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Bogetz JF, Strub B, Bradford MC, McGalliard J, Shipman K, Jeyte A, Patneaude A, Johnston EE, Ananth P, Thienprayoon R, Rosenberg AR. Quality of Care in the Last Two Years of Life for Children With Complex Chronic Conditions. J Pain Symptom Manage 2024; 68:488-498.e1. [PMID: 39097243 DOI: 10.1016/j.jpainsymman.2024.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 07/25/2024] [Accepted: 07/29/2024] [Indexed: 08/05/2024]
Abstract
CONTEXT Limited data exists about care received by children with complex chronic conditions (CCCs) in the final years of their disease and end-of-life (EOL). OBJECTIVE To examine hospital performance on EOL quality measures and to describe healthcare services during the last two years of life for children with CCCs who died in-hospital. METHODS Retrospective automated electronic health record review of children with ≥1 CCC ICD-10 diagnosis code, who died inpatient between October 2020 and March 2023 at a single quaternary U.S. children's hospital. Quality was assessed based on performance on 15 measures across five domains: healthcare utilization, interprofessional supports, medical intensity, symptom management, and communication. Quality EOL care and healthcare services in the last two years of life were determined overall by age group and per patient. Descriptive statistics were used to evaluate demographic differences by age. RESULTS 266 children with CCCs died in the study timeframe; 45% were infants (n = 120), 52% (n = 137) were male, 42% (n = 113) were white, 64% (n = 170) were non-Hispanic, and 59% (n=156) had public insurance. Children had a median of three CCCs (IQR 2.4; range 1-8). On average, children met 69% (SD 13%) of EOL quality measures for which they were eligible. In the two years prior to death, 98% (n = 261) had an ICU admission, 75% (n = 200) had a procedure requiring sedation, and 29% (n = 79) had received cardiopulmonary resuscitation. 86% (n = 229) died in the ICU. CONCLUSION In this study, children with CCCs met 69% of quality measures and received high-intensity healthcare in the last two years of life.
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Affiliation(s)
- Jori F Bogetz
- Department of Pediatrics (J.F.B.), Division of Bioethics and Palliative Care, University of Washington School of Medicine; Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA.
| | - Bryan Strub
- Biostatistics (B.S., M.C.B., J.M.G.), Epidemiology and Analytics in Research (BEAR) Core, Seattle Children's Research Institute, Seattle, WA, USA
| | - Miranda C Bradford
- Biostatistics (B.S., M.C.B., J.M.G.), Epidemiology and Analytics in Research (BEAR) Core, Seattle Children's Research Institute, Seattle, WA, USA
| | - Julie McGalliard
- Biostatistics (B.S., M.C.B., J.M.G.), Epidemiology and Analytics in Research (BEAR) Core, Seattle Children's Research Institute, Seattle, WA, USA
| | - Kelly Shipman
- Center for Clinical and Translational Research (K.S.), Seattle Children's Research Institute, Seattle, WA, USA; Center for Clinical Immunotherapies (K.S.), University of Pennsylvania, Philadelphia, PA, USA
| | - Astan Jeyte
- Behavioral and Clinical Outcomes Research Program (A.J.), Seattle Children's Research Institute, Seattle WA, USA
| | - Arika Patneaude
- Division of Bioethics and Palliative Care (A.P.), Seattle Children's Hospital, Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, University of Washington School of Social Work, Seattle, WA, USA
| | - Emily E Johnston
- Department of Pediatrics (E.E.J.), Division of Pediatric Hematology-Oncology, University of Alabama at Birmingham School of Medicine; Institute for Cancer Outcomes and Survivorship, UAB School of Medicine, Birmingham, AL, USA
| | - Prasanna Ananth
- Department of Pediatrics, Yale School of Medicine (P.A.), Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT, USA
| | - Rachel Thienprayoon
- Department of Anesthesia (R.T.), Division of Palliative Care, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Abby R Rosenberg
- Department of Psychosocial Oncology and Palliative Care (A.R.R.), Department of Pediatrics, Department of Pediatrics Harvard Medical School, Dana Farber Cancer Institute, Boston Children's Hospital, Boston, MA, USA
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Kotler H, Hinds PS, Wolfe AHJ. "Death is Not a Dirty Word:" A Qualitative Study of Emergency Clinician End-of-Life Communication. Pediatrics 2024:e2024067876. [PMID: 39390970 DOI: 10.1542/peds.2024-067876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 07/26/2024] [Accepted: 07/29/2024] [Indexed: 10/12/2024] Open
Abstract
OBJECTIVES Pediatric patients with life-limiting diagnoses frequently seek care in the pediatric emergency department (PED) during times of acute illness, or at end-of-life (EOL) . Although the population of patients with life-limiting diagnoses is heterogenous, clinician expertise in EOL communication is essential to providing family-centered care. In this study, we explored PED physician and nurse experiences with communication when eliciting EOL values, including factors specified to the PED environment, clinician perceptions of family supports and preferences, and clinicians' self-reflection of their skills and challenges in this sphere. METHODS We performed a prospective qualitative study using semistructured interviews of PED physicians and nurses recruited from a quaternary care center. Thematic content analysis was performed on the transcribed interviews to identify codes and, ultimately, themes. RESULTS We interviewed 17 emergency department clinicians, including 10 physicians and 7 nurses. Thematic content analysis revealed 6 salient themes. The first theme related to contextual factors of the emergency department environment. Two additional themes related to patient and family characteristics, including unique patient and family factors and clinician interpretation of parental/family needs. Lastly, we found 3 clinician-focused themes including knowledge gaps in EOL communication, communication styles and priorities in EOL conversations with families, and coping with ethical challenges. CONCLUSIONS PED clinicians report communication-related challenges to providing optimal care for families and patients with life-limiting diagnoses. Participants self-identified gaps in communication skills in this area. Future studies should focus on clinician educational interventions on the basis of this needs assessment and include family perspectives to develop best practice.
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Affiliation(s)
- Hannah Kotler
- Departments of Emergency Medicine
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Amy Hope Jones Wolfe
- Critical Care Medicine, Children's National Hospital, Washington, District of Columbia
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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Lindsay ME, de Oliveira S, Sciacca K, Lindvall C, Ananth PJ. Harnessing Natural Language Processing to Assess Quality of End-of-Life Care for Children With Cancer. JCO Clin Cancer Inform 2024; 8:e2400134. [PMID: 39265122 PMCID: PMC11407740 DOI: 10.1200/cci.24.00134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/29/2024] [Accepted: 07/18/2024] [Indexed: 09/14/2024] Open
Abstract
PURPOSE Data on end-of-life care (EOLC) quality, assessed through evidence-based quality measures (QMs), are difficult to obtain. Natural language processing (NLP) enables efficient quality measurement and is not yet used for children with serious illness. We sought to validate a pediatric-specific EOLC-QM keyword library and evaluate EOLC-QM attainment among childhood cancer decedents. METHODS In a single-center cohort of children with cancer who died between 2014 and 2022, we piloted a rule-based NLP approach to examine the content of clinical notes in the last 6 months of life. We identified documented discussions of five EOLC-QMs: goals of care, limitations to life-sustaining treatments (LLST), hospice, palliative care consultation, and preferred location of death. We assessed performance of NLP methods, compared with gold standard manual chart review. We then used NLP to characterize proportions of decedents with documented EOLC-QM discussions and timing of first documentation relative to death. RESULTS Among 101 decedents, nearly half were minorities (Hispanic/Latinx [24%], non-Hispanic Black/African American [20%]), female (48%), or diagnosed with solid tumors (43%). Through iterative refinement, our keyword library achieved robust performance statistics (for all EOLC-QMs, F1 score = 1.0). Most decedents had documented discussions regarding goals of care (83%), LLST (83%), and hospice (74%). Fewer decedents had documented discussions regarding palliative care consultation (49%) or preferred location of death (36%). For all five EOLC-QMs, first documentation occurred, on average, >30 days before death. CONCLUSION A high proportion of decedents attained specified EOLC-QMs more than 30 days before death. Our findings indicate that NLP is a feasible approach to measuring quality of care for children with cancer at the end of life and is ripe for multi-center research and quality improvement.
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Affiliation(s)
- Meghan E Lindsay
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
| | | | - Kate Sciacca
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA
| | - Prasanna J Ananth
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
- Department of Pediatrics, Yale School of Medicine, New Haven, CT
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Sidra M, Sebastianski M, Ohinmaa A, Rahman S. Reported costs of children with medical complexity-A systematic review. J Child Health Care 2024; 28:377-401. [PMID: 35751147 DOI: 10.1177/13674935221109683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Examining reported costs for Children with Medical Complexity (CMCs) is essential because costing and resource utilization studies influence policy and operational decisions. Our objectives were to (1) examine how authors identified CMCs in administrative databases, (2) compare reported costs for the CMC population in different study settings, and (3) analyze author recommendations related to reported costs. We undertook a systematic search of the following databases: Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library with a focus on CMCs as a heterogeneous group. The most common method used n = 11 (41%) to identify the CMC population in administrative data was the Complex Chronic Conditions methodology. The majority of included studies reported on health care service costs n = 24 (89%). Only n = 3 (11%) of the studies included costs from the family perspective. Author recommendations included standardizing how costs are reported and including the family perspective when making care delivery or policy decisions. Health system administrators and policymakers must consider the limitations of reported costs when assessing local costing studies or comparing costs across jurisdictions.
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Affiliation(s)
- Michael Sidra
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Meghan Sebastianski
- Alberta Strategy for Patient-Oriented Research (SPOR) Knowledge Synthesis Platform, University of Alberta, Edmonton, AB, Canada
| | - Arto Ohinmaa
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Sholeh Rahman
- Alberta Strategy for Patient-Oriented Research (SPOR) Knowledge Synthesis Platform, University of Alberta, Edmonton, AB, Canada
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Phillips H, Perry S, Shinkunas LA, Carlisle EM. Procedural Interventions for Terminally Ill Children - Are We Aiding Palliation? J Palliat Care 2024:8258597241255453. [PMID: 38772674 DOI: 10.1177/08258597241255453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
Objectives: Many children undergo surgery or an invasive procedure during their terminal hospital admission.1 The types of procedures, patients, and the intent of the procedures has not been well defined. Understanding these details may help pediatric surgeons better determine the clinical settings in which certain procedures will not enhance palliation or survival. Methods: A retrospective single institution chart review was performed for patients age 14 days to 18 years with chronic conditions who died while inpatient from 2013-2017. Data was gathered on demographics, primary diagnosis, intubation status, palliative care involvement, duration of hospital stay, length of palliative care involvement, and total number of procedures. Negative binomial regression was used to assess association with number of procedures. Results: 132 children met inclusion criteria. Most children were White and less than one year old. The most common type of diagnosis was cardiac in nature. Children underwent an average of three procedures. 75% were intubated and 77.5% had palliative care involved. Patients who were less than one year old at death were more likely to have been intubated, had longer terminal hospital stays, and had more procedures. Those who were intubated underwent more procedures and had longer hospital stays. Those with longer palliative care involvement had fewer procedures. Conclusions: Children undergo a significant number of surgical procedures during their terminal hospitalization. This may be influenced by age, intubation status, and length of stay. Ongoing study may help refine which procedures may have limited impact on survival in the chronically ill pediatric population.
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Affiliation(s)
- Hannah Phillips
- University of Kansas Health Systems, Department of Surgery, Kansas City, Kansas, USA
| | - Sarah Perry
- University of Iowa College of Public Health, Department of Biostatistics, Iowa City, Iowa, USA
| | - Laura A Shinkunas
- University of Iowa Carver College of Medicine, Program in Bioethics and Humanities, Iowa City, Iowa, USA
| | - Erica M Carlisle
- University of Iowa Carver College of Medicine, Program in Bioethics and Humanities, Iowa City, Iowa, USA
- University of Iowa Hospitals and Clinics, Department of Surgery, Division of Pediatric Surgery, Iowa City, Iowa, USA
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Shack AR, Fried I, Siedner-Weintraub Y. Palliative team involvement in end-of-life care for Jewish and Muslim children in Jerusalem: A unique clinical and cultural context. Palliat Support Care 2024; 22:163-168. [PMID: 36872568 DOI: 10.1017/s1478951523000159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
OBJECTIVES Pediatric palliative care services improve the quality of life for children with life-limiting and life-threatening diseases, although little has been published about variation based on cultural and religious factors. This article sets out to describe clinical and cultural characteristics of pediatric end-of-life patients in a majority Jewish and Muslim country with religious and legal constraints around end-of-life care. METHODS We conducted a retrospective chart review of 78 pediatric patients who died during a 5-year period and could potentially have utilized pediatric palliative care services. RESULTS Patients reflected a range of primary diagnoses, most commonly oncologic diseases and multisystem genetic disorders. Patients followed by the pediatric palliative care team had less invasive therapies, more pain management and advance directives, and more psychosocial support. Patients from different cultural and religious backgrounds had similar levels of pediatric palliative care team follow-up but certain differences in end-of-life care. SIGNIFICANCE OF RESULTS In a culturally and religiously conservative context that poses constraints on decision-making around end-of-life care, pediatric palliative care services are a feasible and important means of maximizing symptom relief, as well as emotional and spiritual support, for children at the end of life and their families.
