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van de Riet L, Aris AM, Verouden NW, van Rooij T, van Woensel JB, van Karnebeek CD, Alsem MW. Designing eHealth interventions for children with complex care needs requires continuous stakeholder collaboration and co-creation. PEC INNOVATION 2024; 4:100280. [PMID: 38596601 PMCID: PMC11002852 DOI: 10.1016/j.pecinn.2024.100280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 04/11/2024]
Abstract
Objective Hospital-to-home (H2H) transitions challenge families of children with medical complexity (CMC) and healthcare professionals (HCP). This study aimed to gain deeper insights into the H2H transition process and to work towards eHealth interventions for its improvement, by applying an iterative methodology involving both CMC families and HCP as end-users. Methods For 20-weeks, the Dutch Transitional Care Unit consortium collaborated with the Amsterdam University of Applied Sciences, HCP, and CMC families. The agile SCREAM approach was used, merging Design Thinking methods into five iterative sprints to stimulate creativity, ideation, and design. Continuous communication allowed rapid adaptation to new information and the refinement of solutions for subsequent sprints. Results This iterative process revealed three domains of care - care coordination, social wellbeing, and emotional support - that were important to all stakeholders. These domains informed the development of our final prototype, 'Our Care Team', an application tailored to meet the H2H transition needs for CMC families and HCP. Conclusion Complex processes like the H2H transition for CMC families require adaptive interventions that empower all stakeholders in their respective roles, to promote transitional care that is anticipatory, rather than reactive. Innovation A collaborative methodology is needed, that optimizes existing resources and knowledge, fosters innovation through collaboration while using creative digital design principles. This way, we might be able to design eHealth solutions with end-users, not just for them.
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Affiliation(s)
- Liz van de Riet
- Amsterdam UMC, University of Amsterdam, Department of Pediatric Intensive Care, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, the Netherlands
- On behalf of the Transitional Care Unit Consortium, the Netherlands
| | - Anna M. Aris
- University of Applied Sciences, Digital Society School, Theo Thijssen Huis, Wibautstraat 2, 1091 GM Amsterdam, the Netherlands
- Athena Institute, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, the Netherlands
| | - Nick W. Verouden
- University of Applied Sciences, Digital Society School, Theo Thijssen Huis, Wibautstraat 2, 1091 GM Amsterdam, the Netherlands
| | - Tibor van Rooij
- Department of Computer Science, University of British Columbia, BC Children's Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada
| | - Job B.M. van Woensel
- Amsterdam UMC, University of Amsterdam, Department of Pediatric Intensive Care, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
- On behalf of the Transitional Care Unit Consortium, the Netherlands
| | - Clara D. van Karnebeek
- On behalf of the Transitional Care Unit Consortium, the Netherlands
- Amsterdam UMC, University of Amsterdam, Emma Center for Personalized Medicine, Departments of Pediatrics and Human Genetics, Amsterdam Gastro-Enterology Endocrinology and Metabolism, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Mattijs W. Alsem
- On behalf of the Transitional Care Unit Consortium, the Netherlands
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation, Amsterdam Movement Sciences, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
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Dewan T, Mackay L, Asaad L, Buchanan F, Hayden KA, Montgomery L. Experiences of Inpatient Healthcare Services Among Children With Medical Complexity and Their Families: A Scoping Review. Health Expect 2024; 27:e14178. [PMID: 39229799 PMCID: PMC11372467 DOI: 10.1111/hex.14178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 07/24/2024] [Accepted: 07/25/2024] [Indexed: 09/05/2024] Open
Abstract
BACKGROUND Children with medical complexity (CMC) have high healthcare utilization and face unique challenges during hospital admissions. The evidence describing their experiences of inpatient care is distributed across disciplines. The aim of this scoping review was to map the evidence related to the inpatient experience of care for CMC and their families, particularly related to key aspects and methodological approaches, and identify gaps that warrant further study. METHODS This scoping review was conducted in accordance with JBI methodology and included all studies that reported experiences of acute hospital care for CMC/families. All study designs were included. Databases searched included EMBASE, CINAHL Plus with Full Text, Web of Science, MEDLINE(R) and APA PsycInfo from 2000 to 2022. Details about the participants, concepts, study methods and key findings were abstracted using a data abstraction tool. A thematic analysis was conducted. RESULTS Forty-nine papers were included: 27 qualitative studies, 10 quantitative studies, six mixed methods studies, two descriptive studies and four reviews. Some quantitative studies used validated instruments to measure experience of care, but many used non-validated surveys. There were a few interventional studies with a small sample size. Results of thematic analysis described the importance of negotiating care roles, shared decision-making, common goal setting, relationship-building, communication, sharing expertise and the hospital setting itself. CONCLUSION CMC and families value relational elements of care and partnering through sharing expertise, decision-making and collaborative goal-setting when admitted to hospital. PATIENT OR PUBLIC CONTRIBUTION This review was conducted in alignment with the principles of patient and family engagement. The review was conceptualized, co-designed and conducted with the full engagement of the project's parent-partner. This team member was involved in all stages from constructing the review question, to developing the protocol, screening articles and drafting this manuscript.
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Affiliation(s)
- Tammie Dewan
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Lyndsay Mackay
- College of Nursing, Trinity Western University, Langley, British Columbia, Canada
| | - Lauren Asaad
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Francine Buchanan
- Patient, Family and Community Engagement, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - K Alix Hayden
- Library and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
| | - Lara Montgomery
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
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Romano CJ, Burrell M, Bukowinski AT, Hall C, Gumbs GR, Conlin AMS, Ramchandar N. Vaccine Completion and Timeliness Among Children in the Military Health System: 2010-2019. Pediatrics 2024:e2023064965. [PMID: 39295511 DOI: 10.1542/peds.2023-064965] [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] [Received: 11/10/2023] [Revised: 06/26/2024] [Accepted: 06/28/2024] [Indexed: 09/21/2024] Open
Abstract
OBJECTIVE Few studies have evaluated pediatric vaccination coverage in the Military Health System, although some evidence suggests lower than ideal coverage. This study assessed vaccine completion and timeliness among military dependents through age 24 months. METHODS Children born at military hospitals from 2010 through 2019 were identified using Department of Defense Birth and Infant Health Research program data. Vaccine completion and timeliness were assessed for diphtheria, tetanus, and pertussis; polio; measles, mumps, and rubella; hepatitis B; Haemophilus influenzae type b; varicella; and pneumococcal conjugate individually and as a combined 7-vaccine series; rotavirus was assessed separately. Modified Poisson regression models were used to calculate risk ratios (RRs) and 95% confidence intervals (CIs) for noncompletion and delays, adjusting for demographic characteristics. RESULTS Of 275 967 children, 74.4% completed the combined 7-vaccine series, and 36.2% of those who completed the series had delays. Completion peaked at 78.7% among children born in 2016 and 2017. Among all vaccines, completion was lowest for rotavirus (77.5%), diphtheria, tetanus, and pertussis (83.1%), Haemophilus influenzae type b (86.6%), and pneumococcal conjugate (88.4%). Risk for noncompletion was higher among children born to younger pregnant parents (adjusted RR = 1.33; 95% CI = 1.27-1.40) and with a well-child care location change (adjusted RR = 1.10; 95% CI = 1.09-1.12). Risk for delays paralleled that for noncompletion. CONCLUSIONS Vaccine completion and timeliness generally improved among military children, but greater noncompletion of vaccine series with more versus fewer doses and disparities for younger and mobile service members suggest system barriers remain.
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Affiliation(s)
- Celeste J Romano
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, Inc., San Diego, California
| | - Monica Burrell
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, Inc., San Diego, California
| | - Anna T Bukowinski
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, Inc., San Diego, California
| | - Clinton Hall
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, Inc., San Diego, California
| | - Gia R Gumbs
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, Inc., San Diego, California
| | - Ava Marie S Conlin
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
| | - Nanda Ramchandar
- Department of Pediatrics, Naval Medical Center San Diego, San Diego, California
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Werner NE, Morgen M, Kooiman S, Jolliff A, Warner G, Feinstein J, Chui M, Katz B, Storhoff B, Sodergren K, Coller R. Effectiveness of a Mobile App (Meds@HOME) to Improve Medication Safety for Children With Medical Complexity: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2024; 13:e60621. [PMID: 39250787 PMCID: PMC11420605 DOI: 10.2196/60621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 07/15/2024] [Accepted: 07/16/2024] [Indexed: 09/11/2024] Open
Abstract
BACKGROUND This study will pilot-test the mobile app, Medication Safety @HOME-Meds@HOME intervention to improve medication administration accuracy, reduce preventable adverse drug events, and ultimately improve chronic care management for children with medical complexity (CMC). The Meds@HOME app was co-designed with CMC families, secondary caregivers (SCGs), and health professionals to support medication management for primary caregivers (PCGs) and SCGs of CMC. We hypothesize that Meds@HOME will improve caregivers' medication administration accuracy, reduce preventable adverse drug events, and ultimately improve chronic care management. OBJECTIVE This study aims to evaluate the effectiveness of Meds@HOME on medication administration accuracy for PCGs and SCGs. METHODS This study will recruit up to 152 PCGs and 304 SCGs of CMC who are prescribed at least 1 scheduled high-risk medication and receive care at the University of Wisconsin American Family Children's Hospital. PCGs will be randomly assigned, for the 6-month trial, to either the control group (not trialing Meds@HOME) or the intervention group (trialing Meds@HOME) using 1:1 ratio. The Meds@HOME app allows caregivers to create a child profile, store medication and care instructions, and receive reminders for upcoming and overdue care routines and medication refills. Surveys completed both at the start and end of the trial measure demographics, medication delivery knowledge, confidence in the CMC's caregiving network, and comfort with medical information. Univariate and multivariate generalized estimation equations will be used for primary statistical analysis. The primary outcome is the PCG's rate of medication administration accuracy measured as correct identification of each of the following for a randomly selected high-risk medication: indication, formulation, dose, frequency, and route at baseline and after 6 months. Secondary outcomes include SCG medication administration accuracy (indication, formulation, dose, frequency, and route), count of University of Wisconsin hospital and emergency department encounters, PCG-reported medication adherence, count of deaths, and PCG medication confidence and understanding. RESULTS Recruitment for this study began on November 29, 2023. As of May 15, 2024, we have enrolled 94/152 (62%) PCGs. We expect recruitment to end by August 1, 2024, and the final participant will complete the study by January 28, 2025, at which point we will start analyzing the complete responses. We expect publication of results at the end of 2025. CONCLUSIONS The Meds@HOME mobile app provides a promising strategy for improving PCG medication safety for CMC who take high-risk medications. In addition, this protocol highlights novel procedures for recruiting SCGs of CMC. In the future, this app could be used more broadly across diverse caregiving networks to navigate complex medication routines and promote medication safety. TRIAL REGISTRATION ClinicalTrials.gov NCT05816590; https://clinicaltrials.gov/study/NCT05816590. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/60621.
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Affiliation(s)
- Nicole E Werner
- Indiana University School of Public Health-Bloomington, Bloomington, IN, United States
| | - Makenzie Morgen
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, United States
| | - Sophie Kooiman
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, United States
| | - Anna Jolliff
- Indiana University School of Public Health-Bloomington, Bloomington, IN, United States
| | - Gemma Warner
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, United States
| | - James Feinstein
- University of Colorado School of Medicine, Aurora, CO, United States
| | - Michelle Chui
- University of Wisconsin-Madison School of Pharmacy, Madison, WI, United States
| | - Barbara Katz
- Family Voices of Wisconsin, Madison, WI, United States
| | - Brittany Storhoff
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, United States
| | - Kristan Sodergren
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, United States
| | - Ryan Coller
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, United States
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Leyenaar JK, Freyleue SD, Arakelyan M, Schaefer AP, Moen EL, Austin AM, Goodman DC, O'Malley AJ. Rural-Urban Disparities in Hospital Services and Outcomes for Children With Medical Complexity. JAMA Netw Open 2024; 7:e2435187. [PMID: 39316395 PMCID: PMC11423179 DOI: 10.1001/jamanetworkopen.2024.35187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/25/2024] Open
Abstract
Importance Limited availability of inpatient pediatric services in rural regions has raised concerns about access, safety, and quality of hospital-based care for children. This may be particularly important for children with medical complexity (CMC). Objectives To describe differences in the availability of pediatric services at acute care hospitals where rural- and urban-residing CMC presented for hospitalization; identify rural-urban disparities in health care quality and in-hospital mortality; and determine whether the availability of pediatric services at index hospitals or the experience of interfacility transfer modified rural-urban differences in outcomes. Design, Setting, and Participants This retrospective cohort study examined all-payer claims data from Colorado, Massachusetts, and New Hampshire from 2012 to 2017. Analysis was conducted from May 2023 to July 2024. Participants included CMC younger than 18 years residing in these states and hospitalized during the study period. Exposures Rural or urban residence was determined using Rural-Urban Commuting Area codes. Hospitals were categorized as children's hospitals or general hospitals with comprehensive, limited, or no dedicated pediatric services using American Hospital Association survey data. Interfacility transfers between index and definitive care hospitals were identified using health care claims. Main Outcomes and Measures In-hospital mortality, all-cause 30-day readmission, medical-surgical safety events, and surgical safety events were operationalized using Agency for Healthcare Research and Quality measure specifications. Results Among 36 943 CMC who experienced 79 906 hospitalizations, 16 525 (44.7%) were female, 26 034 (70.5%) were Medicaid-insured, and 34 008 (92.1%) were urban-residing. Rural-residing CMC were 6.55 times more likely to present to hospitals without dedicated pediatric services (rate ratio [RR], 6.55 [95% CI, 5.86-7.33]) and 2.03 times more likely to present to hospitals without pediatric beds (RR, 2.03 [95% CI, 1.88-2.21]) than urban-residing CMC, with no significant differences in interfacility transfer rates. In unadjusted analysis, rural-residing CMC had a 44% increased risk of in-hospital mortality (RR, 1.44 [95% CI, 1.03-2.02]) with no significant differences in other outcomes. Adjusting for clinical characteristics, the difference in in-hospital mortality was no longer significant. Index hospital type was not a significant modifier of observed rural-urban outcomes, but interfacility transfer was a significant modifier of rural-urban differences in surgical safety events. Conclusions and Relevance In this cohort study, rural-residing CMC were significantly more likely to present to hospitals without dedicated pediatric services. These findings suggest that efforts are justified to ensure that all hospital types are prepared to care for CMC.
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Affiliation(s)
- JoAnna K Leyenaar
- Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Seneca D Freyleue
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Mary Arakelyan
- Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Andrew P Schaefer
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Erika L Moen
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Andrea M Austin
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - David C Goodman
- Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - A James O'Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
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Johansen S, Andersen GL, Lydersen S, Kalleson R, Hollung SJ. Use of primary health care services among children and adolescents with cerebral palsy. Dev Med Child Neurol 2024; 66:1234-1243. [PMID: 38321621 DOI: 10.1111/dmcn.15879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 01/09/2024] [Accepted: 01/16/2024] [Indexed: 02/08/2024]
Abstract
AIM To investigate the use of general practitioners and urgent care centres (UCC) among children and adolescents with cerebral palsy (CP) compared to a control group, and per gross motor function level. METHOD Data on children with CP born 1996 to 2014 were collected from the Norwegian Quality and Surveillance Registry for Cerebral Palsy. A control group was extracted from Statistics Norway. The date and diagnosis codes for general practitioner and UCC contacts from 2006 to 2015 were collected from the Norwegian Control and Payment of Health Reimbursement Database. Incidence rate ratios (IRR) for the number of contacts per person-year with 95% confidence intervals (CI) were calculated using Poisson regression. Risk differences with 95% CI were used to compare cumulative diagnosis incidences between children with CP and the control group. RESULTS The study included 2510 children (1457 males; 58.1%) with CP and 12 041 (7003 males; 58.2%) without CP (mean age in both groups 7 years 2 months, SD 4 years 8 months, range 0-19 years), with 336 250 contacts. Children with CP had more general practitioner (IRR 1.47; 95% CI 1.29-1.67) and UCC (IRR 1.30; 95% CI 1.13-1.50) contacts than children without CP, for all ages. IRRs remained unchanged when comparing children with CP in Gross Motor Function Classification System (GMFCS) levels I and II to children without CP. Among children with CP, contact increased as GMFCS levels increased, and they were in contact most often for respiratory and general and unspecified diagnoses. The risk for epilepsy was highest for those in contact with general practitioners. INTERPRETATION Children with CP, including those with less severe motor impairments, contacted general practitioners and UCCs more than children without CP. However, contact increased as gross motor impairment increased. They had contact for many diagnoses, mostly respiratory.
