Special Care ClinicChildren’s Hospital ColoradoAuroraCOUSA
| | - Peter J Gill
- Division of Paediatric MedicineDepartment of PaediatricsThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada,Child Health Evaluative SciencesSickKids Research InstituteTorontoOntarioCanada,Institute for Health Policy, Management and EvaluationUniversity of TorontoTorontoOntarioCanada,Centre for Evidence‐Based MedicineUniversity of OxfordOxfordUK
| | - Nada Rashid
- The Hospital for Sick ChildrenTorontoOntarioCanada
| | - Carol Y Chan
- Child Health Evaluative SciencesSickKids Research InstituteTorontoOntarioCanada
| | - Katherine E Nelson
- Division of Paediatric MedicineDepartment of PaediatricsThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada,Child Health Evaluative SciencesSickKids Research InstituteTorontoOntarioCanada,Institute for Health Policy, Management and EvaluationUniversity of TorontoTorontoOntarioCanada
| | - Joanna Thomson
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA,Division of Hospital MedicineCincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
| | - Jay Berry
- Division of General PediatricsChildren’s Hospital BostonBostonMAUSA,Department of PediatricsHarvard Medical SchoolBostonMAUSA
| | - Rishi Agrawal
- Department of PediatricsHarvard Medical SchoolBostonMAUSA,Division of Hospital‐Based MedicineDepartment of PediatricsAnn & Robert H. Lurie Children’s Hospital of ChicagoNorthwestern University Feinberg School of MedicineChicagoILUSA,Section of Chronic DiseaseLa Rabida Children’s HospitalChicagoILUSA
| | - Julia Orkin
- Division of Paediatric MedicineDepartment of PaediatricsThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada,Child Health Evaluative SciencesSickKids Research InstituteTorontoOntarioCanada
| | - Eyal Cohen
- Division of Paediatric MedicineDepartment of PaediatricsThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada,Child Health Evaluative SciencesSickKids Research InstituteTorontoOntarioCanada,Institute for Health Policy, Management and EvaluationUniversity of TorontoTorontoOntarioCanada,Edwin S.H. Leong Centre for Healthy ChildrenUniversity of TorontoTorontoOntarioCanada,CanChild Centre for Childhood Disability ResearchMcMaster UniversityHamiltonOntarioCanada
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35
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Bayer ND, Hall M, Li Y, Feinstein JA, Thomson J, Berry JG. Trends in Health Care Use and Spending for Young Children With Neurologic Impairment. Pediatrics 2022; 149:183773. [PMID: 34854922 PMCID: PMC8762668 DOI: 10.1542/peds.2021-050905] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Children with neurologic impairment (NI) are a growing subset of children who frequently use health care. We examined health care use and spending trends across services for children with NI during their first 5 years of life. METHODS This was a retrospective study of 13 947 children with NI in the multistate IBM Medicaid MarketScan Database (2009-2017). We established birth cohorts of children with NI and analyzed claims from birth to 5 years. NI, identified by using International Classification of Diseases, 9th Revision, diagnosis codes, was defined as ≥1 neurologic diagnosis that was associated with functional and/or intellectual impairment. We measured annual health care use and per-member-per-year spending by inpatient, emergency department (ED), and outpatient services. Population trends in use and spending were assessed with logistic and linear regression, respectively. RESULTS During their first versus fifth year, 66.8% vs 5.8% of children with NI used inpatient services, and 67.8% vs 44.4% used ED services. Annual use in both categories decreased over 0-5 years (inpatient odds ratio: 0.35, 95% confidence interval: 0.34 to 0.36; ED odds ratio: 0.78, 95% confidence interval: 0.77 to 0.79). The use of outpatient services (primary care, specialty care, home health) decreased gradually. Per-member-per-year spending on inpatient services remained the largest spending category: $83 352 (90.2% of annual spending) in the first year and $1944 (25.5%) in the fifth year. CONCLUSIONS For children with early-onset NI from 0-5 years, use and spending on inpatient services decreased dramatically; ED and outpatient service use decreased more gradually. These findings may help systems, clinicians, and families optimize care by anticipating and adjusting for shifting use of health care services.
