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Bruton L, Storey M, Gentile J, Smith TL, Bhatti P, Davis MM, Cartland J, Foster C. Access to Home- and Community-Based Services for Children with Disability: Academic Institutions' Role and Areas for Improvement. Acad Pediatr 2024; 24:596-604. [PMID: 37939827 PMCID: PMC11056305 DOI: 10.1016/j.acap.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 10/26/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE This project sought to describe provider- and parent-identified needs and barriers to obtaining home- and community-based services (HCBS) for children with disability (CWD) and to determine ways pediatric health care institutions can improve access to HCBS services. METHODS In this exploratory sequential mixed methods evaluation, semi-structured interviews and focus groups were conducted with multidisciplinary providers and staff from an independent children's hospital, followed by a survey of English and Spanish-speaking parents of CWD. Data from interviews and surveys were then triangulated for overarching common themes regarding how pediatric health care institutions can better support access to HCBS. RESULTS Among 382 parent respondents, 74.1% reported that their child needed a HCBS, most commonly physical/occupational/speech therapies, school-based support, and case management services. Two-thirds of parents reported at least one barrier to accessing HCBS and one-third experience >3 barriers. While multiple current institutional strengths were noted, internal weaknesses included lack of provider knowledge, staffing difficulties, and lack of protocols for identifying and tracking patients needing or receiving HCBS. External threats included requirements to entry for HCBS and transfer of care, with opportunities for improvement involving dissemination of information, funding support, and connection between providers/support staff and services. CONCLUSIONS Parents of CWD identified HCBS as necessary for the health of this population, but multiple barriers to HCBS were identified by both parents and providers. Multiple internal and external opportunities for improvement relative to pediatric health care institutions were identified, suggesting a need for a comprehensive approach to ensure that CWD receive necessary HCBS.
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Affiliation(s)
- Lucas Bruton
- Division of Advanced General Pediatrics and Primary Care (L Bruton, MM Davis, and C Foster), Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Ill; Department of Pediatrics (L Bruton, MM Davis, and C Foster), Northwestern University Feinberg School of Medicine, Chicago, Ill.
| | - Margaret Storey
- Ann and Robert H. Lurie Children's Hospital of Chicago Family Advisory Board (M Storey), Chicago, Ill
| | - Jennifer Gentile
- Tulane University School of Social Work (J Gentile), Tulane University, New Orleans, La
| | - Tracie L Smith
- Department of Data Analytics and Reporting (TL Smith), Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Punreet Bhatti
- Mary Ann and J. Milburn Smith Child Health Outcomes (P Bhatti, MM Davis, J Cartland, and C Foster), Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Matthew M Davis
- Division of Advanced General Pediatrics and Primary Care (L Bruton, MM Davis, and C Foster), Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Ill; Department of Pediatrics (L Bruton, MM Davis, and C Foster), Northwestern University Feinberg School of Medicine, Chicago, Ill; Mary Ann and J. Milburn Smith Child Health Outcomes (P Bhatti, MM Davis, J Cartland, and C Foster), Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill; Department of Medical Social Sciences (MM Davis), Northwestern University Feinberg School of Medicine, Chicago, Ill; Departments of Medicine and Preventive Medicine (MM Davis), Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Jenifer Cartland
- Mary Ann and J. Milburn Smith Child Health Outcomes (P Bhatti, MM Davis, J Cartland, and C Foster), Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Carolyn Foster
- Division of Advanced General Pediatrics and Primary Care (L Bruton, MM Davis, and C Foster), Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Ill; Department of Pediatrics (L Bruton, MM Davis, and C Foster), Northwestern University Feinberg School of Medicine, Chicago, Ill; Mary Ann and J. Milburn Smith Child Health Outcomes (P Bhatti, MM Davis, J Cartland, and C Foster), Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
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Chien AT, Spence SJ, Okumura MJ, Lu S, Chan CH, Houtrow AJ, Kuo DZ, Van Cleave JM, Shanske SA, Schuster MA, Kuhlthau KA, Toomey SL. Impairment Types and Combinations Among Adolescents and Young Adults with Disabilities: Colorado 2014-2018. Acad Pediatr 2024; 24:587-595. [PMID: 37925071 PMCID: PMC11056312 DOI: 10.1016/j.acap.2023.10.010] [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: 06/06/2023] [Revised: 10/25/2023] [Accepted: 10/29/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVE Understanding the types of functional challenges faced by adolescents and young adults with disabilities (AYA-WD) can help payers, clinicians, community-based service providers, and policymakers recognize and meet needs. This paper describes state-level prevalence rates for 1) AYA-WD overall and for 2) impairment types singly and in combinations; and 3) examines how rates may differ between those insured by Medicaid versus commercial insurance. METHODS This descriptive study uses Colorado's All Payer Claims Dataset 2014-2018 to identify insured 10- to 26-year-olds (Medicaid only: 333,931; commercially only: 392,444). It then applies the previously validated Children with Disabilities Algorithm (CWDA) and its companion, the Diagnosis-to-Impairment-Type Algorithm (DITA), to compare state-level prevalence rates by insurance source for disability overall and for each of five impairment types singly and in combination. RESULTS Disability prevalence was greater among the Medicaid-insured AYA-WD by +7.6% points (pp)-Medicaid: 11.9% (47,654/333,931), commercial: 4.3% (16,907/392,444). Most AYA-WD had a single impairment, but the prevalence of AYA-WD with two or more impairments was greater among the Medicaid-insured than the commercially insured (+9.9 pp; Medicaid: 33.5% [15,963/47,654], commercial: 23.7% [3992/16, 907]), as was the prevalence of impairment types that were physical (+6.7 pp; Medicaid: 54.7% [26,054/47,654], commercial: 48.0% [8121/16,907]); developmental (+4.1 pp; Medicaid: 35.4% [16,874/47,654], commercial: 31.3% [5290/16,907]); psychiatric (+6.7 pp; Medicaid 21.3% [10,175/47,654], commercial: 14.6% [2470/16,907]), and intellectual (+9.3 pp; Medicaid: 26.2% [12,501/47,654], commercial: 16.9% [2858/16,907]). CONCLUSIONS CWDA and DITA can be used to understand the rates at which impairment types and combinations occur in a population with childhood-onset disabilities.
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Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics (AT Chien and SL Toomey), Boston Children's Hospital, Boston, Mass; Department of Pediatrics (AT Chien and SL Toomey), Harvard Medical School, Boston, Mass.
