Cost saving and quality of care in a pediatric accountable care organization

Predicting Dental General Anesthesia Use among Children with Behavioral Health Conditions

OBJECTIVES

To evaluate how different data sources affect the performance of machine learning algorithms that predict dental general anesthesia use among children with behavioral health conditions.

STUDY DESIGN

Observational study using claims data.

METHODS

Using Medicaid claims from Partners For Kids (2013-2019), electronic medical record data, and the Ohio Child Opportunity Index, we conducted a retrospective cohort study of 12,410 children with behavioral health diagnoses. Four lasso-regularized logistic regression models were developed to predict dental general anesthesia use, each incorporating different data sources. Lift scores, or the ratio of positive predictive value to base case prevalence, were used to compare models, and a lift score of 2.5 was considered minimally acceptable for risk prediction.

RESULTS

Dental general anesthesia use ranged from 3.2% to 3.9% across models, which made it difficult for the machine learning models to achieve high positive predictive value. Model performance was best when either the electronic medical record (lift = 2.59) or Ohio Child Opportunity Index (lift = 2.56), but not both (lift = 2.34) or neither (lift = 1.87), was used.

CONCLUSIONS

Incorporating additional data sources improved machine learning model performance, and 2 models achieved satisfactory performance. The model using electronic medical record data could be applied in hospital-based settings, and the model using the Ohio Child Opportunity Index could be more valuable in community-based settings.

KNOWLEDGE TRANSFER STATEMENT

Machine learning was applied to satisfactorily predict which children with behavioral health diagnoses would require dental treatment under general anesthesia. Incorporating electronic medical record data or area-level social determinants of health data, but not both, improved the performance of the machine learning predictions. The 2 highest performing models could be applied by hospitals using medical record data or by organizations using area-level social determinants of health data to risk stratify the pediatric behavioral health population.

Age of first dental visits: A benefit of the pediatric medical home

OBJECTIVE

This retrospective cohort study compared differences in age one dental visit use and age at first dental visit according to fluoride varnish receipt at the pediatric medical home.

METHODS

Enrollment and claims data were used from Partners For Kids, a pediatric accountable care organization covering Medicaid-enrolled children living in 47 of 88 counties in Ohio. The main outcomes were having an age one dental visit and the mean age at first dental visit. Descriptive statistics and bivariate comparisons were applied.

RESULTS

Among 17,675 children, 2.8% had an age one dental visit. The mean age at first dental visit was 4.8 years. Children who received fluoride varnish from their medical home (12% of study population) were significantly younger at their first dental visit (4.1 vs. 4.9 years, p < 0.001).

CONCLUSION

Despite longstanding recommendations for the age one dental visit, very few Medicaid-enrolled children in Ohio had one. The pediatric medical home lowered the age of first dental visit.

The Impact of Medicaid Accountable Care Organizations on Health Care Utilization, Quality Measures, Health Outcomes and Costs from 2012 to 2023: A Scoping Review

Most of the evidence regarding the success of ACOs is from the Medicare program. This review evaluates the impacts of ACOs within the Medicaid population. We identified 32 relevant studies published between 2012 and 2023 which analyzed the association of Medicaid ACOs and health care utilization (n = 21), quality measures (n = 18), health outcomes (n = 10), and cost reduction (n = 3). The results of our review regarding the effectiveness of Medicaid ACOs are mixed. Significant improvements included increased primary care visits, reduced admissions, and reduced inpatient stays. Cost reductions were reported in a few studies, and savings were largely dependent on length of attribution and years elapsed after ACO implementation. Adopting the ACO model for the Medicaid population brings some different challenges from those with the Medicare population, which may limit its success, particularly given differences in state Medicaid programs.

An Accountable Care Organization Maintains Access for Appendicitis During the COVID-19 Pandemic

INTRODUCTION

It has been reported that pediatric patients experienced a delay in treatment for acute appendicitis during the pandemic, resulting in increased rates of complicated appendicitis. We investigated the association of the COVID-19 pandemic and the incidence and severity of acute appendicitis among pediatric Medicaid patients using a population-based approach.

METHODS

The claims database of Partners For Kids, a pediatric Medicaid accountable care organization (ACO) in Ohio, was queried for cases of acute appendicitis from April to August 2017-2020. The monthly rate of acute appendicitis/100,000 covered lives was calculated each year and compared over time. Rates of complicated appendicitis were also compared. Diagnosis code validation for classification as complicated or uncomplicated appendicitis was performed for patients treated at our hospital.

RESULTS

During the study period, 465 unique cases of acute appendicitis were identified. Forty percent (186/465) were coded as complicated. No significant difference in the incidence of acute appendicitis cases was observed across the 4 y, either in an overall comparison or in pairwise comparisons (P > 0.15 for all). The proportion of acute appendicitis cases that were coded as complicated did vary significantly over the 4-year study period (P = 0.005); this was due to this proportion being significantly higher in 2018 than in either 2019 (P = 0.005 versus 2018) or 2020 (P = 0.03 versus 2018).

CONCLUSIONS

The COVID-19 pandemic was not associated with reduced access to treatment for acute appendicitis among patients in a pediatric Medicaid ACO. This suggests that an ACO may promote continued healthcare access for their covered population during an unexpected crisis.

Analysis of North Carolina Medicaid Claims Data to Simulate a Pediatric Accountable Care Organization

Importance

Despite momentum for pediatric value-based payment models, little is known about tailoring design elements to account for the unique needs and utilization patterns of children and young adults.

Objective

To simulate attribution to a hypothetical pediatric accountable care organization (ACO) and describe baseline demographic characteristics, expenditures, and utilization patterns over the subsequent year.

Design, Setting, and Participants

This retrospective cohort study used Medicaid claims data for children and young adults aged 1 to 20 years enrolled in North Carolina Medicaid at any time during 2017. Children and young adults receiving at least 50% of their primary care at a large academic medical center (AMC) in 2017 were attributed to the ACO. Data were analyzed from April 2020 to March 2021.

Main Outcomes and Measures

Primary outcomes were total cost of care and care utilization during the 2018 performance year.

Results

Among 930 266 children and young adults (377 233 children [40.6%] aged 6-12 years; 470 612 [50.6%] female) enrolled in Medicare in North Carolina in 2017, 27 290 children and young adults were attributed to the ACO. A total of 12 306 Black non-Hispanic children and young adults (45.1%), 6308 Hispanic or Latinx children and young adults (23.1%), and 6531 White non-Hispanic children and young adults (23.9%) were included. Most attributed individuals (23 133 individuals [84.7%]) had at least 1 claim in the performance year. The median (IQR) total cost of care in 2018 was $347 ($107-$1123); 272 individuals (1.0%) accounted for nearly half of total costs. Compared with children and young adults in the lowest-cost quartile, those in the highest-cost quartile were more likely to have complex medical conditions (399 individuals [6.9%] vs 3442 individuals [59.5%]) and to live farther from the AMC (median [IQR distance, 6.0 [4.6-20.3] miles vs 13.9 [4.6-30.9] miles). Total cost of care was accrued in home (43%), outpatient specialty (19%), inpatient (14%) and primary (8%) care. More than half of attributed children and young adults received care outside of the ACO; the median (IQR) cost for leaked care was $349 ($130-$1326). The costliest leaked encounters included inpatient, ancillary, and home health care, while the most frequently leaked encounters included behavioral health, emergency, and primary care.

Conclusions and Relevance

This cohort study found that while most children attributed to the hypothetical Medicaid pediatric ACO lived locally with few health care encounters, a small group of children with medical complexity traveled long distances for care and used frequent and costly home-based and outpatient specialty care. Leaked care was substantial for all attributed children, with the cost of leaked care being higher than the total cost of care. These pediatric-specific clinical and utilization profiles have implications for future pediatric ACO design choices related to attribution, accounting for children with high costs, and strategies to address leaked care.

