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Jones MN, Simpson SL, Beck AF, Cortezzo DE, Thienprayoon R, Corley AMS, Thomson J. Racial Inequities in Palliative Referral for Children with High-Intensity Neurologic Impairment. J Pediatr 2024; 268:113930. [PMID: 38309525 DOI: 10.1016/j.jpeds.2024.113930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 12/05/2023] [Accepted: 01/28/2024] [Indexed: 02/05/2024]
Abstract
OBJECTIVE To evaluate whether racial and socioeconomic inequities in pediatric palliative care utilization extend to children with high-intensity neurologic impairment (HI-NI), which is a chronic neurological diagnosis resulting in substantial functional morbidity and mortality. STUDY DESIGN We conducted a retrospective study of patients with HI-NI who received primary care services at a tertiary care center from 2014 through 2019. HI-NI diagnoses that warranted a palliative care referral were identified by consensus of a multidisciplinary team. The outcome was referral to palliative care. The primary exposure was race, categorized as Black or non-Black to represent the impact of anti-Black racism. Additional exposures included ethnicity (Hispanic/non-Hispanic) and insurance status (Medicaid/non-Medicaid). Descriptive statistics, bivariate analyses, and multivariable logistic regression models were performed to assess associations between exposures and palliative care referral. RESULTS A total of 801 patients with HI-NI were included; 7.5% received a palliative referral. There were no differences in gestational age, sex, or ethnicity between patients who received a referral and those who did not. In multivariable analysis, adjusting for ethnicity, sex, gestational age, and presence of complex chronic conditions, Black children (aOR 0.47, 95% CI 0.26, 0.84) and children with Medicaid insurance (aOR 0.40, 95% CI 0.23, 0.70) each had significantly lower odds of palliative referral compared with their non-Black and non-Medicaid-insured peers, respectively. CONCLUSIONS We identified inequities in pediatric palliative care referral among children with HI-NI by race and insurance status. Future work is needed to develop interventions, with families, aimed at promoting more equitable, antiracist systems of palliative care.
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Affiliation(s)
- Margaret N Jones
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Samantha L Simpson
- Division of Neonatal and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Andrew F Beck
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - DonnaMaria E Cortezzo
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Neonatal and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Palliative Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Rachel Thienprayoon
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Palliative Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alexandra M S Corley
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Joanna Thomson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Ng GMC, Bourassa MH, Patel H. How Do Children With Medical Complexity Die? A Scoping Review. J Palliat Med 2024. [PMID: 38285483 DOI: 10.1089/jpm.2023.0322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024] Open
Abstract
Introduction: Advancement in medical expertise and technology has led to a growing cohort of children with medical complexity (CMC), who make up a rising proportion of childhood deaths. However, end of life in CMC is poorly understood and little is known about illness trajectories, communication, and decision-making experiences. Objective: To synthesize existing literature and characterize the end-of-life experience in CMC. Methods: A literature search of MEDLINE, CINAHL, PsycINFO, Scopus, Embase, and Google Scholar was conducted up to August 26, 2021. Studies reporting CMC at end of life were included and the extracted data were analyzed descriptively. Findings: Of 1535 publications identified, 23 studies were included. Most studies (15/23 [65%]) were published from 2015 to 2021 and were quantitative in nature (20/23 [87%]). The majority of studies that extracted data from a single country (18/20 [90%]) originated from North America. Study outcomes were categorized into four main domains: (1) place of death (2) health care use (3) interventions received or withdrawn (4) communication, and end-of-life experiences. The weighted percentage of in-hospital CMC deaths was 80.6%. Studies reported that CMC had increased health care use and were subjected to more intensive interventions at end of life compared with non-CMC. Qualitative studies highlighted the following themes: Intrinsic prognostic uncertainty, differing perspectives of the child's quality of life, the chronic illness experience, a desire to have parental expertise acknowledged, surprise at the terminal event, the experience of multiple losses, with an overarching theme of the need for compassionate care at end of life. Conclusions: This scoping review highlighted important characteristics of end of life in CMC, outlining the emerging evidence and knowledge gaps on this topic. A better understanding of this cohort of seriously and chronically ill children would serve to inform clinical practice, service development, and future research.
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Affiliation(s)
- Grace Mei Chan Ng
- Department of Pediatrics, McGill University Health Center, Montreal, Canada
- Department of Pediatrics, McGill University, Montreal, Canada
- Star PALS (Pediatric Advanced Life Support), HCA Hospice Limited, Singapore, Singapore
| | - Marie-Hélène Bourassa
- Department of Pediatrics, McGill University Health Center, Montreal, Canada
- Department of Pediatrics, McGill University, Montreal, Canada
| | - Hema Patel
- Department of Pediatrics, McGill University Health Center, Montreal, Canada
- Department of Pediatrics, McGill University, Montreal, Canada
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3
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Keim G, Hsu JY, Pinto NP, McSherry ML, Gula AL, Christie JD, Yehya N. Readmission Rates After Acute Respiratory Distress Syndrome in Children. JAMA Netw Open 2023; 6:e2330774. [PMID: 37682574 PMCID: PMC10492185 DOI: 10.1001/jamanetworkopen.2023.30774] [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: 05/12/2023] [Accepted: 07/19/2023] [Indexed: 09/09/2023] Open
Abstract
Importance An increasing number of children survive after acute respiratory distress syndrome (ARDS). The long-term morbidity affecting these survivors, including the burden of hospital readmission and key factors associated with readmission, is unknown. Objective To determine 1-year readmission rates among survivors of pediatric ARDS and to investigate the associations of 3 key index hospitalization factors (presence or development of a complex chronic condition, receipt of a tracheostomy, and hospital length of stay [LOS]) with readmission. Design, Setting, and Participants This retrospective cohort study used data from the commercial or Medicaid IBM MarketScan databases between 2013 and 2017, with follow-up data through 2018. Participants included hospitalized children (aged ≥28 days to <18 years) who received mechanical ventilation and had algorithm-identified ARDS. Data analysis was completed from March 2022 to March 2023. Exposures Complex chronic conditions (none, nonrespiratory, and respiratory), receipt of tracheostomy, and index hospital LOS. Main Outcomes and Measures The primary outcome was 1-year, all-cause hospital readmission. Univariable and multivariable Cox proportional hazard models were created to test the association of key hospitalization factors with readmission. Results One-year readmission occurred in 3748 of 13 505 children (median [IQR] age, 4 [0-14] years; 7869 boys [58.3%]) with mechanically ventilated ARDS who survived to hospital discharge. In survival analysis, the probability of 1-year readmission was 30.0% (95% CI, 29.0%-30.8%). One-half of readmissions occurred within 61 days of discharge (95% CI, 56-67 days). Both respiratory (adjusted hazard ratio [aHR], 2.69; 95% CI, 2.42-2.98) and nonrespiratory (aHR, 1.86; 95% CI, 1.71-2.03) complex chronic conditions were associated with 1-year readmission. Placement of a new tracheostomy (aHR, 1.98; 95% CI, 1.69-2.33) and LOS 14 days or longer (aHR, 1.87; 95% CI, 1.62-2.16) were associated with readmission. After exclusion of children with chronic conditions, LOS 14 days or longer continued to be associated with readmission (aHR, 1.92; 95% CI, 1.49-2.47). Conclusions and Relevance In this retrospective cohort study of children with ARDS who survived to discharge, important factors associated with readmission included the presence or development of chronic medical conditions during the index admission, tracheostomy placement during index admission, and index hospitalization of 14 days or longer. Future studies should evaluate whether postdischarge interventions (eg, telephonic contact, follow-up clinics, and home health care) may help reduce the readmission burden.
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Affiliation(s)
- Garrett Keim
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Jesse Y. Hsu
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Neethi P. Pinto
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Megan L. McSherry
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Annie Laurie Gula
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jason D. Christie
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of Pulmonary, Allergy and Critical Care Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Choi J, Park E, Choi AY, Son MH, Cho J. Incidence and Mortality Trends in Critically Ill Children: A Korean Population-Based Study. J Korean Med Sci 2023; 38:e178. [PMID: 37309697 DOI: 10.3346/jkms.2023.38.e178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/24/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Monitoring mortality trends can help design ways to improve survival, but observation of national mortality trends in critically ill children is lacking for the Korean population. METHODS We analyzed the incidence and mortality trends of children younger than 18 years admitted to an intensive care unit (ICU) from 2012 to 2018 using the Korean National Health Insurance database. Neonates and neonatal ICU admissions were excluded. Multivariable logistic regression analyses were performed to estimate the odds ratio of in-hospital mortality according to admission year. Trends in incidence and in-hospital mortality of subgroups according to admission department, age, presence of intensivists, admissions to pediatric ICU, mechanical ventilation, and use of vasopressors were evaluated. RESULTS The overall mortality of critically ill children was 4.4%. There was a significant decrease in mortality from 5.5% in 2012 to 4.1% in 2018 (P for trend < 0.001). The incidence of ICU admission in children remained around 8.5/10,000 population years (P for trend = 0.069). In-hospital mortality decreased by 9.2% yearly in adjusted analysis (P < 0.001). The presence of dedicated intensivists (P for trend < 0.001, mortality decrease from 5.7% to 4.0%) and admission to pediatric ICU (P for trend < 0.001, mortality decrease from 5.0% to 3.2%) were associated with significant decreasing trends in mortality. CONCLUSION Mortality among critically ill children improved during the study period, and the improving trend was prominent in children with high treatment requirements. Varying mortality trends, according to ICU organizations, highlight that advances in medical knowledge should be supported structurally.
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Affiliation(s)
- Jaeyoung Choi
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Esther Park
- Department of Pediatrics, Jeonbuk National University Children's Hospital, Jeonju, Korea
| | - Ah Young Choi
- Department of Pediatrics, Chungnam National University Hospital, Daejeon, Korea
| | - Meong Hi Son
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joongbum Cho
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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5
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Frenkel B, Gerasimov E, Gustafson A, Gustafson P, McLean G, Ochasi A, Waanders A, Ramaswamy V. Postmortem Tissue Donation: Giving Families the Ability to Choose. J Clin Oncol 2023; 41:447-451. [PMID: 36027484 DOI: 10.1200/jco.21.02839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Beth Frenkel
- Children's Hospital of Philadelphia, Philadelphia, PA
| | | | | | | | | | - Aloysius Ochasi
- Center for Clinical Bioethics, St Joseph's University, Philadelphia, PA
| | - Angela Waanders
- Division of Hematology, Oncology, and Stem Cell Transplant, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL
- Department of Pediatrics, Feinberg School of Medicine Northwestern University, Chicago, IL
| | - Vijay Ramaswamy
- Division of Hematology/Oncology, Arthur and Sonia Labatt Brain Tumour Research Centre, Hospital for Sick Children, Toronto, ON, Canada
- Departments of Medical Biophysics and Pediatrics, University of Toronto, Toronto, ON, Canada
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6
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Leite MM, Bello FPS, Sakano TMS, Schvartsman C, da Costa Reis AGA. Analysis of death in children not submitted to cardiopulmonary resuscitation. J Pediatr (Rio J) 2022; 98:477-483. [PMID: 35139342 PMCID: PMC9510803 DOI: 10.1016/j.jped.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 11/02/2021] [Accepted: 12/06/2021] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Describe the epidemiology of deaths in children not submitted to CPR, compare to a CPR group and evaluate patients' medical records of those not submitted to CPR. METHODS Observational cross-sectional study assessing deaths between 2015 and 2018 in a pediatric tertiary hospital, divided into two groups: CPR and no- CPR. The source of data included the cardiorespiratory arrest register, based on Utstein style. Children's medical records in no-CPR group were researched by hand. RESULTS 241 deaths were included, 162 in CPR group and 79 in the no-CPR group. Preexisting diseases were observed in 98.3% of patients and prior advanced intervention in 78%. Of the 241 deaths, 212 (88%) occurred in the PICU, being 138/162 (85.2%) in CPR group and 74/79 (93.7%) in no-CPR group (p = 0.018). Bradycardia as the initial rhythm was five times more frequent in the CPR group (OR 5.06, 95% CI 1.94-13,19). There was no statistically significant difference regarding age, gender, preexisting diseases, and period of the day of the occurrence of death. Medical records revealed factors related to the family decision-making process or the suitability of therapeutic effort. Discrepancies between the practice of CPR and medical records were identified in 9/79 (11,4%) records allocated to the no-CPR group. CONCLUSION Most deaths with CPR and with the no-CPR occurred in the PICU. Bradycardia as the initial rhythm was five times more frequent in the CPR group. Medical records reflected the complexity of the decision not to perform CPR. Discrepancies were identified between practice and medical records in the no-CPR group.