| | - Sarah J Spence
- Department of Neurology (SJ Spence), Boston Children's Hospital, Boston, Mass
| | - Megumi J Okumura
- Division of General Pediatrics (MJ Okumura), University of California San Francisco Benioff Children's Hospital
| | - Sifan Lu
- College of Medicine, State University of New York-Downstate (S Lu), Brooklyn, NY
| | - Christina H Chan
- Biostatistics and Research Design Center (CH Chan), Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Mass
| | - Amy J Houtrow
- Department of Physical Medicine and Rehabilitation (AJ Houtrow), University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Dennis Z Kuo
- Department of Pediatrics (DZ Kuo), University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Jeanne M Van Cleave
- Department of Pediatrics (JM Van Cleave), Anschutz School of Medicine, University of Colorado, Aurora, CO
| | - Susan A Shanske
- Department of Social Work (SA Shanske), Boston Children's Hospital, Boston, Mass
| | - Mark A Schuster
- Kaiser Permanent Bernard J. Tyson School of Medicine (MA Schuster), Pasadena, Calif
| | - Karen A Kuhlthau
- Center for Child and Adolescent Health Research and Policy (KA Kuhlthau), Department of General Pediatrics, Massachusetts General Hospital for Children, Boston, Mass
| | - Sara L Toomey
- Division of General Pediatrics (AT Chien and SL Toomey), Boston Children's Hospital, Boston, Mass; Department of Pediatrics (AT Chien and SL Toomey), Harvard Medical School, Boston, Mass
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Wisk LE, Garvey KC, Fu C, Landrum MB, Beaulieu ND, Chien AT. Diabetes-Focused Health Care Utilization Among Adolescents and Young Adults With Type 1 Diabetes. Acad Pediatr 2024; 24:59-67. [PMID: 37148967 DOI: 10.1016/j.acap.2023.05.001] [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: 04/08/2022] [Revised: 04/27/2023] [Accepted: 05/01/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVE To describe the current rates of health services use with various types of providers among adolescents and young adults (AYA) with type 1 diabetes (T1D) and evaluate which patient factors are associated with rates of service use from different provider types. METHODS Using 2012-16 claims data from a national commercial insurer, we identified 18,927 person-years of AYA with T1D aged 13 to 26 years and evaluated the frequency at which: 1) AYA skipped diabetes care for a year despite being insured; 2) received care from pediatric or non-pediatric generalists or endocrinologists if care was sought; and 3) received annual hemoglobin A1c (HbA1c) testing as recommended for AYA. We used descriptive statistics and multivariable regression to examine patient, insurance, and physician characteristics associated with utilization and quality outcomes. RESULTS Between ages 13 and 26, the percentage of AYA with: any diabetes-focused visits declined from 95.3% to 90.3%; the mean annual number of diabetes-focused visits, if any, decreased from 3.5 to 3.0; receipt of ≥2 HbA1c tests annually decreased from 82.3% to 60.6%. Endocrinologists were the majority providers of diabetes care across ages, yet the relative proportion of AYA whose diabetes care was endocrinologist-dominated decreased from 67.3% to 52.7% while diabetes care dominated by primary care providers increased from 19.9% to 38.2%. The strongest predictors of diabetes care utilization were younger age and use of diabetes technology (pumps and continuous glucose monitors). CONCLUSIONS Several provider types are involved in the care of AYA with T1D, though predominate provider type and care quality changes substantially across age in a commercially-insured population.
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Affiliation(s)
- Lauren E Wisk
- Division of General Internal Medicine and Health Services Research (LE Wisk), David Geffen School of Medicine at the University of California, Los Angeles (UCLA); Department of Health Policy and Management (LE Wisk), Fielding School of Public Health at UCLA, Los Angeles, Calif.
| | | | - Christina Fu
- Department of Health Care Policy (C Fu, MB Landrum, and ND Beaulieu), Harvard Medical School, Boston, Mass
| | - Mary Beth Landrum
- Department of Health Care Policy (C Fu, MB Landrum, and ND Beaulieu), Harvard Medical School, Boston, Mass
| | - Nancy D Beaulieu
- Department of Health Care Policy (C Fu, MB Landrum, and ND Beaulieu), Harvard Medical School, Boston, Mass
| | - Alyna T Chien
- Department of Pediatrics (AT Chien), Harvard Medical School, Boston, Mass; Division of General Pediatrics (AT Chien), Boston Children's Hospital, Mass
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Chung J, Pecora PJ, Sinha A, Prichett L, Lin FY, Seltzer RR. A gap in the data: Defining, identifying, and tracking children with medical complexity in the child welfare system. CHILD ABUSE & NEGLECT 2024; 147:106600. [PMID: 38118290 DOI: 10.1016/j.chiabu.2023.106600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/30/2023] [Accepted: 12/06/2023] [Indexed: 12/22/2023]
Abstract
BACKGROUND Among nearly 400,000 children in US foster care, an estimated 10 % are medically complex. Yet, population-level data about children with medical complexity (CMC) served by the child welfare system, both for prevention and foster care services, are largely unavailable. OBJECTIVE To understand how US child welfare agencies define, identify, and track CMC. PARTICIPANTS AND SETTING Child welfare agencies across the US. METHODS Agencies were recruited to complete a survey as part of a larger study exploring how CMC are served by the child welfare system. Survey responses related to defining, identifying, and tracking CMC were included in analysis. Descriptive statistical analysis was conducted with Stata. Qualitative content and thematic analysis were applied to free text responses. RESULTS Surveys were completed by agencies from 28 states and 2 major cities. Nearly half of the agencies did not have a clear definition to identify CMC; those that did have a definition often lacked standardization. The majority of agencies could not easily identify CMC or access CMC-related data within data systems. Agencies described lack of a clear definition as a barrier to collecting population level data. CONCLUSIONS Many US child welfare agencies lack a clear definition to identify and track CMC, impacting the ability to tailor care and service delivery to meet their unique needs. To address this, a clear definition for CMC should be developed and consistently applied within child welfare data systems. Once CMC are identifiable, future research can collect population-level data and provide recommendations for best practices and policies.
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Affiliation(s)
- Joyce Chung
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Peter J Pecora
- University of Washington School of Social Work, Seattle, WA, United States of America; Casey Family Programs, Seattle, WA, United States of America
| | - Aakanksha Sinha
- Casey Family Programs, Seattle, WA, United States of America
| | - Laura Prichett
- Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Fang-Yi Lin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America; Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Rebecca R Seltzer
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America; Johns Hopkins University School of Medicine, Baltimore, MD, United States of America; Berman Institute of Bioethics, Baltimore, MD, United States of America.
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Austin AM, Schaefer AP, Arakelyan M, Freyleue SD, Goodman DC, Leyenaar JK. Specialties Providing Ambulatory Care and Associated Health Care Utilization and Quality for Children With Medical Complexity. Acad Pediatr 2023; 23:1542-1552. [PMID: 37468062 PMCID: PMC10792122 DOI: 10.1016/j.acap.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/30/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE Although children with medical complexity (CMC) have substantial health care needs, the extent to which they receive ambulatory care from primary care versus specialist clinicians is unknown. We aimed to determine the predominant specialty providing ambulatory care to CMC (primary care or specialty discipline), the extent to which specialists deliver well-child care, and associations between having a specialty predominant provider and health care utilization and quality. METHODS In a retrospective cohort analysis of 2012-17 all-payer claims data from Colorado, New Hampshire, and Massachusetts, we identified the predominant specialty providing ambulatory care for CMC <18 years. Propensity score weighting was used to create a balanced sample of CMC and assess differences in outcomes, including adequate well-child care, continuity of care, emergency visits, and hospitalizations, between CMC with a primary care versus specialty predominant provider. RESULTS Among 67,218 CMC, 75.3% (n = 50,584) received the plurality of care from a primary care discipline. Body system involvement, age > 2 years, urban residence, and cooccurring disabilities were associated with predominantly receiving care from specialists. After propensity score weighting, there were no significant differences between CMC with a primary care or specialist "predominant specialty seen" (PSS) in ambulatory visit counts, adequate well-child care, hospitalizations, or overall continuity of care. Specialists were the sole providers of well-child care and vaccines for 49.9% and 53.1% of CMC with a specialist PSS. CONCLUSIONS Most CMC received the plurality of care from primary care disciplines, and there were no substantial differences in overall utilization or quality based on the PSS.
