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Ault AK, Comer-HaGans D, Faubert SJ, Wallace BA, Weller BE. Reasons for Unmet Health Care Needs Among Black, Hispanic, and White Children in the United States With or at Risk for Physical and Mental Health Conditions. Clin Pediatr (Phila) 2024:99228241263042. [PMID: 38912591 DOI: 10.1177/00099228241263042] [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: 06/25/2024]
Abstract
Children with special health care needs (CSHCN)-ie, children who are at increased risk for, or currently manage, persistent physical and mental health conditions-require more health care resources than children without special health care needs. Furthermore, CSHCN who identify as racial/ethnic minorities disproportionately encounter unmet needs, according to reports from their caregivers. However, the reasons for their unmet needs are relatively unknown. This study estimated and compared the US national prevalence of caregiver-reported reasons for unmet health care needs for Hispanic, non-Hispanic black, and non-Hispanic white CSHCN. The most common reasons were problems getting an appointment for black CSHCN and cost for Hispanic and white CSHCN. Issues related to transportation were significantly less likely for black than for white and Hispanic CSHCN. Cost-related issues were significantly less likely for black than Hispanic CSHCN. To address reasons for unmet needs for CSHCN, effective structural changes are needed.
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Pulcini CD, Luan X, Brooks ES, Hogan A, Penrose T, Kenyon CC, Rubin DM. Pediatric Population Management Classification for Children with Medical Complexity. Popul Health Manag 2024; 27:192-198. [PMID: 38613470 DOI: 10.1089/pop.2023.0303] [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] [Indexed: 04/15/2024] Open
Abstract
Improving the overall care of children with medical complexity (CMC) is often beset by challenges in proactively identifying the population most in need of clinical management and quality improvement. The objective of the current study was to create a system to better capture longitudinal risk for sustained and elevated utilization across time using real-time electronic health record (EHR) data. A new Pediatric Population Management Classification (PPMC), drawn from visit diagnoses and continuity problem lists within the EHR of a tristate health system, was compared with an existing complex chronic conditions (CCC) system for agreement (with weighted κ) on identifying CCMC, as well as persistence of elevated charges and utilization from 2016 to 2019. Agreement of assignment PPMC was lower among primary care provider (PCP) populations than among other children traversing the health system for specialty or hospital services only (weighted κ 62% for PCP vs. 82% for non-PCP). The PPMC classification scheme, displaying greater precision in identifying CMC with persistently high utilization and charges for those who receive primary care within a large integrated health network, may offer a more pragmatic approach to selecting children with CMC for longitudinal care management.
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Affiliation(s)
- Christian D Pulcini
- Department of Emergency Medicine & Pediatrics, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Xianqun Luan
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth S Brooks
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Annique Hogan
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Tina Penrose
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Chen C Kenyon
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David M Rubin
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Pilarz MS, Bleed E, Rodriguez VA, Daniels LA, Jackson KL, Sanchez-Pinto LN, Foster CC. Medical Complexity, Language Use, and Outcomes in the Pediatric ICU. Pediatrics 2024; 153:e2023063359. [PMID: 38747049 PMCID: PMC11153320 DOI: 10.1542/peds.2023-063359] [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: 07/24/2023] [Revised: 02/27/2024] [Accepted: 03/05/2024] [Indexed: 06/02/2024] Open
Abstract
OBJECTIVES To determine whether use of a language other than English (LOE) would be associated with medical complexity, and whether medical complexity and LOE together would be associated with worse clinical outcomes. METHODS The primary outcome of this single-site retrospective cohort study of PICU encounters from September 1, 2017, through August 31, 2022 was an association between LOE and medical complexity. Univariable and multivariable analyses were performed between demographic factors and medical complexity, both for unique patients and for all encounters. We investigated outcomes of initial illness severity (using Pediatric Logistic Organ Dysfunction-2), length of stay (LOS), days without mechanical ventilation or organ dysfunction using a mixed effects regression model, controlling for age, sex, race and ethnicity, and insurance status. RESULTS There were 6802 patients and 10 011 encounters. In multivariable analysis for all encounters, Spanish use (adjusted odds ratio [aOR], 1.29; 95% confidence interval [CI], 1.11-1.49) and language other than English or Spanish (LOES) (aOR, 1.36; 95% CI, 1.02-1.80) were associated with medical complexity. Among unique patients, there remained an association between use of Spanish and medical complexity in multivariable analysis (aOR, 1.26; 95% CI, 1.05-1.52) but not between LOES and medical complexity (aOR, 1.30; 95% CI, 0.92-1.83). Children with medical complexity (CMC) who used an LOES had fewer organ dysfunction-free days (P = .003), PICU LOS was 1.53 times longer (P = .01), and hospital LOS was 1.45 times longer (P = .01) compared with CMC who used English. CONCLUSIONS Use of an LOE was independently associated with medical complexity. CMC who used an LOES had a longer LOS.
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Affiliation(s)
| | | | - Victoria A. Rodriguez
- Division of Hospital Based Medicine
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - L. Nelson Sanchez-Pinto
- Division of Critical Care
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Carolyn C. Foster
- Division of Advanced General Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Harvey AR, Meehan E, Merrick N, D'Aprano AL, Cox GR, Williams K, Gibb SM, Mountford NJ, Connell TG, Cohen E. Comprehensive care programmes for children with medical complexity. Cochrane Database Syst Rev 2024; 5:CD013329. [PMID: 38813833 PMCID: PMC11137836 DOI: 10.1002/14651858.cd013329.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
BACKGROUND Children with medical complexity (CMC) represent a small, but growing, proportion of all children. Regardless of their underlying diagnosis, by definition, all CMC have similar functional limitations and high healthcare needs. It has been suggested that improving aspects of healthcare delivery for CMC improves health- and quality of life-related outcomes for children and their families and reduces healthcare-related expenditure. As a result, dedicated comprehensive care programmes have been established at many hospitals to meet the needs of CMC; however, it is unclear if such programmes are effective. OBJECTIVES Our main objective was to assess the effectiveness of comprehensive care programmes that aim to improve care coordination and other aspects of health care for CMC and to assess whether the effectiveness of such programmes differs according to the programme setting and structure. We aimed to assess their effectiveness in relation to child and parent health, functioning, and quality of life, quality of care, number of healthcare encounters, unmet healthcare needs, and total healthcare-related costs. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and CINAHL in May 2023. We also searched reference lists, trial registries, and the grey literature. SELECTION CRITERIA Randomised and non-randomised trials, controlled before-after studies, and interrupted time series studies were included. Studies that compared enrolment in a comprehensive care programme with non-enrolment in such a programme/treatment as usual were included. Participants were children that met the criteria for the definition of CMC, which is: having (i) a chronic condition, (ii) functional limitations, (iii) increased health and other service needs, and (iv) increased healthcare costs. Studies that included the following types of outcomes were included: health; quality of care; utilisation, coverage and access; resource use and costs; equity; and adverse outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data, assessed the risk of bias in each included study, and evaluated the certainty of evidence according to GRADE criteria. Where possible, data were represented in forest plots and pooled. We were unable to undertake a meta-analysis for comparisons and outcomes, so we used a structured synthesis approach. MAIN RESULTS We included four studies with a total of 912 CMC as participants. All included studies were randomised controlled trials conducted in hospitals in the USA or Canada. Participants varied across the included studies; however, all four studies included children with complex and chronic illness and high healthcare needs. While the primary aim of the intervention was similar across all four studies, the components of the interventions differed: in the four studies, the intervention involved some element of care coordination; in two of the studies, it involved the child receiving care from a multidisciplinary team, while in one study, the intervention was primarily centred on access to an advanced practice nurse care coordinator and another study involved nurse a practitioner-paediatrician dyad partnering with families. The risk of bias in the four studies varied across domains, with issues primarily relating to the lack of blinding of participants, personnel, and outcome assessors, inadequate allocation concealment, and incomplete outcome data. Comprehensive care for CMC compared to usual care may make little to no difference to child health, functioning, and quality of life at 12 or 24 months (three studies with 404 participants) and we assessed the evidence for the outcomes in this category (child health-related quality of life and functional status) as being of low certainty. For CMC, comprehensive care probably makes little or no difference to parent health, functioning, and quality of life compared to usual care at 12 months (one study with 117 participants) and we assessed the evidence for this outcome as being of moderate certainty. Comprehensive care for CMC compared to usual care may slightly improve child and family satisfaction with, and perceptions of, care and service delivery at 12 months (three studies with 453 participants); however, we assessed the evidence for these outcomes as being of low certainty. For CMC, comprehensive care probably makes little or no difference to the number of healthcare encounters (emergency department visits) and the number of hospitalised days (hospital admissions) compared to usual care at 12 months (three studies with 668 participants), and we assessed the evidence for these outcomes as being of moderate certainty. Three of the included studies (668 participants) reported cost outcomes and had conflicting results, with one study reporting significantly lower healthcare costs at 12 months in the intervention group compared to the control group, one reporting no differences between groups, and the other study reporting a greater increase in total healthcare costs in the intervention group compared to the control group. Overall, comprehensive care may make little or no difference to overall healthcare costs in CMC; however, the methods used to measure total healthcare costs varied across studies and the certainty of the evidence relating to this outcome is low. No studies assessed the costs to the family. AUTHORS' CONCLUSIONS The findings of this review should be treated with caution due to the limited amount and quality of the published research that was available to be included. Overall, the certainty of the evidence for the effectiveness of comprehensive care for CMC ranged from low to moderate across outcomes and there is currently insufficient evidence on which to draw strong conclusions. There is a need for more high-quality randomised trials with consistency of the target population and intervention components, methods of reporting outcomes, and follow-up periods, as well as full cost analyses, taking into account both costs to the family and costs to the healthcare system.
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Affiliation(s)
- Adrienne R Harvey
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Melbourne, Australia
| | - Elaine Meehan
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Melbourne, Australia
| | - Nicole Merrick
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Anita L D'Aprano
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Georgina R Cox
- Neurodevelopment and Disability, Royal Children's Hospital, Melbourne, Australia
| | - Katrina Williams
- Department of Paediatrics, Monash University, Melbourne, Australia
| | - Susan M Gibb
- Neurodevelopment and Disability, Royal Children's Hospital, Melbourne, Australia
| | - Nicki J Mountford
- Complex Care Hub, The Royal Children's Hospital, Melbourne, Australia
| | - Tom G Connell
- General Medicine, The Royal Children's Hospital, Melbourne, Australia
| | - Eyal Cohen
- Paediatrics and Health Policy, Management & Evaluation, University of Toronto, Toronto, Canada
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Bhoopathi V, Wells C, Tripicchio G, Tran NC. Association between more complex special care needs and overweight status and adolescents' difficulty with dental caries. J Public Health Dent 2024. [PMID: 38733308 DOI: 10.1111/jphd.12622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 03/12/2024] [Accepted: 04/25/2024] [Indexed: 05/13/2024]
Abstract
OBJECTIVE Little is known about dental caries experience in adolescents with overweight and complex special health care needs (SHCNs). METHODS Adolescent data (10-17 years) from the 2016-2020 National Survey of Children's Health (n = 91,196) was analyzed. The sample was grouped into the following: more complex SHCN and overweight, more complex SHCN without overweight, less complex SHCN and overweight, less complex SHCN without overweight, no SHCN but with overweight, and neither SHCN nor overweight. A multivariable-adjusted logistic regression model was conducted. RESULTS Adolescents with more complex SHCNs with (OR: 1.82, 95% CI: 1.44-2.30, p < 0.001) or without overweight (OR: 1.51, 95% CI: 1.30-1.76, p < 0.001) were at higher odds of experiencing dental caries compared to healthy adolescents. No significant associations were observed between adolescents with less complex or no SHCN regardless of the overweight status with healthy adolescents. CONCLUSIONS Adolescents with more complex SHCNs, irrespective of overweight status, experienced a higher caries severity than adolescents with no SHCNs or overweight.
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Affiliation(s)
- Vinodh Bhoopathi
- Section of Public and Population Oral Health, University of California at Los Angeles School of Dentistry, Los Angeles, California, USA
| | - Christine Wells
- Statistical Methods and Data Analytics, University of California at Los Angeles Office of Advanced Research Computing, Los Angeles, California, USA
| | - Gina Tripicchio
- Department of Social and Behavioral Sciences, Center for Obesity Research and Education, College of Public Health, Temple University, Philadelphia, Pennsylvania, USA
| | - Nini Chaichanasakul Tran
- Section of Pediatric Dentistry, University of California at Los Angeles School of Dentistry, Los Angeles, California, USA
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Harris KW, Ray KN, Yu J. Family Caregivers of Children With Medical Complexity: Changes in Health-Related Quality of Life and Experiences of Care Coordination. Acad Pediatr 2024; 24:605-612. [PMID: 38061581 PMCID: PMC11056298 DOI: 10.1016/j.acap.2023.11.023] [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: 05/24/2023] [Revised: 11/17/2023] [Accepted: 11/29/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVE Examine the longitudinal association between family experiences of care coordination (FECC) and health-related quality of life (HR-QOL) for family caregivers of children with medical complexity (CMC). METHODS A longitudinal survey of family caregivers of CMC was completed between July 2018 and June 2020. Baseline data were collected at initial contact with a regional complex care center; follow-up data were collected 12 to 16 months later. Assessed receipt of care coordination and caregiver HR-QOL via FECC questionnaire and Center for Disease Control's HR-QOL-14 measure, respectively. Baseline and follow-up results were compared via McNemar's and Wilcoxon signed-rank tests. Relationships between changes in FECC and changes in HR-QOL were examined using multivariable logistic regression. RESULTS Of 185 eligible, 136 caregivers enrolled and completed baseline surveys (74%) and 103 (76% initial sample) follow-up surveys. Caregivers reported significant improvements in 8 of 9 FECC measures after 1 year of care within a complex care center (all P < .05). In contrast, caregiver HR-QOL (general health status, unhealthy days, symptom days) remained stable over the study period (all P > .05) except for monthly days of poor sleep (baseline vs follow-up median; 16 vs 15 [P = .05]). At both timepoints, >20% participants rated their general health status as fair-to-poor, and >50% reported frequent poor sleep and fatigue. No significant associations were observed between changes in FECC and changes in HR-QOL. CONCLUSIONS After receiving 1 year of care through a complex care center, CMC family caregivers report improvement in care coordination but not in HR-QOL. Caregivers' continued mentally unhealthy days and negative mental symptom days highlight the need for a directed intervention.