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Affiliation(s)
- Avram R Shack
- Pediatric Palliative Care Unit, Wilf Children's Hospital, Shaare Zedek Medical Center, Jerusalem, Israel
- Departmet of Pediatrics, Wilf Children's Hospital, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Iris Fried
- Pediatric Palliative Care Unit, Wilf Children's Hospital, Shaare Zedek Medical Center, Jerusalem, Israel
- Pediatric Hemato-Oncology Unit, Wilf Children's Hospital, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Yael Siedner-Weintraub
- Pediatric Palliative Care Unit, Wilf Children's Hospital, Shaare Zedek Medical Center, Jerusalem, Israel
- Pediatric Intensive Care Unit, Wilf Children's Hospital, Shaare Zedek Medical Center, Jerusalem, Israel
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Ng GMC, Bourassa MH, Patel H. How Do Children With Medical Complexity Die? A Scoping Review. J Palliat Med 2024. [PMID: 38285483 DOI: 10.1089/jpm.2023.0322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024] Open
Abstract
Introduction: Advancement in medical expertise and technology has led to a growing cohort of children with medical complexity (CMC), who make up a rising proportion of childhood deaths. However, end of life in CMC is poorly understood and little is known about illness trajectories, communication, and decision-making experiences. Objective: To synthesize existing literature and characterize the end-of-life experience in CMC. Methods: A literature search of MEDLINE, CINAHL, PsycINFO, Scopus, Embase, and Google Scholar was conducted up to August 26, 2021. Studies reporting CMC at end of life were included and the extracted data were analyzed descriptively. Findings: Of 1535 publications identified, 23 studies were included. Most studies (15/23 [65%]) were published from 2015 to 2021 and were quantitative in nature (20/23 [87%]). The majority of studies that extracted data from a single country (18/20 [90%]) originated from North America. Study outcomes were categorized into four main domains: (1) place of death (2) health care use (3) interventions received or withdrawn (4) communication, and end-of-life experiences. The weighted percentage of in-hospital CMC deaths was 80.6%. Studies reported that CMC had increased health care use and were subjected to more intensive interventions at end of life compared with non-CMC. Qualitative studies highlighted the following themes: Intrinsic prognostic uncertainty, differing perspectives of the child's quality of life, the chronic illness experience, a desire to have parental expertise acknowledged, surprise at the terminal event, the experience of multiple losses, with an overarching theme of the need for compassionate care at end of life. Conclusions: This scoping review highlighted important characteristics of end of life in CMC, outlining the emerging evidence and knowledge gaps on this topic. A better understanding of this cohort of seriously and chronically ill children would serve to inform clinical practice, service development, and future research.
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Affiliation(s)
- Grace Mei Chan Ng
- Department of Pediatrics, McGill University Health Center, Montreal, Canada
- Department of Pediatrics, McGill University, Montreal, Canada
- Star PALS (Pediatric Advanced Life Support), HCA Hospice Limited, Singapore, Singapore
| | - Marie-Hélène Bourassa
- Department of Pediatrics, McGill University Health Center, Montreal, Canada
- Department of Pediatrics, McGill University, Montreal, Canada
| | - Hema Patel
- Department of Pediatrics, McGill University Health Center, Montreal, Canada
- Department of Pediatrics, McGill University, Montreal, Canada
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Oliveira PV, Enes CC, Nucci LB. How are children with medical complexity being identified in epidemiological studies? A systematic review. World J Pediatr 2023; 19:928-938. [PMID: 36574212 DOI: 10.1007/s12519-022-00672-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 12/05/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND There are different definitions to identify/classify children with medical complexity (CMC). We aimed to investigate and describe the definitions used to classify CMC in epidemiological studies. METHODS PubMed, SciELO, LILACS, and EMBASE were searched from 2015 to 2020 (last updated September 15th, 2020) for original studies that presented the definition used to classify/identify CMC in the scientific research method. We applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. From the included studies, the following were identified: first author, year of publication, design, population, study period, the definition of CMC used, limitations, and strengths. RESULTS Nine hundred and sixty-seven records were identified in the searched databases, and 42 met the inclusion criteria. Of the 42 studies included, the four most frequent definitions used in the articles included in this review were classification of CMC into nine diagnostic categories based on the International Classification of Diseases, Ninth Revision (ICD-9) (35.7%, 15 articles); update of the previous classification for ICD-10 codes with the inclusion of other conditions in the definition (21.4%, nine articles); definition based on a medical complexity algorithm for classification (16.7%, seven articles); and a risk rating system (7.1%, three articles). CONCLUSIONS CMC definitions using diagnostic codes were more frequent. However, several limitations were found in its uses. Our research highlighted the need to improve health information systems to accurately characterize the CMC population and promote the provision of comprehensive care.
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Affiliation(s)
- Patrícia Vicente Oliveira
- Postgraduate Program in Health Sciences, Center for Life Sciences, Pontifical Catholic University of Campinas, Av. John Boyd Dunlop s/n, Campinas, CEP 13060-904, Brazil.
| | - Carla C Enes
- Postgraduate Program in Health Sciences, School of Nutrition, Pontifical Catholic University of Campinas, São Paulo, Brazil
| | - Luciana B Nucci
- Postgraduate Program in Health Sciences, School of Medicine, Pontifical Catholic University of Campinas, São Paulo, Brazil
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Widger K, Brennenstuhl S, Nelson KE, Seow H, Rapoport A, Siden H, Vadeboncoeur C, Gupta S, Tanuseputro P. Intensity of end-of-life care among children with life-threatening conditions: a national population-based observational study. BMC Pediatr 2023; 23:375. [PMID: 37488553 PMCID: PMC10364373 DOI: 10.1186/s12887-023-04186-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 07/12/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Children with life-threatening conditions frequently experience high intensity care at the end of life, though most of this research only focused on children with cancer. Some research suggests inequities in care provided based on age, disease type, socioeconomic status, and distance that the child lives from a tertiary hospital. We examined: 1) the prevalence of indicators of high intensity end-of-life care (e.g., hospital stays, intensive care unit [ICU] stays, death in ICU, use of cardiopulmonary resuscitation [CPR], use of mechanical ventilation) and 2) the association between demographic and diagnostic factors and each indicator for children with any life-threatening condition in Canada. METHODS We conducted a population-based retrospective cohort study using linked health administrative data to examine care provided in the last 14, 30, and 90 days of life to children who died between 3 months and 19 years of age from January 1, 2008 to December 31, 2014 from any underlying life-threatening medical condition. Logistic regression was used to model the association between demographic and diagnostic variables and each indicator of high intensity end-of-life care except number of hospital days where negative binomial regression was used. RESULTS Across 2435 child decedents, the most common diagnoses included neurology (51.1%), oncology (38.0%), and congenital illness (35.9%), with 50.9% of children having diagnoses in three or more categories. In the last 30 days of life, 42.5% (n = 1035) of the children had an ICU stay and 36.1% (n = 880) died in ICU. Children with cancer had lower odds of an ICU stay (OR = 0.47; 95% CI = 0.36-0.62) and ICU death (OR = 0.37; 95%CI = 0.28-0.50) than children with any other diagnoses. Children with 3 or more diagnoses (vs. 1 diagnosis) had higher odds of > 1 hospital stay in the last 30 days of life (OR = 2.08; 95%CI = 1.29-3.35). Living > 400 km (vs < 50 km) from a tertiary pediatric hospital was associated with higher odds of multiple hospitalizations (OR = 2.09; 95%CI = 1.33-3.33). CONCLUSION High intensity end of life care is prevalent in children who die from life threatening conditions, particularly those with a non-cancer diagnosis. Further research is needed to understand and identify opportunities to enhance care across disease groups.
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Affiliation(s)
- Kimberley Widger
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.
- Hospital for Sick Children, Toronto, Canada.
| | - Sarah Brennenstuhl
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | | | | | - Adam Rapoport
- Hospital for Sick Children, Toronto, Canada
- Emily's House Children's Hospice, Toronto, Canada
| | - Harold Siden
- Canuck Place Children's Hospice, Vancouver, Canada
- British Columbia Children's Hospital, Vancouver, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Christina Vadeboncoeur
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
- CHEO, Ottawa, Canada
- Roger Neilson House, Ottawa, Canada
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Koch A, Albrecht T, Kozhumam AS, Son H, Brandon D, Docherty SL. Crossroads of parental decision making: Intersections of hope, communication, relationships, and emotions. J Child Health Care 2023; 27:300-315. [PMID: 34967680 PMCID: PMC10155486 DOI: 10.1177/13674935211059041] [Citation(s) in RCA: 1] [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] [Indexed: 11/17/2022]
Abstract
Parents of children born with complex life-threatening chronic conditions (CLTCs) experience an uncertain trajectory that requires critical decision making. Along this trajectory, hope plays an influential but largely unexplored role; therefore, this qualitative descriptive study explores how parent and provider hope may influence decision making and care of a child born with CLTCs. A total of 193 interviews from 46 individuals (parents, nurses, physicians, and nurse practitioners) responsible for the care of 11 infants with complex congenital heart disease (CCHD) were analyzed to understand how hope features in experiences related to communication, relationships, and emotions that influence decision making. Overall, parental hope remained strong and played a pivotal role in parental decision making. Parents and professional healthcare providers expressed a range of emotions that appeared to be integrally linked to hope and affected decision making. Providers and parents brought their own judgments, perceptions, and measure of hope to relationships, when there was common ground for expressing, and having, hope, shared decision making was more productive and they developed more effective relationships and communication. Relationships between parents and providers were particularly influenced by and contributory to hope. Communication between parents and providers was also responsible for and responsive to hope.
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Affiliation(s)
- Amie Koch
- Duke University School of Nursing, Lincoln Community Health Clinic, Transitions LifeCare Hospice and Palliative Care, Durham, NC, USA
| | | | | | - Heeyeon Son
- Duke University School of Nursing, Durham, NC, USA
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11
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Cleveland RW, Deming RS, Helton G, Wilson CR, Ullrich CK. Revisiting medical neglect concerns in children with life-threatening complex chronic conditions. CHILD ABUSE & NEGLECT 2023; 141:106220. [PMID: 37207521 DOI: 10.1016/j.chiabu.2023.106220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/13/2023] [Accepted: 04/20/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND/OBJECTIVES Life-Threatening Complex Chronic Conditions (LT-CCCs) increase the complexity of medical neglect concerns. Clinicians' perspectives are central in concerns for medical neglect, yet little is currently known regarding clinicians' understanding of and approach to these situations. We explored how clinicians who care for children with LT-CCCs understand medical neglect. METHODS We conducted a semi-structured qualitative interview study with 20 clinicians of varying disciplines from critical, palliative, and complex care services about medical neglect in children with LT-CCCs. We used inductive thematic analysis to generate themes. RESULTS Three primary themes emerged: Relationship between family and medical community, family overwhelmed with medical demands, and insufficient support. Taken together these themes suggest that concerns for medical neglect are directly related to clinician perception of family inability to meet medical needs. CONCLUSION Clinicians report that concerns for medical neglect in children with LT-CCCs often arise from a mismatch of medical expectations and the perception of familial ability to provide said medical care. Given the complex and delicate medical and psychosocial environments of care for children with LT-CCCs, these medical neglect concerns are more accurately described as Medical Insufficiency, a new term. By reframing this entity, we can reframe the dialogue surrounding this issue, and reconsider approaches to studying, preventing, and resolving it.
