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Malthaner LQ, McLeigh JD, Knell G, Jetelina KK, Atem F, Messiah SE. Child maltreatment and behavioral health outcomes in child welfare: Exploring the roles of severity and polyvictimization. CHILD ABUSE & NEGLECT 2024; 156:106998. [PMID: 39213879 DOI: 10.1016/j.chiabu.2024.106998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 08/02/2024] [Accepted: 08/15/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Child maltreatment and polyvictimization are known risk factors for long-term detrimental health and development outcomes, including behavioral health challenges. However, effects from specific types and combinations of maltreatments are unclear. This study examined the association between maltreatment or polyvictimization and behavioral health in a child welfare sample. PARTICIPANTS AND SETTING Medical records of children with child welfare involvement with at least one behavioral health condition (i.e., mental, behavioral or neurodevelopmental disorder, ICD-10 F01-F99) between 1/1/2018-12/31/2021 were extracted from a large, academic hospital system. METHODS Behavioral health complexity was categorized as non-chronic, non-complex chronic, or complex chronic using the Pediatric Medical Complexity Algorithm. Partial proportional logistic regression models adjusted for age, sex, race/ethnicity, caregiver type, and physical health complexity generated odds of behavioral health complexity by maltreatment type (physical abuse, sexual abuse, neglect) and maltreatment combinations. RESULTS The analytic sample included 3992 participants (mean age 7.6 (Standard Deviation, 5.0) 44 % female, 29 % white, 32 % black, 22 % Hispanic). Participants who experienced physical abuse (Odds Ratio [OR]: 1.79, 95 % Confidence Interval [CI]: 1.10-2.91), or neglect (OR: 1.69, 95 % CI: 1.38-2.07) were more likely to have increasing behavioral health complexity versus those without maltreatment. Participants with both physical abuse and neglect were over twice as likely (OR: 2.44, 95 % CI: 1.88-3.16) to have increasing behavioral health complexity versus those who did not experience maltreatment. CONCLUSION Results emphasize the differential impacts of maltreatment and polyvictimization exposures on behavioral health complexity among children with child welfare involvement that can guide risk assessment and clinical care.
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Affiliation(s)
- Lauren Q Malthaner
- Department of Epidemiology, University of Texas Health Science Center at Houston School of Public Health, 2777 N. Stemmons Freeway, Suite 8400, Dallas, TX 75207, United States of America; Center for Pediatric Population Health, University of Texas Health Science Center at Houston School of Public Health, 2777 N. Stemmons Freeway, Suite 8400, Dallas, TX 75207, United States of America.
| | - Jill D McLeigh
- Rees-Jones Center for Foster Care Excellence, Children's Health Medical Center, 2350 N. Stemmons Freeway, Ste F2100, Dallas, TX 75207, United States of America
| | - Gregory Knell
- The University of North Texas Health Science Center School of Public Health, 3500 Camp Bowie Boulevard, Fort Worth, TX 76107, United States of America
| | | | - Folefac Atem
- Center for Pediatric Population Health, University of Texas Health Science Center at Houston School of Public Health, 2777 N. Stemmons Freeway, Suite 8400, Dallas, TX 75207, United States of America; Department of Biostatistics, University of Texas Health Science Center School of Public Health, 2777 N. Stemmons Freeway, Suite 8400, Dallas, TX 75207, United States of America
| | - Sarah E Messiah
- Department of Epidemiology, University of Texas Health Science Center at Houston School of Public Health, 2777 N. Stemmons Freeway, Suite 8400, Dallas, TX 75207, United States of America; Center for Pediatric Population Health, University of Texas Health Science Center at Houston School of Public Health, 2777 N. Stemmons Freeway, Suite 8400, Dallas, TX 75207, United States of America; Department of Pediatrics, McGovern Medical School, 6431 Fannin Street, MSB 3.151, Houston, TX 77030, United States of America
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Studenmund C, Lyndon A, Stotts JR, Peralta-Neel C, Sharma AE, Bardach NS. What do patients and families observe about pediatric safety?: A thematic analysis of real-time narratives. J Hosp Med 2024; 19:765-776. [PMID: 38741257 DOI: 10.1002/jhm.13388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 03/04/2024] [Accepted: 04/18/2024] [Indexed: 05/16/2024]
Abstract
OBJECTIVES Data on inpatient safety are documented by hospital staff through incident reporting (IR) systems. Safety observations from families or patients are rarely captured. The Family Input for Quality and Safety (FIQS) study created a mobile health tool for pediatric patients and their families to anonymously report safety observations in real time during hospitalization. The study objectives were to describe these observations and identify domains salient to safety. METHODS In this observational study, we analyzed pediatric patient safety reports from June 2017 to April 2018. Participants were: English-speaking family members and hospitalized patients ≥13 years old. The analysis had two stages: (1) assessment of whether narratives met established safety event criteria and whether there were companion IRs; (2) thematic analysis to identify domains. RESULTS Of 248 enrolled participants, 58 submitted 120 narrative reports. Of the narratives, 68 (57%) met safety event criteria, while only 1 (0.8%) corresponded to a staff-reported IR. Twenty-five percent of narratives shared positive feedback about patient safety efforts; 75% shared constructive feedback. We identified domains particularly salient to safety: (1) patients and families as safety actors; (2) emotional safety; (3) system-centered care; and (4) shared safety domains, including medication, communication, and environment of care. Some domains capture data that is otherwise difficult to obtain (#1-3), while others fit within standard healthcare safety domains (#4). CONCLUSIONS Patients and families observe and report salient safety events that can fill gaps in IR data. Healthcare leaders should consider incorporating patient and family observations-collected with an option for anonymity and eliciting both positive and constructive comments.
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Affiliation(s)
- Christine Studenmund
- Department of Pediatrics, School of Medicine, University of California, San Francisco, California, USA
| | - Audrey Lyndon
- Rory Meyers College of Nursing, New York University, New York, New York, USA
| | - James R Stotts
- Department of Quality and Patient Safety, University of California, San Francisco, California, USA
| | - Caroline Peralta-Neel
- Department of Pediatrics, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Anjana E Sharma
- Department of Family & Community Medicine, University of California, San Francisco, California, USA
| | - Naomi S Bardach
- Department of Pediatrics, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
- Department of Pediatrics, University of California, San Francisco, California, USA
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Zhang D, Stein R, Lu Y, Zhou T, Lei Y, Li L, Chen J, Arnold J, Becich MJ, Chrischilles EA, Chuang CH, Christakis DA, Fort D, Geary CR, Hornig M, Kaushal R, Liebovitz DM, Mosa ASM, Morizono H, Mirhaji P, Dotson JL, Pulgarin C, Sills MR, Suresh S, Williams DA, Baldassano RN, Forrest CB, Chen Y. Pediatric Gastrointestinal Outcomes During the Post-Acute Phase of COVID-19: Findings from RECOVER Initiative from 29 Hospitals in the US. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.21.24307699. [PMID: 38826331 PMCID: PMC11142297 DOI: 10.1101/2024.05.21.24307699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
Importance The profile of gastrointestinal (GI) outcomes that may affect children in post-acute and chronic phases of COVID-19 remains unclear. Objective To investigate the risks of GI symptoms and disorders during the post-acute phase (28 days to 179 days after SARS-CoV-2 infection) and the chronic phase (180 days to 729 days after SARS-CoV-2 infection) in the pediatric population. Design We used a retrospective cohort design from March 2020 to Sept 2023. Setting twenty-nine healthcare institutions. Participants A total of 413,455 patients aged not above 18 with SARS-CoV-2 infection and 1,163,478 patients without SARS-CoV-2 infection. Exposures Documented SARS-CoV-2 infection, including positive polymerase chain reaction (PCR), serology, or antigen tests for SARS-CoV-2, or diagnoses of COVID-19 and COVID-related conditions. Main Outcomes and Measures Prespecified GI symptoms and disorders during two intervals: post-acute phase and chronic phase following the documented SARS-CoV-2 infection. The adjusted risk ratio (aRR) was determined using a stratified Poisson regression model, with strata computed based on the propensity score. Results Our cohort comprised 1,576,933 patients, with females representing 48.0% of the sample. The analysis revealed that children with SARS-CoV-2 infection had an increased risk of developing at least one GI symptom or disorder in both the post-acute (8.64% vs. 6.85%; aRR 1.25, 95% CI 1.24-1.27) and chronic phases (12.60% vs. 9.47%; aRR 1.28, 95% CI 1.26-1.30) compared to uninfected peers. Specifically, the risk of abdominal pain was higher in COVID-19 positive patients during the post-acute phase (2.54% vs. 2.06%; aRR 1.14, 95% CI 1.11-1.17) and chronic phase (4.57% vs. 3.40%; aRR 1.24, 95% CI 1.22-1.27). Conclusions and Relevance In the post-acute phase or chronic phase of COVID-19, the risk of GI symptoms and disorders was increased for COVID-positive patients in the pediatric population.
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Affiliation(s)
- Dazheng Zhang
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Ronen Stein
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Yiwen Lu
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, United States
- Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, United States
| | - Ting Zhou
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Yuqing Lei
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Lu Li
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, United States
- Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, United States
| | - Jiajie Chen
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Jonathan Arnold
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Michael J. Becich
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Elizabeth A. Chrischilles
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, IA, United States
| | - Cynthia H. Chuang
- Division of General Internal Medicine, Penn State College of Medicine, Hershey, PA, United States
| | - Dimitri A Christakis
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA, United States
| | - Daniel Fort
- Ochsner Center for Outcomes Research, Ochsner Health, New Orleans, LA, United States
| | - Carol R. Geary
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, United States
| | - Mady Hornig
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States
| | - Rainu Kaushal
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, United States
| | - David M. Liebovitz
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Abu Saleh Mohammad Mosa
- Department of Biomedical Informatics, Biostatistics and Medical Epidemiology, University of Missouri School of Medicine, Columbia, MO, United States
| | - Hiroki Morizono
- Center for Genetic Medicine Research, Children’s National Hospital, Washington, DC, United States
| | - Parsa Mirhaji
- Institute for Clinical Translational Research, Albert Einstein College of Medicine, New York, NY, United States
| | - Jennifer L. Dotson
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Claudia Pulgarin
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Marion R. Sills
- Department of Research, OCHIN, Inc., Portland, OR, United States
- University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Srinivasan Suresh
- Divisions of Health Informatics & Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - David A. Williams
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - Robert N. Baldassano
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Christopher B. Forrest
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Yong Chen
- The Center for Health AI and Synthesis of Evidence (CHASE), University of Pennsylvania, Philadelphia, PA, United States
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
- Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, United States
- Penn Institute for Biomedical Informatics (IBI), Philadelphia, PA, United States
- Leonard Davis Institute of Health Economics, Philadelphia, PA, United States
- Penn Medicine Center for Evidence-based Practice (CEP), Philadelphia, PA, United States
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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 PMCID: PMC11322619 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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5
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Heneghan JA, Akande MY, Ramgopal S, Evans MD, Hallman M, Goodman DM. New Morbidities During Critical Illness and Associated Risk of ICU Readmission: Virtual Pediatric Systems Cohort, 2017-2020. Pediatr Crit Care Med 2024:00130478-990000000-00345. [PMID: 38780383 DOI: 10.1097/pcc.0000000000003542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
OBJECTIVES To describe change in Functional Status Scale (FSS) associated with critical illness and assess associated development of new morbidities with PICU readmission. DESIGN Retrospective, cross-sectional cohort study using the Virtual Pediatric Systems (VPS; Los Angeles, CA) database. SETTING One hundred twenty-six U.S. PICUs participating in VPS. SUBJECTS Children younger than 21 years old admitted 2017-2020 and followed to December 2022. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 40,654 patients, 86.2% were classified as having good function or mild dysfunction before illness. Most patients did not have a change in their FSS category during hospitalization. Survival with new morbidity occurred most in children with baseline good/mild dysfunction (8.7%). Hospital mortality increased across categories of baseline dysfunction. Of 39,701 survivors, 14.2% were readmitted within 1 year. Median time to readmission was 159 days. In multivariable, mixed-effects Cox modeling, time to readmission was most associated with discharge functional status (hazard ratio [HR], 5.3 [95% CI, 4.6-6.1] for those with very severe dysfunction), and associated with lower hazard in those who survived with new morbidity (HR, 0.7 [95% CI, 0.6-0.7]). CONCLUSIONS Development of new morbidities occurs commonly in pediatric critical illness, but we failed to find an association with greater hazard of PICU readmission. Instead, patient functional status is associated with hazard of PICU readmission.
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Affiliation(s)
- Julia A Heneghan
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, MN
| | - Manzilat Y Akande
- Section of Critical Care, Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, OK
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michael D Evans
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota; Minneapolis, MN
| | - Madhura Hallman
- Division of Pediatric Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Denise M Goodman
- Division of Pediatric Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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Wu Q, Tong J, Zhang B, Zhang D, Chen J, Lei Y, Lu Y, Wang Y, Li L, Shen Y, Xu J, Bailey LC, Bian J, Christakis DA, Fitzgerald ML, Hirabayashi K, Jhaveri R, Khaitan A, Lyu T, Rao S, Razzaghi H, Schwenk HT, Wang F, Gage Witvliet MI, Tchetgen Tchetgen EJ, Morris JS, Forrest CB, Chen Y. Real-World Effectiveness of BNT162b2 Against Infection and Severe Diseases in Children and Adolescents. Ann Intern Med 2024; 177:165-176. [PMID: 38190711 DOI: 10.7326/m23-1754] [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: 01/10/2024] Open
Abstract
BACKGROUND The efficacy of the BNT162b2 vaccine in pediatrics was assessed by randomized trials before the Omicron variant's emergence. The long-term durability of vaccine protection in this population during the Omicron period remains limited. OBJECTIVE To assess the effectiveness of BNT162b2 in preventing infection and severe diseases with various strains of the SARS-CoV-2 virus in previously uninfected children and adolescents. DESIGN Comparative effectiveness research accounting for underreported vaccination in 3 study cohorts: adolescents (12 to 20 years) during the Delta phase and children (5 to 11 years) and adolescents (12 to 20 years) during the Omicron phase. SETTING A national collaboration of pediatric health systems (PEDSnet). PARTICIPANTS 77 392 adolescents (45 007 vaccinated) during the Delta phase and 111 539 children (50 398 vaccinated) and 56 080 adolescents (21 180 vaccinated) during the Omicron phase. INTERVENTION First dose of the BNT162b2 vaccine versus no receipt of COVID-19 vaccine. MEASUREMENTS Outcomes of interest include documented infection, COVID-19 illness severity, admission to an intensive care unit (ICU), and cardiac complications. The effectiveness was reported as (1-relative risk)*100, with confounders balanced via propensity score stratification. RESULTS During the Delta period, the estimated effectiveness of the BNT162b2 vaccine was 98.4% (95% CI, 98.1% to 98.7%) against documented infection among adolescents, with no statistically significant waning after receipt of the first dose. An analysis of cardiac complications did not suggest a statistically significant difference between vaccinated and unvaccinated groups. During the Omicron period, the effectiveness against documented infection among children was estimated to be 74.3% (CI, 72.2% to 76.2%). Higher levels of effectiveness were seen against moderate or severe COVID-19 (75.5% [CI, 69.0% to 81.0%]) and ICU admission with COVID-19 (84.9% [CI, 64.8% to 93.5%]). Among adolescents, the effectiveness against documented Omicron infection was 85.5% (CI, 83.8% to 87.1%), with 84.8% (CI, 77.3% to 89.9%) against moderate or severe COVID-19, and 91.5% (CI, 69.5% to 97.6%) against ICU admission with COVID-19. The effectiveness of the BNT162b2 vaccine against the Omicron variant declined 4 months after the first dose and then stabilized. The analysis showed a lower risk for cardiac complications in the vaccinated group during the Omicron variant period. LIMITATION Observational study design and potentially undocumented infection. CONCLUSION This study suggests that BNT162b2 was effective for various COVID-19-related outcomes in children and adolescents during the Delta and Omicron periods, and there is some evidence of waning effectiveness over time. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Qiong Wu
- The Center for Health Analytics and Synthesis of Evidence (CHASE), Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (Q.W., J.T., D.Z., J.C., Y.Lei, Y.W.)
| | - Jiayi Tong
- The Center for Health Analytics and Synthesis of Evidence (CHASE), Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (Q.W., J.T., D.Z., J.C., Y.Lei, Y.W.)
| | - Bingyu Zhang
- The Center for Health Analytics and Synthesis of Evidence (CHASE), The Graduate Group in Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania (B.Z., Y.Lu, L.L., Y.S.)
| | - Dazheng Zhang
- The Center for Health Analytics and Synthesis of Evidence (CHASE), Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (Q.W., J.T., D.Z., J.C., Y.Lei, Y.W.)
| | - Jiajie Chen
- The Center for Health Analytics and Synthesis of Evidence (CHASE), Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (Q.W., J.T., D.Z., J.C., Y.Lei, Y.W.)
| | - Yuqing Lei
- The Center for Health Analytics and Synthesis of Evidence (CHASE), Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (Q.W., J.T., D.Z., J.C., Y.Lei, Y.W.)