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Affiliation(s)
- Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice (AM Austin, AP Schaefer, SD Freyleue, D Goodman, and JK Leyenaar), Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Andrew P Schaefer
- The Dartmouth Institute for Health Policy and Clinical Practice (AM Austin, AP Schaefer, SD Freyleue, D Goodman, and JK Leyenaar), Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Mary Arakelyan
- Department of Pediatrics (M Arakelyan and JK Leyenaar), Dartmouth Health Children's, Lebanon, NH
| | - Seneca D Freyleue
- The Dartmouth Institute for Health Policy and Clinical Practice (AM Austin, AP Schaefer, SD Freyleue, D Goodman, and JK Leyenaar), Geisel School of Medicine at Dartmouth, Hanover, NH
| | - David C Goodman
- The Dartmouth Institute for Health Policy and Clinical Practice (AM Austin, AP Schaefer, SD Freyleue, D Goodman, and JK Leyenaar), Geisel School of Medicine at Dartmouth, Hanover, NH
| | - JoAnna K Leyenaar
- The Dartmouth Institute for Health Policy and Clinical Practice (AM Austin, AP Schaefer, SD Freyleue, D Goodman, and JK Leyenaar), Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Pediatrics (M Arakelyan and JK Leyenaar), Dartmouth Health Children's, Lebanon, NH.
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Leyenaar JK, Freyleue SD, Arakelyan M, Goodman DC, O’Malley AJ. Pediatric Hospitalizations at Rural and Urban Teaching and Nonteaching Hospitals in the US, 2009-2019. JAMA Netw Open 2023; 6:e2331807. [PMID: 37656457 PMCID: PMC10474556 DOI: 10.1001/jamanetworkopen.2023.31807] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/07/2023] [Indexed: 09/02/2023] Open
Abstract
Importance National analyses suggest that approximately 1 in 5 US hospitals closed their pediatric units between 2008 and 2018. The extent to which pediatric hospitalizations at general hospitals in rural and urban communities decreased during this period is not well understood. Objective To describe changes in the number and proportion of pediatric hospitalizations and costs at urban teaching, urban nonteaching, and rural hospitals vs freestanding children's hospitals from 2009 to 2019; to estimate the number and proportion of hospitals providing inpatient pediatric care; and to characterize changes in clinical complexity. Design, Setting, and Participants This study is a retrospective cross-sectional analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative data set of US pediatric hospitalizations among children younger than 18 years. Data were analyzed from February to June 2023. Exposures Pediatric hospitalizations were grouped as birth or nonbirth hospitalizations. Hospitals were categorized as freestanding children's hospitals or as rural, urban nonteaching, or urban teaching general hospitals. Main Outcomes and Measures The primary outcomes were annual number and proportion of birth and nonbirth hospitalizations and health care costs, changes in the proportion of hospitalizations with complex diagnoses, and estimated number and proportion of hospitals providing pediatric care and associated hospital volumes. Regression analyses were used to compare health care utilization in 2019 vs that in 2009. Results The data included 23.2 million (95% CI, 22.7-23.6 million) weighted hospitalizations. From 2009 to 2019, estimated national annual pediatric hospitalizations decreased from 6 425 858 to 5 297 882, as birth hospitalizations decreased by 10.6% (95% CI, 6.1%-15.1%) and nonbirth hospitalizations decreased by 28.9% (95% CI, 21.3%-36.5%). Concurrently, hospitalizations with complex chronic disease diagnoses increased by 45.5% (95% CI, 34.6%-56.4%), and hospitalizations with mental health diagnoses increased by 78.0% (95% CI, 61.6%-94.4%). During this period, the most substantial decreases were in nonbirth hospitalizations at rural hospitals (4-fold decrease from 229 263 to 62 729) and urban nonteaching hospitals (6-fold decrease from 581 320 to 92 118). In 2019, birth hospitalizations occurred at 2666 hospitals. Nonbirth pediatric hospitalizations occurred at 3507 hospitals, including 1256 rural hospitals and 843 urban nonteaching hospitals where the median nonbirth hospitalization volumes were fewer than 25 per year. Conclusions and Relevance Between 2009 and 2019, the largest decreases in pediatric hospitalizations occurred at rural and urban nonteaching hospitals. Clinical and policy initiatives to support hospitals with low pediatric volumes may be needed to maintain hospital access and pediatric readiness, particularly in rural communities.
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Affiliation(s)
- JoAnna K. Leyenaar
- Department of Pediatrics, Dartmouth Health Children’s, Lebanon, New Hampshire
| | - Seneca D. Freyleue
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Mary Arakelyan
- Department of Pediatrics, Dartmouth Health Children’s, Lebanon, New Hampshire
| | - David C. Goodman
- Department of Pediatrics, Dartmouth Health Children’s, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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Boyden JY, Bogetz JF, Johnston EE, Thienprayoon R, Williams CSP, McNeil MJ, Patneaude A, Widger KA, Rosenberg AR, Ananth P. Measuring Pediatric Palliative Care Quality: Challenges and Opportunities. J Pain Symptom Manage 2023; 65:e483-e495. [PMID: 36736860 PMCID: PMC10106436 DOI: 10.1016/j.jpainsymman.2023.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023]
Abstract
Pediatric palliative care (PPC) programs vary widely in structure, staffing, funding, and patient census, resulting in inconsistency in service provision. Improving the quality of palliative care for children living with serious illness and their families requires measuring care quality, ensuring that quality measurement is embedded into day-to-day clinical practice, and aligning quality measurement with healthcare policy priorities. Yet, numerous challenges exist in measuring PPC quality. This paper provides an overview of PPC quality measurement, including challenges, current initiatives, and future opportunities. While important strides toward addressing quality measurement challenges in PPC have been made, including ongoing quality measurement initiatives like the Cambia Metrics Project, the PPC What Matters Most study, and collaborative learning networks, more work remains. Providing high-quality PPC to all children and families will require a multi-pronged approach. In this paper, we suggest several strategies for advancing high-quality PPC, which includes 1) considering how and by whom success is defined, 2) evaluating, adapting, and developing PPC measures, including those that address care disparities within PPC for historically marginalized and excluded communities, 3) improving the infrastructure with which to routinely and prospectively measure, monitor, and report clinical and administrative quality measures, 4) increasing endorsement of PPC quality measures by prominent quality organizations to facilitate accountability and possible reimbursement, and 5) integrating PPC-specific quality measures into the administrative, funding, and policy landscape of pediatric healthcare.