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Affiliation(s)
- Kelly W Harris
- Division of Palliative Medicine and Supportive Care (KW Harris and J Yu), Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pa.
| | - Kristin N Ray
- Division of General Academic Pediatrics (KN Ray), Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pa.
| | - Justin Yu
- Division of Palliative Medicine and Supportive Care (KW Harris and J Yu), Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pa.
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Bruton L, Storey M, Gentile J, Smith TL, Bhatti P, Davis MM, Cartland J, Foster C. Access to Home- and Community-Based Services for Children with Disability: Academic Institutions' Role and Areas for Improvement. Acad Pediatr 2024; 24:596-604. [PMID: 37939827 PMCID: PMC11056305 DOI: 10.1016/j.acap.2023.11.002] [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: 04/19/2023] [Revised: 10/26/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE This project sought to describe provider- and parent-identified needs and barriers to obtaining home- and community-based services (HCBS) for children with disability (CWD) and to determine ways pediatric health care institutions can improve access to HCBS services. METHODS In this exploratory sequential mixed methods evaluation, semi-structured interviews and focus groups were conducted with multidisciplinary providers and staff from an independent children's hospital, followed by a survey of English and Spanish-speaking parents of CWD. Data from interviews and surveys were then triangulated for overarching common themes regarding how pediatric health care institutions can better support access to HCBS. RESULTS Among 382 parent respondents, 74.1% reported that their child needed a HCBS, most commonly physical/occupational/speech therapies, school-based support, and case management services. Two-thirds of parents reported at least one barrier to accessing HCBS and one-third experience >3 barriers. While multiple current institutional strengths were noted, internal weaknesses included lack of provider knowledge, staffing difficulties, and lack of protocols for identifying and tracking patients needing or receiving HCBS. External threats included requirements to entry for HCBS and transfer of care, with opportunities for improvement involving dissemination of information, funding support, and connection between providers/support staff and services. CONCLUSIONS Parents of CWD identified HCBS as necessary for the health of this population, but multiple barriers to HCBS were identified by both parents and providers. Multiple internal and external opportunities for improvement relative to pediatric health care institutions were identified, suggesting a need for a comprehensive approach to ensure that CWD receive necessary HCBS.
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Affiliation(s)
- Lucas Bruton
- Division of Advanced General Pediatrics and Primary Care (L Bruton, MM Davis, and C Foster), Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Ill; Department of Pediatrics (L Bruton, MM Davis, and C Foster), Northwestern University Feinberg School of Medicine, Chicago, Ill.
| | - Margaret Storey
- Ann and Robert H. Lurie Children's Hospital of Chicago Family Advisory Board (M Storey), Chicago, Ill
| | - Jennifer Gentile
- Tulane University School of Social Work (J Gentile), Tulane University, New Orleans, La
| | - Tracie L Smith
- Department of Data Analytics and Reporting (TL Smith), Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Punreet Bhatti
- Mary Ann and J. Milburn Smith Child Health Outcomes (P Bhatti, MM Davis, J Cartland, and C Foster), Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Matthew M Davis
- Division of Advanced General Pediatrics and Primary Care (L Bruton, MM Davis, and C Foster), Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Ill; Department of Pediatrics (L Bruton, MM Davis, and C Foster), Northwestern University Feinberg School of Medicine, Chicago, Ill; Mary Ann and J. Milburn Smith Child Health Outcomes (P Bhatti, MM Davis, J Cartland, and C Foster), Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill; Department of Medical Social Sciences (MM Davis), Northwestern University Feinberg School of Medicine, Chicago, Ill; Departments of Medicine and Preventive Medicine (MM Davis), Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Jenifer Cartland
- Mary Ann and J. Milburn Smith Child Health Outcomes (P Bhatti, MM Davis, J Cartland, and C Foster), Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Carolyn Foster
- Division of Advanced General Pediatrics and Primary Care (L Bruton, MM Davis, and C Foster), Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Ill; Department of Pediatrics (L Bruton, MM Davis, and C Foster), Northwestern University Feinberg School of Medicine, Chicago, Ill; Mary Ann and J. Milburn Smith Child Health Outcomes (P Bhatti, MM Davis, J Cartland, and C Foster), Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
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McLachlan LM, Engster S, Winger JG, Haupt A, Levin-Decanini T, Decker M, Noll RB, Yu JA. Self-Reported Well-Being of Family Caregivers of Children with Medical Complexity. Acad Pediatr 2024:S1876-2859(24)00145-1. [PMID: 38609015 DOI: 10.1016/j.acap.2024.04.002] [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: 11/08/2023] [Revised: 03/08/2024] [Accepted: 04/06/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE Provide an in-depth and psychometrically rigorous profile of the emotional well-being and sleep-related health of family caregivers of children with medical complexity (CMC). METHODS Cross-sectional survey study of family caregivers of CMC receiving care from a pediatric complex care center between May 2021 and March 2022. Patient Reported Outcomes Measurement Information System Short-Forms (PROMIS-SF) assessed global mental health, emotional distress (anxiety, depression, anger), psychological strengths (self-efficacy, emotional regulation, meaning and purpose), and sleep-related health (fatigue, sleep-related impairment). Student's t-tests compared the sample's mean T-scores to US population norms. Pearson's correlation coefficient (ρ) examined associations between measures of psychological strengths and emotional distress. Unadjusted linear regression analyses explored relationships between well-being outcomes and child and caregiver characteristics. RESULTS Compared to US population norms, caregivers of CMC (n = 143) reported significantly lower global mental health and emotional regulation ability as well as elevated symptoms of anxiety, depression, anger, fatigue, and sleep-related impairment (all P < .01). Whereas participants reported a significantly higher sense of meaning and purpose (P < .05), levels of self-efficacy were not significantly different from population norms. We observed moderate-to-strong inverse relationships between psychological strengths and emotional distress (ρ range, -0.39 to -0.69); with the strongest inverse associations found between emotional regulation ability and emotional distress. In exploratory analyses, caregiver race and ethnicity, socioeconomic status, and child health insurance type were significantly associated with caregiver well-being. CONCLUSION Family caregivers of CMC report poor well-being, most notably, increased symptoms of anxiety and reduced global mental health and sleep-related health.
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Affiliation(s)
| | - Stacey Engster
- Jose F. Alvarado and Associates (S Engster), Salisbury, Md
| | - Joseph G Winger
- Department of Psychiatry and Behavioral Sciences (JG Winger), Duke University School of Medicine, Durham, NC; Duke Cancer Institute (JG Winger), Duke University Health System, Durham, NC
| | - Alicia Haupt
- Complex Care Center (A Haupt and M Decker), UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa; Department of Pediatrics (A Haupt, M Decker, and RB Noll), University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Tal Levin-Decanini
- Complex Care Center (T Levin-Decanini), General Academic Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa
| | - Michael Decker
- Complex Care Center (A Haupt and M Decker), UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa; Department of Pediatrics (A Haupt, M Decker, and RB Noll), University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Robert B Noll
- Department of Pediatrics (A Haupt, M Decker, and RB Noll), University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Justin A Yu
- Divisions of Pediatric Supportive and Palliative Care and Hospital Medicine (JA Yu), University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa.
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Pérez-Ardanaz B, Gutiérrez-Rodríguez L, Pelaez-Cantero MJ, Morales-Asencio JM, Gómez-González A, García-Piñero JM, Lupiañez-Perez I. Healthcare service use for children with chronic complex diseases: A longitudinal six-year follow-up study. J Pediatr Nurs 2024:S0882-5963(24)00119-2. [PMID: 38594165 DOI: 10.1016/j.pedn.2024.04.001] [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: 01/19/2023] [Revised: 04/01/2024] [Accepted: 04/01/2024] [Indexed: 04/11/2024]
Abstract
PURPOSE The objective was analysed the patterns use of healthcare services of this population and the influence of their clinical and sociodemographic characteristics. DESIGN AND METHODS A six-year longitudinal follow-up study was performed to evaluate the annual healthcare resources use and clinical data among children with complex chronic diseases in Spain between 2015 and 2021. The sample trends in healthcare usage and the associated factors were analysed using ANCOVA and multivariable linear regression models. RESULTS Patients had high attendance during the follow-up period, with >15 episodes year. This trend decreased over time, especially in children with oncological diseases compared with other diseases (F (16.75; 825.4) = 32.457; p < 0.001). A multivariable model showed that children with a greater number of comorbidities (β = 0.17), shorter survival time (β = -0.23), who had contact with the palliative care unit (β = 0.16), and whose mothers had a higher professional occupation (β = 0.14), had a greater use of the healthcare system. CONCLUSIONS Children with a higher number of comorbidities and the use of medical devices made a greater frequentation of health services, showing a trend of decreasing use over time. Socioeconomic factors such as mothers' occupational status determine healthcare frequentation. These results suggest the existence of persistent gaps in care coordination sustained over time. PRACTICAL IMPLICATIONS Systematized and coordinated models of care for this population should consider the presence of inequalities in health care use.
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Affiliation(s)
- Bibiana Pérez-Ardanaz
- Universidad de Málaga, Faculty of Health Sciences, Department of Nursing, Spain; Instituto de Investigación Biomédica de Málaga-Bionand (IBIMA), Spain.
| | - Laura Gutiérrez-Rodríguez
- Universidad de Málaga, Faculty of Health Sciences, Department of Nursing, Spain; Instituto de Investigación Biomédica de Málaga-Bionand (IBIMA), Spain.
| | | | - José Miguel Morales-Asencio
- Universidad de Málaga, Faculty of Health Sciences, Department of Nursing, Spain; Instituto de Investigación Biomédica de Málaga-Bionand (IBIMA), Spain.
| | - Alberto Gómez-González
- Universidad de Málaga, Faculty of Health Sciences, Department of Nursing, Spain; Instituto de Investigación Biomédica de Málaga-Bionand (IBIMA), Spain.
| | - José Miguel García-Piñero
- Universidad de Málaga, Faculty of Health Sciences, Department of Nursing, Spain; Pediatric Intensive Care Unit, Hospital Materno-Infantil, Málaga, Spain
| | - Inmaculada Lupiañez-Perez
- Universidad de Málaga, Faculty of Health Sciences, Department of Nursing, Spain; Instituto de Investigación Biomédica de Málaga-Bionand (IBIMA), Spain.
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Avery M, Wolfe J, DeCourcey DD. Economic Hardship at the End of Life for Families of Children With Complex Chronic Conditions. J Pain Symptom Manage 2024; 67:e313-e319. [PMID: 38151216 DOI: 10.1016/j.jpainsymman.2023.12.014] [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: 10/10/2023] [Revised: 12/14/2023] [Accepted: 12/16/2023] [Indexed: 12/29/2023]
Abstract
CONTEXT Many children with complex chronic medical conditions (CCC), though living longer, die prematurely. Little is known about family economic hardship during end of life (EOL), nor associated differences in patterns of care. OBJECTIVES To describe the prevalence, experience, and characteristics of families of patients with CCC who report great economic hardship (GEH), and associations with end-of-life care patterns and suffering. METHODS We conducted a 183-item cross-sectional survey of bereaved parents of patients cared for at Boston Children's Hospital and chart reviews for each patient. Fifteen survey items on economic hardship related to financial and material hardships including food, housing, and utility insecurity. RESULTS A total of 114 bereaved parents completed the survey (54% response rate) and economic hardship data was analyzed for 105. Nearly a fifth reported GEH. This group was characterized by fewer two parent households. Children from families with GEH had spent more time hospitalized than those without GEH. CONCLUSION Economic burden on families of children with CCC correlates with higher health care utilization demonstrating the need for ameliorative resources and preventative measures.
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Affiliation(s)
- Madeline Avery
- Pediatric Palliative Care (M.V., J.W.), Department of Pediatrics, Massachusetts General Hospital, Boston Massachusetts, USA.
| | - Joanne Wolfe
- Pediatric Palliative Care (M.V., J.W.), Department of Pediatrics, Massachusetts General Hospital, Boston Massachusetts, USA
| | - Danielle D DeCourcey
- Division of Medical Critical Care (D.D.D.), Department of Pediatrics, Boston Children's Hospital, Boston Massachusetts, USA
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Wright SM, Zaniletti I, Goodwin EJ, Gupta RC, Larson IA, Winterer C, Hall M, Colvin JD. Income and Household Material Hardship in Children With Medical Complexity. Hosp Pediatr 2024; 14:e195-e200. [PMID: 38487829 DOI: 10.1542/hpeds.2023-007563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND AND OBJECTIVES Household economic hardship negatively impacts child health but may not be adequately captured by income. We sought to determine the prevalence of household material hardship (HMH), a measure of household economic hardship, and to examine the relationship between household poverty and material hardship in a population of children with medical complexity. METHODS We conducted a cross-sectional survey study of parents of children with medical complexity receiving primary care at a tertiary children's hospital. Our main predictor was household income as a percentage of the federal poverty limit (FPL): <50% FPL, 51% to 100% FPL, and >100% FPL. Our outcome was HMH measured as food, housing, and energy insecurity. We performed logistic regression models to calculate adjusted odds ratios of having ≥1 HMH, adjusted for patient and clinical characteristics from surveys and the Pediatric Health Information System. RESULTS At least 1 material hardship was present in 40.9% of participants and 28.2% of the highest FPL group. Families with incomes <50% FPL and 51% to 100% FPL had ∼75% higher odds of having ≥1 material hardship compared with those with >100% FPL (<50% FPL: odds ratio 1.74 [95% confidence interval: 1.11-2.73], P = .02; 51% to 100% FPL: 1.73 [95% confidence interval: 1.09-2.73], P = .02). CONCLUSIONS Poverty underestimated household economic hardship. Although households with incomes <100% FPL had higher odds of having ≥1 material hardship, one-quarter of families in the highest FPL group also had ≥1 material hardship.