Children's surgery verification and value-based care in pediatric surgery

With the prevailing focus on increasing value in healthcare, understanding the different components of the value equation is of primary importance. Michael E. Porter's writings on the value agenda and the use of integrated practice units (IPUs) have provided easy correlation to adult disease entities with large populations sharing common pathways and providers in the diagnosis and care of these patients. In pediatric surgery, with smaller populations and larger numbers of rare or unique conditions and anatomic challenges, utilizing the concept of an IPU is more challenging. The literature has generally shown the improvements in quality of care through participation in various programs through the American College of Surgeons (ACS) such as trauma verification, or the National Surgical Quality Improvement Project (NSQIP), but that participation alone does not guarantee better outcomes. Use of these programs in conjunction with participation in quality collaboratives have tended to show favorable returns on investment for these programs. We seek to demonstrate how the Children's Surgery Verification (CSV) program provides pediatric surgeons an effective vehicle with which to engage the value agenda, evaluating and improving care over the care continuum in order to improve the function of children's hospitals as larger integrated units.

Evaluating Inpatient Hospital Charges Associated With Trauma Service Patients Participating in an Accountable Care Organization

Background

The Medicare Accountable Care Organization (ACO) Program has created a vehicle for providers who practice cost containment and exceed quality for the Medicare population. The success of ACO's nationwide have been well documented. However, there is little research evaluating if there is a cost saving benefit in trauma care with respect to participating in an ACO. Thus, the primary objective of this study was to evaluate inpatient hospital charges associated with trauma service utilization of patients participating in the ACO compared to non-ACO patients.

Methods

This case-control retrospective study includes a comparison of inpatients charges of ACO patients (cases) and general trauma patients (controls) presenting to our trauma center in Staten Island, New York from January 1st, 2019 to December 31st, 2021. A 1:1 matching of case to control was performed based on age, sex, race, and injury severity score. Statistical analysis was performed with IBM SPSS, with P < .05 as significant.

Results

A total of 80 patients were included in the ACO cohort and 80 matched in the General Trauma cohort. Patient demographics were similar. Comorbidities were similar with the exception of a higher in incidence of hypertension (75.0% vs 47.5%, P < .001) and cardiac disease (35.0% vs 17.5%, P = .012) in the ACO cohort. Both the ACO and general trauma cohort had similar Injury Severity Scores, number of visits and lenght of stay. Both charge total ($76 148.93 vs $70 916.82, P = .630) receipt total ($15 080.26 vs $14 180, P = .662) charges were similar between ACO and General Trauma patients.

Conclusion

In spite of increased incidence of hypertension and cardiac disease in ACO trauma patients, mean Injury Severity Score, number of visits, length of hospital stay, ICU admission rate and charge total was similar compared to general trauma patients presenting to our Level 1 Adult Trauma Center.

Dental Care Differences Among the Behavioral Health Population in an Accountable Care Organization: A Retrospective Cohort

OBJECTIVE

To compare dental utilization and expenditures between children with and without behavioral health (BH) diagnoses in an accountable care organization.

METHODS

This retrospective cohort study used enrollment and claims data of Medicaid-enrolled children in Ohio. Children with 7 years of continuous enrollment from 2013 to 2019 were included. We calculated 5 dental utilization outcomes: 1) Diagnostic only visits, 2) Preventive visits, 3) Treatment visits, 4) Treatment visits under general anesthesia (GA), and 5) Orthodontic visits. Total 7-year cumulative expenditures were calculated for each outcome. Multivariable logistic regression models were run for each outcome adjusting for demographics and medical comorbidities.

RESULTS

Among 77,962 children, 23% had ≥1 BH diagnosis. No utilization differences were noted between children with and without BH for diagnostic only visits, treatment visits, and orthodontic visits. BH status modified the likelihood of having a preventive visit and dental GA visits based on medical comorbidity. For example, children with BH diagnoses had significantly lower odds of a preventive visit (eg, non-complex chronic comorbidity: odds ratio [OR] = 0.87, 95% confidence interval [CI]: 0.85-0.89), and significantly higher odds of a dental treatment under general anesthesia visit (eg, non-chronic comorbidity: OR = 3.69, 95% CI: 3.26-4.18). The total cumulative dental expenditures were $10.5M greater for children with BH.

CONCLUSIONS

Children with BH diagnoses were significantly less likely to have preventive visits and more likely to have dental GA visits, which was expensive. Early identification and intervention could alter treatment approaches, improve care, reduce risk of harm, and achieve cost-savings within a pediatric accountable care organization.

Guiding Principles for Managed Care Arrangements for the Health of Newborns, Infants, Children, Adolescents and Young Adults

Managed care arrangements are an approach to health care delivery in which the payer or other health care entity has policies that affect where care is delivered, what services are covered, and how payment is determined. When policies are intentionally designed, transparently administered, and continuously monitored, they are more likely to improve the population's utilization of services, access to quality primary and specialty care, and access to appropriate medications. When managed care arrangements are designed well, particularly within evolving payment models, health care can be delivered in a manner that supports the goals of the Quadruple Aim: to reduce per capita costs of health care, to improve the health of populations, to improve the experience of patients receiving care, and to improve the experience of those who are providing care. The American Academy of Pediatrics (AAP) urges payers and health care entities to use the key principles outlined in this statement when designing and implementing managed care arrangements and policies that cover newborn infants, infants, children, adolescents, and young adults to support the goal of improving the effectiveness of the health care delivery system for the pediatric population. The principles described in this statement are intended to complement those previously published in other AAP policies including "Principles of Child Health Care Financing," "Scope of Health Care Benefits for Children From Birth Through Age 26," "Patient- and Family-Centered Care and the Pediatrician's Role," and the "AAP Access Principles."

What Can Canada Learn From Accountable Care Organizations: A Comparative Policy Analysis

Introduction:

Accountable Care Organizations (ACOs), implemented in the United States (US), aim to reduce costs and integrate care by aligning incentives among providers and payers. Canadian governments are interested adopting such models to integrate care, though comparative studies assessing the applicability and transferability of ACOs in Canada are lacking. In this comparative study, we performed a narrative literature review to examine how Canadian health systems could support ACO models.

Methods:

We reviewed empirical studies (published 2011–2020) that evaluated ACO impacts in the US. Thematic analysis and critical appraisal were performed to identify factors associated with positive ACO impacts. These factors were compared with the Canadian context to assess the applicability and transferability of ACO models within Canada.

Findings:

Physician-led models, global budgets and financial incentives, and focus on collaborative care may optimize ACO impacts. While reforms towards alternative payments and team-based care are not unprecedented in Canada, significant further reforms to physician remuneration, intersectoral collaboration, and accountability for performance are required to support ACO-like models.

Conclusion:

This comparative study uncovered several insights on the applicability and transferability of ACOs to the Canadian context. Further comparative research outside the US is needed to infer the essential components of successful ACO models.

Research Agenda for Implementation of Principles of Care for Children and Youth With Special Health Care Needs

OBJECTIVE

Children and youth with special health care needs (CYSHCN) have a range of medical, educational, and support service needs to achieve optimal health and wellness. Principles of care for CYSHCN have been well described, but the literature is lacking particularly on implementation and integration of care across different settings and systems. The objective of this manuscript is to define a research agenda for principles of care for CYSHCN.

METHODS

Literature review examined principles of care for CYSHCN. Existing research gaps and priorities for principles of care were drawn from the literature review, a recently developed national research agenda for CYSHCN, and stakeholder consensus.

