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Mitterer S, Zimmermann K, Fink G, Simon M, Gerber AK, Bergsträsser E. Hospitalization- and death-related financial and employment effects in parents of children with life-limiting conditions: a fixed-effects analysis. Eur J Pediatr 2024:10.1007/s00431-024-05680-7. [PMID: 38985175 DOI: 10.1007/s00431-024-05680-7] [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: 01/19/2024] [Revised: 05/24/2024] [Accepted: 06/30/2024] [Indexed: 07/11/2024]
Abstract
The purpose of this study is to investigate out-of-pocket non-medical expenses and employment-related outcomes in families of children with life-limiting conditions, specifically, to quantify the financial and employment implications of two events: a child's hospitalization and death. This cohort study used panel data collected prospectively for a larger study investigating the effectiveness of specialized pediatric palliative care. Participants were recruited by medical professionals between November 2019 and May 2022 at four Swiss children's hospitals. The care follow-up and bereavement follow-up assessments were 330 and 300 days, respectively. We measured out-of-pocket non-medical expenses, individual full-time equivalent units, and personal income, as well as sick leave and vacation days taken. Analyses included descriptive statistics and two-way linear fixed-effects regressions. The analysis included 110 parents (mothers n = 59, fathers n = 51) of 61 children. Children were hospitalized for a median of 7 days (interquartile range 0-21, range 0-227). The fixed-effects models found a positive association between hospitalization, i.e., length of stay, and travel and accommodation expenses (coefficient 4.18, 95% confidence interval 2.20-6.16). On average, for each week of hospitalization, parents spent an additional 29 Swiss francs on travel and accommodation. During the 300-day bereavement follow-up, six (26%) of 23 parents increased their work commitments, while one reported a decrease. CONCLUSIONS Families incur higher travel and accommodation expenses during hospitalization than during non-hospitalized periods. Instrumental support, e.g., parking vouchers, can help families minimize these costs. Future studies should investigate whether early return to work during bereavement is driven by economic considerations or a desire for distraction. CLINICAL TRIAL REGISTRATION Data analyzed in this study were collected as part of a clinical trial, registered on ClinicalTrials.gov, No. NCT04236180, 15 March 2019 What Is Known: • Families of children with life-limiting conditions are at risk of substantial financial burden from high out-of-pocket medical expenses. • It is also known that parents often have to incur out-of-pocket non-medical expenses and reduce their work commitments. Little is known about the economic consequences of losing a child to a life-limiting condition. WHAT IS NEW • We provide new longitudinal evidence on the hospitalization- and death-related financial and employment implications for families of children with life-limiting conditions. • Child hospitalizations add to families' financial burden through increased travel and accommodation expenses. Work commitments rose during early bereavement.
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Affiliation(s)
- Stefan Mitterer
- Institute of Nursing Science, Department of Public Health, University of Basel, Bernoullistrasse 28, CH-4065, Basel, Switzerland
| | - Karin Zimmermann
- Institute of Nursing Science, Department of Public Health, University of Basel, Bernoullistrasse 28, CH-4065, Basel, Switzerland.
- Paediatric Palliative Care and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.
| | - Günther Fink
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
| | - Michael Simon
- Institute of Nursing Science, Department of Public Health, University of Basel, Bernoullistrasse 28, CH-4065, Basel, Switzerland
| | - Anne-Kathrin Gerber
- Institute of Nursing Science, Department of Public Health, University of Basel, Bernoullistrasse 28, CH-4065, Basel, Switzerland
| | - Eva Bergsträsser
- Paediatric Palliative Care and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
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Asay S, Abramsohn EM, Winslow V, Jagai JS, Waxman E, Makelarski JA, Lindau ST. Food Insecurity and Community-Based Food Resources Among Caregivers of Hospitalized Children. Hosp Pediatr 2024; 14:520-531. [PMID: 38881356 PMCID: PMC11208882 DOI: 10.1542/hpeds.2023-007597] [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: 10/12/2023] [Revised: 02/23/2024] [Accepted: 03/05/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE Children's hospitals are implementing interventions to connect families to community-based resources. This study describes food insecurity (FI) and food resource knowledge, need, and use among families with a hospitalized child. METHODS Between November 2020 and June 2022, 637 caregivers of hospitalized children in an urban 42-ZIP-code area were surveyed as part of a randomized controlled trial. The United States Department of Agriculture 18-item Household Food Security Survey was used to evaluate 12-month food security (food secure [score of 0=FS]; marginally secure [1-2=MFS]; insecure [3-18=FI]). Food resource knowledge, need, and use were described by food security status and examined using Cochran-Armitage tests. The distribution of local resources was obtained from a database and mapped by ZIP code. RESULTS Comparing FI (35.0%) with MFS (17.6%) and FS (47.4%) groups, the rates of resource knowledge were lower (70.2% vs 78.5%, 80.5%), and the rates of need (55.1% vs 30.6%, 14.2%) and use (55.3% vs 51.4%, 40.8%) were higher. Rates of food resource knowledge increased linearly with increasing food security (FI to MFS to FS; P = .008), whereas the rates of resource need (P < .001) and use (P = .001) decreased with increasing food security. There were 311 community-based organizations across 36 ZIP codes with participants (range/ZIP code = 0-20, median = 8). CONCLUSIONS Half of families with a hospitalized child experienced FI or MFS. Although families exhibited high food resource knowledge, nearly half of families with FI had unmet food needs or had never used resources.
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Affiliation(s)
- Spencer Asay
- University of Chicago Pritzker School of Medicine
| | | | | | | | | | | | - Stacy Tessler Lindau
- Department of Obstetrics and Gynecology
- Department of Medicine-Geriatrics and Palliative Medicine
- Comprehensive Cancer Center, University of Chicago, Chicago, Illinois
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Gutierrez SA, Chiou SH, Rhee S, Lai JC, Wadhwani SI. The influence of neighborhood income on healthcare utilization in pediatric liver transplant. J Pediatr Gastroenterol Nutr 2024; 79:100-109. [PMID: 38693791 PMCID: PMC11216888 DOI: 10.1002/jpn3.12234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/08/2024] [Accepted: 04/13/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVES Neighborhood contextual factors are associated with liver transplant outcomes. We analyzed associations between neighborhood-level socioeconomic status and healthcare utilization for pediatric liver transplant recipients. METHODS We merged the Pediatric Health Information System and Scientific Registry of Transplant Recipients databases and included liver transplant recipients ≤21 years hospitalized between January 2004 and May 2022. Outcomes were annual inpatient bed-days, risk of hospitalizations, and risk of liver biopsies. The primary exposure was zip code-based neighborhood income at transplant. We applied causal inference for variable selection in multivariable analysis. We modeled annual inpatient bed-days with mixed-effect zero-inflated Poisson regression, and rates of hospitalization and liver biopsy with a Cox-type proportional rate model. RESULTS We included 1006 participants from 29 institutions. Children from low-income neighborhoods were more likely to be publicly insured (67% vs. 46%), Black (20% vs. 12%), Hispanic (30% vs. 17%), and have higher model for end-stage liver disease/pediatric end-stage liver disease model scores at transplant (17 vs. 13) than the remaining cohort. We found no differences in inpatient bed-days or rates of hospitalization across neighborhood groups. In univariable analysis, low-income neighborhoods were associated with increased rates of liver biopsy (rate ratio [RR]: 1.57, 95% confidence interval [CI]: 1.04-2.34, p = 0.03). These findings persisted after adjusting for insurance, race, and ethnicity (RR: 1.86, 95% CI: 1.23-2.83, p < 0.01). CONCLUSIONS Children from low-income neighborhoods undergo more liver biopsies than other children. These procedures are invasive and potentially preventable. In addition to improving outcomes, interventions to mitigate health inequities among liver transplant recipients may reduce resource utilization.
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Affiliation(s)
- Susan A Gutierrez
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Sy Han Chiou
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
- Department of Statistics and Data Science, Southern Methodist University, Dallas, Texas, USA
| | - Sue Rhee
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer C Lai
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sharad I Wadhwani
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
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Herrmann LE, Hubbell B, Taylor A, Duma E, Warniment A, Smith L, Mailloux E, Szczepanski K, Schmidlin E, Mitchell M, Kientz L, Albrecht J, White CM, Statile AM. Closer to Home: A Quality Improvement Initiative to Optimize Satellite Site Bed Capacity. Hosp Pediatr 2024; 14:556-563. [PMID: 38853656 DOI: 10.1542/hpeds.2023-007377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 03/02/2024] [Accepted: 03/09/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND The coronavirus disease 2019 pandemic resulted in the underutilization of inpatient beds at our satellite location. A lack of clarity and standardized admission criteria for the satellite led to frequent transfers to the main campus, resulting in patients traveling larger distances to receive inpatient care. We sought to optimize inpatient resource use at the satellite campus and keep patients "closer to home" by admitting eligible patients to that inpatient unit (LA4). Our aim was to increase bed capacity use at the satellite from 45% to 70% within 10 months. Our process measure was to increase the proportion of patients needing hospitalization who presented to the satellite emergency department (ED) and were then admitted to LA4 from 76% to 85%. METHODS A multidisciplinary team used quality improvement methods to optimize bed capacity use. Interventions included (1) the revision and dissemination of satellite admission guidelines, (2) steps to create shared understanding of appropriate satellite admissions between ED and inpatient providers, (3) directed provider feedback on preventable main campus admissions, and (4) consistent patient and family messaging about the potential for transfer. Data were collected via chart review. Annotated run charts were used to assess the impact of interventions over time. RESULTS Average LA4 bed capacity use increased from 45% to 69%, which was sustained for 1 year. The average percentage of patients admitted from the satellite ED to LA4 increased from 76% to 84%. CONCLUSIONS We improved bed capacity use at our satellite campus through transparent admission criteria and shared mental models of patient care needs between ED and inpatient providers.