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Affiliation(s)
- S Margaret Wright
- Division of General Academic Pediatrics, Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, University of Kansas School of Medicine, Kansas City, Missouri
| | | | - Emily J Goodwin
- Division of General Academic Pediatrics, Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, University of Kansas School of Medicine, Kansas City, Missouri
| | | | | | | | - Matt Hall
- Division of General Academic Pediatrics, Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, University of Kansas School of Medicine, Kansas City, Missouri
- Children's Hospital Association, Lenexa, Kansas
| | - Jeffrey D Colvin
- Division of General Academic Pediatrics, Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, University of Kansas School of Medicine, Kansas City, Missouri
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12
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Hess SM, Adu-Amankwah D, Elaiho CR, Butler LR, Ranade SC, Shah BJ, Shadman K, Fields R, Lin EP. Qualitative feedback from caregivers in a multidisciplinary pediatric neuromuscular clinic. J Pediatr Rehabil Med 2024:PRM230011. [PMID: 38427510 DOI: 10.3233/prm-230011] [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: 03/03/2024] Open
Abstract
PURPOSE This study explored family satisfaction and perceived quality of care in a pediatric neuromuscular care clinic to assess the value of the multidisciplinary clinic (MDC) model in delivering coordinated care to children with neuromuscular disorders, such as cerebral palsy. METHODS Caregivers of 22 patients were administered a qualitative survey assessing their perceptions of clinic efficiency, care coordination, and communication. Surveys were audio-recorded and transcribed. Thematic analysis was completed using both deductive and inductive methods. RESULTS All caregivers reported that providers adequately communicated next steps in the patient's care, and most reported high confidence in caring for the patient as a result of the clinic. Four major themes were identified from thematic analysis: Care Delivery, Communication, Care Quality, and Family-Centeredness. Caregivers emphasized that the MDC model promoted access to care, enhanced efficiency, promoted provider teamwork, and encouraged shared care planning. Caregivers also valued a physical environment that was suitable for patients with complex needs. CONCLUSION This study demonstrated that caregivers believed the MDC model was both efficient and convenient for pediatric patients with neuromuscular disorders. This model has the potential to streamline medical care and can be applied more broadly to improve care coordination for children with medical complexity.
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Affiliation(s)
- Skylar M Hess
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dorothy Adu-Amankwah
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Liam R Butler
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sheena C Ranade
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brijen J Shah
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kristin Shadman
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Robert Fields
- Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elaine P Lin
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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13
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Seltzer RR, Thompson BS. Pediatrician as Advocate and Protector: An Approach to Medical Neglect for Children with Medical Complexity. Pediatr Clin North Am 2024; 71:59-70. [PMID: 37973307 DOI: 10.1016/j.pcl.2023.08.006] [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] [Indexed: 11/19/2023]
Abstract
For children with medical complexity (CMC), gaps in medical care can result in significant harm. When concerns for medical neglect arise for CMC, pediatricians may experience ethical challenges in attempting to simultaneously avoid harm, promote well-being, respect family goals and values, and maintain a positive therapeutic relationship. This article proposes an ethics-guided approach to identifying and addressing underlying modifiable risk factors for medical neglect through collaboration with family caregivers and other stakeholders (eg, medical providers, school staff, and community resources). Pediatricians should recognize their critical role, beyond only as a mandated reporter, to be a mandated supporter.
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Affiliation(s)
- Rebecca R Seltzer
- Department of Pediatrics, Johns Hopkins School of Medicine; Johns Hopkins Berman Institute of Bioethics; Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health.
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14
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Kennedy HM, Cole A, Berbert L, Schenkel SR, DeGrazia M. An examination of characteristics, social supports, caregiver resilience and hospital readmissions of children with medical complexity. Child Care Health Dev 2024; 50:e13206. [PMID: 38123168 DOI: 10.1111/cch.13206] [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: 03/13/2023] [Revised: 08/18/2023] [Accepted: 11/19/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Children with medical complexity (CMC) account for 1% of children in the United States. These children experience frequent hospital readmissions, high healthcare costs and poor health outcomes. A link between CMC caregiver social support, resilience and hospital readmissions has never been fully investigated. This study examines the feasibility of a prospective, descriptive, repeated measures research design to characterize CMC and their caregivers, social supports, caregiver resilience and hospital readmissions to inform a larger prospective investigation. METHODS Caregivers of CMC with unplanned hospitalizations completed surveys at the index hospitalization and 30 and 60 days after discharge. CMC caregiver and child characteristics, social supports and hospital readmissions were examined using an investigator-developed survey. Resilience was measured using the Resilience Scale-14© (7-Point Likert Scale, score range 14-98), and feasibility was measured by calculating enrolment, attrition, survey completion and item response. Analysis included descriptive statistics and qualitative data visualization. RESULTS Of caregivers who were approached for participation, 81.1% consented and completed 76 surveys. Attrition was 31%. Item response rates were ≥ 90% for all but one item. A total of 62.1% of children had hospital readmissions within 90 days and 37.9% within 30 days. Additionally, 70% of caregivers had home care nursing, but the approved hours were only partially filled. More than 70% of caregiver resilience scores were moderate to high (score range 74-98) and were stable across repeated measures and hospital readmissions. Open-ended question responses revealed the following five categories: All-consuming, Family Reliance, Impact of Covid, Taking Action and Broken System. CONCLUSIONS Studying CMC caregiver social supports and resilience using repeated measures is feasible. CMC caregivers reported stressors including coordinating their child's substantial healthcare needs and managing partially filled home care nursing hours. Caregiver resilience remained stable over time, amidst frequent CMC hospital readmissions. Findings can inform future research priorities and power analyses for CMC caregiver resilience.
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Affiliation(s)
- Heather M Kennedy
- Department of Nursing Patient Care Services, Boston Children's Hospital, Boston, MA, USA
- Department of Neurology and Neurosurgery, Boston Children's Hospital, Boston, MA
| | - Alexandra Cole
- Cardiovascular and Critical Care Services, Boston Children's Hospital, Boston, MA, USA
| | - Laura Berbert
- Biostatistics and Research Design Center, Boston Children's Hospital, Boston, MA, USA
| | | | - Michele DeGrazia
- Department of Nursing Patient Care Services, Boston Children's Hospital, Boston, MA, USA
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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15
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Houlihan BV, Ethier E, Veerakone R, Eaves M, Turchi R, Louis CJ, Comeau M. Trauma-Informed Leadership in Quality Improvement: What We Learned From Practicing in a Pandemic. Pediatrics 2024; 153:e2023063424G. [PMID: 38165240 DOI: 10.1542/peds.2023-063424g] [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] [Accepted: 10/25/2023] [Indexed: 01/03/2024] Open
Abstract
In 2020, midway through the Collaborative Improvement and Innovation Network to Advance Care for Children with Medical Complexity project, the coronavirus disease 2019 pandemic erupted and caused significant disruptions for the 10 participating state teams, the project leadership, and collaborative partner organizations. Clinics shut down for in-person care, a scramble ensued to quickly leverage telehealth to fill the gap, and the trauma caused by anxiety, isolation, and exhaustion affected the health and wellbeing of children, families, and clinicians alike. We conducted a series of key informant interviews and surveys, alongside other process measures, to learn from state teams what it was like "on the ground" to try to continue improving care delivery, child quality of life, and family wellbeing under such upheaval. In this article, we synthesize qualitative and descriptive findings from these varied data sources within the framework of the trauma-informed principles we applied as a leadership team to prevent burnout, increase resilience, and maintain progress among all project participants, especially clinicians and the uniquely vulnerable family leaders. Lessons learned will be offered that can be applied to future natural and human-made emergencies that impact responsive pediatric care delivery improvement.
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Affiliation(s)
- Bethlyn Vergo Houlihan
- Boston University School of Social Work, Center for Innovation in Social Work & Health, Boston, Massachusetts
| | - Elizabeth Ethier
- Boston University School of Social Work, Center for Innovation in Social Work & Health, Boston, Massachusetts
| | - Rubina Veerakone
- Boston University School of Social Work, Center for Innovation in Social Work & Health, Boston, Massachusetts
| | - Megan Eaves
- Boston University School of Social Work, Center for Innovation in Social Work & Health, Boston, Massachusetts
| | - Renee Turchi
- St Christopher's Hospital for Children & Drexel University, Philadelphia, Pennsylvania
| | | | - Meg Comeau
- Boston University School of Social Work, Center for Innovation in Social Work & Health, Boston, Massachusetts
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16
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Nageswaran S, Dailey-Farley H, Golden SL. Telehealth for Children With Medical Complexity During the COVID Pandemic: A Qualitative Study Exploring Caregiver Experiences. Clin Pediatr (Phila) 2024; 63:53-65. [PMID: 37840305 DOI: 10.1177/00099228231204707] [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] [Indexed: 10/17/2023]
Abstract
Children with medical complexity (CMC) receive care from many clinicians. Our objective is to describe caregivers' experiences about telehealth for CMC. This qualitative study conducted in North Carolina involves semistructured interviews with 23 caregivers of CMC (15 English; 8 Spanish). Data were analyzed using thematic content analysis. Five themes were identified: (1) telehealth allayed caregivers' fears about their children's exposure to COVID-19 and mitigated the challenges with in-person visits during the pandemic. (2) Telehealth reduced the logistical challenges of in-person visits for CMC, enabled providers to see children in their home environment, and prevented appointment cancelations. (3) System inaccessibility, technical problems, and providers' inability to deliver telehealth were challenges. (4) Inadequate evaluation of the child and caregiver-provider communication were limitations. (5) Caregivers were satisfied with telehealth, found variability in telehealth offering, and wished telehealth continued to remain an option. Telehealth is a viable option for outpatient care delivery for CMC.
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Affiliation(s)
- Savithri Nageswaran
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Social Sciences & Health Policy, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Heather Dailey-Farley
- Department of Social Sciences & Health Policy, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Vasan A, Kyle MA, Venkataramani AS, Kenyon CC, Fiks AG. Inequities in Time Spent Coordinating Care for Children and Youth With Special Health Care Needs. Acad Pediatr 2023; 23:1526-1534. [PMID: 36918094 PMCID: PMC10495536 DOI: 10.1016/j.acap.2023.03.002] [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: 11/18/2022] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVE In the United States, caregivers of children and youth with special health care needs (CYSHCN) must navigate complex, inefficient health care and insurance systems to access medical care. We assessed for sociodemographic inequities in time spent coordinating care for CYSHCN and examined the association between time spent coordinating care and forgone medical care. METHODS This cross-sectional study used data from the 2018-2020 National Survey of Children's Health, which included 102,740 children across all 50 states. We described the time spent coordinating care for children with less complex special health care needs (SHCN) (managed through medications) and more complex SHCN (resulting in functional limitations or requiring specialized therapies). We examined race-, ethnicity-, income-, and insurance-based differences in time spent coordinating care among CYSHCN and used multivariable logistic regression to examine the association between time spent coordinating care and forgone medical care. RESULTS Over 40% of caregivers of children with more complex SHCN reported spending time coordinating their children's care each week. CYSHCN whose caregivers spent ≥ 5 h/wk on care coordination were disproportionately Hispanic, low-income, and publicly insured or uninsured. Increased time spent coordinating care was associated with an increasing probability of forgone medical care: 6.7% for children whose caregivers spent no weekly time coordinating care versus 9.4% for< 1 hour; 11.4% for 1 to 4 hours; and 15.8% for ≥ 5 hours. CONCLUSIONS Reducing time spent coordinating care and providing additional support to low-income and minoritized caregivers may be beneficial for pediatric payers, policymakers, and health systems aiming to promote equitable access to health care for CYSHCN.
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Affiliation(s)
- Aditi Vasan
- Department of Pediatrics (A Vasan, CC Kenyon, and AG Fiks), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; PolicyLab and Center for Pediatric Clinical Effectiveness (A Vasan, CC Kenyon, and AG Fiks), Children's Hospital of Philadelphia, Pa; Leonard Davis Institute of Health Economics (A Vasan, AS Venkataramani, CC Kenyon, and AG Fiks), University of Pennsylvania, Philadelphia, Pa.
| | - Michael Anne Kyle
- Department of Health Care Policy (MA Kyle), Harvard Medical School and Dana Farber Cancer Institute, Boston, Mass.
| | - Atheendar S Venkataramani
- Leonard Davis Institute of Health Economics (A Vasan, AS Venkataramani, CC Kenyon, and AG Fiks), University of Pennsylvania, Philadelphia, Pa; Department of Medical Ethics and Health Policy (AS Venkataramani), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Calif.
| | - Chén C Kenyon
- Department of Pediatrics (A Vasan, CC Kenyon, and AG Fiks), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; PolicyLab and Center for Pediatric Clinical Effectiveness (A Vasan, CC Kenyon, and AG Fiks), Children's Hospital of Philadelphia, Pa; Leonard Davis Institute of Health Economics (A Vasan, AS Venkataramani, CC Kenyon, and AG Fiks), University of Pennsylvania, Philadelphia, Pa.
| | - Alexander G Fiks
- Department of Pediatrics (A Vasan, CC Kenyon, and AG Fiks), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; PolicyLab and Center for Pediatric Clinical Effectiveness (A Vasan, CC Kenyon, and AG Fiks), Children's Hospital of Philadelphia, Pa; Leonard Davis Institute of Health Economics (A Vasan, AS Venkataramani, CC Kenyon, and AG Fiks), University of Pennsylvania, Philadelphia, Pa.
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18
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Austin AM, Schaefer AP, Arakelyan M, Freyleue SD, Goodman DC, Leyenaar JK. Specialties Providing Ambulatory Care and Associated Health Care Utilization and Quality for Children With Medical Complexity. Acad Pediatr 2023; 23:1542-1552. [PMID: 37468062 PMCID: PMC10792122 DOI: 10.1016/j.acap.2023.07.002] [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: 03/20/2023] [Revised: 06/30/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE Although children with medical complexity (CMC) have substantial health care needs, the extent to which they receive ambulatory care from primary care versus specialist clinicians is unknown. We aimed to determine the predominant specialty providing ambulatory care to CMC (primary care or specialty discipline), the extent to which specialists deliver well-child care, and associations between having a specialty predominant provider and health care utilization and quality. METHODS In a retrospective cohort analysis of 2012-17 all-payer claims data from Colorado, New Hampshire, and Massachusetts, we identified the predominant specialty providing ambulatory care for CMC <18 years. Propensity score weighting was used to create a balanced sample of CMC and assess differences in outcomes, including adequate well-child care, continuity of care, emergency visits, and hospitalizations, between CMC with a primary care versus specialty predominant provider. RESULTS Among 67,218 CMC, 75.3% (n = 50,584) received the plurality of care from a primary care discipline. Body system involvement, age > 2 years, urban residence, and cooccurring disabilities were associated with predominantly receiving care from specialists. After propensity score weighting, there were no significant differences between CMC with a primary care or specialist "predominant specialty seen" (PSS) in ambulatory visit counts, adequate well-child care, hospitalizations, or overall continuity of care. Specialists were the sole providers of well-child care and vaccines for 49.9% and 53.1% of CMC with a specialist PSS. CONCLUSIONS Most CMC received the plurality of care from primary care disciplines, and there were no substantial differences in overall utilization or quality based on the PSS.