RESULTS

Specific implementation areas of inquiry include family partner roles within and across systems; life course approach for CYSHCN; roles and training of interdisciplinary team members; and implementation, spread, and sustainability studies. Proposed methods include implementation science-based and comparative effectiveness research. A common set of metrics including health care utilization, clinical outcomes, and family and provider needs should be considered to evaluate implementation of principles of care.

CONCLUSIONS

Implementation science and comparative effectiveness methods are needed to further understanding about how to adopt and spread principles of care for CYSHCN. The evolving demographics of CYSHCN add relevance and urgency for research findings.

Pediatric Primary Health Care: The Central Role of Pediatricians in Maintaining Children's Health in Evolving Health Care Models

Pediatric primary health care (PPHC) is of principal importance to the health and development of all children, helping them reach their true potential. Pediatricians, as the clinicians most intensively trained and experienced in child health, are the natural leaders of PPHC within the context of the medical home. Given the rapidly evolving models of pediatric health care delivery, including the explosion of telehealth in the wake of the COVID-19 pandemic, pediatricians, together with their representative national organizations such as the American Academy of Pediatrics (AAP), are the most capable clinicians to guide policy innovations on both the local and national stage.

Advanced imaging use and payment trends in a large pediatric accountable care organization

BACKGROUND

Pediatric imaging use and payment trends in accountable care organizations (ACOs) are seldom studied but are important for health policy decisions and resource allocation.

OBJECTIVE

To evaluate patterns of advanced imaging use and associated payments over a 7-year period at a large ACO in the USA serving a Medicaid population.

MATERIALS AND METHODS

We reviewed paid claims data from 2011 through 2017 from an ACO, analyzing the MRI, CT and US use trends and payments from emergency department (ED) and outpatient encounters. We defined "utilization rate" as the number of advanced imaging procedures per 100 enrolled children per calendar year. Average yearly utilization and payments trends were analyzed using Pearson correlation.

RESULTS

Across 7 years, 186,552 advanced imaging procedures were performed. The average overall utilization rate was 6.99 (95% confidence interval [CI]: 6.9-7.1). In the ED this was 2.7 (95% CI: 2.6-2.8) and in outpatients 4.3 (95% CI: 4.2-4.3). The overall utilization rate grew by 0.7% yearly (P=0.077), with US growing the most at 4.0% annually (P=0.0005), especially in the ED in the US, where it grew 10.8% annually (P=0.000019). The overall payments were stable from 2011 to 2017, with outpatient MRI seeing the largest payment decrease at 1.8% (P=0.24) and ED US showing the most growth at 3.3% (P=0.00016). Head CT and abdominal US were the two most common procedures.

CONCLUSION

Over the study period, advanced imaging utilization at this large pediatric ACO serving the Medicaid population increased, especially with US use in the ED. Overall payments related to advanced imaging remained stable over this period.

Evaluation of a Care Management Program for Pediatric Epilepsy Patients

OBJECTIVE

To evaluate the impact of a pediatric epilepsy care management intervention on emergency department visits, hospitalizations, and seizure freedom.

METHODS

We conducted a prospective observational study at a single academic medical center. Children with epilepsy with high risk of frequent emergency department use were enrolled in the intervention from January through May 2015, which included a baseline visit and follow-up support from a care management team. Controls selected from the same institution received standard of care. Baseline and follow-up information were collected from electronic health records and surveys (Family Impact Scale, Pediatric Epilepsy Medication Self-Management Questionnaire). Propensity score-weighted logistic regression compared emergency department visits, unplanned hospitalizations, and 3-month seizure freedom after 1 year in the intervention vs control groups.

RESULTS

A total of 56 children were enrolled in the intervention and 359 received standard of care. The intervention group was younger and had greater use of health services at baseline. When comparing the intervention to standard of care after 1 year, we found no significant difference in the risk of any emergency department visit (adjusted odds ratio [OR] 2.2, 95% confidence interval [CI] 0.6-8.5) or seizure freedom (adjusted OR 2.5, 95% CI 0.3-21.5). However, the risk of unplanned hospital admissions remained higher in the intervention group (adjusted OR 23.1, 95% CI 5.1-104).

CONCLUSION

We did not find that children with epilepsy who received a care management intervention had less use of health services or better clinical outcomes after a year compared with controls. The study is limited by small sample size and nonrandomized study design.

A Machine Learning Approach to Uncovering Hidden Utilization Patterns of Early Childhood Dental Care Among Medicaid-Insured Children

Background: Early childhood dental care (ECDC) is a significant public health opportunity since dental caries is largely preventable and a prime target for reducing healthcare expenditures. This study aims to discover underlying patterns in ECDC utilization among Ohio Medicaid-insured children, which have significant implications for public health prevention, innovative service delivery models, and targeted cost-saving interventions.

Methods: Using 9 years of longitudinal Medicaid data of 24,223 publicly insured child members of an accountable care organization (ACO), Partners for Kids in Ohio, we applied unsupervised machine learning to cluster patients based on their cumulative dental cost curves in early childhood (24–60 months). Clinical validity, analytical validity, and reproducibility were assessed.

Results: The clustering revealed five novel subpopulations: (1) early-onset of decay by age (0.5% of the population, as early as 28 months), (2) middle-onset of decay (3.0%, as early as 35 months), (3) late-onset of decay (5.8%, as early as 44 months), (4) regular preventive care (67.7%), and (5) zero utilization (23.0%). Patients with early-onset of decay incurred the highest dental cost [median annual cost (MAC) = $9,499, InterQuartile Range (IQR): $7,052–$11,216], while patients with regular preventive care incurred the lowest dental cost (MAC = $191, IQR: $99–$336). We also found a plausible correlation of early-onset of decay with complex medical conditions diagnosed at 0–24 months. Almost one-third of patients with early-onset of decay had complex medical conditions diagnosed at 0–24 months. Patients with early-onset of decay also incurred the highest medical cost (MAC = $7,513, IQR: $4,527–$12,546) at 0–24 months.

Conclusion: Among Ohio Medicaid-insured children, five subpopulations with distinctive clinical, cost, and utilization patterns were discovered and validated through a data-driven approach. This novel discovery promotes innovative prevention strategies that differentiate Medicaid subpopulations, and allows for the development of cost-effective interventions that target high-risk patients. Furthermore, an integrated medical-dental care delivery model promises to reduce costs further while improving patient outcomes.

Pediatric accountable health communities: Insights on needed capabilities and potential solutions

BACKGROUND

Pediatric accountable health communities (AHCs) are emerging collaborative models that integrate care across health and social service sectors. We aimed to identify needed capabilities and potential solutions for implementing pediatric AHCs.

METHODS

We conducted a directed content analysis of responses to a Request for Information (RFI) from the Center for Medicare & Medicaid Innovation on the Integrated Care for Kids Model (n = 1550 pages from 202 respondents). We then interviewed pediatric health policy stakeholders (n = 18) to further investigate responses from the RFI. All responses were coded using a consensual qualitative research approach in 2019.

RESULTS

To facilitate service integration, respondents emphasized the need for cross-sector organizational alignment and data sharing. Recommended solutions included designating "Bridge Organizations" to operationalize service integration across sectors and developing integrated data sharing systems. Respondents called for improved validation and collection methods for data relating to school performance, social drivers of health, family well-being, and patient experience. Recommended solutions included aligning health and education data privacy regulations and utilizing metrics with cross-sector relevance. Respondents identified that mechanisms are needed to blend health and social service funding in alternative payment models (APMs). Recommended solutions included guidance on cross-sector care coordination payments, shared savings arrangements, and capitation to maximize spending flexibility.

CONCLUSIONS

Pediatric AHCs could provide more integrated, high-value care for children. Respondents highlighted the need for shared infrastructure and cross-sector alignment of measures and financing.