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Affiliation(s)
- Ross W Cleveland
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, United States of America.
| | - Rachel S Deming
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Gabrielle Helton
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Celeste R Wilson
- Harvard Medical School, Boston, MA, United States of America; Division of General Pediatrics, Boston Children's Hospital, Boston, MA, United States of America
| | - Christina K Ullrich
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Division of Pediatric Hematology/Oncology, Department of Pediatrics, Boston Children's Hospital, Boston, MA, United States of America
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Ananth P, Lindsay M, Mun S, McCollum S, Shabanova V, de Oliveira S, Pitafi S, Kirch R, Ma X, Gross CP, Boyden JY, Feudtner C, Wolfe J. Parent Priorities in End-of-Life Care for Children With Cancer. JAMA Netw Open 2023; 6:e2313503. [PMID: 37184834 PMCID: PMC10878399 DOI: 10.1001/jamanetworkopen.2023.13503] [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] [Indexed: 05/16/2023] Open
Abstract
Importance Robust quality measures to benchmark end-of-life care for children with cancer do not currently exist; 28 candidate patient-centered quality measures were previously developed. Objective To prioritize quality measures among parents who lost a child to cancer. Design, Setting, and Participants This survey study was conducted using an electronic, cross-sectional discrete choice experiment (DCE) with maximum difference scaling from January to June 2021 in the US. In each of 21 questions in the DCE, participants were presented with a set of 4 quality measures and were asked to select the most and least important measures within each set. All 28 quality measures were presented an equal number of times in different permutations. In the volunteer sample, 69 eligible bereaved parents enrolled in the study; 61 parents completed the DCE (participation rate, 88.4%). Main Outcomes and Measures Using choices participants made, a hierarchical bayesian multinomial logistic regression was fit to derive mean importance scores with 95% credible intervals (95% Crs) for each quality measure, representing the overall probability of a quality measure being selected as most important. Importance scores were rescaled proportionally from 0 to 100, with the sum of scores for all quality measures adding up to 100. This enabled interpretation of scores as the relative importance of quality measures. Results Participants included 61 bereaved parents (median [range] age, 48 [24-74] years; 55 individuals self-identified as women [90.2%]; 1 American Indian or Alaska Native [1.6%], 1 Asian [1.6%], 2 Black or African American [3.3%], 1 Native Hawaiian or Pacific Islander, and 58 White [91.8%]; 58 not Hispanic or Latinx [95.1%]). Highest-priority quality measures by mean importance score included having a child's symptoms treated well (9.25 [95% Cr, 9.06-9.45]), feeling that a child's needs were heard by the health care team (8.39 [95% Cr, 8.05-8.73]), and having a goal-concordant end-of-life experience (7.45 [95% Cr, 6.84-8.05]). Lowest-priority quality measures included avoiding chemotherapy (0.33 [95% Cr, 0.21-0.45]), provision of psychosocial support for parents (1.01 [95% Cr, 0.57-1.45]), and avoiding the intensive care unit (1.09 [95% Cr, 0.74-1.43]). Rank-ordering measures by mean importance revealed that symptom management was 9 times more important to parents than psychosocial support for themselves. Conclusions and Relevance This study found that bereaved parents prioritized end-of-life quality measures focused on symptom management and goal-concordant care while characterizing quality measures assessing their own psychosocial support and their child's hospital resource use as substantially less important. These findings suggest that future research should explore innovative strategies to measure care attributes that matter most to families of children with advanced cancer.
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Affiliation(s)
- Prasanna Ananth
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
- Yale Cancer Outcomes, Public Policy and Effectiveness Research Center, New Haven, Connecticut
| | - Meghan Lindsay
- Yale Cancer Outcomes, Public Policy and Effectiveness Research Center, New Haven, Connecticut
| | - Sophia Mun
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Sarah McCollum
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Veronika Shabanova
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | | | - Sarah Pitafi
- University College London, London, United Kingdom
| | - Rebecca Kirch
- National Patient Advocate Foundation, Washington, District of Columbia
| | - Xiaomei Ma
- Yale Cancer Outcomes, Public Policy and Effectiveness Research Center, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Cary P Gross
- Yale Cancer Outcomes, Public Policy and Effectiveness Research Center, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jackelyn Y Boyden
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia
- Justin Michael Ingerman Center for Palliative Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chris Feudtner
- Justin Michael Ingerman Center for Palliative Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Departments of Pediatrics, Medical Ethics, and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Joanne Wolfe
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston
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13
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Brown SES, Hall M, Cassidy RB, Zhao X, Kheterpal S, Feudtner C. Tracheostomy, Feeding-Tube, and In-Hospital Postoperative Mortality in Children: A Retrospective Cohort Study. Anesth Analg 2023; 136:1133-1142. [PMID: 37014983 DOI: 10.1213/ane.0000000000006413] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
BACKGROUND Neuromuscular/neurologic disease confers increased risk of perioperative mortality in children. Some patients require tracheostomy and/or feeding tubes to ameliorate upper airway obstruction or respiratory failure and reduce aspiration risk. Empiric differences between patients with and without these devices and their association with postoperative mortality have not been previously assessed. METHODS This retrospective cohort study using the Pediatric Health Information System measured 3- and 30-day in-hospital postsurgical mortality among children 1 month to 18 years of age with neuromuscular/neurologic disease at 44 US children's hospitals, from April 2016 to October 2018. We summarized differences between patients presenting for surgery with and without these devices using standardized differences. Then, we calculated 3- and 30-day mortality among patients with tracheostomy, feeding tube, both, and neither device, overall and stratified by important exposures, using Fisher exact test to test whether differences were significant. RESULTS There were 43,193 eligible patients. Unadjusted 3-day mortality was 1.3% (549/43,193); 30-day mortality was 2.7% (1168/43,193). Most (79.1%) used neither a feeding tube or tracheostomy, 1.2% had tracheostomy only, 15.5% had feeding tube only, and 4.2% used both devices. Compared to children with neither device, children using either or both devices were more likely to have multiple CCCs, dysphagia, chronic pulmonary disease, cerebral palsy, obstructive sleep apnea, or malnutrition, and a prolonged intensive care unit (ICU) stay within the previous year. They were less likely to present for high-risk surgeries (33% vs 57%). Having a feeding tube was associated with decreased 3-day mortality overall compared to having neither device (0.9% vs 1.3%, P = .003), and among children having low-risk surgery, and surgery during urgent or emergent hospitalizations. Having both devices was associated with decreased 3-day mortality among children having low-risk surgery (0.8% vs 1.9%; P = .013), and during urgent or emergent hospitalizations (1.6% vs 2.9%; P = .023). For 30-day mortality, having a feeding tube or both devices was associated with lower mortality when the data were stratified by the number of CCCs. CONCLUSIONS Patients requiring tracheostomy, feeding tube, or both are generally sicker than patients without these devices. Despite this, having a feeding tube was associated with lower 3-day mortality overall and lower 30-day mortality when the data were stratified by the number of CCCs. Having both devices was associated with lower 3-day mortality in patients presenting for low-risk surgery, and surgery during urgent or emergent hospitalizations.
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Affiliation(s)
- Sydney E S Brown
- From the Department of Anesthesiology, The University of Michigan, Ann Arbor, Michigan
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Ruth B Cassidy
- From the Department of Anesthesiology, The University of Michigan, Ann Arbor, Michigan
| | - Xinyi Zhao
- From the Department of Anesthesiology, The University of Michigan, Ann Arbor, Michigan
| | - Sachin Kheterpal
- From the Department of Anesthesiology, The University of Michigan, Ann Arbor, Michigan
| | - Chris Feudtner
- The Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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14
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Stoesslein S, Gramm JD, Bender HU, Müller P, Rabenhorst D, Borasio GD, Führer M. "More life and more days"-patient and care characteristics in a specialized acute pediatric palliative care inpatient unit. Eur J Pediatr 2023; 182:1847-1855. [PMID: 36795188 PMCID: PMC10167193 DOI: 10.1007/s00431-023-04813-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/30/2022] [Accepted: 01/06/2023] [Indexed: 02/17/2023]
Abstract
UNLABELLED Only a few acute hospital inpatient units dedicated to pediatric palliative care (PPC) patients exist today. Clinical data on the patients and care provided at specialized acute PPC inpatient units (PPCUs) are scarce. This study aims at describing patient and care characteristics on our PPCU to learn about the complexity and relevance of inpatient PPC. A retrospective chart analysis was performed on the 8-bed PPCU of the Center for Pediatric Palliative Care of the Munich University Hospital, including demographic, clinical, and treatment characteristics (487 consecutive cases; 201 individual patients; 2016-2020). Data were analyzed descriptively; the chi-square test was used for comparisons. Patients' age (1-35.5 years, median: 4.8 years) and length of stay (1-186 days, median 11 days) varied widely. Thirty-eight percent of patients were admitted repeatedly (range 2-20 times). Most patients suffered from neurological diseases (38%) or congenital abnormalities (34%); oncological diseases were rare (7%). Patients' predominant acute symptoms were dyspnea (61%), pain (54%), and gastrointestinal symptoms (46%). Twenty percent of patients suffered from > 6 acute symptoms, 30% had respiratory support incl. invasive ventilation, 71% had a feeding tube, and 40% had full resuscitation code. In 78% of cases, patients were discharged home; 11% died on the unit. CONCLUSION This study shows the heterogeneity, high symptom burden, and medical complexity of the patients on the PPCU. The high dependency on life-sustaining medical technology points to the parallelism of life-prolonging and palliative treatments that is typical for PPC. Specialized PPCUs need to offer care at the intermediate care level in order to respond to the needs of patients and families. WHAT IS KNOWN • Pediatric patients in outpatient PPC or hospices present with a variety of clinical syndromes and different levels of complexity and care intensity. • There are many children with life-limiting conditions (LLC) in hospitals, but specialized PPC hospital units for these patients are rare and poorly described. WHAT IS NEW • Patients on a specialized PPC hospital unit show a high symptom burden and a high level of medical complexity, including dependency on medical technology and frequent full resuscitation code. • The PPC unit is mainly a place for pain and symptom management as well as crisis intervention, and needs to be able to offer treatment at the intermediate care level.
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Affiliation(s)
- Sophie Stoesslein
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Julia D Gramm
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Hans-Ulrich Bender
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany.,Pediatric Palliative Care, Department of Pediatrics, Bern University Hospital, Bern, Switzerland
| | - Petra Müller
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Dorothee Rabenhorst
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Monika Führer
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany.
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15
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Harmon A, Jordan M, Platt A, Wilson J, Keith K, Chandrashekaran S, Schlichte L, Pendergast J, Ming D. Goal-Concordance in Children with Complex Chronic Conditions. J Pediatr 2023; 253:278-285.e4. [PMID: 36257348 DOI: 10.1016/j.jpeds.2022.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 10/01/2022] [Accepted: 10/05/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To characterize delivery of goal-concordant end-of-life (EOL) care among children with complex chronic conditions and to determine factors associated with goal-concordance. STUDY DESIGN This was a retrospective review of goals of care discussions for 272 children with at least 1 complex chronic condition who died at a tertiary care hospital between January 1, 2014, and December 31, 2017. Goals of care and code status were assessed before and within the last 72 hours of life. Goals of care discussions were coded as full interventions; considering withdrawal of interventions (palliation); planned transition to palliation; or actively transitioning/transitioned to palliation. RESULTS In total, 158 children had documented goals of care discussions before and within the last 72 hours of life, 18 had goals of care discussions only >72 hours before death, 54 only in the last 72 hours of life, and 42 had no documented goals of care. For children with goals of care, EOL care was goal-concordant for 82.2%, discordant in 7%, and unclear in 10.8%. Black children had a greater than 8-fold greater odds of discordant care compared with White children (OR 8.34, P = .007). Comparison of goals of care and code status before and within the last 72 hours of life revealed trends toward nonescalation of care. Specifically, rates of active palliation increased from 11.7% to 63.0%, and code status shifted from 32.6% do not resuscitate to 65.2% (P < .001). CONCLUSIONS In this cohort, a majority of children had documented goals of care discussions and received goal-concordant EOL care. However, Black children had greater odds of receiving goal-discordant care. Goals of care and code status shifted toward palliation during the last 72 hours of life.
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Affiliation(s)
- Alexis Harmon
- Department of Pediatrics, McGaw Medical Center of Northwestern University, Chicago, IL
| | - Megan Jordan
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Alyssa Platt
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Jonathon Wilson
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Kevin Keith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | | | | | - Jane Pendergast
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - David Ming
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC.