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Affiliation(s)
- Lisa E Herrmann
- Division of Hospital Medicine
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Brittany Hubbell
- Division of Hospital Medicine
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Elena Duma
- Division of Emergency Medicine
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Lauren Smith
- Division of Emergency Medicine, Seattle Children's Hospital, Seattle, Washington
| | | | - Karen Szczepanski
- Department of Pediatrics, TriHealth, Group Health Associates, Cincinnati, Ohio
| | | | | | | | - Jennifer Albrecht
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Christine M White
- Division of Hospital Medicine
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Angela M Statile
- Division of Hospital Medicine
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Luke MJ, Vasan A. Addressing Food Insecurity Among Hospitalized Children: Upstream and Downstream Approaches. Hosp Pediatr 2024; 14:e314-e316. [PMID: 38881355 PMCID: PMC11208880 DOI: 10.1542/hpeds.2024-007807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 03/21/2024] [Accepted: 03/28/2024] [Indexed: 06/18/2024]
Affiliation(s)
- Michael J. Luke
- Clinical Futures, and PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, and Leonard David Institute of Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Aditi Vasan
- Clinical Futures, and PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, and Leonard David Institute of Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Smith M, Tepe KA, Sauers-Ford H, Atarama D, Gilliam M, Unaka N, Beck AF, Shah AN, Schondelmeyer AC, Auger KA. Addressing food insecurity in the inpatient setting: Results of a postdischarge pilot study. J Hosp Med 2024. [PMID: 38837594 DOI: 10.1002/jhm.13421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 05/06/2024] [Accepted: 05/14/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND AND OBJECTIVES With a growing interest in screening for food insecurity (FI) during pediatric hospitalization, there is a parallel need to develop interventions. With input from caregivers experiencing FI, we sought to identify interventions to assist with short-term FI after discharge and evaluate their feasibility, acceptability, and appropriateness. METHODS We first employed qualitative methods to identify potential interventions. Next, we conducted a pilot study of selected interventions for families experiencing FI. Seven days postdischarge, caregivers rated the intervention's feasibility, acceptability, and appropriateness. We also assessed for ongoing FI. We summarized the median and proportion of "completely agree" responses to feasibility, acceptability, and appropriateness questions, and we compared in-hospital and postdischarge FI using McNemar's test. RESULTS In the qualitative stage, 14 caregivers prioritized three interventions: grocery store gift cards, grocery delivery/pick-up, and frozen meals. In the pilot study, 53 caregivers (25% of those screened) endorsed FI during their child's hospitalization and received one or more of the interventions. Every caregiver selected the grocery gift card option; 37 families (69.8%) also received frozen meals. Seven days after discharge, most caregivers rated the intervention as "completely" feasible (76%), acceptable (90%), and appropriate (88%). There was a significant decrease in caregivers who reported FI after discharge compared to during the hospitalization (p < .001). CONCLUSIONS This study demonstrates the feasibility, acceptability, and appropriateness of inpatient interventions to address FI, particularly at the time of pediatric hospital discharge and transition home. Randomized trials are needed to further evaluate the efficacy of interventions employed during hospitalization.
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Affiliation(s)
- Megan Smith
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kerry A Tepe
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Hadley Sauers-Ford
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Denise Atarama
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Monique Gilliam
- Division of Hospital Medicine, Parent Partner Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ndidi Unaka
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Andrew F Beck
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Anita N Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Amanda C Schondelmeyer
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Katherine A Auger
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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7
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Hersh C, Warren M, Horick N, Sorbo J, Callans K, Fracchia S, Radano M, Hartnick C. Development and validation of the caregiver Burden from infant home NGT care instrument. Int J Pediatr Otorhinolaryngol 2024; 181:111986. [PMID: 38805934 DOI: 10.1016/j.ijporl.2024.111986] [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: 04/02/2024] [Revised: 05/10/2024] [Accepted: 05/17/2024] [Indexed: 05/30/2024]
Abstract
OBJECTIVE To design and validate an age and condition-specific health status instrument to best reflect the parental experience caring for these children with complex needs and home Nasogastric Tube (NGT) placement. STUDY DESIGN Combined Qualitative and Quantitative design, testing and implementation for item production and reduction, followed by formal validation by evaluating validity, reliability, and establishing a clinically meaningful change score. SETTINGS Tertiary care, multi-disciplinary aerodigestive center. PARTICIPANTS All caregivers whose infant met criteria for eligibility for discharge home from the NICU or Special Care Nursery (SCN) with NGT in place were offered inclusion in this group. Intervention/Exposure: Structured qualitative interviews of these caregivers to explore and define these concepts and domains, to item generate and then reduce, and then psychometric analyses. METHODS Structured, moderated qualitative interviews with parents/caregivers of children who have undergone home NGT care of their children for item creation, design, and then reduction. Reliability was assessed by Cronbach alpha analysis. Construct validity and clinically meaningful change score was assessed using various query methods. MAIN OUTCOME MEASURES Cronbach's alpha to assess reliability, a priori hypotheses validity analyses, and minimally important clinical difference calculation. RESULTS Scaled scores of this condition specific instrument ranged from 14 to 74 where higher scores indicate better QOL related to managing the NGT. Cronbach's alpha with all 14 items was 0.93. Validity was assessed by a self-assessment question to discriminate between change (95% CI: 8.5-14.1; p < 0.0001) as well as by other comparators to identify the instrument's ability to discriminate among populations where parents felt a difference in experience. The minimally important difference was calculated at 18 points. CONCLUSION This represents the initial validation of the first condition and age-specific health status instrument to assess parent experience of caring for infants requiring a home NGT for dysphagia.
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Affiliation(s)
- Cheryl Hersh
- Massachusetts General Hospital for Children, Boston, MA, USA
| | | | - Nora Horick
- Brigham and Women's Hospital, Boston, MA, USA
| | - Jessica Sorbo
- Massachusetts General Hospital for Children, Boston, MA, USA
| | | | | | - Marcela Radano
- Massachusetts General Hospital for Children, Boston, MA, USA
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Molloy MJ, Morris C, Caldwell A, LaChance D, Woeste L, Lenk MA, Brady PW, Schondelmeyer AC. Increasing the Use of Enteral Antibiotics in Hospitalized Children With Uncomplicated Infections. Pediatrics 2024; 153:e2023062427. [PMID: 38712446 DOI: 10.1542/peds.2023-062427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND Route of administration is an important component of antimicrobial stewardship. Early transition from intravenous to enteral antibiotics in hospitalized children is associated with fewer catheter-related adverse events, as well as decreased costs and length of stay. Our aim was to increase the percentage of enteral antibiotic doses for hospital medicine patients with uncomplicated common bacterial infections (community-acquired pneumonia, skin and soft tissue infection, urinary tract infection, neck infection) from 50% to 80% in 6 months. METHODS We formed a multidisciplinary team to evaluate key drivers and design plan-do-study-act cycles. Interventions included provider education, structured discussion at existing team huddles, and pocket-sized printed information. Our primary measure was the percentage of antibiotic doses given enterally to patients receiving other enteral medications. Secondary measures included antibiotic cost, number of peripheral intravenous catheters, length of stay, and 7-day readmission. We used statistical process control charts to track our measures. RESULTS Over a 6-month baseline period and 12 months of improvement work, we observed 3183 antibiotic doses (888 in the baseline period, 2295 doses during improvement work). We observed an increase in the percentage of antibiotic doses given enterally per week for eligible patients from 50% to 67%. We observed decreased antibiotic costs and fewer peripheral intravenous catheters per encounter after the interventions. There was no change in length of stay or readmissions. CONCLUSIONS We observed increased enteral antibiotic doses for children hospitalized with common bacterial infections. Interventions targeting culture change and communication were associated with sustained improvement.
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Affiliation(s)
- Matthew J Molloy
- Divisions of Hospital Medicine
- Biomedical Informatics
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Calli Morris
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alicia Caldwell
- Divisions of Hospital Medicine
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Dennis LaChance
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Laura Woeste
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mary Anne Lenk
- James M. Anderson Center for Health System Excellence, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Patrick W Brady
- Divisions of Hospital Medicine
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health System Excellence, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Amanda C Schondelmeyer
- Divisions of Hospital Medicine
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health System Excellence, Cincinnati Children's Hospital, Cincinnati, Ohio
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9
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Nadarajah A, Lazor T, Meserve A, Buchanan F, Birken C, van den Heuvel M. Experiences of Financial Stress and Supports in Caregivers During Pediatric Hospital Admission. Hosp Pediatr 2024; 14:233-241. [PMID: 38495016 DOI: 10.1542/hpeds.2023-007453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND AND OBJECTIVE In Canada and the United States, ∼1 in 5 children live in poverty, contributing to poor health outcomes. Families with children with chronic illness may experience additional financial stress related to hospitalization. This study aimed to capture experiences of financial needs and supports among caregivers with a child admitted to a tertiary care pediatric hospital to inform hospital-based financial services to reduce financial stress in families. METHODS We recruited caregivers of children admitted to the general inpatient ward of an academic pediatric center using purposive sampling with no exclusion criteria. Individual, semistructured, in-depth interviews with participants were conducted. Data collected included socio-demographics, financial needs, and experiences with financial supports. Interviews were audio-recorded, transcribed verbatim, coded, and analyzed on NVivo software using a modified-grounded theory approach and summative content analysis. RESULTS Fifteen caregivers of diverse backgrounds were interviewed, including non-English speakers (n = 4). Three themes and associated subthemes (in parentheses) were identified: (1) financial stress expressed by participants (acute admission-related and chronic financial stress), (2) challenges associated with accessing and utilizing financial supports (caregiver factors, systemic hospital factors, and systemic government factors), and (3) ideas for financial services at the pediatric hospital (services that will provide acute- and chronic financial assistance including education about financial supports and benefits). CONCLUSIONS Our study highlighted acute and chronic financial needs as well as challenges in accessing financial support. Participants were interested in the healthcare system gaining a comprehensive understanding of their financial circumstances and accessing financial services in a hospital setting.