| | - Yiwen Lu
- The Center for Health Analytics and Synthesis of Evidence (CHASE), The Graduate Group in Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania (B.Z., Y.Lu, L.L., Y.S.)
| | - Yudong Wang
- The Center for Health Analytics and Synthesis of Evidence (CHASE), Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (Q.W., J.T., D.Z., J.C., Y.Lei, Y.W.)
| | - Lu Li
- The Center for Health Analytics and Synthesis of Evidence (CHASE), The Graduate Group in Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania (B.Z., Y.Lu, L.L., Y.S.)
| | - Yishan Shen
- The Center for Health Analytics and Synthesis of Evidence (CHASE), The Graduate Group in Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania (B.Z., Y.Lu, L.L., Y.S.)
| | - Jie Xu
- Department of Health Outcomes Biomedical Informatics, University of Florida, Gainesville, Florida (J.X., J.B., T.L.)
| | - L Charles Bailey
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (L.C.B., K.H., H.R., C.B.F.)
| | - Jiang Bian
- Department of Health Outcomes Biomedical Informatics, University of Florida, Gainesville, Florida (J.X., J.B., T.L.)
| | - Dimitri A Christakis
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington (D.A.C.)
| | - Megan L Fitzgerald
- Department of Medicine, Grossman School of Medicine, New York University, New York, New York (M.L.F.)
| | - Kathryn Hirabayashi
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (L.C.B., K.H., H.R., C.B.F.)
| | - Ravi Jhaveri
- Division of Pediatric Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois (R.J.)
| | - Alka Khaitan
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, Indiana (A.K.)
| | - Tianchen Lyu
- Department of Health Outcomes Biomedical Informatics, University of Florida, Gainesville, Florida (J.X., J.B., T.L.)
| | - Suchitra Rao
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado (S.R.)
| | - Hanieh Razzaghi
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (L.C.B., K.H., H.R., C.B.F.)
| | - Hayden T Schwenk
- Department of Pediatrics, Stanford School of Medicine, Stanford, California (H.T.S.)
| | - Fei Wang
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York (F.W.)
| | - Margot I Gage Witvliet
- Department of Sociology, Social Work and Criminal Justice, Lamar University, Beaumont, Texas (M.I.G.W.)
| | - Eric J Tchetgen Tchetgen
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (E.J.T.T., J.S.M.)
| | - Jeffrey S Morris
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (E.J.T.T., J.S.M.)
| | - Christopher B Forrest
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (L.C.B., K.H., H.R., C.B.F.)
| | - Yong Chen
- The Center for Health Analytics and Synthesis of Evidence (CHASE), Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, and The Graduate Group in Applied Mathematics and Computational Science, School of Arts and Sciences, University of Pennsylvania, Leonard Davis Institute of Health Economics, Penn Medicine Center for Evidence-based Practice (CEP), and Penn Institute for Biomedical Informatics (IBI), Philadelphia, Pennsylvania (Y.C.)
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7
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Gutman CK, Aronson PL, Singh NV, Pickett ML, Bouvay K, Green RS, Roach B, Kotler H, Chow JL, Hartford EA, Hincapie M, St. Pierre-Hetz R, Kelly J, Sartori L, Hoffmann JA, Corboy JB, Bergmann KR, Akinsola B, Ford V, Tedford NJ, Tran TT, Gifford S, Thompson AD, Krack A, Piroutek MJ, Lucrezia S, Chung S, Chowdhury N, Jackson K, Cheng T, Pulcini CD, Kannikeswaran N, Truschel LL, Lin K, Chu J, Molyneaux ND, Duong M, Dingeldein L, Rose JA, Theiler C, Bhalodkar S, Powers E, Waseem M, Lababidi A, Yan X, Lou XY, Fernandez R, Lion KC. Race, Ethnicity, Language, and the Treatment of Low-Risk Febrile Infants. JAMA Pediatr 2024; 178:55-64. [PMID: 37955907 PMCID: PMC10644247 DOI: 10.1001/jamapediatrics.2023.4890] [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: 05/19/2023] [Accepted: 08/02/2023] [Indexed: 11/14/2023]
Abstract
Importance Febrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language. Objective To investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection. Design, Setting, and Participants This was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source. Exposures Infant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English). Main Outcomes and Measures The primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes. Results Across 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46). Conclusions and Relevance Among low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.
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Affiliation(s)
- Colleen K. Gutman
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville
- Department of Pediatrics, University of Florida College of Medicine, Gainesville
| | - Paul L. Aronson
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Nidhi V. Singh
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Kamali Bouvay
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Rebecca S. Green
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School and Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Britta Roach
- Division of Pediatric Emergency Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Hannah Kotler
- Division of Emergency Medicine, The George Washington University School of Medicine and Health Sciences and Children’s National Health System, Washington, DC
| | - Jessica L. Chow
- Division of Emergency Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Emergency Medicine, University of California, Los Angeles
| | - Emily A. Hartford
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children’s Hospital, Seattle
| | - Mark Hincapie
- Department of Pediatrics, University of Pittsburgh Medical Center and Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Pediatric Emergency Medicine, Nicklaus Children’s Hospital, Miami, Florida
| | - Ryan St. Pierre-Hetz
- Department of Pediatrics, University of Pittsburgh Medical Center and Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jessica Kelly
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Laura Sartori
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jennifer A. Hoffmann
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jacqueline B. Corboy
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kelly R. Bergmann
- Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis, Minnesota
| | - Bolanle Akinsola
- Department of Pediatrics and Emergency Medicine, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Vanessa Ford
- Department of Pediatrics and Emergency Medicine, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Natalie J. Tedford
- Division of Pediatric Emergency Medicine, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City
| | - Theresa T. Tran
- Division of Pediatric Emergency Medicine, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City
| | - Sasha Gifford
- Ronald O. Perelman Department of Emergency Medicine/New York University Langone Health, New York, New York
- Department of Emergency Medicine, Weill Cornell Medical College, New York, New York
| | - Amy D. Thompson
- Department of Pediatrics, Nemours Children’s Hospital of Delaware, Wilmington
| | - Andrew Krack
- Department of Pediatrics, School of Medicine, Section of Emergency Medicine, University of Colorado and Children’s Hospital Colorado, Aurora
| | - Mary Jane Piroutek
- Department of Emergency Medicine, University of California Irvine and Children’s Hospital of Orange County, Orange
| | - Samantha Lucrezia
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
| | - SunHee Chung
- Department of Emergency Medicine, Oregon Health and Science University, Portland
- Department of Pediatrics, Oregon Health and Science University, Portland
| | - Nabila Chowdhury
- Division of Pediatric Emergency Medicine, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Kathleen Jackson
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston
| | - Tabitha Cheng
- Department of Emergency Medicine, Harbor University of California Los Angeles Medical Center and the David Geffen School of Medicine at the University of California, Los Angeles
| | - Christian D. Pulcini
- Department of Pediatrics, University of Vermont Larner College of Medicine, Burlington
- Department of Emergency Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Nirupama Kannikeswaran
- Department of Pediatrics, Central Michigan University College of Medicine and Children’s Hospital of Michigan, Detroit
| | - Larissa L. Truschel
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Karen Lin
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Jamie Chu
- Department of Emergency Medicine, McGovern Medical School, UTHealth Houston, Houston, Texas
- Texas Children’s Pediatrics, Houston
| | - Neh D. Molyneaux
- Department of Emergency Medicine, McGovern Medical School, UTHealth Houston, Houston, Texas
| | - Myto Duong
- Division of Pediatric Emergency Medicine, Southern Illinois University, Carbondale
| | - Leslie Dingeldein
- Rainbow Babies and Children’s Hospital and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jerri A. Rose
- Rainbow Babies and Children’s Hospital and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Carly Theiler
- Department of Emergency Medicine, University of Iowa, Iowa City
| | - Sonali Bhalodkar
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Emily Powers
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Muhammad Waseem
- Department of Pediatrics, Lincoln Medical Center, Bronx, New York
- Department of Emergency Medicine, Lincoln Medical Center, Bronx, New York
| | - Ahmed Lababidi
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville
- Department of Pediatrics, University of Florida College of Medicine, Gainesville
| | - Xinyu Yan
- Department of Biostatistics, University of Florida College of Medicine and College of Public Health and Health Professions, Gainesville
| | - Xiang-Yang Lou
- Department of Biostatistics, University of Florida College of Medicine and College of Public Health and Health Professions, Gainesville
| | - Rosemarie Fernandez
- Department of Emergency Medicine and the Center for Experiential Learning and Simulation, University of Florida College of Medicine, Gainesville
| | - K. Casey Lion
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington
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8
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Horton DB, Yang Y, Neikirk A, Huang C, Crystal S, Davidow A, Haynes K, Gerhard T, Rose CD, Strom BL, Parlett L. Impact of the COVID-19 Pandemic on the Management of Juvenile Idiopathic Arthritis: Analysis of United States Commercial Insurance Data. J Clin Rheumatol 2023; 29:388-395. [PMID: 37798830 PMCID: PMC10843854 DOI: 10.1097/rhu.0000000000002035] [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] [Indexed: 10/07/2023]
Abstract
BACKGROUND/OBJECTIVE Given limited information on health care and treatment utilization for juvenile idiopathic arthritis (JIA) during the pandemic, we studied JIA-related health care and treatment utilization in a commercially insured retrospective US cohort. METHODS We studied rates of outpatient visits, new disease-modifying antirheumatic drug (DMARD) initiations, intra-articular glucocorticoid injections (iaGC), dispensed oral glucocorticoids and opioids, DMARD adherence, and DMARD discontinuation by quarter in March 2018-February 2021 (Q1 started in March). Incident rate ratios (IRR, pandemic vs prepandemic) with 95% confidence intervals (CIs) were estimated using multivariable Poisson or Quasi-Poisson models stratified by diagnosis recency (incident JIA, <12 months ago; prevalent JIA, ≥12 months ago). RESULTS Among 1294 children diagnosed with JIA, total and in-person outpatient visits for JIA declined during the pandemic (IRR, 0.88-0.90), most markedly in Q1 2020. Telemedicine visits, while higher during the pandemic, declined from 21% (Q1) to 13% (Q4) in 2020 to 2021. During the pandemic, children with prevalent JIA, but not incident JIA, had lower usage of iaGC (IRR, 0.60; 95% CI, 0.34-1.07), oral glucocorticoids (IRR, 0.47; 95% CI, 0.33-0.67), and opioids (IRR, 0.44; 95% CI, 0.26-0.75). Adherence to and discontinuation of DMARDs was similar before and during the pandemic. CONCLUSIONS In the first year of the pandemic, visits for JIA dropped by 10% to 12% in commercially insured children in the United States, declines partly mitigated by use of telemedicine. Pandemic-related declines in intra-articular glucocorticoids, oral glucocorticoids, and opioids were observed for children with prevalent, but not incident, JIA. These changes may have important implications for disease control and quality of life.
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Affiliation(s)
- Daniel B. Horton
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
| | | | | | - Cecilia Huang
- Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
| | - Stephen Crystal
- Rutgers Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
- Rutgers School of Social Work, New Brunswick, NJ, USA
| | - Amy Davidow
- New York University School of Global Public Health, New York, NY, USA
| | - Kevin Haynes
- Janssen Research & Development, Titusville, NJ, USA
| | - Tobias Gerhard
- Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, New Brunswick, NJ, USA
| | | | - Brian L. Strom
- Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ, USA
- Rutgers Biomedical and Health Sciences, Newark, NJ, USA
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9
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Mitsnefes MM, Maltenfort M, Denburg MR, Flynn JT, Schuchard J, Dixon BP, Patel HP, Claes D, Dickinson K, Chen Y, Gluck C, Leonard M, Verghese PS, Forrest CB. Derivation of paediatric blood pressure percentiles from electronic health records. EBioMedicine 2023; 98:104885. [PMID: 37988770 PMCID: PMC10679476 DOI: 10.1016/j.ebiom.2023.104885] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/06/2023] [Accepted: 11/08/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Identification of abnormal blood pressure (BP) in children requires normative data. We sought to examine the feasibility of using "real-world" office BP data obtained from electronic health records (EHR) to generate age-, sex- and height-specific BP percentiles for children. METHODS Using data collected 01/01/2009-8/31/2021 from eight large children's healthcare organisations in PEDSnet, we applied a mixed-effects polynomial regression model with random slopes to generate Z-scores and BP percentiles and compared them with currently used normative BP distributions published in the 2017 American Academy of Paediatrics (AAP) Clinical Practise Guidelines (CPG). FINDINGS We identified a study sample of 292,412 children (1,085,083 BP measurements), ages 3-17 years (53% female), with no chronic medical conditions, who were not overweight/obese and who were primarily seen for general paediatric care in outpatient settings. Approximately 45,000-75,000 children contributed data to each age category. The PEDSnet systolic BP percentile values were 1-4 mmHg higher than AAP CPG BP values across age-sex-height groups, with larger differences observed in younger children. Diastolic BP values were also higher in younger children; starting with age 7 years, diastolic BP percentile values were 1-3 mmHg lower than AAP CPG values. Cohen's Kappa was 0.90 for systolic BP, 0.66 for diastolic BP, and 0.80 overall indicating excellent agreement between PEDSnet and 2017 AAP CPG data for systolic BP and substantial agreement for diastolic BP. INTERPRETATION Our analysis indicates that real-word EHR data can be used to generate BP percentiles consistent with current clinical practise on BP management in children. FUNDING Funding for this work was provided by the Preserving Kidney Function in Children with Chronic Kidney Disease (PRESERVE) study; Patient-Centred Outcomes Research Institute (PCORI) RD-2020C2020338 (Principal Investigator: Dr. Forrest; Co-Principal Investigator: Dr. Denburg).
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Affiliation(s)
- Mark M Mitsnefes
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, OH, USA.
| | - Mitchell Maltenfort
- Children's Hospital of Philadelphia, Applied Clinical Research Center, Philadelphia, PA, USA
| | - Michelle R Denburg
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania: Philadelphia, PA, USA; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph T Flynn
- Division of Nephrology, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Julia Schuchard
- Children's Hospital of Philadelphia, Applied Clinical Research Center, Philadelphia, PA, USA
| | - Bradley P Dixon
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Denver, CO, USA
| | | | - Donna Claes
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, OH, USA
| | - Kimberley Dickinson
- Children's Hospital of Philadelphia, Applied Clinical Research Center, Philadelphia, PA, USA
| | - Yong Chen
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Caroline Gluck
- Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | | | - Priya S Verghese
- Ann & Robert H Lurie Children's Hospital, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - Christopher B Forrest
- Children's Hospital of Philadelphia, Applied Clinical Research Center, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania: Philadelphia, PA, USA
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10
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Rao S, Jing N, Liu X, Lorman V, Maltenfort M, Schuchard J, Wu Q, Tong J, Razzaghi H, Mejias A, Lee GM, Pajor NM, Schulert GS, Thacker D, Jhaveri R, Christakis DA, Bailey LC, Forrest CB, Chen Y. Spectrum of severity of multisystem inflammatory syndrome in children: an EHR-based cohort study from the RECOVER program. Sci Rep 2023; 13:21005. [PMID: 38017007 PMCID: PMC10684592 DOI: 10.1038/s41598-023-47655-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 11/16/2023] [Indexed: 11/30/2023] Open
Abstract
Multi-system inflammatory syndrome in children (MIS-C) is a severe post-acute sequela of SARS-CoV-2 infection in children, and there is a critical need to unfold its highly heterogeneous disease patterns. Our objective was to characterize the illness spectrum of MIS-C for improved recognition and management. We conducted a retrospective cohort study using data from March 1, 2020-September 30, 2022, in 8 pediatric medical centers from PEDSnet. We included 1139 children hospitalized with MIS-C and used their demographics, symptoms, conditions, laboratory values, and medications for analyses. We applied heterogeneity-adaptive latent class analyses and identified three latent classes. We further characterized the sociodemographic and clinical characteristics of the latent classes and evaluated their temporal patterns. Class 1 (47.9%) represented children with the most severe presentation, with more admission to the ICU, higher inflammatory markers, hypotension/shock/dehydration, cardiac involvement, acute kidney injury and respiratory involvement. Class 2 (23.3%) represented a moderate presentation, with 4-6 organ systems involved, and some overlapping features with acute COVID-19. Class 3 (28.8%) represented a mild presentation. Our results indicated that MIS-C has a spectrum of clinical severity ranging from mild to severe and the proportion of severe or critical MIS-C decreased over time.