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Affiliation(s)
- Márcia Marques Leite
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria, Hospital das Clínicas, Instituto da Criança, Pronto-Socorro, São Paulo, SP, Brazil.
| | - Fernanda Paixão Silveira Bello
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria, Hospital das Clínicas, Instituto da Criança, Pronto-Socorro, São Paulo, SP, Brazil
| | - Tânia Miyuki Shimoda Sakano
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria, Hospital das Clínicas, Instituto da Criança, Pronto-Socorro, São Paulo, SP, Brazil
| | - Claudio Schvartsman
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria, Hospital das Clínicas, Instituto da Criança, Pronto-Socorro, São Paulo, SP, Brazil
| | - Amélia Gorete Afonso da Costa Reis
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria, Hospital das Clínicas, Instituto da Criança, Pronto-Socorro, São Paulo, SP, Brazil
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Rees CA, Neuman MI, Monuteaux MC, Michelson KA, Duggan CP. Mortality During Readmission Among Children in United States Children's Hospitals. J Pediatr 2022; 246:161-169.e7. [PMID: 35364094 PMCID: PMC9233053 DOI: 10.1016/j.jpeds.2022.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/28/2022] [Accepted: 03/24/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To identify demographic, clinical, and hospital factors associated with mortality on readmission within 180 days following an inpatient hospitalization. STUDY DESIGN We conducted a retrospective cohort study including 33 US children's hospitals in the Pediatric Health Information System from January 2010 to June 2020. Our primary outcome was death during readmission within 180 days of an index hospitalization among children aged 0-18 years. Illness severity during the index hospitalization was defined according to the All Patient-Refined Diagnosis-Related Group-categorized illness severity (ie, minor, moderate, or major/extreme). We performed multivariable logistic regression analysis to identify factors during the index hospitalization associated with mortality during readmission. RESULTS Among 2 677 111 children discharged, 337 385 (12.6%) were readmitted within 180 days of the index hospitalization and 2913 (0.8%) died during readmission. More than one-quarter (26.2%) of deaths among children who were readmitted and died occurred within 10 days after discharge from the index hospitalization. Factors independently associated with mortality during readmission included multiple complex chronic conditions, index admissions lasting >7 days, moderate or severe/extreme illness during the index hospitalization, and public insurance. Children whose race was reported as Black had greater odds of mortality during readmission compared with children of other races. CONCLUSIONS Among hospitalized children, several demographic and clinical factors present during index hospitalizations were associated with mortality during readmission. Greater odds of mortality during readmission among children whose race was reported as Black likely reflects disparities in social determinants of health and clinical care. Interventions to reduce mortality during readmission may target high-risk populations in the period immediately following discharge.
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Affiliation(s)
- Chris A. Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America,Children's Healthcare of Atlanta, Atlanta, Georgia, United States of America
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Michael C. Monuteaux
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kenneth A. Michelson
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Christopher P. Duggan
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America,Center for Nutrition, Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, Massachusetts, United States of America
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8
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Marcus KL, Kao PC, Ma C, Wolfe J, DeCourcey DD. Symptoms and Suffering at End of Life for Children With Complex Chronic Conditions. J Pain Symptom Manage 2022; 63:88-97. [PMID: 34311060 DOI: 10.1016/j.jpainsymman.2021.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/22/2021] [Accepted: 07/16/2021] [Indexed: 11/25/2022]
Abstract
CONTEXT Children with cancer and cardiac disease suffer with high symptom burden at end of life (EOL). Little is known about the EOL experience for children with other complex chronic conditions (CCCs). OBJECTIVES To evaluate symptoms and suffering at EOL for children with noncancer, noncardiac CCCs as well as parental distress related to child suffering. METHODS This study is a secondary data analysis of a cross-sectional, single-center survey of bereaved parents of children with CCCs who died between 2006 to 2015. The primary outcome was parent-reported child suffering in the final two days of life. RESULTS Among 211 eligible parents contacted for participation, 114 completed the survey, and 99 had complete primary outcome data (participation rate 47%). Most children had congenital/chromosomal (42%) or progressive central nervous system (22%) conditions. Twenty-eight percent of parents reported high child suffering in the final two days of life. Parents reported that pain and difficulty breathing caused the greatest suffering for children and distress among themselves. Some parents also reported distress related to uncertainty about child suffering. Parents were less likely to report high child suffering if they were confident in knowing what to expect when their child was dying (AOR 0.20; 95% CI 0.07-0.60) or felt prepared for medical problems at EOL (AOR 0.12; 95% CI 0.04-0.42). CONCLUSION Nearly one-third of parents of children with CCCs report high suffering in their child's final days of life. Parent preparedness was associated with lower perceived child suffering. Future research should target symptoms contributing to parent and child distress and assess whether enhancing parent preparedness reduces perceived child suffering.
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Affiliation(s)
- Katherine L Marcus
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.
| | - Pei-Chi Kao
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Clement Ma
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Joanne Wolfe
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Danielle D DeCourcey
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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9
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Berry JG, Rodean J, Leahy I, Rangel S, Johnson C, Crofton C, Staffa SJ, Hall M, Methot C, Desmarais A, Ferrari L. Hospital Volumes of Inpatient Pediatric Surgery in the United States. Anesth Analg 2021; 133:1280-1287. [PMID: 34673726 DOI: 10.1213/ane.0000000000005748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Perioperative outcomes of children depend on the skill and expertise in managing pediatric patients, as well as integration of surgical, anesthesiology, and medical teams. We compared the types of pediatric patients and inpatient surgical procedures performed in low- versus higher-volume hospitals throughout the United States. METHODS Retrospective analysis of 323,258 hospitalizations with an operation for children age 0 to 17 years in 2857 hospitals included in the Agency for Healthcare Research and Quality (AHRQ) Kids' Inpatient Database (KID) 2016. Hospitals were categorized by their volume of annual inpatient surgical procedures. Specific surgeries were distinguished with the AHRQ Clinical Classification System. We assessed complex chronic conditions (CCCs) using Feudtner and Colleagues' system. RESULTS The median annual volume of pediatric inpatient surgeries across US hospitals was 8 (interquartile range [IQR], 3-29). The median volume of inpatient surgeries for children with a CCC was 4 (IQR, 1-13). Low-volume hospitals performed significantly fewer types of surgeries (median 2 vs 131 types of surgeries in hospitals with 1-24 vs ≥2000 volumes). Appendectomy and fixation of bone fracture were among the most common surgeries in low-volume hospitals. As the volume of surgical procedures increased from 1 to 24 to ≥2000, the percentage of older children ages 11 to 17 years decreased (70.9%-32.0% [P < .001]) and the percentage of children with a CCC increased (11.2%-60.0% [P < .001]). CONCLUSIONS Thousands of US hospitals performed inpatient surgeries on few pediatric patients, including those with CCCs who have the highest risk of perioperative morbidity and mortality. Evaluation of perioperative decision making, workflows, and pediatric clinicians in low- and higher-volume hospitals is warranted.
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Affiliation(s)
- Jay G Berry
- From the Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Rodean
- Department of Informatics and Statistics, Children's Hospital Association, Overland Park, Kansas
| | - Izabela Leahy
- Department of Anesthesiology, Perioperative, and Pain Medicine
| | - Shawn Rangel
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Connor Johnson
- Department of Anesthesiology, Perioperative, and Pain Medicine
| | - Charis Crofton
- From the Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Steven J Staffa
- Department of Anesthesiology, Perioperative, and Pain Medicine
| | - Matt Hall
- Department of Informatics and Statistics, Children's Hospital Association, Overland Park, Kansas
| | - Craig Methot
- Department of Anesthesiology, Perioperative, and Pain Medicine
| | - Anna Desmarais
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Lynne Ferrari
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Department of Anesthesiology, Perioperative, and Pain Medicine
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10
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Mitchell S, Slowther AM, Coad J, Dale J. Experiences of healthcare, including palliative care, of children with life-limiting and life-threatening conditions and their families: a longitudinal qualitative investigation. Arch Dis Child 2021; 106:570-576. [PMID: 33199300 PMCID: PMC8142456 DOI: 10.1136/archdischild-2020-320189] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/23/2020] [Accepted: 09/24/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To understand the experiences and perceptions of healthcare services of children with life-limiting and life-threatening conditions and their family members, including palliative care. DESIGN Longitudinal qualitative interview study with children and their family members. Up to three in-depth interviews were conducted over 13 months with each child and family. Data were analysed using thematic analysis. SETTING Community and hospital settings in the West Midlands, UK. PARTICIPANTS Children with a diverse range of life-limiting and life-threatening conditions, aged between 5 and 18 years, and their family members. FINDINGS 31 participants from 14 families including 10 children took part in 41 interviews. Two children died during the course of the study. Children accepted their conditions as part of life and had other priorities for living. Experiences of 'fighting' a fragmented healthcare system that focused on the biomedical aspects of their care were described. The possibility of death was rarely openly discussed. Palliative care tended to be conceptualised as a distinct service or phase of a child's condition, rather than a broad approach. Access to palliative care depended on the availability of specialist services, and on trusted interpersonal relationships with healthcare professionals who could share uncertainty and the family's emotional burden. CONCLUSIONS There is an urgent need to create a more child and family centred approach that enables palliative care to be truly integrated into the wider healthcare of children with life-limiting and life-threatening conditions. Trusted, interpersonal relationships with healthcare professionals, and more effective coordination of care are fundamental to achieving this, and should be valued and enabled throughout the healthcare system.
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Affiliation(s)
- Sarah Mitchell
- Academic Unit of Primary Care, University of Warwick, Coventry, UK .,Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | | | - Jane Coad
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Jeremy Dale
- Academic Unit of Primary Care, University of Warwick, Coventry, UK
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11
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Lewen MO, Berry J, Johnson C, Grace R, Glader L, Crofton C, Leahy I, Pallikonda N, Litvinova A, Staffa SJ, Glotzbecker M, Emans J, Hresko MT, Ellen M, Troy M, Singer SJ, Ferrari L. Preoperative hematocrit and platelet count are associated with blood loss during spinal fusion for children with neuromuscular scoliosis. J Perioper Pract 2021; 32:74-82. [PMID: 33826437 DOI: 10.1177/1750458920962634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To assess the relationship of preoperative hematology laboratory results with intraoperative estimated blood loss and transfusion volumes during posterior spinal fusion for pediatric neuromuscular scoliosis. METHODS Retrospective chart review of 179 children with neuromuscular scoliosis undergoing spinal fusion at a tertiary children's hospital between 2012 and 2017. The main outcome measure was estimated blood loss. Secondary outcomes were volumes of packed red blood cells, fresh frozen plasma, and platelets transfused intraoperatively. Independent variables were preoperative blood counts, coagulation studies, and demographic and surgical characteristics. Relationships between estimated blood loss, transfusion volumes, and independent variables were assessed using bivariable analyses. Classification and Regression Trees were used to identify variables most strongly correlated with outcomes. RESULTS In bivariable analyses, increased estimated blood loss was significantly associated with higher preoperative hematocrit and lower preoperative platelet count but not with abnormal coagulation studies. Preoperative laboratory results were not associated with intraoperative transfusion volumes. In Classification and Regression Trees analysis, binary splits associated with the largest increase in estimated blood loss were hematocrit ≥44% vs. <44% and platelets ≥308 vs. <308 × 109/L. CONCLUSIONS Preoperative blood counts may identify patients at risk of increased bleeding, though do not predict intraoperative transfusion requirements. Abnormal coagulation studies often prompted preoperative intervention but were not associated with increased intraoperative bleeding or transfusion needs.
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Affiliation(s)
- Margaret O Lewen
- Department of Pediatric Critical Care Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Jay Berry
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Connor Johnson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rachael Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Laurie Glader
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Charis Crofton
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Izabela Leahy
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nikhil Pallikonda
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anna Litvinova
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Glotzbecker
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - John Emans
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - M Timothy Hresko
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mary Ellen
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Troy
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sara J Singer
- Department of Organizational Behavior and Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lynne Ferrari
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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12
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Boyden JY, Feudtner C, Deatrick JA, Widger K, LaRagione G, Lord B, Ersek M. Developing a family-reported measure of experiences with home-based pediatric palliative and hospice care: a multi-method, multi-stakeholder approach. BMC Palliat Care 2021; 20:17. [PMID: 33446192 PMCID: PMC7809872 DOI: 10.1186/s12904-020-00703-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/28/2020] [Indexed: 11/21/2022] Open
Abstract
Background Many children with serious illnesses are receiving palliative and end-of-life care from pediatric palliative and hospice care teams at home (PPHC@Home). Despite the growth in PPHC@Home, no standardized measures exist to evaluate whether PPHC@Home provided in the U.S. meets the needs and priorities of children and their families. Methods We developed and conducted a preliminary evaluation of a family-reported measure of PPHC@Home experiences using a multi-method, multi-stakeholder approach. Our instrument development process consisted of four phases. Item identification and development (Phase 1) involved a comprehensive literature search of existing instruments, guidelines, standards of practice, and PPHC@Home outcome studies, as well as guidance from a PPHC stakeholder panel. Phase 2 involved the initial item prioiritization and reduction using a discrete choice experiment (DCE) with PPHC professionals and parent advocates. Phase 3 involved a second DCE with bereaved parents and parents currently receiving care for their child to further prioritize and winnow the items to a set of the most highly-valued items. Finally, we conducted cognitive interviews with parents to provide information about the content validity and clarity of the newly-developed instrument (Phase 4). Results Items were compiled predominantly from three existing instruments. Phase 2 participants included 34 PPHC providers, researchers, and parent advocates; Phase 3 participants included 47 parents; and Phase 4 participants included 11 parents. At the completion of Phase 4, the Experiences of Palliative and Hospice Care for Children and Caregivers at Home (EXPERIENCE@Home) Measure contains 22 of the most highly-valued items for evaluating PPHC@Home. These items include “The care team treats my child’s physical symptoms so that my child has as good a quality of life as possible”, “I have regular access to on-call services from our care team”, and “The nurses have the knowledge, skills, and experience to support my child’s palliative or hospice care at home.” Conclusions The EXPERIENCE@Home Measure is the first known to specifically measure family-reported experiences with PPHC@Home in the U.S. Future work will include formal psychometric evaluation with a larger sample of parents, as well as evaluation of the clinical utility of the instrument with PPHC@Home teams. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-020-00703-0.