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Affiliation(s)
- Nathaniel D. Bayer
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Rochester and Golisano Children’s Hospital, Rochester, New York,Address correspondence to Nathaniel D. Bayer, MD, Division of Pediatric Hospital Medicine, Golisano Children’s Hospital and Department of Pediatrics, University of Rochester, 601 Elmwood Ave, Box 667, Rochester, NY 14642. E-mail:
| | | | - Yue Li
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - James A. Feinstein
- Adult and Child Consortium for Health Outcomes Research & Delivery Science, University of Colorado and Children’s Hospital Colorado, Aurora, Colorado
| | - Joanna Thomson
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, College of Medicine University of Cincinnati, Cincinnati, Ohio
| | - Jay G. Berry
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
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Kobussen TA, Hansen G, Holt TR. Comparing subspecialty and intensive care providers perspectives on pediatric complex chronic patients: A survey study. INTERNATIONAL JOURNAL OF CARE COORDINATION 2021. [DOI: 10.1177/20534345211068094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Pediatric complex chronic care patients present unique challenges regarding healthcare provision: complex medical regimes, complicated family/provider dynamics, and multiple healthcare teams that can result in inconsistent care. This study examined subspecialty providers’ perspectives regarding pediatric complex chronic care patients and compared them with acute care providers while exploring opportunities to better facilitate care provided to pediatric complex chronic care patients. Methods This survey study occurring within a Canadian tertiary care pediatric center, utilized REDCap to deploy surveys involving Likert Scale and short answer questions. The Kruskal–Wallis test compared subspecialty provider perspectives when providing care to pediatric complex chronic care patients versus non-pediatric complex chronic care patients; and perspectives between subspecialty and acute care providers. Results Survey response rate was 24/46 (52.2%). Eight overarching themes emerged from Likert scale questions. Short answer questions revealed factors that may facilitate care provided to pediatric complex chronic care patients: access to funding; discharge planning; communication methods between specialists; and healthcare provider continuity. Several differences were identified when working with pediatric complex chronic care patients, compared to non-pediatric complex chronic care patients: increased time/resource burden; managing expectations of patients/families; navigating discrepancies in goals of care; complexity of coordination between services; increased efforts in coordinating discharge from hospital and working with medicalized patients/families. Discussion Exploring pediatric subspecialty provider perspectives of pediatric complex chronic care patients revealed opportunities to enhance care provided: increased resources to ease the strain of care provision for parents, implementation of a discharge coordinator, complex care clinics with a pediatrician to “quarterback” care, and co-management between the complex care pediatrician and acute care physician when admitted to an acute care service. Implementation of these initiatives may improve the care provided to pediatric complex chronic care patients.
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Affiliation(s)
| | - Gregory Hansen
- Division of Critical Care, Department of Pediatrics, University of Saskatchewan, Canada
| | - Tanya R Holt
- Division of Critical Care, Department of Pediatrics, University of Saskatchewan, Canada
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Paget S, Ostojic K, Goldsmith S, Nassar N, McIntyre S. Determinants of hospital-based health service utilisation in cerebral palsy: a systematic review. Arch Phys Med Rehabil 2021; 103:1628-1637. [PMID: 34968439 DOI: 10.1016/j.apmr.2021.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/25/2021] [Accepted: 12/01/2021] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To systematically review and synthesize evidence of determinants associated with hospital-based health service utilisation among individuals with cerebral palsy (CP). DATA SOURCES Electronic databases MEDLINE, Embase, APA Psycinfo were searched from January 2000 to April 2020. STUDY SELECTION Observational studies were included that described people with CP, reported quantitative measures of hospital-based health service utilisation (inpatient, outpatient, emergency department), and based in high-income countries. We excluded studies that included only subsets of people with CP, or those that only reported therapy service utilisation. DATA EXTRACTION After initial screen, two reviewers reviewed full texts for inclusion and performed data extraction and risk of bias assessment using the Newcastle Ottawa scale. Determinants of health service utilisation were identified and categorised using the Andersen Behavioural Model. DATA SYNTHESIS Seventeen studies met inclusion criteria. Study quality was high. Twenty-six determinants were reported across eight Andersen Model characteristics. Individual predisposing factors such as sex showed no difference in health service utilisation; inpatient admissions decreased with increasing age during childhood and was lower in adults. Increased health service utilisation was associated with "individual need" including severe gross motor disability, epilepsy, developmental/ intellectual disability and gastrostomy-use across inpatient, outpatient and emergency department settings. There was little information reported on socio-demographic and health system contextual determinants. CONCLUSIONS CP health service utilisation was associated with age, severity and comorbidities. Improved understanding of determinants of health service utilisation can support health service access for people with CP.