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Affiliation(s)
- Stine Johansen
- Habilitation Centre, Vestfold Hospital Trust, Tønsberg, Norway
| | - Guro L Andersen
- Habilitation Centre, Vestfold Hospital Trust, Tønsberg, Norway
- Norwegian Quality and Surveillance Registry for Cerebral Palsy, Vestfold Hospital Trust, Tønsberg, Norway
| | - Stian Lydersen
- Regional Centre for Child and Youth Mental Health and Child Welfare, Norwegian University of Science and Technology, Trondheim, Norway
| | - Runa Kalleson
- Department of Rehabilitation Science and Health Technology, Oslo Metropolitan University, Oslo, Norway
| | - Sandra Julsen Hollung
- Norwegian Quality and Surveillance Registry for Cerebral Palsy, Vestfold Hospital Trust, Tønsberg, Norway
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Finlay M, Chakravarti V, Buchanan F, Dewan T, Adams S, Mahant S, Nicholas D, Widger K, McGuire KM, Nelson KE. Learning to Trust Yourself: Decision-Making Skills Among Parents of Children With Medical Complexity. J Pain Symptom Manage 2024; 68:237-245.e5. [PMID: 38810951 DOI: 10.1016/j.jpainsymman.2024.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 05/16/2024] [Accepted: 05/20/2024] [Indexed: 05/31/2024]
Abstract
CONTEXT Children with medical complexity have substantial medical needs and their caregivers must make many challenging decisions about their care. Caregivers often become more involved in decisions over time, but it is unclear what skills they develop that facilitate this engagement. OBJECTIVES To describe the skills that caregivers developed as they gained experience making medical decisions. METHODS Eligible caregivers had a child who met referral criteria for their centre's Complex Care program for >1 year, were adults responsible for their child's medical decisions, and spoke English or a language with an available interpreter. We followed a semistructured interview guide to ask caregivers to describe and reflect on two challenging medical decisions that they made for their child-one early and one recent. Guided by interpretive description, we identified and refined themes in an iterative process. RESULTS We conducted 15 interviews with 16 parents (14 [88%] women, two [13%] men) of a child with medical complexity (aged 1-17 years). Parents described 1) becoming more adept at managing decisional information, 2) recognizing the influence of the decision's context, 3) building stronger relationships with providers, and 4) becoming more effective at guiding their child's care as a decision-maker. As parents built these skills, they developed a greater sense of agency and confidence as decision-makers. CONCLUSION Parents of children with medical complexity change how they approach decision making over time as they acquire relevant skills. These findings can inform the development of interventions to support skill-building among new caregivers.
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Affiliation(s)
- Melissa Finlay
- Child Health Evaluative Sciences (M.F., F.B., S.A., S.M., K.E.N.), SickKids Research Institute, Toronto, Ontario, Canada
| | | | - Francine Buchanan
- Child Health Evaluative Sciences (M.F., F.B., S.A., S.M., K.E.N.), SickKids Research Institute, Toronto, Ontario, Canada
| | - Tammie Dewan
- Alberta Children's Hospital Research Institute (T.D.), Calgary, Alberta, Canada; Department of Pediatrics (T.D.), University of Calgary, Calgary, Alberta, Canada
| | - Sherri Adams
- Child Health Evaluative Sciences (M.F., F.B., S.A., S.M., K.E.N.), SickKids Research Institute, Toronto, Ontario, Canada; Lawrence S. Bloomberg Faculty of Nursing (S.A., K.W.), University of Toronto, Toronto, Ontario, Canada; Department of Paediatrics (S.A., S.M., K.E.N.), Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sanjay Mahant
- Child Health Evaluative Sciences (M.F., F.B., S.A., S.M., K.E.N.), SickKids Research Institute, Toronto, Ontario, Canada; Department of Paediatrics (S.A., S.M., K.E.N.), Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (S.M., K.W., K.E.N.), Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation (S.M., K.E.N.), Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; CanChild Centre for Childhood Disability Research (S.M.), McMaster University, Hamilton, Ontario, Canada
| | - David Nicholas
- Faculty of Social Work (D.N.), University of Calgary, Edmonton, Alberta, Canada
| | - Kimberley Widger
- Lawrence S. Bloomberg Faculty of Nursing (S.A., K.W.), University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (S.M., K.W., K.E.N.), Toronto, Ontario, Canada; Pediatric Advanced Care Team (K.W., K.E.N.), Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kristina Mangonon McGuire
- Patient Research Partner (K.M.), Patient and Community Engagement Research, Calgary, Alberta, Canada
| | - Katherine E Nelson
- Child Health Evaluative Sciences (M.F., F.B., S.A., S.M., K.E.N.), SickKids Research Institute, Toronto, Ontario, Canada; Department of Paediatrics (S.A., S.M., K.E.N.), Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (S.M., K.W., K.E.N.), Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation (S.M., K.E.N.), Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Pediatric Advanced Care Team (K.W., K.E.N.), Hospital for Sick Children, Toronto, Ontario, Canada.
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8
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Moore C, Adams S, Beatty M, Dharmaraj B, Desai AD, Bartlett L, Culbert E, Cohen E, Stinson JN, Orkin J. Caregiver and Care Team Perceptions of Online Collaborative Care Planning for CMC. Pediatrics 2024; 154:e2024065884. [PMID: 39188252 DOI: 10.1542/peds.2024-065884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 06/10/2024] [Accepted: 06/12/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Care plans summarize a child with medical complexity's (CMC) medical history and ongoing care needs. Often, the health care team controls the care plan content, limiting caregivers' ability to edit the document in real time and potentially compromising accuracy and utility. With this study, we aimed to provide caregivers of CMC with online access and shared editing control of their child's care plan and to explore the experiences of caregivers and care team members (CTMs) after using an online collaborative care plan (OCCP). METHODS Caregivers of CMC were recruited from a tertiary complex care program to use an online, patient-facing platform for 6 months, which included the ability to edit and share their child's care plan. Caregivers and CTMs participated in semi-structured interviews to explore their experiences in using the OCCP. Consistent with grounded theory methodology, a constant comparative analysis was used, which allowed for theoretical sampling and theory generation. RESULTS A total of 15 caregivers and 20 CTMs completed interviews. Interviews revealed 3 major themes and 9 subthemes, including (1) the navigation of uncharted roles (trust, responsibility), (2) the requirements for success (electronic medical record integration, online access, collaborative care plan review), and (3) cohesive care (accessibility and convenience, being on the same page, autonomy). Themes informed the creation of a theoretical model for the implementation and utility of OCCPs. CONCLUSIONS Online, collaborative care plans, when implemented safely and thoughtfully, promote shared understanding, improve caregiver autonomy, and increase the accessibility of health information. Together, these benefits facilitate cohesive care and authentic partnership between caregivers and CTMs in the care of CMC.
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Affiliation(s)
| | - Sherri Adams
- SickKids Research Institute
- Division of Pediatric Medicine
- Lawrence S Bloomberg Faculty of Nursing
| | - Madison Beatty
- SickKids Research Institute
- Division of Pediatric Medicine
| | | | - Arti D Desai
- University of Washington School of Medicine, Seattle, Washington
| | - Leah Bartlett
- Royal Victoria Regional Health Centre, Barrie, Canada
| | | | - Eyal Cohen
- SickKids Research Institute
- Division of Pediatric Medicine
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Jennifer N Stinson
- SickKids Research Institute
- Department of Anesthesia and Pain Medicine, SickKids, Toronto, Canada
- Lawrence S Bloomberg Faculty of Nursing
| | - Julia Orkin
- SickKids Research Institute
- Division of Pediatric Medicine
- Department of Pediatrics, University of Toronto, Toronto, Canada
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9
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Esser K, Adams S, Chung C, McKay T, Moore C, Wagman H, Lee S, Orkin J. A quality improvement evaluation of a standardized intervention for children with medical complexity transitioning to adult care. Paediatr Child Health 2024; 29:274-279. [PMID: 39281362 PMCID: PMC11398935 DOI: 10.1093/pch/pxae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 06/12/2024] [Indexed: 09/18/2024] Open
Abstract
Children with medical complexity have medical fragility, chronic disease, technology dependence, and high healthcare use. Their transition to adult health care at age 18 involves medical and social elements and follows no standardized process. Our goal was to improve transition readiness in children with medical complexity using a transition intervention within a Complex Care program. All children with medical complexity aged 14 to 18 were included in this quality improvement (QI) project (n = 54). We conducted a pre- and post-intervention chart review to assess transition outcomes and implemented a transition intervention for 6 months, which included an age-stratified checklist, charting template, and transition rounds. Before the intervention, 72% of 17- to 18-year-old patients had documented transition discussions, which increased to 86%. Patients with a family physician increased as well (61% to 73% for 17- to 18-year-olds). Three transition education rounds were held. The intervention increased transition readiness, provided tools to facilitate transition, and created a forum for conversation.
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Affiliation(s)
- Kayla Esser
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Sherri Adams
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Canada
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Christopher Chung
- Division of Neonatology and Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Taylor McKay
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Clara Moore
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Hayley Wagman
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Stephanie Lee
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Julia Orkin
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
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Ozcan G, Zirek F, Tekin MN, Bayav S, Bakirarar B, Duman B, Cobanoglu N. Psychosocial factors affecting the quality of life of parents who have children with home mechanical ventilation. Pediatr Pulmonol 2024; 59:2153-2162. [PMID: 38088218 DOI: 10.1002/ppul.26799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 11/02/2023] [Accepted: 11/10/2023] [Indexed: 07/27/2024]
Abstract
INTRODUCTION Most children with medical complexity have to live with home mechanical ventilation (HMV). Undertaking the care of a child with HMV creates a psychosocial burden on parents. This study investigated the impact of selected potential determinants on the quality of life of parents who have children with HMV. METHODS A cross-sectional survey study was conducted using a structured questionnaire to determine the sociodemographic characteristics of the parents. The World Health Organization Quality of Life Assessment-Brief version, the Beck Depression Inventory (BDI), and the Multidimensional Scale of Perceived Social Support were applied. RESULTS A total of 35 participants responded to the questionnaires. Paired data from mothers and fathers were obtained from 12 families. A moderately significant positive correlation was found between the perceived social support levels of the parents and all domains of the quality of life scale (for the physical domain: r = .455, p = .006; for the psychological domain: r = .549, p = .001; for the social domain: r = .726, p = .000; and for the environment domain: r = .442, p = .008). A moderate negative relationship was found between parents' perceived social support levels and BDI scores (r = -.557, p = .001). The multivariate regression analysis determined that being a mother, quitting a job to become a caregiver, being the only caregiver at home, and having a neurological/neuromuscular disease as the primary disease of the child were associated with lower scores in more than one quality of life domain. CONCLUSION Our results emphasize that appropriate social support is important for improving the quality of life scores of parents of children with HMV.
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Affiliation(s)
- Gizem Ozcan
- Division of Pediatric Pulmonology, Department of Pediatrics, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Fazilcan Zirek
- Division of Pediatric Pulmonology, Department of Pediatrics, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Merve Nur Tekin
- Division of Pediatric Pulmonology, Department of Pediatrics, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Secahattin Bayav
- Division of Pediatric Pulmonology, Department of Pediatrics, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Batuhan Bakirarar
- Department of Biostatistics, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Berker Duman
- Division of Consultation-Liaison Psychiatry, Department of Psychiatry, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Nazan Cobanoglu
- Division of Pediatric Pulmonology, Department of Pediatrics, Faculty of Medicine, Ankara University, Ankara, Turkey
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Thibault LP, Bourque CJ, Gaucher N, Marano M, Couture K, Saad L, Chartrand C, Frégeau S, Doré-Bergeron MJ, Fiscaletti M, Kleiber N. Drivers that decrease hospital-delivered care in children with medical complexity: Parental perspectives. Paediatr Child Health 2024; 29:286-291. [PMID: 39281360 PMCID: PMC11398940 DOI: 10.1093/pch/pxad051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/26/2023] [Indexed: 09/18/2024] Open
Abstract
Background and objective Children with medical complexity (CMC) have chronic and severe conditions leading to medical fragility. CMC represent less than 1% of children but account for one-third of paediatric healthcare expenditures. Enrollment to a complex care program (CCP) decreases health care resource utilization while improving parental satisfaction. An in-depth understanding of how these changes operate in real-world setting is needed to further support CMC and their families. This study aimed at assessing the possible reasons for a decrease in emergency department (ED) visits and hospitalization length of stay related to enrollment to a CCP, based on parental perspectives. Study design Using a qualitative approach, data were collected using in-depth, semi-structured interviews with parents of CMC enrolled in a CCP from a university hospital centre in Montreal, Canada. The interview guide was co-constructed by an interdisciplinary team, including a parent partner and a clinical nurse coordinator. Themes have been identified inductively, using thematic analysis. Results Parents identified personalized care, family empowerment and guidance as enablers arising from the CCP that contributed to the decrease in hospital-delivered care utilization. Improvement in medical baseline condition was also identified as a contributing factor, while not necessarily related to program's support. Conclusions In this study, we identified personalized care, parental empowerment, and guidance as three strategies for a CCP to potentially decrease ED visits and hospital length of stay, from the parents' perspective. Parents identified the clinical nurse coordinator as playing a central role in supporting the implementation of these strategies.
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Affiliation(s)
- Louis-Philippe Thibault
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Canada
- CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
- Centre for Applied Health Sciences Education, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Claude Julie Bourque
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Canada
- Clinical Ethics Unit, CHU Sainte-Justine, Université de Montréal, Montreal, Canada
- CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
- Centre for Applied Health Sciences Education, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Nathalie Gaucher
- Department of Pediatric Emergency Medicine, CHU Sainte-Justine, Université de Montréal, Montreal, Canada
- Clinical Ethics Unit, CHU Sainte-Justine, Université de Montréal, Montreal, Canada
- CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Maria Marano
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Canada
| | - Karine Couture
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Canada
| | - Lydia Saad
- Department of Pediatrics, Université Laval, Quebec, Canada
| | - Caroline Chartrand
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Canada
| | - Sandra Frégeau
- Parent partner, CHU Sainte-Justine, Université de Montréal, Montreal, Canada
| | | | - Melissa Fiscaletti
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Canada
- CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Niina Kleiber
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Canada
- CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
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12
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McLeigh JD, Singh G, Huang R. The Impact of Health Status on Health Care Utilization of Children in Foster Care. J Dev Behav Pediatr 2024:00004703-990000000-00194. [PMID: 39023862 DOI: 10.1097/dbp.0000000000001302] [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] [Received: 02/12/2024] [Accepted: 05/24/2024] [Indexed: 07/20/2024]
Abstract
OBJECTIVES This study sought to understand the health status of children in foster care; the relationship between their health status and health care utilization; and demographic and placement factors associated with health care utilization. METHODS To estimate relationships between health status and health care utilization, this study used electronic health records from 4976 children in foster care seen at a children's hospital in the southwestern United States, 2017 to 2020. An algorithm classified patients' health status as nonchronic, noncomplex chronic, or complex chronic. Descriptive statistics were used to describe patients and utilization. The χ2, Kruskal-Wallis, and pairwise comparison post hoc tests were used to examine relationships between health status and health care utilization. Zero-inflated negative binomial (ZINB) regression further estimated relationships between health status and health care utilization while factoring in demographic and placement characteristics. RESULTS Within the sample, 35.6% had complex chronic health status. Significant differences were found among health status groups in age, gender, ethnicity, and maltreatment exposure. Both nonparametric pairwise comparisons and the ZINB regression model showed that having complex chronic health was associated with higher utilization of all hospital resources: emergency, admission, primary and specialty care, and various therapies, relative to having noncomplex chronic and nonchronic health. CONCLUSION A high percentage of children in foster care had complex chronic health, and these patients used significantly more resources. This study suggests that hospital-based health clinics focused on children in foster care and care coordination may be warranted.