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Affiliation(s)
- Jackelyn Y Boyden
- School of Nursing, University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA, 19104, USA. .,Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, USA.
| | - Chris Feudtner
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, USA
| | - Janet A Deatrick
- School of Nursing, University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA, 19104, USA
| | - Kimberley Widger
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Toronto, Ontario, Canada.,Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada
| | - Gwenn LaRagione
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, USA
| | - Blyth Lord
- Courageous Parents Network, Newton, MA, USA
| | - Mary Ersek
- School of Nursing, University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, USA.,Corporal Michael J. Crescenz VA Medical Center, 21 S University Ave, Philadelphia, PA, USA
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13
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Larson IA, Rodean J, Richardson T, Bergman D, Morehous J, Colvin JD. Agreement of Provider and Parent Perceptions of Complex Care Medical Homes After a Care Management Intervention. J Pediatr Health Care 2021; 35:91-98. [PMID: 32958456 DOI: 10.1016/j.pedhc.2020.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/29/2020] [Accepted: 08/01/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Children with medical complexity frequently lack coordinated and family-centered care and are best cared for in a medical home. METHOD We assessed concordance between provider and family perceptions of care management improvements during a prospective, 3-year study of nine complex care clinics and 42 primary care clinics. Using a pre-post design, we compared provider and parent perceptions of changes in care coordination and family-centered care responses using paired t tests, Spearman rank correlations, and linear regression. RESULTS Provider scores significantly increased in every domain (range: 14.1 points [data management], 23.0 points [chronic care management]; p < .001). Parent perceptions improved only for shared decision making improved significantly (2.2 points, p < .01). DISCUSSION These results indicate that it is possible to improve the medical home for children with medical complexity through a quality improvement initiative, but that provider perception of the improvement may be greater than parents' perceptions.
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14
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Papadatou D, Kalliani V, Karakosta E, Liakopoulou P, Bluebond-Langner M. Home or hospital as the place of end-of-life care and death: A grounded theory study of parents' decision-making. Palliat Med 2021; 35:219-230. [PMID: 33307990 PMCID: PMC7797614 DOI: 10.1177/0269216320967547] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND While several studies have examined 'what' families want with regard to the place of a child's end-of-life care and death, few have explored 'how' parents reach a decision. AIMS (1) to develop a model explaining how parents of a child with a life-threatening illness in Greece decide about the place of end-of-life care and death; (2) to identify the factors affecting decision-making; (3) to consider the implications for clinical practice. DESIGN Grounded theory study of bereaved parents using semi-structured open-ended interviews following Strauss and Corbin's principles of data collection and analysis. SETTING/PARTICIPANTS Semi-structured interviews with 36 bereaved parents of 22 children who died at home (n = 9) or in a paediatric hospital (n = 13) in Athens, Greece. RESULTS (1) Decisions regarding place of care and death were reached in one of four ways: consensus, accommodation, imposition of professional decisions on parents or imposition of parents' decisions without including professionals. (2) Six factors were identified as affecting decisions: awareness of dying, perceived parental caregiving competence, perceived professional competence, parents' view of symptom management, timing of decision-making, and being a 'good parent'. (3) Decisions were clear-cut or shifting. Few parents did not engage in decisions. CONCLUSION Parents' decisions about place of end-of-life care and death are affected by personal, interpersonal, timing and disease-related factors. Parents are best supported in decision-making when information is presented clearly and honestly with recognition of what acting as 'good parents' means to them, and opportunities to enhance their caregiving competence to care for their child at home, if they choose so.
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Affiliation(s)
- Danai Papadatou
- Faculty of Nursing, School of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasiliki Kalliani
- "Merimna" Society for the Care of Children and Families Facing Illness and Death, Athens, Greece
| | - Eleni Karakosta
- "Merimna" Society for the Care of Children and Families Facing Illness and Death, Athens, Greece
| | - Panagiota Liakopoulou
- "Merimna" Society for the Care of Children and Families Facing Illness and Death, Athens, Greece
| | - Myra Bluebond-Langner
- UCL-School of Life and Medical Sciences, Faculty of Population Health Sciences Great Ormond Street Institute of Child Health, Population, Policy and Practice Research and Teaching Department, Louis Dundas Centre for Children's Palliative Care, UK
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15
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Boyden JY, Ersek M, Deatrick JA, Widger K, LaRagione G, Lord B, Feudtner C. What Do Parents Value Regarding Pediatric Palliative and Hospice Care in the Home Setting? J Pain Symptom Manage 2021; 61:12-23. [PMID: 32745574 PMCID: PMC9747513 DOI: 10.1016/j.jpainsymman.2020.07.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 07/22/2020] [Accepted: 07/27/2020] [Indexed: 12/16/2022]
Abstract
CONTEXT Children with life-shortening serious illnesses and medically-complex care needs are often cared for by their families at home. Little, however, is known about what aspects of pediatric palliative and hospice care in the home setting (PPHC@Home) families value the most. OBJECTIVES To explore how parents rate and prioritize domains of PPHC@Home as the first phase of a larger study that developed a parent-reported measure of experiences with PPHC@Home. METHODS Twenty domains of high-value PPHC@Home, derived from the National Consensus Project's Guidelines for Quality Palliative Care, the literature, and a stakeholder panel, were evaluated. Using a discrete choice experiment, parents provided their ratings of the most and least valued PPHC@Home domains. We also explored potential differences in how subgroups of parents rated the domains. RESULTS Forty-seven parents participated. Overall, highest-rated domains included Physical aspects of care: Symptom management, Psychological/emotional aspects of care for the child, and Care coordination. Lowest-rated domains included Spiritual and religious aspects of care and Cultural aspects of care. In exploratory analyses, parents who had other children rated the Psychological/emotional aspects of care for the sibling(s) domain significantly higher than parents who did not have other children (P = 0.02). Furthermore, bereaved parents rated the Caregiversupportat the end of life domain significantly higher than parents who were currently caring for their child (P = 0.04). No other significant differences in domain ratings were observed. CONCLUSION Knowing what parents value most about PPHC@Home provides the foundation for further exploration and conversation about priority areas for resource allocation and care improvement efforts.
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Affiliation(s)
- Jackelyn Y Boyden
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Mary Ersek
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Janet A Deatrick
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kimberley Widger
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada; Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gwenn LaRagione
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Blyth Lord
- Courageous Parents Network, Newton, MA, USA
| | - Chris Feudtner
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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16
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Crandall H, Kapusta A, Killpack J, Heyrend C, Nilsson K, Dickey M, Daly JA, Ampofo K, Pavia AT, Mulvey MA, Yandell M, Hulten KG, Blaschke AJ. Clinical and molecular epidemiology of invasive Staphylococcus aureus infection in Utah children; continued dominance of MSSA over MRSA. PLoS One 2020; 15:e0238991. [PMID: 32946486 PMCID: PMC7500648 DOI: 10.1371/journal.pone.0238991] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 08/27/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Invasive Staphylococcus aureus infections are a common cause of morbidity and mortality in children. In the early 2000's the proportion of infections due the methicillin-resistant S. aureus (MRSA) increased rapidly. We described the clinical and molecular epidemiology of invasive S. aureus disease in a pediatric population. METHODS We prospectively identified children in Utah with invasive S. aureus infections. Medical records were reviewed to determine diagnosis and clinical characteristics. Isolates were genotyped using multi-locus sequence typing. The presence of genes encoding the Panton-Valentine leukocidin (PVL) was determined using polymerase chain reaction. RESULTS Over a 4-year period between January 2009 and December 2012, we identified 357 children, hospitalized at Primary Children's Hospital, with invasive S. aureus infections and isolates available for the study. Methicillin-susceptible S. aureus (MSSA) caused 79% of disease, while MRSA caused only 21% of disease. Mortality associated with invasive S. aureus infection was 3.6%. The most common diagnoses were osteoarticular infections (38%) followed by central line associated blood stream infections (19%) and pneumonia (12%). We identified 41 multi-locus sequence types. The majority of isolates belonged to 6 predominant clonal complexes (CC5, CC8, CC15, CC30, CC45, CC59). PVL was present in a minority (16%) of isolates, of which most were ST8 MRSA. CONCLUSIONS MSSA was the primary cause of invasive S. aureus infections at our institution throughout the study period. A limited number of predominant strains accounted for the majority of invasive disease. The classic virulence factor PVL was uncommon in MSSA isolates. Further study is needed to improve our understanding of S. aureus virulence and disease pathogenesis.
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Affiliation(s)
- Hillary Crandall
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
- * E-mail:
| | - Aurélie Kapusta
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
- Department of Human Genetics, University of Utah, Salt Lake City, Utah, United States of America
| | - Jarrett Killpack
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
| | - Carly Heyrend
- Primary Children’s Hospital, Salt Lake City, Utah, United States of America
| | - Kody Nilsson
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
| | - Mandy Dickey
- Primary Children’s Hospital, Salt Lake City, Utah, United States of America
| | - Judy A. Daly
- Primary Children’s Hospital, Salt Lake City, Utah, United States of America
- Department of Pathology, University of Utah, Salt Lake City, Utah, United States of America
| | - Krow Ampofo
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
| | - Andrew T. Pavia
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
| | - Matthew A. Mulvey
- Department of Pathology, University of Utah, Salt Lake City, Utah, United States of America
| | - Mark Yandell
- Department of Human Genetics, University of Utah, Salt Lake City, Utah, United States of America
- Department of Human Genetics, USTAR Center for Genetic Discovery, University of Utah, Salt Lake City, Utah, United States of America
| | - Kristina G. Hulten
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States of America
| | - Anne J. Blaschke
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
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17
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Goldin AB, Raval MV, Thurm CW, Hall M, Billimoria Z, Juul S, Berman L. The Resource Use Inflection Point for Safe NICU Discharge. Pediatrics 2020; 146:peds.2019-3708. [PMID: 32699067 DOI: 10.1542/peds.2019-3708] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES (1) To identify a resource use inflection point (RU-IP) beyond which patients in the NICU no longer received NICU-level care, (2) to quantify variability between hospitals in patient-days beyond the RU-IP, and (3) to describe risk factors associated with reaching an RU-IP. METHODS We evaluated infants admitted to any of the 43 NICUs over 6 years. We determined the day that each patient's total daily standardized cost was <10% of the mean first-day NICU room cost and remained within this range through discharge (RU-IP). We compared days beyond an RU-IP, the total standardized cost of hospital days beyond the RU-IP, and the percentage of patients by hospital beyond the RU-IP. RESULTS Among 80 821 neonates, 80.6% reached an RU-IP. In total, there were 234 478 days after the RU-IP, representing 24.3% of the total NICU days and $483 281 268 in costs. Variability in the proportion of patients reaching an RU-IP was 33.1% to 98.7%. Extremely preterm and very preterm neonates, patients discharged with home health care services, or patients receiving mechanical ventilation, extracorporeal membrane oxygenation, or feeding support exhibited fewer days beyond the RU-IP. Conversely, receiving methadone was associated with increased days beyond the RU-IP. CONCLUSIONS Identification of an RU-IP may allow health care systems to identify readiness for discharge from the NICU earlier and thereby save significant NICU days and health care dollars. These data reveal the need to identify best practices in NICUs that consistently discharge infants more efficiently. Once these best practices are known, they can be disseminated to offer guidance in creating quality improvement projects to provide safer and more predictable care across hospitals for patients of all socioeconomic statuses.
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Affiliation(s)
- Adam B Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, Washington; .,Department of General Surgery and
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Cary W Thurm
- Childern's Hospital Association, Overland Park, Kansas; and
| | - Matt Hall
- Childern's Hospital Association, Overland Park, Kansas; and
| | - Zeenia Billimoria
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | - Sandra Juul
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | - Loren Berman
- Department of Pediatric Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
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18
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Johnston EE, Martinez I, Currie E, Brock KE, Wolfe J. Hospital or Home? Where Should Children Die and How Do We Make That a Reality? J Pain Symptom Manage 2020; 60:106-115. [PMID: 31887402 DOI: 10.1016/j.jpainsymman.2019.12.370] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 01/31/2023]
Abstract
CONTEXT Most of the 20,000 U.S. children dying of serious illnesses annually die in the hospital. It is unknown if this hospital death predominance reflects family wishes or systemic issues such as lack of hospice access. Hence, we need to better understand location of death preferences for children and their families. OBJECTIVE To better understand location of death preferences in North America, we reviewed the literature to examine the evidence for and against home death in seriously ill children (0-18 years). METHODS We searched English articles in PubMed, PsycINFO, and Embase published during 2000-2018 for articles related to parental, child/adolescent, and provider preference for death location and articles that correlated death location with bereavement or quality of life outcomes. RESULTS The search results (n = 877 articles and n = 58 abstracts of interest) were reviewed, and 34 relevant articles were identified. Parent, child, and provider preferences, bereavement outcomes, and associated factors all point to some preference for home death. These findings should be interpreted with several caveats: 1) many studies are small and prone to selection bias, 2) not all families prefer home death and some that do are not able to achieve home death due to inadequate home support, 3) studies of bereavement outcomes are lacking. CONCLUSION Adequate resources are needed to ensure children can die in their chosen location-be that home, hospital, or free-standing hospice. This review highlights research areas needed to better understand death location preference and programs and policies that will support home death for those that desire it.
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Affiliation(s)
- Emily E Johnston
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA; Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA.
| | - Isaac Martinez
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Erin Currie
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Katharine E Brock
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA; Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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Bobillo-Perez S, Segura S, Girona-Alarcon M, Felipe A, Balaguer M, Hernandez-Platero L, Sole-Ribalta A, Guitart C, Jordan I, Cambra FJ. End-of-life care in a pediatric intensive care unit: the impact of the development of a palliative care unit. BMC Palliat Care 2020; 19:74. [PMID: 32466785 PMCID: PMC7254653 DOI: 10.1186/s12904-020-00575-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 05/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this paper is to describe how end-of-life care is managed when life-support limitation is decided in a Pediatric Intensive Care Unit and to analyze the influence of the further development of the Palliative Care Unit. METHODS A 15-year retrospective study of children who died after life-support limitation was initiated in a pediatric intensive care unit. Patients were divided into two groups, pre- and post-palliative care unit development. Epidemiological and clinical data, the decision-making process, and the approach were analyzed. Data was obtained from patient medical records. RESULTS One hundred seventy-five patients were included. The main reason for admission was respiratory failure (86/175). A previous pathology was present in 152 patients (61/152 were neurological issues). The medical team and family participated together in the decision-making in 145 cases (82.8%). The family made the request in 10 cases (9 vs. 1, p = 0.019). Withdrawal was the main life-support limitation (113/175), followed by withholding life-sustaining treatments (37/175). Withdrawal was more frequent in the post-palliative group (57.4% vs. 74.3%, p = 0.031). In absolute numbers, respiratory support was the main type of support withdrawn. CONCLUSIONS The main cause of life-support limitation was the unfavourable evolution of the underlying pathology. Families were involved in the decision-making process in a high percentage of the cases. The development of the Palliative Care Unit changed life-support limitation in our unit, with differences detected in the type of patient and in the strategy used. Increased confidence among intensivists when providing end-of-life care, and the availability of a Palliative Care Unit may contribute to improvements in the quality of end-of-life care.