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16
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Nogueira A, Correia D, Loureiro M, Gomes B, Cancelinha C. The needs of children receiving end of life care and the impact of a paediatric palliative care team: a retrospective cohort study. Eur J Pediatr 2023; 182:525-531. [PMID: 36445514 DOI: 10.1007/s00431-022-04683-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 10/01/2022] [Accepted: 10/26/2022] [Indexed: 11/30/2022]
Abstract
UNLABELLED Published data collected in hospital during the last year of life of children with life-limiting complex chronic conditions (CCC) is scarce, yet critical, for the implementation of paediatric palliative care (PPC). This study aims to describe the last year of life of children with CCC, in terms of clinical characteristics, hospital resources and the impact of referral to a hospital-based PPC team (PPCT). Using a retrospective cohort study, we examined the clinical records of children aged 1-18 years of age with CCC who died in a tertiary hospital between January 2016 and December 2020. Hospital resources utilised in the last year of life, therapies and procedures during the final week of life, decision to limit treatment (DLT), referral to the PPCT and place of death were analysed. Seventy-two patients (60% male) with a median age of 10.1 years were included. Most had ≥ 2 CCC (58%) with cancer as the most common diagnosis (47%). The group with ≥ 3 CCC (n = 23) had longer hospital stays (p = 0.041). Of the 17 patients referred to the PPCT, there was a higher frequency of DLT (94% vs. 40% in non-referred, p < 0.001), greater use of subcutaneous route (53% vs. 0%, p < 0.001), lower frequency of blood transfusions (12% vs. 55%, p = 0.002) and a lower proportion of deaths in the Intensive Care Unit (6% vs. 64%, p < 0.001). CONCLUSIONS Early implementation of PPC optimises the use of hospital resources, minimises invasive procedures and therapies, and may develop effective and sustainable alternatives which are better suited to the needs of children and families. WHAT IS KNOWN • In recent years, there has been an increased prevalence of complex chronic condition (CCC), which has led to more specialised and prolonged medical care until the end of life. • There are few paediatric studies on use of hospital resources and the invasiveness of procedures in the last year of life for children. WHAT IS NEW • This study is one of the few to provide a comprehensive characterisation of the last year of life of children/adolescents with CCC. • Timely referral to a specialised PPC team optimises the use of hospital resources, minimise invasive procedures and develop effective and sustainable alternatives which are better suited to the needs of children and/or families.
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Affiliation(s)
- Andreia Nogueira
- Paediatrics Department, Coimbra Hospital and University Center, Avenida Rua Dr. Afonso Romão, Coimbra, 3000-602, Portugal.
| | - Diana Correia
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Marisa Loureiro
- Laboratory of Biostatistics and Medical Informatics, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Barbara Gomes
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Cândida Cancelinha
- Paediatrics Department, Coimbra Hospital and University Center, Avenida Rua Dr. Afonso Romão, Coimbra, 3000-602, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Paediatric Palliative Care Team, Coimbra Hospital and University Center, Avenida Rua Dr. Afonso Romão, PT, Coimbra, 3000-602, Portugal
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17
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Ellis DI, Nye RT, Wolfe J, Feudtner C. Surgical Intervention in Patients Receiving Pediatric Palliative Care Services. Pediatrics 2023; 151:e2022058905. [PMID: 36606343 PMCID: PMC9890391 DOI: 10.1542/peds.2022-058905] [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] [Accepted: 11/07/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Many patients receiving pediatric palliative care (PPC) present with surgically treatable problems. The role of surgery in the care of these patients, however, has not yet been defined. We conducted a cohort study of children receiving PPC to assess the incidence, type, and likely purpose of surgical interventions performed after the initiation of PPC. METHODS We performed a cohort analysis of surgical interventions performed on children enrolled in an ongoing, multicenter, prospective cohort study. Patients aged <30 years receiving PPC services were eligible for inclusion in the study. Analyses included descriptive and comparative statistics, as well as logistic regression models. RESULTS After initiation of PPC, 81.1% (n = 488) of patients had undergone at least 1 surgical intervention (range, 1-71) with a median of 4 interventions (interquartile range, 1-9). The most frequent surgical interventions were feeding tubes, endoscopic biopsy, tracheostomy, bone marrow biopsy, tunneled catheters, bronchoscopy, and chest tube placement, followed by sternum closure, abdominal closure, atrial and ventricular septal defect repairs, and heart transplantation. Children who underwent surgical interventions were statistically less likely to die while receiving PPC (29% vs 40%, P < .03). CONCLUSIONS Most children receiving PPC services undergo at least 1 surgical intervention, and many undergo numerous interventions. Undergoing intervention is not futile because surgical intervention is associated with longer survival. Various patient populations that are more likely, as well as less likely, to undergo surgical intervention warrant specific focus.
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Affiliation(s)
| | - Russell T. Nye
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute
- Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chris Feudtner
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Pediatric Advanced Care Team and Department of Medical Ethics, Children’s Hospital of Philadelphia, the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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18
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Rees CA, Neuman MI, Monuteaux MC, Michelson KA, Duggan CP. Mortality During Readmission Among Children in United States Children's Hospitals. J Pediatr 2022; 246:161-169.e7. [PMID: 35364094 PMCID: PMC9233053 DOI: 10.1016/j.jpeds.2022.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/28/2022] [Accepted: 03/24/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To identify demographic, clinical, and hospital factors associated with mortality on readmission within 180 days following an inpatient hospitalization. STUDY DESIGN We conducted a retrospective cohort study including 33 US children's hospitals in the Pediatric Health Information System from January 2010 to June 2020. Our primary outcome was death during readmission within 180 days of an index hospitalization among children aged 0-18 years. Illness severity during the index hospitalization was defined according to the All Patient-Refined Diagnosis-Related Group-categorized illness severity (ie, minor, moderate, or major/extreme). We performed multivariable logistic regression analysis to identify factors during the index hospitalization associated with mortality during readmission. RESULTS Among 2 677 111 children discharged, 337 385 (12.6%) were readmitted within 180 days of the index hospitalization and 2913 (0.8%) died during readmission. More than one-quarter (26.2%) of deaths among children who were readmitted and died occurred within 10 days after discharge from the index hospitalization. Factors independently associated with mortality during readmission included multiple complex chronic conditions, index admissions lasting >7 days, moderate or severe/extreme illness during the index hospitalization, and public insurance. Children whose race was reported as Black had greater odds of mortality during readmission compared with children of other races. CONCLUSIONS Among hospitalized children, several demographic and clinical factors present during index hospitalizations were associated with mortality during readmission. Greater odds of mortality during readmission among children whose race was reported as Black likely reflects disparities in social determinants of health and clinical care. Interventions to reduce mortality during readmission may target high-risk populations in the period immediately following discharge.
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Affiliation(s)
- Chris A. Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America,Children's Healthcare of Atlanta, Atlanta, Georgia, United States of America
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Michael C. Monuteaux
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kenneth A. Michelson
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts, United States of America,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Christopher P. Duggan
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America,Center for Nutrition, Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, Massachusetts, United States of America
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19
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Jarvis S, Richardson G, Flemming K, Fraser LK. Numbers, characteristics, and medical complexity of children with life-limiting conditions reaching age of transition to adult care in England: a repeated cross-sectional study [version 1; peer review: 2 approved]. NIHR OPEN RESEARCH 2022; 2:27. [PMID: 35923178 PMCID: PMC7613215 DOI: 10.3310/nihropenres.13265.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/17/2022] [Indexed: 12/22/2022]
Abstract
Background The number of children with life-limiting conditions in England is known to be increasing, which has been attributed in part to increased survival times. Consequently, more of these young people will reach ages at which they start transitioning to adult healthcare (14-19 years). However, no research exists that quantifies the number of young people with life-limiting conditions in England reaching transition ages or their medical complexity, both essential data for good service planning. Methods National hospital data in England (Hospital Episode Statistics) from NHS Digital were used to identify the number of young people aged 14-19 years from 2012/13 to 2018/19 with life-limiting conditions diagnosed in childhood. The data were assessed for indicators of medical complexity: number of conditions, number of main specialties of consultants involved, number of hospital admissions and Accident & Emergency Department visits, length of stay, bed days and technology dependence (gastrostomies, tracheostomies). Overlap between measures of complexity was assessed. Results The number of young people with life-limiting conditions has increased rapidly over the study period, from 20363 in 2012/13 to 34307 in 2018/19. There was evidence for increased complexity regarding the number of conditions and number of distinct main specialties of consultants involved in care, but limited evidence of increases in average healthcare use per person or increased technology dependence. The increasing size of the group meant that healthcare use increased overall. There was limited overlap between measures of medical complexity. Conclusions The number of young people with life-limiting conditions reaching ages at which transition to adult healthcare should take place is increasing rapidly. Healthcare providers will need to allocate resources to deal with increasing healthcare demands and greater complexity. The transition to adult healthcare must be managed well to limit impacts on healthcare resource use and improve experiences for young people and their families.
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Affiliation(s)
- Stuart Jarvis
- Martin House Research Centre, University of York, York, YO10 5DD, UK
| | - Gerry Richardson
- Centre for Health Economics, University of York, York, YO10 5DD, UK
| | - Kate Flemming
- Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Lorna K Fraser
- Martin House Research Centre, University of York, York, YO10 5DD, UK
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20
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Ananth P, Mun S, Reffat N, Kang SJ, Pitafi S, Ma X, Gross CP, Wolfe J. Refining Patient-Centered Measures of End-of-Life Care Quality for Children With Cancer. JCO Oncol Pract 2022; 18:e372-e382. [PMID: 34613797 PMCID: PMC8932486 DOI: 10.1200/op.21.00447] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE There are no existing quality measures (QMs) to optimize end-of-life care for children with cancer. Previously, we developed a set of 26 candidate QMs. Our primary objective in this study was to achieve stakeholder consensus on priority measures. METHODS We conducted an iterative, cross-sectional electronic survey, using a modified Delphi method to build consensus among clinician and family stakeholders. In each of the two rounds of surveys, stakeholders were asked to rate QMs on a 9-point Likert scale, on the basis of perceived importance. Health care professionals were additionally asked to rate measures on perceived feasibility. After each round, we computed median scores on importance and feasibility of measurement, retaining QMs with median importance scores ≥ 8. RESULTS Twenty-five participants completed both rounds of the survey. In round 1, participants were asked to rate 26 QMs; nine QMs, including QMs pertaining to health care use, were removed because of median importance scores < 8. Two new measures were proposed for consideration in round 2, on the basis of participant feedback. Following round 2, 17 QMs were ultimately retained. QMs related to symptom screening and palliative care consultation were rated highly in importance and feasibility. QMs related to communication were rated highly important, yet less feasible. Measuring whether a patient's needs were heard by their health care team was rated among the least feasible. CONCLUSION Childhood cancer stakeholders prioritized QMs pertaining to patient-reported outcomes, deeming measures of health care resource use less important. Future research should seek to develop novel tools for quality assessment to enhance feasibility of implementing priority measures.
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Affiliation(s)
- Prasanna Ananth
- Department of Pediatrics, Yale School of Medicine, New Haven, CT,Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT,Prasanna Ananth, MD, MPH, Department of Pediatrics, Section of Pediatric Hematology/Oncology, Yale School of Medicine, 330 Cedar St, LMP 2082C, New Haven, CT 06510; e-mail:
| | - Sophia Mun
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
| | - Noora Reffat
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
| | - Soo Jung Kang
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
| | - Sarah Pitafi
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
| | - Xiaomei Ma
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Cary P. Gross
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT,Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA,Department of Pediatrics, Boston Children's Hospital, Boston, MA,Harvard Medical School, Boston, MA
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21
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Bogetz JF, Revette A, DeCourcey D. Bereaved Parent Perspectives on the Benefits and Burdens of Technology Assistance among Children with Complex Chronic Conditions. J Palliat Med 2022; 25:250-258. [PMID: 34618616 PMCID: PMC8861906 DOI: 10.1089/jpm.2021.0221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background: Many children with complex chronic conditions (CCCs) are supported by medical technologies. Objective: The aim of this study was to understand bereaved parent perspectives on technology assistance among this unique population. Design: Mixed methods design was used to analyze data from the cross-sectional Survey of Caring for Children with CCCs.Setting/Subjects: Bereaved parents of children with CCCs who received care at a large academic institution in the United States and died between 2006 and 2015. Measurements: Survey items were analyzed descriptively and integrated with thematic analysis of open-response items to identify key themes pertaining to parents' perspectives on technology. Results: 110/211 (52%) parents completed the survey and at least 1 open-response item. More than 60% of parents had children with congenital/chromosomal or central nervous system progressive CCCs, used technology at baseline, and died in the hospital. A subset of parents recalled making decisions either not to initiate (n = 26/101, 26%) or to discontinue (n = 46/104, 44%) technology at end of life. Parents described both the benefits and burdens of technology. Two themes emerged regarding technology's association with the (1) intersection with goals of care and (2) complications and regret. Within goals of care, two subthemes arose: (a) technology was necessary to give time for life extension and/or to say goodbye, and (b) technology greatly impacted the child's quality of life and symptoms. Conclusions: Parents have nuanced perspectives about the benefits and burdens of technology. It is essential to understand parent's most important goals when supporting decisions about technology assistance for children with CCCs.