IMPLICATIONS

Insights and solutions from this study can inform policymakers planning or implementing innovative, child-centered AHC models.

LEVEL OF EVIDENCE

Level V.

Trends in 30-Day Readmission for Medicaid and Privately Insured Pediatric Patients: 2010-2017

BACKGROUND

Children insured by Medicaid have higher readmission rates than privately insured children. However, little is known about whether this disparity has changed over time.

METHODS

Data from the 2010 to 2017 Healthcare Cost and Utilization Project Nationwide Readmissions Database were used to compare trends in 30-day readmission rates for children insured by Medicaid and private insurers. Patient-level crude and risk-adjusted readmission rates were compared by using Poisson regression. Hospital-level risk-adjusted readmission rates were compared between Medicaid- and privately insured patients within a hospital by using linear regression.

RESULTS

Approximately 60% of pediatric admissions were covered by Medicaid. From 2010 to 2017, the percentage of children with a complex or chronic condition increased for both Medicaid- and privately insured patients. Readmission rates were consistently higher for Medicaid beneficiaries from 2010 to 2017. Readmission rates declined slightly for both Medicaid- and privately insured patients; however, they declined faster for privately insured patients (rate ratio: 0.988 [95% confidence interval: 0.986-0.989] vs 0.995 [95% confidence interval: 0.994-0.996], P for interaction <.001]). After adjustment, readmission rates for Medicaid- and privately insured patients declined at a similar rate (P for interaction = .87). Risk-adjusted hospital readmission rates were also consistently higher for Medicaid beneficiaries. The within-hospital difference in readmission rates for Medicaid versus privately insured patients remained stable over time (slope for difference: 0.015 [SE 0.011], P = .019).

CONCLUSIONS

Readmission rates for Medicaid- and privately insured pediatric patients declined slightly from 2010 to 2017 but remained substantially higher among Medicaid beneficiaries suggesting a persistence of the disparity by insurance status.

Are Children's Hospitals Unique in the Community Benefits They Provide? Exploring Decisions to Prioritize Community Health Needs Among U.S. Children's and General Hospitals

The Affordable Care Act expanded community benefit requirements for nonprofit hospitals, which now must demonstrate that they take into account the needs of their surrounding community in deciding where to make community benefit investments. No study to date has assessed the Community Health Needs Assessments (CHNAs) of a large sample of nonprofit hospitals to understand how hospitals determine the priority health needs that they include for their community or how prioritized health needs differ between general and children's hospitals. We analyzed the CHNAs of a 20% random sample of general hospitals in the United States as well as all children's hospitals. After identifying the five most common needs across all hospitals-mental health, substance misuse, social needs, chronic illness, and access to care-we used descriptive statistics and multivariate logistic regression to determine which hospitals were most likely to prioritize each of these five needs in their CHNA and the organizational, county, and regional factors associated with prioritizing a need. We found that children's hospitals were more likely than general hospitals to prioritize each of these five needs in their CHNA and that related county-level health indicators were significantly associated with hospitals prioritizing social needs and substance misuse as top needs in their CHNAs. County-level demographic variation, such as the percentage of white residents, and regional location were significantly related to whether hospitals prioritized a need in their CHNA. Our results suggest that children's hospitals are more likely to include a similar list of health issues on their CHNAs and that factors beyond county-level health indicators (e.g., organizational mission, regional health indicators, etc.) are operative in hospital decisions to include needs on their CHNAs.

The Financial Impact of Genetic Diseases in a Pediatric Accountable Care Organization

Background: Previous studies revealed patients with genetic disease have more frequent and longer hospitalizations and therefore higher healthcare costs. To understand the financial impact of genetic disease on a pediatric accountable care organization (ACO), we analyzed medical claims from 2014 provided by Partners for Kids, an ACO in partnership with Nationwide Children's Hospital (NCH; Columbus, OH, USA). Methods: Study population included insurance claims from 258,399 children. We assigned patients to four different categories (1-A, 1-B, 2, & 3) based on the strength of genetic basis of disease. Results: We identified 22.7% of patients as category 1A or 1B- having a disease with a "strong genetic basis" (e.g., single gene diseases, chromosomal abnormalities). Total ACO paid claims in 2014 were $379M, of which $161M (42.5%) was attributed to category 1 patients. Furthermore, we identified 23.3% of patients as category 2- having a disease with a suspected genetic component or predisposition (e.g., asthma, type 1 diabetes)- whom accounted for an additional 28.6% of 2014 costs. Category 1 patients were more likely to experience at least one hospitalization compared to category 3 patients- those without genetic disease [odds ratio [OR] = 4.12; 95% confidence interval [CI] = 3.86-4.39; p < 0.0001]. Overall, category 1 patients experienced nearly five times the number of inpatient (IP) admissions and twice the number of outpatient (OP) visits compared to category 3 patients (p < 0.0001). Conclusion: Nearly half (42.5%) of healthcare paid claims cost in 2014 for this study population were accounted for by patients with single-gene diseases or chromosomal abnormalities. These findings precede and support a need for an ACO to plan for effective healthcare strategies and capitation models for children with genetic disease.

Principles of Financing the Medical Home for Children

A well-implemented and adequately funded medical home not only is the best approach to optimize the health of the individual patient but also can function as an effective instrument for improving population health. Key financing elements to providing quality, effective, comprehensive care in the pediatric medical home include the following: (1) first dollar coverage without deductibles, copays, or other cost-sharing for necessary preventive care services as recommended by Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents; (2) adoption of a uniform definition of medical necessity across payers that embraces services that promote optimal growth and development and prevent, diagnose, and treat the full range of pediatric physical, mental, behavioral, and developmental conditions, in accord with evidence-based science or evidence-informed expert opinion; (3) payment models that promote appropriate use of pediatric primary care and pediatric specialty services and discourage inappropriate, inefficient, or excessive use of medical services; and (4) payment models that strengthen the patient- and family-physician relationship and do not impose additional administrative burdens that will only erode the effectiveness of the medical home. These goals can be met by designing payment models that provide adequate funding of the cost of medical encounters, care coordination, population health services, and quality improvement activities; provide incentives for quality and effectiveness of care; and ease administrative burdens.

Association of a Targeted Population Health Management Intervention with Hospital Admissions and Bed-Days for Medicaid-Enrolled Children

IMPORTANCE

As the proportion of children with Medicaid coverage increases, many pediatric health systems are searching for effective strategies to improve management of this high-risk population and reduce the need for inpatient resources.

OBJECTIVE

To estimate the association of a targeted population health management intervention for children eligible for Medicaid with changes in monthly hospital admissions and bed-days.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study, using difference-in-differences analysis, deployed integrated team interventions in an academic pediatric health system with 31 in-network primary care practices among children enrolled in Medicaid who received care at the health system's hospital and primary care practices. Data were collected from January 2014 to June 2017. Data analysis took place from January 2018 to June 2019.

EXPOSURES

Targeted deployment of integrated team interventions, each including electronic medical record registry development and reporting alongside a common longitudinal quality improvement framework to distribute workflow among interdisciplinary clinicians and community health workers.

MAIN OUTCOMES AND MEASURES

Trends in monthly inpatient admissions and bed-days (per 1000 beneficiaries) during the preimplementation period (ie, January 1, 2014, to June 30, 2015) compared with the postimplementation period (ie, July 1, 2015, to June 30, 2017).