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Affiliation(s)
- Jackelyn Y Boyden
- Department of Family and Community Health, School of Nursing (J.Y.B.), University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Jori F Bogetz
- Department of Pediatrics, Division of Bioethics and Palliative Care (J.F.B.), University of Washington School of Medicine, Seattle, Washington, USA; Center for Clinical and Translational Research (J.F.B.), Seattle Children's Research Institute, Seattle, Washington, USA
| | - Emily E Johnston
- Department of Pediatrics, Division of Hematology and Oncology (E.E.J.), University of Alabama at Birmingham, Birmingham, Alabama, USA; Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham (E.E.J.), Birmingham, Alabama, USA
| | - Rachel Thienprayoon
- Department of Anesthesia, Division of Palliative Care, Cincinnati Children's Hospital Medical Center (R.T.), Cincinnati, Ohio, USA; Department of Pediatrics, Cincinnati Children's Hospital Medical Center (R.T.), Cincinnati, Ohio, USA
| | - Conrad S P Williams
- Palliative Care Program and Department of Pediatrics (C.S.P.W.), Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael J McNeil
- St. Jude Children's Research Hospital, Department of Global Pediatric Medicine (M.J.M.), Memphis, Tennessee, USA; St. Jude Children's Research Hospital, Division of Quality and Life and Palliative Care, Department of Oncology (M.J.M.), Memphis, Tennessee, USA
| | - Arika Patneaude
- Bioethics and Palliative Care, Seattle Children's Hospital (A.P.), Seattle, Washington, USA; University of Washington School of Social Work (A.P.), Seattle, Washington, USA; Treuman Katz Center for Pediatric Bioethics (A.P.), Seattle, Washington, USA
| | - Kimberley A Widger
- Lawrence S. Bloomberg Faculty of Nursing (K.A.W.), University of Toronto, Toronto, Ontario, Canada; Hospital for Sick Children (K.A.W.), Toronto, Ontario, Canada
| | - Abby R Rosenberg
- Department of Psychosocial Oncology and Palliative Care (A.R.S.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School (A.R.S.), Boston, Massachusetts, USA
| | - Prasanna Ananth
- Department of Pediatrics, Yale School of Medicine (P.A.), New Haven, Connecticut, USA; Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center (P.A.), New Haven, Connecticut, USA
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8
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Arakelyan M, Freyleue S, Avula D, McLaren JL, O’Malley AJ, Leyenaar JK. Pediatric Mental Health Hospitalizations at Acute Care Hospitals in the US, 2009-2019. JAMA 2023; 329:1000-1011. [PMID: 36976279 PMCID: PMC10051095 DOI: 10.1001/jama.2023.1992] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 02/06/2023] [Indexed: 03/29/2023]
Abstract
Importance Approximately 1 in 6 youth in the US have a mental health condition, and suicide is a leading cause of death among this population. Recent national statistics describing acute care hospitalizations for mental health conditions are lacking. Objectives To describe national trends in pediatric mental health hospitalizations between 2009 and 2019, to compare utilization among mental health and non-mental health hospitalizations, and to characterize variation in utilization across hospitals. Design, Setting, and Participants Retrospective analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative database of US acute care hospital discharges. Analysis included 4 767 840 weighted hospitalizations among children 3 to 17 years of age. Exposures Hospitalizations with primary mental health diagnoses were identified using the Child and Adolescent Mental Health Disorders Classification System, which classified mental health diagnoses into 30 mutually exclusive disorder types. Main Outcomes and Measures Measures included number and proportion of hospitalizations with a primary mental health diagnosis and with attempted suicide, suicidal ideation, or self-injury; number and proportion of hospital days and interfacility transfers attributable to mental health hospitalizations; mean lengths of stay (days) and transfer rates among mental health and non-mental health hospitalizations; and variation in these measures across hospitals. Results Of 201 932 pediatric mental health hospitalizations in 2019, 123 342 (61.1% [95% CI, 60.3%-61.9%]) were in females, 100 038 (49.5% [95% CI, 48.3%-50.7%]) were in adolescents aged 15 to 17 years, and 103 456 (51.3% [95% CI, 48.6%-53.9%]) were covered by Medicaid. Between 2009 and 2019, the number of pediatric mental health hospitalizations increased by 25.8%, and these hospitalizations accounted for a significantly higher proportion of pediatric hospitalizations (11.5% [95% CI, 10.2%-12.8%] vs 19.8% [95% CI, 17.7%-21.9%]), hospital days (22.2% [95% CI, 19.1%-25.3%] vs 28.7% [95% CI, 24.4%-33.0%]), and interfacility transfers (36.9% [95% CI, 33.2%-40.5%] vs 49.3% [95% CI, 45.9%-52.7%]). The percentage of mental health hospitalizations with attempted suicide, suicidal ideation, or self-injury diagnoses increased significantly from 30.7% (95% CI, 28.6%-32.8%) in 2009 to 64.2% (95% CI, 62.3%-66.2%) in 2019. Length of stay and interfacility transfer rates varied significantly across hospitals. Across all years, mental health hospitalizations had significantly longer mean lengths of stay and higher transfer rates compared with non-mental health hospitalizations. Conclusions and Relevance Between 2009 and 2019, the number and proportion of pediatric acute care hospitalizations due to mental health diagnoses increased significantly. The majority of mental health hospitalizations in 2019 included a diagnosis of attempted suicide, suicidal ideation, or self-injury, underscoring the increasing importance of this concern.
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Affiliation(s)
- Mary Arakelyan
- Department of Pediatrics, Dartmouth Health Children’s, Lebanon, New Hampshire
| | - Seneca Freyleue
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Divya Avula
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- University of Louisville School of Medicine, University of Louisville, Louisville, Kentucky
| | - Jennifer L. McLaren
- Department of Pediatrics, Dartmouth Health Children’s, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Department of Psychiatry, Dartmouth Health, Lebanon, New Hampshire
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - JoAnna K. Leyenaar
- Department of Pediatrics, Dartmouth Health Children’s, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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9
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Heneghan JA, Goodman DM, Ramgopal S. Demographic and Clinical Differences Between Applied Definitions of Medical Complexity. Hosp Pediatr 2022; 12:654-663. [PMID: 35652303 DOI: 10.1542/hpeds.2021-006432] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To identify the degree of concordance and characterize demographic and clinical differences between commonly used definitions of multisystem medical complexity in children hospitalized in children's hospitals. METHODS We conducted a retrospective, cross-sectional cohort study of children <21 years of age hospitalized at 47 US Pediatric Health Information System-participating children's hospitals between January 2017 to December 2019. We classified patients as having multisystem complexity when using 3 definitions of medical complexity (pediatric complex chronic conditions, pediatric medical complexity algorithm, and pediatric chronic critical illness) and assessed their overlap. We compared demographic, clinical, outcome, cost characteristics, and longitudinal healthcare utilization for each grouping. RESULTS Nearly one-fourth (23.5%) of children hospitalized at Pediatric Health Information System-participating institutions were identified as meeting at least 1 definition of multisystem complexity. Children with multisystem complexity ranged from 1.0% to 22.1% of hospitalized children, depending on the definition, with 31.2% to 95.9% requiring an ICU stay during their index admission. Differences were seen in demographic, clinical, and resource utilization patterns across the definitions. Definitions of multisystem complexity demonstrated poor agreement (Fleiss' κ 0.21), with 3.5% of identified children meeting all 3. CONCLUSIONS Three definitions of multisystem complexity identified varied populations of children with complex medical needs, with poor overall agreement. Careful consideration is required when applying definitions of medical complexity in health services research, and their lack of concordance should result in caution in the interpretation of research using differing definitions of medical complexity.