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Affiliation(s)
- Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice (AM Austin, AP Schaefer, SD Freyleue, D Goodman, and JK Leyenaar), Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Andrew P Schaefer
- The Dartmouth Institute for Health Policy and Clinical Practice (AM Austin, AP Schaefer, SD Freyleue, D Goodman, and JK Leyenaar), Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Mary Arakelyan
- Department of Pediatrics (M Arakelyan and JK Leyenaar), Dartmouth Health Children's, Lebanon, NH
| | - Seneca D Freyleue
- The Dartmouth Institute for Health Policy and Clinical Practice (AM Austin, AP Schaefer, SD Freyleue, D Goodman, and JK Leyenaar), Geisel School of Medicine at Dartmouth, Hanover, NH
| | - David C Goodman
- The Dartmouth Institute for Health Policy and Clinical Practice (AM Austin, AP Schaefer, SD Freyleue, D Goodman, and JK Leyenaar), Geisel School of Medicine at Dartmouth, Hanover, NH
| | - JoAnna K Leyenaar
- The Dartmouth Institute for Health Policy and Clinical Practice (AM Austin, AP Schaefer, SD Freyleue, D Goodman, and JK Leyenaar), Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Pediatrics (M Arakelyan and JK Leyenaar), Dartmouth Health Children's, Lebanon, NH.
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Narayanan AM, Dabbous H, St John R, Kou YF, Johnson RF, Chorney SR. Pediatric tracheostomy audiometric outcomes - A quality improvement initiative. Int J Pediatr Otorhinolaryngol 2023; 173:111694. [PMID: 37625278 DOI: 10.1016/j.ijporl.2023.111694] [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: 05/05/2023] [Revised: 06/29/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVE Pediatric tracheostomy patients disproportionately experience hearing loss and are at risk for delayed identification due to their medical complexity. Nonetheless, protocols to monitor hearing in these children are lacking. This quality improvement (QI) initiative aimed to increase the rates of audiometric testing within 12 months of pediatric tracheostomy placement. METHODS A retrospective cohort study included children who underwent tracheostomy under 18 months of age between 2012 and 2020. Rates of audiometric assessments before and after QI project implementation (2015) were reported along with hearing loss characteristics. RESULTS A total of 253 children met inclusion. Before project initiation (2012-2014), 32% of children (28/87) obtained audiometric testing within 12 months after tracheostomy. During the first three years of implementation (2015-2017), 39% (38/97) were tested, while 55% (38/69) were tested during the subsequent three years (2018-2020) (P = .01). A passing newborn hearing screen was obtained for 70% of the 210 children with a recorded result, and 198 survived at least 12 months to receive audiometric testing at a median of 11.3 months (IQR: 6.2-22.8) after tracheostomy. Hearing loss was identified for 44% of children (N = 88), of which 42 children initially passed newborn hearing screen. A second assessment was obtained for 62% of children (123/198) at a median of 11.3 months (IQR: 4.5-17.5) after the initial test. In this group, 23% with a previously normal audiometric exam were found to have hearing loss (15/66). CONCLUSIONS QI initiatives designed to monitor hearing loss in children with a tracheostomy can result in improved rates of audiometric assessments. This population has disproportionately high rates of hearing loss, including delayed onset hearing loss making audiometric protocols valuable to address speech and language development delays.
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Affiliation(s)
- Ajay M Narayanan
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Helene Dabbous
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rachel St John
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, TX, USA
| | - Yann-Fuu Kou
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, TX, USA
| | - Romaine F Johnson
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, TX, USA
| | - Stephen R Chorney
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, TX, USA.
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McLorie EV, Fraser L, Hackett J. Provision of care for children with medical complexity in tertiary hospitals in England: qualitative interviews with health professionals. BMJ Paediatr Open 2023; 7:e001932. [PMID: 37451703 PMCID: PMC10351257 DOI: 10.1136/bmjpo-2023-001932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/28/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Due to medical and technological advancements, children with medical complexity are a growing population. Although previous research has identified models of care and experiences when caring for this population, the majority are the USA or Canadian based. Therefore, the aim was to identify models of care for children with medical complexity and barriers and facilitators to delivering high-quality care for this population from a 'free at point of care' national health service. METHOD Qualitative semistructured interviews were conducted with hospital clinicians across England and analysed using a thematic framework approach. RESULTS Thirty-seven clinicians from 11 hospital sites were interviewed. In 6 of the hospital sites, there were 14 services identified. Majority of services had a variety of components, some shared and some unique to the individual service. Clinicians faced barriers and facilitators when caring for this population as demonstrated across five categories. CONCLUSIONS There is limited guidance and evidence on the most effective and efficient models for providing care for this population. It is not possible to determine what a service should look like as there is no consensus on the most appropriate model of care as shown in this study. Due to their complex needs, this population require coordination to ensure high standards of care. However, this was not always possible as clinicians faced barriers such as time constraints, silo thinking and a lack of available housing.
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Curfman AL, Haycraft M, McSwain SD, Dooley M, Simpson KN. Implementation and Evaluation of a Wraparound Virtual Care Program for Children with Medical Complexity. Telemed J E Health 2023; 29:947-953. [PMID: 36355064 PMCID: PMC10277989 DOI: 10.1089/tmj.2022.0344] [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: 08/11/2022] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 11/11/2022] Open
Abstract
Objectives: Children and adolescents with medical complexity benefit from care coordination and specialized pediatric care, but many access barriers exist. We implemented a virtual wraparound model to support patients with medical complexity and their families and used an economic framework to measure outcomes. Methods: Children with medical complexity were identified and enrolled in a virtual complex care program with a dedicated multidisciplinary team, which provided care coordination, education, parental support, acute care triage, and virtual visits. A retrospective pre- and postanalysis of data obtained from the Hospital Industry Data Institute (HIDI) database measured inpatient, outpatient, and emergency department (ED) utilization and charges before implementation and during the 2-year program. Results: Eighty (n = 80) children were included in the economic evaluation, and 75 had sufficient data for analysis. Compared to the 12 months before enrollment, patients had a 35.3% reduction in hospitalizations (p = 0.0268), a 43.9% reduction in emergency visits (p = 0.0005), and a 16.9% reduction in overall charges (p = 0.1449). Parents expressed a high degree of satisfaction, with a 70% response rate and 90% satisfaction rate. Conclusions: We implemented a virtual care model to provide in-home support and care coordination for medically complex children and adolescents and used an economic framework to assess changes in utilization and cost. The program had high engagement rates and parent satisfaction, and a pre/postanalysis demonstrated statistically significant reduction in hospitalizations and ED visits for this high-cost population. Further economic evaluation is needed to determine sustainability of this model in a value-based payment system.
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Affiliation(s)
- Alison L. Curfman
- Mercy Clinic Department of Pediatrics, St. Louis, Missouri, USA
- Imagine Pediatrics, Nashville, Tennessee, USA
| | | | - S. David McSwain
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Mary Dooley
- Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kit N. Simpson
- Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina, USA
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22
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Hu JC, Cummings JR, Ji X, Wilk AS. Evaluating Medicaid Managed Care Network Adequacy Standards And Associations With Specialty Care Access For Children. Health Aff (Millwood) 2023; 42:759-769. [PMID: 37276470 PMCID: PMC10706697 DOI: 10.1377/hlthaff.2022.01439] [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: 06/07/2023]
Abstract
Medicaid managed care plans cover more than 80 percent of Medicaid-enrolled children, including many children with special health care needs (CSHCN). Federal rules require states to set network adequacy standards to improve specialty care access for Medicaid managed care enrollees. Using a quasi-experimental design and 2016-19 National Survey of Children's Health data, we examined the association between quantitative network adequacy standards and access to specialty care among 8,614 Medicaid-enrolled children, including 3,157 with special health care needs, in eighteen states. Outcomes included whether the child had any visit to non-mental health specialists, any visit to mental health professionals, or any unmet health care needs and whether the caregiver ever felt frustrated in getting services for the child in the past year. We observed no association between the adoption of any quantitative network adequacy standard and the above outcomes among Medicaid-enrolled children. Among CSHCN, however, adopting any quantitative standard was positively associated with caregivers feeling frustrated in getting services for the child, especially among CSHCN who visited non-mental health specialists. Without additional interventions, adopting new network adequacy standards may have unintended consequences for CSHCN.
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Affiliation(s)
- Ju-Chen Hu
- Ju-Chen Hu , Emory University, Atlanta, Georgia
| | | | - Xu Ji
- Xu Ji, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
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23
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Sinha A, Rubin S, Jarvis JM. Promoting Functional Recovery in Critically Ill Children. Pediatr Clin North Am 2023; 70:399-413. [PMID: 37121633 PMCID: PMC11113330 DOI: 10.1016/j.pcl.2023.01.008] [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] [Indexed: 05/02/2023]
Abstract
Over two-thirds of pediatric critical illness survivors will experience functional impairments that persist after discharge, that is, post-intensive care syndrome in pediatrics (PICS-p). Risk factors include child and family characteristics, invasive procedures, and social determinants of health. Approaches to remediate PICS-p include early rehabilitation, minimizing sedation, psychosocial resources for caregivers, delivery of family-centered care, and longitudinal screening for PICS-p. Challenges include feasible and validated approaches to screening, and resources and coordination for multidisciplinary care. Next steps should include resources to identify and address adverse social determinants of health and examination of treatment efficacy and implementation equity.
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Affiliation(s)
- Amit Sinha
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, 3471 Fifth Avenue, Suite 910, Pittsburgh, PA 15213, USA
| | - Sarah Rubin
- Department of Critical Care Medicine, University of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 2nd Floor, Pittsburgh, PA 15224, USA
| | - Jessica M Jarvis
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, 3471 Fifth Avenue, Suite 910, Pittsburgh, PA 15213, USA.
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24
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Teicher J, Moore C, Esser K, Weiser N, Arje D, Cohen E, Orkin J. The Experience of Parental Caregiving for Children With Medical Complexity. Clin Pediatr (Phila) 2023; 62:633-644. [PMID: 36475307 PMCID: PMC10676025 DOI: 10.1177/00099228221142102] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Children with medical complexity (CMC) have complex chronic conditions with significant functional impairment, contributing to high caregiving demand. This study seeks to explore impacts of parental caregiving for CMC. Fifteen caregivers of CMC followed at a tertiary care hospital participated in semi-structured interviews. Interviews were concurrently analyzed using a qualitative description framework until thematic saturation was reached. Codes were grouped by shared concepts to clarify emergent findings. Four affected domains of parental caregiver experience with associated subthemes (in parentheses) were identified: personal (identity, physical health, mental health), family (marriage, siblings, family quality of life), social (time limitations, isolating lived experience), and financial (employment, medical costs, accessibility costs). Despite substantial challenges, caregivers identified two core determinants of personal resilience: others' support (hands-on, interpersonal, informational, material) and a positive outlook (self-efficacy, self-compassion, reframing expectations). Further research is needed to understand the unique needs and strengths of caregivers for this vulnerable population.
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Affiliation(s)
- Jessica Teicher
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Clara Moore
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, SickKids Research Institute, Toronto, ON, Canada
| | - Kayla Esser
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, SickKids Research Institute, Toronto, ON, Canada
| | - Natalie Weiser
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, SickKids Research Institute, Toronto, ON, Canada
| | - Danielle Arje
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, SickKids Research Institute, Toronto, ON, Canada
| | - Eyal Cohen
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, SickKids Research Institute, Toronto, ON, Canada
- Division of Paediatric Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
- Edwin S.H. Leong Centre for Healthy Children, Toronto, ON, Canada
| | - Julia Orkin
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, SickKids Research Institute, Toronto, ON, Canada
- Division of Paediatric Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
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25
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Boerner KE, Pearl-Dowler L, Holsti L, Wharton MN, Siden H, Oberlander TF. Family Perspectives on In-Home Multimodal Longitudinal Data Collection for Children Who Function Across the Developmental Spectrum. J Dev Behav Pediatr 2023; 44:e284-e291. [PMID: 37074803 PMCID: PMC10150630 DOI: 10.1097/dbp.0000000000001183] [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: 10/11/2022] [Accepted: 03/07/2023] [Indexed: 04/20/2023]
Abstract
OBJECTIVE Quality child health research requires multimodal, multi-informant, longitudinal tools for data collection to ensure a holistic description of real-world health, function, and well-being. Although advances have been made, the design of these tools has not typically included community input from families with children whose function spans the developmental spectrum. METHODS We conducted 24 interviews to understand how children, youth, and their families think about in-home longitudinal data collection. We used examples of smartphone-based Ecological Momentary Assessment of everyday experiences, activity monitoring with an accelerometer, and salivary stress biomarker sampling to help elicit responses. The children and youth who were included had a range of conditions and experiences, including complex pain, autism spectrum disorder, cerebral palsy, and severe neurologic impairments. Data were analyzed using reflexive thematic analysis and descriptive statistics of quantifiable results. RESULTS Families described (1) the importance of flexibility and customization within the data collection process, (2) the opportunity for a reciprocal relationship with the research team; families inform the research priorities and the development of the protocol and also benefit from data being fed back to them, and (3) the possibility that this research approach would increase equity by offering accessible participation opportunities for families who might otherwise not be represented. Most families expressed interest in participating in in-home research opportunities, would find most methods discussed acceptable, and cited 2 weeks of data collection as feasible. CONCLUSION Families described diverse areas of complexity that necessitate thoughtful adaptations to traditional research designs. There was considerable interest from families in active engagement in this process, particularly if they could benefit from data sharing. This feedback is being incorporated into pilot demonstration projects to iteratively codesign an accessible research platform.
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Affiliation(s)
- Katelynn E. Boerner
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Leora Pearl-Dowler
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Liisa Holsti
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- BC Women's Hospital Research Institute, Vancouver, BC, Canada
- Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, BC, Canada
| | - Marie-Noelle Wharton
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Harold Siden
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
- Canuck Place Children's Hospice, Vancouver, BC, Canada; and
| | - Tim F. Oberlander
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, and BC Children's Hospital Research Institute, Vancouver, BC, Canada
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26
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Chiang JA, Tran T, Swami S, Shin E, Nussbaum N, DeLeon R, Hermann BP, Clarke D, Schraegle WA. Neighborhood disadvantage and health-related quality of life in pediatric epilepsy. Epilepsy Behav 2023; 142:109171. [PMID: 36989568 DOI: 10.1016/j.yebeh.2023.109171] [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: 12/12/2022] [Revised: 03/04/2023] [Accepted: 03/05/2023] [Indexed: 03/31/2023]
Abstract
INTRODUCTION While several demographic and epilepsy-specific characteristics are associated with diminished HRQoL in children and adolescents with epilepsy, prior investigations have failed to incorporate and address the influence of broader social contextual factors on functional outcomes. To address this gap, the purpose of the current study was to investigate the role of neighborhood disadvantage on HRQoL, including the extent to which familial and seizure-specific risk factors are impacted. METHODS Data included parental ratings on the Quality of Life in Childhood Epilepsy (QOLCE) questionnaire for 135 children and adolescents with epilepsy, and the Area Deprivation Index (ADI) to measure neighborhood disadvantage. Bivariate correlations were conducted to identify significant associations with neighborhood disadvantage, followed by a three-stage hierarchical multiple regression to predict HRQoL. Follow-up binary logistic regressions were used to determine the risk conferred by neighborhood disadvantage on sociodemographic, seizure-specific, and HRQoL factors. RESULTS Moderate associations between neighborhood disadvantage and familial factors, including parental psychiatric history and Medicaid insurance, were identified, while disadvantage and greater seizure frequency were marginally associated. Neighborhood disadvantage independently predicted HRQoL, and was the sole significant predictor of HRQoL when familial factors were incorporated. Children with epilepsy living in disadvantaged areas were four times more likely to have diminished HRQoL, five times more likely to live with a parent with a significant psychiatric history, and four times more likely to reside with a family receiving Medicaid insurance. CONCLUSIONS These results highlight the importance of identifying high-risk groups, as the cumulative burden of social context, familial factors, and seizure-specific characteristics contribute to lower HRQoL in pediatric epilepsy which disproportionately affects patients from lower-resourced backgrounds. Potentially modifiable factors such as parental psychiatric status exist within the child's environment, emphasizing the importance of a whole-child approach to patient care. Further exploration of disadvantage in this population is needed to better understand these relationships over time.