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Affiliation(s)
| | - Tanya Lazor
- Department of Paediatrics, University of Toronto, Toronto, Canada
- Department of Social Work
| | | | | | - Catherine Birken
- Department of Paediatrics, University of Toronto, Toronto, Canada
- Division of Paediatrics
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada
| | - Meta van den Heuvel
- Department of Paediatrics, University of Toronto, Toronto, Canada
- Division of Paediatrics
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada
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Gilley SP, Ta A, Pryor W, Roper B, Erickson M, Fenton LZ, Tchou MJ, Cotter JM, Moore JM. What Do We C in Children With Scurvy? A Case Series Focused on Musculoskeletal Symptoms. Hosp Pediatr 2024; 14:e98-e103. [PMID: 38234212 PMCID: PMC11316608 DOI: 10.1542/hpeds.2023-007336] [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] [Indexed: 01/19/2024]
Abstract
OBJECTIVES Vitamin C deficiency in children commonly presents with musculoskeletal symptoms such as gait disturbance, refusal to bear weight, and bone or joint pain. We aimed to identify features that could facilitate early diagnosis of scurvy and estimate the cost of care for patients with musculoskeletal symptoms related to scurvy. METHODS We conducted a retrospective chart review of patients at a single site with diagnostic codes for vitamin C deficiency, ascorbic acid deficiency, or scurvy. Medical records were reviewed to identify characteristics including presenting symptoms, medical history, and diagnostic workup. The Pediatric Health Information System was used to estimate diagnostic and hospitalization costs for each patient. RESULTS We identified 47 patients with a diagnosis of scurvy, 49% of whom had a neurodevelopmental disorder. Sixteen of the 47 had musculoskeletal symptoms and were the focus of the cost analysis. Three of the 16 had moderate or severe malnutrition, and 3 had overweight or obesity. Six patients presented to an emergency department for care, 11 were managed inpatient, and 3 required critical care. Diagnostic workups included MRI, computed tomography, echocardiogram, endoscopy, lumbar puncture, and/or EEG. Across all patients evaluated, the cost of emergency department utilization, imaging studies, diagnostic procedures, and hospitalization totaled $470 144 (median $14 137 per patient). CONCLUSIONS Children across the BMI spectrum, particularly those with neurodevelopmental disorders, can develop vitamin C deficiency. Increased awareness of scurvy and its signs and symptoms, particularly musculoskeletal manifestations, may reduce severe disease, limit adverse effects related to unnecessary tests/treatments, and facilitate high-value care.
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Affiliation(s)
- Stephanie P. Gilley
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, Colorado
| | - Allison Ta
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, Colorado
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, University of Cincinnati School of Medicine, Cincinnati, Ohio
- Digestive Health Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - William Pryor
- Department of Radiology, University of Colorado School of Medicine, Aurora, Colorado
- Department of Radiology, University of North Carolina, Chapel Hill, North Carolina
| | - Brennan Roper
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
- Department of Orthopedics, University of Texas, Houston, Houston, Texas
| | - Mark Erickson
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
| | - Laura Z. Fenton
- Department of Radiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Michael J. Tchou
- Section of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Jillian M. Cotter
- Section of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Jaime M. Moore
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, Colorado
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11
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Demetriou EA, Boulton KA, Thapa R, Sun C, Gilroy J, Bowden MR, Guastella A. Burden of paediatric hospitalisations to the health care system, child and family: a systematic review of Australian studies (1990-2022). THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 40:100878. [PMID: 38116503 PMCID: PMC10730319 DOI: 10.1016/j.lanwpc.2023.100878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 07/15/2023] [Accepted: 08/03/2023] [Indexed: 12/21/2023]
Abstract
Background Paediatric hospitalisations represent a significant cost to the health system and cause significant burden to children and their families. Understanding trends in hospitalisation costs can assist with health planning and support strategies across stakeholders. The objective of this systematic review is to examine the trends in costs and burden of paediatric hospitalisations in Australia to help inform policy and promote the well-being of children and their families. Methods Electronic data sources (Embase, Medline, Web of Science, PSYCH-Info, CINAHL and Scopus) were searched from 1990 until December 2022. Any quantitative or qualitative studies conducted in Australian tertiary hospitals were included in the review. Eligible studies were those that included paediatric (<18 years) hospitalisations and reported on economic and/or non-economic costs for the child, family unit and/or health system. Study quality and risk of bias for each study were assessed with the Joanna Briggs Critical Appraisal Tools. We present a summary of the findings of the hospitalisation burden across major diagnostic admission categories and for the child and family unit. The systematic review was registered with Prospero (ID: CRD42021276202). Findings The review summarises a total of 88 studies published between 1990 and December 2022. Overall, the studies identified that paediatric hospitalisations incur significant financial costs, which have not shown significant reductions over time. In-patient direct hospital costs varied depending on the type of treatment and diagnostic condition. The costs per-case were found to range from just below AUD$2000 to AUD$20,000 or more. The financial burden on the family unit included loss of productivity, transport and travel costs. Some studies reported estimates of these costs upward of AUD$500 per day. Studies evaluating 'hospital in the home' options identified significant benefits in reducing hospitalisations and costs without compromising care. Interpretation Increasing focus on alternative models of care may help alleviate the significant costs associated with paediatric hospitalisation. Funding This research was supported by Hospitals United for Sick Kids (formerly Curing Homesickness).
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Affiliation(s)
- Eleni Andrea Demetriou
- Brain and Mind Centre, Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, 2050, Australia
| | - Kelsie Ann Boulton
- Brain and Mind Centre, Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, 2050, Australia
| | - Rinku Thapa
- Brain and Mind Centre, Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, 2050, Australia
| | - Carter Sun
- Brain and Mind Centre, Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, 2050, Australia
| | | | - Michael Russell Bowden
- Mental Health Branch, NSW Health, Sydney Children's Hospitals Network, Discipline of Psychiatry, Westmead Clinical School and The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Australia
| | - Adam Guastella
- Brain and Mind Centre, Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, 2050, Australia
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Warniment A, Sauers-Ford H, Brady PW, Beck AF, Callahan SR, Giambra BK, Herzog D, Huang B, Loechtenfeldt A, Loechtenfeldt L, Miller CL, Perez E, Riddle SW, Shah SS, Shepard M, Sucharew HJ, Tegtmeyer K, Thomson JE, Auger KA. Garnering effective telehealth to help optimize multidisciplinary team engagement (GET2HOME) for children with medical complexity: Protocol for a pragmatic randomized control trial. J Hosp Med 2023; 18:877-887. [PMID: 37602537 DOI: 10.1002/jhm.13192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Children and young adults with medical complexity (CMC) experience high rates of healthcare reutilization following hospital discharge. Prior studies have identified common hospital-to-home transition failures that may increase the risk for reutilization, including medication, technology and equipment issues, financial concerns, and confusion about which providers can help with posthospitalization needs. Few interventions have been developed and evaluated for CMC during this transition period. OBJECTIVE We will compare the effectiveness of the garnering effective telehealth 2 help optimize multidisciplinary team engagement (GET2HOME) transition bundle intervention to the standard hospital-based care coordination discharge process by assessing healthcare reutilization and patient- and family-centered outcomes. DESIGNS, SETTINGS, AND PARTICIPANTS We will conduct a pragmatic 2-arm randomized controlled trial (RCT) comparing the GET2HOME bundle intervention to the standard hospital-based care discharge process on CMC hospitalized and discharged from hospital medicine at two sites of our pediatric medical center between November 2022 and February 2025. CMC of any age will be identified as having complex chronic disease using the Pediatric Medical Complexity Algorithm tool. We will exclude CMC who live independently, live in skilled nursing facilities, are in custody of the county, or are hospitalized for suicidal ideation or end-of-life care. INTERVENTION We will randomize participants to the bundle intervention or standard hospital-based care coordination discharge process. The bundle intervention includes (1) predischarge telehealth huddle with inpatient providers, outpatient providers, patients, and their families; (2) care management discharge task tracker; and (3) postdischarge telehealth huddle with similar participants within 7 days of discharge. As part of the pragmatic design, families will choose if they want to complete the postdischarge huddle. The standard hospital-based discharge process includes a pharmacist, social worker, and care management support when consulted by the inpatient team but does not include huddles between providers and families. MAIN OUTCOME AND MEASURES Primary outcome will be 30-day urgent healthcare reutilization (unplanned readmission, emergency department, and urgent care visits). Secondary outcomes include 7-day urgent healthcare reutilization, patient- and family-reported transition quality, quality of life, and time to return to baseline using electronic health record and surveys at 7, 30, 60, and 90 days following discharge. We will also evaluate heterogeneity of treatment effect for the intervention across levels of financial strain and for CMC with high-intensity neurologic impairment. The primary analysis will follow the intention-to-treat principle with logistic regression used to study reutilization outcomes and generalized linear mixed modeling to study repeated measures of patient- and family-reported outcomes over time. RESULTS This pragmatic RCT is designed to evaluate the effectiveness of enhanced discharge transition support, including telehealth huddles and a care management discharge tool, for CMC and their families. Enrollment began in November 2022 and is projected to complete in February 2025. Primary analysis completion is anticipated in July 2025 with reporting of results following.