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Affiliation(s)
- Suchitra Rao
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, 13123 E 16th Ave Box 090, Aurora, CO, 80045, USA.
| | - Naimin Jing
- Department of Biostatistics, Epidemiology and Informatics, The Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Blockley Hall 602, Philadelphia, PA, 19104, USA
- Biostatistics and Research Decision Sciences, Merck & Co., Inc, Kenilworth, NJ, USA
| | - Xiaokang Liu
- Department of Biostatistics, Epidemiology and Informatics, The Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Blockley Hall 602, Philadelphia, PA, 19104, USA
| | - Vitaly Lorman
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mitchell Maltenfort
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julia Schuchard
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Qiong Wu
- Department of Biostatistics, Epidemiology and Informatics, The Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Blockley Hall 602, Philadelphia, PA, 19104, USA
| | - Jiayi Tong
- Department of Biostatistics, Epidemiology and Informatics, The Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Blockley Hall 602, Philadelphia, PA, 19104, USA
| | - Hanieh Razzaghi
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Asuncion Mejias
- Division of Infectious Diseases, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Grace M Lee
- Department of Pediatrics (Infectious Diseases), Stanford University School of Medicine, Stanford, CA, USA
| | - Nathan M Pajor
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Grant S Schulert
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Deepika Thacker
- Division of Cardiology, Nemours Children's Health, Wilmington, DE, USA
| | - Ravi Jhaveri
- Division of Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Dimitri A Christakis
- Center for Child Health, Behavior and Development, Seattle Children's Hospital, Seattle, WA, USA
| | - L Charles Bailey
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher B Forrest
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Yong Chen
- Department of Biostatistics, Epidemiology and Informatics, The Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Blockley Hall 602, Philadelphia, PA, 19104, USA.
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11
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Keim-Malpass J, Lunsford C, Letzkus LC, Scheer E, Valdez RS. Establishing the Need for Anticipatory Symptom Guidance and Networked Models of Disease in Adaptive Family Management Among Children With Medical Complexity: Qualitative Study. JMIR Form Res 2023; 7:e52454. [PMID: 37801346 PMCID: PMC10704321 DOI: 10.2196/52454] [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: 09/04/2023] [Revised: 10/04/2023] [Accepted: 10/06/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Caregivers of children with medical complexity navigate complex family management tasks for their child both in the hospital and home-based setting. The roles and relationships of members of their social network and the dynamic evolution of these family management tasks have been underexamined. OBJECTIVE The purpose of this study was to explore the structures and processes of family management among caregivers of children with medical complexity, with a focus on the underlying dynamic nature of family management practices and the role of members of their social network. METHODS This study used a qualitative approach to interview caregivers of children with medical complexity and members of their social network. Caregivers of children with medical complexity were recruited through an academic Children's Hospital Complex Care Clinic in the mid-Atlantic region and interviewed over a period of 1 to 3 days. Responses were analyzed using constructivist grounded theory and situational analysis to construct a new conceptual model. Only caregiver responses are reported here. RESULTS In total, 20 caregivers were included in this analysis. Caregiver perspectives revealed the contextual processes that allowed for practices of family management within the setting of rapidly evolving symptoms and health concerns. The dynamic and adaptive nature of this process is a key underlying action supporting this novel conceptual model. The central themes underpinning the adaptive family management model include symptom cues, ongoing surveillance, information gathering, and acute on chronic health concerns. The model also highlights facilitators and threats to successful family management among children with medical complexity and the networked relationship among the structures and processes. CONCLUSIONS The adaptive family management model provides a basis for further quantitative operationalization and study. Previously described self- or family management frameworks do not account for the underlying dynamic nature of the disease trajectory and the developmental stage progression of the child or adolescent, and our work extends existing work. For future work, there is a defined role for technology-enhanced personalized approaches to home-based monitoring. Due to the disparities caregivers and the children in this population already experience, technology-enhanced approaches must be built alongside key stakeholders with an equity orientation to technology co-development. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/14810.
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Affiliation(s)
- Jessica Keim-Malpass
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Christopher Lunsford
- Department of Physical Medicine and Rehabilitation, Duke University School of Medicine, Durham, NC, United States
| | - Lisa C Letzkus
- Division of Developmental Pediatrics, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Eleanore Scheer
- Department of Systems and Information Engineering, University of Virginia School of Engineering and Applied Sciences, Charlottesville, VA, United States
| | - Rupa S Valdez
- Department of Systems and Information Engineering, University of Virginia School of Engineering and Applied Sciences, Charlottesville, VA, United States
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, United States
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12
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Larson IA, Zaniletti I, Gupta R, Wright SM, Winterer C, Toburen C, Williams K, Goodwin EJ, Northup RM, Roderick E, Hall M, Colvin JD. Accuracy of the Exeter Hospitalizations-Office Visits-Medical Conditions-Extra Care-Social Concerns Index for Identifying Children With Complex Chronic Medical Conditions in the Clinical Setting. Acad Pediatr 2023; 23:1553-1560. [PMID: 37516350 DOI: 10.1016/j.acap.2023.07.010] [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: 01/03/2023] [Revised: 07/20/2023] [Accepted: 07/22/2023] [Indexed: 07/31/2023]
Abstract
OBJECTIVE Our objective was to determine the accuracy of a point-of-care instrument, the Hospitalizations-Office Visits-Medical Conditions-Extra Care-Social Concerns (HOMES) instrument, in identifying patients with complex chronic conditions (CCCs) compared to an algorithm used to identify patients with CCCs within large administrative data sets. METHODS We compared the HOMES to Feudtner's CCCs classification system. Using administrative algorithms, we categorized primary care patients at a children's hospital into 3 categories: no chronic conditions, non-complex chronic conditions, and CCCs. We randomly selected 100 patients from each category. HOMES scoring was completed for each patient. We performed an optimal cut-point analysis on 80% of the sample to determine which total HOMES score best identified children with ≥1 CCC and ≥2 CCCs. Using the optimal cut points and the remaining 20% of the study population, we determined the odds and area under the curve (AUC) of having ≥1 CCC and ≥2 CCCs. RESULTS The median (interquartile range [IQR]) age was 4 (IQR: 0, 8). Using optimal cut points of ≥7 for ≥1 CCC and ≥11 for ≥2 CCCs, the odds of having ≥1 CCC was 19 times higher than lower scores (odds ratio [OR] 19.1 [95% confidence interval [CI]: 9.75, 37.5]) and of having ≥2 CCCs was 32 times higher (OR 32.3 [95% CI: 12.9, 50.6]). The AUCs were 0.76 for ≥1 CCC (sensitivity 0.82, specificity 0.80) and 0.74 for ≥2 CCCs (sensitivity 0.92, specificity 0.74). CONCLUSIONS The HOMES accurately identified patients with CCCs.
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Affiliation(s)
- Ingrid A Larson
- Administration (IA Larson), Children's Mercy Hospital Kansas, Overland Park
| | - Isabella Zaniletti
- Analytics, Children's Hospital Association (I Zaniletti and M Hall), Kansas City, Kans
| | - Rupal Gupta
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - S Margaret Wright
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Courtney Winterer
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Cristy Toburen
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Kristi Williams
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Emily J Goodwin
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Ryan M Northup
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Edie Roderick
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Matt Hall
- Analytics, Children's Hospital Association (I Zaniletti and M Hall), Kansas City, Kans; Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Jeffrey D Colvin
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo.
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13
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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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14
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Stenson EK, Banks RK, Reeder RW, Maddux AB, Zimmerman J, Meert KL, Mourani PM. Fluid Balance and Its Association With Mortality and Health-Related Quality of Life: A Nonprespecified Secondary Analysis of the Life After Pediatric Sepsis Evaluation. Pediatr Crit Care Med 2023; 24:829-839. [PMID: 37260317 PMCID: PMC10689573 DOI: 10.1097/pcc.0000000000003294] [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: 06/02/2023]
Abstract
OBJECTIVES To evaluate the association between fluid balance (FB) and health-related quality of life (HRQL) among children at 1 month following community-acquired septic shock. DESIGN Nonprespecified secondary analysis of the Life After Pediatric Sepsis Evaluation. FB was defined as 100 × [(cumulative PICU fluid input - cumulative PICU fluid output)/PICU admission weight]. Three subgroups were identified: low FB (< 5%), medium FB (5%-15%), and high FB (> 15%) based on cumulative FB on days 0-3 of ICU stay. HRQL was measured at ICU admission and 1 month after using Pediatric Quality of Life Inventory 4.0 Generic Core or Infant Scales or the Stein-Jessop Functional Status Scale. The primary outcome was a composite of mortality or greater than 25% decline in HRQL 1 month after admission compared with baseline. SETTING Twelve academic PICUs in the United States. PATIENTS Critically ill children between 1 month and 18 years, with community-acquired septic shock who survived to at least day 4. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two hundred ninety-three patients were included of whom 66 (23%) had low FB, 127 (43%) had medium FB, and 100 (34%) had high FB. There was no difference in Pediatric Risk of Mortality Score 3 (median 11 [6, 17]), age (median 5 [1, 12]), or gender (47% female) between FB groups. After adjusting for potential confounders and comparing with medium FB, higher odds of mortality or greater than 25% HRQL decline were seen in both the low FB (odds ratio [OR] 2.79 [1.20, 6.57]) and the high FB (OR 2.16 [1.06, 4.47]), p = 0.027. Compared with medium FB, low FB (OR 4.3 [1.62, 11.84]) and high FB (OR 3.29 [1.42, 8.00]) had higher odds of greater than 25% HRQL decline. CONCLUSIONS Over half of the children who survived septic shock had low or high FB, which was associated with a significant decline in HRQL scores. Prospective studies are needed to determine if optimization of FB can improve HRQL outcomes.
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Affiliation(s)
- Erin K. Stenson
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Colorado, Aurora, CO
| | - Russell K Banks
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Ron W. Reeder
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Aline B. Maddux
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Colorado, Aurora, CO
| | - Jerry Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children’s Hospital, Seattle Children’s Research Institute, University of Washington School of Medicine, Seattle, WA
| | - Kathleen L. Meert
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Peter M. Mourani
- Section of Critical Care Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little Rock, AR
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15
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Oliveira PV, Enes CC, Nucci LB. How are children with medical complexity being identified in epidemiological studies? A systematic review. World J Pediatr 2023; 19:928-938. [PMID: 36574212 DOI: 10.1007/s12519-022-00672-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 12/05/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND There are different definitions to identify/classify children with medical complexity (CMC). We aimed to investigate and describe the definitions used to classify CMC in epidemiological studies. METHODS PubMed, SciELO, LILACS, and EMBASE were searched from 2015 to 2020 (last updated September 15th, 2020) for original studies that presented the definition used to classify/identify CMC in the scientific research method. We applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. From the included studies, the following were identified: first author, year of publication, design, population, study period, the definition of CMC used, limitations, and strengths. RESULTS Nine hundred and sixty-seven records were identified in the searched databases, and 42 met the inclusion criteria. Of the 42 studies included, the four most frequent definitions used in the articles included in this review were classification of CMC into nine diagnostic categories based on the International Classification of Diseases, Ninth Revision (ICD-9) (35.7%, 15 articles); update of the previous classification for ICD-10 codes with the inclusion of other conditions in the definition (21.4%, nine articles); definition based on a medical complexity algorithm for classification (16.7%, seven articles); and a risk rating system (7.1%, three articles). CONCLUSIONS CMC definitions using diagnostic codes were more frequent. However, several limitations were found in its uses. Our research highlighted the need to improve health information systems to accurately characterize the CMC population and promote the provision of comprehensive care.
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Affiliation(s)
- Patrícia Vicente Oliveira
- Postgraduate Program in Health Sciences, Center for Life Sciences, Pontifical Catholic University of Campinas, Av. John Boyd Dunlop s/n, Campinas, CEP 13060-904, Brazil.
| | - Carla C Enes
- Postgraduate Program in Health Sciences, School of Nutrition, Pontifical Catholic University of Campinas, São Paulo, Brazil
| | - Luciana B Nucci
- Postgraduate Program in Health Sciences, School of Medicine, Pontifical Catholic University of Campinas, São Paulo, Brazil
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16
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Elia J, Pajer K, Prasad R, Pumariega A, Maltenfort M, Utidjian L, Shenkman E, Kelleher K, Rao S, Margolis PA, Christakis DA, Hardan AY, Ballard R, Forrest CB. Electronic health records identify timely trends in childhood mental health conditions. Child Adolesc Psychiatry Ment Health 2023; 17:107. [PMID: 37710303 PMCID: PMC10503059 DOI: 10.1186/s13034-023-00650-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 08/20/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Electronic health records (EHRs) data provide an opportunity to collect patient information rapidly, efficiently and at scale. National collaborative research networks, such as PEDSnet, aggregate EHRs data across institutions, enabling rapid identification of pediatric disease cohorts and generating new knowledge for medical conditions. To date, aggregation of EHR data has had limited applications in advancing our understanding of mental health (MH) conditions, in part due to the limited research in clinical informatics, necessary for the translation of EHR data to child mental health research. METHODS In this cohort study, a comprehensive EHR-based typology was developed by an interdisciplinary team, with expertise in informatics and child and adolescent psychiatry, to query aggregated, standardized EHR data for the full spectrum of MH conditions (disorders/symptoms and exposure to adverse childhood experiences (ACEs), across 13 years (2010-2023), from 9 PEDSnet centers. Patients with and without MH disorders/symptoms (without ACEs), were compared by age, gender, race/ethnicity, insurance, and chronic physical conditions. Patients with ACEs alone were compared with those that also had MH disorders/symptoms. Prevalence estimates for patients with 1+ disorder/symptoms and for specific disorders/symptoms and exposure to ACEs were calculated, as well as risk for developing MH disorder/symptoms. RESULTS The EHR study data set included 7,852,081 patients < 21 years of age, of which 52.1% were male. Of this group, 1,552,726 (19.8%), without exposure to ACEs, had a lifetime MH disorders/symptoms, 56.5% being male. Annual prevalence estimates of MH disorders/symptoms (without exposure to ACEs) rose from 10.6% to 2010 to 15.1% in 2023, a 44% relative increase, peaking to 15.4% in 2019, prior to the Covid-19 pandemic. MH categories with the largest increases between 2010 and 2023 were exposure to ACEs (1.7, 95% CI 1.6-1.8), anxiety disorders (2.8, 95% CI 2.8-2.9), eating/feeding disorders (2.1, 95% CI 2.1-2.2), gender dysphoria/sexual dysfunction (43.6, 95% CI 35.8-53.0), and intentional self-harm/suicidality (3.3, 95% CI 3.2-3.5). White youths had the highest rates in most categories, except for disruptive behavior disorders, elimination disorders, psychotic disorders, and standalone symptoms which Black youths had higher rates. Median age of detection was 8.1 years (IQR 3.5-13.5) with all standalone symptoms recorded earlier than the corresponding MH disorder categories. CONCLUSIONS These results support EHRs' capability in capturing the full spectrum of MH disorders/symptoms and exposure to ACEs, identifying the proportion of patients and groups at risk, and detecting trends throughout a 13-year period that included the Covid-19 pandemic. Standardized EHR data, which capture MH conditions is critical for health systems to examine past and current trends for future surveillance. Our publicly available EHR-mental health typology codes can be used in other studies to further advance research in this area.
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Affiliation(s)
- Josephine Elia
- Department of Pediatrics, Nemours Children's Health Delaware, Sydney Kimmel School of Medicine, Philadelphia, PA, US.
| | - Kathleen Pajer
- Department of Psychiatry, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Raghuram Prasad
- Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, US
| | - Andres Pumariega
- Department of Psychiatry, University of Florida College of Medicine, University of Florida Health, Gainesville, FL, US
| | - Mitchell Maltenfort
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, US
| | - Levon Utidjian
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, US
| | - Elizabeth Shenkman
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, US
| | - Kelly Kelleher
- The Research Institute, Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University College of Medicine, Ohio, US
| | - Suchitra Rao
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado, Aurora, CO, US
| | - Peter A Margolis
- James Anderson Center for Health Systems Excellence, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, US
| | - Dimitri A Christakis
- Center for Child Health, Behavior and Development, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington, US
| | - Antonio Y Hardan
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, US
| | - Rachel Ballard
- Department of Psychiatry and Behavioral Sciences and Pediatrics, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, US
| | - Christopher B Forrest
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, US
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Department of Healthcare Management, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, US
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17
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Leyenaar JK, Freyleue SD, Arakelyan M, Goodman DC, O’Malley AJ. Pediatric Hospitalizations at Rural and Urban Teaching and Nonteaching Hospitals in the US, 2009-2019. JAMA Netw Open 2023; 6:e2331807. [PMID: 37656457 PMCID: PMC10474556 DOI: 10.1001/jamanetworkopen.2023.31807] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/07/2023] [Indexed: 09/02/2023] Open
Abstract
Importance National analyses suggest that approximately 1 in 5 US hospitals closed their pediatric units between 2008 and 2018. The extent to which pediatric hospitalizations at general hospitals in rural and urban communities decreased during this period is not well understood. Objective To describe changes in the number and proportion of pediatric hospitalizations and costs at urban teaching, urban nonteaching, and rural hospitals vs freestanding children's hospitals from 2009 to 2019; to estimate the number and proportion of hospitals providing inpatient pediatric care; and to characterize changes in clinical complexity. Design, Setting, and Participants This study is a retrospective cross-sectional analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative data set of US pediatric hospitalizations among children younger than 18 years. Data were analyzed from February to June 2023. Exposures Pediatric hospitalizations were grouped as birth or nonbirth hospitalizations. Hospitals were categorized as freestanding children's hospitals or as rural, urban nonteaching, or urban teaching general hospitals. Main Outcomes and Measures The primary outcomes were annual number and proportion of birth and nonbirth hospitalizations and health care costs, changes in the proportion of hospitalizations with complex diagnoses, and estimated number and proportion of hospitals providing pediatric care and associated hospital volumes. Regression analyses were used to compare health care utilization in 2019 vs that in 2009. Results The data included 23.2 million (95% CI, 22.7-23.6 million) weighted hospitalizations. From 2009 to 2019, estimated national annual pediatric hospitalizations decreased from 6 425 858 to 5 297 882, as birth hospitalizations decreased by 10.6% (95% CI, 6.1%-15.1%) and nonbirth hospitalizations decreased by 28.9% (95% CI, 21.3%-36.5%). Concurrently, hospitalizations with complex chronic disease diagnoses increased by 45.5% (95% CI, 34.6%-56.4%), and hospitalizations with mental health diagnoses increased by 78.0% (95% CI, 61.6%-94.4%). During this period, the most substantial decreases were in nonbirth hospitalizations at rural hospitals (4-fold decrease from 229 263 to 62 729) and urban nonteaching hospitals (6-fold decrease from 581 320 to 92 118). In 2019, birth hospitalizations occurred at 2666 hospitals. Nonbirth pediatric hospitalizations occurred at 3507 hospitals, including 1256 rural hospitals and 843 urban nonteaching hospitals where the median nonbirth hospitalization volumes were fewer than 25 per year. Conclusions and Relevance Between 2009 and 2019, the largest decreases in pediatric hospitalizations occurred at rural and urban nonteaching hospitals. Clinical and policy initiatives to support hospitals with low pediatric volumes may be needed to maintain hospital access and pediatric readiness, particularly in rural communities.