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Affiliation(s)
- Julia A Heneghan
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
| | | | - Sriram Ramgopal
- Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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10
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Leyenaar JK, Schaefer AP, Freyleue SD, Austin AM, Simon TD, Van Cleave J, Moen EL, O’Malley AJ, Goodman DC. Prevalence of Children With Medical Complexity and Associations With Health Care Utilization and In-Hospital Mortality. JAMA Pediatr 2022; 176:e220687. [PMID: 35435932 PMCID: PMC9016603 DOI: 10.1001/jamapediatrics.2022.0687] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 01/12/2022] [Indexed: 02/05/2023]
Abstract
Importance Children with medical complexity (CMC) have substantial health care needs and frequently experience poor health care quality. Understanding the population prevalence and associated health care needs can inform clinical and public health initiatives. Objective To estimate the prevalence of CMC using open-source pediatric algorithms, evaluate performance of these algorithms in predicting health care utilization and in-hospital mortality, and identify associations between medical complexity as defined by these algorithms and clinical outcomes. Design, Setting, and Participants This retrospective cohort study used all-payer claims data from Colorado, Massachusetts, and New Hampshire from 2012 through 2017. Children and adolescents younger than 18 years residing in these states were included if they had 12 months or longer of enrollment in a participating health care plan. Analyses were conducted from March 12, 2021, to January 7, 2022. Exposures The pediatric Complex Chronic Condition Classification System, Pediatric Medical Complexity Algorithm, and Children With Disabilities Algorithm were applied to 3 years of data to identify children with complex and disabling conditions, first in their original form and then using more conservative criteria that required multiple health care claims or involvement of 3 or more body systems. Main Outcomes and Measures Primary outcomes, examined over 2 years, included in-hospital mortality and a composite measure of health care services, including specialized therapies, specialized medical equipment, and inpatient care. Outcomes were modeled using logistic regression. Model performance was evaluated using C statistics, sensitivity, and specificity. Results Of 1 936 957 children, 48.4% were female, 87.8% resided in urban core areas, and 45.1% had government-sponsored insurance as their only primary payer. Depending on the algorithm and coding criteria applied, 0.67% to 11.44% were identified as CMC. All 3 algorithms had adequate discriminative ability, sensitivity, and specificity to predict in-hospital mortality and composite health care services (C statistic = 0.76 [95% CI, 0.73-0.80] to 0.81 [95% CI, 0.78-0.84] for mortality and 0.77 [95% CI, 0.76-0.77] to 0.80 [95% CI, 0.79-0.80] for composite health care services). Across algorithms, CMC had significantly greater odds of mortality (adjusted odds ratio [aOR], 9.97; 95% CI, 7.70-12.89; to aOR, 69.35; 95% CI, 52.52-91.57) and composite health care services (aOR, 4.59; 95% CI, 4.44-4.73; to aOR, 18.87; 95% CI, 17.87-19.93) than children not identified as CMC. Conclusions and Relevance In this study, open-source algorithms identified different cohorts of CMC in terms of prevalence and magnitude of risk, but all predicted increased health care utilization and in-hospital mortality. These results can inform research, programs, and policies for CMC.
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Affiliation(s)
- JoAnna K. Leyenaar
- Department of Pediatrics, Children’s Hospital at Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Andrew P. Schaefer
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Seneca D. Freyleue
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Andrea M. Austin
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Tamara D. Simon
- Department of Pediatrics, Keck School of Medicine at the University of Southern California, Los Angeles
- The Saban Research Institute, Children’s Hospital Los Angeles, Los Angeles, California
| | - Jeanne Van Cleave
- Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Erika L. Moen
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - David C. Goodman
- Department of Pediatrics, Children’s Hospital at Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
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11
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Leyenaar JK, Esporas M, Mangione-Smith R. How Does Pediatric Quality Measure Development Reflect the Real World Needs of Hospitalized Children? Acad Pediatr 2022; 22:S70-S72. [PMID: 35339245 PMCID: PMC9614710 DOI: 10.1016/j.acap.2021.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/14/2021] [Accepted: 01/31/2021] [Indexed: 12/25/2022]
Affiliation(s)
- JoAnna K. Leyenaar
- The Department of Pediatrics and The Dartmouth Institute of Health Policy & Clinical Practice, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03755
| | - Megan Esporas
- Children’s Hospital Association, 600 13th Street, NW, Suite 500, Washington, DC 20005
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12
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Gonzalez M, Saxena S, Chowdhury F, Dyck Holzinger S, Martens R, Oskoui M, Shikako-Thomas K. Informing the development of the Canadian Neurodiversity Platform: What is important to parents of children with neurodevelopmental disabilities? Child Care Health Dev 2022; 48:88-98. [PMID: 34374115 DOI: 10.1111/cch.12906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 06/04/2021] [Accepted: 08/04/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND A crowd-sourced Canadian platform that collects information across neurodevelopmental disabilities (NDDs) can (1) facilitate knowledge mobilization; (2) provide epidemiological data that can benefit knowledge, treatment, and advocacy; and (3) inform policy and resource allocation decisions. We obtained input from parents of children with NDDs about relevance and feasibility of questionnaire items as a first step to inform questionnaire development of a stakeholder-driven, national platform for data collection on children with NDDs. METHODS A parent of a teenager with NDDs was a research partner on the project. Through four focus groups and using a guided discussion consensus process, 16 participants provided feedback on whether questionnaire items from existing instruments related to function and disability were feasible for parents to complete and important to include in the platform. Data were analysed using content analysis. RESULTS Participants (1) indicated that questions about medical history, general health, body functioning, self-care, access to resources, and outcomes (e.g., quality of life) are important to include in the platform and are feasible for self-completion; (2) provided various suggestions for the questionnaire ranging from additional items to include, using non-medical language, and keeping completion time from 20 to 30 min; (3) identified incentives and knowing the purpose of the platform as strong motivators to platform participation; (4) spoke about the challenges of their caregiver experience including impact of caregiving on themselves and barriers to accessing services; and (5) highlighted the isolation experienced by their children. CONCLUSION Through the focus groups, parent stakeholders contributed to questionnaire development and shared their caregiver experiences. Obtaining feedback from youths with NDDs and healthcare providers on the questionnaire is a next step to validating findings. Stakeholder engagement is fundamental to developing a platform that will inform research that is relevant to the needs of children with NDDs and their families.