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Affiliation(s)
- Amanda Warniment
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Hadley Sauers-Ford
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Patrick W Brady
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Andrew F Beck
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Cincinnati Children's HealthVine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Michael Fisher Child Health Equity Center Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Scott R Callahan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Barbara K Giambra
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- College of Nursing, University of Cincinnati, Cincinnati, Ohio, USA
| | - Diane Herzog
- Department of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Bin Huang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Allison Loechtenfeldt
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Chelsey L Miller
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Combined Pediatrics/Medicine House Staff, Cincinnati Children's Hospital Medical Center and University of Cincinnati Hospital, Cincinnati, Ohio, USA
| | | | - Sarah W Riddle
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Heidi J Sucharew
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ken Tegtmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Center for Telehealth, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Joanna E Thomson
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Katherine A Auger
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Hussain T, van den Berg S, Ziesemer KA, Markhorst DG, Vijverberg SJH, Kapitein B. The influence of disparities on intensive care outcomes in children with respiratory diseases: A systematic review. Pediatr Pulmonol 2023. [PMID: 37560882 DOI: 10.1002/ppul.26629] [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: 01/14/2023] [Revised: 07/18/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023]
Abstract
CONTEXT The negative effects of socioeconomic, environmental and ethnic inequalities on childhood respiratory diseases are known in the development of persistent asthma and can result in adverse outcomes. However, little is known about the effects of these disparities on pediatric intensive care unit (PICU) outcomes in respiratory diseases. OBJECTIVE The purpose of this systematic review is to evaluate the literature on disparities in socioeconomic, environmental and ethnic determinants and PICU outcomes. We hypothesize that these disparities negatively influence the outcomes of children's respiratory diseases at the PICU. METHODS A literature search (in PubMed, Embase.com and Web of Science Core Collection) was performed up to September 30, 2022. Two authors extracted the data and independently evaluated the risk of bias with appropriate assessment methods. Articles were included if the patients were below 18 years of age (excluding neonatal intensive care unit admissions), they concerned respiratory diseases and incorporated socioeconomic, ethnic or environmental disparities. RESULTS Eight thousand seven hundred fourty-six references were reviewed, and 15 articles were included; seven articles on the effect of socioeconomic status, five articles on ethnicity, one on the effect of sex and lastly two on environmental factors. All articles but one showed an unfavorable outcome at the PICU. CONCLUSION Disparities in socioeconomic (such as a low-income household, public health insurance), ethnic and environmental factors (such as exposure to tobacco smoke and diet) have been assessed as risk factors for the severity of children's respiratory diseases and can negatively influence the outcomes of these children admitted and treated at the PICU.
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Affiliation(s)
- Tahira Hussain
- Pediatric intensive care unit, Emma Children's Hospital, Amsterdam UMC, Amsterdam, The Netherlands
| | - Sarah van den Berg
- Pediatric intensive care unit, Emma Children's Hospital, Amsterdam UMC, Amsterdam, The Netherlands
| | - Kirsten A Ziesemer
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Dick G Markhorst
- Pediatric intensive care unit, Emma Children's Hospital, Amsterdam UMC, Amsterdam, The Netherlands
| | - Susanne J H Vijverberg
- Department of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Berber Kapitein
- Pediatric intensive care unit, Emma Children's Hospital, Amsterdam UMC, Amsterdam, The Netherlands
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14
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Vari D, Temple J, Tadeo D, Kurek N, Zang H, Evers PD, Anderson JB, Spar DS, Czosek RJ. Transesophageal pacing studies reduce readmission but prolong initial admission in infants with supraventricular tachycardia: A cost-comparison analysis. Heart Rhythm O2 2023; 4:359-366. [PMID: 37361613 PMCID: PMC10288021 DOI: 10.1016/j.hroo.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
Background Supraventricular tachycardia (SVT) is a common arrhythmia. Infants with SVT are often admitted to initiate antiarrhythmics. Transesophageal pacing (TEP) studies can be used to guide therapy prior to discharge. Objective The objective of this study was to investigate the impact of TEP studies on length of stay (LOS), readmission, and cost in infants with SVT. Methods This was a 2-site retrospective review of infants with SVT. One site (Center TEPS) utilized TEP studies in all patients. The other (Center NOTEP) did not. Patients with structural heart disease, patients with gestational age <34 weeks, and patients diagnosed after 6 months were excluded. At Center TEPS, repeat TEP studies were performed after titration of medication until SVT was not inducible. Primary endpoints were LOS and readmission for breakthrough SVT within 31 days of discharge. Hospital reimbursement data were utilized for cost-effectiveness analysis. Results The cohort included 131 patients, 59 in Center TEPS and 72 in Center NOTEP. One patient was readmitted in Center TEPS vs 17 in Center NOTEP (1.6% vs 23.6%; P ≤ .001). Median LOS was longer for Center TEPS at 118.0 (interquartile range [IQR] 74.0-189.5) hours vs Center NOTEP at 66.9 (IQR 45.5-118.3) hours (P = .001). Twenty-one patients had multiple TEP studies. Median length of readmission for Center NOTEP was 65 (IQR 41-101) hours. Including readmission costs, utilization of TEP studies resulted in a probability-weighted cost of $45,531 per patient compared with $31,087 per patient without TEP studies. Conclusion Utilization of TEP studies was associated with decreased readmission rates but longer LOS and greater cost compared with SVT management without TEP studies.
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Affiliation(s)
- Daniel Vari
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Joel Temple
- Nemours Cardiac Center, Nemours Children’s Health, Wilmington, Delaware
| | - Danilo Tadeo
- Nemours Cardiac Center, Nemours Children’s Health, Wilmington, Delaware
| | - Nicholas Kurek
- Division of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Huaiyu Zang
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Patrick D. Evers
- Division of Pediatric Cardiology, Oregon Health and Sciences University, Portland, Oregon
| | - Jeffrey B. Anderson
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Division of Cardiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David S. Spar
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Division of Cardiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Richard J. Czosek
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Division of Cardiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
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15
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Lewis KN, Tilford JM, Goudie A, Beavers J, Casey PH, McKelvey LM. Cost-benefit analysis of home visiting to reduce infant mortality among preterm infants. J Pediatr Nurs 2023:S0882-5963(23)00111-2. [PMID: 37183165 DOI: 10.1016/j.pedn.2023.05.003] [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: 02/21/2023] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/16/2023]
Abstract
PURPOSE The Following Baby Back Home (FBBH) visiting program, which is provided by nurse and social worker teams, supports families of low-birthweight preterm infants after discharge from a neonatal intensive care unit. Enrollment in the FBBH program has been documented to reduce the likelihood of infant death. In this study, we conducted a cost-benefit analysis of the FBBH program. DESIGN AND METHODS Infants enrolled in the FBBH program (N = 416) were identified through administrative records. Infants in the FBBH program were propensity score matched with comparison infants to estimate the difference in healthcare costs in the first year of life. RESULTS Infants enrolled in the FBBH program incurred similar medical care costs compared to a comparison group. Avoided deaths, program costs, healthcare costs resulted in net economic benefits of the FBBH program to avoid infant death estimate at $83,020, cost per life saved at $3080, and benefit-to-cost ratio at 27.95. CONCLUSIONS The FBBH program's net economic benefits from avoided deaths suggest a substantial return on investment of resources, yielding benefits in excess of program and healthcare costs. PRACTICE IMPLICATIONS It is economically beneficial to provide home visiting services to families of low-birthweight babies by a team comprised of a registered nurse and social worker.
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Affiliation(s)
- Kanna N Lewis
- Department of Family and Preventive Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America.
| | - J Mick Tilford
- Department of Health Policy and Management, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Anthony Goudie
- Department of Health Policy and Management, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America; Arkansas Center for Health Improvement, Little Rock, AR, United States of America
| | - Jared Beavers
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Patrick H Casey
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Lorraine M McKelvey
- Department of Family and Preventive Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
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16
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Carlton EF, Becker NV, Moniz MH, Scott JW, Prescott HC, Chua KP. Out-of-Pocket Spending for Non-Birth-Related Hospitalizations of Privately Insured US Children, 2017 to 2019. JAMA Pediatr 2023; 177:516-525. [PMID: 36972040 PMCID: PMC10043803 DOI: 10.1001/jamapediatrics.2023.0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/13/2022] [Indexed: 03/29/2023]
Abstract
Importance Privately insured US children account for 40% of non-birth-related pediatric hospitalizations. However, there are no national data on the magnitude or correlates of out-of-pocket spending for these hospitalizations. Objective To estimate out-of-pocket spending for non-birth-related hospitalizations among privately insured children and identify factors associated with this spending. Design, Setting, and Participants This study is a cross-sectional analysis of the IBM MarketScan Commercial Database, which reports claims from 25 to 27 million privately insured enrollees annually. In the primary analysis, all non-birth-related hospitalizations of children 18 years and younger from 2017 through 2019 were included. In a secondary analysis focused on insurance benefit design, hospitalizations that could be linked to the IBM MarketScan Benefit Plan Design Database and were covered by plans with a family deductible and inpatient coinsurance requirements were analyzed. Main Outcomes and Measures In the primary analysis, factors associated with out-of-pocket spending per hospitalization (sum of deductibles, coinsurance, and copayments) were identified using a generalized linear model. In the secondary analysis, variation in out-of-pocket spending was assessed by level of deductible and inpatient coinsurance requirements. Results Among 183 780 hospitalizations in the primary analysis, 93 186 (50.7%) were for female children, and the median (IQR) age of hospitalized children was 12 (4-16) years. A total of 145 108 hospitalizations (79.0%) were for children with a chronic condition and 44 282 (24.1%) were covered by a high-deductible health plan. Mean (SD) total spending per hospitalization was $28 425 ($74 715). Mean (SD) and median (IQR) out-of-pocket spending per hospitalization were $1313 ($1734) and $656 ($0-$2011), respectively. Out-of-pocket spending exceeded $3000 for 25 700 hospitalizations (14.0%). Factors associated with higher out-of-pocket spending included hospitalization in quarter 1 compared with quarter 4 (average marginal effect [AME], $637; 99% CI, $609-$665) and lack of chronic conditions compared with having a complex chronic condition (AME, $732; 99% CI, $696-$767). The secondary analysis included 72 165 hospitalizations. Among hospitalizations covered by the least generous plans (deductible of $3000 or more and coinsurance of 20% or more) and most generous plans (deductible less than $1000 and coinsurance of 1% to 19%), mean (SD) out-of-pocket spending was $1974 ($1999) and $826 ($798), respectively (AME, $1123; 99% CI, $1069-$1179). Conclusions and Relevance In this cross-sectional study, out-of-pocket spending for non-birth-related pediatric hospitalizations were substantial, especially when they occurred early in the year, involved children without chronic conditions, or were covered by plans with high cost-sharing requirements.