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Affiliation(s)
- JoAnna K. Leyenaar
- Department of Pediatrics, Dartmouth Health Children’s, Lebanon, New Hampshire
| | - Seneca D. Freyleue
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Mary Arakelyan
- Department of Pediatrics, Dartmouth Health Children’s, Lebanon, New Hampshire
| | - David C. Goodman
- Department of Pediatrics, Dartmouth Health Children’s, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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18
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McLeigh JD, Malthaner LQ, Tovar MC, Khan M. Mental Health Disorders and Psychotropic Medication: Prevalence and Related Characteristics Among Individuals in Foster Care. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2023; 16:745-757. [PMID: 37593050 PMCID: PMC10427591 DOI: 10.1007/s40653-023-00547-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/05/2023] [Indexed: 08/19/2023]
Abstract
This study sought to provide prevalence data for mental health (MH) diagnoses and psychotropic medication prescriptions among individuals in foster care and to examine their relationships with physical health status, maltreatment type, placement type, and demographic variables. Data were retrieved from electronic health records for 3,067 patients seen at integrated pediatric primary care clinics serving individuals in care. Descriptive and bivariate statistics for presence of MH diagnoses and psychotropic medication prescription were calculated. Multivariable zero-inflated negative binomial regressions were used to assess relationships. Half (50.0%) of patients had at least one MH diagnosis; trauma and stressor-related (31.5%) and attention deficit hyperactivity (22.6%) disorders were most common. 27.8% of patients were prescribed at least 1 psychotropic medication. Complex chronic physical health, having 1 and 2 or more maltreatment exposures, and being 6-11 and 12-20 years of age had significantly higher rates of having a MH diagnosis while being female, Black, Hispanic, and other race were significantly associated with lower rates. Patients with at least 1 MH diagnosis that had complex chronic physical health status, experienced sexual abuse, and were 6-11 and 12-20 years of age had significantly higher rates of psychotropic medication prescription while shelter and kinship placement and female gender were significantly associated with lower rates. Findings suggest that initial and ongoing MH screening is vital for individuals in care so that appropriate interventions can be offered. Results support implementing strategies designed to increase access to MH services for this population, such as integrated care and child psychiatry consult programs. Supplementary Information The online version contains supplementary material available at 10.1007/s40653-023-00547-9.
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Affiliation(s)
- Jill D. McLeigh
- Rees-Jones Center for Foster Care Excellence, Children’s Health, 1935 Medical District Drive, Mailstop ST7.03, Dallas, TX 75235 USA
- Center for Pediatric Population Health, UTHealth School of Public Health, Dallas, TX USA
| | - Lauren Q. Malthaner
- University of Texas Health Science Center School of Public Health, Dallas, TX USA
| | | | - Mohsin Khan
- Rees-Jones Center for Foster Care Excellence, Children’s Health, 1935 Medical District Drive, Mailstop ST7.03, Dallas, TX 75235 USA
- University of Texas Southwestern Medical Center, Dallas, TX USA
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19
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Boyden JY, Bogetz JF, Johnston EE, Thienprayoon R, Williams CSP, McNeil MJ, Patneaude A, Widger KA, Rosenberg AR, Ananth P. Measuring Pediatric Palliative Care Quality: Challenges and Opportunities. J Pain Symptom Manage 2023; 65:e483-e495. [PMID: 36736860 PMCID: PMC10106436 DOI: 10.1016/j.jpainsymman.2023.01.021] [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: 12/05/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023]
Abstract
Pediatric palliative care (PPC) programs vary widely in structure, staffing, funding, and patient census, resulting in inconsistency in service provision. Improving the quality of palliative care for children living with serious illness and their families requires measuring care quality, ensuring that quality measurement is embedded into day-to-day clinical practice, and aligning quality measurement with healthcare policy priorities. Yet, numerous challenges exist in measuring PPC quality. This paper provides an overview of PPC quality measurement, including challenges, current initiatives, and future opportunities. While important strides toward addressing quality measurement challenges in PPC have been made, including ongoing quality measurement initiatives like the Cambia Metrics Project, the PPC What Matters Most study, and collaborative learning networks, more work remains. Providing high-quality PPC to all children and families will require a multi-pronged approach. In this paper, we suggest several strategies for advancing high-quality PPC, which includes 1) considering how and by whom success is defined, 2) evaluating, adapting, and developing PPC measures, including those that address care disparities within PPC for historically marginalized and excluded communities, 3) improving the infrastructure with which to routinely and prospectively measure, monitor, and report clinical and administrative quality measures, 4) increasing endorsement of PPC quality measures by prominent quality organizations to facilitate accountability and possible reimbursement, and 5) integrating PPC-specific quality measures into the administrative, funding, and policy landscape of pediatric healthcare.
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Affiliation(s)
- Jackelyn Y Boyden
- Department of Family and Community Health, School of Nursing (J.Y.B.), University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Jori F Bogetz
- Department of Pediatrics, Division of Bioethics and Palliative Care (J.F.B.), University of Washington School of Medicine, Seattle, Washington, USA; Center for Clinical and Translational Research (J.F.B.), Seattle Children's Research Institute, Seattle, Washington, USA
| | - Emily E Johnston
- Department of Pediatrics, Division of Hematology and Oncology (E.E.J.), University of Alabama at Birmingham, Birmingham, Alabama, USA; Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham (E.E.J.), Birmingham, Alabama, USA
| | - Rachel Thienprayoon
- Department of Anesthesia, Division of Palliative Care, Cincinnati Children's Hospital Medical Center (R.T.), Cincinnati, Ohio, USA; Department of Pediatrics, Cincinnati Children's Hospital Medical Center (R.T.), Cincinnati, Ohio, USA
| | - Conrad S P Williams
- Palliative Care Program and Department of Pediatrics (C.S.P.W.), Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael J McNeil
- St. Jude Children's Research Hospital, Department of Global Pediatric Medicine (M.J.M.), Memphis, Tennessee, USA; St. Jude Children's Research Hospital, Division of Quality and Life and Palliative Care, Department of Oncology (M.J.M.), Memphis, Tennessee, USA
| | - Arika Patneaude
- Bioethics and Palliative Care, Seattle Children's Hospital (A.P.), Seattle, Washington, USA; University of Washington School of Social Work (A.P.), Seattle, Washington, USA; Treuman Katz Center for Pediatric Bioethics (A.P.), Seattle, Washington, USA
| | - Kimberley A Widger
- Lawrence S. Bloomberg Faculty of Nursing (K.A.W.), University of Toronto, Toronto, Ontario, Canada; Hospital for Sick Children (K.A.W.), Toronto, Ontario, Canada
| | - Abby R Rosenberg
- Department of Psychosocial Oncology and Palliative Care (A.R.S.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School (A.R.S.), Boston, Massachusetts, USA
| | - Prasanna Ananth
- Department of Pediatrics, Yale School of Medicine (P.A.), New Haven, Connecticut, USA; Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center (P.A.), New Haven, Connecticut, USA
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20
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Mejias A, Schuchard J, Rao S, Bennett TD, Jhaveri R, Thacker D, Bailey LC, Christakis DA, Pajor NM, Razzaghi H, Forrest CB, Lee GM. Leveraging serologic testing to identify children at risk for post-acute sequelae of SARS-CoV-2 infection: An EHR-based cohort study from the RECOVER program. J Pediatr 2023:S0022-3476(23)00117-8. [PMID: 36822507 PMCID: PMC9943558 DOI: 10.1016/j.jpeds.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 12/23/2022] [Accepted: 02/16/2023] [Indexed: 02/23/2023]
Abstract
Using an EHR-based algorithm we identified children with COVID-19 based exclusively on serologic testing from 3/2020 through 4/2022. The 2,714 serology-positive children were more likely to be inpatients (24% vs. 2%), have chronic conditions (37% vs 24%), or a MIS-C diagnosis (23% vs. <1%) than the 131,537 PCR-positive children. Identification of children who could have been asymptomatic or paucisymptomatic and not tested is critical to define the burden of PASC in children.
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Affiliation(s)
- Asuncion Mejias
- Division of Infectious Diseases, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, OH.
| | - Julia Schuchard
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Suchitra Rao
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Tellen D Bennett
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Ravi Jhaveri
- Division of Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Deepika Thacker
- Division of Cardiology, Nemours Children's Health, Wilmington, DE
| | - L Charles Bailey
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Dimitri A Christakis
- Center for Child Health, Behavior and Development, Seattle Children's Hospital, Seattle, WA
| | - Nathan M Pajor
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Hanieh Razzaghi
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christopher B Forrest
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Grace M Lee
- Department of Pediatrics (Infectious Diseases), Stanford University School of Medicine, Stanford, CA
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21
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Lakhaney D, Matiz LA. Telemedicine for Children With Medical Complexity During the COVID-19 Pandemic: Implications for Practice. Clin Pediatr (Phila) 2023; 62:89-91. [PMID: 35941789 PMCID: PMC9364064 DOI: 10.1177/00099228221116707] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Divya Lakhaney
- Department of Pediatrics, Division of Child and Adolescent Health, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA,Department of Pediatrics, Division of Critical Care and Hospital Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA,NewYork-Presbyterian Hospital, New York, NY, USA,Divya Lakhaney, Department of Pediatrics, Division of Critical Care and Hospital Medicine, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, VC4-417, New York, NY 10032, USA.
| | - Luz Adriana Matiz
- Department of Pediatrics, Division of Child and Adolescent Health, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA,NewYork-Presbyterian Hospital, New York, NY, USA
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22
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Wittman SR, Yabes JG, Sabik LM, Kahn JM, Ray KN. Patient and Family Factors Associated with Use of Telemedicine Visits for Pediatric Acute Respiratory Tract Infections, 2018-2019. Telemed J E Health 2023; 29:127-136. [PMID: 35639360 PMCID: PMC9918348 DOI: 10.1089/tmj.2022.0097] [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: 02/28/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 01/12/2023] Open
Abstract
Background: Pediatric acute respiratory tract infections (ARTIs) were a common reason for commercial direct-to-consumer (DTC) telemedicine use before the COVID-19 pandemic, but the factors associated with this use are unknown. Objective: To identify child and family factors associated with use of commercial DTC telemedicine for ARTIs in 2018-2019. Methods: We performed a retrospective cohort analysis of claims data from the Optum Clinformatics® Data Mart Database. Among children with ARTI visits, we fitted logit models to examine child and family characteristics associated with DTC telemedicine use. Results: Of 660,725 children with ARTI visits, 12,944 (2.0%) had ≥1 commercial DTC telemedicine encounter. The odds of DTC telemedicine use were higher for children with age ≥12 years, lower parent educational attainment, higher household income, white non-Hispanic race/ethnicity, and residency in the West South Central census division. Conclusion: In 2018-2019, commercial DTC telemedicine use varied with child age, child race/ethnicity parent educational attainment, household income, and geography.
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Affiliation(s)
- Samuel R. Wittman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jonathan G. Yabes
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Jeremy M. Kahn
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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23
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Heneghan JA, Goodman DM, Ramgopal S. Variable Identification of Children With Medical Complexity in United States PICUs. Pediatr Crit Care Med 2023; 24:56-61. [PMID: 36594799 DOI: 10.1097/pcc.0000000000003112] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Children with medical complexity are at increased risk for critical illness and adverse outcomes. However, there is currently no consensus definition of medical complexity in pediatric critical care research. DESIGN Retrospective, cross-sectional cohort study. SETTING One hundred thirty-one U.S. PICUs participating in the Virtual Pediatric Systems Database. SUBJECTS Children less than 21 years old admitted from 2017 to 2019. Multisystem complexity was identified on the basis of two common definitions of medical complexity, Pediatric Complex Chronic Conditions (CCC), greater than or equal to 2 qualifying diagnoses, and Pediatric Medical Complexity Algorithm (PMCA), complex chronic disease. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 291,583 index PICU admissions, 226,430 (77.7%) met at least one definition of multisystem complexity, including 168,332 patients identified by CCC and 201,537 by PMCA. Of these, 143,439 (63.3%) were identified by both definitions. Cohen kappa was 0.39, indicating only fair agreement between definitions. Children identified by CCC were younger and were less frequently scheduled admissions and discharged home from the ICU than PMCA. The most common reason for admission was respiratory in both groups, although this represented a larger proportion of CCC patients. ICU and hospital length of stay were longer for patients identified by CCC. No difference in median severity of illness scoring was identified between definitions, but CCC patients had higher inhospital mortality. Readmission to the ICU in the subsequent year was seen in approximately one-fifth of patients in either group. CONCLUSIONS Commonly used definitions of medical complexity identified distinct populations of children with multisystem complexity in the PICU with only fair agreement.
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Affiliation(s)
- Julia A Heneghan
- Division of Pediatric Critical Care, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, MN
| | - Denise M Goodman
- Division of Pediatric Critical Care, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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24
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Bose-Brill S, Hirabayashi K, Pajor NM, Rao S, Mejias A, Jhaveri R, Forrest CB, Bailey C, Christakis DA, Thacker D, Hanley PC, Patel PB, Cogen JD, Block JP, Prahalad P, Lorman V, Lee GM. Pediatric Nirmatrelvir/Ritonavir Prescribing Patterns During the COVID-19 Pandemic. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2022:2022.12.23.22283868. [PMID: 36597537 PMCID: PMC9810217 DOI: 10.1101/2022.12.23.22283868] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Objective This study was conducted to identify rates of pediatric nirmatrelvir/ritonavir (Paxlovid) prescriptions overall and by patient characteristics. Methods Patients up to 23 years old with a clinical encounter and a nirmatrelvir/ritonavir (Paxlovid, n/r) prescription in a PEDSnet-affiliated institution between December 1, 2021 and September 14, 2022 were identified using electronic health record (EHR) data. Results Of the 1,496,621 patients with clinical encounters during the study period, 920 received a nirmatrelvir/ritonavir prescription (mean age 17.2 years; SD 2.76 years). 40% (367/920) of prescriptions were provided to individuals aged 18-23, and 91% (838/920) of prescriptions occurred after April 1, 2022. The majority of patients (70%; 648/920) had received at least one COVID-19 vaccine dose at least 28 days before nirmatrelvir/ritonavir prescription. Only 40% (371/920) of individuals had documented COVID-19 within the 0 to 6 days prior to receiving a nirmatrelvir/ritonavir prescription. 53% (485/920) had no documented COVID-19 infection in the EHR. Among nirmatrelvir/ritonavir prescription recipients, 64% (586/920) had chronic or complex chronic disease and 9% (80/920) had malignant disease. 38/920 (4.5%) were hospitalized within 30 days of receiving nirmatrelvir/ritonavir. Conclusion Clinicians prescribe nirmatrelvir/ritonavir infrequently to children. While individuals receiving nirmatrelvir/ritonavir generally have significant chronic disease burden, a majority are receiving nirmatrelvir/ritonavir prescriptions without an EHR-recorded COVID-19 positive test or diagnosis. Development and implementation of concerted pediatric nirmatrelvir/ritonavir prescribing workflows can help better capture COVID-19 presentation, response, and adverse events at the population level.