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Affiliation(s)
- Jori F. Bogetz
- Division of Pediatric Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, USA.,Address correspondence to: Jori F. Bogetz, MD, Seattle Children's Research Institute, Center for Clinical and Translational Research, 1900 Ninth Street, JMB-6, Seattle, WA 98101, USA
| | - Anna Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Danielle DeCourcey
- Division of Critical Care, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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22
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Marcus KL, Kao PC, Ma C, Wolfe J, DeCourcey DD. Symptoms and Suffering at End of Life for Children With Complex Chronic Conditions. J Pain Symptom Manage 2022; 63:88-97. [PMID: 34311060 DOI: 10.1016/j.jpainsymman.2021.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/22/2021] [Accepted: 07/16/2021] [Indexed: 11/25/2022]
Abstract
CONTEXT Children with cancer and cardiac disease suffer with high symptom burden at end of life (EOL). Little is known about the EOL experience for children with other complex chronic conditions (CCCs). OBJECTIVES To evaluate symptoms and suffering at EOL for children with noncancer, noncardiac CCCs as well as parental distress related to child suffering. METHODS This study is a secondary data analysis of a cross-sectional, single-center survey of bereaved parents of children with CCCs who died between 2006 to 2015. The primary outcome was parent-reported child suffering in the final two days of life. RESULTS Among 211 eligible parents contacted for participation, 114 completed the survey, and 99 had complete primary outcome data (participation rate 47%). Most children had congenital/chromosomal (42%) or progressive central nervous system (22%) conditions. Twenty-eight percent of parents reported high child suffering in the final two days of life. Parents reported that pain and difficulty breathing caused the greatest suffering for children and distress among themselves. Some parents also reported distress related to uncertainty about child suffering. Parents were less likely to report high child suffering if they were confident in knowing what to expect when their child was dying (AOR 0.20; 95% CI 0.07-0.60) or felt prepared for medical problems at EOL (AOR 0.12; 95% CI 0.04-0.42). CONCLUSION Nearly one-third of parents of children with CCCs report high suffering in their child's final days of life. Parent preparedness was associated with lower perceived child suffering. Future research should target symptoms contributing to parent and child distress and assess whether enhancing parent preparedness reduces perceived child suffering.
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Affiliation(s)
- Katherine L Marcus
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.
| | - Pei-Chi Kao
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Clement Ma
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Joanne Wolfe
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Danielle D DeCourcey
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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23
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Traynor MD, Antiel RM, Camazine MN, Blinman TA, Nance ML, Eghtesady P, Lam SK, Hall M, Feudtner C. Surgical Interventions During End-of-Life Hospitalizations in Children's Hospitals. Pediatrics 2021; 148:183483. [PMID: 34850192 DOI: 10.1542/peds.2020-047464] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To characterize patterns of surgery among pediatric patients during terminal hospitalizations in children's hospitals. METHODS We reviewed patients ≤20 years of age who died among 4 424 886 hospitalizations from January 2013-December 2019 within 49 US children's hospitals in the Pediatric Health Information System database. Surgical procedures, identified by International Classification of Diseases procedure codes, were classified by type and purpose. Descriptive statistics characterized procedures, and hypothesis testing determined if undergoing surgery varied by patient age, race and ethnicity, or the presence of chronic complex conditions (CCCs). RESULTS Among 33 693 terminal hospitalizations, the majority (n = 30 440, 90.3%) of children were admitted for nontraumatic causes. Of these children, 15 142 (49.7%) underwent surgery during the hospitalization, with the percentage declining over time (P < .001). When surgical procedures were classified according to likely purpose, the most common were to insert or address hardware or catheters (31%), explore or aid in diagnosis (14%), attempt to rescue patient from mortality (13%), or obtain a biopsy (13%). Specific CCC types were associated with undergoing surgery. Surgery during terminal hospitalization was less likely among Hispanic children (47.8%; P < .001), increasingly less likely as patient age increased, and more so for Black, Asian American, and Hispanic patients compared with white patients (P < .001). CONCLUSIONS Nearly half of children undergo surgery during their terminal hospitalization, and accordingly, pediatric surgical care is an important aspect of end-of-life care in hospital settings. Differences observed across race and ethnicity categories of patients may reflect different preferences for and access to nonhospital-based palliative, hospice, and end-of-life care.
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Affiliation(s)
| | - Ryan M Antiel
- Division of Pediatric Surgery, Department of Surgery, Indiana University, Indianapolis, Indiana
| | - Maraya N Camazine
- Department of Surgery, Mayo Clinic, Rochester, Minnesota.,School of Medicine, University of Missouri in Columbia, Columbia, Missouri
| | - Thane A Blinman
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael L Nance
- Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Pirooz Eghtesady
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, School of Medicine, Washington University, St Louis, Missouri
| | - Sandi K Lam
- Division of Pediatric Neurosurgery, Ann and Robert H Lurie Children's Hospital of Chicago, Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Chris Feudtner
- Pediatric Advanced Care Team, Department of Medical Ethics, The Children's Hospital of Philadelphia; Philadelphia, Pennsylvania.,Department of Pediatrics, Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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24
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Mun S, Wang R, Ma X, Ananth P. Sociodemographic and hospital-based predictors of intense end-of-life care among children, adolescents, and young adults with hematologic malignancies. Cancer 2021; 127:3817-3824. [PMID: 34185881 PMCID: PMC8478813 DOI: 10.1002/cncr.33764] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/07/2021] [Accepted: 04/26/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Children, adolescents, and young adults with hematologic malignancies tend to receive high-intensity end-of-life care (HI-EOLC), but sociodemographic and hospital-based predictors of HI-EOLC remain unclear. METHODS The authors conducted a population-based, retrospective cohort study with the Premier Healthcare Database. They identified individuals with hematologic malignancies who were 0 to 39 years old at death and died between 2010 and 2017. HI-EOLC was defined as experiencing 2 or more of the following: cardiopulmonary resuscitation, intravenous chemotherapy, hemodialysis, mechanical ventilation, tracheostomy placement, or an emergency department visit within the last 30 days of life and death in the intensive care unit. Multivariable logistic regression models were constructed to identify patient sociodemographic and hospital characteristics associated with HI-EOLC. RESULTS Among 1454 decedents, more than half (55%) experienced HI-EOLC. In multivariable models, patients treated in medium (adjusted odds ratio [aOR], 1.63; 95% confidence interval [CI], 1.07-2.50) or large hospitals (aOR, 2.21; 95% CI, 1.45-3.39), insured by Medicaid (aOR, 1.40 ; 95% CI, 1.09-2.06), or receiving cancer-directed treatment in the Northeast (aOR, 1.50; 95% CI, 1.05-2.15) were more likely to receive HI-EOLC. CONCLUSIONS A majority of children, adolescents, and young adults with hematologic malignancies experienced HI-EOLC, and the likelihood of HI-EOLC was influenced by the hospital size, type of insurance, and geographic region. Further research is needed to determine how to mitigate these risks.
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Affiliation(s)
- Sophia Mun
- Yale Cancer Outcomes, Public Policy, and Effectiveness
Research (COPPER) Center, New Haven, CT
| | - Rong Wang
- Yale Cancer Outcomes, Public Policy, and Effectiveness
Research (COPPER) Center, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of
Public Health, New Haven, CT
| | - Xiaomei Ma
- Yale Cancer Outcomes, Public Policy, and Effectiveness
Research (COPPER) Center, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of
Public Health, New Haven, CT
| | - Prasanna Ananth
- Yale Cancer Outcomes, Public Policy, and Effectiveness
Research (COPPER) Center, New Haven, CT
- Department of Pediatrics, Yale School of Medicine, New
Haven, CT
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25
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Ribeiro ILA, de Castro RD, Costa RC, Damascena LCL, de Lucena NNN, Maracajá PMB, Dos Santos FG, de Medeiros Serpa EB, Sousa SA, Valença AMG. Integrated oral care contributes positively to the course of treatment of oncopediatric patients. Eur J Pediatr 2021; 180:2757-2764. [PMID: 33754206 DOI: 10.1007/s00431-021-04024-z] [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: 12/07/2020] [Revised: 03/04/2021] [Accepted: 03/10/2021] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to implement a model of permanent oral health care for oncopediatric patients and to observe its effects on severe oral mucositis and subsequent treatment interruptions. We performed a quasi-experimental study in the Pediatric Department of Napoleão Laureano Hospital, in the city of João Pessoa, Brazil. A integrated oral care was implemented by a dentistry team for prevention of comorbidities, such as infections, oral pain, oral function maintenance, oral mucositis, and interventions for lesions due to severe oral mucositis. The oral comorbidities were compared before and after the implementation. The duration of severe oral mucositis (SOM) before and after the interventions and the interruptions in treatment due to SOM were the main outcome measures. Permanent oral health care reduced the duration of SOM and reduced pediatric chemotherapy interruptions due to SOM by 81.8%.Conclusion: The permanent oral health care to offer to oncopediatric patients increased surveillance regarding oral comorbidities and reduced chemotherapy interruptions due to severe oral mucositis. This care plan could be adopted anywhere around the world. What is Known: • Several studies on oral care for pediatric oncology patients, especially regarding both prevention of and treatment for oral mucositis during antineoplastic therapy, have been published. What is New: • This study describes the benefits of permanent oral care with daily oral surveillance for pediatric patients, which reduced the duration of severe oral mucositis, increased surveillance and the efficiency in diagnostic for signs of oral mucositis, enabling early intervention, and decreased chemotherapy interruptions, contributing positively to the course of treatment.
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Affiliation(s)
| | - Ricardo Dias de Castro
- Postgraduate Program in Dentistry, Federal University of Paraíba, Campus I, João Pessoa, PB, 58051900, Brazil
| | - Raphael Cavalcante Costa
- Postgraduate Program in Clinical Dentistry, State University of Campinas, Piracicaba, SP, Brazil
| | | | | | | | - Fabio Gomes Dos Santos
- Postgraduate Program in Dentistry, Federal University of Paraíba, Campus I, João Pessoa, PB, 58051900, Brazil
| | | | - Simone Alves Sousa
- Postgraduate Program in Dentistry, Federal University of Paraíba, Campus I, João Pessoa, PB, 58051900, Brazil
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26
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Delgado-Corcoran C, Bennett EE, Bodily SA, Wawrzynski SE, Green D, Moore D, Cook LJ, Olson LM. Prevalence of specialised palliative care consultation for eligible children within a paediatric cardiac ICU. Cardiol Young 2021; 31:1458-1464. [PMID: 33597068 PMCID: PMC8547172 DOI: 10.1017/s1047951121000433] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Retrospectively apply criteria from Center to Advance Palliative Care to a cohort of children treated in a cardiac ICU and compare children who received a palliative care consultation to those who were eligible for but did not receive one. METHODS Medical records of children admitted to a cardiac ICU between January 2014 and June 2017 were reviewed. Selected criteria include cardiac ICU length of stay >14 days and/or ≥ 3 hospitalisations within a 6-month period. MEASUREMENTS AND RESULTS A consultation occurred in 17% (n = 48) of 288 eligible children. Children who received a consult had longer cardiac ICU (27 days versus 17 days; p < 0.001) and hospital (91 days versus 35 days; p < 0.001) lengths of stay, more complex chronic conditions at the end of first hospitalisation (3 versus1; p < 0.001) and the end of the study (4 vs.2; p < 0.001), and higher mortality (42% versus 7%; p < 0.001) when compared with the non-consulted group. Of the 142 pre-natally diagnosed children, only one received a pre-natal consult and 23 received it post-natally. Children who received a consultation (n = 48) were almost 2 months of age at the time of the consult. CONCLUSIONS Less than a quarter of eligible children received a consultation. The consultation usually occurred in the context of medical complexity, high risk of mortality, and at an older age, suggesting potential opportunities for more and earlier paediatric palliative care involvement in the cardiac ICU. Screening criteria to identify patients for a consultation may increase the use of palliative care services in the cardiac ICU.
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Affiliation(s)
- Claudia Delgado-Corcoran
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, 84108, USA
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, 100 N. Mario Capecchi Dr. Salt Lake City, UT, 84113, USA
| | - Erin E Bennett
- Division of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital. 1 Children's Way, Little Rock, AR, 72202, USA
| | - Stephanie A Bodily
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, 100 N. Mario Capecchi Dr. Salt Lake City, UT, 84113, USA
| | - Sarah E Wawrzynski
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, 100 N. Mario Capecchi Dr. Salt Lake City, UT, 84113, USA
| | - Danielle Green
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, 84108, USA
| | - Dominic Moore
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, 100 N. Mario Capecchi Dr. Salt Lake City, UT, 84113, USA
| | - Lawrence J Cook
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, 84108, USA
| | - Lenora M Olson
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, 84108, USA
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27
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Lindley LC, Fortney CA, Cozad MJ. Predictive Ability of an Illness Severity Measure: Implications for Nursing Research. J Nurs Meas 2021; 29:213-226. [PMID: 33795485 PMCID: PMC8543733 DOI: 10.1891/jnm-d-19-00106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Illness severity among children with life-limiting illnesses is measured with the pediatric complex chronic conditions (CCC) measure. Developed in 2000/2001, it was revised in 2014 to include infant-specific categories. METHODS Discrimination, calibration, accuracy, and validation tests were used to examine the predictive performance of the measures. RESULTS Among the 10,175 infants in the analysis, both measures poorly discriminated-palliative care consultation (C-statistics 0.6396 vs. C-statistics 0.5905) and any inpatient procedure (C-statistics 0.6101 vs. C-statistics 0.5160). The Hosmer-Lemeshow goodness-of-fit tests revealed good calibration for both measures. The original measure was more accurate in predicting end-of-life outcomes-palliative care consultation (Brier Score 0.3892 vs. 0.7787) and any inpatient procedures (Brier Score 0.3115 vs. 0.4738). CONCLUSIONS The revised measure did not perform any better than the original in predicting end-of-life outcomes among infants.