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Affiliation(s)
- Sara Bobillo-Perez
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Susana Segura
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Monica Girona-Alarcon
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Aida Felipe
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Monica Balaguer
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Lluisa Hernandez-Platero
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Anna Sole-Ribalta
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Carmina Guitart
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Iolanda Jordan
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain.
- Paediatric Infectious Diseases Research Group, Institut Recerca Hospital Sant Joan de Déu, CIBERESP, Passeig Sant Joan de Déu, 2, 08950, Esplugues de Llobregat, Barcelona, Spain.
| | - Francisco Jose Cambra
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
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Kaye EC, Applegarth J, Gattas M, Kiefer A, Reynolds J, Zalud K, Baker JN. Hospice nurses request paediatric-specific educational resources and training programs to improve care for children and families in the community: Qualitative data analysis from a population-level survey. Palliat Med 2020; 34:403-412. [PMID: 31347446 PMCID: PMC7074592 DOI: 10.1177/0269216319866576] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Children with serious illness who receive hospice care often interface with nurses who lack training, experience and comfort in the provision of paediatric palliative and hospice care. Hospice nurse preferences for paediatric-specific training are not well known. AIM To describe the types of paediatric-specific training received and educational content preferred by hospice nurses. DESIGN Population-level dissemination of a cross-sectional survey with qualitative analysis of open-ended survey items. SETTING/PARTICIPANTS Nurses from 71 community-based hospice organizations across 3 states completed the survey. RESULTS An open-ended response was provided by 278/551 (50.5%) survey respondents. A total of 55 respondents provided 58 descriptions of prior paediatric-specific training, including a formal 2-day course (n = 36; 65.5%), on-the-job education (n = 13, 23.6%), online training (n = 5, 9.1%), nursing school (n = 2, 3.6%) and paediatric advanced life support courses (n = 2, 3.6%). A total of 67 respondents described 74 hospice-led educational efforts, largely comprised of a 2-day course (n = 39; 54.2%) or provision of written materials (n = 11; 15.3%). A total of 189 respondents described 258 preferences for paediatric-specific training, with nearly half (n = 93; 49.2%) requesting 'any' or 'all' types of education and the remainder requesting education around medication use (n = 48; 25.4%), symptom assessment/management (n = 32; 16.9%), pain assessment/management (n = 28; 14.8), communication (n = 29; 15.3%) and psychosocial assessment/management (n = 28; 14.8). CONCLUSIONS Hospice nurses self-report inadequate exposure to educational resources and programs, in conjunction with a strong desire for increased paediatric-specific training. Identification of targetable gaps should inform the development of educational resources, policies and other supportive interventions to improve delivery of care to children and families in the community.
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Affiliation(s)
- Erica C Kaye
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | - Ashley Kiefer
- St. Jude Children's Research Hospital, Memphis, TN, USA
- Le Bonheur Children's Hospital, Memphis, TN, USA
- The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jason Reynolds
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kristina Zalud
- School of Medicine, Creighton University, Omaha, NE, USA
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21
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Lizotte MH, Barrington KJ, Sultan S, Pennaforte T, Moussa A, Lachance C, Sureau M, Zao Y, Janvier A. Techniques to Communicate Better With Parents During End-of-Life Scenarios in Neonatology. Pediatrics 2020; 145:peds.2019-1925. [PMID: 31988171 DOI: 10.1542/peds.2019-1925] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Clinicians are urged to optimize communication with families, generally without empirical practical recommendations. The objective of this study was to identify core behaviors associated with good communication during and after an unsuccessful resuscitation, including parental perspectives. METHODS Clinicians from different backgrounds participated in a standardized, videotaped, simulated neonatal resuscitation in the presence of parent actors. The infant remained pulseless; participants communicated with the parent actors before, during, and after discontinuing resuscitation. Twenty-one evaluators with varying expertise (including 6 bereaved parents) viewed the videos. They were asked to score clinician-parent communication and identify the top communicators. In open-ended questions, they were asked to describe 3 aspects that were well done and 3 that were not. Answers to open-ended questions were coded for easily reproducible behaviors. All the videos were then independently reviewed to evaluate whether these behaviors were present. RESULTS Thirty-one participants' videos were examined by 21 evaluators (651 evaluations). Parents and actors agreed with clinicians 81% of the time about what constituted optimal communication. Good communicators were more likely to introduce themselves, use the infant's name, acknowledge parental presence, prepare the parents (for the resuscitation, then death), stop resuscitation without asking parents, clearly mention death, provide or enable proximity (clinician-parent, infant-parent, clinician-infant, mother-father), sit down, decrease guilt, permit silence, and have knowledge about procedures after death. Consistently, clinicians who displayed such behaviors had evaluations >9 out of 10 and were all ranked top 10 communicators. CONCLUSIONS During a neonatal end-of-life scenario, many simple behaviors, identified by parents and providers, can optimize clinician-parent communication.
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Affiliation(s)
- Marie-Hélène Lizotte
- Centre de Recherche.,Department of Pediatrics, Hôpital de Rimouski, Rimouski, Canada
| | | | - Serge Sultan
- Centre de Recherche.,Departments of Pediatrics.,Psychology, and
| | - Thomas Pennaforte
- Centre de Recherche.,Education, Université de Montréal, Montréal, Canada; and
| | - Ahmed Moussa
- Centre de Recherche.,Mother-Child Simulation Center.,Division of Neonatology.,Soins Palliatifs, and.,Centre de Pédagogie Appliquée aux Sciences de la Santé, and.,Departments of Pediatrics
| | | | | | | | - Annie Janvier
- Centre de Recherche, .,Division of Neonatology.,Unités des Éthique Clinique and.,Soins Palliatifs, and.,Bureau du Partenariat Patients-Familles-Soignants, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Canada.,Bureau de L'éthique Clinique.,Departments of Pediatrics
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22
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Caring for Children With Medical Complexity With the Emergency Information Form. Pediatr Emerg Care 2020; 36:57-61. [PMID: 31895202 DOI: 10.1097/pec.0000000000002021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVE The American Academy of Pediatrics recommends an emergency information form (EIF) for children with medical complexity (CMC) to facilitate emergency care. We sought to increase the EIF completion rate at our children's hospital's CMC clinic and to evaluate the effect on caregiver and emergency department (ED) provider opinion of preparation, comfort, and communication. METHODS We used a pre/post-quality improvement design. The main outcomes were (1) the proportion of completed EIFs and (2) caregiver and ED provider opinion of preparation, comfort, and communication, using a Likert scale survey (1, low; 5, high). RESULTS Emergency information form completion increased from 3.1% (4/133) before the intervention to 47.0% (78/166) after (P < 0.001). Twenty-three providers completed presurveys, and 8 completed postsurveys. Seventy-two caregivers completed presurveys, and 38 completed postsurveys (25 with ED visit and 13 without). There were no changes in preparation, comfort, or communication for caregivers who had an ED visit after the intervention. For those without a postintervention ED visit, caregiver median scores rose for preparation (4 [interquartile range {IQR}, 3-5] vs 5 [IQR, 4-5], P = 0.02) and comfort (4 [IQR, 2.25-5] vs 5 [IQR, 4-5], P = 0.05). After the intervention, ED providers had increased median communication scores (3 [IQR, 2.75-4.25] vs 5 [IQR, 4-5], P = 0.02), whereas scores of preparation and comfort were unchanged. CONCLUSION A quality improvement project at a CMC clinic increased EIF completion, caregiver preparation and comfort, and ED provider communication in emergencies.
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Advance Care Planning and Parent-Reported End-of-Life Outcomes in Children, Adolescents, and Young Adults With Complex Chronic Conditions. Crit Care Med 2019; 47:101-108. [PMID: 30303834 DOI: 10.1097/ccm.0000000000003472] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES For children, adolescents, and young adults with complex chronic conditions advance care planning may be a vital component of optimal care. Advance care planning outcomes research has previously focused on seriously ill adults and adolescents with cancer where it is correlated with high-quality end-of-life care. The impact of advance care planning on end-of-life outcomes for children, adolescents, and young adults with complex chronic conditions is unknown, thus we sought to evaluate parental preferences for advance care planning and to determine whether advance care planning and assessment of specific family considerations during advance care planning were associated with differences in parent-reported end-of-life outcomes. DESIGN Cross-sectional survey. SETTING Large, tertiary care children's hospital. SUBJECTS Bereaved parents of children, adolescents, and young adults with complex chronic conditions who died between 2006 and 2015. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS One-hundred fourteen parents were enrolled (54% response rate) and all parents reported that advance care planning was important, with a majority (70%) endorsing that discussions should occur early in the illness course. Parents who reported advance care planning (65%) were more likely to be prepared for their child's last days of life (adjusted odds ratio, 3.78; 95% CI, 1.33-10.77), to have the ability to plan their child's location of death (adjusted odds ratio, 2.93; 95% CI, 1.06-8.07), and to rate their child's quality of life during end-of-life as good to excellent (adjusted odds ratio, 3.59; 95% CI, 1.23-10.37). Notably, advance care planning which included specific assessment of family goals was associated with a decrease in reported child suffering at end-of-life (adjusted odds ratio, 0.23; 95% CI, 0.06-0.86) and parental decisional regret (adjusted odds ratio, 0.42; 95% CI, 0.02-0.87). CONCLUSIONS Parents of children, adolescents, and young adults with complex chronic conditions highly value advance care planning, early in the illness course. Importantly, advance care planning is associated with improved parent-reported end-of-life outcomes for this population including superior quality of life. Further studies should evaluate strategies to ensure high-quality advance care planning including specific assessment of family goals.
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Abstract
BACKGROUND Children with complex medical needs (CMN) are high healthcare resource utilizers, have varying underlying diagnoses, and experience repeated hospitalizations. Outcomes on neonatal intensive care (NICU) patients with CMN are unknown. PURPOSE The primary aim is to describe the clinical profile, resource use, prevalence, and both in-hospital and postdischarge outcomes of neonates with CMN. The secondary aim is to assess the feasibility of sustaining the use of the neonatal complex care team (NCCT). METHODS A retrospective cohort study was conducted after implementing a new model of care for neonates with CMN in the NICU. All neonates born between January 2013 and December 2016 and who met the criteria for CMN and were cared for by the NCCT were included. RESULTS One hundred forty-seven neonates with a mean (standard deviation) gestational age of 34 (5) weeks were included. The major underlying diagnoses were genetic/chromosomal abnormalities (48%), extreme prematurity (26%), neurological abnormality (12%), and congenital anomalies (11%). Interventions received included mechanical ventilation (69%), parenteral nutrition (68%), and technology dependency at discharge (91%). Mortality was 3% before discharge and 17% after discharge. Postdischarge hospital attendances included emergency department visits (44%) and inpatient admissions (58%), which involved pediatric intensive care unit admissions (26%). IMPLICATIONS FOR PRACTICE Neonates with CMN have multiple comorbidities, high resource needs, significant postdischarge mortality, and rehospitalization rates. These cohorts of NICU patients can be identified early during their NICU course and serve as targets for implementing innovative care models to meet their unique needs. IMPLICATIONS FOR RESEARCH Future studies should explore the feasibility of implementing innovative care models and their potential impact on patient outcomes and cost-effectiveness.
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25
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Brehaut JC, Guèvremont A, Arim RG, Garner RE, Miller AR, McGrail KM, Brownell M, Lach LM, Rosenbaum PL, Kohen DE. Using Canadian administrative health data to examine the health of caregivers of children with and without health problems: A demonstration of feasibility. Int J Popul Data Sci 2019; 4:584. [PMID: 32935023 PMCID: PMC7479927 DOI: 10.23889/ijpds.v4i1.584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Introduction Caregivers of children with health problems experience poorer health than the caregivers of healthy children. To date, population-based studies on this issue have primarily used survey data. Objectives We demonstrate that administrative health data may be used to study these issues, and explore how non-categorical indicators of child health in administrative data can enable population-level study of caregiver health. Methods Dyads from Population Data British Columbia (BC) databases, encompassing nearly all mothers in BC with children aged 6-10 years in 2006, were grouped using a non-categorical definition based on diagnoses and service use. Regression models examined whether four maternal health outcomes varied according to indicators of child health. Results 162,847 mother-child dyads were grouped according to the following indicators: Child High Service Use (18%) vs. Not (82%), Diagnosis of Major and/or Chronic Condition (12%) vs. Not (88%), and Both High Service Use and Diagnosis (5%) vs. Neither (75%). For all maternal health and service use outcomes (number of physician visits, chronic condition, mood or anxiety disorder, hospitalization), differences were demonstrated by child health indicators. Conclusions Mothers of children with health problems had poorer health themselves, as indicated by administrative data groupings. This work not only demonstrates the research potential of using routinely collected health administrative data to study caregiver and child health, but also the importance of addressing maternal health when treating children with health problems.