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Affiliation(s)
- Erin F. Carlton
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan Medical School, Ann Arbor
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Nora V. Becker
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of General Medicine, University of Michigan Medical School, Ann Arbor
| | - Michelle H. Moniz
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor
| | - John W. Scott
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Hallie C. Prescott
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan Medical School, Ann Arbor
- Veterans Affairs Center for Clinical Management Research, Health Sciences Research and Development Center of Innovation, Ann Arbor, Michigan
| | - Kao-Ping Chua
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
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17
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Phelps KB, Gebremariam A, Andrist E, Barbaro RP, Freed GL, Carlton EF. Children with severe sepsis: relationship between community level income and morbidity and mortality. Pediatr Res 2023:10.1038/s41390-023-02500-w. [PMID: 36804502 DOI: 10.1038/s41390-023-02500-w] [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: 08/30/2022] [Revised: 01/05/2023] [Accepted: 01/13/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Health disparities surrounding pediatric severe sepsis outcomes remains unclear. We aimed to measure the relationship between indicators of socioeconomic status and mortality, hospital length of stay (LOS), and readmission rates among children hospitalized with severe sepsis. METHODS Children 0-18 years old, hospitalized with severe sepsis in the Nationwide Readmissions Database (2016-2018) were included. The primary exposure was median household income by ZIP Code of residence, divided into quartiles. RESULTS We identified 15,214 index pediatric severe sepsis hospitalizations. There was no difference in hospital mortality rate or readmission rate across income quartiles. Among survivors, patients in Q1 (lowest income) had a 2 day longer LOS compared to those in Q4 (Median 10 days [IQR 4-21] vs 8 days [IQR 4-18]; p < 0.0001). However, there was no difference after adjusting for multiple covariates. CONCLUSIONS Children living in Q1 had a 2 day longer LOS versus their peers in Q4. This was not significant on multivariable analysis, suggesting income quartile is not driving this difference. As pediatric severe sepsis remains an important source of morbidity and mortality in critically ill children, more sensitive metrics of socioeconomic status may better elucidate any disparities. IMPACT Children with severe sepsis living in the lowest income ZIP Codes may have longer hospital stays compared to peers in higher income communities. More precise metrics of socioeconomic status are needed to better understand health disparities in pediatric severe sepsis.
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Affiliation(s)
- Kayla B Phelps
- Divison of Pediatric Critical Care Medicine, Louisiana State University School of Medicine, New Orleans, LA, USA.
| | - Acham Gebremariam
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Erica Andrist
- Division of Pediatric Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Ryan P Barbaro
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.,Division of Pediatric Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Gary L Freed
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.,Division of General Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Erin F Carlton
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.,Division of Pediatric Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
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18
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The understated issue of caregiver anxiety for pediatric surgical hospital admissions: opening the blindfolds. Pediatr Surg Int 2023; 39:100. [PMID: 36735080 DOI: 10.1007/s00383-023-05380-7] [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] [Accepted: 01/17/2023] [Indexed: 02/04/2023]
Abstract
KEY MESSAGE Hospitalization is a nerve-wrecking experience for patients and their families (Lam et al. in Int J Nurs Stud 43:535-545, 2006). The financial burden of hospitalization is the prime perpetrator, however, multiple other factors also contribute significantly to the underlying problem which can be eliminated by efforts of the doctors and other healthcare workers and by modifying the hospital policies (Bassett et al. in J Hosp Med 15:652-658, 2020). We can reduce the number of outpatient visits and switch to telemedicine for rescheduling the cases. The pre-anaesthetic clearance and all the relevant investigations can be done on a single OPD visit thereby reducing the requirement of repeated commutes to the hospital. The free of charge category of the hospital can be extended to the patient requiring prolonged hospital stay or for solid tumor patients who require repeated hospital admissions for chemotherapy. Association with child welfare Non-government organizations (NGO's) can also solve major monetary issues for parents of patients suffering from complex congenital anomalies and solid tumors. The pre-operative NPO period can be shortened to 2-4 h, antibiotic use can be completely avoided or minimized in clean elective cases, children living in the same city requiring dressing/catheter removal after a few days (e.g. hypospadias, posterior sagittal anorectoplasty) can be discharged and called for a OPD visit after 5-7 days if the parents are willing to take care of the child at home. Patients undergoing minor elective surgeries can be followed up on telemedicine visits only. Parents of patients suffering from complex congenital anomalies should be referred to a clinical psychologist and receive periodic counseling sessions. A child psychologist should also be included in the management of cases which have social stigma attached as bladder exstrophy, anorectal malformations, spina bifida requiring lifelong follow-up and bowel washes or repeated clean intermittent catheterisation. Anxiety assessment questionnaires must be incorporated in the management of chronic patients and high-risk parents must be identified (Tiedeman in J Pediatr Nurs 12:110-119, 1997). We hereby propose adoption of family centric approach during the management of a patient as this may minimize the overall burden of the hospitalization of the family. BACKGROUND Hospital admission of a child leads to a myriad responses in the parents. Thus, we conducted a hospital-based cross-sectional study to determine the prevalence of anxiety and depression among the primary caregivers of hospitalized children and the factors causing it. METHODS Parents of 228 children admitted in the pediatric surgery ward at a tertiary care hospital were interviewed using the HADS-A and Hamilton Anxiety Questionnaire to assess the prevalence of anxiety and depression during hospital admission. They were also subjected to a questionnaire comprising of 52 questions spread over 5 segments-demographic details, monetary burden, effect on siblings and other family members, practical problems faced, and surgery-specific concerns. FINDINGS Thirty percent of the parents had severe anxiety and 20% developed depression due to the hospitalization of their child. We tested the association of this depression and anxiety against 56 variables in this study. Exorbitant loan amounts (ra - 0.449, rd- 0.557), repeated commute to the hospital (ra - 0.274, rd - 0.231), monetary burden (ra - 0.193, rd - 0.186), repetitive sampling (ra - 0.248, rd - 0.203), prolonged absence from work (ra - 0.440, rd - 0.424) were found to be the chief perpetrators of this anxiety and depression. INTERPRETATION The burden of anxiety and depression in the primary caregivers of pediatric surgical patients is enormous. Identification of the implicating factors is essential. Simple reforms such as reduction in the number of OPD visits, extension of free of charge category, association with non-governmental organizations and involvement of a clinical psychologist can significantly meliorate the hospital journey of both the patients and their parents. (rd-correlation coefficient of for depression, ra-correlation coefficient of for anxiety).
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19
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Bradley SV, Hall M, Rajan D, Johnston J, Ondrasek E, Chen C, Mittal V. Sustaining Long-Term Asthma Outcomes at a Community and Tertiary Care Pediatric Hospital. Hosp Pediatr 2023; 13:130-138. [PMID: 36632719 DOI: 10.1542/hpeds.2021-006224] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Implementing asthma Clinical Practice Guidelines (CPG) have been shown to improve length of stay (LOS) and readmission rates on a short-term basis at both tertiary care and community hospital settings. Whether these outcomes are sustained long term is not known. The goal of this study was to measure the long-term impact of CPG implementation at both tertiary and community sites in 1 hospital system. METHODS A retrospective study was conducted using the Pediatric Health Information System database. LOS and 7- and 14-day emergency department (ED) revisit and readmission rates from 2009 to 2020 were compared pre and post implementation of asthma CPG in 2012 at both sites. Implementation involved electronic order sets, early metered dose inhaler introduction, and empowering respiratory therapists to wean per the bronchodilator weaning protocol. Interrupted time series and statistical process control charts were used to assess CPG impact. RESULTS Implementation of asthma CPG was associated with significant reductions in the variability of LOS without impacting ED revisit or readmission rates at both the tertiary and community sites. Secular trends in the interrupted time series did not demonstrate significant impact of CPG on LOS. However, the overall trend toward decreased LOS that started before CPG implementation was sustained for 7 years after CPG implementation. CONCLUSIONS Early metered dose inhaler introduction, respiratory therapist-driven bronchodilator weaning, and electronic order sets at both the community and tertiary care site led to a significant reduction in the variation of LOS, without impacting ED revisit or readmission rate.