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28
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Bogetz JF, Revette A, DeCourcey DD. Clinical Care Strategies That Support Parents of Children With Complex Chronic Conditions. Pediatr Crit Care Med 2021; 22:595-602. [PMID: 33813549 DOI: 10.1097/pcc.0000000000002726] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Children with complex chronic conditions often receive inpatient and end-of-life care in the ICU, yet little is known about the clinical care strategies that best support this unique group of parents. This study aimed to elucidate supportive clinical care strategies identified by bereaved parents of children with complex chronic conditions. DESIGN Qualitative analysis of 21 open-response items from the cross-sectional "Survey of Caring for Children with Complex Chronic Conditions" querying communication, decision-making, and end-of-life experiences. SETTING Large tertiary care children's hospital. PATIENTS Parents of children with complex chronic conditions who received care at a large academic institution and died between 2006 and 2015. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS An iterative multistage thematic analysis of responses was used to identify key themes pertaining to clinical care strategies that support parents of children with complex chronic conditions. Open-ended responses were analyzed from 110 of 114 (96%) of survey respondents. The majority of parents had children with congenital/chromosomal complex chronic conditions who died 3.9 years (interquartile range, 2.2-6.7 yr) prior to their parents' study participation. Although informational themes related to clear honest communication, consistent messaging, and enhanced care coordination were identified, parents emphasized the relational aspects of clinical care including inclusivity of their expertise about their child's needs, recognition of their unique experience as parents, and maintenance of connection with clinicians through bereavement. CONCLUSIONS Clinical care strategies that support parents of children with complex chronic conditions reflect the unique needs of this group of children. Relational strategies such as including parents as experts in their child's care were paramount to parents of children with complex chronic conditions throughout their child's medical journey and at end of life.
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Affiliation(s)
- Jori F Bogetz
- Division of Bioethics and Palliative Care, Department of Pediatric, University of Washington, Seattle, WA
- Treuman Katz Center for Bioethics, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA
- Palliative Care Resilience Research Lab, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, MA
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Anna Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, MA
| | - Danielle D DeCourcey
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA
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29
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Wolff S, Christiansen CF, Johnsen SP, Schroeder H, Darlington A, Neergaard MA. Disparities in intensity of treatment at end-of-life among children according to the underlying cause of death. Acta Paediatr 2021; 110:1673-1681. [PMID: 33289933 DOI: 10.1111/apa.15713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/15/2020] [Accepted: 12/04/2020] [Indexed: 11/28/2022]
Abstract
AIM To compare indicators of high-intensity treatment at end-of-life (HI-EOL) among children according to causes of death. METHODS We conducted a nationwide registry study in Denmark among 938 children of 1-17 years of age who died from natural causes from 2006 to 2016. We identified and compared indicators of HI-EOL within the last month of life across diagnoses. Indicators were hospital admissions, days in hospital, intensive care unit admission, mechanical ventilation, and hospital death. RESULTS Proportions of each indicator of HI-EOL ranged from 27% to 75%. The most common indicators were hospital death (75%) and ICU admission (39%). Compared to children with solid tumours, children with non-cancerous conditions had an adjusted odds ratio of 3.5 (95% CI 2.1-5.9) of having ≥3 indicators of HI-EOL within the last month of life and children with haematological cancer had an odds ratio of 11.8 (95% CI 6.1-23.0). CONCLUSION The underlying diagnosis was strongly associated with HI-EOL. Children who died from solid tumours experienced substantially less intensive treatment than both children with haematological cancer and non-cancerous conditions did. Across non-cancerous diagnoses, the intensity of treatment appeared consistent, which may indicate, that the awareness of palliative care is higher among oncologists than within other paediatric fields.
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Affiliation(s)
- Sanne Wolff
- Palliative Care Unit Department of Oncology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Epidemiology Aarhus University Aarhus Denmark
| | | | - Soeren Paaske Johnsen
- Department of Clinical Medicine Danish Center for Clinical Health Services Research Aalborg University Aalborg Denmark
| | - Henrik Schroeder
- Department of Paediatrics and Adolescent Medicine Aarhus University Hospital Aarhus Denmark
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30
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Rogers J, Reed MP, Blaine K, Manning H. Children with medical complexity: A concept analysis. Nurs Forum 2021; 56:676-683. [PMID: 33625740 DOI: 10.1111/nuf.12559] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 01/01/2021] [Accepted: 01/29/2021] [Indexed: 11/27/2022]
Abstract
AIM The aim of this paper is to conduct a concept analysis on the term, "children with medical complexity." BACKGROUND Children with medical complexity (CMC) describes pediatric patients with chronic, sustained acuity; however, there is a lack of consensus in the literature regarding its exact meaning, characteristics, and implications. DESIGN This analysis relied upon the framework described by Walker and Avant. DATA SOURCE The CINAHL, MEDLINE, and PubMed databases were queried from April 2020 to December 2020 with an initial search of the literature for the keyword, "children with medical complexity" and other associated terms, such as "pediatric medical complexity" and "nursing care of children with medical complexity." REVIEW METHODS This analysis will explore the concept of CMC and its significance, attributes, antecedents, and consequences. RESULTS This investigation revealed that CMC are a growing population of pediatric patients who have one or more complex chronic conditions that affect multiple body systems, experience functional limitations, require extensive care coordination from multiple providers, and are dependent upon life-sustaining medical technology. CONCLUSIONS The findings can serve as a foundation for future work advancing the understanding of the topic of CMC.
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Affiliation(s)
- Jayne Rogers
- Medical Nursing Service, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mary P Reed
- Medical Nursing Service, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kevin Blaine
- Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Haylee Manning
- Medical Nursing Service, Boston Children's Hospital, Boston, Massachusetts, USA
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31
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Bogetz JF, Revette A, Rosenberg AR, DeCourcey D. "I Could Never Prepare for Something Like the Death of My Own Child": Parental Perspectives on Preparedness at End of Life for Children With Complex Chronic Conditions. J Pain Symptom Manage 2020; 60:1154-1162.e1. [PMID: 32629083 DOI: 10.1016/j.jpainsymman.2020.06.035] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 11/17/2022]
Abstract
CONTEXT Children with complex chronic conditions (CCCs) have high morbidity and mortality. While these children often receive palliative care services, little is known about parental preparedness for their child's end of life (EOL). OBJECTIVES This study aimed to elucidate aspects important to preparedness at EOL among bereaved parents of children with CCCs. METHODS In this cross-sectional study, parents of children who received care at Boston Children's Hospital and died between 2006 and 2015 completed 21 open-response items querying communication, decision-making, and EOL experiences as part of the Survey of Caring for Children with CCCs. Additional demographic data were extracted from the child's medical record. An iterative multistage thematic analysis of responses was utilized to identify key contexts, conditions, and themes pertaining to preparedness. RESULTS One hundred ten of 114 parents responded to open-ended items; 63% (n = 69) had children with congenital or central nervous system progressive primary conditions for a median of 7.5 years (IQR 0.8-18.1) before death. Seventy-one percent (n = 78/110) had palliative care involvement and 65% (n = 69/106) completed advance care planning. Parents described preparedness as a complex concept that extended beyond "readiness" for their child's death. Three domains emerged that contributed to parents' lack of preparedness: 1) chronic illness experiences; 2) pretense of preparedness; and 3) circumstances and emotions surrounding their child's death. CONCLUSIONS Most bereaved parents of children with CCCs described feeling unprepared for their child's EOL, despite palliative care and advance care planning, suggesting preparedness is a nuanced concept beyond "readiness." More research is needed to identify supportive elements among parents facing their child's EOL.
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Affiliation(s)
- Jori F Bogetz
- Division of Pediatric Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA; Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, USA.
| | - Anna Revette
- Qualitative Research Scientist, Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Abby R Rosenberg
- Division of Hematology and Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA; Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, USA
| | - Danielle DeCourcey
- Division of Critical Care, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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32
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Allen J, Brenner M, Hauer J, Molloy E, McDonald D. Severe Neurological Impairment: A delphi consensus-based definition. Eur J Paediatr Neurol 2020; 29:81-86. [PMID: 32951992 DOI: 10.1016/j.ejpn.2020.09.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/26/2020] [Accepted: 09/07/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Severe Neurological Impairment (SNI) is a term for which there is no consistently used definition. This may hamper consistency in the reporting of research in the area and communication between professionals involved in the care of those with SNI. OBJECTIVE We aimed to create an international, multidisciplinary, consensus-based definition of SNI. DESIGN The Delphi method was employed to reach consensus on the definition of SNI. METHOD An international, multi-disciplinary expert panel was recruited. The process proceeded over three rounds with feedback provided to panellists between each of them. Consensus was defined as 70% agreement. A working definition was created and, following presentation at an international meeting and consultation with parent representatives, further refined, to create a finalised definition. RESULTS Thirty-four expert panellists commenced the process. Six items reached the threshold of consensus. The finalised definition is as follows: "Severe Neurological Impairment describes a group of disorders of the central nervous system which arise in childhood, resulting in motor impairment, cognitive impairment and medical complexity, where much assistance is required with activities of daily living. The impairment is permanent but can be progressive or static." CONCLUSION A consensus-based definition of SNI which includes multi-disciplinary, international and parental input has been created. This should prove useful for clinical, research and resource-planning purposes.
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Affiliation(s)
- John Allen
- Department of Paediatrics, Tallaght University Hospital, Tallaght, Dublin, Ireland; Discipline of Paediatrics and Child Health, Trinity College, The University of Dublin, Ireland; Trinity Research in Childhood Centre, Trinity College, The University of Dublin, Ireland.
| | - Maria Brenner
- Trinity Research in Childhood Centre, Trinity College, The University of Dublin, Ireland; School of Nursing and Midwifery, Trinity College, The University of Dublin, Ireland
| | - Julie Hauer
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Eleanor Molloy
- Department of Paediatrics, Tallaght University Hospital, Tallaght, Dublin, Ireland; Discipline of Paediatrics and Child Health, Trinity College, The University of Dublin, Ireland; Trinity Research in Childhood Centre, Trinity College, The University of Dublin, Ireland; Trinity Translational Medicine Institute, St. James' Hospital, Dublin, Ireland; Neonatology, Coombe Women and Infants' University Hospital, Dublin, Ireland; Neonatology, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Denise McDonald
- Department of Paediatrics, Tallaght University Hospital, Tallaght, Dublin, Ireland; Discipline of Paediatrics and Child Health, Trinity College, The University of Dublin, Ireland; Trinity Research in Childhood Centre, Trinity College, The University of Dublin, Ireland
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From Tramadol to Methadone: Opioids in the Treatment of Pain and Dyspnea in Pediatric Palliative Care. Clin J Pain 2020; 35:501-508. [PMID: 30985399 DOI: 10.1097/ajp.0000000000000704] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND More than 15,000 children die annually in the United States due to an underlying life-limiting disease and the majority of those children experience distressing symptoms, which are not adequately relieved, such as pain and dyspnea. Multimodal analgesia, that is multiple agents, interventions, rehabilitation, psychological modalities, and integrative (nonpharmacologic) therapies, act synergistically for more effective pediatric pain and symptom control with fewer side effects than a single analgesic or modality. However, opioids, such as morphine, fentanyl, hydromorphone, oxycodone, and methadone (in the United Kingdom: diamorphine) remain the mainstay medication to effectively treat pain and dyspnea in children with serious illness. METHODS This article reviews commonly used opioids in Pediatric Palliative Care, which a special emphasis on 2 potentially particularly effective multimechanistic opioids: tramadol and methadone. RESULTS Methadone, due to its multimechanistic action profile, is possibly among the most effective and most underutilized opioid analgesics in children with severe unrelieved pain at end of life. However, methadone should not be prescribed by those unfamiliar with its use: Its effects should be closely monitored for several days, particularly when it is first started and after any dose changes. CONCLUSIONS Tramadol appears to play a key role in treating episodes of inconsolability in children with progressive neurologic, metabolic, or chromosomally based condition with impairment of the central nervous system. However, the recent 2017 United States Food and Drug Administration (FDA) warning against pediatric use of tramadol does not seem to be based on clinical evidence, and therefore puts children at risk for unrelieved pain or increased respiratory depression.