RESULTS

Of 25 460 children admitted to the hospital's health system during the study period, 8418 (33.1%) (3869 [46.0%] girls; 3308 [39.3%] aged ≤1 year; 5694 [67.6%] black) were from in-network practices, and 17 042 (67.9%) (7779 [45.7%] girls; 6031 [35.4%] aged ≤1 year; 7167 [41.2%] black) were from out-of-network practices. Compared with out-of-network patients, in-network patients experienced a decrease of 0.39 (95% CI, 0.10-0.68) monthly admissions per 1000 beneficiaries (P = .009) and 2.20 (95% CI, 0.90-3.49) monthly bed-days per 1000 beneficiaries (P = .001). Accounting for disproportionate growth in the number of children with medical complexity who were in-network to the health system, this group experienced a monthly decrease in admissions of 0.54 (95% CI, 0.13-0.95) per 1000 beneficiaries (P = .01) and in bed-days of 3.25 (95% CI, 1.46-5.04) per 1000 beneficiaries (P = .001) compared with out-of-network patients. Annualized, these differences could translate to a reduction of 3600 bed-days for a population of 93 000 children eligible for Medicaid.

CONCLUSIONS AND RELEVANCE

In this quality improvement study, a population health management approach providing targeted integrated care team interventions for children with medical and social complexity being cared for in a primary care network was associated with a reduction in service utilization compared with an out-of-network comparison group. Standardizing the work of care teams with quality improvement methods and integrated information technology tools may provide a scalable strategy for health systems to mitigate risk from a growing population of children who are eligible for Medicaid.

Lung Transplant Index: A Quality Improvement Initiative

Limited long-term survival is a recognized problem in adolescent/young adult lung transplant recipients. A quality improvement (QI) initiative included the development of a Lung Transplant Index (LTI) composed of key elements that we used as a comprehensive approach to screen and identify potential harms in this at-risk patient population.

Methods

A single-center, uncontrolled QI study was completed from January 2014 to February 2019. The elements of the LTI are events that should have occurred within the most recent 12 months. If an element did not occur, it was counted as a missed element of preventing harm and summated later serving as the LTI score. Implementation of the LTI occurred on January 1, 2015, with a retrospective chart review of patients seen in clinic the prior year serving as baseline measures for comparison.

Results

The year before implementing the LTI, numerous opportunities failed to identify preventable harm in our adolescent/young adult lung transplant population. The LTI resulted in a sustained reduction of these missed opportunities without negatively influencing patient/family satisfaction with lengthening of the clinic visit.

Conclusions

A single-center QI initiative identified preventable harms in an adolescent/young adult lung transplant population and reduced the number of preventable harm elements not performed. Future work is needed to determine if this type of QI initiative is associated with less healthcare utilization.

Coordinated Care Organizations and mortality among low-income infants in Oregon

OBJECTIVE

To examine the impact of Oregon's Coordinated Care Organizations (CCOs), an accountable care model for Oregon Medicaid enrollees implemented in 2012, on neonatal and infant mortality.

DATA SOURCES

Oregon birth certificates linked with death certificates, and Medicaid/CCO enrollment files for years 2008-2016.

STUDY DESIGN

The sample consisted of the pre-CCO birth cohort of 135 753 infants (August 2008-July 2011) and the post-CCO birth cohort of 148 650 infants (August 2012-December 2015). We used a difference-in-differences probit model to estimate the difference in mortality between infants enrolled in Medicaid and infants who were not enrolled. We examined heterogeneous effects of CCOs for preterm and full-term infants and the impact of CCOs over the implementation timeline. All models were adjusted for maternal and infant characteristics and secular time trends.

PRINCIPAL FINDINGS

The CCO model was associated with a 56 percent reduction in infant mortality compared to the pre-CCO level (-0.20 percentage points [95% CI: -0.35; -0.05]), and also with a greater reduction in infant mortality among preterm infants compared to full-term infants. The impact on mortality grew in magnitude over the postimplementation timeline.

CONCLUSIONS

The CCO model contributed to a reduction in mortality within the first year of birth among infants enrolled in Medicaid.

Effect of Comprehensive Care Coordination on Medicaid Expenditures Compared With Usual Care Among Children and Youth With Chronic Disease: A Randomized Clinical Trial

IMPORTANCE

Medicaid spending on children and young adults with chronic disease could be decreased through care coordination programs by reducing unnecessary hospital and emergency care.

OBJECTIVE

To assess whether a comprehensive care coordination program reduces Medicaid expenditures by decreasing hospital and emergency department (ED) utilization.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial included 6259 children and young adults with chronic disease who received public insurance through Illinois Medicaid. In April 2016, eligible youth were randomized to receive comprehensive care coordination through the Coordinated Healthcare for Complex Kids (CHECK) program (n = 3126) or usual care (n = 3119) to measure the effect of the CHECK program on Medicaid expenditures and health care utilization using a difference-in-differences (DID) approach. Data were collected from May 1, 2014, to April 30, 2017, and analyzed in May 2018.

INTERVENTIONS

Care coordination, mental health care, education, and social support were provided to CHECK participants and their family members. Services were tailored based on family and participant need.

MAIN OUTCOMES AND MEASURES

Mean annual Medicaid expenditures, mean annual health care utilization by category (ED and inpatient), and chronic disease type and risk level.

RESULTS

A total of 6259 participants (mean [SD] age, 11.3 [6.4] years; 2918 [46.6%] female; 2594 [41.4%] with medium and high risk) were randomized. Following the exclusion of 14 outliers, 6245 participants were analyzed. The mean (SD) annual Medicaid expenditure before the intervention was $1633 ($4006) for the intervention group and $1703 ($4466) for the usual care group, which decreased to a mean (SD) of $1341 ($3004) and $1413 ($3785), respectively, after the intervention (DID, -$1; 95% CI, -$199 to $196; P = .99). The mean (SD) inpatient utilization before the intervention was 63.0 (344.4) per 1000 person-years (PYs) for the intervention group and 69.3 (370.9) per 1000 PYs for the usual care group, which decreased to 43.5 (297.2) per 1000 PYs and 47.8 (304.9) per 1000 PYs, respectively, after the intervention (DID, 2.0; 95% CI, -17.9 to 21.8; P = .85). Among participants with asthma, those in the intervention group had a greater mean (SD) decrease in ED utilization compared with usual care, but the difference was not significant (-225.9 [65.3] vs -104.5 [80.0] visits per 1000 PY; DID, -121.5; 95% CI, -268.9 to 26.0; P = .11). Similarly, enrolled participants with sickle cell disease had a smaller but not significant mean (SD) increase in ED utilization compared with usual care (583.3 [839.0] vs 3761.9 [4611.2] visits per 1000 PYs; DID, -3178.6; 95% CI, -10 724.3 to 4367.2; P = .41).

CONCLUSIONS AND RELEVANCE

Overall Medicaid expenditures and health care utilization (hospital and ED) decreased similarly for both CHECK participants and the usual care group.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04057521.

A Primer on Understanding Pediatric Health Care Quality Measurement

Advanced practice registered nurses implement evidence-based care guidelines and assess the quality of care delivered to pediatric and adolescent populations to ensure that the highest standards of care are provided to the patients and their families. Standardized health care quality measures allow for assessment of clinical competence, monitoring of equitable health care distribution, improvement of provider/institutional accountability, development of standards for accreditation and certification, informing of quality improvement efforts, and creation of criteria for provider incentive payments. The purpose of this article is to explain why health care quality measures are established, what agencies oversee the development of meaningful pediatric quality measures, and how these measures inform and improve the care provided by pediatric-focused advanced practice registered nurses.

How does being part of a pediatric accountable care organization impact health service use for children with disabilities?

OBJECTIVE

To examine the impact of a Medicaid-serving pediatric accountable care organization (ACO) on health service use by children who qualify for Medicaid by virtue of a disability under the "aged, blind, and disabled" (ABD) eligibility criteria.