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Affiliation(s)
- Simon Paget
- The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Kids Rehab, the Children's Hospital at Westmead, Westmead NSW Australia.
| | - Katarina Ostojic
- Cerebral Palsy Alliance, Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia
| | - Shona Goldsmith
- Cerebral Palsy Alliance, Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia
| | - Natasha Nassar
- Child Population and Translational Health, The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Sarah McIntyre
- Cerebral Palsy Alliance, Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia
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Gene-Targeted Therapies in Pediatric Neurology: Challenges and Opportunities in Diagnosis and Delivery. Pediatr Neurol 2021; 125:53-57. [PMID: 34628144 PMCID: PMC9472447 DOI: 10.1016/j.pediatrneurol.2021.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 09/18/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Gene-targeted therapies are becoming a reality for infants and children with diseases of the nervous system. Rapid scientific advances have led to disease-modifying or even curative treatments. However, delays and gaps in diagnosis, inequitable delivery, and the need for long-term surveillance pose unresolved challenges. OBJECTIVE AND METHODS The goal of the Child Neurology Society Research Committee was to evaluate and provide guidance on the obstacles, opportunities, and uncertainties in gene-targeted therapies for pediatric neurological disease. The Child Neurology Society Research Committee engaged in collaborative, iterative literature review and committee deliberations to prepare this consensus statement. RESULTS We identified important challenges for gene-targeted therapies that require resource investments, infrastructure development, and strategic planning. Barriers include inequities in diagnosis and delivery of therapies, high costs, and a need for long-term surveillance of efficacy and safety, including systematic tracking of unanticipated effects. Key uncertainties regarding technical aspects and usage of gene-targeted therapies should be addressed, and characterization of new natural histories of diseases will be needed. Counterbalanced with these obstacles and uncertainties is the tremendous potential being demonstrated in treatments and clinical trials of gene-targeted therapies. CONCLUSIONS Given that gene-targeted therapies for neurological diseases are in their earliest phase, the pediatric neurology community can play a vital role in their guidance and implementation. This role includes facilitating development of infrastructure and guidelines; ensuring efficient, equitable, and ethical implementation of treatments; and advocating for affordable and broad access for all children.
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Antoon JW, Hall M, Herndon A, Johnson DP, Brown CM, Browning WL, Florin TA, Howard LM, Grijalva CG, Williams DJ. Prevalence, Risk Factors, and Outcomes of Influenza-Associated Neurologic Complications in Children. J Pediatr 2021; 239:32-38.e5. [PMID: 34216629 PMCID: PMC8604779 DOI: 10.1016/j.jpeds.2021.06.075] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/01/2021] [Accepted: 06/28/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To determine the frequency of neurologic complications associated with influenza in hospitalized children. STUD DESIGN We performed a cross-sectional study of children (2 months through 17 years of age) with influenza discharged from 49 children's hospitals in the Pediatric Health Information System during the influenza seasons of 2015-2020. Neurologic complications were defined as encephalopathy, encephalitis, aseptic meningitis, febrile seizure, nonfebrile seizure, brain abscess and bacterial meningitis, Reye syndrome, and cerebral infarction. We assessed length of stay (LOS), intensive care unit (ICU) admission, ICU LOS, 30-day hospital readmissions, deaths, and hospital costs associated with these events. Patient-level risk factors associated with neurologic complications were identified using multivariable logistic regression. RESULTS Of 29 676 children hospitalized with influenza, 2246 (7.6%) had a concurrent diagnosis of a neurologic complication; the most frequent were febrile seizures (5.0%), encephalopathy (1.7%), and nonfebrile seizures (1.2%). Hospital LOS, ICU admission, ICU LOS, deaths, and hospital costs were greater in children with neurologic complications compared with those without complications. Risk factors associated with neurologic complications included male sex (aOR 1.1, 95% CI 1.02-1.21), Asian race/ethnicity (aOR 1.7, 95% CI 1.4-2.1) (compared with non-Hispanic White), and the presence of a chronic neurologic condition (aOR 3.7, 95% CI 3.1-4.2). CONCLUSIONS Neurologic complications are common in children hospitalized with influenza, especially among those with chronic neurologic conditions, and are associated with worse outcomes compared with children without neurologic complications. These findings emphasize the strategic importance of influenza immunization and treatment, especially in high-risk populations.
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Affiliation(s)
- James W Antoon
- Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN; Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN.
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS
| | - Alison Herndon
- Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN; Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - David P Johnson
- Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN; Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Charlotte M Brown
- Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN; Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Whitney L Browning
- Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN; Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Todd A Florin
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago & Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Leigh M Howard
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Derek J Williams
- Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN; Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
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Feinstein JA, Berry JG, Feudtner C. Intervention research to improve care and outcomes for children with medical complexity and their families. Curr Probl Pediatr Adolesc Health Care 2021; 51:101126. [PMID: 34996708 PMCID: PMC8825706 DOI: 10.1016/j.cppeds.2021.101126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Healthcare and outcomes for children with medical complexity (CMC) and their families can be improved by conducting well-conceived, designed, implemented, and analyzed research studies of clinical interventions. This article presents a framework for how to approach the study of clinical interventions for CMC, including 7 key questions and example answers to each: (1) What intervention questions should be our focus? (2) What barriers to intervention research exist? (3) How do we design and optimize interventions? (4) How do we characterize and select patients to enroll? (5) How can we enhance data collection and integration? (6) How can we improve enrollment and participation? And (7) which intervention experimental designs should we choose? By exploring each of these key aspects of intervention-based research, we hope to expand thinking about and spark ideas for specific research projects focused on clinical interventions for CMC.