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Affiliation(s)
- Jill D McLeigh
- Rees-Jones Center for Foster Care Excellence, Children's Health, Dallas, TX
| | - Gunjan Singh
- Rees-Jones Center for Foster Care Excellence, Children's Health, Dallas, TX
- Division of Developmental Behavioral Pediatrics, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX; and
| | - Rong Huang
- Research Administration, Children's Health, Dallas, TX
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13
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Belza C, Szentkúti P, Horváth-Puhó E, Ray JG, Nelson KE, Grandi SM, Brown HK, Sørensen HT, Cohen E. Use of Latent Class Analysis to Predict Intensive Care Unit Admission and Mortality in Children with a Major Congenital Anomaly. J Pediatr 2024; 270:114013. [PMID: 38494089 DOI: 10.1016/j.jpeds.2024.114013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/08/2024] [Accepted: 03/12/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVE To define major congenital anomaly (CA) subgroups and assess outcome variability based on defined subgroups. STUDY DESIGN This population-based cohort study used registries in Denmark for children born with a major CA between January 1997 and December 2016, with follow-up until December 2018. We performed a latent class analysis (LCA) using child and family clinical and sociodemographic characteristics present at birth, incorporating additional variables occurring until age of 24 months. Cox proportional hazards regression models estimated hazard ratios (HRs) of pediatric mortality and intensive care unit (ICU) admissions for identified LCA classes. RESULTS The study included 27 192 children born with a major CA. Twelve variables led to a 4-class solution (entropy = 0.74): (1) children born with higher income and fewer comorbidities (55.4%), (2) children born to young mothers with lower income (24.8%), (3) children born prematurely (10.0%), and (4) children with multiorgan involvement and developmental disability (9.8%). Compared with those in Class 1, mortality and ICU admissions were highest in Class 4 (HR = 8.9, 95% CI = 6.4-12.6 and HR = 4.1, 95% CI = 3.6-4.7, respectively). More modest increases were observed among the other classes for mortality and ICU admissions (Class 2: HR = 1.7, 95% CI = 1.1-2.5 and HR = 1.3, 95% CI = 1.1-1.4, respectively; Class 3: HR = 2.5, 95% CI = 1.5-4.2 and HR = 1.5, 95% CI = 1.3-1.9, respectively). CONCLUSIONS Children with a major CA can be categorized into meaningful subgroups with good discriminative ability. These groupings may be useful for risk-stratification in outcome studies.
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Affiliation(s)
- Christina Belza
- Edwin S.H. Leong Centre for Health Children, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Péter Szentkúti
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Erzsébet Horváth-Puhó
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Joel G Ray
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Katherine E Nelson
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sonia M Grandi
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Hilary K Brown
- Department of Health & Society, University of Toronto Scarborough, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark; Clinical Excellence Research Center, Stanford University, Stanford, CA
| | - Eyal Cohen
- Edwin S.H. Leong Centre for Health Children, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada.
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14
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Starnes LS, Hall M, Williams DJ, Katz S, Clayton DB, Antoon JW, Bell D, Carroll AR, Gastineau KAB, Wolf R, Ngo ML, Herndon A, Brown CM, Freundlich K. Intravenous antibiotics for urinary tract infections in children with neurologic impairment. J Hosp Med 2024; 19:572-580. [PMID: 38558453 PMCID: PMC11222036 DOI: 10.1002/jhm.13349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/08/2024] [Accepted: 03/17/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Children with high-intensity neurologic impairment (HINI) have an increased risk of urinary tract infection (UTI) and prolonged intravenous (IV) antibiotic exposure. OBJECTIVE To determine the association between short (≤3 days) and long (>3 days) IV antibiotic courses and UTI treatment failure in hospitalized children with HINI. METHODS We performed a retrospective cohort study examining UTI hospitalizations at 49 hospitals in the Pediatric Health Information System from 2016 to 2021 for children (1-18 years) with HINI. The primary outcome was UTI readmission within 30 days. Our secondary outcome was the association of hospital-level variation in short IV antibiotic course use with readmission. Readmission rates were compared between short and long courses using multivariable regression. RESULTS Of 5612 hospitalizations, 3840 (68.4%) had short IV antibiotic courses. In our adjusted model, children with short IV courses were less likely than with long courses to have a 30-day UTI readmission (4.0%, 95% CI [3.6%, 4.5%] vs. 6.3%, 95% CI [5.1%, 7.8%]). Despite marked hospital-level variation in short IV course use (50.0%-87.5% of hospitalizations), there was no correlation with readmissions. CONCLUSIONS Children with HINI hospitalized with UTI had low UTI readmission rates, but those who received long IV antibiotic courses were more likely to experience UTI readmission versus those receiving short courses. While residual confounding may influence our results, we did not find that short IV courses impacted readmission at the hospital level despite variation in use across institutions. Long IV antibiotic courses are associated with risks and may not confer benefit in this population.
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Affiliation(s)
- Lauren S. Starnes
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas, USA
| | - Derek J. Williams
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sophie Katz
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Douglass B. Clayton
- Division of Pediatric Urology, Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James W. Antoon
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Deanna Bell
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alison R. Carroll
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelsey A. B. Gastineau
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ryan Wolf
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - My-Linh Ngo
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alison Herndon
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Charlotte M. Brown
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Katherine Freundlich
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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15
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Belza C, Cohen E, Orkin J, Fayed N, Major N, Quartarone S, Moretti M. Out-of-pocket expenses reported by families of children with medical complexity. Paediatr Child Health 2024; 29:216-223. [PMID: 39045474 PMCID: PMC11261824 DOI: 10.1093/pch/pxad040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 06/19/2023] [Indexed: 07/25/2024] Open
Abstract
Objectives Due to their medical and technology dependence, families of children with medical complexity (CMC) have significant costs associated with care. Financial impact on families in general have been described, but detailed exploration of expenses in specific categories has not been systematically explored. Our objective was to describe out-of-pocket (OOP) expenses incurred by caregivers of CMC and to determine factors associated with increased expenditures. Methods This is a secondary observational analysis of data primary caregiver-reported OOP expenses as part of a randomized control trial conducted in Ontario, Canada. Caregivers completed questionnaires reporting OOP costs. Descriptive statistics were utilized to report OOP expenses and a linear regression model was conducted. Results 107 primary caregivers of CMC were included. The median (IQR) age of participants was 34.5 years (30.5 to 40.5) and 83.2% identified as the mother. The majority were married or common-law (86.9%) and 50.5% were employed. The participant's children [median (IQR) age 4.5 (2.2 to 9.7); 57.9% male] most commonly had a neurological/neuromuscular primary diagnosis (46.1%) and 88% utilized medical technology. Total OOP expenses were $8,639 CDN annually (IQR = $4,661 to $31,326) with substantial expenses related to childcare/homemaking, travel to appointments, hospitalizations, and device costs. No factors associated with greater likelihood of OOP expenses were identified. A P-value of <0.05 was considered significant. Conclusion Caregivers of CMC incur significant OOP expenses related to the care of their children resulting in financial burden. Future exploration of the financial impact on caregiver productivity, employment, and identification of resources to mitigate OOP expenses will be important for this patient population.
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Affiliation(s)
- Christina Belza
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Edwin S.H. Leong Centre for Healthy Children, Toronto, Ontario, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eyal Cohen
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Edwin S.H. Leong Centre for Healthy Children, Toronto, Ontario, Canada
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Julia Orkin
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Nora Fayed
- School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada
| | - Nathalie Major
- Division of Pediatric Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Samantha Quartarone
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Myla Moretti
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Ontario Child Health Support Unit, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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16
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Berkalieva A, Kelly NR, Fisher A, Hohmann SF, Abul-Husn NS, Greally JM, Horowitz CR, Wasserstein MP, Kenny EE, Gelb BD, Ferket BS. Physician and informal care use explained by the Pediatric Quality of Life Inventory (PedsQL) in children with suspected genetic disorders. Qual Life Res 2024; 33:1997-2009. [PMID: 38743313 DOI: 10.1007/s11136-024-03677-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2024] [Indexed: 05/16/2024]
Abstract
PURPOSE To examine associations between Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales and PedsQL Infant Scales with formal health care resource utilization (HCRU) and informal caregiver burden. METHODS We studied a pediatric cohort of 837 patients (median age: 8.4 years) with suspected genetic disorders enrolled January 2019 through July 2021 in the NYCKidSeq program for diagnostic sequencing. Using linked ~ nine-month longitudinal survey and physician claims data collected through May 2022, we modeled the association between baseline PedsQL scores and post-baseline HCRU (median follow-up: 21.1 months) and informal care. We also assessed the longitudinal change in PedsQL scores with physician services using linear mixed-effects models. RESULTS Lower PedsQL total and physical health scores were independently associated with increases in 18-month physician services, encounters, and weekly informal care. Comparing low vs. median total scores, increases were 10.6 services (95% CI: 1.0-24.6), 3.3 encounters (95% CI: 0.5-6.8), and $668 (95% CI: $350-965), respectively. For the psychosocial domain, higher scores were associated with decreased informal care. Based on adjusted linear mixed-effects modeling, every additional ten physician services was associated with diminished improvement in longitudinal PedsQL total score trajectories by 1.1 point (95% confidence interval: 0.6-1.6) on average. Similar trends were observed in the physical and psychosocial domains. CONCLUSION PedsQL scores were independently associated with higher utilization of physician services and informal care. Moreover, longitudinal trajectories of PedsQL scores became less favorable with increased physician services. Adding PedsQL survey instruments to conventional measures for improved risk stratification should be evaluated in further research.
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Affiliation(s)
- Asem Berkalieva
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, 10029-6574, USA
| | - Nicole R Kelly
- Division of Pediatric Genetic Medicine, Department of Pediatrics, Children's Hospital at Montefiore/Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ashley Fisher
- Center for Advanced Analytics, Vizient, Chicago, IL, USA
| | | | - Noura S Abul-Husn
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- 23andMe Inc, Sunnyvale, CA, USA
- Division for Genomic Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John M Greally
- Division of Genomics, Department of Genetics, Children's Hospital at Montefiore/Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Carol R Horowitz
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Melissa P Wasserstein
- Division of Pediatric Genetic Medicine, Department of Pediatrics, Children's Hospital at Montefiore/Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eimear E Kenny
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division for Genomic Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bruce D Gelb
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bart S Ferket
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, 10029-6574, USA.
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17
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Pai VV, Lu T, Gray EE, Davis A, Rogers EE, Jocson MAL, Hintz SR. Resource and Service Use after Discharge Among Infants 22-25 Weeks Estimated Gestational Age at the First High-Risk Infant Follow-Up Visit in California. J Pediatr 2024; 274:114172. [PMID: 38945445 DOI: 10.1016/j.jpeds.2024.114172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/15/2024] [Accepted: 06/24/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVE To examine resource and service use after discharge among infants born extraordinarily preterm in California who attended high-risk infant follow-up (HRIF) clinic by 12 months corrected age. STUDY DESIGN We included infants born 2010-2017 between 22 + 0/7 and 25 + 6/7 weeks' gestational age in the California Perinatal Quality Care Collaborative and California Perinatal Quality Care Collaborative-California Children's Services HRIF databases. We evaluated rates of hospitalization, surgeries, medications, equipment, medical service and special service use, and referrals. We examined factors associated with receiving ≥ 2 medical services, and ≥ 1 special service. RESULTS A total of 3941 of 5284 infants received a HRIF visit by 12 months corrected age. Infants born at earlier gestational ages used more medications, equipment, medical services, and special services and had higher rates of referral to medical and special services at the first HRIF visit. Infants with major morbidity, surgery, caregiver concerns, and mothers with more years of education had higher odds of receiving ≥ 2 medical services. Infants with Black maternal race, younger maternal age, female sex, and discharge from lower level neonatal intensive care units (NICUs) had lower odds of receiving ≥ 2 medical services. Infants with more educated mothers, multiple gestation, major morbidity, surgery, caregiver concerns, and discharge from lower level NICUs had increased odds of receiving a special service. CONCLUSIONS Infants born extraordinarily preterm have substantial resource use after discharge. High resource utilization was associated with maternal/sociodemographic factors and expected clinical factors. Early functional and service use information is valuable to parents and underscores the need for NICU providers to appropriately prepare and refer families.
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Affiliation(s)
- Vidya V Pai
- Division of Neonatology, UCSF Benioff Children's Hospital Oakland, Oakland, CA.
| | - Tianyao Lu
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford School of Medicine, Stanford, CA; California Perinatal Quality of Care Collaborative-California Children's Services High Risk Infant Follow-Up Quality of Care Initiative, Stanford, CA
| | - Erika E Gray
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford School of Medicine, Stanford, CA; California Perinatal Quality of Care Collaborative-California Children's Services High Risk Infant Follow-Up Quality of Care Initiative, Stanford, CA
| | - Alexis Davis
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford School of Medicine, Stanford, CA
| | - Elizabeth E Rogers
- Division of Neonatology, Department of Pediatrics, University of California, San Francisco, CA
| | - Maria A L Jocson
- California Children's Services, Integrated Systems of Care, Department of Health Care Services, Sacramento, CA
| | - Susan R Hintz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford School of Medicine, Stanford, CA; California Perinatal Quality of Care Collaborative-California Children's Services High Risk Infant Follow-Up Quality of Care Initiative, Stanford, CA
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Shinjo D, Yotani N, Ito A, Isayama T. Children with medical complexity receiving home healthcare devices in Japan: a retrospective cohort study. BMJ Paediatr Open 2024; 8:e002685. [PMID: 38942589 PMCID: PMC11227824 DOI: 10.1136/bmjpo-2024-002685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 06/13/2024] [Indexed: 06/30/2024] Open
Abstract
BACKGROUND Limited evidence exists regarding children receiving home healthcare devices (HHDs). This study aimed to describe the range and type of HHD use by children with chronic medical conditions in Japan and explore factors leading to increased use of these devices. METHODS This retrospective cohort study was conducted using data from the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Children receiving HHD aged ≤18 years between April 2011 and March 2019 were included. Children newly administered HHD between 2011 and 2013 were followed up for 5 years, and logistic regression analysis was performed to assess the relationship between increased HHD use and each selected risk factor (comorbidity or types of HHD). The models were adjusted for age category at home device introduction, sex and region. RESULTS Overall, 52 375 children receiving HHD were identified. The number (proportion) of children receiving HHD increased during the study period (11 556 [0.05%] in 2010 and 25 593 [0.13%] in 2018). The most commonly administered HHD was oxygen (51.0% in 2018). Among the 12 205 children receiving HHD followed up for 5 years, 70.4% and 68.3% who used oxygen or continuous positive airway pressure, respectively, were released from the devices, while only 25.8% who used mechanical ventilation were released from the device. The following diagnosis/comorbidities were associated with increased HHD use: other neurological diseases (OR): 2.85, 95% CI): 2.54-3.19), cerebral palsy (OR: 2.16, 95% CI: 1.87 to 2.49), congenital malformations of the nervous system (OR: 1.70, 95% CI: 1.34 to 2.13) and low birth weight (OR: 1.68, 95% CI: 1.41 to 2.00). CONCLUSIONS This study provides nationwide population-based empirical data to clarify the detailed information regarding children receiving HHD in Japan. This information could assist healthcare professionals in improving the quality of life of these children and their families and help health policymakers consider measures.