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25
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Quintero AM, Eisner M, Sayegh R, Wright T, Ramilo O, Leber AL, Wang H, Mejias A. Differences in SARS-CoV-2 Clinical Manifestations and Disease Severity in Children and Adolescents by Infecting Variant. Emerg Infect Dis 2022; 28:2270-2280. [PMID: 36285986 PMCID: PMC9622241 DOI: 10.3201/eid2811.220577] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Since the COVID-19 pandemic began, different SARS-CoV-2 variants have been identified and associated with higher transmissibility than the ancestral nonvariant strain. During January 1, 2021–January 15, 2022, we assessed differences in clinical and viral parameters in a convenience sample of COVID-19 outpatients and inpatients 0–21 years of age in Columbus, Ohio, USA, according to the infecting variant, identified using a mutation-specific reverse transcription PCR assay. Of the 676 patients in the study, 17.75% were infected with nonvariant strains, 18.49% with the Alpha variant, 41.72% with Delta, and 16.42% with Omicron. Rates of SARS-COV-2/viral co-infections were 15.66%–29.41% and were comparable across infecting variants. Inpatients with acute Delta and Omicron infections had lower SARS-CoV-2 cycle threshold values and more frequent fever and respiratory symptoms than those with nonvariant strain infections. In addition, SARS-COV-2/viral co-infections and the presence of underlying conditions were independently associated with worse clinical outcomes, irrespective of the infecting variant.
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26
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Rao S, Lee GM, Razzaghi H, Lorman V, Mejias A, Pajor NM, Thacker D, Webb R, Dickinson K, Bailey LC, Jhaveri R, Christakis DA, Bennett TD, Chen Y, Forrest CB. Clinical Features and Burden of Postacute Sequelae of SARS-CoV-2 Infection in Children and Adolescents. JAMA Pediatr 2022; 176:1000-1009. [PMID: 35994282 PMCID: PMC9396470 DOI: 10.1001/jamapediatrics.2022.2800] [Citation(s) in RCA: 67] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/08/2022] [Indexed: 01/20/2023]
Abstract
Importance The postacute sequelae of SARS-CoV-2 infection (PASC) has emerged as a long-term complication in adults, but current understanding of the clinical presentation of PASC in children is limited. Objective To identify diagnosed symptoms, diagnosed health conditions, and medications associated with PASC in children. Design, Setting and Participants This retrospective cohort study used electronic health records from 9 US children's hospitals for individuals younger than 21 years who underwent antigen or reverse transcriptase-polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 between March 1, 2020, and October 31, 2021, and had at least 1 encounter in the 3 years before testing. Exposures SARS-CoV-2 positivity by viral test (antigen or RT-PCR). Main Outcomes and Measures Syndromic (symptoms), systemic (conditions), and medication PASC features were identified in the 28 to 179 days following the initial test date. Adjusted hazard ratios (aHRs) were obtained for 151 clinically predicted PASC features by contrasting viral test-positive groups with viral test-negative groups using proportional hazards models, adjusting for site, age, sex, testing location, race and ethnicity, and time period of cohort entrance. The incidence proportion for any syndromic, systemic, or medication PASC feature was estimated in the 2 groups to obtain a burden of PASC estimate. Results Among 659 286 children in the study sample, 348 091 (52.8%) were male, and the mean (SD) age was 8.1 (5.7) years. A total of 59 893 (9.1%) tested positive by viral test for SARS-CoV-2, and 599 393 (90.9%) tested negative. Most were tested in outpatient testing facility settings (322 813 [50.3%]) or office settings (162 138 [24.6%]). The most common syndromic, systemic, and medication features were loss of taste or smell (aHR, 1.96; 95% CI, 1.16-3.32), myocarditis (aHR, 3.10; 95% CI, 1.94-4.96), and cough and cold preparations (aHR, 1.52; 95% CI, 1.18-1.96), respectively. The incidence of at least 1 systemic, syndromic, or medication feature of PASC was 41.9% (95% CI, 41.4-42.4) among viral test-positive children vs 38.2% (95% CI, 38.1-38.4) among viral test-negative children, with an incidence proportion difference of 3.7% (95% CI, 3.2-4.2). A higher strength of association for PASC was identified in those cared for in the intensive care unit during the acute illness phase, children younger than 5 years, and individuals with complex chronic conditions. Conclusions and Relevance In this large-scale, exploratory study, the burden of pediatric PASC that presented to health systems was low. Myocarditis was the most commonly diagnosed PASC-associated condition. Acute illness severity, young age, and comorbid complex chronic disease increased the risk of PASC.
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Affiliation(s)
- Suchitra Rao
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora
| | - Grace M. Lee
- Department of Pediatrics (Infectious Diseases), Stanford University School of Medicine, Stanford, California
| | - Hanieh Razzaghi
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Vitaly Lorman
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Asuncion Mejias
- Division of Infectious Diseases, Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University, Columbus
| | - Nathan M. Pajor
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Deepika Thacker
- Division of Cardiology, Nemours Children’s Health, Wilmington, Delaware
| | - Ryan Webb
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kimberley Dickinson
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - L. Charles Bailey
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ravi Jhaveri
- Division of Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Dimitri A. Christakis
- Center for Child Health, Behavior and Development, Seattle Children’s Hospital, Seattle, Washington
- Editor, JAMA Pediatrics
| | - Tellen D. Bennett
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora
| | - Yong Chen
- Department of Biostatistics, Epidemiology and Informatics, the Perelman School of Medicine, University of Pennsylvania, Pennsylvania
| | - Christopher B. Forrest
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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27
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Rao S, Jing N, Liu X, Lorman V, Maltenfort M, Schuchard J, Wu Q, Tong J, Razzaghi H, Mejias A, Lee GM, Pajor NM, Schulert GS, Thacker D, Jhaveri R, Christakis DA, Bailey LC, Forrest CB, Chen Y. Clinical Subphenotypes of Multisystem Inflammatory Syndrome in Children: An EHR-based cohort study from the RECOVER program. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2022:2022.09.26.22280364. [PMID: 36203555 PMCID: PMC9536089 DOI: 10.1101/2022.09.26.22280364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Background Multi-system inflammatory syndrome in children (MIS-C) represents one of the most severe post-acute sequelae of SARS-CoV-2 infection in children, and there is a critical need to characterize its disease patterns for improved recognition and management. Our objective was to characterize subphenotypes of MIS-C based on presentation, demographics and laboratory parameters. Methods We conducted a retrospective cohort study of children with MIS-C from March 1, 2020 - April 30, 2022 and cared for in 8 pediatric medical centers that participate in PEDSnet. We included demographics, symptoms, conditions, laboratory values, medications and outcomes (ICU admission, death), and grouped variables into eight categories according to organ system involvement. We used a heterogeneity-adaptive latent class analysis model to identify three clinically-relevant subphenotypes. We further characterized the sociodemographic and clinical characteristics of each subphenotype, and evaluated their temporal patterns. Findings We identified 1186 children hospitalized with MIS-C. The highest proportion of children (44·4%) were aged between 5-11 years, with a male predominance (61.0%), and non- Hispanic white ethnicity (40·2%). Most (67·8%) children did not have a chronic condition. Class 1 represented children with a severe clinical phenotype, with 72·5% admitted to the ICU, higher inflammatory markers, hypotension/shock/dehydration, cardiac involvement, acute kidney injury and respiratory involvement. Class 2 represented a moderate presentation, with 4-6 organ systems involved, and some overlapping features with acute COVID-19. Class 3 represented a mild presentation, with fewer organ systems involved, lower CRP, troponin values and less cardiac involvement. Class 1 initially represented 51·1% of children early in the pandemic, which decreased to 33·9% from the pre-delta period to the omicron period. Interpretation MIS-C has a spectrum of clinical severity, with degree of laboratory abnormalities rather than the number of organ systems involved providing more useful indicators of severity. The proportion of severe/critical MIS-C decreased over time. Research in context Evidence before this study: We searched PubMed and preprint articles from December 2019, to July 2022, for studies published in English that investigated the clinical subphenotypes of MIS-C using the terms "multi-system inflammatory syndrome in children" or "pediatric inflammatory multisystem syndrome" and "phenotypes". Most previous research described the symptoms, clinical characteristics and risk factors associated with MIS-C and how these differ from acute COVID-19, Kawasaki Disease and Toxic Shock Syndrome. One single-center study of 63 patients conducted in 2020 divided patients into Kawasaki and non-Kawasaki disease subphenotypes. Another CDC study evaluated 3 subclasses of MIS-C in 570 children, with one class representing the highest number of organ systems, a second class with predominant respiratory system involvement, and a third class with features overlapping with Kawasaki Disease. However, this study evaluated cases from March to July 2020, during the early phase of the pandemic when misclassification of cases as Kawasaki disease or acute COVID-19 may have occurred. Therefore, it is not known from the existing literature whether the presentation of MIS-C has changed with newer variants such as delta and omicron.Added value of this study: PEDSnet provides one of the largest MIS-C cohorts described so far, providing sufficient power for detailed analyses on MIS-C subphenotypes. Our analyses span the entire length of the pandemic, including the more recent omicron wave, and provide an update on the presentations of MIS-C and its temporal dynamics. We found that children have a spectrum of illness that can be characterized as mild (lower inflammatory markers, fewer organ systems involved), moderate (4-6 organ involvement with clinical overlap with acute COVID-19) and severe (higher inflammatory markers, critically ill, more likely to have cardiac involvement, with hypotension/shock and need for vasopressors).Implications of all the available evidence: These results provide an update to the subphenotypes of MIS-C including the more recent delta and omicron periods and aid in the understanding of the various presentations of MIS-C. These and other findings provide a useful framework for clinicians in the recognition of MIS-C, identify factors associated with children at risk for increased severity, including the importance of laboratory parameters, for risk stratification, and to facilitate early evaluation, diagnosis and treatment.
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28
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Gutman CK, Lion KC, Aronson P, Fisher C, Bylund C, McFarlane A, Lou X, Patterson MD, Lababidi A, Fernandez R. Disparities and implicit bias in the management of low-risk febrile infants: a mixed methods study protocol. BMJ Open 2022; 12:e063611. [PMID: 36127098 PMCID: PMC9490627 DOI: 10.1136/bmjopen-2022-063611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The management of low-risk febrile infants presents a model population for exploring how implicit racial bias promotes inequitable emergency care for children who belong to racial, ethnic and language minority groups. Although widely used clinical standards guide the clinical care of febrile infants, there remains substantial variability in management strategies. Deviations from recommended care may be informed by the physician's assessment of the family's values, risk tolerance and access to supportive resources. However, in the fast-paced emergency setting, such assessments may be influenced by implicit racial bias. Despite significant research to inform the clinical care of febrile infants, there is a dearth of knowledge regarding health disparities and clinical guideline implementation. The proposed mixed methods approach will (1) quantify the extent of disparities by race, ethnicity and language proficiency and (2) explore the role of implicit bias in physician-patient communication when caring for this population. METHODS AND ANALYSIS With 42 participating sites from the Pediatric Emergency Medicine Collaborative Research Committee, we will conduct a multicenter, cross-sectional study of low-risk febrile infants treated in the emergency department (ED) and apply multivariable logistic regression to assess the association between (1) race and ethnicity and (2) limited English proficiency with the primary outcome, discharge to home without lumbar puncture or antibiotics. We will concurrently perform an interpretive study using purposive sampling to conduct individual semistructured interviews with (1) minority parents of febrile infants and (2) paediatric ED physicians. We will triangulate or compare perspectives to better elucidate disparities and bias in communication and medical decision-making. ETHICS AND DISSEMINATION This study has been approved by the University of Florida Institutional Review Board. All participating sites in the multicenter analysis will obtain local institutional review board approval. The results of this study will be presented at academic conferences and in peer-reviewed publications.
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Affiliation(s)
- Colleen K Gutman
- Department of Emergency Medicine, University of Florida, Gainesville, Florida, USA
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - K Casey Lion
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Paul Aronson
- Departments of Emergency Medicine and Pediatrics, Yale University, New Haven, Connecticut, USA
| | - Carla Fisher
- College of Journalism and Communications, University of Florida, Gainesville, Florida, USA
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida, USA
| | - Carma Bylund
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida, USA
| | - Antionette McFarlane
- Department of Emergency Medicine, University of Florida, Gainesville, Florida, USA
| | - Xiangyang Lou
- Department of Biostatistics, University of Florida, Gainesville, Florida, USA
| | - Mary D Patterson
- Department of Emergency Medicine, University of Florida, Gainesville, Florida, USA
- Center for Experiential Learning and Simulation, University of Florida, Gainesville, Florida, USA
| | - Ahmed Lababidi
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Rosemarie Fernandez
- Department of Emergency Medicine, University of Florida, Gainesville, Florida, USA
- Center for Experiential Learning and Simulation, University of Florida, Gainesville, Florida, USA
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29
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Nelson KE, Chakravarti V, Diskin C, Thomson J, Cohen E, Mahant S, Feudtner C, Widger K, Pullenayegum E, Berry JG, Feinstein JA. Validation of Neurologic Impairment Diagnosis Codes as Signifying Documented Functional Impairment in Hospitalized Children. Acad Pediatr 2022; 22:782-788. [PMID: 34320414 PMCID: PMC8786975 DOI: 10.1016/j.acap.2021.07.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 07/15/2021] [Accepted: 07/20/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the performance of previously published high-intensity neurologic impairment (NI) diagnosis codes in identification of hospitalized children with clinical NI. METHODS Retrospective study of 500 randomly selected discharges in 2019 from a freestanding children's hospital. All charts were reviewed for 1) NI discharge diagnosis codes and 2) documentation of clinical NI (a neurologic diagnosis and indication of functional impairment like medical technology). Test statistics of clinical NI were calculated for discharges with and without an NI diagnosis code. A sensitivity analysis varied the threshold for "substantial functional impairment." Secondary analyses evaluated misclassified discharges and a more stringent definition for NI. RESULTS Diagnosis codes identified clinically documented NI with 88.1% (95% confidence interval [CI]: 84.7, 91) specificity, and 79.4% (95% CI: 67.3, 88.5) sensitivity; negative predictive value (NPV) was 96.7% (95% CI: 94.8, 98.0), and positive predictive value (PPV) was 49% (95% CI: 42, 56.1). Including children with milder functional impairment (lower threshold) resulted in NPV of 95.7% and PPV of 77.5%. Restricting to children with more severe functional impairment (higher threshold) resulted in NPV of 98.2% and PPV of 44.1%. Misclassification was primarily due to inclusion of children without functional impairments. A more stringent NI definition including diagnosis codes for NI and feeding tubes had a specificity of 98.4% (95% CI: 96.7-99.3) and sensitivity of 28.6% (19.4-41.3). CONCLUSIONS All scenarios evaluated demonstrated high NPV and low-to-moderate PPV of the diagnostic code list. To maximize clinical utility, NI diagnosis codes should be used with strategies to mitigate the risk of misclassification.