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Affiliation(s)
- James A Feinstein
- Adult and Child Consortium for Health Outcomes Research & Delivery Science (ACCORDS), University of Colorado and Children's Hospital Colorado, Aurora, CO, United States; Department of Pediatrics, University of Colorado, Aurora, CO, United States.
| | - Jay G Berry
- Complex Care, Division of General Pediatrics, Boston Children's Hospital, Boston, MA, United States
| | - Chris Feudtner
- Division of General Pediatrics, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
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Bogetz JF, Trowbridge A, Lewis H, Shipman KJ, Jonas D, Hauer J, Rosenberg AR. Parents Are the Experts: A Qualitative Study of the Experiences of Parents of Children With Severe Neurological Impairment During Decision-Making. J Pain Symptom Manage 2021; 62:1117-1125. [PMID: 34147578 PMCID: PMC8648906 DOI: 10.1016/j.jpainsymman.2021.06.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 06/09/2021] [Accepted: 06/10/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT Parents of children with severe neurologic impairment (SNI) often face high-stakes medical decisions when their child is hospitalized. These decisions involve technology and/or surgery, goals of care and/or advance care planning, or transitions of care. OBJECTIVES This study describes the experiences of parents of children with SNI during decision-making. METHODS Eligible participants were parents facing a decision for a child with SNI admitted to acute or intensive care units at a single tertiary pediatric center. Parents completed 1:1 semi-structured interviews and brief surveys between August 2019 and February 2020. Demographic information was extracted from the child's electronic health record. A team of palliative and complex care researchers with expertise in qualitative methods used thematic content analysis to formulate results. RESULTS 25 parents participated. The majority had children with congenital/chromosomal SNI conditions (n = 13, 65%), >5 subspecialists (n = 14, 61%), and chronic technology assistance (n = 25, 100%). 68% (n = 17) were mothers and 100% identified as being their child's primary decision-maker. Responses from parents included 3 major themes: 1) our roles and actions; 2) our stresses and challenges; and 3) our meaning and purpose. Responses highlighted the pervasiveness of parental decision-making efforts and parents' advocacy and vigilance regarding their child's needs. Despite this, parents often felt unheard and undervalued in the hospital. CONCLUSION During hospitalizations, when parents of children with SNI often face high-stakes medical decisions, interventions are needed to support parents and ensure they feel heard and valued as they navigate their child's medical needs and system challenges.
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Affiliation(s)
- Jori F Bogetz
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Palliative Care and Resilience Lab, Center for Clinical and Translational Research; Seattle Children's Hospital and Research Institute, Seattle, WA, USA.
| | - Amy Trowbridge
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Palliative Care and Resilience Lab, Center for Clinical and Translational Research; Seattle Children's Hospital and Research Institute, Seattle, WA, USA
| | - Hannah Lewis
- Treuman Katz Center for Bioethics, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA
| | - Kelly J Shipman
- Palliative Care and Resilience Lab, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA
| | - Danielle Jonas
- Silver School of Social Work, New York University; New York, NY
| | - Julie Hauer
- Seven Hills Pediatric Center; Assistant Professor, Division of General Pediatrics, Department of Pediatrics, Harvard Medical School; Boston Children's Hospital, Boston, MA
| | - Abby R Rosenberg
- Division of Hematology/Oncology, Department of Pediatrics, University of Washington School of Medicine; Palliative Care and Resilience Lab, Center for Clinical and Translational Research, Seattle Children's Hospital and Research Institute, Seattle, WA
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Warniment A, Steuart R, Rodean J, Hall M, Chinchilla S, Shah SS, Thomson J. Variation in Bacterial Respiratory Culture Results in Children With Neurologic Impairment. Hosp Pediatr 2021; 11:e326-e333. [PMID: 34716209 DOI: 10.1542/hpeds.2020-005314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To examine bacterial respiratory cultures in children with neurologic impairment (NI) (eg, cerebral palsy), both with and without tracheostomies, who were hospitalized with acute respiratory infections (ARIs) (eg, pneumonia) and to compare culture results across hospitals and age groups. METHODS This multicenter retrospective cohort study included ARI hospitalizations for children aged 1 to 18 years with NI between 2007 and 2012 who had a bacterial respiratory culture obtained within 2 days of admission. Data from 5 children's hospitals in the Pediatric Health Information System Plus database were used. Organisms consistent with oral flora and nonspeciated organisms were omitted from analysis. The prevalence of positive respiratory culture results and the prevalence of organisms identified were compared across hospitals and age groups and in subanalyses of children with and without tracheostomies by using generalized estimating equations to account for within-patient clustering. RESULTS Of 4900 hospitalizations, 693 from 485 children had bacterial respiratory cultures obtained. Of these, 54.5% had positive results, although this varied across hospitals (range 18.6%-83.2%; P < .001). Pseudomonas aeruginosa and Staphylococcus aureus were the most commonly identified organisms across hospitals and age groups and in patients with and without tracheostomies. Large variation in growth prevalence was identified across hospitals but not age groups. CONCLUSIONS The bacteriology of ARI in hospitalized children with NI differs from that of otherwise healthy children. Significant variation in prevalence of positive bacterial respiratory culture results and organism growth were observed across hospitals, which may be secondary to local environmental factors and microbiology reporting practices.