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Affiliation(s)
- Daisuke Shinjo
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
- Department of Information Technology and Management, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Nobuyuki Yotani
- Department of Palliative Medicine, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Ai Ito
- Department of General Pediatrics & Interdisciplinary Medicine, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Tetsuya Isayama
- Department of Neonatology, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
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Chen LP, Singh-Verdeflor K, Kelly MM, Sklansky DJ, Shadman KA, Edmonson MB, Zhao Q, DeMuri GP, Coller RJ. Disparities in COVID-19 vaccine intentions, testing and trusted sources by household language for children with medical complexity. PLoS One 2024; 19:e0305553. [PMID: 38875256 PMCID: PMC11178204 DOI: 10.1371/journal.pone.0305553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 06/02/2024] [Indexed: 06/16/2024] Open
Abstract
OBJECTIVES Children with medical complexity experienced health disparities during the coronavirus disease 2019 (COVID-19) pandemic. Language may compound these disparities since people speaking languages other than English (LOE) also experienced worse COVID-19 outcomes. Our objective was to investigate associations between household language for children with medical complexity and caregiver COVID-19 vaccine intentions, testing knowledge, and trusted sources of information. METHODS This cross-sectional survey of caregivers of children with medical complexity ages 5 to 17 years was conducted from April-June 2022. Children with medical complexity had at least 1 Complex Chronic Condition. Households were considered LOE if they reported speaking any language other than English. Multivariable logistic regression examined associations between LOE and COVID-19 vaccine intentions, interpretation of COVID-19 test results, and trusted sources of information. RESULTS We included 1,338 caregivers of children with medical complexity (49% response rate), of which 133 (10%) had household LOE (31 total languages, 58% being Spanish). There was no association between household LOE and caregiver COVID-19 vaccine intentions. Caregivers in households with LOE had similar interpretations of positive COVID-19 test results, but significantly different interpretations of negative results. Odds of interpreting a negative test as expected (meaning the child does not have COVID-19 now or can still get the virus from others) were lower in LOE households (aOR [95% CI]: 0.56 [0.34-0.95]). Households with LOE were more likely to report trusting the US government to provide COVID-19 information (aOR [95% CI]: 1.86 [1.24-2.81]). CONCLUSION Differences in COVID-19 test interpretations based on household language for children with medical complexity were observed and could contribute to disparities in outcomes. Opportunities for more inclusive public health messaging likely exist.
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Affiliation(s)
- Laura P. Chen
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Kristina Singh-Verdeflor
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Michelle M. Kelly
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Daniel J. Sklansky
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Kristin A. Shadman
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - M. Bruce Edmonson
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Qianqian Zhao
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Gregory P. DeMuri
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Ryan J. Coller
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
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Pulcini CD, Luan X, Brooks ES, Hogan A, Penrose T, Kenyon CC, Rubin DM. Pediatric Population Management Classification for Children with Medical Complexity. Popul Health Manag 2024; 27:192-198. [PMID: 38613470 PMCID: PMC11322619 DOI: 10.1089/pop.2023.0303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2024] Open
Abstract
Improving the overall care of children with medical complexity (CMC) is often beset by challenges in proactively identifying the population most in need of clinical management and quality improvement. The objective of the current study was to create a system to better capture longitudinal risk for sustained and elevated utilization across time using real-time electronic health record (EHR) data. A new Pediatric Population Management Classification (PPMC), drawn from visit diagnoses and continuity problem lists within the EHR of a tristate health system, was compared with an existing complex chronic conditions (CCC) system for agreement (with weighted κ) on identifying CCMC, as well as persistence of elevated charges and utilization from 2016 to 2019. Agreement of assignment PPMC was lower among primary care provider (PCP) populations than among other children traversing the health system for specialty or hospital services only (weighted κ 62% for PCP vs. 82% for non-PCP). The PPMC classification scheme, displaying greater precision in identifying CMC with persistently high utilization and charges for those who receive primary care within a large integrated health network, may offer a more pragmatic approach to selecting children with CMC for longitudinal care management.
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Affiliation(s)
- Christian D. Pulcini
- Department of Emergency Medicine & Pediatrics, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Xianqun Luan
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth S. Brooks
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Annique Hogan
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Tina Penrose
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Chen C. Kenyon
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David M. Rubin
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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21
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Millar K, Rodd C, Rempel G, Cohen E, Sibley KM, Garland A. The Clinical Definition of Children With Medical Complexity: A Modified Delphi Study. Pediatrics 2024; 153:e2023064556. [PMID: 38804054 DOI: 10.1542/peds.2023-064556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Children with medical complexity (CMC) comprise a subgroup of children with severe chronic diseases. A conceptual definition for CMC has been formulated, but there is no agreement on criteria to fulfill each of the 4 proposed domains: diagnostic conditions, functional limitations, health care use, and family-identified needs. Our objective with this study was to identify a standardized definition of CMC. METHODS Through a scoping review of the CMC literature, we identified potential criteria to fulfill each domain. These were incorporated into an electronic survey that was completed by a geographic and professionally varied panel of 81 American and Canadian respondents with expertise in managing CMC (response rate 70%) as part of a 4-iteration Delphi procedure. Respondents were asked to vote for the inclusion of each criterion in the definition, and for those with quantitative components (eg, hospitalization rates), to generate a consensus threshold value for meeting that criterion. The final criteria were analyzed by a committee and collapsed when situations of redundancy arose. RESULTS Of 1411 studies considered, 132 informed 55 criteria for the initial survey, which was presented to 81 respondents. Consensus for inclusion was reached on 48 criteria and for exclusion on 1 criterion. The committee collapsed those 48 criteria into 39 final criteria, 1 for diagnostic conditions, 2 for functional limitations, 13 for health care use, and 23 for family needs. CONCLUSIONS These results represent the first consensus-based, standardized definition of CMC. Standardized identification is needed to advance understanding of their epidemiology and outcomes, as well as to rigorously study treatment strategies and care models.
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Affiliation(s)
| | | | | | - Eyal Cohen
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | | | - Allan Garland
- Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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22
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Sidra M, Sebastianski M, Ohinmaa A, Rahman S. Reported costs of children with medical complexity-A systematic review. J Child Health Care 2024; 28:377-401. [PMID: 35751147 DOI: 10.1177/13674935221109683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Examining reported costs for Children with Medical Complexity (CMCs) is essential because costing and resource utilization studies influence policy and operational decisions. Our objectives were to (1) examine how authors identified CMCs in administrative databases, (2) compare reported costs for the CMC population in different study settings, and (3) analyze author recommendations related to reported costs. We undertook a systematic search of the following databases: Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library with a focus on CMCs as a heterogeneous group. The most common method used n = 11 (41%) to identify the CMC population in administrative data was the Complex Chronic Conditions methodology. The majority of included studies reported on health care service costs n = 24 (89%). Only n = 3 (11%) of the studies included costs from the family perspective. Author recommendations included standardizing how costs are reported and including the family perspective when making care delivery or policy decisions. Health system administrators and policymakers must consider the limitations of reported costs when assessing local costing studies or comparing costs across jurisdictions.
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Affiliation(s)
- Michael Sidra
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Meghan Sebastianski
- Alberta Strategy for Patient-Oriented Research (SPOR) Knowledge Synthesis Platform, University of Alberta, Edmonton, AB, Canada
| | - Arto Ohinmaa
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Sholeh Rahman
- Alberta Strategy for Patient-Oriented Research (SPOR) Knowledge Synthesis Platform, University of Alberta, Edmonton, AB, Canada
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23
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Harvey AR, Meehan E, Merrick N, D'Aprano AL, Cox GR, Williams K, Gibb SM, Mountford NJ, Connell TG, Cohen E. Comprehensive care programmes for children with medical complexity. Cochrane Database Syst Rev 2024; 5:CD013329. [PMID: 38813833 PMCID: PMC11137836 DOI: 10.1002/14651858.cd013329.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
BACKGROUND Children with medical complexity (CMC) represent a small, but growing, proportion of all children. Regardless of their underlying diagnosis, by definition, all CMC have similar functional limitations and high healthcare needs. It has been suggested that improving aspects of healthcare delivery for CMC improves health- and quality of life-related outcomes for children and their families and reduces healthcare-related expenditure. As a result, dedicated comprehensive care programmes have been established at many hospitals to meet the needs of CMC; however, it is unclear if such programmes are effective. OBJECTIVES Our main objective was to assess the effectiveness of comprehensive care programmes that aim to improve care coordination and other aspects of health care for CMC and to assess whether the effectiveness of such programmes differs according to the programme setting and structure. We aimed to assess their effectiveness in relation to child and parent health, functioning, and quality of life, quality of care, number of healthcare encounters, unmet healthcare needs, and total healthcare-related costs. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and CINAHL in May 2023. We also searched reference lists, trial registries, and the grey literature. SELECTION CRITERIA Randomised and non-randomised trials, controlled before-after studies, and interrupted time series studies were included. Studies that compared enrolment in a comprehensive care programme with non-enrolment in such a programme/treatment as usual were included. Participants were children that met the criteria for the definition of CMC, which is: having (i) a chronic condition, (ii) functional limitations, (iii) increased health and other service needs, and (iv) increased healthcare costs. Studies that included the following types of outcomes were included: health; quality of care; utilisation, coverage and access; resource use and costs; equity; and adverse outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data, assessed the risk of bias in each included study, and evaluated the certainty of evidence according to GRADE criteria. Where possible, data were represented in forest plots and pooled. We were unable to undertake a meta-analysis for comparisons and outcomes, so we used a structured synthesis approach. MAIN RESULTS We included four studies with a total of 912 CMC as participants. All included studies were randomised controlled trials conducted in hospitals in the USA or Canada. Participants varied across the included studies; however, all four studies included children with complex and chronic illness and high healthcare needs. While the primary aim of the intervention was similar across all four studies, the components of the interventions differed: in the four studies, the intervention involved some element of care coordination; in two of the studies, it involved the child receiving care from a multidisciplinary team, while in one study, the intervention was primarily centred on access to an advanced practice nurse care coordinator and another study involved nurse a practitioner-paediatrician dyad partnering with families. The risk of bias in the four studies varied across domains, with issues primarily relating to the lack of blinding of participants, personnel, and outcome assessors, inadequate allocation concealment, and incomplete outcome data. Comprehensive care for CMC compared to usual care may make little to no difference to child health, functioning, and quality of life at 12 or 24 months (three studies with 404 participants) and we assessed the evidence for the outcomes in this category (child health-related quality of life and functional status) as being of low certainty. For CMC, comprehensive care probably makes little or no difference to parent health, functioning, and quality of life compared to usual care at 12 months (one study with 117 participants) and we assessed the evidence for this outcome as being of moderate certainty. Comprehensive care for CMC compared to usual care may slightly improve child and family satisfaction with, and perceptions of, care and service delivery at 12 months (three studies with 453 participants); however, we assessed the evidence for these outcomes as being of low certainty. For CMC, comprehensive care probably makes little or no difference to the number of healthcare encounters (emergency department visits) and the number of hospitalised days (hospital admissions) compared to usual care at 12 months (three studies with 668 participants), and we assessed the evidence for these outcomes as being of moderate certainty. Three of the included studies (668 participants) reported cost outcomes and had conflicting results, with one study reporting significantly lower healthcare costs at 12 months in the intervention group compared to the control group, one reporting no differences between groups, and the other study reporting a greater increase in total healthcare costs in the intervention group compared to the control group. Overall, comprehensive care may make little or no difference to overall healthcare costs in CMC; however, the methods used to measure total healthcare costs varied across studies and the certainty of the evidence relating to this outcome is low. No studies assessed the costs to the family. AUTHORS' CONCLUSIONS The findings of this review should be treated with caution due to the limited amount and quality of the published research that was available to be included. Overall, the certainty of the evidence for the effectiveness of comprehensive care for CMC ranged from low to moderate across outcomes and there is currently insufficient evidence on which to draw strong conclusions. There is a need for more high-quality randomised trials with consistency of the target population and intervention components, methods of reporting outcomes, and follow-up periods, as well as full cost analyses, taking into account both costs to the family and costs to the healthcare system.
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Affiliation(s)
- Adrienne R Harvey
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Melbourne, Australia
| | - Elaine Meehan
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Melbourne, Australia
| | - Nicole Merrick
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Anita L D'Aprano
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Georgina R Cox
- Neurodevelopment and Disability, Royal Children's Hospital, Melbourne, Australia
| | - Katrina Williams
- Department of Paediatrics, Monash University, Melbourne, Australia
| | - Susan M Gibb
- Neurodevelopment and Disability, Royal Children's Hospital, Melbourne, Australia
| | - Nicki J Mountford
- Complex Care Hub, The Royal Children's Hospital, Melbourne, Australia
| | - Tom G Connell
- General Medicine, The Royal Children's Hospital, Melbourne, Australia
| | - Eyal Cohen
- Paediatrics and Health Policy, Management & Evaluation, University of Toronto, Toronto, Canada
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Michelson KA, Bucher BT, Neuman MI. Cost and Late Hospital Care of Publicly Insured Children After Appendectomy. J Surg Res 2024; 297:41-46. [PMID: 38430861 PMCID: PMC11023751 DOI: 10.1016/j.jss.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 01/03/2024] [Accepted: 02/05/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Immediate complications of appendicitis are common, but the prevalence of long-term complications is uncertain. METHODS We studied all publicly-insured children in the US with uncomplicated or complicated appendicitis in 2018-2019 using administrative claims. The main outcome was late hospital care defined as hospitalization or abdominal procedure within 180 d of an appendicitis discharge, excluding interval appendectomies. Time to late hospital care was evaluated using Cox regression. We evaluated health-care expenditures arising from appendicitis episodes. RESULTS Among 95,942 children with appendicitis, 5727 (6.0%) had late hospital care, with 5062 requiring rehospitalization and 2012 (2.1%) surgery. The median time to late hospital care was 10 d (interquartile range 4-33). Age under 5 y (compared with >14 y, hazard ratio [HR] 1.88, 95% confidence interval [CI] 1.70-2.08), complex chronic conditions (HR 2.35, 95% CI 2.13-2.59), and complicated appendicitis (HR 2.81, 95% CI 2.67, 2.96) were each associated with time to late hospital care. Expenditures over 180 d were a median $6553 and $19,589 respectively in those requiring no late hospital care versus those requiring it (P < 0.001). CONCLUSIONS Late hospital care is uncommon in pediatric appendicitis but is costly. Prevention efforts should be targeted to the youngest, most complex children, and those with complicated appendicitis at presentation.
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Affiliation(s)
- Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.
| | - Brian T Bucher
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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Baumbusch J. Cliff or bridge: breaking up with the paediatric healthcare system. Paediatr Child Health 2024; 29:84-86. [PMID: 38586492 PMCID: PMC10996575 DOI: 10.1093/pch/pxad061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 08/10/2023] [Indexed: 04/09/2024] Open
Abstract
Transition from paediatric to adult healthcare is a normal part of the care trajectory, yet the process often leaves much to be desired. In this commentary, I share my family's journey of this care transition, particularly the handover aspect, by providing examples of different ways that relationships were ended by paediatric healthcare professionals. The ending of these relationships often felt like 'breaking up'. I also share an example of a supported handover, which bridged the transition from paediatric to adult care. To improve transitions, we need genuine acknowledgement of the paediatric medical trauma stress (PMTS) experienced by families such as mine following years of interactions in the healthcare system. Along with following transition checklists, patients and families need authentic and meaningful closure to longitudinal relationships and trauma-informed care practices as we move forward into the adult care system.
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Alotaibi F, Alkhalaf H, Alshalawi H, Almijlad H, Ureeg A, Alghnam S. Unplanned Readmissions in Children with Medical Complexity in Saudi Arabia: A Large Multicenter Study. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2024; 12:134-144. [PMID: 38764560 PMCID: PMC11098271 DOI: 10.4103/sjmms.sjmms_352_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 01/26/2024] [Accepted: 02/07/2024] [Indexed: 05/21/2024]
Abstract
Background Children with medical complexity (CMC) account for a substantial proportion of healthcare spending, and one-third of their expenditures are due to readmissions. However, knowledge regarding the healthcare-resource utilization and characteristics of CMC in Saudi Arabia is limited. Objectives To describe hospitalization patterns and characteristics of Saudi CMC with an unplanned 30-day readmission. Methodology This retrospective study included Saudi CMC (aged 0-14 years) who had an unplanned 30-day readmission at six tertiary centers in Riyadh, Jeddah, Dammam, Alahsa, and Almadina between January 2016 and December 2020. Hospital-based inclusion criteria focused on CMC with multiple complex chronic conditions (CCCs) and technology assistance (TA) device use. CMC were compared across demographics, clinical characteristics, and hospital-resource utilization. Results A total of 9139 pediatric patients had unplanned 30-day readmission during the study period, of which 680 (7.4%) met the inclusion criteria. Genetic conditions were the most predominant primary pathology (66.3%), with one-third of cases (33.7%) involving the neuromuscular system. During the index admission, pneumonia was the most common diagnosis (33.1%). Approximately 35.1% of the readmissions were after 2 weeks. Pneumonia accounted for 32.5% of the readmissions. After readmission, 16.9% of patients were diagnosed with another CCC or received a new TA device, and the in-hospital mortality rate was 6.6%. Conclusion The rate of unplanned 30-day readmissions in children with medical complexity in Saudi Arabia is 7.4%, which is lower than those reported from developed countries. Saudi children with CCCs and TA devices were readmitted approximately within similar post-discharge time and showed distinct hospitalization patterns associated with specific diagnoses. To effectively reduce the risk of 30-day readmissions, targeted measures must be introduced both during the hospitalization period and after discharge.