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Affiliation(s)
- Jamie C Brehaut
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Room 1284 Centre for Practice-Changing Research; Box 201B, Ottawa, Ontario, K1H 8L6, Canada
| | - Anne Guèvremont
- Health Analysis Division, Statistics Canada, 100 Tunney's Pasture Driveway, Ottawa, Ontario, K1A 0T6, Canada
| | - Rubab G Arim
- Health Analysis Division, Statistics Canada, 100 Tunney's Pasture Driveway, Ottawa, Ontario, K1A 0T6, Canada
| | - Rochelle E Garner
- Health Analysis Division, Statistics Canada, 100 Tunney's Pasture Driveway, Ottawa, Ontario, K1A 0T6, Canada
| | - Anton R Miller
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, 4480 Oak Street, Vancouver, British Columbia, V6H 3V4, Canada
| | - Kimberlyn M McGrail
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, 2206 East Mall, Vancouver, British Columbia, V6T 1Z9, Canada
| | - Marni Brownell
- Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, 727 McDermot Avenue, Winnipeg, Manitoba, R3E 3P5, Canada
| | - Lucyna M Lach
- School of Social Work, McGill University, 3506 University Street, Montreal, Quebec, H3A 2A7, Canada
| | - Peter L Rosenbaum
- Department of Paediatrics, Faculty of Health Sciences, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
| | - Dafna E Kohen
- Health Analysis Division, Statistics Canada, 100 Tunney's Pasture Driveway, Ottawa, Ontario, K1A 0T6, Canada
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Rosenberg AR, Bona K, Coker T, Feudtner C, Houston K, Ibrahim A, Macauley R, Wolfe J, Hays R. Pediatric Palliative Care in the Multicultural Context: Findings From a Workshop Conference. J Pain Symptom Manage 2019; 57:846-855.e2. [PMID: 30685496 DOI: 10.1016/j.jpainsymman.2019.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 01/14/2019] [Indexed: 12/26/2022]
Abstract
CONTEXT In our increasingly multicultural society, providing sensitive and respectful pediatric palliative care is vital. OBJECTIVES We held a one-day workshop conference with stakeholders and pediatric clinicians to identify suggestions for navigating conflict when cultural differences are present and for informing standard care delivery. METHODS Participants explored cases in one of four workshops focused on differences based on race/ethnicity, economic disparity, religion/spirituality, or family values. Each workshop was facilitated by two authors; separate transcriptionists recorded workshop discussions in real time. We used content analyses to qualitatively evaluate the texts and generate recommendations. RESULTS Participants included 142 individuals representing over six unique disciplines, 25 of the U.S., and three nations. Although the conference focused on pediatric palliative care, findings were broadly generalizable to most medical settings. Participants identified key reasons cultural differences may create tension and then provided frameworks for communication, training, and clinical care. Specifically, recommendations included phrases to navigate emotional conflict, broken trust, unfamiliar family values, and conflict. Suggested approaches to training and clinical care included the development of core competencies in communication, history taking, needs assessment, and emotional intelligence. Important opportunities for scholarship included qualitative studies exploring diverse patient and family experiences, quantitative studies examining health disparities, and randomized clinical trials testing interventions designed to improve community partnerships, communication, or child health outcomes. CONCLUSION Taken together, findings provide a foundation for collaboration between patients, families, and clinicians of all cultures.
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Affiliation(s)
- Abby R Rosenberg
- Seattle Children's Research Institute, Treuman Katz Center for Pediatric Bioethics and Center for Clinical and Translational Research, Seattle, Washington, USA; Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA; Division of Hematology/Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.
| | - Kira Bona
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Tumaini Coker
- Seattle Children's Research Institute, Center for Diversity and Health Equity, Center for Child Health and Development, Seattle, Washington, USA; Division of General Academic Pediatrics, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Chris Feudtner
- Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Departments of Pediatrics, Ethics, and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kelli Houston
- Seattle Children's Research Institute, Center for Diversity and Health Equity, Center for Child Health and Development, Seattle, Washington, USA
| | - Anisa Ibrahim
- Division of General Academic Pediatrics, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Robert Macauley
- Department of Pediatrics, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ross Hays
- Seattle Children's Research Institute, Treuman Katz Center for Pediatric Bioethics and Center for Clinical and Translational Research, Seattle, Washington, USA; Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
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Berry JG, Johnson C, Crofton C, Staffa SJ, DiTillio M, Leahy I, Salem J, Rangel SJ, Singer SJ, Ferrari L. Predicting Postoperative Physiologic Decline After Surgery. Pediatrics 2019; 143:peds.2018-2042. [PMID: 30824493 DOI: 10.1542/peds.2018-2042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Projecting postoperative recovery in pediatric surgical patients is challenging. We assessed how the patients' number of complex chronic conditions (CCCs) and chronic medications interacted with active health issues to influence the likelihood of postoperative physiologic decline (PoPD). METHODS A prospective study of 3295 patients undergoing elective surgery at a freestanding children's hospital. During preoperative clinical evaluation, active health problems, CCCs, and medications were documented. PoPD (compromise of cardiovascular, respiratory, and/or neurologic systems) was measured prospectively every 4 hours by inpatient nurses. PoPD odds were estimated with multivariable logistic regression. Classification and regression tree analysis distinguished children with the highest and lowest likelihood of PoPD. RESULTS Median age at surgery was 8 years (interquartile range: 2-15); 2336 (70.9%) patients had a CCC; and 241 (7.3%) used ≥11 home medications. During preoperative evaluation, 1556 (47.2%) patients had ≥1 active health problem. After surgery, 882 (26.8%) experienced PoPD. The adjusted odds of PoPD were 1.2 (95% confidence interval [CI]: 1.0-1.4) for presence versus absence of an active health problem; 1.4 (95% CI: 1.0-1.9) for ≥11 vs 0 home medications; and 2.2 (95% CI: 1.7-2.9) for ≥3 vs 0 CCCs. In classification and regression tree analysis, the lowest rate of PoPD (8.6%) occurred in children without an active health problem at the preoperative evaluation; the highest rate (57.2%) occurred in children with a CCC who used ≥11 home medications. CONCLUSIONS Greater than 1 in 4 pediatric patients undergoing elective surgery experienced PoPD. Combinations of active health problems at preoperative evaluation, polypharmacy, and multimorbidity distinguished patients with a low versus high risk of PoPD.
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Affiliation(s)
- Jay G Berry
- Division of General Pediatrics, Complex Care Service and .,Harvard Medical School, Boston, Massachusetts
| | - Connor Johnson
- Departments of Anesthesiology, Critical Care, and Pain Medicine and
| | - Charis Crofton
- Division of General Pediatrics, Complex Care Service and
| | - Steven J Staffa
- Departments of Anesthesiology, Critical Care, and Pain Medicine and
| | - Maura DiTillio
- Departments of Anesthesiology, Critical Care, and Pain Medicine and
| | - Izabela Leahy
- Harvard Medical School, Boston, Massachusetts.,Departments of Anesthesiology, Critical Care, and Pain Medicine and
| | - Joseph Salem
- Healthcare Systems Engineering Institute, Northeastern University, Boston, Massachusetts; and
| | - Shawn J Rangel
- Harvard Medical School, Boston, Massachusetts.,Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Sara J Singer
- Department of Medicine, School of Medicine, Stanford University, Stanford, California
| | - Lynne Ferrari
- Harvard Medical School, Boston, Massachusetts.,Departments of Anesthesiology, Critical Care, and Pain Medicine and
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Bjur KA, Wi CI, Ryu E, Crow SS, King KS, Juhn YJ. Epidemiology of Children With Multiple Complex Chronic Conditions in a Mixed Urban-Rural US Community. Hosp Pediatr 2019; 9:281-290. [PMID: 30923070 PMCID: PMC6434974 DOI: 10.1542/hpeds.2018-0091] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Children with multiple complex chronic conditions (MCCs) represent a small fraction of our communities but a disproportionate amount of health care cost and mortality. Because the temporal trends of children with MCCs within a geographically well-defined US pediatric population has not been previously assessed, health care planning and policy for this vulnerable population is limited. METHODS In this population-based, repeated cross-sectional study, we identified and enrolled all eligible children residing in Olmsted County, Minnesota, through the Rochester Epidemiology Project, a medical record linkage system of Olmsted County residents. The pediatric complex chronic conditions classification system version 2 was used to identify children with MCCs. Five-year period prevalence and incidence rates were calculated during the study period (1999-2014) and characterized by age, sex, ethnicity, and socioeconomic status (SES) by using the housing-based index of socioeconomic status, a validated individual housing-based SES index. Age-, sex-, and ethnicity-adjusted prevalence and incidence rates were calculated, adjusting to the 2010 US total pediatric population. RESULTS Five-year prevalence and incidence rates of children with MCCs in Olmsted County increased from 1200 to 1938 per 100 000 persons and from 256 to 335 per 100 000 person-years, respectively, during the study period. MCCs tend to be slightly more prevalent among children with a lower SES and with a racial minority background. CONCLUSIONS Both 5-year prevalence and incidence rates of children with MCCs have significantly increased over time, and health disparities are present among these children. The clinical and financial outcomes of children with MCCs need to be assessed for formulating suitable health care planning given limited resources.
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Shumskiy I, Richardson T, Brar S, Hall M, Cox J, Crofton C, Peltz A, Samuels-Kalow M, Alpern ER, Neuman MI, Berry JG. Well-Child Visits of Medicaid-Insured Children with Medical Complexity. J Pediatr 2018; 199:223-230.e2. [PMID: 29752175 DOI: 10.1016/j.jpeds.2018.04.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/28/2018] [Accepted: 04/03/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Well-child visits (WCVs) help optimize children's health. We measured annual WCVs for children with medical complexity (CMC) and correlated WCVs with hospitalizations. STUDY DESIGN This was a retrospective analysis of 93 121 CMC aged 1-18 years continuously enrolled in 10 state Medicaid programs in the Truven MarketScan Database between 2010 and 2014. CMC had a complex chronic condition or 3 or more chronic conditions of any complexity identified from International Classification of Diseases, Ninth Revision codes, and the use of 1 or more chronic medications. We measured the number of years with 1 or more WCVs. The χ2 test and logistic regression were used to assess the relationships of WCV-years with the children's characteristics and hospitalization. RESULTS Over 5 years, 13.4% of CMC had 0 WCVs; 17.3% had WCVs in 1 year, 40.8% had WCVs in 2-3 years, and 28.5% had WCVs in 4-5 years. Fewer children received WCVs in 4-5 years when enrolled in Medicaid fee-for-service compared with managed care (20.9% vs 31.5%; P < .001) and when enrolled due to a disability compared with another reason (18.2% vs 32.2%; P < .001). The percentage of CMC hospitalized decreased as the number of years receiving WCV increased (21.5% at 0 years vs 16.9% at 5 years; P < .001). The adjusted odds of hospitalization were higher in CMC with WCVs in 0-4 years compared with CMC with WCVs in all 5 years (OR range across years, 1.1 [95% CI, 1.0-1.2] to 1.3 [95% CI, 1.3-1.4]). CONCLUSIONS Most Medicaid-insured CMC do not receive annual WCVs consistently over time. Children with fewer annual WCVs have a higher likelihood of hospitalization. Further investigation is needed to improve the use of WCVs in CMC.
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Affiliation(s)
- Igor Shumskiy
- Boston Combined Residency Program in Pediatrics, Harvard Medical School, Boston University School of Medicine, Boston, MA
| | | | - Sumeet Brar
- Boston University School of Public Health, Boston, MA
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS
| | - Joanne Cox
- Complex Care Service, Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Charis Crofton
- Complex Care Service, Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA
| | - Alon Peltz
- Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Medicine, New Haven, CT
| | | | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mark I Neuman
- Harvard Medical School, Boston, MA; Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA
| | - Jay G Berry
- Complex Care Service, Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
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Simon TD, Haaland W, Hawley K, Lambka K, Mangione-Smith R. Development and Validation of the Pediatric Medical Complexity Algorithm (PMCA) Version 3.0. Acad Pediatr 2018; 18:577-580. [PMID: 29496546 PMCID: PMC6035108 DOI: 10.1016/j.acap.2018.02.010] [Citation(s) in RCA: 139] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 02/10/2018] [Accepted: 02/17/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To modify the Pediatric Medical Complexity Algorithm (PMCA) to include both International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification (ICD-9/10-CM) codes for classifying children with chronic disease (CD) by level of medical complexity and to assess the sensitivity and specificity of the new PMCA version 3.0 for correctly identifying level of medical complexity. METHODS To create version 3.0, PMCA version 2.0 was modified to include ICD-10-CM codes. We applied PMCA version 3.0 to Seattle Children's Hospital data for children with ≥1 emergency department (ED), day surgery, and/or inpatient encounter from January 1, 2016, to June 30, 2017. Starting with the encounter date, up to 3 years of retrospective discharge data were used to classify children as having complex chronic disease (C-CD), noncomplex chronic disease (NC-CD), and no CD. We then selected a random sample of 300 children (100 per CD group). Blinded medical record review was conducted to ascertain the levels of medical complexity for these 300 children. The sensitivity and specificity of PMCA version 3.0 was assessed. RESULTS PMCA version 3.0 identified children with C-CD with 86% sensitivity and 86% specificity, children with NC-CD with 65% sensitivity and 84% specificity, and children without CD with 77% sensitivity and 93% specificity. CONCLUSIONS PMCA version 3.0 is an updated publicly available algorithm that identifies children with C-CD, who have accessed tertiary hospital emergency department, day surgery, or inpatient care, with very good sensitivity and specificity when applied to hospital discharge data and with performance to earlier versions of PMCA.