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Affiliation(s)
- Jenna A Chiang
- Department of Neurology, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Thomas Tran
- Comprehensive Pediatric Epilepsy Center, Dell Children's Medical Center, Austin, TX, USA
| | - Sonya Swami
- Comprehensive Pediatric Epilepsy Center, Dell Children's Medical Center, Austin, TX, USA
| | - Elice Shin
- Comprehensive Pediatric Epilepsy Center, Dell Children's Medical Center, Austin, TX, USA
| | - Nancy Nussbaum
- Department of Neurology, Dell Medical School, University of Texas at Austin, Austin, TX, USA; Comprehensive Pediatric Epilepsy Center, Dell Children's Medical Center, Austin, TX, USA
| | - Rosario DeLeon
- Department of Neurology, Dell Medical School, University of Texas at Austin, Austin, TX, USA; Comprehensive Pediatric Epilepsy Center, Dell Children's Medical Center, Austin, TX, USA; Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Bruce P Hermann
- Department of Neurology, University of Wisconsin, School of Medicine and Public Health, USA
| | - Dave Clarke
- Department of Neurology, Dell Medical School, University of Texas at Austin, Austin, TX, USA; Comprehensive Pediatric Epilepsy Center, Dell Children's Medical Center, Austin, TX, USA; Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, TX, USA; Department of Neurosurgery, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - William A Schraegle
- Department of Neurology, Dell Medical School, University of Texas at Austin, Austin, TX, USA; Comprehensive Pediatric Epilepsy Center, Dell Children's Medical Center, Austin, TX, USA; Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, TX, USA.
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27
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Gigli KH, Graaf G. Changes in Use and Access to Care for Children and Youth With Special Health Care Needs During the COVID-19 Pandemic. J Pediatr Health Care 2023; 37:185-192. [PMID: 36216644 PMCID: PMC9489986 DOI: 10.1016/j.pedhc.2022.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/18/2022] [Indexed: 12/02/2022]
Abstract
INTRODUCTION Children and youth with special health care needs (CYSHCN) are vulnerable to health care disruption, and policies were adopted to mitigate COVID-19-related disruptions. We compare CYSHCN use of and access to care in 2019 to 2020. METHOD Using the National Survey of Children's Health, we identified CYSHCN and assessed differences in health care use, unmet health care needs, frustrations accessing care, and barriers to care using multivariable logistic regression analysis. RESULTS The final sample included 17,065 CYSHCN. In the fully adjusted analysis, there was a significant decrease in odds of accessing preventive dental care (adjusted odds ratio [AOR], 0.63; 95%confidence interval [CI], 0.51-0.77) and increased odds of unmet mental health care needs (AOR,1.34; 95% CI, 1.02-1.77). The inability to obtain an appointment was a barrier that increased during the study period (AOR, 2.77; 95% CI, 1.71-4.46). DISCUSSION Novel pandemic related policies may have mitigated negative impacts on health care access for CYSHCN.
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Affiliation(s)
- Kristin Hittle Gigli
- Kristin Hittle Gigli, Assistant Professor, College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX..
| | - Genevieve Graaf
- Genevieve Graaf, Assistant Professor, School of Social Work, University of Texas at Arlington, Arlington, TX
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28
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Ramgopal S, Goodman DM, Kan K, Smith T, Foster CC. Children With Medical Complexity and Mental and Behavioral Disorders in the Emergency Department. Hosp Pediatr 2023; 13:9-16. [PMID: 36472088 PMCID: PMC10719868 DOI: 10.1542/hpeds.2022-006835] [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: 12/12/2022]
Abstract
BACKGROUND To assess the overlap and admission or transfer rate of children with chronic complex conditions (CCC) and with mental or behavioral health (MBH) disorders among children presenting to the emergency department (ED). METHODS We performed a cross-sectional analysis from 2 data sources: hospitals in the Pediatric Health Information System (PHIS) and from a statewide sample (Illinois COMPdata). We included ED encounters 2 to 21 years and compared differences in admission and/or transfer between subgroups. Among patients with both a CCC and MBH, we evaluated if a primary MBH diagnosis was associated with admission or transfer. RESULTS There were 11 880 930 encounters in the PHIS dataset; 0.7% had an MBH and CCC, 2.2% had an MBH, and 8.0% had a CCC. Patients with an MBH and CCC had a greater need for admission or transfer (86.5%) compared with patients with an MBH alone (57.7%) or CCC alone (52.0%). Among 5 362 701 patients in the COMPdata set, 0.2% had an MBH and CCC, 2.1% had an MBH, and 3.2% had a CCC, with similar admission or transfer needs between groups (61.8% admission or transfer with CCC and MBH; 42.8% MBH alone, and 27.3% with CCC alone). Within both datasets, patients with both a MBH and CCC had a higher odds of admission or transfer when their primary diagnosis was an MBH disorder. CONCLUSIONS While accounting for a small proportion of ED patients, CCC with concomitant MBH have a higher need for admission or transfer relative to other patients.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Denise M. Goodman
- Division of Pediatric Critical Care, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kristin Kan
- Division of Advanced General Pediatrics and Primary Care, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Mary Ann and J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center
| | - Tracie Smith
- Population Health Analytics, Division of Data Analytics and Reporting, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Carolyn C. Foster
- Division of Advanced General Pediatrics and Primary Care, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Mary Ann and J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center
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29
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Rush M, Khan A, Barber J, Bloom M, Anspacher M, Fratantoni K, Parikh K. Length of Stay and Barriers to Discharge for Technology-Dependent Children During the COVID-19 Pandemic. Hosp Pediatr 2023; 13:80-87. [PMID: 36519266 PMCID: PMC9808615 DOI: 10.1542/hpeds.2021-006506] [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: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVE During the coronavirus disease 2019 pandemic, technology-dependent children are at risk of encountering barriers to hospital discharge because of limits to in-home services. Transition difficulties could increase length of stay (LOS). With this study, we aim to (1) evaluate change in LOS and (2) describe barriers to hospital discharge between prepandemic and early pandemic periods for technology-dependent children. METHODS A retrospective chart review of technology-dependent children discharged from an acute and specialty pediatric hospital within a single urban area between January 1 and May 28, 2020 was conducted. Technology dependence was defined by using a validated complex chronic condition coding system. Patients discharged prepandemic and during the pandemic were compared. Outcomes included LOS and the number and type of discharge barriers (a factor not related to a medical condition that delays discharge). Multivariate regression modeling and parametric and nonparametric analysis were used to compare cohorts. RESULTS Prepandemic, 163 patients were discharged, and 119 were discharged during the early stages of the pandemic. The most common technology dependence was a feeding tube. The unadjusted median LOS was 7 days in both groups. After adjusting for patient-level factors, discharge during the pandemic resulted in a 32.2% longer LOS (confidence interval 2.1%-71.2%). The number of discharge barriers was high but unchanged between cohorts. Lack of a trained caregiver was more frequent during the pandemic (P = .03). CONCLUSIONS Barriers to discharge were frequent for both cohorts. Discharge during the pandemic was associated with longer LOS. It was more difficult to identify a trained caregiver during the pandemic.
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Affiliation(s)
- Margaret Rush
- Children’s National Hospital, Washington, District of Columbia
- George Washington University, Washington, District of Columbia
| | - Amina Khan
- Children’s National Hospital, Washington, District of Columbia
- George Washington University, Washington, District of Columbia
| | - John Barber
- Children’s National Hospital, Washington, District of Columbia
| | - Miriam Bloom
- Children’s National Hospital, Washington, District of Columbia
- George Washington University, Washington, District of Columbia
| | - Melanie Anspacher
- Children’s National Hospital, Washington, District of Columbia
- George Washington University, Washington, District of Columbia
| | - Karen Fratantoni
- Children’s National Hospital, Washington, District of Columbia
- George Washington University, Washington, District of Columbia
| | - Kavita Parikh
- Children’s National Hospital, Washington, District of Columbia
- George Washington University, Washington, District of Columbia
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Howley E, Davies EG, Kreins AY. Congenital Athymia: Unmet Needs and Practical Guidance. Ther Clin Risk Manag 2023; 19:239-254. [PMID: 36935770 PMCID: PMC10022451 DOI: 10.2147/tcrm.s379673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/04/2023] [Indexed: 03/14/2023] Open
Abstract
Inborn errors of thymic stromal cell development and function which are associated with congenital athymia result in life-threatening immunodeficiency with susceptibility to infections and autoimmunity. Athymic patients can be treated by thymus transplantation using cultured donor thymus tissue. Outcomes in patients treated at Duke University Medical Center and Great Ormond Street Hospital (GOSH) over the past three decades have shown that sufficient T-cell immunity can be recovered to clear and prevent infections, but post-treatment autoimmune manifestations are relatively common. Whilst thymus transplantation offers the chance of long-term survival, significant challenges remain to optimise the outcomes for the patients. In this review, we will discuss unmet needs and offer practical guidance based on the experience of the European Thymus Transplantation programme at GOSH. Newborn screening (NBS) for severe combined immunodeficiency (SCID) and routine use of next-generation sequencing (NGS) platforms have improved early recognition of congenital athymia and increasing numbers of patients are being referred for thymus transplantation. Nevertheless, there remain delays in diagnosis, in particular when the cause is genetically undefined, and treatment accessibility needs to be improved. The majority of athymic patients have syndromic features with acute and chronic complex health issues, requiring life-long multidisciplinary and multicentre collaboration to optimise their medical and social care. Comprehensive follow up after thymus transplantation including monitoring of immunological results, management of co-morbidities and patient and family quality-of-life experience, is vital to understanding long-term outcomes for this rare cohort of patients. Alongside translational research into improving strategies for thymus replacement therapy, patient-focused clinical research will facilitate the design of strategies to improve the overall care for athymic patients.
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Affiliation(s)
- Evey Howley
- Department of Immunology and Gene Therapy, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - E Graham Davies
- Department of Immunology and Gene Therapy, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Alexandra Y Kreins
- Department of Immunology and Gene Therapy, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Infection, Immunity and Inflammation Research & Teaching Department, University College London, London, UK
- Correspondence: Alexandra Y Kreins, Email
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31
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Ming DY, Jones KA, White MJ, Pritchard JE, Hammill BG, Bush C, Jackson GL, Raman SR. Healthcare Utilization for Medicaid-Insured Children with Medical Complexity: Differences by Sociodemographic Characteristics. Matern Child Health J 2022; 26:2407-2418. [PMID: 36198851 PMCID: PMC10026355 DOI: 10.1007/s10995-022-03543-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To compare differences in healthcare utilization and costs for Medicaid-insured children with medical complexity (CMC) by race/ethnicity and rurality. METHODS Retrospective cohort of North Carolina (NC) Medicaid claims for children 3-20 years old with 3 years continuous Medicaid coverage (10/1/2015-9/30/2018). Exposures were medical complexity, race/ethnicity, and rurality. Three medical complexity levels were: without chronic disease, non-complex chronic disease, and complex chronic disease; the latter were defined as CMC. Race/ethnicity was self-reported in claims; we defined rurality by home residence ZIP codes. Utilization and costs were summarized for 1 year (10/1/2018-9/30/2019) by complexity level classification and categorized as acute care (hospitalization, emergency [ED]), outpatient care (primary, specialty, allied health), and pharmacy. Per-complexity group utilization rates (per 1000 person-years) by race/ethnicity and rurality were compared using adjusted rate ratios (ARR). RESULTS Among 859,166 Medicaid-insured children, 118,210 (13.8%) were CMC. Among CMC, 36% were categorized as Black non-Hispanic, 42.7% White non-Hispanic, 14.3% Hispanic, and 35% rural. Compared to White non-Hispanic CMC, Black non-Hispanic CMC had higher hospitalization (ARR = 1.12; confidence interval, CI 1.08-1.17) and ED visit (ARR = 1.17; CI 1.16-1.19) rates; Hispanic CMC had lower ED visit (ARR = 0.77; CI 0.75-0.78) and hospitalization rates (ARR = 0.79; CI 0.73-0.84). Black non-Hispanic and Hispanic CMC had lower outpatient visit rates than White non-Hispanic CMC. Rural CMC had higher ED (ARR = 1.13; CI 1.11-1.15) and lower primary care utilization rates (ARR = 0.87; CI 0.86-0.88) than urban CMC. DISCUSSION Healthcare utilization varied by race/ethnicity and rurality for Medicaid-insured CMC. Further studies should investigate mechanisms for these variations and expand higher value, equitable care delivery for CMC.
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Affiliation(s)
- David Y Ming
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Department of Pediatrics, Duke University School of Medicine, Box 102376, Durham, NC, 27710, USA.
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
| | - Kelley A Jones
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Michelle J White
- Department of Pediatrics, Duke University School of Medicine, Box 102376, Durham, NC, 27710, USA
| | - Jessica E Pritchard
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Bradley G Hammill
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | | | - George L Jackson
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Sudha R Raman
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
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Giambra BK, Spratling R. Examining Children With Complex Care and Technology Needs in the Context of Social Determinants of Health. J Pediatr Health Care 2022; 37:262-268. [PMID: 36462998 DOI: 10.1016/j.pedhc.2022.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/09/2022] [Accepted: 11/11/2022] [Indexed: 12/05/2022]
Abstract
Children with complex care and technology needs require daily, intensive care from family caregivers. These children are understudied, particularly in relation to the social determinants of health (SDOH) that affect their health, well-being, and quality of life. This paper examines the salient research on SDOH among this population, focusing on the Healthy People 2030 domains. Gaps in the research are identified and recommendations for future research, practice, policy, and education are presented. Pediatric nurses, advanced practice nurses, and other health care provider teams that care for these children and families can improve their health by examining and addressing SDOH.