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Affiliation(s)
| | | | | | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | | | - Samir S Shah
- Divisions of Hospital Medicine.,Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics
| | - Joanna Thomson
- Divisions of Hospital Medicine .,Department of Pediatrics
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Bogetz JF, Lewis H, Trowbridge A, Jonas D, Hauer J, Wilfond BS. From Monochromatic to Technicolor: Parent Perspectives on Challenges and Approaches to Seeing Children with Severe Neurological Impairment Holistically. J Palliat Med 2021; 25:437-444. [PMID: 34551279 DOI: 10.1089/jpm.2021.0344] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Children with severe neurological impairment (SNI) commonly receive care in the hospital setting necessitating frequent interactions with clinicians. Yet, parents report that clinicians often have a limited understanding of their child's unique needs and abilities which hinders their care. Objectives: This study aimed to understand the challenges and suggested approaches parents identified to seeing their child holistically. Design: Cross-sectional qualitative study. Setting/Subjects: Parents/legal guardians of children with SNI at a tertiary pediatric academic center in the United States completed 1:1 interviews between August 2019 and February 2020. Measurements: Qualitative researchers with expertise in care for children with SNI, palliative care, and bioethics used thematic content analysis to inductively analyze data for relevant themes. Results: Twenty-five parents/legal guardians of 23 children with SNI participated. Sixty-eight percent were mothers and 24% were fathers; and 68% were white. Thirty-two percent were from other racial and/or ethnic backgrounds. Children predominantly had congenital/chromosomal (n = 15, 65%) and central nervous system static (n = 6, 26%) SNI diagnoses. Four themes emerged regarding both challenges and approaches to understanding children with SNI holistically. These included uniqueness, interdependency, complexity, and universality. Parents felt that by eliciting and incorporating their perspective on these sometimes contrasting but inherently necessary aspects of their child's care, clinicians would understand their children more fully. Conclusion: By viewing the child through the prismed lens of parents, participants described how clinicians could transition from a monochromatic to a technicolor view of their child-including the inherent contrasting needs required for their comprehensive care.
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Affiliation(s)
- Jori F Bogetz
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Palliative Care and Resilience Research Lab, Center for Clinical and Translational Research, Seattle Children's Hospital and Research Institute, Seattle, Washington, USA.,Treuman Katz Center for Bioethics, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Hannah Lewis
- Treuman Katz Center for Bioethics, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Amy Trowbridge
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Palliative Care and Resilience Research Lab, Center for Clinical and Translational Research, Seattle Children's Hospital and Research Institute, Seattle, Washington, USA.,Treuman Katz Center for Bioethics, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Danielle Jonas
- Silver School of Social Work, New York University, New York, New York, USA
| | - Julie Hauer
- Seven Hills Pediatric Center, Groton, Massachusetts, USA.,Division of General Pediatrics, Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benjamin S Wilfond
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Treuman Katz Center for Bioethics, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA.,Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
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Mpody C, Hayes S, Rusin N, Tobias JD, Nafiu OO. Risk Assessment for Postoperative Pneumonia in Children Living With Neurologic Impairments. Pediatrics 2021; 148:peds.2021-050130. [PMID: 34349030 DOI: 10.1542/peds.2021-050130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Approximately one-third of all pediatric hospital charges are attributable to the care for children living with neurologic comorbidities. These children often require various surgical procedures and may have an elevated risk of lower respiratory infections because of poor neuromuscular coordination, poor cough, uncoordinated swallowing, and poor oral hygiene. Our objective was to evaluate the risk of pneumonia in children presenting with neurologic comorbidities. METHODS We performed a retrospective study of children (<18 years) who underwent inpatient surgery between 2012 and 2018 in hospitals participating in the National Surgical Quality Improvement Program. Our primary outcome was the time to incident pneumonia within the 30 days after surgery. RESULTS We identified 349 163 children, of whom 2191 developed pneumonia (30-day cumulative incidence: 0.6%). The presence of a preoperative neurologic comorbidity conferred approximately twofold higher risk of postoperative pneumonia (hazard ratio [HR]: 1.91, 95% confidence interval [CI]: 1.73-2.11). We explored the risk of pneumonia conferred by the components of neurologic comorbidity: cerebral palsy (HR: 3.92, 95% CI: 3.38-4.56), seizure disorder (HR: 2.93, 95% CI: 2.60-3.30), neuromuscular disorder (HR: 2.63, 95% CI: 2.32-2.99). The presence of a neurologic comorbidity was associated with a longer length of hospital stay (incidence rate ratio: 1.26, 95% CI: 1.25-1.28). CONCLUSIONS The risk of postoperative pneumonia was almost twofold higher in children with neurologic comorbidity. The magnitude of these associations underscores the need to identify areas of research and preventive strategies to reduce the excess risk of pneumonia in children with preoperative neurologic conditions.