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Affiliation(s)
- Katherine E Nelson
- Pediatric Advanced Care Team, Hospital for Sick Children (KE Nelson, V Chakravarti, and K Widger), Toronto, Ontario, Canada; Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children (KE Nelson, C Diskin, E Cohen, and S Mahant), Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute (KE Nelson, V Chakravarti, E Cohen, S Mahant, and E Pullenayegum), Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (KE Nelson, E Cohen, and S Mahant), Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto (KE Nelson, E Cohen, S Mahant, and E Pullenayegum), Toronto, Ontario, Canada.
| | - Vishakha Chakravarti
- Pediatric Advanced Care Team, Hospital for Sick Children (KE Nelson, V Chakravarti, and K Widger), Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute (KE Nelson, V Chakravarti, E Cohen, S Mahant, and E Pullenayegum), Toronto, Ontario, Canada
| | - Catherine Diskin
- Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children (KE Nelson, C Diskin, E Cohen, and S Mahant), Toronto, Ontario, Canada
| | - Joanna Thomson
- Department of Pediatrics, University of Cincinnati College of Medicine (J Thomson), Cincinnati, Ohio; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center (J Thomson), Cincinnati, Ohio
| | - Eyal Cohen
- Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children (KE Nelson, C Diskin, E Cohen, and S Mahant), Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute (KE Nelson, V Chakravarti, E Cohen, S Mahant, and E Pullenayegum), Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (KE Nelson, E Cohen, and S Mahant), Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto (KE Nelson, E Cohen, S Mahant, and E Pullenayegum), Toronto, Ontario, Canada; CanChild Centre for Childhood Disability Research, McMaster University (E Cohen and S Mahant), Hamilton, Ontario, Canada; Edwin S.H. Leong Centre for Healthy Children, University of Toronto (E Cohen), Toronto, Ontario, Canada
| | - Sanjay Mahant
- Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children (KE Nelson, C Diskin, E Cohen, and S Mahant), Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute (KE Nelson, V Chakravarti, E Cohen, S Mahant, and E Pullenayegum), Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (KE Nelson, E Cohen, and S Mahant), Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto (KE Nelson, E Cohen, S Mahant, and E Pullenayegum), Toronto, Ontario, Canada; CanChild Centre for Childhood Disability Research, McMaster University (E Cohen and S Mahant), Hamilton, Ontario, Canada
| | - Chris Feudtner
- The Justin Michael Ingerman Center for Palliative Care, Children's Hospital of Philadelphia (C Feudtner), Philadelphia, Pa; Departments of Pediatrics and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania (C Feudtner), Philadelphia, Pa
| | - Kimberley Widger
- Pediatric Advanced Care Team, Hospital for Sick Children (KE Nelson, V Chakravarti, and K Widger), Toronto, Ontario, Canada; Lawrence S. Bloomberg Faculty of Nursing, University of Toronto (K Widger), Toronto, Ontario, Canada
| | - Eleanor Pullenayegum
- Child Health Evaluative Sciences, SickKids Research Institute (KE Nelson, V Chakravarti, E Cohen, S Mahant, and E Pullenayegum), Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto (KE Nelson, E Cohen, S Mahant, and E Pullenayegum), Toronto, Ontario, Canada
| | - Jay G Berry
- Complex Care, Division of General Pediatrics, Children's Hospital Boston (JG Berry), Boston, Mass; Department of Pediatrics, Harvard Medical School (JG Berry), Boston, Mass
| | - James A Feinstein
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado and Children's Hospital Colorado (JA Feinstein), Aurora, Colo
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Heneghan JA, Goodman DM, Ramgopal S. Demographic and Clinical Differences Between Applied Definitions of Medical Complexity. Hosp Pediatr 2022; 12:654-663. [PMID: 35652303 DOI: 10.1542/hpeds.2021-006432] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To identify the degree of concordance and characterize demographic and clinical differences between commonly used definitions of multisystem medical complexity in children hospitalized in children's hospitals. METHODS We conducted a retrospective, cross-sectional cohort study of children <21 years of age hospitalized at 47 US Pediatric Health Information System-participating children's hospitals between January 2017 to December 2019. We classified patients as having multisystem complexity when using 3 definitions of medical complexity (pediatric complex chronic conditions, pediatric medical complexity algorithm, and pediatric chronic critical illness) and assessed their overlap. We compared demographic, clinical, outcome, cost characteristics, and longitudinal healthcare utilization for each grouping. RESULTS Nearly one-fourth (23.5%) of children hospitalized at Pediatric Health Information System-participating institutions were identified as meeting at least 1 definition of multisystem complexity. Children with multisystem complexity ranged from 1.0% to 22.1% of hospitalized children, depending on the definition, with 31.2% to 95.9% requiring an ICU stay during their index admission. Differences were seen in demographic, clinical, and resource utilization patterns across the definitions. Definitions of multisystem complexity demonstrated poor agreement (Fleiss' κ 0.21), with 3.5% of identified children meeting all 3. CONCLUSIONS Three definitions of multisystem complexity identified varied populations of children with complex medical needs, with poor overall agreement. Careful consideration is required when applying definitions of medical complexity in health services research, and their lack of concordance should result in caution in the interpretation of research using differing definitions of medical complexity.
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Affiliation(s)
- Julia A Heneghan
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
| | | | - Sriram Ramgopal
- Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Bardach NS, Stotts JR, Fiore DM, Sarkar U, Sharma AE, Boscardin WJ, Avina L, Peralta-Neel C, Rosenbluth G. Family Input for Quality and Safety (FIQS): Using mobile technology for in-hospital reporting from families and patients. J Hosp Med 2022; 17:456-465. [PMID: 35535946 DOI: 10.1002/jhm.2777] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 12/29/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Despite three decades of effort, ensuring inpatient safety remains elusive. Patients and family members are a potential source of safety observations, but systems gathering these are limited. Our goal was to test a system to gather safety observations from hospitalized patients and their family members via a real-time mobile health tool. METHODS We developed a mobile-responsive website for reporting safety observations. We piloted the tool during June 2017-April 2018 on the medical-surgical unit of a children's hospital. Participants were English-speaking family members and patients ≥13 years. We sent a daily text with a website link. We assessed: (1) face validity by comparing observations to incident reporting (IR) criteria and to hospital IRs and (2) associations between the number of safety observations/100 patient-days and participant characteristics using Poisson regression. RESULTS We enrolled 235 patients (43.8% of 537 reviewed for eligibility), resulting in 8.15 safety reports/100 patient-days, most frequently regarding medications (29% of reports) and communication (20% of reports). Fifty-one (40% of 125) met IR criteria; only one (1.1%) had been reported via the IR system. Latinx participants submitted fewer observations than White participants (3.9 vs. 10.1, p = .002); participants with more prior hospitalizations submitted more observations (p < .001). In adjusted analyses, including measures of preference in decision making, and patient activation, the difference between Latinx and White participants diminished substantially (6.4 vs. 11.3, p = .16). CONCLUSIONS We demonstrated the feasibility of real-time patient and family-member technology-enabled safety observation reporting and elicited reports not otherwise identified. Variation in reporting may potentially exacerbate disparities in safety if not addressed.
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Affiliation(s)
- Naomi S Bardach
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Jim R Stotts
- Department of Patient Safety and Regulatory Affairs, University of California San Francisco, San Francisco, California, USA
| | - Darren M Fiore
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Urmimala Sarkar
- Division of General Internal Medicine, University of California San Francisco, San Francisco, California, USA
- Department of Medicine, UCSF Center for Vulnerable Populations, University of California San Francisco, San Francisco, California, USA
| | - Anjana E Sharma
- Department of Medicine, UCSF Center for Vulnerable Populations, University of California San Francisco, San Francisco, California, USA
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, California, USA
| | - W John Boscardin
- Departments of Medicine and Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Lizette Avina
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Caroline Peralta-Neel
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Glenn Rosenbluth
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
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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: 31] [Impact Index Per Article: 15.5] [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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Rao S, Lee GM, Razzaghi H, Lorman V, Mejias A, Pajor NM, Thacker D, Webb R, Dickinson K, Bailey LC, Jhaveri R, Christakis DA, Bennett TD, Chen Y, Forrest CB. Clinical features and burden of post-acute sequelae of SARS-CoV-2 infection in children and adolescents: an exploratory EHR-based cohort study from the RECOVER program. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2022:2022.05.24.22275544. [PMID: 35665016 PMCID: PMC9164455 DOI: 10.1101/2022.05.24.22275544] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Importance The post-acute sequelae of SARS-CoV-2 (PASC) has emerged as a long-term complication in adults, but current understanding of the clinical presentation of PASC in children is limited. Objective To identify diagnosed symptoms, diagnosed health conditions and medications associated with PASC in children. Design Setting and Participants Retrospective cohort study using electronic health records from 9 US children's hospitals for individuals <21 years-old who underwent reverse transcriptase polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 between March 1, 2020 - October 31, 2021 and had at least 1 encounter in the 3 years before testing. Exposure SARS-CoV-2 PCR positivity. Main Outcomes and Measures We identified syndromic (symptoms), systemic (conditions), and medication PASC features in the 28-179 days following the initial test date. Adjusted hazard ratios (aHRs) were obtained for 151 clinically predicted PASC features by contrasting PCR-positive with PCR-negative groups using proportional hazards models, adjusting for site, age, sex, testing location, race/ethnicity, and time-period of cohort entrance. We estimated the incidence proportion for any syndromic, systemic or medication PASC feature in the two groups to obtain a burden of PASC estimate. Results Among 659,286 children in the study sample, 59,893 (9.1%) tested positive by PCR for SARS-CoV-2. Most were tested in outpatient testing facility (50.3%) or office (24.6%) settings. The most common syndromic, systemic, and medication features were loss of taste or smell (aHR 1.96 [95% CI 1.16-3.32), myocarditis (aHR 3.10 [95% CI 1.94-4.96]), and cough and cold preparations (aHR 1.52 [95% CI 1.18-1.96]). The incidence of at least one systemic/syndromic/medication feature of PASC was 41.9% among PCR-positive children versus 38.2% among PCR-negative children, with an incidence proportion difference of 3.7% (95% CI 3.2-4.2%). A higher strength of association for PASC was identified in those cared for in the ICU during the acute illness phase, children less than 5 years-old, and individuals with complex chronic conditions. Conclusions and Relevance In this large-scale, exploratory study, the burden of pediatric PASC that presented to health systems was low. Myocarditis was the most commonly diagnosed PASC-associated condition. Acute illness severity, young age, and comorbid complex chronic disease increased the risk of PASC. Key Points Question: What are the incidence and clinical features of post-acute sequelae of SARS-CoV-2 infection (PASC) in children?Findings: In this retrospective cohort study of 659,286 children tested for SARS-CoV-2 by polymerase chain reaction (PCR), the symptom, condition and medication with the strongest associations with SARS-CoV-2 infection were loss of taste/smell, myocarditis, and cough and cold preparations. The incidence proportion of non-MIS-C related PASC in the PCR-positive group exceeded the PCR-negative group by 3.7% (95% CI 3.2-4.2), with increased rates associated with acute illness severity, young age, and medical complexity.Meaning: PASC in children appears to be uncommon, with features that differ from adults.
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Forrest CB, Burrows EK, Mejias A, Razzaghi H, Christakis D, Jhaveri R, Lee GM, Pajor NM, Rao S, Thacker D, Bailey LC. Severity of Acute COVID-19 in Children <18 Years Old March 2020 to December 2021. Pediatrics 2022; 149:185621. [PMID: 35322270 DOI: 10.1542/peds.2021-055765] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2022] [Indexed: 12/24/2022] Open
Abstract
This national study evaluated trends in illness severity among 82 798 children with coronavirus disease 2019 from March 1, 2020, to December 30, 2021.
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Affiliation(s)
- Christopher B Forrest
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Evanette K Burrows
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Asuncion Mejias
- Division of Infectious Diseases, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Hanieh Razzaghi
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Dimitri Christakis
- Center for Child Health, Behavior and Development, Seattle Children's Hospital, Seattle, Washington
| | - Ravi Jhaveri
- Division of Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Grace M Lee
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Nathan M Pajor
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Suchitra Rao
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Deepika Thacker
- Division of Cardiology, Nemours Children's Health, Wilmington, Delaware
| | - L Charles Bailey
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Abstract
OBJECTIVES Children with severe chronic illness are a prevalent, impactful, vulnerable group in PICUs, whose needs are insufficiently met by transitory care models and a narrow focus on acute care needs. Thus, we sought to provide a concise synthetic review of published literature relevant to them and a compilation of strategies to address their distinctive needs. DATA SOURCES English language articles were identified in MEDLINE using a variety of phrases related to children with chronic conditions, prolonged admissions, resource utilization, mortality, morbidity, continuity of care, palliative care, and other critical care topics. Bibliographies were also reviewed. STUDY SELECTION Original articles, review articles, and commentaries were considered. DATA EXTRACTION Data from relevant articles were reviewed, summarized, and integrated into a narrative synthetic review. DATA SYNTHESIS Children with serious chronic conditions are a heterogeneous group who are growing in numbers and complexity, partly due to successes of critical care. Because of their prevalence, prolonged stays, readmissions, and other resource use, they disproportionately impact PICUs. Often more than other patients, critical illness can substantially negatively affect these children and their families, physically and psychosocially. Critical care approaches narrowly focused on acute care and transitory/rotating care models exacerbate these problems and contribute to ineffective communication and information sharing, impaired relationships, subpar and untimely decision-making, patient/family dissatisfaction, and moral distress in providers. Strategies to mitigate these effects and address these patients' distinctive needs include improving continuity and communication, primary and secondary palliative care, and involvement of families. However, there are limited outcome data for most of these strategies and little consensus on which outcomes should be measured. CONCLUSIONS The future of pediatric critical care medicine is intertwined with that of children with serious chronic illness. More concerted efforts are needed to address their distinctive needs and study the effectiveness of strategies to do so.
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McDade JE, Olszewski AE, Qu P, Ramos J, Bell S, Adiele A, Roberts J, Coker TR. Association Between Language Use and ICU Transfer and Serious Adverse Events in Hospitalized Pediatric Patients Who Experience Rapid Response Activation. Front Pediatr 2022; 10:872060. [PMID: 35865710 PMCID: PMC9295993 DOI: 10.3389/fped.2022.872060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/13/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Hospitalized patients and caregivers who use a language other than English have worse health outcomes, including longer length of stay, more frequent readmissions, and increased rates of in-hospital adverse events. Children who experience clinical deterioration (as measured by a Rapid Response Team event) during a hospitalization are at increased risk for adverse events and mortality. METHODS We describe the results of a retrospective cohort study using hospital records at a free-standing, quaternary children's hospital, to examine the association of language of care with outcomes (transfer to intensive care, adverse event, mortality prior to discharge) following Rapid Response Team event, and whether increased interpreter use among patients who use a language other than English is associated with improved outcomes following Rapid Response Team event. RESULTS In adjusted models, Rapid Response Team events for patients who use a language other than English were associated with higher transfer rates to intensive care (RR 1.1, 95% CI 1.01, 1.21), but not with adverse event or mortality. Among patients who use a language other than English, use of 1-2 interpreted sessions per day was associated with lower transfer rates to intensive care compared to use of less than one interpreted session per day (RR 0.79, 95% 0.66, 0.95). CONCLUSION Rapid Response Team events for hospitalized children of families who use a language other than English are more often followed by transfer to intensive care, compared with Rapid Response Team events for children of families who use English. Improved communication with increased interpreter use for hospitalized children who use a language other than English may lead to improvements in Rapid Response Team outcomes.
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Affiliation(s)
- Jessica E McDade
- Division of Critical Care, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, WA, United States
| | - Aleksandra E Olszewski
- Division of Critical Care, Department of Pediatrics, McGaw Medical Center of Northwestern University, Chicago, IL, United States.,Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Pingping Qu
- Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, WA, United States
| | - Jessica Ramos
- Center for Diversity and Health Equity, Seattle Children's Hospital, Seattle, WA, United States
| | - Shaquita Bell
- Center for Diversity and Health Equity, Seattle Children's Hospital, Seattle, WA, United States
| | - Alicia Adiele
- Center for Diversity and Health Equity, Seattle Children's Hospital, Seattle, WA, United States
| | - Joan Roberts
- Division of Critical Care, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, WA, United States
| | - Tumaini R Coker
- Center for Diversity and Health Equity, Seattle Children's Hospital, Seattle, WA, United States
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Roy S, Valdez AMD, Trejo B, Bakewell T, Gallarde-Kim S, Martin AJ. "All circuits ended": Family experiences of transitioning from pediatric to adult healthcare for young adults with medical complexity in Oregon. J Pediatr Nurs 2022; 62:171-176. [PMID: 34158213 DOI: 10.1016/j.pedn.2021.06.008] [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: 03/10/2021] [Revised: 06/14/2021] [Accepted: 06/14/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Transition to adult health care for young adults with medical complexity (YAMC) is challenging and much work needs to be done in this area. The Oregon Center for Children and Youth with Special Health Needs participates in a federally-funded Collaborative Improvement and Innovation Network (CoIIN) to improve the quality of care for children with medical complexity. AIMS This study aimed to explore the experiences of Oregon families of YAMC who had recently transitioned to adult health care providers, and obtain recommendations for transition from family members, to inform the development of the CoIIN quality improvement project. METHODS We recruited caregivers of YAMC, ages 18 through 22 years, using a purposive sampling approach and conducted semi-structured interviews with 12 parents and grandparents. We analyzed the interview data to generate themes and sub-themes. RESULTS Families described having little to no notice about transitioning out of pediatric care and reported that their providers did not communicate with them about the steps needed to ensure a continuation of care into adulthood. Poor transition processes contributed to gaps in needed care, decline in health status of the young adults and psychological burden on the family. Families had to take on the responsibility of meeting the transition needs of YAMC and faced challenges in finding adult providers. CONCLUSIONS The results of this study suggest that YAMC and their families cared for by Oregon health care settings are not adequately prepared for, or supported in, the transition from pediatric to adult health care.
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Affiliation(s)
- Shreya Roy
- Oregon Center for Children and Youth With Special Health Needs, Institute on Development and Disability, Oregon Health & Science University, Portland, USA.
| | - Ana M D Valdez
- Oregon Center for Children and Youth With Special Health Needs, Institute on Development and Disability, Oregon Health & Science University, Portland, USA.
| | - BranDee Trejo
- Oregon Center for Children and Youth With Special Health Needs, Institute on Development and Disability, Oregon Health & Science University, Portland, USA.
| | - Tamara Bakewell
- Oregon Center for Children and Youth With Special Health Needs, Institute on Development and Disability, Oregon Health & Science University, Portland, USA.
| | - Sheryl Gallarde-Kim
- Oregon Center for Children and Youth With Special Health Needs, Institute on Development and Disability, Oregon Health & Science University, Portland, USA.
| | - Alison J Martin
- Oregon Center for Children and Youth With Special Health Needs, Institute on Development and Disability, Oregon Health & Science University, Portland, USA; Oregon Health & Science University-Portland State University School of Public Health, Portland, USA.