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Affiliation(s)
- Miriam Gonzalez
- Department of Neurology and Neurosurgery, McGill University, Montréal, Quebec, Canada.,Research Institute of the McGill University Health Centre, McGill University, Montréal, Quebec, Canada
| | - Shikha Saxena
- School of Human Kinetics, University of Ottawa, Ottawa, Ontario, Canada
| | - Farhin Chowdhury
- Department of Educational and Counselling Psychology, Faculty of Education, McGill University, Montréal, Canada
| | - Sasha Dyck Holzinger
- Research Institute of the McGill University Health Centre, McGill University, Montréal, Quebec, Canada
| | - Rachel Martens
- CHILD BRIGHT Network, Montreal, Quebec, Canada.,Kids Brain Health Network, Surrey, British Columbia, Canada
| | - Maryam Oskoui
- Department of Neurology and Neurosurgery, McGill University, Montréal, Quebec, Canada.,Research Institute of the McGill University Health Centre, McGill University, Montréal, Quebec, Canada.,Department of Pediatrics, McGill University, Montréal, Quebec, Canada
| | - Keiko Shikako-Thomas
- Research Institute of the McGill University Health Centre, McGill University, Montréal, Quebec, Canada.,School of Physical and Occupational Therapy, McGill University, Montréal, Quebec, Canada.,Canada Research Chair in Childhood Disabilities: Participation and Knowledge Translation, McGill University, Montréal, Quebec, Canada
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13
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Conroy K, Samnaliev M, Cheek S, Chien AT. Pediatric Primary Care-Based Social Needs Services and Health Care Utilization. Acad Pediatr 2021; 21:1331-1337. [PMID: 33516898 DOI: 10.1016/j.acap.2021.01.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To evaluate the relationship between use of primary care-based social needs services and subsequent utilization of ambulatory, emergency, and inpatient services. METHODS This retrospective 2012 to 2015 cohort study uses electronic medical record data from an academic pediatric primary care practice that screens universally for social needs and delivers services via in-house social work staff. Logistic regression (N = 7300) examines how patient characteristics relate to practice-based social service use. Negative binomial models with inverse probability of treatment weights (N = 4893) estimate adjusted incidence rate ratios for ambulatory, emergency, and inpatient service use among those who used social services compared to those who did not. RESULTS Forty-five percent of patients used primary care-based social needs services. This use was significantly greater among those with disabling or complex medical conditions than those without (adjusted odds ratio and 95% confidence interval (CI) of 9.81 [7.39-13.01] and 2.76 [2.44-3.13], respectively); those from low-income versus high-income backgrounds (1.40 [1.21-1.61]); and Blacks and Latinos than Whites (1.33 [1.09-1.62] and 1.29 [1.05-1.59], respectively). Patients who used social services subsequently utilized ambulatory, emergency, and inpatient services at significantly higher rates than those who did not (adjusted incidence rate ratios and 95% CI of 1.54 [1.45-1.63], 1.50 [1.36-1.65], and 3.23 [2.31-4.51], respectively). CONCLUSIONS Primary care-based social needs service use was associated with increased utilization of ambulatory services without reductions in emergency or inpatient admissions. This pattern suggests increased health care needs or access and could have payment model-dependent financial implications for practices.
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Affiliation(s)
- Kathleen Conroy
- Division of General Pediatrics, Boston Children's Hospital (K Conroy, M Samnaliev, S Cheek, and AT Chien), Boston, Mass; Harvard Medical School (K Conroy, M Samnaliev, and AT Chien), Boston, Mass.
| | - Mihail Samnaliev
- Division of General Pediatrics, Boston Children's Hospital (K Conroy, M Samnaliev, S Cheek, and AT Chien), Boston, Mass; Harvard Medical School (K Conroy, M Samnaliev, and AT Chien), Boston, Mass
| | - Sara Cheek
- Division of General Pediatrics, Boston Children's Hospital (K Conroy, M Samnaliev, S Cheek, and AT Chien), Boston, Mass
| | - Alyna T Chien
- Division of General Pediatrics, Boston Children's Hospital (K Conroy, M Samnaliev, S Cheek, and AT Chien), Boston, Mass; Harvard Medical School (K Conroy, M Samnaliev, and AT Chien), Boston, Mass
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14
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Identifying reproductive-aged women with physical and sensory disabilities in administrative health data: A systematic review. Disabil Health J 2020; 13:100909. [PMID: 32139320 DOI: 10.1016/j.dhjo.2020.100909] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 02/05/2020] [Accepted: 02/11/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Women with disabilities experience significant health disparities. A barrier to progress in addressing these disparities is the lack of population-based data on their health outcomes, which are needed to plan health care delivery systems. Administrative health data are increasingly being used to measure the health of entire populations, but these data may only capture impairment and not activity and participation restrictions. OBJECTIVE We conducted a systematic review to identify and appraise existing literature on the development and validation of algorithms to identify reproductive-aged women with physical and sensory disabilities in administrative health data. METHODS We searched Medline, EMBASE, CINAHL, PsycINFO, and Scopus from inception to April 2019 for studies of the development and/or validation of algorithms using diagnostic, procedural, or prescription codes to identify physical and sensory disabilities in administrative health data. Study and algorithm characteristics were extracted and quality was assessed using standardized instruments. RESULTS Of 14,073 articles initially identified, we reviewed 6 articles representing 2 unique algorithms. One algorithm aimed to correlate diagnoses, procedure codes, and prescriptions with ability to access routine care as an indicator of functional limitation. The other algorithm used diagnostic and procedure codes to identify use of mobility-assistive devices to measure functional limitation. Only one algorithm was validated against self-reported disability. CONCLUSIONS Our findings underscore the need to strengthen current methods to identify disability in administrative health data, including linkage with other sources of information on functional limitations, so that population-based data can be used to optimize health care for women with disabilities.
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15
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Adams JS, Chien AT, Wisk LE. Mental Illness Among Youth With Chronic Physical Conditions. Pediatrics 2019; 144:peds.2018-1819. [PMID: 31201229 DOI: 10.1542/peds.2018-1819] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Youth with chronic physical conditions (CPCs) may be at greater risk for developing chronic mental health conditions (MHCs), and limitations in the ability to engage in developmentally appropriate activities may contribute to the risk of MHCs among youth with CPCs. We compared the risk of incident MHCs in youth with and without CPCs and explored whether activity limitations contribute to any such association. METHODS The 2003-2014 Medical Expenditure Panel Survey provided a nationally representative cohort of 48 572 US youth aged 6 to 25 years. We calculated the 2-year cumulative incidence of MHCs overall and by baseline CPC status. Cox proportional hazard models were used to estimate the association between CPCs and incident MHCs, adjusting for sociodemographic characteristics. Stepwise models and the Sobel test evaluated activity limitations as a mediator of this relationship. RESULTS The 2-year cumulative incidence of MHCs was 7.8% overall, 11.5% in youth with CPCs (14.7% of sample), and 7.1% in those without. The adjusted risk of incident MHCs was 51% greater (adjusted hazard ratio 1.51; 95% confidence interval 1.30-1.74) in youth with CPCs compared with those without. Activity limitations mediated 13.5% of this relationship (P < .001). CONCLUSIONS This nationally representative cohort study supports the hypotheses that youth with CPCs have increased risk for MHCs and that activity limitations may play a role in MHC development. Youth with CPCs may benefit from services to bolster their ability to participate in developmentally important activities and to detect and treat new onset MHCs.
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Affiliation(s)
- John S Adams
- Department of Pediatrics, Cambridge Health Alliance, Cambridge, Massachusetts; .,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Alyna T Chien
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts; and.,Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Lauren E Wisk
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts; and.,Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
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16
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Brehaut JC, Guèvremont A, Arim RG, Garner RE, Miller AR, McGrail KM, Brownell M, Lach LM, Rosenbaum PL, Kohen DE. Using Canadian administrative health data to examine the health of caregivers of children with and without health problems: A demonstration of feasibility. Int J Popul Data Sci 2019; 4:584. [PMID: 32935023 PMCID: PMC7479927 DOI: 10.23889/ijpds.v4i1.584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Introduction Caregivers of children with health problems experience poorer health than the caregivers of healthy children. To date, population-based studies on this issue have primarily used survey data. Objectives We demonstrate that administrative health data may be used to study these issues, and explore how non-categorical indicators of child health in administrative data can enable population-level study of caregiver health. Methods Dyads from Population Data British Columbia (BC) databases, encompassing nearly all mothers in BC with children aged 6-10 years in 2006, were grouped using a non-categorical definition based on diagnoses and service use. Regression models examined whether four maternal health outcomes varied according to indicators of child health. Results 162,847 mother-child dyads were grouped according to the following indicators: Child High Service Use (18%) vs. Not (82%), Diagnosis of Major and/or Chronic Condition (12%) vs. Not (88%), and Both High Service Use and Diagnosis (5%) vs. Neither (75%). For all maternal health and service use outcomes (number of physician visits, chronic condition, mood or anxiety disorder, hospitalization), differences were demonstrated by child health indicators. Conclusions Mothers of children with health problems had poorer health themselves, as indicated by administrative data groupings. This work not only demonstrates the research potential of using routinely collected health administrative data to study caregiver and child health, but also the importance of addressing maternal health when treating children with health problems.