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Affiliation(s)
- Futoon Alotaibi
- Department of Pediatrics, King Abdullah Specialist Children’s Hospital, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Hamad Alkhalaf
- Department of Pediatrics, King Abdullah Specialist Children’s Hospital, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Hissah Alshalawi
- Department of Pediatrics, King Abdullah Specialist Children’s Hospital, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Hadeel Almijlad
- Department of Pediatrics, King Abdullah Specialist Children’s Hospital, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abdulaziz Ureeg
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Suliman Alghnam
- Public Health Intelligence, Saudi Public Health Authority, Riyadh, Saudi Arabia
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Glick AF, Yin HS, Silva B, Modi AC, Huynh V, Goodwin EJ, Farkas JS, Turock JS, Famiglietti HS, Dickson VV. Pediatrician perspectives on barriers and facilitators to discharge instruction comprehension and adherence for parents of children with medical complexity. J Hosp Med 2024; 19:278-286. [PMID: 38445808 PMCID: PMC10987266 DOI: 10.1002/jhm.13319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/06/2024] [Accepted: 02/12/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND High rates of posthospitalization errors are observed in children with medical complexity (CMC). Poor parent comprehension of and adherence to complex discharge instructions can contribute to errors. Pediatrician views on common barriers and facilitators to parent comprehension and adherence are understudied. OBJECTIVE To examine pediatrician perspectives on barriers and facilitators experienced by parents in comprehension of and adherence to inpatient discharge instructions for CMC. DESIGN, SETTINGS, AND PARTICIPANTS We conducted a qualitative, descriptive study of attending pediatricians (n = 20) caring for CMC in inpatient settings (United States and Canada) and belonging to listservs for pediatric hospitalists/complex care providers. We used purposive/maximum variation sampling to ensure heterogeneity (e.g., hospital, region). MAIN OUTCOME AND MEASURES A multidisciplinary team designed and piloted a semistructured interview guide with pediatricians who care for CMC. Team members conducted semistructured interviews via phone or video call. Interviews were audiorecorded and transcribed. We analyzed transcripts using content analysis; codes were derived a priori from a conceptual framework (based on the Pediatric Self-Management Model) and a preliminary transcript analysis. We applied codes and identified emerging themes. RESULTS Pediatricians identified three themes as barriers and facilitators to discharge instruction comprehension and adherence: (1) regimen complexity, (2) access to the healthcare team (e.g., inpatient team, outpatient pediatrician, home nursing) and resources (e.g., medications, medical equipment), and (3) need for a family centered and health literacy-informed approach to discharge planning and education. Next steps include the assessment of parent perspectives on barriers and facilitators to discharge instruction comprehension and adherence for prents of CMC and the development of intervention strategies.
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Affiliation(s)
- Alexander F. Glick
- Department of Pediatrics, NYU Langone Health and Bellevue Hospital Center, New York, New York, USA
| | - H. Shonna Yin
- Department of Pediatrics, NYU Langone Health and Bellevue Hospital Center, New York, New York, USA
- Department of Population Health, NYU Langone Health, New York, New York, USA
| | - Benjamin Silva
- NYU Grossman School of Medicine, New York, New York, USA
| | - Avani C. Modi
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Behavioral Medicine and Clinical Psychology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Vincent Huynh
- Department of Pediatrics, NYU Langone Health and Bellevue Hospital Center, New York, New York, USA
| | - Emily J. Goodwin
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri-Kansas City School of Medicine, University of Kansas School of Medicine, Kansas City, Missouri, USA
| | - Jonathan S. Farkas
- Department of Pediatrics, NYU Langone Health and Bellevue Hospital Center, New York, New York, USA
| | - Julia S. Turock
- Department of Pediatrics, NYU Langone Health and Bellevue Hospital Center, New York, New York, USA
| | - Hannah S. Famiglietti
- Department of Pediatrics, NYU Langone Health and Bellevue Hospital Center, New York, New York, USA
| | - Victoria V. Dickson
- University of Connecticut School of Nursing, Storrs, Connecticut, USA
- NYU Rory Meyers College of Nursing, New York, New York, USA
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Quinn J, Bodenstab HM, Wo E, Parrish RH. Medication Management Through Collaborative Practice for Children With Medical Complexity: A Prospective Case Series. J Pediatr Pharmacol Ther 2024; 29:119-129. [PMID: 38596413 PMCID: PMC11001202 DOI: 10.5863/1551-6776-29.2.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/08/2023] [Indexed: 04/11/2024]
Abstract
OBJECTIVE Care coordination for children and youth with special health care needs and medical complexity (CYSHCN-CMC), especially medication management, is difficult for providers, parents/caregivers, and -patients. This report describes the creation of a clinical pharmacotherapy practice in a pediatric long-term care facility (pLTCF), application of standard operating procedures to guide comprehensive medication management (CMM), and establishment of a collaborative practice agreement (CPA) to guide drug therapy. METHODS In a prospective case series, 102 patients characterized as CYSHCN-CMC were included in this pLTCF quality improvement project during a 9-month period. RESULTS Pharmacists identified, prevented, or resolved 1355 drug therapy problems (DTP) with an average of 13 interventions per patient. The patients averaged 9.5 complex chronic medical conditions with a -median length of stay of 2815 days (7.7 years). The most common medications discontinued due to pharmacist assessment and recommendation included diphenhydramine, albuterol, sodium phosphate enema, ipratropium, and metoclopramide. The average number of medications per patient was reduced from 23 to 20. A pharmacoeconomic analysis of 244 of the interventions revealed a monthly direct cost savings of $44,304 ($434 per patient per month) and monthly cost avoidance of $48,835 ($479 per patient per month). Twenty-eight ED visits/admissions and 61 clinic and urgent care visits were avoided. Hospital -readmissions were reduced by 44%. Pharmacist recommendations had a 98% acceptance rate. CONCLUSIONS Use of a CPA to conduct CMM in CYSHCN-CMC decreased medication burden, resolved, and prevented adverse events, reduced health care-related costs, reduced hospital readmissions and was well-accepted and implemented collaboratively with pLTCF providers.
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Affiliation(s)
- Jena Quinn
- Perfecting Peds (JQ, HMB, EW), Haddon Heights, NJ
| | - Heather Monk Bodenstab
- Perfecting Peds (JQ, HMB, EW), Haddon Heights, NJ
- Medical Affairs (HMB), Sobi, Waltham, MA
| | - Emily Wo
- Perfecting Peds (JQ, HMB, EW), Haddon Heights, NJ
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Lefton-Greif MA, Arvedson JC, Farneti D, Levy DS, Jadcherla SR. Global State of the Art and Science of Childhood Dysphagia: Similarities and Disparities in Burden. Dysphagia 2024:10.1007/s00455-024-10683-5. [PMID: 38503935 DOI: 10.1007/s00455-024-10683-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 02/02/2024] [Indexed: 03/21/2024]
Abstract
Feeding/swallowing and airway protection are complex functions, essential for survival, and continue to evolve throughout the lifetime. Medical and surgical advances across the globe have improved the long-term survival of medically complex children at the cost of increasing comorbidities, including dysfunctional swallowing (dysphagia). Dysphagia is prominent in children with histories of preterm birth, neurologic and neuromuscular diagnoses, developmental delays, and aerodigestive disorders; and is associated with medical, health, and neurodevelopmental problems; and long-term socioeconomic, caregiver, health system, and social burdens. Despite these survival and population trends, data on global prevalence of childhood dysphagia and associated burdens are limited, and practice variations are common. This article reviews current global population and resource-dependent influences on current trends for children with dysphagia, disparities in the availability and access to specialized multidisciplinary care, and potential impacts on burdens. A patient example will illustrate some questions to be considered and decision-making options in relation to age and development, availability and accessibility to resources, as well as diverse cultures and family values. Precise recognition of feeding/swallowing disorders and follow-up intervention are enhanced by awareness and knowledge of global disparities in resources. Initiatives are needed, which address geographic and economic barriers to providing optimal care to children with dysphagia.
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Affiliation(s)
- Maureen A Lefton-Greif
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University, Baltimore, MD, USA.
- Departments of Pediatrics, Otolaryngology-Head and Neck Surgery, and Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, USA.
| | - Joan C Arvedson
- Department of Speech-Language Pathology, Children's Wisconsin, Milwaukee, WI, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Daniele Farneti
- Audiologic Phoniatric Service, ENT Department AUSL Romagna, Infermi Hospital, Rimini, Italy
| | - Deborah S Levy
- Department of Health and Human Communication, Universidade Federal, do Rio Grande do Sul, Brazil
- Department of Speech Pathology and Audiology, Hospital de Clínicas, de Porto Alegre, Brazil
- Multi-Professional Residency Program, Hospital de Clínicas, de Porto Alegre, Brazil
| | - Sudarshan R Jadcherla
- Divisions of Neonatology, Pediatric Gastroenterology and Nutrition, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- The Ohio State University College of Medicine, Columbus, OH, USA
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King KP, Humiston T, Gowey MA, Murdaugh DL, Dutton GR, Lansing AH. A biobehavioural and social-structural model of inflammation and executive function in pediatric chronic health conditions. Health Psychol Rev 2024; 18:24-40. [PMID: 36581801 PMCID: PMC10307927 DOI: 10.1080/17437199.2022.2162430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 12/20/2022] [Indexed: 12/31/2022]
Abstract
Evidence indicates that pediatric chronic health conditions (CHCs) often impair executive functioning (EF) and impaired EF undermines pediatric CHC management. This bidirectional relationship likely occurs due to biobehavioural and social-structural factors that serve to maintain this feedback loop. Specifically, biobehavioural research suggests that inflammation may sustain a feedback loop that links together increased CHC severity, challenges with EF, and lower engagement in health promoting behaviours. Experiencing social and environmental inequity also maintains pressure on this feedback loop as experiencing inequities is associated with greater inflammation, increased CHC severity, as well as challenges with EF and engagement in health promoting behaviours. Amidst this growing body of research, a model of biobehavioural and social-structural factors that centres inflammation and EF is warranted to better identify individual and structural targets to ameliorate the effects of CHCs on children, families, and society at large. This paper proposes this model, reviews relevant literature, and delineates actionable research and clinical implications.
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Affiliation(s)
| | - Tori Humiston
- University of Vermont, Department of Psychological Sciences
| | - Marissa A. Gowey
- University of Alabama-Birmingham School of Medicine, Department of Pediatrics
| | - Donna L. Murdaugh
- University of Alabama-Birmingham School of Medicine, Department of Pediatrics
| | - Gareth R. Dutton
- University of Alabama-Birmingham School of Medicine, Department of Preventive Medicine
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Jafari K, Carlin K, Caglar D, Klein EJ, Simon TD. National Characteristics of Emergency Care for Children with Neurologic Complex Chronic Conditions. West J Emerg Med 2024; 25:237-245. [PMID: 38596925 PMCID: PMC11000559 DOI: 10.5811/westjem.17834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 11/16/2023] [Accepted: 11/21/2023] [Indexed: 04/11/2024] Open
Abstract
Introduction Most pediatric emergency care occurs in general emergency departments (GED), where less pediatric experience and lower pediatric emergency readiness may compromise care. Medically vulnerable pediatric patients, such as those with chronic, severe, neurologic conditions, are likely to be disproportionately affected by suboptimal care in GEDs; however, little is known about characteristics of their care in either the general or pediatric emergency setting. In this study our objective was to compare the frequency, characteristics, and outcomes of ED visits made by children with chronic neurologic diseases between general and pediatric EDs (PED). Methods We conducted a retrospective analysis of the 2011-2014 Nationwide Emergency Department Sample (NEDS) for ED visits made by patients 0-21 years with neurologic complex chronic conditions (neuro CCC). We compared patient, hospital, and ED visits characteristics between GEDs and PEDs using descriptive statistics. We assessed outcomes of admission, transfer, critical procedure performance, and mortality using multivariable logistic regression. Results There were 387,813 neuro CCC ED visits (0.3% of 0-21-year-old ED visits) in our sample. Care occurred predominantly in GEDs, and visits were associated with a high severity of illness (30.1% highest severity classification score). Compared to GED visits, PED neuro CCC visits were comprised of individuals who were younger, more likely to have comorbid conditions (32.9% vs 21%, P < 0.001), and technology assistance (65.4% vs. 45.9%) but underwent fewer procedures and had lower ED charges ($2,200 vs $1,520, P < 0.001). Visits to PEDs had lower adjusted odds of critical procedures (adjusted odds ratio [aOR] 0.74, 95% confidence interval [CI] 0.62-0.87), transfers (aOR 0.14, 95% CI 0.04-0.56), and mortality (aOR 0.38, 95% CI 0.19-0.75) compared to GEDs. Conclusion Care for children with neuro CCCs in a pediatric ED is associated with less resource utilization and lower rates of transfer and mortality. Identifying features of PED care for neuro CCCs could lead to lower costs and mortality for this population.
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Affiliation(s)
- Kaileen Jafari
- University of Washington, Department of Pediatrics, Seattle, Washington
- Seattle Children’s Research Institute, Center for Clinical and Translational Research, Seattle, Washington
| | - Kristen Carlin
- Seattle Children’s Research Institute, Center for Clinical and Translational Research, Seattle, Washington
| | - Derya Caglar
- University of Washington, Department of Pediatrics, Seattle, Washington
- Seattle Children’s Research Institute, Center for Clinical and Translational Research, Seattle, Washington
| | - Eileen J. Klein
- University of Washington, Department of Pediatrics, Seattle, Washington
- Seattle Children’s Research Institute, Center for Clinical and Translational Research, Seattle, Washington
| | - Tamara D. Simon
- University of Southern California, Keck School of Medicine, Department of Pediatrics, Los Angeles, California
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Yeager VA, Gutta J, Kutschera L, Stelzner SM. Perceived Value of the Inclusion of Parent-to-Parent Support in Case Conferences and Care Planning for Children With Special Healthcare Needs. Adv Health Care Manag 2024; 22:211-229. [PMID: 38262017 DOI: 10.1108/s1474-823120240000022010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
This chapter qualitatively explored the impact of including parent liaisons (i.e., parents with lived experience caring for a child with complex needs, who support other caregivers in navigating child and family needs) in a case conferencing model for children with complex medical/social needs. Case conferences are used to address fragmented care, shared decision-making, and set patient-centered goals. Seventeen semi-structured interviews were conducted with clinicians and parent liaisons to assess the involvement of parent liaisons in case conferencing. Two main themes included benefits of parent liaison involvement (10 subthemes) and challenges to parent liaison involvement (5 subthemes). Clinicians reported that liaison participation and support of patients reduced stress for clinicians as well as family members. Challenges to liaison involvement included clinical team/parent liaison communication delays, which were further exacerbated by the COVID-19 pandemic. Parent liaison involvement in case conferences is perceived to be beneficial to children with complex needs, their families, and the clinical team. Integration of liaisons ensures the familial perspective is included in clinical goal setting.