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Perkins EM, Sorensen I, Susi A, Hisle-Gorman E. The Impact of Having a Child With Special Healthcare Needs on Length of Military Service. Mil Med 2021; 188:e1246-e1251. [PMID: 34850102 DOI: 10.1093/milmed/usab495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/15/2021] [Accepted: 11/16/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION In 2010, the National Survey of Children with Special Healthcare Needs revealed that parents of children with special healthcare needs (CSHCN) report employment decisions are influenced by healthcare coverage needs. The U.S. military healthcare system arguably offers service member parents of CSHCN with the most comprehensive, inexpensive, long-term healthcare in the country-potentially increasing their incentive to remain in the military. This study explored the effect of having a CSHCN on the length of parental military service. MATERIALS AND METHODS A retrospective cohort was formed using the Military Health System database from 2008 to 2018. Included children were <10 years in 2010 and received ≥1 year of military healthcare between 2008 and 2010. The Pediatric Medical Complexity Algorithm categorized children as having special healthcare needs via ICD 9/10 codes as having complex chronic (C-CD), non-complex chronic (NC-CD), or no chronic disease (CD). Families were classified by the child with the most complex healthcare need. Duration of military healthcare eligibility measured parental length of service (LOS). ANOVA and linear regression analysis compared LOS by category. Logistic regression determined odds of parental LOS lasting the full 8-year study length. Adjusted analyses controlled for child age and sex, and military parent sex, rank, and marital status. RESULTS Over 1.45 million children in 915,584 families were categorized as per the algorithm. Of individual children included, 292,050 (20.1%) were CSHCN including those with complex chronic and non-complex chronic conditions. After grouping by family, 80,909 (8.8%) families had a child/children with C-CD (mean LOS 6.39 years), 170,787 (18.7%) families had a child/children with NC-CD (mean LOS 6.41 years), and 663,888 (72.5%) families had children with no CD (mean LOS 5.7 years). In adjusted analysis, parents of children with C-CD and NC-CD served 0.4 [0.37-0.42] and 0.33 [0.31-0.34] years longer than parents of children with no CD; odds of parents serving for the full study period were increased 33% (1.33 [1.31-1.36]) in families of children with C-CD and 27% (1.27 [1.26-1.29]) in families of children with NC-CD. CONCLUSIONS Findings indicate that military parents of CSHCN serve longer military careers than parents of children with no chronic conditions. Continued provision of free, high-quality healthcare coverage for dependent children may be important for service member retention. Retaining trained and experienced service members is key to ensuring a ready and lethal U.S. military.
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Affiliation(s)
- Elizabeth M Perkins
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Ian Sorensen
- Department of Pediatrics, F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | - Apryl Susi
- Department of Pediatrics, F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | - Elizabeth Hisle-Gorman
- Department of Pediatrics, F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA
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Tain YL, Kuo HC, Hsu CN. Changing trends in dialysis modalities utilization and mortality in children, adolescents and young adults with acute kidney injury, 2010-2017. Sci Rep 2021; 11:11887. [PMID: 34088938 PMCID: PMC8178371 DOI: 10.1038/s41598-021-91171-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/07/2021] [Indexed: 11/09/2022] Open
Abstract
The aim of the study was to assess trends in the relative use of dialysis modalities in the hospital-based pediatric cohort and to determine risk factors associated with in-hospital morality among pediatric patients receiving dialysis for acute kidney injury (AKI). Patients aged < 20 years who received dialysis between 2010 and 2017 were identified from electronic health records databases of a Taiwan's healthcare delivery system. The annual uses of intermittent hemodialysis (HD), continuous and automated peritoneal dialysis (PD) and continuous kidney replacement therapy (CKRT) were assessed using Cochran-Armitage Tests for trend. Among patients who received their first dialysis as inpatients for AKI, a multivariate logistic regression model was employed to assess mortality risks associated with dialysis modalities, patient demographics, complexity of baseline chronic disease, and healthcare service use during their hospital stays. Kidney dialysis was performed 37.9 per patient per year over the study period. Intermittent hemodialysis (HD) (73.3%) was the most frequently used dialysis modality. In the inpatient setting, the relative annual use of CKRT increased over the study period, while HD use concomitantly declined (P < 0.0001). The overall in-hospital mortality rate after dialysis for AKI was 33.6%, which remained steady over time (P = 0.2411). Patients aged < 2 years [adjusted odds ratio: (aOR) 3.36; 95% confidence interval (CI) 1.34-8.93] and greater vasoactive regimen use (aOR: 17.1; 95% CI: 5.3-55.21) were significantly associated with dialysis-related mortality. Overall treatment modality used for dialysis in pediatric patients increased slowly in the study period, and HD and CRKT modality uses largely evolved in the inpatient setting. Younger ages and use of more vasoactive medication regimens were independently associated with increased early mortality in patients on AKI-dialysis.
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Affiliation(s)
- You-Lin Tain
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung, 833, Taiwan
| | - Hsiao-Ching Kuo
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, 833, Taiwan
| | - Chien-Ning Hsu
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, 833, Taiwan.
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung, 807, Taiwan.
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Desai AD, Wang G, Wignall J, Kinard D, Singh V, Adams S, Pratt W. User-centered design of a longitudinal care plan for children with medical complexity. J Am Med Inform Assoc 2021; 27:1860-1870. [PMID: 33043368 DOI: 10.1093/jamia/ocaa193] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/17/2020] [Accepted: 08/19/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To determine the content priorities and design preferences for a longitudinal care plan (LCP) among caregivers and healthcare providers who care for children with medical complexity (CMC) in acute care settings. MATERIALS AND METHODS We conducted iterative one-on-one design sessions with CMC caregivers (ie, parents/legal guardians) and providers from 5 groups: complex care, primary care, subspecialists, emergency care, and care coordinators. Audio-recorded sessions included content categorization activities, drawing exercises, and scenario-based testing of an electronic LCP prototype. We applied inductive content analysis of session materials to elicit content priorities and design preferences between sessions. Analysis informed iterative prototype revisions. RESULTS We conducted 30 design sessions (10 with caregivers, 20 with providers). Caregivers expressed high within-group variability in their content priorities compared to provider groups. Emergency providers had the most unique content priorities among clinicians. We identified 6 key design preferences: a familiar yet customizable layout, a problem-based organization schema, linked content between sections, a table layout for most sections, a balance between unstructured and structured data fields, and use of family-centered terminology. DISCUSSION Findings from this study will inform enhancements of electronic health record-embedded LCPs and the development of new LCP tools and applications. The design preferences we identified provide a framework for optimizing integration of family and provider content priorities while maintaining a user-tailored experience. CONCLUSION Health information platforms that incorporate these design preferences into electronic LCPs will help meet the information needs of caregivers and providers caring for CMC in acute care settings.
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Affiliation(s)
- Arti D Desai
- Department of Pediatrics, University of Washington, Seattle, Washington, USA.,Seattle Children's Research Institute, Seattle, Washington, USA
| | - Grace Wang
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Julia Wignall
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Dylan Kinard
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Vidhi Singh
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Sherri Adams
- Division of Paediatric Medicine, SickKids, Toronto, Canada.,SickKids Research Institute, Toronto, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Wanda Pratt
- The Information School, University of Washington, Seattle, Washington, USA.,Biomedical and Health Informatics, University of Washington, Seattle, Washington, USA
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Lion KC, Gritton J, Scannell J, Brown JC, Ebel BE, Klein EJ, Mangione-Smith R. Patterns and Predictors of Professional Interpreter Use in the Pediatric Emergency Department. Pediatrics 2021; 147:peds.2019-3312. [PMID: 33468598 PMCID: PMC7906072 DOI: 10.1542/peds.2019-3312] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Professional interpretation for patients with limited English proficiency remains underused. Understanding predictors of use is crucial for intervention. We sought to identify factors associated with professional interpreter use during pediatric emergency department (ED) visits. METHODS We video recorded ED visits for a subset of participants (n = 50; 20% of the total sample) in a randomized trial of telephone versus video interpretation for Spanish-speaking limited English proficiency families. Medical communication events were coded for duration, health professional type, interpreter (none, ad hoc, or professional), and content. With communication event as the unit of analysis, associations between professional interpreter use and assigned interpreter modality, health professional type, and communication content were assessed with multivariate random-effects logistic regression, clustered on the patient. RESULTS We analyzed 312 communication events from 50 ED visits (28 telephone arm, 22 video arm). Professional interpretation was used for 36% of communications overall, most often for detailed histories (89%) and least often for procedures (11%) and medication administrations (8%). Speaker type, communication content, and duration were all significantly associated with professional interpreter use. Assignment to video interpretation was associated with significantly increased use of professional interpretation for communication with providers (adjusted odds ratio 2.7; 95% confidence interval: 1.1-7.0). CONCLUSIONS Professional interpreter use was inconsistent over the course of an ED visit, even for patients enrolled in an interpretation study. Assignment to video rather than telephone interpretation led to greater use of professional interpretation among physicians and nurse practitioners but not nurses and other staff.
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Affiliation(s)
- K. Casey Lion
- Department of Pediatrics and,Center for Child Health, Behavior and Development and
| | - Jesse Gritton
- Center for Child Health, Behavior and Development and
| | - Jack Scannell
- Center for Child Health, Behavior and Development and
| | - Julie C. Brown
- Department of Pediatrics and,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Beth E. Ebel
- Department of Pediatrics and,Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington; and,Center for Child Health, Behavior and Development and
| | - Eileen J. Klein
- Department of Pediatrics and,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Rita Mangione-Smith
- Department of Pediatrics and,Center for Child Health, Behavior and Development and
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Bailey LC, Razzaghi H, Burrows EK, Bunnell HT, Camacho PEF, Christakis DA, Eckrich D, Kitzmiller M, Lin SM, Magnusen BC, Newland J, Pajor NM, Ranade D, Rao S, Sofela O, Zahner J, Bruno C, Forrest CB. Assessment of 135 794 Pediatric Patients Tested for Severe Acute Respiratory Syndrome Coronavirus 2 Across the United States. JAMA Pediatr 2021; 175:176-184. [PMID: 33226415 PMCID: PMC7684518 DOI: 10.1001/jamapediatrics.2020.5052] [Citation(s) in RCA: 150] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
IMPORTANCE There is limited information on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing and infection among pediatric patients across the United States. OBJECTIVE To describe testing for SARS-CoV-2 and the epidemiology of infected patients. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted using electronic health record data from 135 794 patients younger than 25 years who were tested for SARS-CoV-2 from January 1 through September 8, 2020. Data were from PEDSnet, a network of 7 US pediatric health systems, comprising 6.5 million patients primarily from 11 states. Data analysis was performed from September 8 to 24, 2020. EXPOSURE Testing for SARS-CoV-2. MAIN OUTCOMES AND MEASURES SARS-CoV-2 infection and coronavirus disease 2019 (COVID-19) illness. RESULTS A total of 135 794 pediatric patients (53% male; mean [SD] age, 8.8 [6.7] years; 3% Asian patients, 15% Black patients, 11% Hispanic patients, and 59% White patients; 290 per 10 000 population [range, 155-395 per 10 000 population across health systems]) were tested for SARS-CoV-2, and 5374 (4%) were infected with the virus (12 per 10 000 population [range, 7-16 per 10 000 population]). Compared with White patients, those of Black, Hispanic, and Asian race/ethnicity had lower rates of testing (Black: odds ratio [OR], 0.70 [95% CI, 0.68-0.72]; Hispanic: OR, 0.65 [95% CI, 0.63-0.67]; Asian: OR, 0.60 [95% CI, 0.57-0.63]); however, they were significantly more likely to have positive test results (Black: OR, 2.66 [95% CI, 2.43-2.90]; Hispanic: OR, 3.75 [95% CI, 3.39-4.15]; Asian: OR, 2.04 [95% CI, 1.69-2.48]). Older age (5-11 years: OR, 1.25 [95% CI, 1.13-1.38]; 12-17 years: OR, 1.92 [95% CI, 1.73-2.12]; 18-24 years: OR, 3.51 [95% CI, 3.11-3.97]), public payer (OR, 1.43 [95% CI, 1.31-1.57]), outpatient testing (OR, 2.13 [1.86-2.44]), and emergency department testing (OR, 3.16 [95% CI, 2.72-3.67]) were also associated with increased risk of infection. In univariate analyses, nonmalignant chronic disease was associated with lower likelihood of testing, and preexisting respiratory conditions were associated with lower risk of positive test results (standardized ratio [SR], 0.78 [95% CI, 0.73-0.84]). However, several other diagnosis groups were associated with a higher risk of positive test results: malignant disorders (SR, 1.54 [95% CI, 1.19-1.93]), cardiac disorders (SR, 1.18 [95% CI, 1.05-1.32]), endocrinologic disorders (SR, 1.52 [95% CI, 1.31-1.75]), gastrointestinal disorders (SR, 2.00 [95% CI, 1.04-1.38]), genetic disorders (SR, 1.19 [95% CI, 1.00-1.40]), hematologic disorders (SR, 1.26 [95% CI, 1.06-1.47]), musculoskeletal disorders (SR, 1.18 [95% CI, 1.07-1.30]), mental health disorders (SR, 1.20 [95% CI, 1.10-1.30]), and metabolic disorders (SR, 1.42 [95% CI, 1.24-1.61]). Among the 5374 patients with positive test results, 359 (7%) were hospitalized for respiratory, hypotensive, or COVID-19-specific illness. Of these, 99 (28%) required intensive care unit services, and 33 (9%) required mechanical ventilation. The case fatality rate was 0.2% (8 of 5374). The number of patients with a diagnosis of Kawasaki disease in early 2020 was 40% lower (259 vs 433 and 430) than in 2018 or 2019. CONCLUSIONS AND RELEVANCE In this large cohort study of US pediatric patients, SARS-CoV-2 infection rates were low, and clinical manifestations were typically mild. Black, Hispanic, and Asian race/ethnicity; adolescence and young adulthood; and nonrespiratory chronic medical conditions were associated with identified infection. Kawasaki disease diagnosis is not an effective proxy for multisystem inflammatory syndrome of childhood.
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Affiliation(s)
- L. Charles Bailey
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hanieh Razzaghi
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Evanette K. Burrows
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - H. Timothy Bunnell
- Biomedical Research Informatics Center, Nemours Biomedical Research, Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Peter E. F. Camacho
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Dimitri A. Christakis
- Seattle Children’s Research Institute, University of Washington, Department of Pediatrics, Seattle,Editor, JAMA Pediatrics
| | - Daniel Eckrich
- Biomedical Research Informatics Center, Nemours Biomedical Research, Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Melody Kitzmiller
- Research IT R&D, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio
| | - Simon M. Lin
- Department of Research Information Solutions and Innovation, Nationwide Children’s Hospital, Columbus, Ohio
| | - Brianna C. Magnusen
- Institute for Informatics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Jason Newland
- Department of Pediatrics, St Louis Children’s Hospital, St Louis, Missouri
| | - Nathan M. Pajor
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Daksha Ranade
- Seattle Children’s Research Institute, University of Washington, Department of Pediatrics, Seattle
| | - Suchitra Rao
- Department of Pediatrics (Infectious Diseases, Hospital Medicine and Epidemiology), University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora
| | - Olamiji Sofela
- Research Informatics–Analytics Resource Center, Children’s Hospital Colorado, Aurora
| | - Janet Zahner
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Cortney Bruno
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christopher B. Forrest
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Blackmer AB, Fox D, Arendt D, Phillips K, Feinstein JA. Perceived Versus Demonstrated Understanding of the Complex Medications of Medically Complex Children. J Pediatr Pharmacol Ther 2021; 26:62-72. [PMID: 33424502 DOI: 10.5863/1551-6776-26.1.62] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 06/10/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Parents and caregivers of children with medical complexity (CMC) manage complex medication regimens (CMRs) at home. Parental understanding of CMRs is critical to safe medication administration. Regarding CMR administration, we 1) described the population of CMC receiving CMRs; 2) assessed parental perceived confidence and understanding; and 3) evaluated parental demonstrated understanding. METHODS Cross-sectional clinic-based assessment of knowledge and understanding of CMC using CMRs who received primary care in a large pediatric complex care clinic. CMRs were identified by the receipt of ≥1 of the following: 1) ≥10 concurrent medications; 2) ≥1 high-risk medication; or 3) ≥1 extemporaneously compounded medication. Parents reported their perceived confidence and understanding of CMRs, and then demonstrated understanding through 3 medication-related tasks. RESULTS Of 156 CMCs, most were <10 years of age (63.5%), white (75%), had neurologic impairment (76.9%), and used a median of 8 medications (IQR, 5-10). Parents were female (76.9%) with a mean age of 38.8 ± 11.5 years, white (69.9%), spoke English (94.2%), and had some college education (82.1%). On 11 confidence and understanding statements, most parents reported a high perceived level of understanding and confidence, with combined agreement or strong agreement ranging between 81.2% and 98.7%. Only 73.1% correctly identified medications taken for specified conditions, 40.4% reported complete dosing parameters, and 54.8% correctly measured 2 different medication doses. Significant differences existed between parental perceived understanding versus the 3 demonstrated tasks (all p < 0.05). CONCLUSIONS Substantial opportunities exist to improve medication safety and efficacy in the outpatient, in-home setting including improved medication-specific education and medication-related supports.