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Affiliation(s)
- Jamie C Brehaut
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Room 1284 Centre for Practice-Changing Research; Box 201B, Ottawa, Ontario, K1H 8L6, Canada
| | - Anne Guèvremont
- Health Analysis Division, Statistics Canada, 100 Tunney's Pasture Driveway, Ottawa, Ontario, K1A 0T6, Canada
| | - Rubab G Arim
- Health Analysis Division, Statistics Canada, 100 Tunney's Pasture Driveway, Ottawa, Ontario, K1A 0T6, Canada
| | - Rochelle E Garner
- Health Analysis Division, Statistics Canada, 100 Tunney's Pasture Driveway, Ottawa, Ontario, K1A 0T6, Canada
| | - Anton R Miller
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, 4480 Oak Street, Vancouver, British Columbia, V6H 3V4, Canada
| | - Kimberlyn M McGrail
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, 2206 East Mall, Vancouver, British Columbia, V6T 1Z9, Canada
| | - Marni Brownell
- Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, 727 McDermot Avenue, Winnipeg, Manitoba, R3E 3P5, Canada
| | - Lucyna M Lach
- School of Social Work, McGill University, 3506 University Street, Montreal, Quebec, H3A 2A7, Canada
| | - Peter L Rosenbaum
- Department of Paediatrics, Faculty of Health Sciences, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
| | - Dafna E Kohen
- Health Analysis Division, Statistics Canada, 100 Tunney's Pasture Driveway, Ottawa, Ontario, K1A 0T6, Canada
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17
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Chien AT, Toomey SL, Kuo DZ, Van Cleave J, Houtrow AJ, Okumura MJ, Westfall MY, Petty CR, Quinn JA, Kuhlthau KA, Schuster MA. Care Quality and Spending Among Commercially Insured Children With Disabilities. Acad Pediatr 2019; 19:291-299. [PMID: 29932986 DOI: 10.1016/j.acap.2018.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 04/16/2018] [Accepted: 06/10/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To identify opportunities to improve care value for children with disabilities (CWD), we examined CWD prevalence within a commercially insured population and compared outpatient care quality and annual health plan spending levels for CWD relative to children with complex medical conditions without disabilities; children with chronic conditions that are not complex; and children without disabling, complex, or chronic conditions. METHODS This cross-sectional study comprised 1,118,081 person-years of Blue Cross Blue Shield Massachusetts data for beneficiaries aged 1 to 19years old during 2008 to 2012. We combined the newly developed and validated Children with Disabilities Algorithm with the Pediatric Medical Complexity Algorithm to identify CWD and non-CWD subgroups. We used 14 validated or National Quality Forum-endorsed measures to assess outpatient care quality and paid claims to examine annual plan spending levels and components. RESULTS CWD constituted 4.5% of all enrollees. Care quality for CWD was between 11% and 59% for 8 of 14 quality measures and >80% for the 6 remaining measures and was generally comparable to that for non-CWD subgroups. Annual plan spending among CWD was a median and mean 23% and 53% higher than that for children with complex medical conditions without disabilities, respectively; CWD mean and median values were higher than for all other groups as well. CONCLUSIONS CWD were prevalent in our commercially insured population. CWD experienced suboptimal levels of care, but those levels were comparable to non-CWD groups. Improving the care value for CWD involves a deeper understanding of what higher spending delivers and additional aspects of care quality.
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Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Department of Medicine; Department of Pediatrics, Harvard Medical School.
| | - Sara L Toomey
- Division of General Pediatrics, Department of Medicine; Department of Pediatrics, Harvard Medical School
| | - Dennis Z Kuo
- Division of General Pediatrics, Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, NY
| | - Jeanne Van Cleave
- Department of Pediatrics, School of Medicine, University of Colorado Denver, Anschutz Medical Campus , Aurora, Colo
| | - Amy J Houtrow
- Division of Pediatric Rehabilitation Medicine, Children's Hospital of Pittsburgh; Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine , Pittsburgh, Pa
| | - Megumi J Okumura
- Division of General Pediatrics, University of California San Francisco Benioff Children's Hospital; Division of General Pediatrics, Department of Pediatrics, University of California San Francisco School of Medicine , San Francisco
| | | | - Carter R Petty
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital
| | | | - Karen A Kuhlthau
- Department of Pediatrics, Harvard Medical School; Division of General Academic Pediatrics, Massachusetts General Hospital for Children , Boston, Mass
| | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine; Department of Pediatrics, Harvard Medical School; Kaiser Permanente School of Medicine , Pasadena, Calif
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18
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Cohen E, Berry JG, Sanders L, Schor EL, Wise PH. Status Complexicus? The Emergence of Pediatric Complex Care. Pediatrics 2018; 141:S202-S211. [PMID: 29496971 DOI: 10.1542/peds.2017-1284e] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2017] [Indexed: 11/24/2022] Open
Abstract
Discourse about childhood chronic conditions has transitioned in the last decade from focusing primarily on broad groups of children with special health care needs to concentrating in large part on smaller groups of children with medical complexity (CMC). Although a variety of definitions have been applied, the term CMC has most commonly been defined as children and youth with serious chronic conditions, substantial functional limitations, increased health and other service needs, and increased health care costs. The increasing attention paid to CMC has occurred because these children are growing in impact, represent a disproportionate share of health system costs, and require policy and programmatic interventions that differ in many ways from broader groups of children with special health care needs. But will this change in focus lead to meaningful changes in outcomes for children with serious chronic diseases, or is the pediatric community simply adopting terminology with resonance in adult-focused health systems? In this article, we will explore the implications of the rapid emergence of pediatric complex care in child health services practice and research. As an emerging field, pediatric care systems should thoughtfully and rapidly develop evidence-based solutions to the new challenges of caring for CMC, including (1) clearer definitions of the target population, (2) a more appropriate incorporation of components of care that occur outside of hospitals, and (3) a more comprehensive outcomes measurement framework, including the recognition of potential limitations of cost containment as a target for improved care for CMC.