DATA SOURCES/STUDY SETTING

We evaluated a 2013 Ohio policy change that effectively moved ABD Medicaid children into an ACO model of care using Ohio Medicaid administrative claims data for years 2011-2016.

STUDY DESIGN

We used a difference-in-difference design to examine changes in patterns of health care service use by ABD-enrolled children before and after enrolling in an ACO compared with ABD-enrolled children enrolled in non-ACO managed care plans.

DATA COLLECTION/EXTRACTION METHODS

We identified 17 356 children who resided in 34 of 88 counties as the ACO "intervention" group and 47 026 ABD-enrolled children who resided outside of the ACO region as non-ACO controls.

PRINCIPAL FINDINGS

Being part of the ACO increased adolescent preventative service and decreased use of ADHD medications as compared to similar children in non-ACO capitated managed care plans. Relative home health service use decreased for children in the ACO.

CONCLUSIONS

Our overall results indicate that being part of an ACO may improve quality in certain areas, such as adolescent well-child visits, though there may be room for improvement in other areas considered important by patients and their families such as home health service.

Value-Based Provider Payment Initiatives Combining Global Payments With Explicit Quality Incentives: A Systematic Review

An essential element in the pursuit of value-based health care is provider payment reform. This article aims to identify and analyze payment initiatives comprising a specific manifestation of value-based payment reform that can be expected to contribute to value in a broad sense: (a) global base payments combined with (b) explicit quality incentives. We conducted a systematic review of the literature, consulting four scientific bibliographic databases, reference lists, the Internet, and experts. We included and compared 18 initiatives described in 111 articles/documents on key design features and impact on value. The initiatives are heterogeneous regarding the operationalization of the two payment components and associated design features. Main commonalities between initiatives are a strong emphasis on primary care, the use of "virtual" spending targets, and the application of risk adjustment and other risk-mitigating measures. Evaluated initiatives generally show promising results in terms of lower spending growth with equal or improved quality.

Impact of a Make-A-Wish experience on healthcare utilization

OBJECTIVES

To evaluate the impact of receiving a wish from the Make-A-Wish^R Foundation on (1) patient healthcare utilization and (2) savings benefit measures.

STUDY DESIGN

Make-A-Wish^R arranges experiences, or "wishes," to children with progressive, life-threatening, or life-limiting illness. A retrospective, case-control analysis was performed comparing patients who received or did not receive a wish and associated impact on healthcare utilization and costs across 2 years. Healthcare utilization was defined as visits to primary, urgent, emergent care, and planned/unplanned inpatient hospitalizations. We defined wish savings benefit as a decline in the cost of care from years 1 to 2, which exceeded the average cost of a wish in 2016, $10,130.

RESULTS

From 2011 to 2016, 496 Nationwide Children's Hospital patients received a wish. We matched these patients to 496 controls based on age, gender, disease category, and disease complexity. Patients who received a wish were 2.5 and 1.9 times more likely to have fewer unplanned hospital admissions and emergency department visits, respectively. These decreases were associated with a higher likelihood (2.3-fold and 2.2-fold greater odds) of the wish achieving a savings benefit compared to hospital charges.

CONCLUSIONS

Participation in the Make-A-Wish^R program may provide children quality of life relief while reducing hospital visits and healthcare expenditures.

Quality Improvement-Driven Reduction in Countywide Medicaid Acute Asthma Health Care Utilization

OBJECTIVE

This study evaluates the impact of a coordinated effort by an urban pediatric hospital and its associated accountable care organization to reduce asthma-related emergency department (ED) and inpatient utilization by a large, countywide Medicaid patient population.

METHODS

Multiple evidence-based interventions targeting general pediatric asthma care and high health care utilizers were implemented using standardized quality improvement methodologies. Annual asthma ED and inpatient utilization rates by 2- to 18-year-old members of an accountable care organization living in the surrounding county (>140,000 eligible members in 2016), adjusted per 1000 children from 2008 through 2016, were analyzed using Poisson regression. We compared these ED utilization rates to national rates from 2006 to 2014.

RESULTS

Asthma ED utilization fell from 18.1 to 12.9 visits/1000 children from 2008 to 2016, representing a 28.7% reduction, with an average annual decrease of 3.9% (P < .001), during a time when national utilization was increasing. Asthma inpatient utilization did not change significantly during the study period.

CONCLUSIONS

Asthma-related ED utilization was significantly reduced in a large population of primarily urban, minority, Medicaid-insured children by implementing a multimodal asthma quality improvement program. With adequate support, a similar approach could be successful in other communities.

Trends in Pediatric Hospitalizations and Readmissions: 2010-2016

BACKGROUND

Health reform and policy initiatives over the last 2 decades have led to significant changes in pediatric clinical practice. However, little is known about recent trends in pediatric hospitalizations and readmissions at a national level.

METHODS

Data from the 2010-2016 Healthcare Cost and Utilization Project Nationwide Readmissions Database and National Inpatient Sample were analyzed to characterize patient-level and hospital-level trends in annual pediatric (ages 1-17 years) admissions and 30-day readmissions. Poisson regression was used to evaluate trends in pediatric readmissions over time.

RESULTS

From 2010 to 2016, the total number of index admissions decreased by 21.3%, but the percentage of admissions for children with complex chronic conditions increased by 5.7%. Unadjusted pediatric 30-day readmission rates increased over time from 6.26% in 2010 to 7.02% in 2016 with a corresponding increase in numbers of admissions for patients with complex chronic conditions. When stratified by complex or chronic conditions, readmission rates declined or remained stable across patient subgroups. Mean risk-adjusted hospital readmission rates increased over time overall (6.46% in 2010 to 7.14% in 2016) and in most hospital subgroups but decreased over time in metropolitan teaching hospitals.

CONCLUSIONS

Pediatric admissions declined from 2010 to 2016 as 30-day readmission rates increased. The increase in readmission rates was associated with greater numbers of admissions for children with chronic conditions. Hospitals serving pediatric patients need to account for the rising complexity of pediatric admissions and develop strategies for reducing readmissions in this high-risk population.

EMR Adaptations to Support the Identification and Risk Stratification of Children with Special Health Care Needs in the Medical Home

Introduction Children with special health care needs (CSHCN) are a high risk population with complex medical issues and needs. It is challenging to care for them in a busy, pediatric practice without understanding how many exist and how best to allocate resources. EMRs can be adapted to develop registries and stratify patients to promote population health management. Methods Adaptations were made to the EMR in September 2013 to capture CSHCN and the associated risk level during well-child visits prospectively. All physicians were trained on the definition of CSHCN and on risk stratification levels 1, 2, 3A and 3B. An analysis using one-way ANOVA for children ages 0-21, seen between September 1, 2011 and August 31, 2015, who were identified and stratified after September 2013, was conducted to determine utilization patterns on hospital admissions, emergency department (ED), subspecialty, and primary care visits. Results A total of 4687 CSHCN were identified during the study period. Of the CSHCN, 45% were Level 1, 41% Level 2, 7% 3A and 7% 3B. There were significant differences in utilization across the tiers of CSHCN with the highest level of stratification (3B) demonstrating the most hospital admissions and primary care visits. Level 3B and level 3A (unstable) had significantly more ED visits. Additionally, as tiers increased from level 1 to 3B there was an increase in subspecialty provider utilization (p < 0.0001). Discussion The EMR adaptations developed for CSHCN identified the expected number of CSHCN and predicted utilization patterns across primary, subspecialty, ED and in-patient care.