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Palliative Care Knowledge and Characteristics in Caregivers of Chronically Ill Children. J Hosp Palliat Nurs 2020; 22:456-464. [DOI: 10.1097/njh.0000000000000685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Predictors for place of death among children:A systematic review and meta-analyses of recent literature. Eur J Pediatr 2020; 179:1227-1238. [PMID: 32607620 DOI: 10.1007/s00431-020-03689-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/11/2020] [Accepted: 05/13/2020] [Indexed: 10/24/2022]
Abstract
Through a systematic review and meta-analyses, we aimed to determine predictors for place of death among children. We searched online databases for studies published between 2008 and 2019 comprising original quantitative data on predictors for place of death among children. Data regarding study design, population characteristics and results were extracted from each study. Meta-analyses were conducted using generic inverse variance method with random effects. Fourteen cohort studies met the inclusion criteria, comprising data on 106,788 decedents. Proportions of home death varied between countries and regions from 7% to 45%. Lower age was associated with higher odds of hospital death in eight studies (meta-analysis was not possible). Children categorised as non-white were less likely to die at home compared to white (pooled OR 0.6; 95% CI 0.5-0.7) as were children of low socio-economic position versus high (pooled OR 0.7; 95% CI 0.6-0.9). Compared to patients with cancer, children with non-cancer diagnoses had lower odds of home death (pooled OR 0.5; 95% CI 0.5-0.5).Conclusion: Country and region of residence, older age of the child, high socio-economic position, 'white' ethnicity and cancer diagnoses appear to be independent predictors of home death among children. What is Known: • Home is often considered an indicator of quality in end-of-life care. • Most terminally ill children die in hospitals. What is New: • Through a systematic review and meta-analyses, this study examined predictors for place of death among children. • Country and region of residence, older age of the child, high socio-economic position, white ethnicity and having a cancer diagnosis appear to be independent predictors of home death among terminally ill children.
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The end-of-life experience for adults with congenital heart disease: Resource utilization, functional decline, and circumstances surrounding death. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2020. [DOI: 10.1016/j.ijcchd.2020.100055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Lindley LC, Cozad MJ, Fortney CA. Pediatric Complex Chronic Conditions: Evaluating Two Versions of the Classification System. West J Nurs Res 2020; 42:454-461. [PMID: 31354080 PMCID: PMC6986991 DOI: 10.1177/0193945919867266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The original pediatric complex chronic conditions (CCC) classification system developed in 2000/2001 is the gold standard in classifying children with life-limiting illnesses. It was significantly modified in 2014; yet the two systems have not been evaluated. The objective of this study was to evaluate the agreement and validity of the original versus the modified CCC classification systems. Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID) data from 2012 was used with a sample of infant decedents less than 1 years. The agreement (i.e., Cohen's Kappa Statistic) and validity (i.e., sensitivity, specificity, and positive predictive value [PPV]) statistics were calculated. Among the 10,175 infants that were classified, the modified system performed well in identifying infants who had a CCC, and it captured infants that the original classification did not. The modified system represents an improvement over the original, but additional testing is warranted.
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Affiliation(s)
- Lisa C Lindley
- College of Nursing, University of Tennessee, Knoxville, Knoxville, TN, USA
| | - Melanie J Cozad
- Department of Health Services Policy and Management, Center for Effectiveness Research in Orthopedics, University of South Carolina, Columbia, SC, USA
| | - Christine A Fortney
- Martha S. Pitzer Center for Women, Children Youth, College of Nursing, The Ohio State University, Columbus, OH, USA
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Ingresos hospitalarios en cuidados paliativos pediátricos: estudio retrospectivo. An Pediatr (Barc) 2020; 92:94-101. [DOI: 10.1016/j.anpedi.2019.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/21/2019] [Accepted: 02/12/2019] [Indexed: 11/17/2022] Open
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de Noriega Í, Barceló M, Pérez MÁ, Puertas V, García-Salido A, Martino R. Hospital admissions into paediatric palliative care: A retrospective study. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2019.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Looman WS, Park YS, Gallagher TT, Weinfurter EV. Outcomes research on children with medical complexity: A scoping review of gaps and opportunities. Child Care Health Dev 2020; 46:121-131. [PMID: 31782818 DOI: 10.1111/cch.12725] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 10/09/2019] [Accepted: 11/23/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND There has been a recent, rapid increase in the number of studies of children with medical complexity (CMC) and their families. There is a need for attention to gaps and patterns in this emerging field of study. OBJECTIVES The purpose of this scoping review was to identify patterns and gaps in the evidence related to classification systems, data, and outcomes in studies of CMC. DATA SOURCES We searched peer-reviewed journals for reports of quantitative studies focused on CMC outcomes published between 2008 and 2018. On the basis of a structured screening process, we selected 63 reports that met our inclusion criteria. STUDY APPRAISAL AND SYNTHESIS We used the methodological framework for scoping studies described by Arskey and O'Malley to map relevant literature in the field and the ECHO model to categorize studies according to three health outcome domains (economic, clinical, and humanistic). RESULTS The terminology used to describe and classify CMC differed across studies depending on outcome domain. Two thirds of the reports focused on economic outcomes; fewer than a quarter included child or family quality of life as an outcome. A majority of studies used a single source of data, with robust analyses of administrative, payer, and publicly available data. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Research on CMC and their families would benefit from standardization of terms and classification systems, the use of measurement strategies that map humanistic outcomes as trajectories, and more attention to outcomes identified as most meaningful to CMC and their families.
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Affiliation(s)
- Wendy S Looman
- School of Nursing, University of Minnesota, Minneapolis, MN
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Castor C, Hallström IK, Landgren K, Hansson H. Accessibility, utilisation and acceptability of a county-based home care service for sick children in Sweden. Scand J Caring Sci 2019; 33:824-832. [PMID: 30865330 PMCID: PMC7432181 DOI: 10.1111/scs.12678] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 02/10/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Home care service (HCS) for sick children is a complex healthcare service, which can be organised in various models. Despite the possibility to support family everyday life, the accessibility and utilisation may still be limited. The aim of this study was to (i) determine characteristics in referrals to county-based HCS, (ii) determine characteristics of referred children and (iii) assess acceptability of parents and children in county-based HCS. METHODS Data on characteristics of referrals and referred children were collected from medical records of children 0-17 years of age, referred to eight HCS units during 2015-2018. Data on parental and child overall experience, satisfaction of, safety with, and preference for care, were collected from parents by a questionnaire. Descriptive and comparative statistics were used to analyse the data. RESULTS Three hundred and fifty-five referrals led to one or more periods of HCS for 171 children in various ages with a wide range of illnesses. Children with cancer (30%) composed the largest group and administration of intravenous antibiotics accounted for 56% of the care tasks. Seven per cent of the referrals were to palliative home care. Thirty-eight referrals of 34 children were refused. There was an uneven distribution of the indication for referral, acceptance rate and diagnoses of children among HCS units. Parents reported their and their child's experience with the HCS visit as highly positive and preferred home care to hospital care in over 96% of the HCS in 212 visits. CONCLUSION County-based HCS constitutes a supplement to hospital care for sick children with various illnesses through different stages of acute and long-term illness and at end of life, with high levels of acceptability. Few referrals and variation in referral characteristics and acceptance rate of referrals between HCS units led to unequal and inequitable accessibility and utilisation of HCS.
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Affiliation(s)
- Charlotte Castor
- Department of Health SciencesFaculty of MedicineLund UniversityLundSweden
| | | | - Kajsa Landgren
- Department of Health SciencesFaculty of MedicineLund UniversityLundSweden
| | - Helena Hansson
- Paediatrics and Adolescent MedicineCopenhagen University Hospital RigshospitaletKøbenhavn ØDenmark
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Pinto M, Gomes R, Tanabe RF, Costa ACCD, Moreira MCN. Analysis of the cost of care for children and adolescents with medical complex chronic conditions. CIENCIA & SAUDE COLETIVA 2019; 24:4043-4052. [PMID: 31664377 DOI: 10.1590/1413-812320182411.08912018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 04/09/2018] [Indexed: 11/21/2022] Open
Abstract
This paper aimed to identify the use of technology and to analyze the cost of hospital care for children and adolescents with medical complex chronic conditions at a public federal hospital specialized in high-complexity pediatric care, and was performed concomitantly with a prospective cohort study conducted over a one-year period. It included 146 patients with complex medical chronic conditions and 37 non-chronic patients. The analysis showed that most patients had, on average, two hospitalizations a year and were diagnosed with diseases related to at least two organic systems. Catheters, drains and gastrostomy were the most common technologies used. Median direct costs of patients with medically complex chronic conditions were higher than those of non-chronic patients when comparing the use of technology. The study shows high hospitalization cost to these patients. Technology use and hospitalization care costs documentation yields more data to support decision-makers in the planning, managing, and financing of pediatric health policies.
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Affiliation(s)
- Márcia Pinto
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF/Fiocruz), Fundação Oswaldo Cruz. Av. Rui Barbosa 716, Flamengo. 20021-140. Rio de Janeiro, RJ, Brasil.
| | - Romeu Gomes
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF/Fiocruz), Fundação Oswaldo Cruz. Av. Rui Barbosa 716, Flamengo. 20021-140. Rio de Janeiro, RJ, Brasil.
| | - Roberta Falcão Tanabe
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF/Fiocruz), Fundação Oswaldo Cruz. Av. Rui Barbosa 716, Flamengo. 20021-140. Rio de Janeiro, RJ, Brasil.
| | - Ana Carolina Carioca da Costa
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF/Fiocruz), Fundação Oswaldo Cruz. Av. Rui Barbosa 716, Flamengo. 20021-140. Rio de Janeiro, RJ, Brasil.
| | - Martha Cristina Nunes Moreira
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF/Fiocruz), Fundação Oswaldo Cruz. Av. Rui Barbosa 716, Flamengo. 20021-140. Rio de Janeiro, RJ, Brasil.
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Advance Care Planning and Parent-Reported End-of-Life Outcomes in Children, Adolescents, and Young Adults With Complex Chronic Conditions. Crit Care Med 2019; 47:101-108. [PMID: 30303834 DOI: 10.1097/ccm.0000000000003472] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES For children, adolescents, and young adults with complex chronic conditions advance care planning may be a vital component of optimal care. Advance care planning outcomes research has previously focused on seriously ill adults and adolescents with cancer where it is correlated with high-quality end-of-life care. The impact of advance care planning on end-of-life outcomes for children, adolescents, and young adults with complex chronic conditions is unknown, thus we sought to evaluate parental preferences for advance care planning and to determine whether advance care planning and assessment of specific family considerations during advance care planning were associated with differences in parent-reported end-of-life outcomes. DESIGN Cross-sectional survey. SETTING Large, tertiary care children's hospital. SUBJECTS Bereaved parents of children, adolescents, and young adults with complex chronic conditions who died between 2006 and 2015. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS One-hundred fourteen parents were enrolled (54% response rate) and all parents reported that advance care planning was important, with a majority (70%) endorsing that discussions should occur early in the illness course. Parents who reported advance care planning (65%) were more likely to be prepared for their child's last days of life (adjusted odds ratio, 3.78; 95% CI, 1.33-10.77), to have the ability to plan their child's location of death (adjusted odds ratio, 2.93; 95% CI, 1.06-8.07), and to rate their child's quality of life during end-of-life as good to excellent (adjusted odds ratio, 3.59; 95% CI, 1.23-10.37). Notably, advance care planning which included specific assessment of family goals was associated with a decrease in reported child suffering at end-of-life (adjusted odds ratio, 0.23; 95% CI, 0.06-0.86) and parental decisional regret (adjusted odds ratio, 0.42; 95% CI, 0.02-0.87). CONCLUSIONS Parents of children, adolescents, and young adults with complex chronic conditions highly value advance care planning, early in the illness course. Importantly, advance care planning is associated with improved parent-reported end-of-life outcomes for this population including superior quality of life. Further studies should evaluate strategies to ensure high-quality advance care planning including specific assessment of family goals.