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Affiliation(s)
- Tamara D Simon
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Wash; Seattle Children's Research Institute, Seattle, Wash.
| | - Wren Haaland
- Seattle Children's Research Institute, Seattle, Wash
| | | | - Karen Lambka
- Seattle Children's Research Institute, Seattle, Wash
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Wash; Seattle Children's Research Institute, Seattle, Wash
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Patterns of Care at the End of Life for Children and Young Adults with Life-Threatening Complex Chronic Conditions. J Pediatr 2018; 193:196-203.e2. [PMID: 29174080 PMCID: PMC5794525 DOI: 10.1016/j.jpeds.2017.09.078] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 09/14/2017] [Accepted: 09/27/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To characterize patterns of care at the end of life for children and young adults with life-threatening complex chronic conditions (LT-CCCs) and to compare them by LT-CCC type. STUDY DESIGN Cross-sectional survey of bereaved parents (n = 114; response rate of 54%) of children with noncancer, noncardiac LT-CCCs who received care at a quaternary care children's hospital and medical record abstraction. RESULTS The majority of children with LT-CCCs died in the hospital (62.7%) with more than one-half (53.3%) dying in the intensive care unit. Those with static encephalopathy (AOR, 0.19; 95% CI, 0.04-0.98), congenital and chromosomal disorders (AOR, 0.28; 95% CI, 0.09-0.91), and pulmonary disorders (AOR, 0.08; 95% CI, 0.01-0.77) were significantly less likely to die at home compared with those with progressive central nervous system (CNS) disorders. Almost 50% of patients died after withdrawal or withholding of life-sustaining therapies, 17.5% died during active resuscitation, and 36% died while receiving comfort care only. The mode of death varied widely across LT-CCCs, with no patients with pulmonary disorders dying receiving comfort care only compared with 66.7% of those with CNS progressive disorders. A majority of patients had palliative care involvement (79.3%); however, in multivariable analyses, there was distinct variation in receipt of palliative care across LT-CCCs, with patients having CNS static encephalopathy (AOR, 0.07; 95% CI, 0.01-0.68) and pulmonary disorders (AOR, 0.07; 95% CI, 0.01-.09) significantly less likely to have palliative care involvement than those with CNS progressive disorders. CONCLUSIONS Significant differences in patterns of care at the end of life exist depending on LT-CCC type. Attention to these patterns is important to ensure equal access to palliative care and targeted improvements in end-of-life care for these populations.
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Boyden JY, Curley MAQ, Deatrick JA, Ersek M. Factors Associated With the Use of U.S. Community-Based Palliative Care for Children With Life-Limiting or Life-Threatening Illnesses and Their Families: An Integrative Review. J Pain Symptom Manage 2018; 55:117-131. [PMID: 28807702 DOI: 10.1016/j.jpainsymman.2017.04.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 03/07/2017] [Accepted: 04/11/2017] [Indexed: 11/17/2022]
Abstract
CONTEXT As children with life-limiting illnesses (LLIs) and life-threatening illnesses (LTIs) live longer, challenges to meeting their complex health care needs arise in homes and communities, as well as in hospitals. Integrated knowledge regarding community-based pediatric palliative care (CBPPC) is needed to strategically plan for a seamless continuum of care for children and their families. OBJECTIVES The purpose of this integrative review article is to explore factors that are associated with the use of CBPPC for U.S. children with LLIs and LTIs and their families. METHODS A literature search of PubMed, CINAHL, Scopus, Google Scholar, and an ancestry search was performed to identify empirical studies and program evaluations published between 2000 and 2016. The methodological protocol included an evaluation of empirical quality and explicit data collection of synthesis procedures. RESULTS Forty peer-reviewed quantitative and qualitative methodological interdisciplinary articles were included in the final sample. Patient characteristics such as older age and a solid tumor cancer diagnosis and interpersonal factors such as family support were associated with higher CBPPC use. Organizational features were the most frequently discussed factors that increased CBPPC, including the importance of interprofessional hospice services and interorganizational care coordination for supporting the child and family at home. Finally, geography, concurrent care and hospice eligibility regulations, and funding and reimbursement mechanisms were associated with CBPPC use on a community and systemic level. CONCLUSION Multilevel factors are associated with increased CBPPC use for children with LLIs or LTIs and their families in the U.S.
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Affiliation(s)
- Jackelyn Y Boyden
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania.
| | - Martha A Q Curley
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Janet A Deatrick
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Mary Ersek
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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Forjaz de Lacerda A, Gomes B. Trends in cause and place of death for children in Portugal (a European country with no Paediatric palliative care) during 1987-2011: a population-based study. BMC Pediatr 2017; 17:215. [PMID: 29273020 PMCID: PMC5741889 DOI: 10.1186/s12887-017-0970-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 12/12/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Children and adolescents dying from complex chronic conditions require paediatric palliative care. One aim of palliative care is to enable a home death if desired and well supported. However, there is little data to inform care, particularly from countries without paediatric palliative care, which constitute the majority worldwide. METHODS This is an epidemiological study analysing death certificate data of decedents aged between 0 and 17 years in Portugal, a developed Western European country without recognised provision of paediatric palliative care, from 1987 to 2011. We analysed death certificate data on cause and place of death; the main outcome measure was home death. Complex chronic conditions included cancer, cardiovascular, neuromuscular, congenital/genetic, respiratory, metabolic, gastro-intestinal, renal, and haematology/immunodeficiency conditions. Multivariate analysis determined factors associated with home death in these conditions. RESULTS Annual deaths decreased from 3268 to 572. Of 38,870 deaths, 10,571 were caused by complex chronic conditions, their overall proportion increasing from 23.7% to 33.4% (22.4% to 45.4% above age 1-year). For these children, median age of death increased from 0.5 to 4.32-years; 19.4% of deaths occurred at home, declining from 35.6% to 11.5%; factors associated with home death were year of death (adjusted odds ratio 0.89, 95% confidence interval 0.89-0.90), age of death (6-10 year-olds 21.46, 16.42-28.04, reference neonates), semester of death (October-March 1.18, 1.05-1.32, reference April-September), and cause of death (neuromuscular diseases 1.59, 1.37-1.84, reference cancer), with wide regional variation. CONCLUSIONS This first trend analysis of paediatric deaths in Portugal (an European country without paediatric palliative care) shows that palliative care needs are increasing. Children are surviving longer and, in contrast with countries where paediatric palliative care is thriving, there is a long-term trend of dying in hospital instead of at home. Age, diagnosis, season and region are associated with home death, and should be considered when planning services to support families choosing this option. Priorities should address needs of the youngest children, those with cancer, neuromuscular and cardiovascular conditions, as well as inequities related to place of residence.
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Affiliation(s)
- Ana Forjaz de Lacerda
- King’s College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ UK
- Portuguese Institute of Oncology – Lisbon Centre, Paediatrics Department, Lisboa, Portugal
| | - Barbara Gomes
- King’s College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ UK
- University of Coimbra, Faculty of Medicine, Coimbra, Portugal
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Bona K, Wolfe J. Disparities in Pediatric Palliative Care: An Opportunity to Strive for Equity. Pediatrics 2017; 140:peds.2017-1662. [PMID: 28963113 PMCID: PMC5613824 DOI: 10.1542/peds.2017-1662] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2017] [Indexed: 11/24/2022] Open
Affiliation(s)
- Kira Bona
- Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; .,Division of Population Sciences.,Departments of Pediatric Oncology and.,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Joanne Wolfe
- Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts;,Division of Population Sciences,,Departments of Pediatric Oncology and,Psychosocial Oncology and Palliative Care, Dana–Farber Cancer Institute, Boston, Massachusetts; and,Harvard Medical School, Harvard University, Boston, Massachusetts
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Johnston EE, Rosenberg AR, Kamal AH. Pediatric-Specific End-of-Life Care Quality Measures: An Unmet Need of a Vulnerable Population. J Oncol Pract 2017; 13:e874-e880. [DOI: 10.1200/jop.2017.021766] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We must ensure that the 20,000 US children (age 0 to 19 years) who die as a result of serious illness annually receive high-quality end-of-life care. Ensuring high-quality end-of-life care requires recognition that pediatric end-of-life care is conceptually and operationally different than that for adults. For example, in-hospital adult death is considered an outcome to be avoided, whereas many pediatric families may prefer hospital death. Because pediatric deaths are comparatively rare, not all centers offer pediatric-focused palliative care and hospice services. The unique psychosocial issues facing families who are losing a child include challenges for parent decision makers and young siblings. Furthermore, the focus on advance directive documentation in adult care may be less relevant in pediatrics because parental decision makers are available. Health care quality measures provide a framework for tracking the care provided and aid in agency and provider accountability, reimbursement, and educated patient choice for location of care. The National Quality Forum, Joint Commission, and other groups have developed several end-of-life measures. However, none of the current quality measures focus on the unique needs of dying pediatric patients and their caregivers. To evolve the existing infrastructure to better measure and report quality pediatric end-of-life care, we propose two changes. First, we outline how existing adult quality measures may be modified to better address pediatric end-of-life care. Second, we suggest the formation of a pediatric quality measure end-of-life task force. These are the next steps to evolving end-of-life quality measures to better fit the needs of seriously ill children.
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Affiliation(s)
- Emily E. Johnston
- Stanford University School of Medicine, Palo Alto, CA; University of Washington School of Medicine, Seattle Children’s Hospital, and Seattle Children’s Research Institute, Seattle, WA; Duke University School of Medicine, Duke University, and Duke Palliative Care, Duke Health, Durham, NC
| | - Abby R. Rosenberg
- Stanford University School of Medicine, Palo Alto, CA; University of Washington School of Medicine, Seattle Children’s Hospital, and Seattle Children’s Research Institute, Seattle, WA; Duke University School of Medicine, Duke University, and Duke Palliative Care, Duke Health, Durham, NC
| | - Arif H. Kamal
- Stanford University School of Medicine, Palo Alto, CA; University of Washington School of Medicine, Seattle Children’s Hospital, and Seattle Children’s Research Institute, Seattle, WA; Duke University School of Medicine, Duke University, and Duke Palliative Care, Duke Health, Durham, NC
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Peltz A, Samuels-Kalow ME, Rodean J, Hall M, Alpern ER, Aronson PL, Berry JG, Shaw KN, Morse RB, Freedman SB, Cohen E, Simon HK, Shah SS, Katsogridakis Y, Neuman MI. Characteristics of Children Enrolled in Medicaid With High-Frequency Emergency Department Use. Pediatrics 2017; 140:peds.2017-0962. [PMID: 28765381 PMCID: PMC5574719 DOI: 10.1542/peds.2017-0962] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Some children repeatedly use the emergency department (ED) at high levels. Among Medicaid-insured children with high-frequency ED use in 1 year, we sought to describe the characteristics of children who sustain high-frequency ED use over the following 2 years. METHODS Retrospective longitudinal cohort study of 470 449 Medicaid-insured children appearing in the MarketScan Medicaid database, aged 1-16 years, with ≥1 ED discharges in 2012. Children with high ED use in 2012 (≥4 ED discharges) were followed through 2014 to identify characteristics associated with sustained high ED use (≥8 ED discharges in 2013-2014 combined). A generalized linear model was used to identify patient characteristics associated with sustained high ED use. RESULTS A total of 39 945 children (8.5%) experienced high ED use in 2012, accounting for 25% of total ED visits in 2012. Sixteen percent of these children experienced sustained high ED use in the following 2 years. Adolescents (adjusted odds ratio [aOR]: 1.4 [95% confidence interval: 1.3-1.5]), disabled children (aOR: 1.3 [95% confidence interval: 1.1-1.5]), and children with 3 or more chronic conditions (aOR: 2.1, [95% confidence interval: 1.9-2.3]) experienced the highest likelihood for sustaining high ED use. CONCLUSIONS One in 6 Medicaid-insured children with high ED use in a single year experienced sustained high levels of ED use over the next 2 years. Adolescents and individuals with multiple chronic conditions were most likely to have sustained high rates of ED use. Targeted interventions may be indicated to help reduce ED use among children at high risk.
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Affiliation(s)
- Alon Peltz
- Robert Wood Johnson Foundation Clinical Scholars Program and .,Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| | | | | | | | - Elizabeth R. Alpern
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Paul L. Aronson
- Section of Pediatric Emergency Medicine, Department of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Kathy N. Shaw
- Departments of Pediatrics and,Emergency Medicine, Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rustin B. Morse
- Children’s Health System of Texas, and Department of Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and,Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Eyal Cohen
- Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Harold K. Simon
- Division of Emergency Medicine, Department of Pediatrics and Emergency Medicine, School of Medicine, Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia; and
| | - Samir S. Shah
- Divisions of Hospital Medicine and,Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Yiannis Katsogridakis
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Mark I. Neuman
- Emergency Medicine, Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts
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Provider Perspectives Regarding Resuscitation Decisions for Neonates and Other Vulnerable Patients. J Pediatr 2017; 188:142-147.e3. [PMID: 28502606 DOI: 10.1016/j.jpeds.2017.03.057] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 02/06/2017] [Accepted: 03/27/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To use structured surveys to assess the perspectives of pediatric residents and neonatal nurses on resuscitation decisions for vulnerable patients, including neonates. STUDY DESIGN Pediatric providers were surveyed using scenarios for 6 critically ill patients of different ages with outcomes explicitly described. Providers were asked (1) whether resuscitation was in each patient's best interest; (2) whether they would accept families' wishes for comfort care (no resuscitation); and (3) to rank patients in order of priority for resuscitation. In a structured interview, each participant explained how they evaluated patient interests and when applicable, why their answers differed for neonates. Interviews were audiotaped; transcripts were analyzed using thematic analysis and mixed methods. RESULTS Eighty pediatric residents and neonatal nurses participated (response rate 74%). When making life and death decisions, participants considered (1) patient characteristics (96%), (2) personal experience/biases (85%), (3) family's wishes and desires (81%), (4) disease characteristics (74%), and (5) societal perspectives (36%). These factors were not in favor of sick neonates: of the participants, 85% reported having negative biases toward neonates and 60% did not read, misinterpreted, and/or distrusted neonatal outcome statistics. Additional factors used to justify comfort care for neonates included limited personhood and lack of relationships/attachment (73%); prioritization of family's best interest, and social acceptability of death (36%). When these preconceptions were discussed, 70% of respondents reported they would change their answers in favor of neonates. CONCLUSIONS Resuscitation decisions for neonates are based on many factors, such as considerations of personhood and family's interests (that are not traditional indicators of benefit), which may explain why decision making is different for the neonatal population.