Medicaid Accountable Care Organizations and Childbirth Outcomes

Some states have adopted Accountable Care Organization (ACO) models to transform their Medicaid programs, but little is known about their impact on health care outcomes and costs. Medicaid ACOs are uniquely positioned to improve childbirth outcomes because of the number of births covered by Medicaid. Using Healthcare Cost and Utilization Project hospital data, we examined the relationship between ACO adoption and (a) neonatal and maternal outcomes, and (b) cost per birth. We compared outcomes in states that have adopted ACO models in their Medicaid programs with adjacent states without ACO models. Implementation of Medicaid ACOs was associated with a moderate reduction in hospital costs per birth and decreased cesarean section rates. Results varied by state. We found no association between Medicaid ACOs and several birth outcomes, including infant inpatient mortality, low birthweight, neonatal intensive care unit utilization, and severe maternal morbidity. Improving these outcomes may require more time or targeted interventions.

Rationale and design for eHealth Familias Unidas Primary Care: A drug use, sexual risk behavior, and STI preventive intervention for hispanic youth in pediatric primary care clinics

Family-based behavioral interventions are efficacious and effective in preventing drug use and sexual risk behaviors; unfortunately, they have not been evaluated and disseminated in pediatric primary care practice, where they can have a significant impact. There is an increased focus on integrating parenting interventions into primary care to reduce health disparities among ethnic minorities such as Hispanics. Although Hispanic youth demonstrate higher levels of drug use and sexual risk behaviors than their non-Hispanic counterparts, few parenting interventions are available for Hispanic youth, and none have been delivered specifically to Hispanic adolescents in primary care. Therefore, this manuscript describes the rationale and design of an Internet-based, family-centered, Hispanic-specific, evidence-based prevention intervention, eHealth Familias Unidas Primary Care. Hispanic adolescents (n = 456) and their care givers will be recruited from pediatric primary care clinics in South Florida and randomized to: eHealth Familias Unidas Primary Care or prevention as usual. The intervention will be delivered by trained interns, clinic volunteers, social workers, mental health counselors, students, and nurses. Outcomes will be measured at baseline and 6, 12, 24, and 36 months post-baseline. This study will determine whether the intervention, compared to prevention as usual, is effective in reducing drug use, unprotected sex, and STI incidence in Hispanic youth through the improvement of family functioning. Additionally, we will determine the cost effectiveness of delivering eHealth Familias Unidas within primary care settings. The effectiveness of eHealth Familias Unidas Primary Care will further inform the need to integrate effective behavioral health interventions into primary care settings.

Validating an Algorithm to Identify Patients With Infantile Spasms Using Medical Claims

An infantile spasm is a brief seizure type that is characteristic of West syndrome. Many infants present with infantile spasms between 3-12 months of age. Early diagnosis and proper treatment of patients with infantile spasms can lead to improved clinical outcomes. However, proper identification of these patients using claims data with validation has not been performed. The authors developed and tested several algorithms using claims data. Claims data consisted of using International Classification of Disease (ICD), Current Procedural Terminology (CPT), and prescription codes. Access to the claims database was from an accountable care organization. The algorithm using the specific ICD code for infantile spasms only performed the best with high sensitivity and specificity. This algorithm can be used to perform additional research in claims data for patients with infantile spasms.

How U.S. children's hospitals define population health: a qualitative, interview-based study

BACKGROUND

The literature suggests that although adult hospitals are establishing population health programs around the country, there is considerable definitional ambiguity regarding whether interventions are aimed at the social determinants of health or the management of existing patient populations. U.S. children's hospitals also undertake population health programs, but less is known about how they define population health. The purpose of this study is to understand how U.S. children's hospitals define population health, and how institutions are adjusting to new preventive health care models.

METHODS

We conducted semi-structured interviews with key stakeholders at ten hospitals with the highest amount of staff time dedicated to population health activities as reported in the 2016 Children's Hospital Association's population health survey. Using a semi-structured interview guide, we interviewed representatives from each hospital. Verbatim interview notes were coded and analyzed using the data analysis software Dedoose. Data analysis followed a modified constructivist grounded theory approach.

RESULTS

Our results suggest that even population health innovators employ a variety of approaches that span both population health management and public health. We present further evidence that U.S. children's hospitals are actively debating the definition and focus of population health.

CONCLUSIONS

Definitional debates are ongoing even within children's hospitals that are dedicating significant resources to population health. Increased clarity on the conceptual boundaries between population health and population health management could help preserve the theoretical differences between the two concepts, especially insofar as they mark two quite different long-term visions for health care. Without agreement about the meaning of population health within and among institutions, hospitals will not be able to know whether projects aimed at addressing the social determinants of health are likely to improve the health of populations.

The Advocacy Portfolio: A Standardized Tool for Documenting Physician Advocacy

Recent changes in health care delivery systems and in medical training have primed academia for a paradigm shift, with strengthened support for an expanded definition of scholarship. Physicians who consider advocacy to be relevant to their scholarly endeavors need a standardized format to display activities and measure the value of health outcomes to which their work can be attributed. Similar to the Educator Portfolio, the authors here propose the Advocacy Portfolio (AP) to document a scholarly approach to advocacy.Despite common challenges faced in the arguments for both education and advocacy to be viewed as scholarship, the authors highlight inherent differences between the two fields. On the basis of prior literature, the authors propose a broad yet comprehensive set of domains to categorize advocacy activities, including advocacy engagement, knowledge dissemination, community outreach, advocacy teaching/mentoring, and advocacy leadership/administration. Documenting quality, quantity, and a scholarly approach to advocacy within each domain is the first of many steps to establish congruence between advocacy and scholarship for physicians using the AP format.This standardized format can be applied in a variety of settings, from medical training to academic promotion. Such documentation will encourage institutional buy-in by aligning measured outcomes with institutional missions. The AP will also provide physician-advocates with a method to display the impact of advocacy projects on health outcomes for patients and populations. Future challenges to broad application include establishing institutional support and developing consensus regarding criteria by which to evaluate the contributions of advocacy activities to scholarship.

Evolving Federal and State Health Care Policy: Toward a More Integrated and Comprehensive Care-Delivery System for Children With Medical Complexity

Irrespective of any future changes in federal health policy, the momentum to shift from fee-for-service to value-based payment systems is likely to persist. Public and private payers continue to move toward alternative payment models that promote novel care-delivery systems and greater accountability for health outcomes. With a focus on population health, patient-centered medical homes, and care coordination, alternative payment models hold the potential to promote care-delivery systems that address the unique needs of children with medical complexity (CMC), including nonmedical needs and the social determinants of health. Notwithstanding, the implementation of care systems with meaningful quality measures for CMC poses unique and substantive challenges. Stakeholders must view policy options for CMC in the context of transformation within the overall health system to understand how broader health system changes impact care delivery for CMC.

Healthcare Claims Data: An Underutilized Tool for Pediatric Outpatient Antimicrobial Stewardship

Background.

Healthcare claims are underutilized to identify factors associated with high outpatient antibiotic use.

Methods.

We evaluated ambulatory encounter claims of Medicaid-insured children in 34 Ohio counties in 2014. Rates of total antibiotic and azithromycin prescriptions dispensed were determined by county of patient residence. Standardized treatment rates by county were estimated for uncomplicated upper respiratory tract encounters (acute otitis media, pharyngitis, sinusitis, presumed viral infection) after adjusting for patient age and encounter provider type. Uncomplicated encounters included healthy children at initial presentation of illness. Adjusted odds of treatment were calculated for patient age, provider type, and county characteristics (rural vs metropolitan; poverty rate).

Results.