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Affiliation(s)
- Sarah V Bradley
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Pediatrics, Children's Health System, Dallas, Texas
| | - Matt Hall
- Informatics, Children's Hospital Association, Lenexa, Kansas
| | - Divya Rajan
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Pediatrics, Children's Health System, Dallas, Texas
| | - Jennifer Johnston
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Pediatrics, Children's Health System, Dallas, Texas
| | - Erika Ondrasek
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Pediatrics, Children's Health System, Dallas, Texas
| | - Clifford Chen
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Pediatrics, Children's Health System, Dallas, Texas
| | - Vineeta Mittal
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Pediatrics, Children's Health System, Dallas, Texas
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20
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Lin K, White MJ, Holliday KM, Parnell LS, Parente VM. Protective and Unequal? Caregiver Presence During Pediatric Hospitalizations. Hosp Pediatr 2023; 13:e1-e5. [PMID: 36482776 PMCID: PMC9881426 DOI: 10.1542/hpeds.2022-006590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Describe the association between caregiver presence on hospital day 1 and outcomes related to readmissions, pain, and adverse events (AE). METHODS Caregiver presence during general pediatrics rounds on hospital day 1 was recorded, along with demographic data and clinical outcomes via chart review. AE data were obtained from the safety reporting system. χ2 tests compared demographic characteristics between present and absent caregivers. Background elimination determined significant predictors of caregiver presence and their association with outcomes. RESULTS A total of 324 families were assessed (34.9% non-Hispanic white, 41.4% Black, 17% Hispanic or Latinx, 6.8% other race or ethnicity). Adolescents (aged ≥14 years) had increased odds of not having a caregiver present compared with 6- to 13-year-olds (36.2% vs 10%; adjusted odds ratio [aOR] 5.11 [95% confidence interval (CI) 1.88-13.87]). Publicly insured children were more likely to not have a caregiver present versus privately insured children (25.1% vs 12.4%; aOR 2.38 [95% CI 1.19-4.73]). Compared with having a caregiver present, children without caregivers were more likely to be readmitted at 7 days (aOR 3.6 [95% CI 1.0-12.2]), receive opiates for moderate/severe pain control (aOR 11.5 [95% CI 1.7-75.7]), and have an AE reported (aOR 4.0 [95% CI 1.0-15.1]). CONCLUSIONS Adolescents and children with public insurance were less likely to have a caregiver present. Not having a caregiver present was associated with increased readmission, opiate prescription, and AE reporting. Further research is needed to delineate whether associations with clinical outcomes reflect differences in quality of care and decrease barriers to caregiver presence.
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Affiliation(s)
- Karen Lin
- Department of Graduate Medical Education, Duke University Health System, Durham, North Carolina
| | - Michelle J. White
- Department of Pediatrics, Duke University Health System, Durham, North Carolina
| | - Katelyn M. Holliday
- Family Medicine and Community Health at Duke University Health System, Durham, North Carolina
| | - Lisa S. Parnell
- Department of Pediatrics, Duke University Health System, Durham, North Carolina
| | - Victoria M. Parente
- Department of Pediatrics, Duke University Health System, Durham, North Carolina
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21
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Improving pediatric idiopathic intracranial hypertension care: a retrospective cohort study. Sci Rep 2022; 12:19218. [PMID: 36357479 PMCID: PMC9649632 DOI: 10.1038/s41598-022-23960-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/08/2022] [Indexed: 11/12/2022] Open
Abstract
To describe the clinical course and prognosis of pediatric idiopathic intracranial hypertension (IIH) and examine the preferred management setting. IIH is characterized by increased intracranial pressure and is often associated with headaches and visual complaints. IIH is a preventable cause of vision loss in children. Hence, a rapid diagnosis followed by prompt treatment and follow-up is essential. However, standardization of the management of IIH in the pediatric population is not well established. Computerized medical charts of all 82 pediatric (< 18 years) patients diagnosed with IIH between 2007 and 2018 in the metropolitan area of Jerusalem were reviewed. Comparison was made between children followed in a multidisciplinary clinic in tertiary centers and those followed elsewhere. Detailed demographic and clinical data, as well as data regarding the follow-up setting and clinical course of the disease, were collected and analyzed. Recurrent IIH-related hospital returns were selected as a measurable marker for the uncontrolled disease. Recurrent IIH-related hospital return rate was significantly lower and occurred later among children followed by multidisciplinary teams compared to individual experts. Follow-up in multidisciplinary clinics improve the quality of life, and financial burden and may prevent permanent visual impairment in children with IIH.
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22
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Markowitz MA, Tiyyagura G, Quallen K, Rosenberg J. Food Insecurity Screening and Intervention in United States Children's Hospitals. Hosp Pediatr 2022; 12:849-857. [PMID: 36120739 DOI: 10.1542/hpeds.2022-006755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Food insecurity (FI) affects many United States families and negatively impacts the health of children. We assessed patterns of FI screening for United States children's hospitals, characterized screening protocols, and assessed how hospitals addressed general and inpatient-specific caregiver FI, including provision of food or meals for caregivers of admitted children. METHODS We conducted a cross-sectional, confidential survey of clinical team members at United States children's hospitals. We evaluated FI screening practices and responses, including which team members conduct FI screening, the types of screeners used, and interventions including social work consultations, referrals to community resources, and provision of food or meals. RESULTS Of the 76 children's hospital representatives (40% response rate) who participated in the survey, 67.1% reported at least some screening, and 34.2% performed universal screening for FI. Screening was conducted most frequently on the inpatient units (58.8%), with social workers (35.5%) and nurses (34.2%) administering screeners most frequently. Responses to positive screens included social work consultation (51.3%), referral to community resources (47.4%), and offering food or meals (43.4%). Eighty-four percent of hospitals provided food or meals to at least some caregivers for admitted pediatric patients. Conditional qualifications for food/meals included need-based (31.6%) and presence of breastfeeding mothers (30.3%). CONCLUSIONS Many United States children's hospitals screen for FI, but most survey respondents reported that their hospital did not conduct universal screening. Screening protocols and interventions varied among institutions. Children's hospitals could consider improving screening protocols and interventions to ensure that needs are identified and addressed.
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Affiliation(s)
- Molly A Markowitz
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Gunjan Tiyyagura
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Kaitlin Quallen
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Julia Rosenberg
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
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23
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Nama N, Hall M, Neuman M, Sullivan E, Bochner R, De Laroche A, Hadvani T, Jain S, Katsogridakis Y, Kim E, Mittal M, Payson A, Prusakowski M, Shastri N, Stephans A, Westphal K, Wilkins V, Tieder J. Risk Prediction After a Brief Resolved Unexplained Event. Hosp Pediatr 2022; 12:772-785. [PMID: 35965279 DOI: 10.1542/hpeds.2022-006637] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Only 4% of brief resolved unexplained events (BRUE) are caused by a serious underlying illness. The American Academy of Pediatrics (AAP) guidelines do not distinguish patients who would benefit from further investigation and hospitalization. We aimed to derive and validate a clinical decision rule for predicting the risk of a serious underlying diagnosis or event recurrence. METHODS We retrospectively identified infants presenting with a BRUE to 15 children's hospitals (2015-2020). We used logistic regression in a split-sample to derive and validate a risk prediction model. RESULTS Of 3283 eligible patients, 565 (17.2%) had a serious underlying diagnosis (n = 150) or a recurrent event (n = 469). The AAP's higher-risk criteria were met in 91.5% (n = 3005) and predicted a serious diagnosis with 95.3% sensitivity, 8.6% specificity, and an area under the curve of 0.52 (95% confidence interval [CI]: 0.47-0.57). A derived model based on age, previous events, and abnormal medical history demonstrated an area under the curve of 0.64 (95%CI: 0.59-0.70). In contrast to the AAP criteria, patients >60 days were more likely to have a serious underlying diagnosis (odds ratio:1.43, 95%CI: 1.03-1.98, P = .03). CONCLUSIONS Most infants presenting with a BRUE do not have a serious underlying pathology requiring prompt diagnosis. We derived 2 models to predict the risk of a serious diagnosis and event recurrence. A decision support tool based on this model may aid clinicians and caregivers in the discussion on the benefit of diagnostic testing and hospitalization (https://www.mdcalc.com/calc/10400/brief-resolved-unexplained-events-2.0-brue-2.0-criteria-infants).
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Affiliation(s)
- Nassr Nama
- Division of General Pediatrics, Department of Pediatrics, University of British Columbia and BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Mark Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Erin Sullivan
- Department of Pediatrics, University of Washington, Seattle Children's Core for Biomedical Statistics, Seattle, Washington
| | - Risa Bochner
- SUNY Downstate Health Sciences University/New York City Health and Hospitals/Kings County Hospital, New York City, New York
| | - Amy De Laroche
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Teena Hadvani
- Division of Hospital Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Shobhit Jain
- Division of Emergency Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Kansas
| | - Yiannis Katsogridakis
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Edward Kim
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Manoj Mittal
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Nirav Shastri
- Division of Emergency Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Kansas
| | | | - Kathryn Westphal
- Division of Hospital Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Victoria Wilkins
- Division of Pediatric Hospital Medicine, University of Utah, Primary Children's Hospital, Salt Lake City, Utah
| | - Joel Tieder
- Division of Pediatric Hospital Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
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24
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Coon ER, Bonafide C, Cohen E, Heath A, McDaniel CE, Schroeder AR, Kaiser SV. HEROIC Trials to Answer Pragmatic Questions for Hospitalized Children. Hosp Pediatr 2022; 12:e312-e318. [PMID: 35989332 DOI: 10.1542/hpeds.2022-006617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Although the number of randomized controlled trials (RCTs) published each year involving adult populations is steadily rising, the annual number of RCTs published involving pediatric populations has not changed since 2005. Barriers to the broader utilization of RCTs in pediatrics include a lower prevalence of disease, less available funding, and more complicated regulatory requirements. Although child health researchers have been successful in overcoming these barriers for isolated diseases such as pediatric cancer, common pediatric diseases are underrepresented in RCTs relative to their burden. This article proposes a strategy called High-Efficiency RandOmIzed Controlled (HEROIC) trials to increase RCTs focused on common diseases among hospitalized children. HEROIC trials are multicenter RCTs that pursue the rapid, low-cost accumulation of study participants with minimal burden for individual sites. Five key strategies distinguish HEROIC trials: (1) dispersed low-volume recruitment, in which a large number of sites (50-150 hospitals) enroll a small number of participants per site (2-10 participants per site), (2) incentivizing site leads with authorship, training, education credits, and modest financial support, (3) a focus on pragmatic questions that examine simple, widely used interventions, (4) the use of a single institutional review board, integrated consent, and other efficient solutions to regulatory requirements, and (5) scaling the HEROIC trial strategy to accomplish multiple trials simultaneously. HEROIC trials can boost RCT feasibility and volume to answer fundamental clinical questions and improve care for hospitalized children.