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Affiliation(s)
- Eyal Cohen
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada; .,Department of Pediatrics and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Jay G Berry
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Lee Sanders
- Center for Policy, Outcomes and Prevention (CPOP) and.,Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
| | - Edward L Schor
- Lucile Packard Foundation for Children's Health, Palo Alto, California
| | - Paul H Wise
- Center for Policy, Outcomes and Prevention (CPOP) and.,Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
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19
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Arim RG, Miller AR, Guèvremont A, Lach LM, Brehaut JC, Kohen DE. Children with neurodevelopmental disorders and disabilities: a population-based study of healthcare service utilization using administrative data. Dev Med Child Neurol 2017; 59:1284-1290. [PMID: 28905997 DOI: 10.1111/dmcn.13557] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2017] [Indexed: 11/28/2022]
Abstract
AIM The aim of this study was to identify children with neurodevelopmental disorders and disabilities (NDD/D) and compare their healthcare service utilization to children without NDD/D using provincial linked administrative data. METHOD The sample included children aged 6 to 10 years (n=183 041), who were registered with the British Columbia Medical Services Plan. Diagnostic information was used for the identification and classification of NDD/D in six functional domains. Healthcare service utilization included outcomes based on physician claims, prescription medication use, and hospitalization. RESULTS Overall, 8.3% of children were identified with NDD/D. Children with NDD/D had higher healthcare service utilization rates than those without NDD/D. Effect sizes were: very large for the number of days a prescription medication was dispensed; large for the number of prescriptions; medium for the number of physician visits, different specialists visited, number of different prescription medications, and ever hospitalized; and small for the number of laboratory visits, X-ray visits, and number of days hospitalized. INTERPRETATION The findings have policy implications for service and resource planning. Given the high use of psychostimulants, specialized services for both NDD/D and psychiatric conditions may be the most needed services for children with NDD/D. Future studies may examine patterns of physician behaviours and costs attributable to healthcare service utilization for children with NDD/D. WHAT THIS PAPER ADDS Children with neurodevelopmental disorders and disabilities (NDD/D) have higher healthcare service utilization than those without. Based on provincial population-based linked administrative health data, a sizeable number of children are living with NDD/D. Given the high use of psychostimulants, specialized services for children with both NDD/D and psychiatric conditions may be the most needed services for children with NDD/D.
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Affiliation(s)
- Rubab G Arim
- Health Analysis Division, Statistics Canada, Ottawa, ON, Canada
| | - Anton R Miller
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Anne Guèvremont
- Health Analysis Division, Statistics Canada, Ottawa, ON, Canada
| | - Lucyna M Lach
- School of Social Work, McGill University, Montreal, QC, Canada
| | - Jamie C Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Dafna E Kohen
- Health Analysis Division, Statistics Canada, Ottawa, ON, Canada
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Chien AT, Kuhlthau KA, Toomey SL, Quinn JA, Okumura MJ, Kuo DZ, Houtrow AJ, Van Cleave J, Landrum MB, Jang J, Janmey I, Furdyna MJ, Schuster MA. Quality of Primary Care for Children With Disabilities Enrolled in Medicaid. Acad Pediatr 2017; 17:443-449. [PMID: 28286057 DOI: 10.1016/j.acap.2016.10.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 09/28/2016] [Accepted: 10/28/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The quality of primary care delivered to Medicaid-insured children with disabilities (CWD) is unknown. We used the newly validated CWD algorithm (CWDA) to examine CWD prevalence among Medicaid enrollees 1 to 18 years old, primary care quality for CWD, and differences in primary care quality for CWD and non-CWD. METHODS Cross-sectional study using 2008 Medicaid Analytic eXtract claims data from 9 states, including children with at least 11 months of enrollment (N = 2,671,922 enrollees). We utilized CWDA to identify CWD and applied 12 validated or endorsed pediatric quality measures to assess preventive/screening, acute, and chronic disease care quality. We compared quality for CWD and non-CWD unmatched and matched on age, sex, and number of nondisabling chronic conditions and outpatient encounters. RESULTS CWDA identified 5.3% (n = 141,384) of our study population as CWD. Care quality levels for CWD were below 50% on 8 of 12 quality measures (eg, adolescent well visits [44.9%], alcohol/drug treatment engagement [24.9%]). CWD care quality was significantly better than the general population of non-CWD by +0.9% to +15.6% on 9 measures, but significantly worse for 2 measures, chlamydia screening (-3.4%) and no emergency department visits for asthma (-5.0%; all P < .01 to .001). Differences in care quality between CWD and non-CWD were generally smaller or changed direction when CWD were compared to a general population or matched group of non-CWD. CONCLUSIONS One in 20 Medicaid-insured children is CWD, and the quality of primary care delivered to CWD is suboptimal. Areas needing improvement include preventive/screening, acute care, and chronic disease management.
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Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass.
| | - Karen A Kuhlthau
- Department of Pediatrics, Harvard Medical School, Boston, Mass; Center for Child and Adolescent Health Research and Policy, Department of General Pediatrics, Massachusetts General Hospital for Children, Boston, Mass
| | - Sara L Toomey
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Jessica A Quinn
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass
| | - Megumi J Okumura
- Division of General Pediatrics, University of California San Francisco Beinoff Children's Hospital, San Francisco, Calif; Division of General Pediatrics, Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, Calif
| | - Dennis Z Kuo
- Department of Pediatrics, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Ark
| | - Amy J Houtrow
- Division of Pediatric Rehabilitation Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pa; Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Jeanne Van Cleave
- Department of Pediatrics, Harvard Medical School, Boston, Mass; Center for Child and Adolescent Health Research and Policy, Department of General Pediatrics, Massachusetts General Hospital for Children, Boston, Mass
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Mass
| | - Jisun Jang
- The Clinical Research Center, Boston Children's Hospital, Boston, Mass
| | - Isabel Janmey
- Case Western Reserve University School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Michael J Furdyna
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
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Chien AT, Schiavoni KH, Sprecher E, Landon BE, McNeil BJ, Chernew ME, Schuster MA. How Accountable Care Organizations Responded to Pediatric Incentives in the Alternative Quality Contract. Acad Pediatr 2016; 16:200-7. [PMID: 26523636 DOI: 10.1016/j.acap.2015.10.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 10/15/2015] [Accepted: 10/24/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVE From 2009 to 2010, 12 accountable care organizations (ACOs) entered into the alternative quality contract (AQC), BlueCross BlueShield of Massachusetts's global payment arrangement. The AQC included 6 outpatient pediatric quality measures among 64 total measures tied to pay-for-performance bonuses and incorporated pediatric populations in their global budgets. We characterized the pediatric infrastructure of these adult-oriented ACOs and obtained leaders' perspectives on their ACOs' response to pediatric incentives. METHODS We used Massachusetts Health Quality Partners and American Hospital Association Survey data to characterize ACOs' pediatric infrastructure as extremely limited, basic, and substantial on the basis of the extent of pediatric primary care, outpatient specialist, and inpatient services. After ACOs had 16 to 43 months of experience with the AQC, we interviewed 22 leaders to gain insight into how organizations made changes to improve pediatric care quality, tried to reduce pediatric spending, and addressed care for children with special health care needs. RESULTS ACOs' pediatric infrastructure ranged from extremely limited (eg, no general pediatricians in their primary care workforce) to substantial (eg, 42% of workforce was general pediatricians). Most leaders reported intensifying their pediatric quality improvement efforts and witnessing changes in quality metrics; most also investigated pediatric spending patterns but struggled to change patients' utilization patterns. All reported that the AQC did little to incentivize care for children with special health care needs and that future incentive programs should include this population. CONCLUSIONS Although ACOs involved in the AQC were adult-oriented, most augmented their pediatric quality improvement and spending reduction efforts when faced with pediatric incentives.
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Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Katherine H Schiavoni
- Harvard Medical School, Boston, Mass; Department of Medicine and Pediatrics, Massachusetts General Hospital, Boston, Mass
| | - Eli Sprecher
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass
| | - Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Mass; Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Barbara J McNeil
- Department of Health Care Policy, Harvard Medical School, Boston, Mass; Department of Radiology, Brigham and Women's Hospital, Boston, Mass
| | - Michael E Chernew
- Department of Health Care Policy, Harvard Medical School, Boston, Mass
| | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
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