Retail pharmacies dispensed 255291 antibiotics to this cohort in 2014. More than 25% were to children <3 years. County rates of total antibiotic and azithromycin prescriptions dispensed were 530.4-1548.3 and 57.3-378.7 per 1000 person-years, respectively. Of 246866 uncomplicated upper respiratory tract encounters, antibiotics were dispensed (within 3 days) in 46.1%. Presumed viral infection accounted for 18.5% of antibiotics. Standardized treatment rates by county ranged widely from 35.9% (95% confidence interval [CI], 33.3%-38.5%) to 63.2% (95% CI, 61.5%-64.9%). Compared to encounters with pediatricians, adjusted odds ratio of treatment was 2.02 (95% CI, 1.96-2.07) for family physicians and 1.74 (95% CI, 1.68-1.79) for nurse practitioners. Residence in rural or high-poverty counties increased odds of treatment.

Conclusions.

Healthcare claims were useful to identify populations and providers with high antibiotic use. Claims data could be considered to track and report antibiotic prescribing frequency, especially where electronic medical records are not available.

Health Care Utilization Following Vagus Nerve Stimulation Therapy in Pediatric Epilepsy Patients From a Pediatric Accountable Care Organization

BACKGROUND

Vagus nerve stimulation has been a therapy for epilepsy approved by the US Food and Drug Administration (FDA) for patients 4 and older and shown efficacy and safety in younger pediatric patients.

METHODS

The authors performed a retrospective analysis utilizing Medicaid claims from an accountable care organization to measure the intervention of vagus nerve stimulation therapy in regard to unplanned health care utilization. Thirteen unique patients were included who had vagus nerve stimulation therapy who had at least 6 months of continuous enrollment in a managed Medicaid health plan. Comparison with 12 months of data before and after vagus nerve stimulation implantation was performed.

RESULTS

Patients had statistically significant fewer unplanned inpatient visits per patient per enrollment month after vagus nerve stimulation implantation.

CONCLUSION

Utilizing claims data, vagus nerve stimulation implantation demonstrates a reduction in unplanned hospitalizations.

Pediatric Type 1 Diabetes: Reducing Admission Rates for Diabetes Ketoacidosis

Background:

Diabetes ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus (T1DM). Reducing DKA admissions in children with T1DM requires a coordinated, comprehensive management plan. We aimed to decrease DKA admissions, 30-day readmissions, and length of stay (LOS) for DKA admissions.

Methods:

A multipronged intervention was designed in 2011 to reach all patients: (1) increase insulin pump use and basal-bolus regimen versus sliding scales, (2) transform educational program, (3) increased access to medical providers, and (4) support for patients and families. A before-after study was conducted comparing performance outcomes in years 2007-2010 (preintervention) to 2012-2014 (postintervention) using administrative data and Wilcoxon rank sum and Fischer exact tests.

Results:

DKA admissions decreased by 44% postintervention (16.7 vs 9.3 per 100 followed patient-years; P = .006), unique patient 30-day readmissions decreased from 20% to 5% postintervention (P = .001), and median LOS significantly decreased postintervention (P < .0001). Although not an original goal of the study, median hemoglobin A1C of a subset of the population transitioned from sliding scale decreased, 10.3% to 8.9% (P < .02).

Conclusions:

When clinical and widespread program interventions were used, significant reductions in DKA hospitalizations, 30-day readmissions, and LOS occurred for pediatric T1DM. Continuous performance improvement efforts are needed for improving DKA outcomes.

Transitioning from General Pediatric to Adult-Oriented Inpatient Care: National Survey of US Children's Hospitals

BACKGROUND

Hospital charges and lengths of stay may be greater when adults with chronic conditions are admitted to children's hospitals. Despite multiple efforts to improve pediatric-adult healthcare transitions, little guidance exists for transitioning inpatient care.

OBJECTIVE

This study sought to characterize pediatricadult inpatient care transitions across general pediatric services at US children's hospitals.

DESIGN, SETTING AND PARTICIPANTS

National survey of inpatient general pediatric service leaders at US children's hospitals from January 2016 to July 2016.

MEASUREMENTS

Questionnaires assessed institutional characteristics, presence of inpatient transition initiatives (having specific process and/or leader), and 22 inpatient transition activities. Scales of highly correlated activities were created using exploratory factor analysis. Logistic regression identified associations between institutional characteristics, transition activities, and presence of an inpatient transition initiative.

RESULTS

Ninety-six of 195 children's hospitals responded (49.2% response rate). Transition initiatives were present at 38% of children's hospitals, more often when there were dual-trained internal medicine-pediatrics providers or outpatient transition processes. Specific activities were infrequent and varied widely from 2.1% (systems to track youth in transition) to 40.5% (addressing potential insurance problems). Institutions with initiatives more often consistently performed the majority of activities, including using checklists and creating patient-centered transition care plans. Of remaining activities, half involved transition planning, the essential step between readiness and transfer.

CONCLUSIONS

Relatively few inpatient general pediatric services at US children's hospitals have leaders or dedicated processes to shepherd transitions to adultoriented inpatient care. Across institutions, there is a wide variability in performance of activities to facilitate this transition. Feasible process and outcome measures are needed.

Impact of Accountable Care Organizations on Utilization, Care, and Outcomes: A Systematic Review

Since 2010, more than 900 accountable care organizations (ACOs) have formed payment contracts with public and private insurers in the United States; however, there has not been a systematic evaluation of the evidence studying impacts of ACOs on care and outcomes across payer types. This review evaluates the quality of evidence regarding the association of public and private ACOs with health service use, processes, and outcomes of care. The 42 articles identified studied ACO contracts with Medicare ( N = 24 articles), Medicaid ( N = 5), commercial ( N = 11), and all payers ( N = 2). The most consistent associations between ACO implementation and outcomes across payer types were reduced inpatient use, reduced emergency department visits, and improved measures of preventive care and chronic disease management. The seven studies evaluating patient experience or clinical outcomes of care showed no evidence that ACOs worsen outcomes of care; however, the impact on patient care and outcomes should continue to be monitored.

Road to the Future: Priorities for Child Health Services Research

BACKGROUND

Prior health services research (HSR) agendas for children have been published, but major ones are now over 15 years old and do not reflect augmented understanding of the drivers and determinants of children's health; recent changes in the organization, financing, and delivery of health care; a growing emphasis on population health; and major demographic shifts in the population. A policy-relevant research agenda that integrates knowledge gained over the past 2 decades is essential to guide future child HSR (CHSR). We sought to develop and disseminate a robust, domestically focused, policy-oriented CHSR agenda.

METHODS

The new CHSR agenda was developed through a series of consultations with leaders in CHSR and related fields. After each round of consultation, the authors synthesized the previous experts' guidance to help inform subsequent discussions. The multistep process in generation of the agenda included identification of major policy-relevant research domains and specification of high-value research questions for each domain. Stakeholders represented in the discussions included those with expertise in child and family advocacy, adult health, population health, community development, racial and ethnic disparities, women's health, health economics, and government research funders and programs.

RESULTS

In total, 180 individuals were consulted in developing the research agenda. Six priority domains were identified for future research, including both enduring and emerging emphases: 1) framing children's health issues so that they are compelling to policy-makers; 2) addressing poverty and other social determinants of child health and wellbeing; 3) promoting equity in population health and health care; 4) preventing, diagnosing, and treating high priority health conditions in children; 5) strengthening performance of the health care system; and 6) enhancing the CHSR enterprise. Within these 6 domains, 40 specific topics were identified as the most pertinent for future research. Three overarching and crosscutting themes that affect research across the domains were also noted: the need for syntheses to build on the current, and sometimes extensive, evidence base to avoid duplication; the interrelated nature of the domains, which could lead to synergies in research; and the need for multidisciplinary collaborations in conducting research because research studies will look beyond the health sector.

CONCLUSIONS

The priorities presented in the agenda are policy-oriented and include a greater emphasis on how findings are framed and communicated to support action. We expect that the agenda will be useful for immediate uptake by investigators and research funders.