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Affiliation(s)
- Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Seth Hayes
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Nathan Rusin
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Olubukola O Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
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45
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Bogetz JF, Lemmon ME. Pediatric Palliative Care for Children With Severe Neurological Impairment and Their Families. J Pain Symptom Manage 2021; 62:662-667. [PMID: 33485937 PMCID: PMC8295396 DOI: 10.1016/j.jpainsymman.2021.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/11/2021] [Accepted: 01/14/2021] [Indexed: 01/11/2023]
Affiliation(s)
- Jori F Bogetz
- Division of Pediatric Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine; Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, WA, United States.
| | - Monica E Lemmon
- Division of Neurology, Department of Pediatrics and Population Health Sciences, Duke University School of Medicine, Duke University Medical Center 3936, Durham, NC, United States
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Kobussen TA, Hansen G, Brockman RJ, Holt TR. Perspectives of Pediatric Providers on Patients With Complex Chronic Conditions: A Mixed-Methods Sequential Explanatory Study. Crit Care Nurse 2021; 40:e10-e17. [PMID: 33000135 DOI: 10.4037/ccn2020710] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Children with complex chronic conditions present unique challenges to the pediatric intensive care unit, including prolonged length of stay, complex medical regimens, and complicated family dynamics. OBJECTIVES To examine perspectives of pediatric intensive care unit health care providers regarding pediatric patients with complex chronic conditions, and to explore potential opportunities to improve these patients' care. METHODS A prospective mixed-methods sequential explanatory study was conducted in a tertiary medical-surgical pediatric intensive care unit using surveys performed with REDCap (Research Electronic Data Capture) followed by semistructured interviews. RESULTS The survey response rate was 70.6% (77 of 109). Perspectives of health care providers did not vary with duration of work experience. Ten semistructured interviews were conducted. Eight overarching themes emerged from the interviews: (1) the desire for increased formal education specific to pediatric complex chronic care patients; (2) designation of a primary intensivist; (3) modifying delivery of care to include a discrete location for care provision; (4) establishing daily, short-term, and long-term goals; (5) monitoring and documenting care milestones; (6) strengthening patient and family communications with the health care team; (7) optimizing discharge coordination and planning; and (8) integrating families into care responsibilities. CONCLUSIONS Pediatric intensive care unit health care providers' perspectives of pediatric patients with complex chronic conditions indicated opportunities to refine the care provided by establishing daily goals, coordinating discharge planning, and creating occasions for close communication between patients, families, and providers.