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Hipper TJ, Popek L, Davis RK, Turchi RM, Massey PM, Lege-Matsuura J, Lubell KM, Pechta L, Briseño L, Rose DA, Chatham-Stephens K, Leeb RT, Chernak E. Communication Preferences of Parents and Caregivers of Children and Youth With Special Healthcare Needs During a Hypothetical Infectious Disease Emergency. Health Secur 2022; 20:467-478. [PMID: 36459634 DOI: 10.1089/hs.2022.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Children and youth with special healthcare needs are at risk for severe consequences during infectious disease emergencies. Messages for parents and caregivers from trusted sources, via preferred channels, that contain the information they need, may improve health outcomes for this population. In this mixed methods study, we conducted a survey (N = 297) and 80 semistructured interviews, with 70 caregivers of children and youth and 10 young adults with special healthcare needs, between April 2018 and June 2019 in Pennsylvania. The survey presented 3 scenarios (ie, storm, disease outbreak, radiation event); the interviews included questions about storms and an outbreak. This article addresses only the disease outbreak data from each set. Participants were recruited through convenience samples from an urban tertiary care children's hospital and practices in a statewide medical home network. In this article, we summarize the preferred information sources, channels, and content needs of caregivers of children and youth with special healthcare needs during an infectious disease emergency. Nearly 84% of caregivers reported that they believe their child's doctor is the best source of information. Other preferred sources include medical experts (31%); the US Centers for Disease Control and Prevention (30%); friends, family, and neighbors (21%); and local or state health and emergency management (17%). Pediatric healthcare providers play an important role in providing information to parents and caregivers of children and youth with special healthcare needs during an infectious disease emergency. Public health agencies can establish health communication plans that integrate medical practices and other reliable sources to promote the dissemination of accurate information from trusted messengers.
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Affiliation(s)
- Thomas J Hipper
- Thomas J. Hipper, MSPH, MA, is Associate Director, Center for Public Health Readiness and Communication, and an Assistant Professor, Department of Environmental and Occupational Health, Dornsife School of Public Health, Drexel University, Philadelphia, PA
| | - Leah Popek
- Leah Popek, MPH, is Project Coordinator, Center for Public Health Readiness and Communication, Department of Environmental and Occupational Health, Dornsife School of Public Health, Drexel University, Philadelphia, PA
| | - Renee K Davis
- Renee K. Davis, MD, MPH, is Program Coordinator, Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, Philadelphia, PA
| | - Renee M Turchi
- Renee M. Turchi, MD, MPH, is a Clinical Professor, Dornsife School of Public Health, Drexel University, Philadelphia, PA.,Renee M. Turchi is also a Professor and Chair of Pediatrics, Drexel University College of Medicine, Philadelphia, PA
| | - Philip M Massey
- Philip M. Massey PhD, MPH, is Director and an Associate Professor, Center for Public Health and Technology, Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville, AR
| | - Jennifer Lege-Matsuura
- Jennifer Lege-Matsuura, MSLIS, is a Medical Librarian, Drexel University Libraries, Drexel University, Philadelphia, PA
| | - Keri M Lubell
- Keri M. Lubell, PhD, is a Behavioral Scientist, Centers for Disease Control and Prevention, Atlanta, GA
| | - Laura Pechta
- Laura Pechta, PhD, is a Senior Health Communication Specialist, Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Lisa Briseño
- Lisa Briseño, MS, is a Health Communication Specialist, Emergency Risk Communication Branch, Division of Emergency Operations, Center for Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, GA
| | - Dale A Rose
- Dale A. Rose, PhD, MSc, is Deputy Director, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kevin Chatham-Stephens
- Kevin Chatham-Stephens, MD, MPH, is Children's Preparedness Unit Lead, Centers for Disease Control and Prevention, Atlanta, GA
| | - Rebecca T Leeb
- Rebecca T. Leeb, PhD, is a Health Scientist/Epidemiologist, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Esther Chernak
- Esther Chernak MD, MPH, is Director, Center for Public Health Readiness and Communication, Dornsife School of Public Health, Drexel University, Philadelphia, PA.,Esther Chernak is also a Professor, Department of Medicine, Drexel University College of Medicine, Philadelphia, PA
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Kusma JD, Davis MM, Foster C. Characteristics of Medicaid Policies for Children With Medical Complexity by State: A Qualitative Study. JAMA Netw Open 2022; 5:e2239270. [PMID: 36315145 PMCID: PMC9623434 DOI: 10.1001/jamanetworkopen.2022.39270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
IMPORTANCE Families of children with medical complexity (CMC) report barriers to accessing affordable coverage for the full range of services their children may need to optimize their health outcomes. Medicaid enrollment through medical need-based eligibility mechanisms can help cover these service gaps. Understanding state-by-state variation in how CMC access Medicaid may allow policy makers and pediatricians to help families navigate needed services for CMC. OBJECTIVE To clarify how eligibility and coverage for CMC differ for Medicaid beneficiaries across states with different policies and managed care penetration. DESIGN, SETTING, AND PARTICIPANTS This qualitative study used semistructured interviews with state Medicaid representatives from 23 states and Washington, DC, from February 1, 2020, to March 1, 2021. Enrollment pathways and coverage processes were discussed. Interviews were transcribed and content analysis was performed. Participants included Medicaid directors, a designee, or a state-identified policy leader with expertise in and/or responsibility for child-focused programs. EXPOSURES State variation in Medicaid eligibility and delivery policies. MAIN OUTCOMES AND MEASURES Eligibility pathways and coverage mechanisms for CMC in each state. RESULTS A total of 43 informants from 23 states and Washington, DC, participated, which permitted data collection regarding almost half of the US. Four distinct eligibility pathways were characterized, with 3 specific to CMC, and the pathways that include the presence of waiting lists were distinguished. In addition, 3 coverage types at the state level were identified, consisting of fee-for-service, Medicaid managed care, or both. Two main connections between pathways and coverage mechanisms for CMC were described. CONCLUSIONS AND RELEVANCE The findings of this qualitative study suggest that state patterns in Medicaid eligibility and coverage for CMC have implications for access, including some states with substantial waiting periods for these families. Future work is needed to understand the implications of these differential Medicaid medical need-based eligibility pathways and subsequent coverage mechanisms on use of health care resources and expenditures, as well as considerations regarding challenges families of CMC face due to state-by-state variation.
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Affiliation(s)
- Jennifer D. Kusma
- Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Matthew M. Davis
- Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Carolyn Foster
- Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
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Smiley Y, Silberholz E, Bekele E, Brodie N. Caregiver stress and social determinants of health in key populations: immigrant parents, parents of children with medical complexity, and adolescent parents. Curr Opin Pediatr 2022; 34:521-530. [PMID: 35993274 DOI: 10.1097/mop.0000000000001163] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To examine the five domains of social determinants of health - economic stability, education access, healthcare access and quality, neighborhood and built environment, and social and community context - and how these relate to caregiver stress in under-resourced populations. RECENT FINDINGS Socioeconomic and family factors are increasingly understood as drivers of child health. Caregiver stress can impact family stability and child wellbeing. Immigrant parents, caregivers of children with medical complexity, and adolescent parents experience stressors due to the unique needs of their families. These groups of parents and caregivers also face various challenges identified as social determinants of health. Interventions to mitigate these challenges can promote resilience, care coordination, and community-based supports. SUMMARY Current research describes caregiver stress in key populations, how caregiver stress affects children, and approaches to minimize and mitigate these effects. Pediatric providers can implement best practices to support families who are navigating stress due to caregiving and social determinants of health.
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Affiliation(s)
- Yael Smiley
- Division of General and Community Pediatrics, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Elizabeth Silberholz
- Division of General Pediatrics, Boston Children's Hospital; Harvard Medical School, Boston, Massachusetts, USA
| | - ElShadey Bekele
- Division of General and Community Pediatrics, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Nicola Brodie
- Division of General and Community Pediatrics, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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Lin JL, Huber B, Amir O, Gehrmann S, Ramirez KS, Ochoa KM, Asch SM, Gajos KZ, Grosz BJ, Sanders LM. Barriers and Facilitators to the Implementation of Family-Centered Technology in Complex Care: Feasibility Study. J Med Internet Res 2022; 24:e30902. [PMID: 35998021 PMCID: PMC9449827 DOI: 10.2196/30902] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/03/2022] [Accepted: 07/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background Care coordination is challenging but crucial for children with medical complexity (CMC). Technology-based solutions are increasingly prevalent but little is known about how to successfully deploy them in the care of CMC. Objective The aim of this study was to assess the feasibility and acceptability of GoalKeeper (GK), an internet-based system for eliciting and monitoring family-centered goals for CMC, and to identify barriers and facilitators to implementation. Methods We used the Consolidated Framework for Implementation Research (CFIR) to explore the barriers and facilitators to the implementation of GK as part of a clinical trial of GK in ambulatory clinics at a children’s hospital (NCT03620071). The study was conducted in 3 phases: preimplementation, implementation (trial), and postimplementation. For the trial, we recruited providers at participating clinics and English-speaking parents of CMC<12 years of age with home internet access. All participants used GK during an initial clinic visit and for 3 months after. We conducted preimplementation focus groups and postimplementation semistructured exit interviews using the CFIR interview guide. Participant exit surveys assessed GK feasibility and acceptability on a 5-point Likert scale. For each interview, 3 independent coders used content analysis and serial coding reviews based on the CFIR qualitative analytic plan and assigned quantitative ratings to each CFIR construct (–2 strong barrier to +2 strong facilitator). Results Preimplementation focus groups included 2 parents (1 male participant and 1 female participant) and 3 providers (1 in complex care, 1 in clinical informatics, and 1 in neurology). From focus groups, we developed 3 implementation strategies: education (parents: 5-minute demo; providers: 30-minute tutorial and 5-minute video on use in a clinic visit; both: instructional manual), tech support (in-person, virtual), and automated email reminders for parents. For implementation (April 1, 2019, to December 21, 2020), we enrolled 11 providers (7 female participants, 5 in complex care) and 35 parents (mean age 38.3, SD 7.8 years; n=28, 80% female; n=17, 49% Caucasian; n=16, 46% Hispanic; and n=30, 86% at least some college). One parent-provider pair did not use GK in the clinic visit, and few used GK after the visit. In 18 parent and 9 provider exit interviews, the key facilitators were shared goal setting, GK’s internet accessibility and email reminders (parents), and GK’s ability to set long-term goals and use at the end of visits (providers). A key barrier was GK’s lack of integration into the electronic health record or patient portal. Most parents (13/19) and providers (6/9) would recommend GK to their peers. Conclusions Family-centered technologies like GK are feasible and acceptable for the care of CMC, but sustained use depends on integration into electronic health records. Trial Registration ClinicalTrials.gov NCT03620071; https://clinicaltrials.gov/ct2/show/NCT03620071
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Affiliation(s)
- Jody L Lin
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Bernd Huber
- John A Paulson School of Engineering and Applied Sciences, Harvard University, Allston, MA, United States
| | - Ofra Amir
- Faculty of Industrial Engineering and Management, Technion - Israel Institute of Technology, Haifa, Israel
| | - Sebastian Gehrmann
- John A Paulson School of Engineering and Applied Sciences, Harvard University, Allston, MA, United States
| | - Kimberly S Ramirez
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Kimberly M Ochoa
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Steven M Asch
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States.,Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Krzysztof Z Gajos
- John A Paulson School of Engineering and Applied Sciences, Harvard University, Allston, MA, United States
| | - Barbara J Grosz
- John A Paulson School of Engineering and Applied Sciences, Harvard University, Allston, MA, United States
| | - Lee M Sanders
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
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Belzer LT, Wright SM, Goodwin EJ, Singh MN, Carter BS. Psychosocial Considerations for the Child with Rare Disease: A Review with Recommendations and Calls to Action. CHILDREN 2022; 9:children9070933. [PMID: 35883917 PMCID: PMC9325007 DOI: 10.3390/children9070933] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/10/2022] [Accepted: 06/11/2022] [Indexed: 01/07/2023]
Abstract
Rare diseases (RD) affect children, adolescents, and their families infrequently, but with a significant impact. The diagnostic odyssey undertaken as part of having a child with RD is immense and carries with it practical, emotional, relational, and contextual issues that are not well understood. Children with RD often have chronic and complex medical conditions requiring a complicated milieu of care by numerous clinical caregivers. They may feel isolated and may feel stigmas in settings of education, employment, and the workplace, or a lack a social support or understanding. Some parents report facing similar loneliness amidst a veritable medicalization of their homes and family lives. We searched the literature on psychosocial considerations for children with rare diseases in PubMed and Google Scholar in English until 15 April 2022, excluding publications unavailable in full text. The results examine RD and their psychosocial ramifications for children, families, and the healthcare system. The domains of the home, school, community, and medical care are addressed, as are the implications of RD management as children transition to adulthood. Matters of relevant healthcare, public policies, and more sophisticated translational research that addresses the intersectionality of identities among RD are proposed. Recommendations for interventions and supportive care in the aforementioned domains are provided while emphasizing calls to action for families, clinicians, investigators, and advocacy agents as we work toward establishing evidence-based care for children with RD.
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Affiliation(s)
- Leslee T. Belzer
- Division of Developmental and Behavioral Health, Section of Pediatric Psychology, Children’s Mercy Kansas City, Kansas City, MO 64108, USA
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA; (S.M.W.); (E.J.G.); (B.S.C.)
- Division of General Academic Pediatrics, The Beacon Program, Children’s Mercy Kansas City, Kansas City, MO 64111, USA
- Correspondence: ; Tel.: +1-816-960-2849
| | - S. Margaret Wright
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA; (S.M.W.); (E.J.G.); (B.S.C.)
- Division of General Academic Pediatrics, The Beacon Program, Children’s Mercy Kansas City, Kansas City, MO 64111, USA
- School of Medicine, University of Kansas, Kansas City, KS 66160, USA
| | - Emily J. Goodwin
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA; (S.M.W.); (E.J.G.); (B.S.C.)
- Division of General Academic Pediatrics, The Beacon Program, Children’s Mercy Kansas City, Kansas City, MO 64111, USA
- School of Medicine, University of Kansas, Kansas City, KS 66160, USA
| | - Mehar N. Singh
- Department of Psychology, Clinical Child Psychology Program, University of Kansas, Lawrence, KS 66045, USA;
| | - Brian S. Carter
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA; (S.M.W.); (E.J.G.); (B.S.C.)