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Affiliation(s)
- Valerie A Yeager
- a Indiana University Richard M. Fairbanks School of Public Health, USA
| | - Jyotsna Gutta
- a Indiana University Richard M. Fairbanks School of Public Health, USA
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Pottorff A, Liu E, Du M, Catacora A, Rosen R, McSweeney M. Assessment of families' experience with care integration within an aerodigestive program. J Pediatr Gastroenterol Nutr 2024; 78:223-230. [PMID: 38374563 DOI: 10.1002/jpn3.12108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 11/06/2023] [Accepted: 11/20/2023] [Indexed: 02/21/2024]
Abstract
OBJECTIVES The objective of this study was to assess if enrollment in a pediatric multidisciplinary aerodigestive program significantly impacted families' experiences with care integration. METHODS A previously validated 48-question Pediatric Integrated Care Survey (PICS) was administered in a cross-sectional manner to both new (new-ADC) and established (est-ADC) patients presenting for an outpatient Aerodigestive Center visit at Boston Children's Hospital. Survey results were grouped into the following five care coordination domains: (1) access to care, (2) care goal creation/planning, (3) family impact, (4) communication with health care providers, and (5) team functioning. Families were asked to rate their care integration experiences in the prior 12 months using yes/no and Likert-based questions. Comparisons were analyzed using logistic regression. Factor analysis was also performed. RESULTS Ninety patient families were surveyed: 54 (60%) est-ADC patients and 36 (40%) new-ADC patients. Est-ADC patients reported higher levels of experience with team functioning, provider awareness of prior testing, provider communication, and access to alternative methods of communication. Self-identified non-White patients reported lower satisfaction in team functioning and provider understanding of their child's long-term care plan. No significant differences in care integration experiences before and after the onset of the coronavirus pandemic were seen. CONCLUSIONS Patients enrolled in aerodigestive centers experienced improved care integration, most significantly in provider communication and team functioning. Despite these improvements, self-identified non-White families reported a lower care integration experience.
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Affiliation(s)
- Alexandra Pottorff
- Division of Gastroenterology, Hepatology and Nutrition, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Enju Liu
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Maritha Du
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Andrea Catacora
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachel Rosen
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Maireade McSweeney
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
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Oumarbaeva-Malone Y, Jurgens V, Rush M, Bloom M, Adusei-Baah C, Hall M, Shah N, Bhansali P, Parikh K. Care Models and Discharge Services for Children With Medical Complexity. Hosp Pediatr 2024; 14:102-107. [PMID: 38196385 DOI: 10.1542/hpeds.2023-007423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND AND OBJECTIVES Children with medical complexity (CMC) are high health care utilizers prompting hospitals to implement care models focused on this population, yet practices have not been evaluated on a national level. Our objective with this study is to describe the presence and structure of care models and the use of discharge services for CMC admitted to freestanding children's hospitals across the nation. METHODS We distributed an electronic survey to 48 hospitals within the Pediatric Health Information System exploring the availability of care models and discharge services for CMC. Care models were grouped by type and number present at each institution. Discharge services were grouped by low (never, rarely), medium (sometimes), and high (most of the time, always) frequency use. RESULTS Of 48 eligible hospitals, 33 completed the survey (69%). There were no significant differences between responders and non-responders for both hospital and patient characteristics. Most participants identified an outpatient care model (67%), whereas 21% had no dedicated care model for CMC in the inpatient or outpatient setting. High-frequency discharge services included durable medical equipment delivery, medication delivery, and communication with outpatient provider before discharge. Low-frequency discharge services included the use of a structured handoff tool for outpatient communication, personalized access plans, inpatient team follow-up with family after discharge, and the use of discharge checklists. CONCLUSIONS Children's hospitals vary largely in care model structure and discharge services. Future work is needed to evaluate the associations between care models and discharge services for CMC with various health care outcomes.
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Affiliation(s)
- Yuliya Oumarbaeva-Malone
- Children's National Hospital, Washington DC
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Valerie Jurgens
- Children's National Hospital, Washington DC
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Margaret Rush
- Children's National Hospital, Washington DC
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Miriam Bloom
- Children's National Hospital, Washington DC
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Charity Adusei-Baah
- Children's National Hospital, Washington DC
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | | | - Neha Shah
- Children's National Hospital, Washington DC
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Priti Bhansali
- Children's National Hospital, Washington DC
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Kavita Parikh
- Children's National Hospital, Washington DC
- The George Washington University School of Medicine and Health Sciences, Washington DC
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Woodgate RL, Isaak CA, Kipling A, Kirk S. Challenges and recommendations for advancing respite care for families of children and youth with special health care needs: A qualitative exploration. Health Expect 2024; 27:e13831. [PMID: 37705308 PMCID: PMC10753137 DOI: 10.1111/hex.13831] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/21/2023] [Accepted: 07/18/2023] [Indexed: 09/15/2023] Open
Abstract
INTRODUCTION Caring for children and youth with special health care needs (CYSHCN) is a significant undertaking for families. While respite care is intended to address this burden, demand continues to exceed supply. Exploring the perspectives of respite service providers (SPs) and stakeholders (SKs) provides unique insight into families' needs and respite care systems. METHODS We conducted semistructured interviews with 41 respite care SPs and SKs across four Canadian provinces to ascertain perspectives on current and ideal respite care for families of CYSHCN. The analysis included delineating units of meaning from the data, clustering units of meaning to form thematic statements and extracting themes. The second-level analysis involved applying themes and subthemes to cross-functional process maps. FINDINGS Participants noted the critical, but sometimes absent role of Community Service Workers, who have the ability to support families accessing and navigating respite care systems. SPs and SKs identified current respite systems as operating in crisis mode. New findings suggest an ideal respite care system would incorporate advocacy for families, empower families and value CYSHCN, their families and respite workers. CONCLUSION The evidence of unmet respite care needs of families of CYSHCN across Canada has long been available. Our findings identifying respite system challenges and solutions can be used by funders and policymakers for planning and enhancing resources, and by healthcare professionals, respite care providers and SKs to understand barriers and take action to improve respite outcomes to meet the respite needs of all families and CYSHCN. PATIENT OR PUBLIC CONTRIBUTION The research team is composed of patients, researchers, clinicians and decision-makers along with our Family Advisory Committee (FAC) composed of members of families of CYSHNC. The FAC was formed and met regularly with research team members, knowledge users and collaborators throughout the study to provide input on design, review themes and ensure findings are translated and disseminated in a meaningful way.
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Affiliation(s)
- Roberta L. Woodgate
- College of NursingRady Faculty of Health Sciences, University of ManitobaWinnipegCanada
| | - Corinne A. Isaak
- College of NursingRady Faculty of Health Sciences, University of ManitobaWinnipegCanada
| | - Ardelle Kipling
- College of NursingRady Faculty of Health Sciences, University of ManitobaWinnipegCanada
| | - Sue Kirk
- School of NursingUniversity of ManchesterManchesterUK
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Sidra M, Pietrosanu M, Ohinmaa A, Zwicker J, Round J, Johnson DW. Clinical and Socioeconomic Associations With Hospital Days and Emergency Department Visits Among Medically Complex Children: A Retrospective Cohort Study. Hosp Pediatr 2024; 14:93-101. [PMID: 38204352 DOI: 10.1542/hpeds.2023-007457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
OBJECTIVES To estimate associations between clinical and socioeconomic variables and hospital days and emergency department (ED) visits for children with medical complexity (CMCs) for 5 years after index admission. METHODS Retrospective, longitudinal, population-based cohort study of CMCs in Alberta (n = 12 621) diagnosed between 2010 and 2013 using administrative data linked to socioeconomic data. The primary outcomes were annual cumulative numbers of hospital days and ED visits for 5 years after index admission. Data were analyzed using mixed-effect hurdle regression. RESULTS Among CMCs utilizing resources, those with more chronic medications had more hospital days (relative difference [RD] 3.331 for ≥5 vs 0 medications in year 1, SE 0.347, P value < .001) and ED visits (RD 1.836 for 0 vs ≥5 medications in year 1, SE 0.133, P value < .001). Among these CMCs, initial length of stay had significant, positive associations with hospital days (RD 1.960-5.097, SE 0.161-0.610, P value < .001 outside of the gastrointestinal and hematology and immunodeficiency groups). Those residing in rural or remote areas had more ED visits than those in urban or metropolitan locations (RD 1.727 for rural versus urban, SE 0.075, P < .001). Material and social deprivation had significant, positive associations with number of ED visits. CONCLUSIONS Clinical factors are more strongly associated with hospitalizations and socioeconomic factors with ED visits. Policy administrators and researchers aiming to optimize resource use and improve outcomes for CMCs should consider interventions that include both clinical care and socioeconomic support.
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Affiliation(s)
- Michael Sidra
- School of Public Health, University of Alberta, Edmonton, Alberta
| | - Matthew Pietrosanu
- Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, Canada
| | - Arto Ohinmaa
- School of Public Health, University of Alberta, Edmonton, Alberta
| | | | - Jeff Round
- School of Public Health, University of Alberta, Edmonton, Alberta
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Lattanza B, Lakhaney D, Scott T, Croker-Benn A, Giordano M, Banker SL. Caring for Children With Medical Complexity: A Clinical, Patient-Focused Curriculum. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2024; 20:11380. [PMID: 38293245 PMCID: PMC10825041 DOI: 10.15766/mep_2374-8265.11380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 11/13/2023] [Indexed: 02/01/2024]
Abstract
Introduction Caring for children with medical complexity (CMC) requires specialized knowledge and skills. However, no standardized curricula are used across training programs as institutions have varying needs and resources. Methods We created a patient-focused, interactive curriculum for two CMC topics: feeding/nutrition and pain/irritability. We integrated the 45-minute sessions into morning protected patient-care time on an inpatient pediatric team at an urban tertiary care hospital. Targeted toward all pediatric residents and medical students rotating in inpatient pediatrics over a 12-month period, the sessions used a mix of didactic, discussion, and hands-on activities. Learners on one of two inpatient teams received the curriculum, while those on the other received a curriculum unrelated to CMC and served as a control group. Both groups completed retrospective pre/post self-assessments to evaluate self-efficacy with respect to the learning objectives. Results Over the 12-month period, 72 surveys were completed for the feeding/nutrition session, 78 surveys for the pain/irritability session, and 42 control surveys. The intervention group saw the greatest increase in self-efficacy scores generally in the feeding/nutrition session. All eight learning objectives saw significant improvement in self-efficacy scores for the intervention group. There was significantly greater improvement in self-efficacy for the intervention group compared to the control for all eight learning objectives. Discussion Through this patient-focused curriculum, learners had improved self-efficacy scores compared to the natural learning occurring on the inpatient service. The curriculum could be adapted to fit the needs of other institutions and provides a practical, hands-on approach to learning about caring for CMC.
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Affiliation(s)
- Brittany Lattanza
- Fellow, Department of Pediatric Nephrology, Icahn School of Medicine at Mount Sinai
| | - Divya Lakhaney
- Assistant Professor, Department of Pediatrics, Columbia University Irving Medical Center
| | - Theresa Scott
- Assistant Professor, Department of Pediatrics, Weill Cornell Medical Center
| | - Ashley Croker-Benn
- Second-Year Student, Mailman School of Public Health, Columbia University Irving Medical Center
| | - Mirna Giordano
- Associate Professor, Department of Pediatrics, Columbia University Irving Medical Center
| | - Sumeet L. Banker
- Associate Professor, Department of Pediatrics, Columbia University Irving Medical Center
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Iskander C, Stukel TA, Diong C, Guan J, Saunders N, Cohen E, Brownell M, Mahar A, Shulman R, Gandhi S, Guttmann A. Acute health care use among children during the first 2.5 years of the COVID-19 pandemic in Ontario, Canada: a population-based repeated cross-sectional study. CMAJ 2024; 196:E1-E13. [PMID: 38228342 PMCID: PMC10802996 DOI: 10.1503/cmaj.221726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND The effects of the decline in health care use at the start of the COVID-19 pandemic on the health of children are unclear. We sought to estimate changes in rates of severe and potentially preventable health outcomes among children during the pandemic. METHODS We conducted a repeated cross-sectional study of children aged 0-17 years using linked population health administrative and disease registry data from January 2017 through August 2022 in Ontario, Canada. We compared observed rates of emergency department visits and hospital admissions during the pandemic to predicted rates based on the 3 years preceding the pandemic. We evaluated outcomes among children and neonates overall, among children with chronic health conditions and among children with specific diseases sensitive to delays in care. RESULTS All acute care use for children decreased immediately at the onset of the pandemic, reaching its lowest rate in April 2020 for emergency department visits (adjusted relative rate [RR] 0.28, 95% confidence interval [CI] 0.28-0.29) and hospital admissions (adjusted RR 0.43, 95% CI 0.42-0.44). These decreases were sustained until September 2021 and May 2022, respectively. During the pandemic overall, rates of all-cause mortality, admissions for ambulatory care-sensitive conditions, newborn readmissions or emergency department visits or hospital admissions among children with chronic health conditions did not exceed predicted rates. However, after declining significantly between March and May 2020, new presentations of diabetes mellitus increased significantly during most of 2021 (peak adjusted RR 1.49, 95% CI 1.28-1.74 in July 2021) and much of 2022. Among these children, presentations for diabetic ketoacidosis were significantly higher than expected during the pandemic overall (adjusted RR 1.14, 95% CI 1.00-1.30). We observed similar time trends for new presentations of cancer, but we observed no excess presentations of severe cancer overall (adjusted RR 0.91, 95% CI 0.62-1.34). INTERPRETATION In the first 30 months of the pandemic, disruptions to care were associated with important delays in new diagnoses of diabetes but not with other acute presentations of select preventable conditions or with mortality. Mitigation strategies in future pandemics or other health system disruptions should include education campaigns around important symptoms in children that require medical attention.
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Affiliation(s)
- Carina Iskander
- ICES (Iskander, Stukel, Diong, Guan, Saunders, Cohen, Mahar, Shulman, Gandhi, Guttmann); Institute of Health Policy, Management and Evaluation (Stukel, Shulman), University of Toronto; Department of Paediatrics (Saunders, Cohen, Guttmann), Hospital for Sick Children, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar), University of Manitoba; Manitoba Centre for Health Policy (Brownell), Winnipeg, Man
| | - Therese A Stukel
- ICES (Iskander, Stukel, Diong, Guan, Saunders, Cohen, Mahar, Shulman, Gandhi, Guttmann); Institute of Health Policy, Management and Evaluation (Stukel, Shulman), University of Toronto; Department of Paediatrics (Saunders, Cohen, Guttmann), Hospital for Sick Children, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar), University of Manitoba; Manitoba Centre for Health Policy (Brownell), Winnipeg, Man
| | - Christina Diong
- ICES (Iskander, Stukel, Diong, Guan, Saunders, Cohen, Mahar, Shulman, Gandhi, Guttmann); Institute of Health Policy, Management and Evaluation (Stukel, Shulman), University of Toronto; Department of Paediatrics (Saunders, Cohen, Guttmann), Hospital for Sick Children, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar), University of Manitoba; Manitoba Centre for Health Policy (Brownell), Winnipeg, Man
| | - Jun Guan
- ICES (Iskander, Stukel, Diong, Guan, Saunders, Cohen, Mahar, Shulman, Gandhi, Guttmann); Institute of Health Policy, Management and Evaluation (Stukel, Shulman), University of Toronto; Department of Paediatrics (Saunders, Cohen, Guttmann), Hospital for Sick Children, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar), University of Manitoba; Manitoba Centre for Health Policy (Brownell), Winnipeg, Man
| | - Natasha Saunders
- ICES (Iskander, Stukel, Diong, Guan, Saunders, Cohen, Mahar, Shulman, Gandhi, Guttmann); Institute of Health Policy, Management and Evaluation (Stukel, Shulman), University of Toronto; Department of Paediatrics (Saunders, Cohen, Guttmann), Hospital for Sick Children, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar), University of Manitoba; Manitoba Centre for Health Policy (Brownell), Winnipeg, Man
| | - Eyal Cohen
- ICES (Iskander, Stukel, Diong, Guan, Saunders, Cohen, Mahar, Shulman, Gandhi, Guttmann); Institute of Health Policy, Management and Evaluation (Stukel, Shulman), University of Toronto; Department of Paediatrics (Saunders, Cohen, Guttmann), Hospital for Sick Children, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar), University of Manitoba; Manitoba Centre for Health Policy (Brownell), Winnipeg, Man
| | - Marni Brownell
- ICES (Iskander, Stukel, Diong, Guan, Saunders, Cohen, Mahar, Shulman, Gandhi, Guttmann); Institute of Health Policy, Management and Evaluation (Stukel, Shulman), University of Toronto; Department of Paediatrics (Saunders, Cohen, Guttmann), Hospital for Sick Children, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar), University of Manitoba; Manitoba Centre for Health Policy (Brownell), Winnipeg, Man
| | - Alyson Mahar
- ICES (Iskander, Stukel, Diong, Guan, Saunders, Cohen, Mahar, Shulman, Gandhi, Guttmann); Institute of Health Policy, Management and Evaluation (Stukel, Shulman), University of Toronto; Department of Paediatrics (Saunders, Cohen, Guttmann), Hospital for Sick Children, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar), University of Manitoba; Manitoba Centre for Health Policy (Brownell), Winnipeg, Man
| | - Rayzel Shulman
- ICES (Iskander, Stukel, Diong, Guan, Saunders, Cohen, Mahar, Shulman, Gandhi, Guttmann); Institute of Health Policy, Management and Evaluation (Stukel, Shulman), University of Toronto; Department of Paediatrics (Saunders, Cohen, Guttmann), Hospital for Sick Children, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar), University of Manitoba; Manitoba Centre for Health Policy (Brownell), Winnipeg, Man
| | - Sima Gandhi
- ICES (Iskander, Stukel, Diong, Guan, Saunders, Cohen, Mahar, Shulman, Gandhi, Guttmann); Institute of Health Policy, Management and Evaluation (Stukel, Shulman), University of Toronto; Department of Paediatrics (Saunders, Cohen, Guttmann), Hospital for Sick Children, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar), University of Manitoba; Manitoba Centre for Health Policy (Brownell), Winnipeg, Man
| | - Astrid Guttmann
- ICES (Iskander, Stukel, Diong, Guan, Saunders, Cohen, Mahar, Shulman, Gandhi, Guttmann); Institute of Health Policy, Management and Evaluation (Stukel, Shulman), University of Toronto; Department of Paediatrics (Saunders, Cohen, Guttmann), Hospital for Sick Children, Toronto, Ont.; Department of Community Health Sciences (Brownell, Mahar), University of Manitoba; Manitoba Centre for Health Policy (Brownell), Winnipeg, Man.