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Parente V, Parnell L, Childers J, Spears T, Jarrett V, Ming D. Point-of-Care Complexity Screening Algorithm to Identify Children With Medical Complexity. Hosp Pediatr 2020; 11:44-51. [PMID: 33298458 DOI: 10.1542/hpeds.2020-0066] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES For pediatric complex care programs to target enhanced care coordination services to the highest-risk patients, it is critical to accurately identify children with medical complexity (CMC); however, no gold standard definition exists. The aim of this study is to describe a point-of-care screening algorithm to identify CMC with high health care use, a group that may benefit the most from improved care coordination. METHODS From July 1, 2015, to June 30, 2016 (fiscal year 2016 [FY16]), a medical complexity screening algorithm was implemented by a pediatric complex care program at a single tertiary care center for hospitalized patients at the time of admission. Using the screening algorithm, we categorized inpatients into 1 of 3 groups: CMC, children with special health care needs (CSHCN), or previously healthy (PH) children. Inpatient resource use for FY16 and FY17 encounters was extracted for children screened in FY16. RESULTS We categorized 2187 inpatients in FY16 into the 3 complexity groups (CMC = 77; CSHCN = 1437; PH children = 673). CMC had more complex chronic conditions (median = 6; interquartile range [IQR] 4-11) than CSHCN (median = 1; IQR 0-2) and PH children (median = 0; IQR 0-0). CMC had greater per-patient and per-encounter hospital use than CSHCN and PH children. CMC and children with ≥4 complex chronic conditions had comparable levels of resource use. CONCLUSIONS By implementation of a point-of-care screening algorithm, we identified CMC with high health care use. By using this algorithm, it was feasible to identify hospitalized CMC that could benefit from care coordination by a pediatric complex care program.
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Affiliation(s)
| | | | - Julie Childers
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
| | - Tracy Spears
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - David Ming
- Departments of Pediatrics and.,Medicine, School of Medicine, Duke University, Durham, North Carolina
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Trends in Antimicrobial Susceptibility of Escherichia coli Isolates in a Taiwanese Child Cohort with Urinary Tract Infections between 2004 and 2018. Antibiotics (Basel) 2020; 9:antibiotics9080501. [PMID: 32785113 PMCID: PMC7460002 DOI: 10.3390/antibiotics9080501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/05/2020] [Accepted: 08/08/2020] [Indexed: 11/28/2022] Open
Abstract
The aim of this study was to investigate the annual incidence of Escherichia coli isolates in urinary tract infections (UTIs) and the antimicrobial resistance of the third-generation cephalosporin (3GCs) to E. coli, including the factors associated with the resistance in hospitalized children in Taiwan. A large electronic database of medical records combining hospital admission and microbiological data during 2004–2018 was used to study childhood UTIs in Taiwan. Annual incidence rate ratios (IRR) of E. coli in children with UTIs and its resistant rate to the 3GCs and other antibiotics were estimated by linear Poisson regression. Factors associated with E. coli resistance to 3GCs were assessed through multivariable logistic regression analysis. E. coli UTIs occurred in 10,756 unique individuals among 41,879 hospitalized children, with 92.58% being community associated based on urine culture results reported within four days after the hospitalization. The overall IRR E. coli UTI was 1.01 (95% confidence interval (CI) 0.99–1.02) in community-associated (CA) and 0.96 (0.90–1.02) in healthcare-associated infections. The trend in 3GCs against E. coli increased (IRR 1.18, 95% CI 1.13–1.24) over time in CA-UTIs. Complex chronic disease (adjusted odds ratio (aOR), 2.04; 95% CI, 1.47–2.83) and antibiotics therapy ≤ 3 months prior (aOR, 1.49; 95% CI, 1.15–1.94) were associated with increased risk of 3GCs resistance to E. coli. The study results suggested little or no change in the trend of E. coli UTIs in Taiwanese youths over the past 15 years. Nevertheless, the increase in 3GCs-resistant E. coli was substantial. Interventions for children with complex chronic comorbidities and prior antibiotic treatment could be effective in reducing the incidence of 3GCs-resistant E. coli in CA-UTIs in this region and more generally.
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Ray KN, Shi Z, Ganguli I, Rao A, Orav EJ, Mehrotra A. Trends in Pediatric Primary Care Visits Among Commercially Insured US Children, 2008-2016. JAMA Pediatr 2020; 174:350-357. [PMID: 31961428 PMCID: PMC6990970 DOI: 10.1001/jamapediatrics.2019.5509] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Primary care is the foundation of pediatric care. While policy interventions have focused on improving access and quality of primary care, trends in overall use of primary care among children have not been described. OBJECTIVE To assess trends in primary care visit rates and out-of-pocket costs, to examine variation in these trends by patient and visit characteristics, and to assess shifts to alternative care options (eg, retail clinics, urgent care, and telemedicine). DESIGN, SETTING, AND PARTICIPANTS Observational cohort study of claims data from 2008 to 2016 for children 17 years and younger covered by a large national commercial health plan. Visit rate per 100 child-years was determined for each year overall, by child and geographic characteristics, and by visit type (eg, primary diagnosis), and trends were assessed with a series of child-year Poisson models. Data were analyzed from November 2017 to September 2019. MAIN OUTCOMES AND MEASURES Visits to primary care and other settings. RESULTS This cohort study included more than 71 million pediatric primary care visits over 29 million pediatric child-years (51% male in 2008 and 2016; 37% between 12-17 years in 2008 and 38% between 12-17 years in 2016). Unadjusted results for primary care visit rates per 100 child-years decreased from 259.6 in 2008 to 227.2 in 2016, yielding a regression-estimated change in primary care visits across the 9 years of -14.4% (95% CI, -15.0% to -13.9%; absolute change: -32.4 visits per 100 child-years). After controlling for shifts in demographics, the relative decrease was -12.8% (95% CI, -13.3% to -12.2%). Preventive care visits per 100 child-years increased from 74.9 in 2008 to 83.2 visits in 2016 (9.9% change in visit rate; 95% CI, 9.0%-10.9%; absolute change: 8.3 visits per 100 child-years), while problem-based visits per 100 child-years decreased from 184.7 in 2008 to 144.1 in 2016 (-24.1%; 95% CI, -24.6% to -23.5%; absolute change: -40.6 visits per 100 child-years). Visit rates decreased for all diagnostic groups except for the behavioral and psychiatric category. Out-of-pocket costs for problem-based primary care visits increased by 42% during the same period. Per 100 child-years, visits to other acute care venues increased from 21.3 to 27.6 (30.3%; 95% CI, 28.5% to 32.1%; absolute change: 6.3 visits per 100 child-years) and visits to specialists from 45.2 to 53.5 (16.4%; 95% CI, 14.8% to 18.0%, absolute change: 8.3 visits per 100 child-years). CONCLUSIONS AND RELEVANCE Primary care visit rates among commercially insured children decreased over the last decade. Increases in out-of-pocket costs and shifts to other venues appear to explain some of this decrease.
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Affiliation(s)
- Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Zhuo Shi
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Ishani Ganguli
- Department of Medicine, Harvard Medical School, Boston, Massachusetts,Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Aarti Rao
- Icahn School of Medicine at Mt Sinai, New York City, New York
| | - E. John Orav
- Department of Medicine, Harvard Medical School, Boston, Massachusetts,Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts,Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Taylor T, Altares Sarik D, Salyakina D. Development and Validation of a Web-Based Pediatric Readmission Risk Assessment Tool. Hosp Pediatr 2020; 10:246-256. [PMID: 32075853 DOI: 10.1542/hpeds.2019-0241] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Accurately predicting and reducing risk of unplanned readmissions (URs) in pediatric care remains difficult. We sought to develop a set of accurate algorithms to predict URs within 3, 7, and 30 days of discharge from inpatient admission that can be used before the patient is discharged from a current hospital stay. METHODS We used the Children's Hospital Association Pediatric Health Information System to identify a large retrospective cohort of 1 111 323 children with 1 321 376 admissions admitted to inpatient care at least once between January 1, 2016, and December 31, 2017. We used gradient boosting trees (XGBoost) to accommodate complex interactions between these predictors. RESULTS In the full cohort, 1.6% of patients had at least 1 UR in 3 days, 2.4% had at least 1 UR in 7 days, and 4.4% had at least 1 UR within 30 days. Prediction model discrimination was strongest for URs within 30 days (area under the curve [AUC] = 0.811; 95% confidence interval [CI]: 0.808-0.814) and was nearly identical for UR risk prediction within 3 days (AUC = 0.771; 95% CI: 0.765-0.777) and 7 days (AUC = 0.778; 95% CI: 0.773-0.782), respectively. Using these prediction models, we developed a publicly available pediatric readmission risk scores prediction tool that can be used before or during discharge planning. CONCLUSIONS Risk of pediatric UR can be predicted with information known before the patient's discharge and that is easily extracted in many electronic medical record systems. This information can be used to predict risk of readmission to support hospital-discharge-planning resources.
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Affiliation(s)
- Thom Taylor
- Nicklaus Children's Research Institute, .,Nicklaus Children's Health System, Miami, Florida; and.,Research Facilitation Laboratory, Northrop Grumman, Monterey, California
| | | | - Daria Salyakina
- Nicklaus Children's Research Institute.,Nicklaus Children's Health System, Miami, Florida; and
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McSweeney ME, Meleedy-Rey P, Kerr J, Chan Yuen J, Fournier G, Norris K, Larson K, Rosen R. A Quality Improvement Initiative to Reduce Gastrostomy Tube Placement in Aspirating Patients. Pediatrics 2020; 145:peds.2019-0325. [PMID: 31996405 PMCID: PMC6993527 DOI: 10.1542/peds.2019-0325] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2019] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Oropharyngeal dysphagia and aspiration may occur in infants and children. Currently, there is wide practice variation regarding when to feed children orally or place more permanent gastrostomy tube placement. Through implementation of an evidence-based guideline (EBG), we aimed to standardize the approach to these patients and reduce the rates of gastrostomy tube placement. METHODS Between January 2014 and December 2018, we designed and implemented a quality improvement intervention creating an EBG to be used by gastroenterologists evaluating patients ≤2 years of age with respiratory symptoms who were found to aspirate on videofluoroscopic swallow study (VFSS). Our primary aim was to encourage oral feeding and decrease the use of gastrostomy tube placement by 10% within 1 year of EBG initiation; balancing measures included total hospital readmissions or emergency department (ED) visits within 6 months of the abnormal VFSS. RESULTS A total of 1668 patients (27.2%) were found to have aspiration or penetration noted on an initial VFSS during our initiative. Mean gastrostomy tube placement in these patients was 10.9% at the start of our EBG implementation and fell to 5.2% approximately 1 year after EBG initiation; this improvement was sustained throughout the next 3 years. Our balancing measures of ED visits and hospital readmissions also did not change during this time period. CONCLUSIONS Through implementation of this EBG, we reduced gastrostomy tube placement by 50% in patients presenting with oropharyngeal dysphagia and aspiration, without increasing subsequent hospital admissions or ED visits.
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Affiliation(s)
- Maireade E. McSweeney
- Aerodigestive Center and Motility and Functional Gastrointestinal Disorders Center, Division of Gastroenterology, Hepatology and Nutrition
| | | | | | | | - Gregory Fournier
- Aerodigestive Center and Motility and Functional Gastrointestinal Disorders Center, Division of Gastroenterology, Hepatology and Nutrition
| | - Kerri Norris
- Finance, Boston Children’s Hospital, Boston, Massachusetts
| | - Kara Larson
- Aerodigestive Center and Motility and Functional Gastrointestinal Disorders Center, Division of Gastroenterology, Hepatology and Nutrition
| | - Rachel Rosen
- Aerodigestive Center and Motility and Functional Gastrointestinal Disorders Center, Division of Gastroenterology, Hepatology and Nutrition
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Valdez RS, Lunsford C, Bae J, Letzkus LC, Keim-Malpass J. Self-Management Characterization for Families of Children With Medical Complexity and Their Social Networks: Protocol for a Qualitative Assessment. JMIR Res Protoc 2020; 9:e14810. [PMID: 32012094 PMCID: PMC7005691 DOI: 10.2196/14810] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 10/31/2019] [Accepted: 12/16/2019] [Indexed: 11/13/2022] Open
Abstract
Background Children with medical complexity (CMC) present rewarding but complex challenges for the health care system. Transforming high-quality care practices for this population requires multiple stakeholders and development of innovative models of care. Importantly, care coordination requires significant self-management by families in home- and community-based settings. Self-management often requires that families of CMC rely on vast and diverse social networks, encompassing both online and offline social relationships with individuals and groups. The result is a support network surrounding the family to help accomplish self-management of medical tasks and care coordination. Objective The goal of this study is to use a theoretically driven perspective to systematically elucidate the range of self-management experiences across families of CMC embedded in diverse social networks and contextual environments. This approach will allow for characterization of the structure and process of self-management of CMC with respect to social networks, both in person and digitally. This research proposal aims to address the significant gaps in the self-management literature surrounding CMC, including the following: (1) how self-management responsibilities are distributed and negotiated among the social network and (2) how individual-, family-, and system-level factors influence self-management approaches for CMC from a theoretically driven perspective. Methods This study will encompass a qualitative descriptive approach to understand self-management practices among CMC and their social networks. Data collection and analysis will be guided by a theoretical and methodological framework, which synthesizes perspectives from nursing, human factors engineering, public health, and family counseling. Data collection will consist of semistructured interviews with children, parents, and social network members, inclusive of individuals such as friends, neighbors, and community members, as well as online communities and individuals. Data analysis will consist of a combination of inductive and deductive methods of qualitative content analysis, which will be analyzed at both individual and multiadic levels, where interview data from two or more individuals, focused on the same experience, will be comparatively analyzed. Results This study will take approximately 18 months to complete. Our long-term goals are to translate the qualitative analysis into (1) health IT design guidance for innovative approaches to self-management and (2) direct policy guidance for families of CMC enrolled in Medicaid and private insurance. Conclusions Multiple innovative components of this study will enable us to gain a comprehensive and nuanced understanding of the lived experience of self-management of CMC. In particular, by synthesizing and applying theoretical and methodological approaches from multiple disciplines, we plan to create novel informatics and policy solutions to support their care within home and community settings. International Registered Report Identifier (IRRID) PRR1-10.2196/14810
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Affiliation(s)
- Rupa S Valdez
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA, United States
| | - Christopher Lunsford
- Department of Orthopaedics, School of Medicine, Duke University, Durham, NC, United States
| | - Jiwoon Bae
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA, United States
| | - Lisa C Letzkus
- School of Nursing, University of Virginia, Charlottesville, VA, United States
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D'Aprano A, Gibb S, Riess S, Cooper M, Mountford N, Meehan E. Important components of a programme for children with medical complexity: An Australian perspective. Child Care Health Dev 2020; 46:90-103. [PMID: 31782538 DOI: 10.1111/cch.12721] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 11/23/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Children with medical complexity (CMC) have high care needs, often unmet by traditional healthcare models. In response to this need, the Complex Care Service (CCS) at The Royal Children's Hospital (RCH), Melbourne was created. Although preliminary parent satisfaction data were available, we lacked knowledge of how the various components of the expanded service were valued and contributed to overall caregiver satisfaction. AIM The aims of this study were to (a) determine what caregivers value most about the CCS and (b) explore caregiver perceptions of care. METHODS All caregivers of children enrolled in the RCH CCS in April 2017 were invited to participate. A purposefully designed survey explored caregiver perceptions of care, including patient quality of care; the extent to which the CCS components added value and satisfaction; and frequency of contact. Participants were also invited to answer open-ended questions and provide general comments. RESULTS Responses were received from 53 families (51%). We found that 24-hr phone advice, coordination of appointments, a key contact, and access to timely information were the most important components of the service. More than 90% of caregivers indicated that they were satisfied with care and that the CCS improved their child's quality of care. Coordination, communication, family-centred care, quality care, and access were emergent themes within comments. CONCLUSION This study provides important information regarding the design and operation of services for CMC throughout Australia and further afield. Our findings highlight the importance of the key contact and family-centred care. This has implications for practice, as maintaining service quality, as the CCS expands and is implemented more widely, is a major sustainability challenge. It is crucial that we have a detailed understanding of what elements are required to support effective care coordination, to achieve successful implementation on a larger scale.
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Affiliation(s)
- Anita D'Aprano
- Department of General Medicine, The Royal Children's Hospital, Melbourne, Melbourne, Victoria, Australia.,Population Health Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Susie Gibb
- Department of General Medicine, The Royal Children's Hospital, Melbourne, Melbourne, Victoria, Australia.,Department of Neurodevelopment & Disability, The Royal Children's Hospital, Melbourne, Melbourne, Victoria, Australia.,Infection and Immunity Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Suzi Riess
- Population Health Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Neurodevelopment & Disability, The Royal Children's Hospital, Melbourne, Melbourne, Victoria, Australia
| | - Monica Cooper
- Department of Neurodevelopment & Disability, The Royal Children's Hospital, Melbourne, Melbourne, Victoria, Australia.,Clinical Sciences Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Nicki Mountford
- Quality and Improvement, The Royal Children's Hospital, Melbourne, Melbourne, Victoria, Australia
| | - Elaine Meehan
- Clinical Sciences Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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