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Affiliation(s)
- Eric R Coon
- Department of Pediatrics, Primary Children's Hospital and University of Utah School of Medicine, Salt Lake City, Utah
| | - Christopher Bonafide
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Pennsylvania Penn Implementation Science Center at the Leonard Davis Institute (PISCE@LDI), University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eyal Cohen
- Department of Pediatrics and Edwin S.H. Leong Centre for Healthy Children.,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation
| | - Anna Heath
- Institute of Health Policy, Management and Evaluation.,Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Department of Statistical Science, University College London, London, United Kingdom
| | - Corrie E McDaniel
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Alan R Schroeder
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
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25
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Baker C, Loresto F, Pickett K, Samay SS, Gance-Cleveland B. Facilitating Health Information Exchange to Improve Health Outcomes for School-Aged Children: School Nurse Electronic Health Record Access. Appl Clin Inform 2022; 13:803-810. [PMID: 35858639 PMCID: PMC9451949 DOI: 10.1055/a-1905-3729] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/15/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND AND OBJECTIVES School-aged children with chronic conditions require care coordination for health needs at school. Access to the student's accurate, real-time medical information is essential for school nurses to maximize their care of students. We aim to analyze school nurse access to medical records in a hospital-based electronic health record (EHR) and the effect on patient outcomes. We hypothesized that EHR access would decrease emergency department (ED) visits and inpatient hospitalizations. METHODS This retrospective secondary data analysis was conducted using EHR data 6 months pre- and post-school nurse access to students' hospital-based EHR. The main outcome measures were the ED visits and inpatient hospitalizations. RESULTS For the sample of 336 students in the study, there was a 34% decrease in ED visits from 190 visits before access to 126 ED visits after access (p <0.01). Inpatient hospitalizations decreased by 44% from 176 before access to 99 after access (p <0.001). The incident rate of ED visits decreased (IRR: 0.66; 95% CI: 0.53-0.83; p = 0.00035), and hospitalizations decreased (IRR: 0.56; 95% CI: 0.44-0.72; p <0.0001) from pre to post access. These findings suggest school nurse access to medical records is a positive factor in improving school-aged patient outcomes. CONCLUSION School nurse access to medical records through the hospital-based EHR may be a factor to improve patient outcomes by utilizing health information technology for more efficient and effective communication and care coordination for school-aged children with chronic medical conditions.
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Affiliation(s)
- Christina Baker
- College of Nursing, University of Colorado, Aurora, Colorado, United States
| | - Figaro Loresto
- Department of Research, Innovation, and Professional Practice, Children's Hospital Colorado, Aurora, Colorado, United States
| | - Kaci Pickett
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, United States
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Sadaf Sara Samay
- Department of Research Informatics and Analytics, Children's Hospital Colorado, Aurora, Colorado, United States
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26
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Liang CS, Forster C, Williams AE. High-Value Care During the COVID-19 Pandemic: Lessons Learned and Future Opportunities. Hosp Pediatr 2022; 12:e216-e218. [PMID: 35641475 DOI: 10.1542/hpeds.2021-006511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Cynthia S Liang
- Department of Pediatrics
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Catherine Forster
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Allison E Williams
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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27
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Fritz CQ, Hall M, Bettenhausen JL, Beck AF, Krager MK, Freundlich KL, Ibrahim D, Thomson JE, Gay JC, Carroll AR, Neeley M, Frost PA, Herndon AC, Kehring AL, Williams DJ. Child Opportunity Index 2.0 and acute care utilization among children with medical complexity. J Hosp Med 2022; 17:243-251. [PMID: 35535923 PMCID: PMC9254633 DOI: 10.1002/jhm.12810] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/24/2022] [Accepted: 01/28/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Disproportionately high acute care utilization among children with medical complexity (CMC) is influenced by patient-level social complexity. OBJECTIVE The objective of this study was to determine associations between ZIP code-level opportunity and acute care utilization among CMC. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional, multicenter study used the Pediatric Health Information Systems database, identifying encounters between 2016-2019. CMC aged 28 days to <16 years with an initial emergency department (ED) encounter or inpatient/observation admission in 2016 were included in primary analyses. MAIN OUTCOME AND MEASURES We assessed associations between the nationally-normed, multi-dimensional, ZIP code-level Child Opportunity Index 2.0 (COI) (high COI = greater opportunity), and total utilization days (hospital bed-days + ED discharge encounters). Analyses were conducted using negative binomial generalized estimating equations, adjusting for age and distance from hospital and clustered by hospital. Secondary outcomes included intensive care unit (ICU) days and cost of care. RESULTS A total of 23,197 CMC were included in primary analyses. In unadjusted analyses, utilization days decreased in a stepwise fashion from 47.1 (95% confidence interval: 45.5, 48.7) days in the lowest COI quintile to 38.6 (36.9, 40.4) days in the highest quintile (p < .001). The same trend was present across all outcome measures, though was not significant for ICU days. In adjusted analyses, patients from the lowest COI quintile utilized care at 1.22-times the rate of those from the highest COI quintile (1.17, 1.27). CONCLUSIONS CMC from low opportunity ZIP codes utilize more acute care. They may benefit from hospital and community-based interventions aimed at equitably improving child health outcomes.
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Affiliation(s)
- Cristin Q. Fritz
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matt Hall
- Children’s Hospital Association, Lenexa, KS
| | - Jessica L Bettenhausen
- Department of Pediatrics, Children’s Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Andrew F Beck
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Molly K Krager
- Department of Pediatrics, Children’s Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Katherine L Freundlich
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dena Ibrahim
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joanna E Thomson
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - James C Gay
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alison R Carroll
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Maya Neeley
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Patricia A Frost
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alison C Herndon
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Allysa L Kehring
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Derek J Williams
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
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28
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Parente V, Stark A, Key-Solle M, Olsen M, Sanders LL, Bartlett KW, Pollak KI. Caregiver Inclusivity and Empowerment During Family-Centered Rounds. Hosp Pediatr 2022; 12:e72-e77. [PMID: 35079809 PMCID: PMC9881425 DOI: 10.1542/hpeds.2021-006034] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Despite widespread adoption of family-centered rounds, few have investigated differences in the experience of family-centered rounds by family race and ethnicity. The purpose of this study was to explore racial and ethnic differences in caregiver perception of inclusion and empowerment during family-centered rounds. METHODS We identified eligible caregivers of children admitted to the general pediatrics team through the electronic health record. Surveys were completed by 99 caregivers (47 non-Latinx White and 52 Black, Latinx, or other caregivers of color). To compare agreement with statements of inclusivity and empowerment, we used the Wilcoxon rank sum test in unadjusted analyses and linear regression for the adjusted analyses. RESULTS Most (91%) caregivers were satisfied or extremely satisfied with family-centered rounds. We found no differences by race or ethnicity in statements of satisfaction or understanding family-centered rounds content. However, in both unadjusted and adjusted analyses, we found that White caregivers more strongly agreed with the statements "I felt comfortable participating in rounds," "I had adequate time to ask questions during rounds," and "I felt a valued member of the team during rounds" compared with Black, Latinx, and other caregivers of color. CONCLUSIONS Congruent with studies of communication in other settings, caregivers of color may experience barriers to inclusion in family-centered rounds, such as medical team bias, less empathic communication, and shorter encounters. Future studies are needed to better understand family-centered rounds disparities and develop interventions that promote inclusive rounds.