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Jolliff A, Coller RJ, Kearney H, Warner G, Feinstein JA, Chui MA, O'Brien S, Willey M, Katz B, Bach TD, Werner NE. An mHealth Design to Promote Medication Safety in Children with Medical Complexity. Appl Clin Inform 2024; 15:45-54. [PMID: 37989249 PMCID: PMC10794091 DOI: 10.1055/a-2214-8000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/09/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Children with medical complexity (CMC) are uniquely vulnerable to medication errors and preventable adverse drug events because of their extreme polypharmacy, medical fragility, and reliance on complicated medication schedules and routes managed by undersupported family caregivers. There is an opportunity to improve CMC outcomes by designing health information technologies that support medication administration accuracy, timeliness, and communication within CMC caregiving networks. OBJECTIVES The present study engaged family caregivers, secondary caregivers, and clinicians who work with CMC in a codesign process to identify: (1) medication safety challenges experienced by CMC caregivers and (2) design requirements for a mobile health application to improve medication safety for CMC in the home. METHODS Study staff recruited family caregivers, secondary caregivers, and clinicians from a children's hospital-based pediatric complex care program to participate in virtual codesign sessions. During sessions, the facilitator-guided codesigners in generating and converging upon medication safety challenges and design requirements. Between sessions, the research team reviewed notes from the session to identify design specifications and modify the prototype. After design sessions concluded, each session recording was reviewed to confirm that all designer comments had been captured. RESULTS A total of N = 16 codesigners participated. Analyses yielded 11 challenges to medication safety and 11 corresponding design requirements that fit into three broader challenges: giving the right medication at the right time; communicating with others about medications; and accommodating complex medical routines. Supporting quotations from codesigners and prototype features associated with each design requirement are presented. CONCLUSION This study generated design requirements for a tool that may improve medication safety by creating distributed situation awareness within the caregiving network. The next steps are to pilot test tools that integrate these design requirements for usability and feasibility, and to conduct a randomized control trial to determine if use of these tools reduces medication errors.
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Affiliation(s)
- Anna Jolliff
- Department of Health and Wellness Design, Indiana University at Bloomington, Bloomington, Indiana, United States
| | - Ryan J. Coller
- Department of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin, United States
| | - Hannah Kearney
- Department of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin, United States
| | - Gemma Warner
- Department of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin, United States
| | - James A. Feinstein
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Michelle A. Chui
- Department of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin, United States
| | - Steve O'Brien
- Noble Applications, Madison, Wisconsin, United States
| | - Misty Willey
- Noble Applications, Madison, Wisconsin, United States
| | - Barbara Katz
- Family Voices of Wisconsin, Madison, Wisconsin, United States
| | - Theodore D. Bach
- Department of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin, United States
| | - Nicole E. Werner
- Department of Health and Wellness Design, Indiana University at Bloomington, Bloomington, Indiana, United States
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Kennedy HM, Cole A, Berbert L, Schenkel SR, DeGrazia M. An examination of characteristics, social supports, caregiver resilience and hospital readmissions of children with medical complexity. Child Care Health Dev 2024; 50:e13206. [PMID: 38123168 DOI: 10.1111/cch.13206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/18/2023] [Accepted: 11/19/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Children with medical complexity (CMC) account for 1% of children in the United States. These children experience frequent hospital readmissions, high healthcare costs and poor health outcomes. A link between CMC caregiver social support, resilience and hospital readmissions has never been fully investigated. This study examines the feasibility of a prospective, descriptive, repeated measures research design to characterize CMC and their caregivers, social supports, caregiver resilience and hospital readmissions to inform a larger prospective investigation. METHODS Caregivers of CMC with unplanned hospitalizations completed surveys at the index hospitalization and 30 and 60 days after discharge. CMC caregiver and child characteristics, social supports and hospital readmissions were examined using an investigator-developed survey. Resilience was measured using the Resilience Scale-14© (7-Point Likert Scale, score range 14-98), and feasibility was measured by calculating enrolment, attrition, survey completion and item response. Analysis included descriptive statistics and qualitative data visualization. RESULTS Of caregivers who were approached for participation, 81.1% consented and completed 76 surveys. Attrition was 31%. Item response rates were ≥ 90% for all but one item. A total of 62.1% of children had hospital readmissions within 90 days and 37.9% within 30 days. Additionally, 70% of caregivers had home care nursing, but the approved hours were only partially filled. More than 70% of caregiver resilience scores were moderate to high (score range 74-98) and were stable across repeated measures and hospital readmissions. Open-ended question responses revealed the following five categories: All-consuming, Family Reliance, Impact of Covid, Taking Action and Broken System. CONCLUSIONS Studying CMC caregiver social supports and resilience using repeated measures is feasible. CMC caregivers reported stressors including coordinating their child's substantial healthcare needs and managing partially filled home care nursing hours. Caregiver resilience remained stable over time, amidst frequent CMC hospital readmissions. Findings can inform future research priorities and power analyses for CMC caregiver resilience.
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Affiliation(s)
- Heather M Kennedy
- Department of Nursing Patient Care Services, Boston Children's Hospital, Boston, MA, USA
- Department of Neurology and Neurosurgery, Boston Children's Hospital, Boston, MA
| | - Alexandra Cole
- Cardiovascular and Critical Care Services, Boston Children's Hospital, Boston, MA, USA
| | - Laura Berbert
- Biostatistics and Research Design Center, Boston Children's Hospital, Boston, MA, USA
| | | | - Michele DeGrazia
- Department of Nursing Patient Care Services, Boston Children's Hospital, Boston, MA, USA
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Corden TE, Bartelt T, Johaningsmeir S, Ehlenbach ML, Coller RJ, Warner GG, Loman E, Steele CA, Granger R, McAtee R, Gordon J. Developing a Sustainable Care Delivery Payment Model for Children With Medical Complexity. Hosp Pediatr 2024; 14:e75-e82. [PMID: 38105673 DOI: 10.1542/hpeds.2023-007288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Children with medical complexity (CMC) are a small but growing population representing <1% of all children while accounting for >30% of childhood health care expenditure. Complex care is a relatively new discipline that has emerged with goals of improving CMC care, optimizing CMC family function, and reducing health care costs. The provision of care coordination services is a major function of most complex care programs. Unfortunately, most complex care programs struggle to achieve financial sustainability in a predominately fee-for-service environment. The article describes how 2 programs in Wisconsin worked with their state Medicaid payer through a Centers for Medicare and Medicaid Services Health Care Innovation Award to develop a sustainable complex care payment model, and the value the payment model is currently bringing to stakeholders. Key elements of the process included: Developing a relationship between payer and clinicians that allowed for an understanding of each's viewpoint, use of an accepted clinical service model, and an effort to measure cost of care for the service provided supported by time-study methodology.
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Affiliation(s)
- Timothy E Corden
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
- Children's Wisconsin, Milwaukee, Wisconsin
| | | | - Sarah Johaningsmeir
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mary L Ehlenbach
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
- American Family Children's Hospital, Madison, Wisconsin
| | - Ryan J Coller
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
- American Family Children's Hospital, Madison, Wisconsin
| | - Gemma G Warner
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
- American Family Children's Hospital, Madison, Wisconsin
| | - Emily Loman
- Department of Health Services, Wisconsin Medicaid, Madison, Wisconsin
| | - Craig A Steele
- Department of Health Services, Wisconsin Medicaid, Madison, Wisconsin
| | - Rebecca Granger
- Department of Health Services, Wisconsin Medicaid, Madison, Wisconsin
| | - Rebecca McAtee
- Department of Health Services, Wisconsin Medicaid, Madison, Wisconsin
- Optum, Madison, Wisconsin
| | - John Gordon
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
- Children's Wisconsin, Milwaukee, Wisconsin
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Nageswaran S, Dailey-Farley H, Golden SL. Telehealth for Children With Medical Complexity During the COVID Pandemic: A Qualitative Study Exploring Caregiver Experiences. Clin Pediatr (Phila) 2024; 63:53-65. [PMID: 37840305 DOI: 10.1177/00099228231204707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Children with medical complexity (CMC) receive care from many clinicians. Our objective is to describe caregivers' experiences about telehealth for CMC. This qualitative study conducted in North Carolina involves semistructured interviews with 23 caregivers of CMC (15 English; 8 Spanish). Data were analyzed using thematic content analysis. Five themes were identified: (1) telehealth allayed caregivers' fears about their children's exposure to COVID-19 and mitigated the challenges with in-person visits during the pandemic. (2) Telehealth reduced the logistical challenges of in-person visits for CMC, enabled providers to see children in their home environment, and prevented appointment cancelations. (3) System inaccessibility, technical problems, and providers' inability to deliver telehealth were challenges. (4) Inadequate evaluation of the child and caregiver-provider communication were limitations. (5) Caregivers were satisfied with telehealth, found variability in telehealth offering, and wished telehealth continued to remain an option. Telehealth is a viable option for outpatient care delivery for CMC.
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Affiliation(s)
- Savithri Nageswaran
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Social Sciences & Health Policy, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Heather Dailey-Farley
- Department of Social Sciences & Health Policy, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Swann-Thomsen HE, Sitts C, Hanks J, Tivis R. Implementing a social work care coordination model for children and youth with special health care needs in a rural-urban health system. SOCIAL WORK IN HEALTH CARE 2024; 63:188-204. [PMID: 38217440 DOI: 10.1080/00981389.2024.2304010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 01/05/2024] [Indexed: 01/15/2024]
Abstract
This retrospective chart review examined care coordination among pediatric patients with varying levels of medical complexity who received care in a rural-urban health system. Care coordination utilization across patient acuity levels was examined for meaningful differences in frequency and duration of care coordination services. Results indicated that patients with more severe medical complexity had increased frequency and duration of care coordination services, as well as different patterns of care coordination activity utilization. This model of pediatric outpatient care coordination provides a flexible and highly targeted approach for stratification of care and services based on the needs of the individual patient.
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Affiliation(s)
| | - Claire Sitts
- St. Luke's Children's Hospital, Boise, Idaho, USA
| | - John Hanks
- St. Luke's Children's Hospital, Boise, Idaho, USA
| | - Rick Tivis
- Applied Research Division, St. Luke's Health System, Boise, Idaho, USA
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Validova A, Strane D, Matone M, Wang X, Rosenquist R, Luan X, Rubin D. Underinsurance Among Children With Special Health Care Needs in the United States. JAMA Netw Open 2023; 6:e2348890. [PMID: 38147335 PMCID: PMC10751585 DOI: 10.1001/jamanetworkopen.2023.48890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/30/2023] [Indexed: 12/27/2023] Open
Abstract
Importance A rise in pediatric underinsurance during the last decade among households with children with special health care needs (CSHCN) requires a better understanding of which households, by health care burden or income level, have been most impacted. Objective To examine the prevalence of underinsurance across categories of child medical complexity and the variation in underinsurance within these categories across different levels of household income. Design, Setting, and Participants This cross-sectional study used data from the National Survey of Children's Health and included 218 621 US children from 2016 to 2021. All children included did not reside in any type of institution (eg, correctional institutions, juvenile facilities, orphanages, long-term care facilities). Data were analyzed from January 2016 to December 2021. Exposures The primary exposure is a categorization of child health care needs constructed using parent-reported child physical and behavioral health conditions, as well as the presence of functional limitations. Main Outcomes and Measures The primary outcome variable is underinsurance, defined as absence of consistent or adequate health insurance. Models were adjusted for demographic and socioeconomic characteristics and stratified by household income. Multivariate logistic regression analysis of pooled cross-sectional survey data across multiple years (2016 to 2021) adjusted for complex survey design (weights). Results In a total sample of 218 621 children who were not in institutions and were aged 0 to 17 years from 2016 to 2021 (105 478 [48.9%] female; 113 143 [51.1%] male; 13 571 [13.0%] non-Hispanic Black children; 149 706 [51.2%] non-Hispanic White children), underinsurance prevalence was higher among the children who had complex physical conditions (3316 [37.0%]), mental or behavioral conditions (5432 [38.1%]), or complex physical conditions and functional limitations (1407 [40.7%]) or mental or behavioral conditions with limitations (3442 [41.1%]), compared with healthy children (ie, children without special health care needs or limitations) (52 429 [31.2%]). The association between underinsurance and complexity of child health care needs varied by household income. In households earning 200% to 399% federal poverty level (FPL), underinsurance was associated with children having complex physical conditions and limitations (OR, 2.74; 95% CI, 2.13-3.51) and mental or behavioral conditions and limitations (OR, 2.21; 95% CI, 1.87-2.62), compared with healthy children. In households earning 400% or more above FPL, children's mental or behavioral conditions and limitations were associated with underinsurance (OR, 3.31; 95% CI, 2.82-3.88) compared with healthy children. Conclusions and relevance In this cross-sectional study, the odds of being underinsured were not uniform among CSHCN. Both medical complexity and daily functional limitations led to increased odds of being underinsured. The concentration of underinsurance among middle-income households underpinned the challenge of health care financing for families of CSHCN whose incomes surpassed eligibility thresholds for dependent Medicaid insurance.