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Lindley LC, Fortney CA. Pediatric Complex Chronic Conditions: Does the Classification System Work for Infants? Am J Hosp Palliat Care 2019; 36:858-863. [PMID: 30943756 PMCID: PMC7203786 DOI: 10.1177/1049909119838985] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND One widely accepted approach to identify children with life-limiting health problems is the complex chronic conditions (CCCs) classification system. Although considered the "gold standard" for classifying children with serious illness, little is known about its performance, especially among infants. OBJECTIVE/HYPOTHESIS This research examined the prevalence of CCCs and the infant characteristics related to a CCC classification. METHODS Multivariate regression analysis was conducted with 2012 Kids' Inpatient Database, Healthcare Cost and Utilization Project data files, using a national sample of infant decedents less than 1 year. RESULTS Our findings showed that 40% of the infants were classified with a CCC. African Americans were negatively associated with a CCC classification (adjusted odds ratio [aOR] = 0.63; 95% confidence interval [CI] = 0.543-0.731). When infants had other insurance coverage, they were less likely (aOR = 0.63; 95% CI = 0.537-0.748) to have a CCC classification. Infants who resided in nonurban areas (aOR = 1.21; 95% CI =1.034-1.415) and had comorbidities (aOR = 38.19; 95% CI = 33.12-44.04) had greater odds of having a CCC classification. CONCLUSIONS The findings suggested that the infants are not commonly classified with a CCC and highlighted the significant variation in race with African American infants exhibiting different CCC classifications than Caucasian infants. Given the importance of reducing disparities in palliative care, critical attention to using CCC classifications in research is warranted.
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Affiliation(s)
- Lisa C Lindley
- 1 College of Nursing, University of Tennessee, Knoxville, TN, USA
| | - Christine A Fortney
- 2 Martha S. Pitzer Center for Women, Children Youth, College of Nursing, The Ohio State University, Columbus, OH, USA
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Friedrichsdorf SJ, Remke S, Hauser J, Foster L, Postier A, Kolste A, Wolfe J. Development of a Pediatric Palliative Care Curriculum and Dissemination Model: Education in Palliative and End-of-Life Care (EPEC) Pediatrics. J Pain Symptom Manage 2019; 58:707-720.e3. [PMID: 31220594 PMCID: PMC6754756 DOI: 10.1016/j.jpainsymman.2019.06.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/08/2019] [Accepted: 06/10/2019] [Indexed: 11/15/2022]
Abstract
CONTEXT Most children living and dying with serious illnesses experience high burden of distressing symptoms. Many seriously ill children and their families do not have access to subspecialist pediatric palliative care (PPC) services nor to clinicians trained in primary PPC. Lack of PPC education appears to be a significant barrier to PPC implementation. OBJECTIVES Description of the development and dissemination of Education in Palliative and End-of-Life Care (EPEC)-Pediatrics. METHODS Funded through a U.S. $1.6 million National Institutes of Health/National Cancer Institute grant 2010-2017, this 24-module curriculum was designed to teach primary palliative care. The target audience included interprofessional pediatric hematology/oncology providers and all other clinicians caring for seriously ill children. RESULTS The curriculum is delivered in a combination of online learning and in-person, face-to-face sessions. In addition, a one-day Professional Development Workshop was developed to teach EPEC-Pediatrics graduates, future "Trainers," thus becoming "Master Facilitators." Between 2012-May 2019, a total of 867 EPEC-Pediatric Trainers and 75 Master Facilitators from 58 countries participated in 17 Become an EPEC-Pediatrics-Trainer conferences and three Professional Development Workshops. The curriculum has also been adapted for large-scale dissemination across Canada and Latin-America, with translation to French and Spanish. Participants overwhelmingly report improvements in their PPC knowledge, attitudes, and skills, including teaching. Trainers subsequently anticipated improvements in patient care for children with serious illness at their home institutions. CONCLUSION EPEC-Pediatrics has developed into the most comprehensive PPC curriculum worldwide. It is highly adaptable for local settings, became self-sustaining and six conferences are offered around the world in 2019.
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Affiliation(s)
- Stefan J Friedrichsdorf
- Department of Pain Medicine, Palliative Care and Integrative Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA; Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA.
| | - Stacy Remke
- Department of Pain Medicine, Palliative Care and Integrative Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA; University of Minnesota School of Social Work, St. Paul, Minnesota, USA
| | - Joshua Hauser
- Department of Medicine (Palliative Medicine), Northwestern Feinberg School of Medicine, Chicago, Illinois, USA; Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Laurie Foster
- University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Andrea Postier
- Department of Pain Medicine, Palliative Care and Integrative Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA
| | - Alison Kolste
- Department of Pain Medicine, Palliative Care and Integrative Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA
| | - Joanne Wolfe
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Boston Children's Hospital, Boston, Massachusetts, USA
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Johnston EE, Bogetz J, Saynina O, Chamberlain LJ, Bhatia S, Sanders L. Disparities in Inpatient Intensity of End-of-Life Care for Complex Chronic Conditions. Pediatrics 2019; 143:peds.2018-2228. [PMID: 30971431 DOI: 10.1542/peds.2018-2228] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/23/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Children with complex chronic conditions (CCCs) require a disproportionate share of health care services and have high mortality rates, but little is known about their end-of-life care. METHODS We performed a retrospective population-based analysis using a California State administrative database of children aged 1 to 21 years with a CCC who died of disease-related causes between 2000 and 2013. Rates of and sociodemographic and clinical factors associated with previously defined inpatient end-of-life intensity indicators were determined. The intensity indicators included: (1) hospital death, (2) receipt of a medically intense intervention within 30 days of death (ICU admission, cardiopulmonary resuscitation, hemodialysis, and/or intubation), and (3) having ≥2 intensity markers (including hospital death). RESULTS There were 8654 children in the study population with a mean death age of 11.8 years (SD 6.8). The 3 most common CCC categories were neuromuscular (47%), malignancy (43%), and cardiovascular (42%). Sixty-six percent of the children died in the hospital, 36% had a medically intense intervention in the last 30 days of life, and 35% had ≥2 intensity markers. Living in a low-income neighborhood was associated with increased odds of hospital death, a medically intense intervention, and ≥2 intensity markers. Hispanic and "other" race and/or ethnicity were associated with hospital death and ≥2 intensity markers. Age 15 to 21 years was associated with hospital death, a medically intense intervention, and ≥2 intensity markers. CONCLUSIONS Sociodemographic disparities in the intensity of end-of-life care for children with CCCs raise concerns about whether all children are receiving high-quality and goal-concordant end-of-life care.
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Affiliation(s)
- Emily E Johnston
- Divisions of Pediatric Hematology/Oncology and .,Institute for Cancer Outcomes and Survivorship, School of Medicine and.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Jori Bogetz
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute and Division of Bioethics and Palliative Care, Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA
| | | | - Lisa J Chamberlain
- General Pediatrics, Department of Pediatrics, School of Medicine and Centers for.,Population Health Sciences, Stanford University, Palo Alto, California
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, School of Medicine and.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Lee Sanders
- Policy, Outcomes, and Prevention and.,General Pediatrics, Department of Pediatrics, School of Medicine and Centers for
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47
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Bjur KA, Wi CI, Ryu E, Crow SS, King KS, Juhn YJ. Epidemiology of Children With Multiple Complex Chronic Conditions in a Mixed Urban-Rural US Community. Hosp Pediatr 2019; 9:281-290. [PMID: 30923070 PMCID: PMC6434974 DOI: 10.1542/hpeds.2018-0091] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Children with multiple complex chronic conditions (MCCs) represent a small fraction of our communities but a disproportionate amount of health care cost and mortality. Because the temporal trends of children with MCCs within a geographically well-defined US pediatric population has not been previously assessed, health care planning and policy for this vulnerable population is limited. METHODS In this population-based, repeated cross-sectional study, we identified and enrolled all eligible children residing in Olmsted County, Minnesota, through the Rochester Epidemiology Project, a medical record linkage system of Olmsted County residents. The pediatric complex chronic conditions classification system version 2 was used to identify children with MCCs. Five-year period prevalence and incidence rates were calculated during the study period (1999-2014) and characterized by age, sex, ethnicity, and socioeconomic status (SES) by using the housing-based index of socioeconomic status, a validated individual housing-based SES index. Age-, sex-, and ethnicity-adjusted prevalence and incidence rates were calculated, adjusting to the 2010 US total pediatric population. RESULTS Five-year prevalence and incidence rates of children with MCCs in Olmsted County increased from 1200 to 1938 per 100 000 persons and from 256 to 335 per 100 000 person-years, respectively, during the study period. MCCs tend to be slightly more prevalent among children with a lower SES and with a racial minority background. CONCLUSIONS Both 5-year prevalence and incidence rates of children with MCCs have significantly increased over time, and health disparities are present among these children. The clinical and financial outcomes of children with MCCs need to be assessed for formulating suitable health care planning given limited resources.
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Corkum KS, Lautz TB, Hebal FN, Rowell EE. Procedural burden experienced by children with cancer during their terminal hospital admission. J Pediatr Surg 2019; 54:133-139. [PMID: 30661597 DOI: 10.1016/j.jpedsurg.2018.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 10/01/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Children with chronic conditions, including cancer, have been shown to have high-intensity end-of-life care. We assessed the frequency and timing of invasive procedures that children with cancer undergo during their terminal hospital admission (THA). METHODS The Pediatric Health Information System database was queried from 2011 to 2015 for patients ages 1-18 years with a "malignancy" flag who died in the hospital. Patient demographics, admission details, procedures codes, and date of service were extracted. Invasive procedures were categorized into 'major operations' or 'minor procedures'. RESULTS 2210 children with cancer were identified as having a THA. During the THA, 1423 (64.4%) patients underwent an invasive procedure and 856 (60.1%) of those children underwent three or more procedures. 466 (21.1%) patients underwent a total of 780 major operations. The most common operations were ventriculostomy/ventriculoperitoneal shunt (n = 211), intracranial mass excision (n = 60), bowel resection (n = 56), and exploratory laparotomy/laparoscopy (n = 46). 101 (21.7%) patients who underwent a major operation died within 48 h of surgery. CONCLUSIONS Children who have cancer and die in the hospital face a large procedural burden prior to their death. This study highlights the need for open, multidisciplinary discussions regarding the necessity of these procedures and for surgeon involvement in complex end-of-life care decisions. TYPE OF STUDY Retrospective cohort review. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Kristine S Corkum
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Timothy B Lautz
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Ferdynand N Hebal
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Erin E Rowell
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.
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Booth A, Maddison J, Wright K, Fraser L, Beresford B. Research prioritisation exercises related to the care of children and young people with life-limiting conditions, their parents and all those who care for them: A systematic scoping review. Palliat Med 2018; 32:1552-1566. [PMID: 30404588 PMCID: PMC6238162 DOI: 10.1177/0269216318800172] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND In planning high-quality research in any aspect of care for children and young people with life-limiting conditions, it is important to prioritise resources in the most appropriate areas. AIM To map research priorities identified from existing research prioritisation exercises relevant to infants, children and young people with life-limiting conditions, in order to inform future research. DESIGN We undertook a systematic scoping review to identify existing research prioritisation exercises; the protocol is publicly available on the project website. DATA SOURCES The bibliographic databases ASSIA, CINAHL, MEDLINE/MEDLINE In Process and Embase were searched from 2000. Relevant reference lists and websites were hand searched. Included were any consultations aimed at identifying research for the benefit of neonates, infants, children and/or young people (birth to age 25 years) with life-limiting, life-threatening or life-shortening conditions; their family, parents, carers; and/or the professional staff caring for them. RESULTS A total of 24 research prioritisation exercises met the inclusion criteria, from which 279 research questions or priority areas for health research were identified. The priorities were iteratively mapped onto an evolving framework, informed by World Health Organization classifications. This resulted in identification of 16 topic areas, 55 sub-topics and 12 sub-sub-topics. CONCLUSION There are numerous similar and overlapping research prioritisation exercises related to children and young people with life-limiting conditions. By mapping existing research priorities in the context in which they were set, we highlight areas to focus research efforts on. Further priority setting is not required at this time unless devoted to ascertaining families' perspectives.
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Affiliation(s)
- Alison Booth
- Martin House Research Centre, Department of Health Sciences, Faculty of Sciences, University of York, York, UK
| | - Jane Maddison
- Social Policy Research Unit, University of York, York, UK
| | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Lorna Fraser
- Martin House Research Centre, Department of Health Sciences, Faculty of Sciences, University of York, York, UK
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Namisango E, Bristowe K, Allsop MJ, Murtagh FEM, Abas M, Higginson IJ, Downing J, Harding R. Symptoms and Concerns Among Children and Young People with Life-Limiting and Life-Threatening Conditions: A Systematic Review Highlighting Meaningful Health Outcomes. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2018; 12:15-55. [DOI: 10.1007/s40271-018-0333-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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