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Affiliation(s)
- Taylor A Kobussen
- Taylor A. Kobussen is a pediatric resident, Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Gregory Hansen
- Gregory Hansen is a pediatric intensive care physician, Department of Pediatrics, University of Saskatchewan
| | - Rebecca J Brockman
- Rebecca J. Brockman is a pediatric intensive care and transport nurse and nurse educator, Department of Pediatrics, University of Saskatchewan
| | - Tanya R Holt
- Tanya R. Holt is Director of the pediatric intensive care unit, Department of Pediatrics, University of Saskatchewan
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47
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Lin JL, Rigdon J, Van Haren K, Buu M, Saynina O, Bhattacharya J, Owens DK, Sanders LM. Gastrostomy Tubes Placed in Children With Neurologic Impairment: Associated Morbidity and Mortality. J Child Neurol 2021; 36:727-734. [PMID: 33750232 DOI: 10.1177/08830738211000179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Gastrostomy tube (G-tube) placement for children with neurologic impairment with dysphagia has been suggested for pneumonia prevention. However, prior studies demonstrated an association between G-tube placement and increased risk of pneumonia. We evaluate the association between timing of G-tube placement and death or severe pneumonia in children with neurologic impairment. METHODS We included all children enrolled in California Children's Services between July 1, 2009, and June 30, 2014, with neurologic impairment and 1 pneumonia hospitalization. Prior to analysis, children with new G-tubes and those without were 1:2 propensity score matched on sociodemographics, medical complexity, and severity of index hospitalization. We used a time-varying Cox proportional hazard model for subsequent death or composite outcome of death or severe pneumonia to compare those with new G-tubes vs those without, adjusting for covariates described above. RESULTS A total of 2490 children met eligibility criteria, of whom 219 (9%) died and 789 (32%) had severe pneumonia. Compared to children without G-tubes, children with new G-tubes had decreased risk of death (hazard ratio [HR] 0.47, 95% confidence interval [CI] 0.39-0.55) but increased risk of the composite outcome (HR 1.21, CI 1.14-1.27). Sensitivity analyses using varied time criteria for definitions of G-tube and outcome found that more recent G-tube placement had greater associated risk reduction for death but increased risk of severe pneumonia. CONCLUSION Recent G-tube placement is associated with reduced risk of death but increased risk of severe pneumonia. Decisions to place G-tubes for pulmonary indications in children with neurologic impairment should weigh the impact of severe pneumonia on quality of life.
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Affiliation(s)
- Jody L Lin
- Division of Pediatric Hospital Medicine, Department of Pediatrics, 14434University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Joseph Rigdon
- Department of Biostatistics and Data Science, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Keith Van Haren
- Division of Child Neurology, Department of Neurology and Neurological Science, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - MyMy Buu
- Division of Pediatric Pulmonary Medicine, Department of Pediatrics, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Olga Saynina
- Division of General Pediatrics, Department of Pediatrics, 10624Stanford University School of Medicine, Stanford, CA, USA
| | - Jay Bhattacharya
- Stanford Health Policy, 166495Stanford University, Stanford, CA, USA
| | - Douglas K Owens
- Stanford Health Policy, 166495Stanford University, Stanford, CA, USA.,VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Lee M Sanders
- Division of General Pediatrics, Department of Pediatrics, 10624Stanford University School of Medicine, Stanford, CA, USA
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Morrison JM, Betensky M, Kiskaddon AL, Goldenberg NA. Venous Thromboembolism among Noncritically Ill Hospitalized Children: Key Considerations for the Pediatric Hospital Medicine Specialist. Semin Thromb Hemost 2021; 48:434-445. [PMID: 33962474 DOI: 10.1055/s-0041-1729170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Venous thromboembolism (VTE) is a leading cause of morbidity and preventable harm among noncritically ill hospitalized children. Several clinical factors relevant to the noncritically ill hospitalized child significantly increase the risk of VTE including the presence of central venous catheters, systemic inflammation, and prolonged immobilization. Although risk mitigation strategies have been described, the diagnosis, treatment, and prevention of VTE require standardization of institutional practices combined with multidisciplinary collaboration among pediatric hospitalists, hematologists, and other care providers. In this narrative review, we summarize the epidemiology of VTE, risk models identifying high-risk conditions associated with VTE, and prevention and treatment strategies. We further describe successful quality improvement efforts implementing institutional VTE risk stratification and thromboprophylaxis procedures. Finally, we highlight unique challenges facing pediatric hospital medicine specialists in the era of the COVID-19 pandemic, including caring for adults admitted to pediatric hospital units, and describe future research opportunities for VTE in the noncritically ill hospitalized child.
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Affiliation(s)
- John M Morrison
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Pediatric Hospital Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Marisol Betensky
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Pediatric Hematology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Amy L Kiskaddon
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Neil A Goldenberg
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Pediatric Hematology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
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Pediatric obesity and perioperative medicine. Curr Opin Anaesthesiol 2021; 34:299-305. [PMID: 33935177 DOI: 10.1097/aco.0000000000000991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Childhood obesity is a public health emergency that has reached a pandemic level and imposed a massive economic burden on healthcare systems. Our objective was to provide an update on (1) challenges of obesity definition and classification in the perioperative setting, (2) challenges of perioperative patient positioning and vascular access, (3) perioperative implications of childhood obesity, (3) anesthetic medication dosing and opioid-sparing techniques in obese children, and (4) research gaps in perioperative childhood obesity research including a call to action. RECENT FINDINGS Despite the near axiomatic observation that obesity is a pervasive clinical problem with considerable impact on perioperative health, there have only been a handful of research into the many ramifications of childhood obesity in the perioperative setting. A nuanced understanding of the surgical and anesthetic risks associated with obesity is essential to inform patients' perioperative consultation and their parents' counseling, improve preoperative risk mitigation, and improve patients' rescue process when complications occur. SUMMARY Anesthesiologists and surgeons will continue to be confronted with an unprecedented number of obese or overweight children with a high risk of perioperative complications.