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Affiliation(s)
- Asiya Validova
- PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Douglas Strane
- PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics at University of Pennsylvania, Philadelphia
| | - Meredith Matone
- PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics at University of Pennsylvania, Philadelphia
| | - Xi Wang
- PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics at University of Pennsylvania, Philadelphia
| | - Rebecka Rosenquist
- PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Xianqun Luan
- PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David Rubin
- PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics at University of Pennsylvania, Philadelphia
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Orlinsky R, Land S, Flohr S, Rintoul N, Goldshore M, Hedrick HL. Birth Admission Length-of-Stay and Hospital Readmission in Children With Congenital Diaphragmatic Hernia. J Pediatr Surg 2023; 58:2368-2374. [PMID: 37659921 DOI: 10.1016/j.jpedsurg.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND The objective of this study was to identify factors associated with prolonged birth admission length of stay (LOS) and to evaluate the association between these characteristics and readmission in the year following discharge for children with congenital diaphragmatic hernia (CDH). METHODS This was a single-center retrospective cohort study of children with isolated CDH born in the Special Delivery Unit and admitted to the Newborn/Infant Intensive Care Unit at Children's Hospital of Philadelphia from April 2008 to August 2019. Birth admission hospitalization was categorized into 3 groups (≤35, 36-75, and >76 days) based on the data distribution. Participant factors included gestational age (days), side of CDH (right/left), liver position (up/down), CDH repair technique (open/minimally invasive), exposure to extracorporeal membrane oxygenation, lung-to-head circumference ratio, and feeding tube at discharge. Chi-squared, t-tests and analysis of variance were used to examine bivariable associations between participant characteristics, birth admission LOS and readmission in the year following initial hospital discharge. Multivariable logistic regression was used to evaluate factors associated with readmission. RESULTS Children hospitalized ≥76 days at birth had 4.33 (95% CI: 1.2, 15.2) higher odds of readmission than those admitted for ≤35 days. Children with a non-operative feeding tube at discharge had 4.12 (895% CI: 1.6, 10.5) higher odds of readmission when compared to those with no feeding tube at discharge. CONCLUSIONS Longer birth hospitalization and non-operative feeding tube are associated with increased readmissions in the year after discharge. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Rachel Orlinsky
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA; University of Maryland Medical Center, Baltimore, MD, USA
| | - Sierra Land
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA.
| | - Sabrina Flohr
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA
| | - Natalie Rintoul
- Division of Neonatology, Children's Hospital of Philadelphia, PA, USA
| | - Matthew Goldshore
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA
| | - Holly L Hedrick
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, PA, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, PA, USA
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Materula D, Currie G, Jia XY, Finlay B, Richard C, Yohemas M, Lachuk G, Estes M, Dewan T, MacEachern S, Gall N, Gibbard B, Zwicker JD. Measure what matters: considerations for outcome measurement of care coordination for children with neurodevelopmental disabilities and medical complexity. Front Public Health 2023; 11:1280981. [PMID: 38026305 PMCID: PMC10656699 DOI: 10.3389/fpubh.2023.1280981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Care Coordination (CC) is a significant intervention to enhance family's capacity in caring for children with neurodevelopmental disability and medical complexity (NDD-MC). CC assists with integration of medical and behavioral care and services, partnerships with medical and community-based supports, and access to medical, behavioral, and educational supports and services. Although there is some consensus on the principles that characterize optimal CC for children with NDD-MC, challenges remain in measuring and quantifying the impacts of CC related to these principles. Two key challenges include: (1) identification of measures that capture CC impacts from the medical system, care provider, and family perspectives; and (2) recognition of the important community context outside of a hospital or clinical setting. Methods This study used a multilevel model variant of the triangulation mixed methods design to assess the impact of a CC project implemented in Alberta, Canada, on family quality of life, resource use, and care integration at the broader environmental and household levels. At the broader environmental level, we used linked administrative data. At the household level we used quantitative pre-post survey datasets, and aggregate findings from qualitative interviews to measure group-level impacts and an embedded multiple-case design to draw comparisons, capture the nuances of children with NDD-MC and their families, and expand on factors driving the high variability in outcome measures. Three theoretical propositions formed the basis of the analytical strategy for our case study evidence to explore factors affecting the high variability in outcome measures. Discussion This study expanded on the factors used to measure the outcomes of CC and adds to our understanding of how CC as an intervention impacts resource use, quality of life, and care integration of children with NDD-MC and their families. Given the heterogeneous nature of this population, evaluation studies that account for the variable and multi-level impacts of CC interventions are critical to inform practice, implementation, and policy of CC for children with NDD-MC.
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Affiliation(s)
- Dércia Materula
- School of Public Policy, University of Calgary, Calgary, AB, Canada
| | - Genevieve Currie
- School of Public Policy, University of Calgary, Calgary, AB, Canada
- School of Nursing and Midwifery, Mount Royal University, Calgary, AB, Canada
| | - Xiao Yang Jia
- School of Public Policy, University of Calgary, Calgary, AB, Canada
| | - Brittany Finlay
- School of Public Policy, University of Calgary, Calgary, AB, Canada
| | | | | | - Gina Lachuk
- Alberta Health Services, Calgary, AB, Canada
| | - Myka Estes
- Alberta Health Services, Calgary, AB, Canada
| | | | - Sarah MacEachern
- Alberta Health Services, Calgary, AB, Canada
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Nadine Gall
- Alberta Health Services, Calgary, AB, Canada
| | - Ben Gibbard
- Alberta Health Services, Calgary, AB, Canada
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jennifer D. Zwicker
- School of Public Policy, University of Calgary, Calgary, AB, Canada
- Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
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47
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Larson IA, Zaniletti I, Gupta R, Wright SM, Winterer C, Toburen C, Williams K, Goodwin EJ, Northup RM, Roderick E, Hall M, Colvin JD. Accuracy of the Exeter Hospitalizations-Office Visits-Medical Conditions-Extra Care-Social Concerns Index for Identifying Children With Complex Chronic Medical Conditions in the Clinical Setting. Acad Pediatr 2023; 23:1553-1560. [PMID: 37516350 DOI: 10.1016/j.acap.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 07/20/2023] [Accepted: 07/22/2023] [Indexed: 07/31/2023]
Abstract
OBJECTIVE Our objective was to determine the accuracy of a point-of-care instrument, the Hospitalizations-Office Visits-Medical Conditions-Extra Care-Social Concerns (HOMES) instrument, in identifying patients with complex chronic conditions (CCCs) compared to an algorithm used to identify patients with CCCs within large administrative data sets. METHODS We compared the HOMES to Feudtner's CCCs classification system. Using administrative algorithms, we categorized primary care patients at a children's hospital into 3 categories: no chronic conditions, non-complex chronic conditions, and CCCs. We randomly selected 100 patients from each category. HOMES scoring was completed for each patient. We performed an optimal cut-point analysis on 80% of the sample to determine which total HOMES score best identified children with ≥1 CCC and ≥2 CCCs. Using the optimal cut points and the remaining 20% of the study population, we determined the odds and area under the curve (AUC) of having ≥1 CCC and ≥2 CCCs. RESULTS The median (interquartile range [IQR]) age was 4 (IQR: 0, 8). Using optimal cut points of ≥7 for ≥1 CCC and ≥11 for ≥2 CCCs, the odds of having ≥1 CCC was 19 times higher than lower scores (odds ratio [OR] 19.1 [95% confidence interval [CI]: 9.75, 37.5]) and of having ≥2 CCCs was 32 times higher (OR 32.3 [95% CI: 12.9, 50.6]). The AUCs were 0.76 for ≥1 CCC (sensitivity 0.82, specificity 0.80) and 0.74 for ≥2 CCCs (sensitivity 0.92, specificity 0.74). CONCLUSIONS The HOMES accurately identified patients with CCCs.
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Affiliation(s)
- Ingrid A Larson
- Administration (IA Larson), Children's Mercy Hospital Kansas, Overland Park
| | - Isabella Zaniletti
- Analytics, Children's Hospital Association (I Zaniletti and M Hall), Kansas City, Kans
| | - Rupal Gupta
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - S Margaret Wright
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Courtney Winterer
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Cristy Toburen
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Kristi Williams
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Emily J Goodwin
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Ryan M Northup
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Edie Roderick
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Matt Hall
- Analytics, Children's Hospital Association (I Zaniletti and M Hall), Kansas City, Kans; Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo
| | - Jeffrey D Colvin
- Department of Pediatrics (R Gupta, SM Wright, C Winterer, C Toburen, K Williams, EJ Goodwin, RM Northup, E Roderick, M Hall, and JD Colvin), Children's Mercy Kansas City, Mo.
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48
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Belza C, Pullenayegum E, Nelson KE, Aoyama K, Fu L, Buchanan F, Diaz S, Goldberg O, Guttmann A, Hepburn CM, Mahant S, Martens R, Nathwani A, Saunders NR, Cohen E. Severe Respiratory Disease Among Children With and Without Medical Complexity During the COVID-19 Pandemic. JAMA Netw Open 2023; 6:e2343318. [PMID: 37962886 PMCID: PMC10646732 DOI: 10.1001/jamanetworkopen.2023.43318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/05/2023] [Indexed: 11/15/2023] Open
Abstract
Importance Severe respiratory disease declined during the COVID-19 pandemic, partially due to decreased circulation of respiratory pathogens. However, the outcomes of children with higher risk have not been described using population-based data. Objective To compare respiratory-related hospitalizations, intensive care unit (ICU) admissions, and mortality during the pandemic vs prepandemic, among children with medical complexity (CMC) and without medical complexity (non-CMC). Design, Setting, and Participants This population-based repeated cross-sectional study used Canadian health administrative data of children aged younger than 18 years in community and pediatric hospitals during a pandemic period (April 1, 2020, to February 28, 2022) compared with a 3-year prepandemic period (April 1, 2017, to March 31, 2020). The pandemic period was analyzed separately for year 1 (April 1, 2020, to March 31, 2021) and year 2 (April 1, 2021, to February 28, 2022). Statistical analysis was performed from October 2022 to April 2023. Main Outcomes and Measures Respiratory-related hospitalizations, ICU admissions, and mortality before and during the pandemic among CMC and non-CMC. Results A total of 139 078 respiratory hospitalizations (29 461 respiratory hospitalizations for CMC and 109 617 for non-CMC) occurred during the study period. Among CMC, there were fewer respiratory hospitalizations in both 2020 (rate ratio [RR], 0.44 [95% CI, 0.42-0.46]) and 2021 (RR, 0.55 [95% CI, 0.51-0.62]) compared with the prepandemic period. Among non-CMC, there was an even larger relative reduction in respiratory hospitalizations in 2020 (RR, 0.18 [95% CI, 0.17-0.19]) and a similar reduction in 2021 (RR, 0.55 [95% CI, 0.54-0.56]), compared with the prepandemic period. Reductions in ICU admissions for respiratory illness followed a similar pattern for CMC (2020: RR, 0.56 [95% CI, 0.53-0.59]; 2021: RR, 0.66 [95% CI, 0.63-0.70]) and non-CMC (2020: RR, 0.22 [95% CI, 0.20-0.24]; RR, 0.65 [95% CI, 0.61-0.69]). In-hospital mortality for these conditions decreased among CMC in both 2020 (RR, 0.63 [95% CI, 0.51-0.77]) and 2021 (RR, 0.72 [95% CI, 0.59-0.87]). Conclusions and Relevance This cross-sectional study found a substantial decrease in severe respiratory disease resulting in hospitalizations, ICU admissions, and mortality during the first 2 years of the pandemic compared with the 3 prepandemic years. These findings suggest that future evaluations of the effect of public health interventions aimed at reducing circulating respiratory pathogens during nonpandemic periods of increased respiratory illness may be warranted.
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Affiliation(s)
- Christina Belza
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eleanor Pullenayegum
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
| | - Katherine E. Nelson
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health, Policy, Management and Evaluation, The University of Toronto, Toronto, Ontario, Canada
| | - Kazuyoshi Aoyama
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine. The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Medical Science, The University of Toronto, Toronto, Ontario, Canada
| | | | | | - Sanober Diaz
- Provincial Council for Maternal and Child Health
| | - Ori Goldberg
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Pulmonology Institute, Schneider Children’s Medical Center of Israel, Petach Tikva, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Astrid Guttmann
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health, Policy, Management and Evaluation, The University of Toronto, Toronto, Ontario, Canada
| | - Charlotte Moore Hepburn
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sanjay Mahant
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health, Policy, Management and Evaluation, The University of Toronto, Toronto, Ontario, Canada
| | | | - Apsara Nathwani
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Natasha R. Saunders
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health, Policy, Management and Evaluation, The University of Toronto, Toronto, Ontario, Canada
| | - Eyal Cohen
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health, Policy, Management and Evaluation, The University of Toronto, Toronto, Ontario, Canada
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49
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Glick AF, Farkas JS, Magro J, Shah AV, Taye M, Zavodovsky V, Rodriguez RH, Modi AC, Dreyer BP, Famiglietti H, Yin HS. Management of Discharge Instructions for Children With Medical Complexity: A Systematic Review. Pediatrics 2023; 152:e2023061572. [PMID: 37846504 PMCID: PMC10598634 DOI: 10.1542/peds.2023-061572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 10/18/2023] Open
Abstract
CONTEXT Children with medical complexity (CMC) are at risk for adverse outcomes after discharge. Difficulties with comprehension of and adherence to discharge instructions contribute to these errors. Comprehensive reviews of patient-, caregiver-, provider-, and system-level characteristics and interventions associated with discharge instruction comprehension and adherence for CMC are lacking. OBJECTIVE To systematically review the literature related to factors associated with comprehension of and adherence to discharge instructions for CMC. DATA SOURCES PubMed/Medline, Embase, Cochrane Central Register of Controlled Trials, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, Web of Science (database initiation until March 2023), and OAIster (gray literature) were searched. STUDY SELECTION Original studies examining caregiver comprehension of and adherence to discharge instructions for CMC (Patient Medical Complexity Algorithm) were evaluated. DATA EXTRACTION Two authors independently screened titles/abstracts and reviewed full-text articles. Two authors extracted data related to study characteristics, methodology, subjects, and results. RESULTS Fifty-one studies were included. More than half were qualitative or mixed methods studies. Few interventional studies examined objective outcomes. More than half of studies examined instructions for equipment (eg, tracheostomies). Common issues related to access, care coordination, and stress/anxiety. Facilitators included accounting for family context and using health literacy-informed strategies. LIMITATIONS No randomized trials met inclusion criteria. Several groups (eg, oncologic diagnoses, NICU patients) were not examined in this review. CONCLUSIONS Multiple factors affect comprehension of and adherence to discharge instructions for CMC. Several areas (eg, appointments, feeding tubes) were understudied. Future work should focus on design of interventions to optimize transitions.
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Affiliation(s)
| | | | - Juliana Magro
- Health Sciences Libraries, NYU Langone Health, New York, New York
| | | | | | | | | | - Avani C. Modi
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | | | - H. Shonna Yin
- Department of Pediatrics
- Department of Population Health, NYU Langone Health, New York, New York
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50
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Mejía González MA, Quijada Morales P, Escobar MÁ, Juárez Guerrero A, Seoane-Reula ME. Navigating the transition of care in patients with inborn errors of immunity: a single-center's descriptive experience. Front Immunol 2023; 14:1263349. [PMID: 37854610 PMCID: PMC10579936 DOI: 10.3389/fimmu.2023.1263349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/15/2023] [Indexed: 10/20/2023] Open
Abstract
The transition from pediatric to adult care is a critical milestone in managing children, especially in those with complex chronic conditions. It involves ensuring the patient and family adapt correctly to the new phase, maintaining continuity of ongoing treatments, and establishing an appropriate follow-up plan with specialists. Patients with Inborn error of immunity (IEI), formerly known as Primary Immune Disorders (PID) are part of a group of disorders characterized by alterations in the proper functioning of the immune system; as the diagnostic and treatment tools for these entities progress, life expectancy increases, and new needs emerge. These children have special needs during the transition. Particularly important in the group of children with PID and syndromic features, who often present multiple chronic medical conditions. In these cases, transition planning is a significant challenge, involving not only the patients and their families but also a wide range of specialists. To achieve this, a multidisciplinary transition team should be established between the pediatric specialists and the adult consultants, designing a circuit in which communication is essential. As few transition care guidelines in the field of PID are available, and to our knowledge, there is no specific information available regarding patients with PID associated with syndromic features, we share our experience in this issue as a Primary Immunodeficiencies Unit that is a National Reference Center for PID, and propose a guide to achieve an adequate and successful transition to adulthood in these patients, especially in those with associated syndromic features.
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Affiliation(s)
- María Alejandra Mejía González
- Immunology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Primary Immunodeficiencies Unit (National Reference Center for Primary Immunodeficiencies (PID)), Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Patricia Quijada Morales
- Primary Immunodeficiencies Unit (National Reference Center for Primary Immunodeficiencies (PID)), Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Pediatric Immuno-Allergy, Allergy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - María Ángeles Escobar
- Primary Immunodeficiencies Unit (National Reference Center for Primary Immunodeficiencies (PID)), Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Day-care Hospital of Immunology, Department of Nursing of Day-care Hospital, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Alba Juárez Guerrero
- Primary Immunodeficiencies Unit (National Reference Center for Primary Immunodeficiencies (PID)), Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Pediatric Immuno-Allergy, Allergy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - María Elena Seoane-Reula
- Primary Immunodeficiencies Unit (National Reference Center for Primary Immunodeficiencies (PID)), Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Pediatric Immuno-Allergy, Allergy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Medical Advisor of the Spanish Association of Primary Immunodeficiencies (AEDIP), Madrid, Spain
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