- Department of Medical Humanities & Bioethics, University of Missouri-Kansas City, Kansas City, MO 64108, USA
- Bioethics Center, Children’s Mercy Kansas City, Kansas City, MO 64108, USA
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McLellan SE, Mann MY, Scott JA, Brown TW. A Blueprint for Change: Guiding Principles for a System of Services for Children and Youth With Special Health Care Needs and Their Families. Pediatrics 2022; 149:188225. [PMID: 35642876 DOI: 10.1542/peds.2021-056150c] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2022] [Indexed: 12/22/2022] Open
Abstract
Children and youth with special health care needs (CYSHCN) and their families continue to face challenges in accessing health care and other services in an integrated, family-centered, evidence-informed, culturally responsive system. More than 12 million, or almost 86%, of CYSHCN ages 1-17 years do not have access to a well-functioning system of services. Further, the inequities experienced by CYSHCN and their families, particularly those in under-resourced communities, highlight the critical need to address social determinants of health and our nation's approach to delivering health care. To advance the system and prioritize well-being and optimal health for CYSHCN, the Health Resources and Services Administration's Maternal and Child Health Bureau, with input from diverse stakeholders, developed a set of core principles and actionable strategies for the field. This article presents principles and strategies in the Blueprint for Change: Guiding Principles for a System of Services for CYSHCN and Their Families (Blueprint for Change), which acknowledges the comprehensive needs of CYSHCN, a changing health care system, and the disparities experienced by many CYSHCN. Four critical areas drive the Blueprint for Change: health equity, family and child well-being and quality of life, access to services, and financing of services. Although discussed separately, these critical areas are inherently interconnected and intend to move the field forward at the community, state, and federal levels. Addressing these critical areas requires a concerted, holistic, and integrated approach that will help us achieve the goal that CYSHCN enjoy a full life from childhood through adulthood and thrive in a system that supports their families and their social, health, and emotional needs, ensuring their dignity, autonomy, independence, and active participation in their communities.
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Leyenaar JK, Schaefer AP, Freyleue SD, Austin AM, Simon TD, Van Cleave J, Moen EL, O’Malley AJ, Goodman DC. Prevalence of Children With Medical Complexity and Associations With Health Care Utilization and In-Hospital Mortality. JAMA Pediatr 2022; 176:e220687. [PMID: 35435932 PMCID: PMC9016603 DOI: 10.1001/jamapediatrics.2022.0687] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 01/12/2022] [Indexed: 02/05/2023]
Abstract
Importance Children with medical complexity (CMC) have substantial health care needs and frequently experience poor health care quality. Understanding the population prevalence and associated health care needs can inform clinical and public health initiatives. Objective To estimate the prevalence of CMC using open-source pediatric algorithms, evaluate performance of these algorithms in predicting health care utilization and in-hospital mortality, and identify associations between medical complexity as defined by these algorithms and clinical outcomes. Design, Setting, and Participants This retrospective cohort study used all-payer claims data from Colorado, Massachusetts, and New Hampshire from 2012 through 2017. Children and adolescents younger than 18 years residing in these states were included if they had 12 months or longer of enrollment in a participating health care plan. Analyses were conducted from March 12, 2021, to January 7, 2022. Exposures The pediatric Complex Chronic Condition Classification System, Pediatric Medical Complexity Algorithm, and Children With Disabilities Algorithm were applied to 3 years of data to identify children with complex and disabling conditions, first in their original form and then using more conservative criteria that required multiple health care claims or involvement of 3 or more body systems. Main Outcomes and Measures Primary outcomes, examined over 2 years, included in-hospital mortality and a composite measure of health care services, including specialized therapies, specialized medical equipment, and inpatient care. Outcomes were modeled using logistic regression. Model performance was evaluated using C statistics, sensitivity, and specificity. Results Of 1 936 957 children, 48.4% were female, 87.8% resided in urban core areas, and 45.1% had government-sponsored insurance as their only primary payer. Depending on the algorithm and coding criteria applied, 0.67% to 11.44% were identified as CMC. All 3 algorithms had adequate discriminative ability, sensitivity, and specificity to predict in-hospital mortality and composite health care services (C statistic = 0.76 [95% CI, 0.73-0.80] to 0.81 [95% CI, 0.78-0.84] for mortality and 0.77 [95% CI, 0.76-0.77] to 0.80 [95% CI, 0.79-0.80] for composite health care services). Across algorithms, CMC had significantly greater odds of mortality (adjusted odds ratio [aOR], 9.97; 95% CI, 7.70-12.89; to aOR, 69.35; 95% CI, 52.52-91.57) and composite health care services (aOR, 4.59; 95% CI, 4.44-4.73; to aOR, 18.87; 95% CI, 17.87-19.93) than children not identified as CMC. Conclusions and Relevance In this study, open-source algorithms identified different cohorts of CMC in terms of prevalence and magnitude of risk, but all predicted increased health care utilization and in-hospital mortality. These results can inform research, programs, and policies for CMC.
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Affiliation(s)
- JoAnna K. Leyenaar
- Department of Pediatrics, Children’s Hospital at Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Andrew P. Schaefer
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Seneca D. Freyleue
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Andrea M. Austin
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Tamara D. Simon
- Department of Pediatrics, Keck School of Medicine at the University of Southern California, Los Angeles
- The Saban Research Institute, Children’s Hospital Los Angeles, Los Angeles, California
| | - Jeanne Van Cleave
- Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Erika L. Moen
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - David C. Goodman
- Department of Pediatrics, Children’s Hospital at Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
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Houtrow A, Martin AJ, Harris D, Cejas D, Hutson R, Mazloomdoost Y, Agrawal RK. Health Equity for Children and Youth With Special Health Care Needs: A Vision for the Future. Pediatrics 2022; 149:188222. [PMID: 35642875 DOI: 10.1542/peds.2021-056150f] [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] [Accepted: 03/04/2022] [Indexed: 11/24/2022] Open
Abstract
Health equity is a key pillar in supporting a future in which CYSHCN enjoy a full life and thrive, as envisioned by experts and community partners who gathered in 2019 and 2020 to develop the Blueprint for Change: Guiding Principles for a System of Services for Children and Youth With Special Health Care Needs and Their Families. However, a variety of contextual factors impact health outcomes across the life course and intergenerationally and must be addressed to achieve this goal. For example, poverty and discrimination, including by some health care professionals and systems, are important, modifiable root causes of poor health outcomes. There are numerous barriers to achieving health equity, including political will, lack of resources, insufficient training, and limited cross-sector collaborations. Political, cultural, societal, and environmental interventions are necessary to eliminate health disparities and achieve health equity. The entities that serve CYSHCN should be equitably designed and implemented to improve health outcomes and address health disparities. Many entities that serve CYSHCN are taking positive steps through workforce development, policy changes, community engagement, and other means. The purpose of this article is to frame health equity for CYSHCN, detail their health disparities, review barriers to health equity, provide examples of strategies to advance health equity for them, and describe a path toward the future in which all CYSHCN have a fair and just opportunity to be as healthy as possible.
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Affiliation(s)
- Amy Houtrow
- Departments of Physical Medicine Rehabilitation.,Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alison J Martin
- Oregon Center for Children and Youth with Special Health Needs, School of Public Health, Oregon Health and Science University-Portland State University, Portland, Oregon.,Institute on Development and Disability, Oregon Health and Science University, Portland, Oregon
| | - Debbi Harris
- The Arc of the United States, Washington, District of Columbia.,Family Voices of Minnesota, St. Paul, Minnesota
| | - Diana Cejas
- Carolina Institute for Developmental Disabilities, University of North Carolina at Chapel Hill, Carrboro, North Carolina
| | - Rachel Hutson
- Title V Maternal and Child Health, Colorado Department of Public Health and Environment
| | | | - Rishi K Agrawal
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Hamilton H, West AN, Ammar N, Chinthala L, Gunturkun F, Jones T, Shaban-Nejad A, Shah SH. Analyzing Relationships Between Economic and Neighborhood-Related Social Determinants of Health and Intensive Care Unit Length of Stay for Critically Ill Children With Medical Complexity Presenting With Severe Sepsis. Front Public Health 2022; 10:789999. [PMID: 35570956 PMCID: PMC9099028 DOI: 10.3389/fpubh.2022.789999] [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: 10/05/2021] [Accepted: 03/09/2022] [Indexed: 11/27/2022] Open
Abstract
Objectives Of the Social Determinants of Health (SDoH), we evaluated socioeconomic and neighborhood-related factors which may affect children with medical complexity (CMC) admitted to a Pediatric Intensive Care Unit (PICU) in Shelby County, Tennessee with severe sepsis and their association with PICU length of stay (LOS). We hypothesized that census tract-level socioeconomic and neighborhood factors were associated with prolonged PICU LOS in CMC admitted with severe sepsis in the underserved community. Methods This single-center retrospective observational study included CMC living in Shelby County, Tennessee admitted to the ICU with severe sepsis over an 18-month period. Severe sepsis CMC patients were identified using an existing algorithm incorporated into the electronic medical record at a freestanding children's hospital. SDoH information was collected and analyzed using patient records and publicly available census-tract level data, with ICU length of stay as the primary outcome. Results 83 encounters representing 73 patients were included in the analysis. The median PICU LOS was 9.04 days (IQR 3.99–20.35). The population was 53% male with a median age of 4.1 years (IQR 1.96–12.02). There were 57 Black/African American patients (68.7%) and 85.5% had public insurance. Based on census tract-level data, about half (49.4%) of the CMC severe sepsis population lived in census tracts classified as suffering from high social vulnerability. There were no statistically significant relationships between any socioeconomic and neighborhood level factors and PICU LOS. Conclusion Pediatric CMC severe sepsis patients admitted to the PICU do not have prolonged lengths of ICU stay related to socioeconomic and neighborhood-level SDoH at our center. A larger sample with the use of individual-level screening would need to be evaluated for associations between social determinants of health and PICU outcomes of these patients.
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Affiliation(s)
- Hunter Hamilton
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Tennessee Health Science Center College of Medicine, Memphis, TN, United States
| | - Alina N West
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Tennessee Health Science Center College of Medicine, Memphis, TN, United States
| | - Nariman Ammar
- University of Tennessee Health Science Center - Oak-Ridge National Laboratory Center for Biomedical Informatics, Department of Pediatrics, College of Medicine, Memphis, TN, United States
| | - Lokesh Chinthala
- Clinical Trials Network of Tennessee, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Fatma Gunturkun
- University of Tennessee Health Science Center - Oak-Ridge National Laboratory Center for Biomedical Informatics, Department of Pediatrics, College of Medicine, Memphis, TN, United States
| | - Tamekia Jones
- Departments of Pediatrics and Preventive Medicine, University of Tennessee Health Science Center College of Medicine, Memphis, TN, United States.,Children's Foundation Research Institute Biostatistics Core, Memphis, TN, United States
| | - Arash Shaban-Nejad
- University of Tennessee Health Science Center - Oak-Ridge National Laboratory Center for Biomedical Informatics, Department of Pediatrics, College of Medicine, Memphis, TN, United States
| | - Samir H Shah
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Tennessee Health Science Center College of Medicine, Memphis, TN, United States
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Xu WY, Li Y, Song C, Bose-Brill S, Retchin SM. Out-of-Network Care in Commercially Insured Pediatric Patients According to Medical Complexity. Med Care 2022; 60:375-380. [PMID: 35250021 DOI: 10.1097/mlr.0000000000001705] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Commercial health plans establish networks and require much higher cost sharing for out-of-network (OON) care. Yet, the adequacy of health plan networks for access to pediatric specialists, especially for children with medical complexity, is largely unknown. OBJECTIVE To examine differences in OON care and associated cost-sharing payments for commercially insured children with different levels of medical complexity. DESIGN Cross-sectional study using a nationwide commercial claims database. SUBJECTS Enrollees 0-18 years old in employer-sponsored insurance plans. The Pediatric Medical Complexity Algorithm was used to classify individuals into 3 levels of medical complexity: children with no chronic disease, children with non-complex chronic diseases, and children with complex chronic diseases. MAIN OUTCOMES OON care rates, cost-sharing payments for OON care and in-network care, OON cost sharing as a proportion of total health care spending, and OON cost sharing as a proportion of total cost sharing. RESULTS The study sample included 6,399,006 individuals with no chronic disease, 1,674,450 with noncomplex chronic diseases, and 603,237 with complex chronic diseases. Children with noncomplex chronic diseases were more likely to encounter OON care by 6.77 percentage points with higher cost-sharing by $288 for OON care, relative to those with no chronic disease. For those with complex chronic diseases, these differences rose to 16.08 percentage points and $599, respectively. Among children who saw behavioral health providers, rates of OON care were especially high. CONCLUSIONS Commercially insured children with medical complexity experience higher rates of OON care with higher OON cost-sharing payments compared with those with no chronic disease.
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Affiliation(s)
- Wendy Y Xu
- Division of Health Services Management and Policy
| | - Yiting Li
- Division of Health Services Management and Policy
| | - Chi Song
- Division of Biostatistics, College of Public Health
| | - Seuli Bose-Brill
- Division of General Internal Medicine, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH
| | - Sheldon M Retchin
- Division of Health Services Management and Policy
- Division of General Internal Medicine, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH
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43
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Breneol S, Curran JA, Macdonald M, Montelpare W, Stewart SA, Martin-Misener R, Vine J. Children With Medical Complexity in the Canadian Maritimes: Protocol for a Mixed Methods Study. JMIR Res Protoc 2022; 11:e33426. [PMID: 35383571 PMCID: PMC9021950 DOI: 10.2196/33426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 02/22/2022] [Accepted: 02/25/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ongoing developments in the medical field have improved survival rates and long-term management of children with complex chronic health conditions. While the number of children with medical complexity is small, they use a significant amount of health resources across various health settings and sectors. Research to date exploring this pediatric population has relied primarily on quantitative or qualitative data alone, leaving significant gaps in our understanding of this population. OBJECTIVE The objective of this research is to use health administrative and family-reported data to gain an in-depth understanding of patterns of health resource use and health care needs of children with medical complexity and their families in the Canadian Maritimes. METHODS An explanatory sequential mixed methods design will be used to achieve our research objective. Phase 1 of this research will leverage the use of health administrative data to examine the prevalence and health service use of children with medical complexity. Phase 2 will use case study methods to collect multiple sources of family-reported data to generate a greater understanding of their experiences, health resource use, and health care needs. Two cases will be developed in each of the 3 provinces. Cases will be developed through semistructured interviews with families and their health care providers and health resource journaling. Findings will be triangulated from phase 1 and 2 using a joint display table to visually depict the convergence and divergence between the quantitative and qualitative findings. This triangulation will result in a comprehensive and in-depth understanding into the population of children with medical complexity. RESULTS This study will be completed in May 2022. Findings from each phase of the research and integration of the two will be reported in full in 2022. CONCLUSIONS There is a current disconnect between the Canadian health care system and the needs of children with medical complexity and their families. By combining health administrative and family-reported data, this study will unveil critical information about children with medical complexity and their families to more efficiently and effectively meet their health care needs. Results from this research will be the first step in designing patient-oriented health policies and programs to improve the health care experiences, health system use, and health outcomes of children with medical complexity and their families. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/33426.