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Edelson JB, Rossano JW, Griffis H, Quarshie WO, Ravishankar C, O'Connor MJ, Mascio CE, Mercer-Rosa L, Glatz AC, Lin KY. Resource Use and Outcomes of Pediatric Congenital Heart Disease Admissions: 2003 to 2016. J Am Heart Assoc 2021; 10:e018286. [PMID: 33554612 PMCID: PMC7955343 DOI: 10.1161/jaha.120.018286] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Children with congenital heart disease (CHD) are known to consume a disproportionate share of resources, yet there are limited data concerning trends in resource use and mortality among admitted children with CHD. We hypothesize that charges in CHD‐related admissions increased but that mortality improved over time. Methods and Results This study, including patients <18 years old with CHD, examined inpatient admissions from the nationally representative Kids' Inpatient Database from 2003 to 2016 in order to assess the frequency, medical complexity, and outcomes of CHD hospital admissions. A total of 859 843 admissions of children with CHD were identified. CHD admissions increased by 31.8% from 2003 to 2016, whereas overall pediatric admissions decreased by 13.4%. Compared with non‐CHD admissions, those with CHD were more likely to be <1 year of age (80.5% versus 63.3%), and to have ≥1 complex chronic condition (39.7% versus 9.3%). For CHD admissions, mortality was higher (2.97% versus 0.31%) and adjusted median charges greater ($48 426 [interquartile range (IQR), $11.932–$161 048] versus $4697 [IQR, $2551–$12 301]) (P<0.0001 for all). Among CHD admissions, whereas adjusted median charges increased from $35 577 (IQR, $9303–$110 439) to $61 696 (IQR, $15 212–$219 237), mortality decreased from 3.2% to 2.7% (P for trend <0.0001). CHD admissions accounted for an increased proportion of all inpatient deaths, from 18.0% in 2003 to 24.5% in 2016. Conclusions Children admitted with CHD are 10 times more likely to die than those without CHD and have higher charges. Although the rate of mortality in CHD admissions decreased, children with CHD accounted for an increasing proportion of all pediatric inpatient deaths. Effective resource allocation is critical to optimize outcomes in these high‐risk patients.
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Affiliation(s)
- Jonathan B Edelson
- Division of Cardiology Cardiac Center, the Children's Hospital of PhiladelphiaUniversity of Pennsylvania Perelman School of Medicine Philadelphia PA.,Cardiovascular OutcomesQuality and Evaluative Research CenterUniversity of Pennsylvania Philadelphia PA.,Leonard Davis Institute of Health EconomicsUniversity of Pennsylvania Philadelphia PA
| | - Joseph W Rossano
- Division of Cardiology Cardiac Center, the Children's Hospital of PhiladelphiaUniversity of Pennsylvania Perelman School of Medicine Philadelphia PA.,Cardiovascular OutcomesQuality and Evaluative Research CenterUniversity of Pennsylvania Philadelphia PA.,Leonard Davis Institute of Health EconomicsUniversity of Pennsylvania Philadelphia PA
| | - Heather Griffis
- Department of Biomedical Health Informatics Healthcare Analytics Unitthe Children's Hospital of Philadelphia PA
| | - William O Quarshie
- Department of Biomedical Health Informatics Healthcare Analytics Unitthe Children's Hospital of Philadelphia PA
| | - Chitra Ravishankar
- Division of Cardiology Cardiac Center, the Children's Hospital of PhiladelphiaUniversity of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Matthew J O'Connor
- Division of Cardiology Cardiac Center, the Children's Hospital of PhiladelphiaUniversity of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery Cardiac Center, the Children's Hospital of PhiladelphiaUniversity of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Laura Mercer-Rosa
- Division of Cardiology Cardiac Center, the Children's Hospital of PhiladelphiaUniversity of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Andrew C Glatz
- Division of Cardiology Cardiac Center, the Children's Hospital of PhiladelphiaUniversity of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Kimberly Y Lin
- Division of Cardiology Cardiac Center, the Children's Hospital of PhiladelphiaUniversity of Pennsylvania Perelman School of Medicine Philadelphia PA
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