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Stockmann C, Pavia AT, Graham B, Vaughn M, Crisp R, Poritz MA, Thatcher S, Korgenski EK, Barney T, Daly J, Rogatcheva M. Detection of 23 Gastrointestinal Pathogens Among Children Who Present With Diarrhea. J Pediatric Infect Dis Soc 2017; 6:231-238. [PMID: 27147712 PMCID: PMC5907859 DOI: 10.1093/jpids/piw020] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 03/19/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Diarrheal diseases are a major cause of ambulatory care visits and hospitalizations among children. Because of overlapping signs and symptoms and expensive and inefficient testing methods, the etiology of pediatric diarrhea is rarely established. METHODS We identified children <18 years of age who were evaluated for diarrhea at Primary Children's Hospital in Salt Lake City, Utah, between October 2010 and September 2012. Stool specimens submitted for testing were evaluated by using the FilmArray gastrointestinal diagnostic system, which is a rapid multiplex polymerase chain reaction platform that can simultaneously detect 23 bacterial, viral, and protozoal agents. RESULTS A pathogen was detected in 561 (52%) of 1089 diarrheal episodes. The most commonly detected pathogens included toxigenic Clostridium difficile (16%), diarrheagenic Escherichia coli (15%), norovirus GI/GII (11%), and adenovirus F 40/41 (7%). Shiga toxin-producing E coli were detected in 43 (4%) specimens. Multiple pathogens were identified in 160 (15%) specimens. Viral pathogens (norovirus, adenovirus, rotavirus, and sapovirus) were more common among children <5 years old than among those 5 to 17 years old (38% vs 16%, respectively; P < .001). Bacterial pathogens were identified most commonly in children 2 to 4 years of age. Children with 1 or more underlying chronic medical conditions were less likely to have a pathogen identified than those without a chronic medical condition (45% vs 60%, respectively; P < .01). Viral pathogens were detected more commonly in the winter, whereas bacterial pathogens were detected more commonly in the summer. CONCLUSIONS Toxigenic C difficile, diarrheagenic E coli, and norovirus were the leading organisms detected among these children with diarrhea. Viral pathogens are identified frequently among young children with acute gastroenteritis.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Trenda Barney
- Primary Children’s Hospital, Intermountain Healthcare, and
| | - Judy Daly
- Primary Children’s Hospital, Intermountain Healthcare, and
- Pathology, University of Utah Health Sciences Center, Salt Lake City
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Ananth P, Melvin P, Berry JG, Wolfe J. Trends in Hospital Utilization and Costs among Pediatric Palliative Care Recipients. J Palliat Med 2017; 20:946-953. [PMID: 28453361 DOI: 10.1089/jpm.2016.0496] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE AND BACKGROUND Few previous studies have explored how pediatric palliative care (PPC) influences hospital utilization. We evaluated this among PPC recipients in a single center. METHODS This is a retrospective cohort study of 109 patients ≥2 years of age who received PPC consultation at a large quaternary children's hospital from April 2009 to September 2010. We assessed frequencies of hospital admissions and emergency department (ED) visits, use of intensive interventions, and hospital costs. Generalized estimating equations were used to compare outcomes in the two years before and after PPC consultation, stratifying by whether a patient survived two or more years following PPC enrollment. RESULTS Median age at PPC consultation was 13 years (interquartile range 6-18); 56.0% were male (n = 61), 69.7% white non-Hispanic (n = 76). Fifty-nine percent (n = 64) of patients died during the study period. Overall, annual hospital admission rates decreased from 4.6 (95% confidence interval [CI] 4.0-5.4) before PPC consultation to 3.7 (95% CI 3.4-4.4) after (p = 0.025). Annual ED visits decreased from 0.9 (95% CI 0.7-1.2) to 0.6 (95% CI 0.4-0.8) (p = 0.030). Survivors had significantly decreased hospital admissions [rate ratio (RR) 0.57 (95% CI 0.45-0.73), p < 0.001] and ED visits [RR 0.33 (95% CI 0.20-0.54), p < 0.001]. Decedents had increased intensive care unit use (p = 0.029) but decreased operations (p = 0.002); survivors experienced no change in these outcomes after PPC consultation. Hospital costs remained stable for all (p = 0.929). DISCUSSION PPC involvement may contribute to decreased hospital and ED use, without escalating costs. These outcomes are most evident in survivors. Hence, PPC may have a measurable long-term impact on hospital use in seriously ill children.
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Affiliation(s)
- Prasanna Ananth
- 1 Department of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center , Boston, Massachusetts.,6 Harvard Medical School , Boston, Massachusetts
| | - Patrice Melvin
- 2 Center for Patient Safety and Quality Research, Boston Children's Hospital , Boston, Massachusetts
| | - Jay G Berry
- 3 Division of General Pediatrics, Boston Children's Hospital , Boston, Massachusetts.,5 Department of Medicine, Boston Children's Hospital , Boston, Massachusetts.,6 Harvard Medical School , Boston, Massachusetts
| | - Joanne Wolfe
- 4 Division of Pediatric Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,5 Department of Medicine, Boston Children's Hospital , Boston, Massachusetts.,6 Harvard Medical School , Boston, Massachusetts
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Place of death of children with complex chronic conditions: cross-national study of 11 countries. Eur J Pediatr 2017; 176:327-335. [PMID: 28070671 DOI: 10.1007/s00431-016-2837-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 12/14/2016] [Accepted: 12/21/2016] [Indexed: 10/20/2022]
Abstract
UNLABELLED Cross-national understanding of place of death is crucial for health service systems for their provision of efficient and equal access to paediatric palliative care. The objectives of this population-level study were to examine where children with complex chronic conditions (CCC) die and to investigate associations between places of death and sex, cause of death and country. The study used death certificate data of all deceased 1- to 17-year-old children (n = 40,624) who died in 2008, in 11 European and non-European countries. Multivariable logistic regression was performed to determine associations between place of death and other factors. Between 24.4 and 75.3% of all children 1-17 years in the countries died of CCC. Of these, between 6.7 and 42.4% died at home. In Belgium and the USA, all deaths caused by CCC other than malignancies were less likely to occur at home, whereas in Mexico and South Korea, deaths caused by neuromuscular diseases were more likely to occur at home than malignancies. In Mexico (OR = 0.91, 95% CI: 0.83-1.00) and Sweden (OR = 0.35, 95% CI: 0.15-0.83), girls had a significantly lower chance of dying at home than boys. CONCLUSION This study shows large cross-national variations in place of death. These variations may relate to health system-related infrastructures and policies, and differences in cultural values related to place of death, although this needs further investigation. The patterns found in this study can inform the development of paediatric palliative care programs internationally. What is known: • There is a scarcity of population-level studies investigating where children with CCC die in different countries. • Cross-national understanding of place of death provides information to health care systems for providing efficient and equal access to paediatric palliative care. What is new : • There are large cross-national variations in the place of death of children with CCC, with few deathsoccuring at home in some countries whereas hospital deaths are generally most common. • In general, deaths caused by neuromuscular diseases and malignancies occur at home more often thanother CCC.
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Stone B, Hester G, Jackson D, Richardson T, Hall M, Gouripeddi R, Butcher R, Keren R, Srivastava R. Effectiveness of Fundoplication or Gastrojejunal Feeding in Children With Neurologic Impairment. Hosp Pediatr 2017; 7:140-148. [PMID: 28159744 DOI: 10.1542/hpeds.2016-0126] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Gastroesophageal reflux (GER), aspiration, and secondary complications lead to morbidity and mortality in children with neurologic impairment (NI), dysphagia, and gastrostomy feeding. Fundoplication and gastrojejunal (GJ) feeding can reduce risk. We compared GJ to fundoplication using first-year postprocedure reflux-related hospitalization (RRH) rates. METHODS We identified children with NI, dysphagia requiring gastrostomy tube feeding and GER undergoing initial GJ placement or fundoplication from January 1, 2007 to December 31, 2012. Data came from the Pediatric Health Information Systems augmented by laboratory, microbiology, and radiology results. GJ placement was ascertained using radiology results and fundoplication by International Classification of Diseases, Ninth Revision, Clinical Modification codes. Subjects were matched within hospital using propensity scores. The primary outcome was first-year postprocedure RRH rate (hospitalization for GER disease, other esophagitis, aspiration pneumonia, other pneumonia, asthma, or mechanical ventilation). Secondary outcomes included failure to thrive, death, repeated initial intervention, crossover intervention, and procedural complications. RESULTS We identified 1178 children with fundoplication and 163 with GJ placement, matching 114 per group. Matched sample RRH incident rate per child-year (95% confidence interval) for GJ was 2.07 (1.62-2.64) and for fundoplication 1.67 (1.28-2.18), P = .19. Odds of death were similar between groups. Failure to thrive, repeat of initial intervention, and crossover intervention were more common in the GJ group. CONCLUSIONS In children with NI, GER, and dysphagia: fundoplication and GJ feeding have similar RRH outcomes. Either intervention can reduce future aspiration risk; the choice can reflect non-RRH-related complication risks, caregiver preference, and clinician recommendation.
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Affiliation(s)
- Bryan Stone
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah;
| | - Gabrielle Hester
- Hospital Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Daniel Jackson
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Troy Richardson
- Biostatistics, Children's Hospital Association, Overland Park, Kansas
| | - Matt Hall
- Biostatistics, Children's Hospital Association, Overland Park, Kansas
| | | | - Ryan Butcher
- Biomedical Informatics, University of Utah, Salt Lake City, Utah
| | - Ron Keren
- Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Rajendu Srivastava
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah.,Institute for Healthcare Leadership, Intermountain Healthcare, Salt Lake City, Utah
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Lam V, Kain N, Joynt C, van Manen MA. A descriptive report of end-of-life care practices occurring in two neonatal intensive care units. Palliat Med 2016; 30:971-978. [PMID: 26934947 DOI: 10.1177/0269216316634246] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND In Canada and other developed countries, the majority of neonatal deaths occur in tertiary neonatal intensive care units. Most deaths occur following the withdrawal of life-sustaining treatments. AIM To explore neonatal death events and end-of-life care practices in two tertiary neonatal intensive care settings. DESIGN A structured, retrospective, cohort study. SETTING/PARTICIPANTS All infants who died under tertiary neonatal intensive care from January 2009 to December 2013 in a regional Canadian neonatal program. Deaths occurring outside the neonatal intensive care unit in delivery rooms, hospital wards, or family homes were not included. Overall, 227 infant deaths were identified. RESULTS The most common reasons for admission included prematurity (53.7%), prematurity with congenital anomaly/syndrome (20.3%), term congenital anomaly (11.5%), and hypoxic ischemic encephalopathy (12.3%). The median age at death was 7 days. Death tended to follow a decision to withdraw life-sustaining treatment with anticipated poor developmental outcome or perceived quality of life, or in the context of a moribund dying infant. Time to death after withdrawal of life-sustaining treatment was uncommonly a protracted event but did vary widely. Most dying infants were held by family members in the neonatal intensive care unit or in a parent room off cardiorespiratory monitors. Analgesic and sedative medications were variably given and not associated with a hastening of death. CONCLUSION Variability exists in end-of-life care practices such as provision of analgesic and sedative medications. Other practices such as discontinuation of cardiorespiratory monitors and use of parent rooms are more uniform. More research is needed to understand variation in neonatal end-of-life care.
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Affiliation(s)
| | - Nicole Kain
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Chloe Joynt
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Michael A van Manen
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada .,John Dossetor Health Ethics Centre, University of Alberta, Edmonton, AB, Canada
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Lindley LC, Edwards SL. Geographic Variation in California Pediatric Hospice Care for Children and Adolescents: 2007-2010. Am J Hosp Palliat Care 2016; 35:15-20. [PMID: 27837156 DOI: 10.1177/1049909116678380] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To map and describe the geographic distribution of pediatric hospice care need versus supply in California over a 4-year time period (2007-2010). METHODS Multiple databases were used for this descriptive longitudinal study. The sample consisted of 2036 children and adolescent decedents and 136 pediatric hospice providers. Geocoded data were used to create the primary variables of interest for this study-need and supply of pediatric hospice care. Geographic information systems were used to create heat maps for analysis. RESULTS Almost 90% of the children and adolescents had a potential need for hospice care, whereas more than 10% had a realized need. The highest density of potential need was found in the areas surrounding Los Angeles. The areas surrounding the metropolitan communities of Los Angeles and San Diego had the highest density of realized hospice care need. Sensitivity analysis revealed neighborhood-level differences in potential and realized need in the Los Angeles area. Over 30 pediatric hospice providers supplied care to the Los Angeles and San Diego areas. CONCLUSION There were distinctive geographic patterns of potential and realized need with high density of potential and realized need in Los Angeles and high density of realized need in the San Diego area. The supply of pediatric hospice care generally matched the needs of children and adolescents. Future research should continue to explore the needs of children and adolescents at end of life at the neighborhood level, especially in large metropolitan areas.