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Affiliation(s)
- Sydney Breneol
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS, Canada.,Strengthening Transitions in Care, Izaac Walton Killam Health Centre, Halifax, NS, Canada
| | - Janet A Curran
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS, Canada.,Strengthening Transitions in Care, Izaac Walton Killam Health Centre, Halifax, NS, Canada
| | - Marilyn Macdonald
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - William Montelpare
- Department of Applied Human Sciences, University of Prince Edward Island, Charlottetown, PE, Canada
| | - Samuel A Stewart
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | - Ruth Martin-Misener
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Jocelyn Vine
- Strengthening Transitions in Care, Izaac Walton Killam Health Centre, Halifax, NS, Canada
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Markham JL, Richardson T, Teufel RJ, Hersh AL, DePorre A, Fleegler EW, Antiel RM, Williams DC, Hotz A, Wilder JL, Shah SS. Impact of COVID-19 on Admissions and Outcomes for Children With Complex Chronic Conditions. Hosp Pediatr 2022; 12:337-353. [PMID: 35257170 DOI: 10.1542/hpeds.2021-006334] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Although pediatric health care use declined during the coronavirus disease 2019 (COVID-19) pandemic, the impact on children with complex chronic conditions (CCCs) has not been well reported. OBJECTIVE To describe the impact of the pandemic on inpatient use and outcomes for children with CCCs. METHODS This multicenter cross-sectional study used data from the Pediatric Health Information System. We examined trends in admissions between January 2020 through March 2021, comparing them to the same timeframe in the previous 3 years (pre-COVID-19). We used generalized linear mixed models to examine the association of the COVID-19 period and outcomes for children with CCCs presenting between March 16, 2020 to March 15, 2021 (COVID-19 period) to the same timeframe in the previous 3 years (pre-COVID-19). RESULTS Children with CCCs experienced a 19.5% overall decline in admissions during the COVID-19 pandemic. Declines began in the second week of March of 2020, reaching a nadir in early April 2020. Changes in admissions varied over time and by admission indication. Children with CCCs hospitalized for pneumonia and bronchiolitis experienced overall declines in admissions of 49.7% to 57.7%, whereas children with CCCs hospitalized for diabetes experienced overall increases in admissions of 21.2%. Total and index length of stay, costs, and ICU use, although statistically higher during the COVID-19 period, were similar overall to the pre-COVID-19 period. CONCLUSIONS Total admissions for children with CCCs declined nearly 20% during the pandemic. Among prevalent conditions, the greatest declines were observed for children with CCCs hospitalized with respiratory illnesses. Despite declines in admissions, overall hospital-level outcomes remained similar.
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Affiliation(s)
- Jessica L Markham
- aChildren's Mercy Kansas City and the University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- bUniversity of Kansas School of Medicine, Kansas City, Kansas
| | - Troy Richardson
- aChildren's Mercy Kansas City and the University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- cChildren's Hospital Association, Lenexa, Kansas
| | - Ronald J Teufel
- dDepartment of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Adam L Hersh
- eDivision of Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Adrienne DePorre
- aChildren's Mercy Kansas City and the University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- bUniversity of Kansas School of Medicine, Kansas City, Kansas
| | - Eric W Fleegler
- fDivision of Emergency Medicine, Departments of Pediatrics and Emergency Medicine
- gHarvard Medical School, Boston, Massachusetts
| | - Ryan M Antiel
- hDivision of Pediatric Surgery, Department of Surgery, Riley Hospital for Children, Indianapolis, Indiana
| | - Daniel C Williams
- dDepartment of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Arda Hotz
- iDivision of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Jayme L Wilder
- iDivision of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Samir S Shah
- jDivisions of Hospital Medicine and Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- kDepartment of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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45
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Seppänen AV, Draper ES, Petrou S, Barros H, Aubert AM, Andronis L, Kim SW, Maier RF, Pedersen P, Gadzinowski J, Lebeer J, Ådén U, Toome L, van Heijst A, Cuttini M, Zeitlin J. High Healthcare Use at Age 5 Years in a European Cohort of Children Born Very Preterm. J Pediatr 2022; 243:69-77.e9. [PMID: 34921871 DOI: 10.1016/j.jpeds.2021.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 11/21/2021] [Accepted: 12/09/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To describe parent-reported healthcare service use at age 5 years in children born very preterm and investigate whether perinatal and social factors and the use of very preterm follow-up services are associated with high service use. STUDY DESIGN We used data from an area-based cohort of births at <32 weeks of gestation from 11 European countries, collected from birth records and parental questionnaires at 5 years of age. Using the published literature, we defined high use of outpatient/inpatient care (≥4 sick visits to general practitioners, pediatricians, or nurses, ≥3 emergency room visits, or ≥1 overnight hospitalization) and specialist care (≥2 different specialists or ≥3 visits). We also categorized countries as having either a high or a low rate of children using very preterm follow-up services at age 5 years. RESULTS Overall, 43% of children had high outpatient/inpatient care use and 48% had high specialist care use during the previous year. Perinatal factors were associated with high outpatient/inpatient and specialist care use, with a more significant association with specialist services. Associations with intermediate parental educational level and unemployment were stronger for outpatient/inpatient services. Living in a country with higher rates of very preterm follow-up service use was associated with lower use of outpatient/inpatient services. CONCLUSIONS Children born very preterm had high healthcare service use at age 5 years, with different patterns for outpatient/inpatient and specialist care by perinatal and social factors. Longer follow-up of children born very preterm may improve care coordination and help avoid undesirable health service use.
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Affiliation(s)
- Anna-Veera Seppänen
- Obstetrical Perinatal and Pediatric Epidemiology Research Team, Center of Research in Epidemiology and Statistics, Université de Paris, INSERM, INRAE, Paris, France.
| | - Elizabeth S Draper
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Henrique Barros
- Epidemiology Research Unit, Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal
| | - Adrien M Aubert
- Obstetrical Perinatal and Pediatric Epidemiology Research Team, Center of Research in Epidemiology and Statistics, Université de Paris, INSERM, INRAE, Paris, France
| | - Lazaros Andronis
- Division of Clinical Trials, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Sung Wook Kim
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rolf F Maier
- Department of Neonatology, Children's Hospital, University Hospital, Philipps University Marburg, Marburg, Germany
| | | | - Janusz Gadzinowski
- Department of Neonatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jo Lebeer
- Department of Family Medicine & Population Health, Disability Studies, Faculty of Medicine & Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Ulrika Ådén
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Liis Toome
- Department of Neonatal and Infant Medicine, Tallinn Children's Hospital, Tallinn, Estonia; Department of Pediatrics, University of Tartu, Tartu, Estonia
| | - Arno van Heijst
- Department of Neonatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marina Cuttini
- Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Jennifer Zeitlin
- Obstetrical Perinatal and Pediatric Epidemiology Research Team, Center of Research in Epidemiology and Statistics, Université de Paris, INSERM, INRAE, Paris, France
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46
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Noritz G, Shah S, Glader L. Estimating fracture risk in children and adults with disabilities: An iniquitous use of race. Dev Med Child Neurol 2022; 64:523. [PMID: 35089608 DOI: 10.1111/dmcn.15170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Garey Noritz
- Nationwide Children's Hospital - Complex Care, Columbus, Ohio, USA
| | - Summit Shah
- Nationwide Children's Hospital - Radiology, Columbus, Ohio, USA
| | - Laurie Glader
- Nationwide Children's Hospital - Complex Care, Columbus, Ohio, USA
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47
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Driansky A, Pilapil M, Mastrogiannis A. Updating the healthcare maintenance visit for children with medical complexity: applying lessons learned from the coronavirus disease 2019 pandemic. Curr Opin Pediatr 2022; 34:248-254. [PMID: 35125381 PMCID: PMC8900886 DOI: 10.1097/mop.0000000000001116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Coronavirus disease 2019 (COVID-19) has exposed the vulnerabilities of children with medical complexity (CMC). This article uniquely describes how pediatric providers in various clinical settings can adapt routine healthcare maintenance visits to meet the needs of CMC in the era of COVID-19. We also discuss unique visit components important to address when providing primary care to CMC, including caregiver support, disaster preparedness, long-term care planning, and telemedicine. RECENT FINDINGS Although some children may be less severely affected by COVID-19 than adults, current literature suggests that CMC may be at higher risk for severe disease. In addition, the COVID-19 pandemic has highlighted the value in consistent, primary care for CMC. Children, especially those with medical complexity, are at risk for interruptions in care, delayed vaccinations, increasing caregiver burden, and barriers to in-person care. SUMMARY This article summarizes the components of the healthcare maintenance visit for CMC, providing salient recommendations on how pediatric providers can adapt their approach to the primary care of CMC in the era of COVID-19.
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Affiliation(s)
- Allison Driansky
- Steven and Alexandra Cohen Children's Medical Center, Pediatrics, New Hyde Park, New York, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
| | - Mariecel Pilapil
- Steven and Alexandra Cohen Children's Medical Center, Pediatrics, New Hyde Park, New York, Division of General Pediatrics, Division of General Internal Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead
| | - Ariana Mastrogiannis
- Steven and Alexandra Cohen Children's Medical Center, Pediatrics, New Hyde Park, New York, USA
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48
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Curfman A, Hackell JM, Herendeen NE, Alexander J, Marcin JP, Moskowitz WB, Bodnar CEF, Simon HK, McSwain SD. Telehealth: Opportunities to Improve Access, Quality, and Cost in Pediatric Care. Pediatrics 2022; 149:184902. [PMID: 35224638 DOI: 10.1542/peds.2021-056035] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The use of telehealth technology to connect with patients has expanded significantly over the past several years, particularly in response to the global coronavirus disease 2019 pandemic. This technical report describes the present state of telehealth and its current and potential applications. Telehealth has the potential to transform the way care is delivered to pediatric patients, expanding access to pediatric care across geographic distances, leveraging the pediatric workforce for care delivery, and improving disparities in access to care. However, implementation will require significant efforts to address the digital divide to ensure that telehealth does not inadvertently exacerbate inequities in care. The medical home model will continue to evolve to use telehealth to provide high-quality care for children, particularly for children and youth with special health care needs, in accordance with current and evolving quality standards. Research and metric development are critical for the development of evidence-based best practices and policies in these new models of care. Finally, as pediatric care transitions from traditional fee-for-service payment to alternative payment methods, telehealth offers unique opportunities to establish value-based population health models that are financed in a sustainable manner.
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Affiliation(s)
- Alison Curfman
- Department of Pediatrics, Mercy Clinic, St Louis, Missouri.,Rubicon Founders
| | - Jesse M Hackell
- Department of Pediatrics, New York Medical College and Boston Children's Health Physicians, Pomona, New York
| | - Neil E Herendeen
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, New York
| | - Joshua Alexander
- Departments of Physical Medicine and Rehabilitation and Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - James P Marcin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of California Davis and University of California Davis Children's Hospital, Sacramento, California
| | - William B Moskowitz
- Division of Pediatric Cardiology, Department of Pediatrics, Children's of Mississippi and University of Mississippi Medical Center, Jackson, Mississippi
| | - Chelsea E F Bodnar
- Robert Wood Johnson Foundation Clinical Scholars Program, University of Montana, Missoula, Montana
| | - Harold K Simon
- Departments of Pediatrics and Emergency Medicine, School of Medicine, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - S David McSwain
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
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49
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Chhibber R, Shrivastava R, Tandale M. Addressing consequences of school closure on oral health care of children during COVID-19. Front Pediatr 2022; 10:725977. [PMID: 35935378 PMCID: PMC9354613 DOI: 10.3389/fped.2022.725977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Radhika Chhibber
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC, Canada
| | | | - Madhura Tandale
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC, Canada
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50
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Yu J, Perrin JM, Hagerman T, Houtrow AJ. Underinsurance Among Children in the United States. Pediatrics 2022; 149:183780. [PMID: 34866156 PMCID: PMC9647940 DOI: 10.1542/peds.2021-050353] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES We describe the change in the percentage of children lacking continuous and adequate health insurance (underinsurance) from 2016 to 2019. We also examine the relationships between child health complexity and insurance type with underinsurance. METHODS Secondary analysis of US children in the National Survey of Children's Health combined 2016-2019 dataset who had continuous and adequate health insurance. We calculated differences in point estimates, with 95% confidence intervals (CIs), to describe changes in our outcomes over the study period. We used multivariable logistic regression adjusted for sociodemographic characteristics and examined relationships between child health complexity and insurance type with underinsurance. RESULTS From 2016 to 2019, the proportion of US children experiencing underinsurance rose from 30.6% to 34.0% (+3.4%; 95% CI, +1.9% to +4.9%), an additional 2.4 million children. This trend was driven by rising insurance inadequacy (24.8% to 27.9% [+3.1%; 95% CI, +1.7% to +4.5%]), which was mainly experienced as unreasonable out-of-pocket medical expenses. Although the estimate of children lacking continuous insurance coverage rose from 8.1% to 8.7% (+0.6%), it was not significant at the 95% CI (-0.5% to +1.7%). We observed significant growth in underinsurance among White and multiracial children, children living in households with income ≥200% of the federal poverty limit, and those with private health insurance. Increased child health complexity and private insurance were significantly associated with experiencing underinsurance (adjusted odds ratio, 1.9 and 3.5, respectively). CONCLUSIONS Underinsurance is increasing among US children because of rising inadequacy. Reforms to the child health insurance system are necessary to curb this problem.
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Affiliation(s)
- Justin Yu
- Departments of Pediatrics,Address correspondence to Justin Yu, MD, MS, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Faculty Pavilion, Suite 3110, 4401 Penn Ave, Pittsburgh, PA, 15224. E-mail:
| | - James M. Perrin
- Department of Pediatrics, Harvard Medical School and MassGeneral Hospital for Children, Boston, Massachusetts
| | - Thomas Hagerman
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan
| | - Amy J. Houtrow
- Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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