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Affiliation(s)
- Lisa C Lindley
- 1 College of Nursing, University of Tennessee, Knoxville, TN, USA
| | - Sheri L Edwards
- 2 Wimberly Library, Florida Atlantic University, Boca Raton, FL, USA
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Vesely C, Newman V, Winters Y, Flori H. Bringing Home to the Hospital: Development of the Reflection Room and Provider Perspectives. J Palliat Med 2016; 20:120-126. [PMID: 27813695 DOI: 10.1089/jpm.2016.0070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Alternative locations for children near end of life (EOL) are lacking in the United States with deaths largely occurring within intensive care units (ICUs). The reflection room (RR) was implemented as a relevant space for providing this care in our hospital. OBJECTIVE We hypothesized staff would report a positive experience in providing EOL and/or postmortem (PM) care here and would recommend this to peers. DESIGN This explorative study summarized room use data and evaluated staff experiences using a voluntary qualitative and quantitative survey. SUBJECTS The survey was administered to the inpatient interdisciplinary team. RESULTS From 2011 to 2014, 116 children used the RR, 64% for PM care, and 34% for EOL care. A total of 201 staff responded to the survey. Of them, 90% described the space as a valuable resource to families, 90% reported a preference for using this location versus a hospital unit, and 93% stated they would encourage their peers to do the same. Advantages listed were increased privacy, allowance for more visitors, and a quieter, calmer environment. Challenges included distance from the unit of transfer, managing assignments in two hospital locations, and medication transportation. Overall, there was a measureable decrease in the number of deaths pronounced in the ICU as the number pronounced in the RR increased, illustrating a significant change in practice. CONCLUSION This study demonstrated an overwhelmingly positive experience in providing EOL and/or PM care to children in the RR and staff would recommend this to peers. This model of care should be a serious consideration for hospitals in the United States.
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Affiliation(s)
- Claire Vesely
- 1 Department of Pediatrics, Division of Palliative Care, UCSF Benioff Children's Hospital Oakland , Oakland, California
| | - Vivienne Newman
- 1 Department of Pediatrics, Division of Palliative Care, UCSF Benioff Children's Hospital Oakland , Oakland, California
| | - Yolanda Winters
- 1 Department of Pediatrics, Division of Palliative Care, UCSF Benioff Children's Hospital Oakland , Oakland, California
| | - Heidi Flori
- 2 Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Michigan C.S. Mott Children's Hospital , Ann Arbor, Michigan
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Zonfrillo MR, Zaniletti I, Hall M, Fieldston ES, Colvin JD, Bettenhausen JL, Macy ML, Alpern ER, Cutler GJ, Raphael JL, Morse RB, Sills MR, Shah SS. Socioeconomic Status and Hospitalization Costs for Children with Brain and Spinal Cord Injury. J Pediatr 2016; 169:250-5. [PMID: 26563534 PMCID: PMC6180292 DOI: 10.1016/j.jpeds.2015.10.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 09/17/2015] [Accepted: 10/09/2015] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine if household income is associated with hospitalization costs for severe traumatic brain injury (TBI) and spinal cord injury (SCI). STUDY DESIGN Retrospective cohort study of inpatient, nonrehabilitation hospitalizations at 43 freestanding children's hospitals for patients <19 years old with unintentional severe TBI and SCI from 2009-2012. Standardized cost of care for hospitalizations was modeled using mixed-effects methods, adjusting for age, sex, race/ethnicity, primary payer, presence of chronic medical condition, mechanism of injury, injury severity, distance from residence to hospital, and trauma center level. Main exposure was zip code level median annual household income. RESULTS There were 1061 patients that met inclusion criteria, 833 with TBI only, 227 with SCI only, and 1 with TBI and SCI. Compared with those with the lowest-income zip codes, patients from the highest-income zip codes were more likely to be older, white (76.7% vs 50.4%), have private insurance (68.9% vs 27.9%), and live closer to the hospital (median distance 26.7 miles vs 81.2 miles). In adjusted models, there was no significant association between zip code level household income and hospitalization costs. CONCLUSIONS Children hospitalized with unintentional, severe TBI and SCI showed no difference in standardized hospital costs relative to a patient's home zip code level median annual household income. The association between household income and hospitalization costs may vary by primary diagnosis.
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Affiliation(s)
- Mark R Zonfrillo
- Department of Emergency Medicine and Injury Prevention Center, Hasbro Children's Hospital, Providence, RI; Alpert Medical School of Brown University, Providence, RI.
| | | | - Matthew Hall
- Children's Hospital Association, Overland Park, KS
| | - Evan S Fieldston
- Alpert Medical School of Brown University, Providence, RI; Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jeffrey D Colvin
- Department of Pediatrics, Children's Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Jessica L Bettenhausen
- Department of Pediatrics, Children's Mercy Hospitals and Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Michelle L Macy
- Department of Emergency Medicine, Child Health Evaluation and Research Unit, Division of General Pediatrics, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, MI
| | - Elizabeth R Alpern
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Gretchen J Cutler
- Department of Pediatric Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN
| | - Jean L Raphael
- Department of Pediatrics, Section on Academic General Pediatrics, Baylor College of Medicine, Houston, TX
| | | | | | - Samir S Shah
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
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Amin D, Ford R, Ghazarian SR, Love B, Cheng TL. Parent and Physician Perceptions Regarding Preventability of Pediatric Readmissions. Hosp Pediatr 2016; 6:80-7. [PMID: 26744363 DOI: 10.1542/hpeds.2015-0059] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess the causes and preventability of pediatric readmissions from the perspectives of parents and their physicians to guide future interventions. METHODS Parent interview, physician survey, and medical record review were completed for children who were readmitted to a pediatric hospitalist service within 30 days of an index admission. Questions were asked about Health Belief Model constructs (perceived severity, susceptibility or preventability of admission, and perceived barriers), discharge readiness, and follow-up plans. Parent and physician perceptions about reasons for readmissions were examined, and responses to open-ended questions were coded. RESULTS 60 parent-physician pairs completed the study. The mean age of the patients was 6.43 (SD 6.42) years; 45% (n=27) had a chronic disease, and 47% (n=28) of patients were readmitted with the same or similar condition as in the previous hospitalization. At readmission, parents were more likely than physicians to think that the condition was serious (parent 98%, physician 76%; P<.001) and that the readmission could have been prevented (parent 59%, physician 36%; P=.04). Most parents (63%) and physicians (65%) thought it was likely that the child may have future hospitalizations. Opportunities to prevent readmission included need for parent education, improving medication access and adherence, and need for coordination of follow-up care. CONCLUSIONS Many parents and physicians thought the readmission was preventable, and the majority of both thought that the patient was susceptible to another hospitalization. Parents and physicians suggest opportunities to improve care processes during hospitalization and in services provided after discharge to reduce readmissions.
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Affiliation(s)
- Dipti Amin
- Department of Pediatric Medicine, All Children's Hospital, Johns Hopkins Medicine, St Petersburg, Florida;
| | - Ronald Ford
- Department of Pediatrics, Joe DiMaggio Hospital, Fort Lauderdale, Florida; and
| | | | - Benjamin Love
- Department of Pediatric Medicine, All Children's Hospital, Johns Hopkins Medicine, St Petersburg, Florida
| | - Tina L Cheng
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
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Ananth P, Melvin P, Feudtner C, Wolfe J, Berry JG. Hospital Use in the Last Year of Life for Children With Life-Threatening Complex Chronic Conditions. Pediatrics 2015; 136:938-46. [PMID: 26438707 PMCID: PMC4621793 DOI: 10.1542/peds.2015-0260] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/18/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Although many adults experience resource-intensive and costly health care in the last year of life, less is known about these health care experiences in children with life-threatening complex chronic conditions (LT-CCCs). We assessed hospital resource use in children by type and number of LT-CCCs. METHODS A retrospective analysis of 1252 children with LT-CCCs, ages 1 to 18 years, who died in 2012 within 40 US children's hospitals of the Pediatric Health Information System database. LT-CCCs were identified with International Classification of Diseases, 9th Revision, Clinical Modification codes. Using generalized linear models, we assessed hospital admissions, days, costs, and interventions (mechanical ventilation and surgeries) in the last year of life by type and number of LT-CCCs. RESULTS In the last year of life, children with LT-CCCs experienced a median of 2 admissions (interquartile range [IQR] 1-5), 27 hospital days (IQR 7-84), and $142 562 (IQR $45 270-$410 087) in hospital costs. During the terminal admission, 76% (n = 946) were mechanically ventilated; 36% (n = 453) underwent surgery. Hospital use was greatest (P < .001) among children with hematologic/immunologic conditions (99 hospital days [IQR 51-146]; cost = $504 145 [IQR $250 147-$879 331]) and children with ≥3 LT-CCCs (75 hospital days [IQR 28-132]; cost = $341 222 [IQR $146 698-$686 585]). CONCLUSIONS Hospital use for children with LT-CCCs in the last year of life varies significantly across the type and number of conditions. Children with hematologic/immunologic or multiple conditions have the greatest hospital use. This information may be useful for clinicians striving to improve care for children with LT-CCCs nearing the end of life.
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Affiliation(s)
- Prasanna Ananth
- Department of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center,
| | - Patrice Melvin
- Center for Patient Safety and Quality Research, Boston Children’s Hospital, Boston, Massachusetts
| | - Chris Feudtner
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joanne Wolfe
- Department of Pediatric Hematology/Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center,,Division of Pediatric Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, and
| | - Jay G. Berry
- Division of General Pediatrics, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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An Evaluation of Family-Centered Rounds in the PICU: Room for Improvement Suggested by Families and Providers. Pediatr Crit Care Med 2015; 16:801-7. [PMID: 26181298 DOI: 10.1097/pcc.0000000000000486] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify areas for improvement in family-centered rounds from both the family and provider perspectives. DESIGN Prospective, cross-sectional mixed-methods study, including an objective measure (direct observation of family-centered rounds) and subjective measures (surveys of English-speaking families and providers) of family-centered rounds. SETTING PICU in a single, tertiary children's hospital. SUBJECTS Families of children admitted to the PICU, physicians, and nurses. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two hundred thirty-two family-centered round encounters were observed over a 10-week period. Family-centered round encounters averaged 10.5 minutes per child. Multivariable regression analysis revealed that family presence was independently associated with length of family-centered rounds (p < 0.002) despite family talk time accounting for an average of 25 seconds (4%) of the encounter. Non-English-speaking families were less likely to attend family-centered rounds compared with English-speaking families even when physically present at the patient's bedside (p < 0.001). Most commonly families and providers agreed that family-centered rounds keep the family informed and reported positive statements about family presence on family-centered rounds; however, PICU fellows did not agree that families provided pertinent information and nurses reported that family presence limited patient discussions. The primary advice families offered providers to improve family-centered rounds was to be more considerate and courteous, including accommodating family schedules, minimizing distractions, and limiting computer viewing. CONCLUSIONS Family presence increased the length of family-centered rounds despite a small percentage of time spoken by families, suggesting longer rounds are due to changes in provider behavior when families are present. Also, non-English-speaking families may need more support to be able to attend and benefit from family-centered rounds. Lastly, in an era of full family-centered rounds acceptance, families and most providers, except fellows, report benefit from family presence during family-centered rounds. However, providers should be aware of the perception of their behaviors to optimize the experience for families.
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Chien AT, Kuhlthau KA, Toomey SL, Quinn JA, Houtrow AJ, Kuo DZ, Okumura MJ, Van Cleave JM, Johnson CK, Mahoney LL, Martin J, Landrum MB, Schuster MA. Development of the Children With Disabilities Algorithm. Pediatrics 2015; 136:e871-8. [PMID: 26416938 DOI: 10.1542/peds.2015-0228] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND A major impediment to understanding quality of care for children with disabilities (CWD) is the lack of a method for identifying this group in claims databases. We developed the CWD algorithm (CWDA), which uses International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes to identify CWD. METHODS We conducted a cross-sectional study that (1) ensured each of the 14,567 codes within the 2012 ICD-9-CM codebook was independently classified by 3 to 9 pediatricians based on the code's likelihood of indicating CWD and (2) triangulated the resulting CWDA against parent and physician assessment of children's disability status by using survey and chart abstraction, respectively. Eight fellowship-trained general pediatricians and 42 subspecialists from across the United States participated in the code classification. Parents of 128 children from a large, free-standing children's hospital participated in the parent survey; charts of 336 children from the same hospital were included in the abstraction study. RESULTS CWDA contains 669 ICD-9-CM codes classified as having a ≥75% likelihood of indicating CWD. Examples include 318.2 Profound intellectual disabilities and 780.72 Functional quadriplegia. CWDA sensitivity was 0.75 (95% confidence interval 0.63-0.84) compared with parent report and 0.98 (0.95-0.99) compared with physician assessment; its specificity was 0.86 (0.72-0.95) and 0.50 (0.41-0.59), respectively. CONCLUSIONS ICD-9-CM codes can be classified by their likelihood of indicating CWD. CWDA triangulates well with parent report and physician assessment of child disability status. CWDA is a new tool that can be used to assess care quality for CWD.
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Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; Departments of Pediatrics, and
| | - Karen A Kuhlthau
- Departments of Pediatrics, and Center for Child and Adolescent Health Research and Policy, Department of General Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Sara L Toomey
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; Departments of Pediatrics, and
| | - Jessica A Quinn
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Amy J Houtrow
- Division of Pediatric Rehabilitation Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Dennis Z Kuo
- Department of Pediatrics, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas; and
| | - Megumi J Okumura
- Division of General Pediatrics, Beinoff Children's Hospital, and Department of Pediatrics, Division of General Pediatrics, School of Medicine, University of California San Francisco, San Francisco, California
| | - Jeanne M Van Cleave
- Departments of Pediatrics, and Center for Child and Adolescent Health Research and Policy, Department of General Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Chelsea K Johnson
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Lindsey L Mahoney
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Julia Martin
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | | | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; Departments of Pediatrics, and
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