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Affiliation(s)
- Victoria Parente
- Department of Pediatrics, Duke University Hospital, Durham, North Carolina
| | - Ashley Stark
- Department of Pediatrics, Duke University Hospital, Durham, North Carolina
| | - Mikelle Key-Solle
- Department of Pediatrics, Duke University Hospital, Durham, North Carolina
| | - Maren Olsen
- Departments of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina,Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Linda L. Sanders
- Department of Pediatrics, Duke University Hospital, Durham, North Carolina
| | | | - Kathryn I. Pollak
- Population Health Sciences, Duke University, Durham, North Carolina,Cancer Prevention and Control, Duke Cancer Institute, Durham, North Carolina
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29
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The Association of the Childhood Opportunity Index on Pediatric Readmissions and Emergency Department Revisits. Acad Pediatr 2022; 22:614-621. [PMID: 34929386 PMCID: PMC9169565 DOI: 10.1016/j.acap.2021.12.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 12/07/2021] [Accepted: 12/13/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Reutilization following discharge is costly to families and the health care system. Singular measures of the social determinants of health (SDOH) have been shown to impact utilization; however, the SDOH are multifactorial. The Childhood Opportunity Index (COI) is a validated approach for comprehensive estimation of the SDOH. Using the COI, we aimed to describe the association between SDOH and 30-day revisit rates. METHODS This retrospective study included children 0 to 17 years within 48 children's hospitals using the Pediatric Health Information System from 1/1/2019 to 12/31/2019. The main exposure was a child's ZIP code level COI. The primary outcome was unplanned readmissions and emergency department (ED) revisits within 30 days of discharge. Primary outcomes were summarized by COI category and compared using chi-square or Kruskal-Wallis tests. Adjusted analysis used generalized linear mixed effects models with adjustments for demographics, clinical characteristics, and hospital clustering. RESULTS Of 728,997 hospitalizations meeting inclusion criteria, 30-day unplanned returns occurred for 96,007 children (13.2%). After adjustment, the patterns of returns were significantly associated with COI. For example, 30-day returns occurred for 19.1% (95% confidence interval [CI]: 18.2, 20.0) of children living within very low opportunity areas, with a gradient-like decrease as opportunity increased (15.5%, 95% CI: 14.5, 16.5 for very high). The relative decrease in utilization as COI increased was more pronounced for ED revisits. CONCLUSIONS Children living in low opportunity areas had greater 30-day readmissions and ED revisits. Our results suggest that a broader approach, including policy and system-level change, is needed to effectively reduce readmissions and ED revisits.
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30
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Comparing Artificial Intelligence and Traditional Methods to Identify Factors Associated With Pediatric Asthma Readmission. Acad Pediatr 2022; 22:55-61. [PMID: 34329757 DOI: 10.1016/j.acap.2021.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 05/20/2021] [Accepted: 07/20/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To identify and contrast risk factors for six-month pediatric asthma readmissions using traditional models (Cox proportional-hazards and logistic regression) and artificial neural-network modeling. METHODS This retrospective cohort study of the 2013 Nationwide Readmissions Database included children 5 to 18 years old with a primary diagnosis of asthma. The primary outcome was time to asthma readmission in the Cox model, and readmission within 180 days in logistic regression. A basic neural network construction with 2 hidden layers and multiple replications considered all dataset variables and potential variable interactions to predict 180-day readmissions. Logistic regression and neural-network models were compared on area-under-the receiver-operating curve. RESULTS Of 18,489 pediatric asthma hospitalizations, 1858 were readmitted within 180 days. In Cox and logistic models, longer index length of stay, public insurance, and nonwinter index admission seasons were associated with readmission risk, whereas micropolitan county was protective. In neural-network modeling, 9 factors were significantly associated with readmissions. Four overlapped with the Cox model (nonwinter-month admission, long length of stay, public insurance, and micropolitan hospitals), whereas 5 were unique (age, hospital bed number, teaching-hospital status, weekend index admission, and complex chronic conditions). The area under the curve was 0.592 for logistic regression and 0.637 for the neural network. CONCLUSIONS Different methods can produce different readmission models. Relying on traditional modeling alone overlooks key readmission risk factors and complex factor interactions identified by neural networks.
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Carroll AR, Hall M, Brown CM, Johnson DP, Antoon JW, Kreth H, Ngo ML, Browning W, Neeley M, Herndon A, Chokshi SB, Plemmons G, Johnson J, Hart SR, Williams DJ. Association of Race/Ethnicity and Social Determinants with Rehospitalization for Mental Health Conditions at Acute Care Children's Hospitals. J Pediatr 2022; 240:228-234.e1. [PMID: 34478747 PMCID: PMC8712354 DOI: 10.1016/j.jpeds.2021.08.078] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/02/2021] [Accepted: 08/26/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To evaluate associations of race/ethnicity and social determinants with 90-day rehospitalization for mental health conditions to acute care nonpsychiatric children's hospitals. STUDY DESIGN We conducted a retrospective cohort analysis of mental health hospitalizations for children aged 5-18 years from 2016 to 2018 at 32 freestanding US children's hospitals using the Children's Hospital Association's Pediatric Health Information System database to assess the association of race/ethnicity and social determinants (insurance payer, neighborhood median household income, and rurality of patient home location) with 90-day rehospitalization. Risk factors for rehospitalization were modeled using mixed-effects multivariable logistic regression. RESULTS Among 23 556 index hospitalizations, there were 1382 mental health rehospitalizations (5.9%) within 90 days. Non-Hispanic Black children were 26% more likely to be rehospitalized than non-Hispanic White children (aOR 1.26, 95% CI 1.08-1.48). Those with government insurance were 18% more likely to be rehospitalized than those with private insurance (aOR 1.18, 95% CI 1.04-1.34). In contrast, those living in a suburban location were 22% less likely to be rehospitalized than those living in an urban location (suburban: aOR 0.78, 95% CI 0.63-0.97). CONCLUSIONS Non-Hispanic Black children and those with public insurance were at greatest risk for 90-day rehospitalization, and risk was lower in those residing in suburban locations. Future work should focus on upstream interventions that will best attenuate social disparities to promote equity in pediatric mental healthcare.
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Affiliation(s)
- Alison R Carroll
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN.
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS
| | - Charlotte M Brown
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - David P Johnson
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - James W Antoon
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Heather Kreth
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - My-Linh Ngo
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Whitney Browning
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Maya Neeley
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Alison Herndon
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Swati B Chokshi
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Gregory Plemmons
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Jakobi Johnson
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Sarah R Hart
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Derek J Williams
- Monroe Carell Jr Children's Hospital at Vanderbilt, Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
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Musial A, Schondelmeyer AC, Statile A. New Prescriptions After Hospitalization: A Bitter Pill or Just What the Doctor Ordered? Hosp Pediatr 2021:hpeds.2021-006357. [PMID: 34807978 DOI: 10.1542/hpeds.2021-006357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Abigail Musial
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine
| | | | - Angela Statile
- Division of Hospital Medicine
- Pediatric Residency Program, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Tchou MJ, Schondelmeyer AC, Alvarez F, Holmes AV, Lee V, Lossius MN, O'Callaghan J, Rajbhandari P, Soung PJ, Quinonez R. Choosing Wisely in Pediatric Hospital Medicine: 5 New Recommendations to Improve Value. Hosp Pediatr 2021; 11:1179-1190. [PMID: 34667087 DOI: 10.1542/hpeds.2021-006037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The health care system faces ongoing challenges due to low-value care. Building on the first pediatric hospital medicine contribution to the American Board of Internal Medicine Foundation Choosing Wisely Campaign, a working group was convened to identify additional priorities for improving health care value for hospitalized children. METHODS A study team composed of nominees from national pediatric medical professional societies was convened, including pediatric hospitalists with expertise in clinical care, hospital leadership, and research. The study team surveyed national pediatric hospitalist LISTSERVs for suggestions, condensed similar responses, and performed a literature search of articles published in the previous 10 years. Using a modified Delphi process, the team completed a series of structured ratings of feasibility and validity and facilitated group discussion. The sum of final mean validity and feasibility scores was used to identify the 5 highest priority recommendations. RESULTS Two hundred seven respondents suggested 397 preliminary recommendations, yielding 74 unique recommendations that underwent evidence review and rating. The 5 highest-scoring recommendations had a focus on the following aspects of hospital care: (1) length of intravenous antibiotic therapy before transition to oral antibiotics, (2) length of stay for febrile infants evaluated for serious bacterial infection, (3) phototherapy for neonatal hyperbilirubinemia, (4) antibiotic therapy for community-acquired pneumonia, and (5) initiation of intravenous antibiotics in infants with maternal risk factors for sepsis. CONCLUSIONS We propose that pediatric hospitalists can use this list to prioritize quality improvement and scholarly work focused on improving the value and quality of patient care for hospitalized children.
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Affiliation(s)
- Michael J Tchou
- Section of Hospital Medicine, Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | - Amanda C Schondelmeyer
- Division of Hospital Medicine.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Francisco Alvarez
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California
| | - Alison V Holmes
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire.,Children's Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire
| | - Vivian Lee
- Division of Hospital Medicine, Children's Hospital Los Angeles and Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Michele N Lossius
- Pediatric Hospital Medicine, Department of Pediatrics, University of Florida Shands Children's Hospital, Gainesville, Florida
| | - James O'Callaghan
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | - Prabi Rajbhandari
- Division of Hospital Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, Ohio
| | - Paula J Soung
- Section of Hospital Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ricardo Quinonez
- Section of Pediatric Hospital Medicine, Texas Children's Hospital and Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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Arora G, Caliboso M, Baird J, Rusch R, Greenman J, Obregon D, Serwint JR. Educational Priorities for Providing End-of-Life Care: Parent Perspectives. Pediatrics 2021; 148:peds.2021-051379. [PMID: 34518315 DOI: 10.1542/peds.2021-051379] [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: 06/16/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Partnership with parents is a tenet of pediatric medicine; however, initiatives to include parents in education and research have been limited. Through focus groups, we included parents at the beginning of curriculum development by asking them to identify the priorities, existing supports, and opportunities for improvement in their child's end-of-life (EOL) care. METHODS English and Spanish-speaking bereaved parents whose child had been cared for by the palliative care team and had died >18 months before the study initiation were invited to participate. In-person focus groups and a follow-up phone call were used to elicit opinions and capture a diversity of viewpoints. Themes were identified and clustered through an iterative analytic process. RESULTS Twenty-seven parents of 17 children participated, with the total sample size determined by thematic saturation. Four themes were identified as important to parents in their child's EOL care: (1) honoring the role of the parent, (2) having confidence in the care team, (3) receiving gestures of love and caring, and (4) navigating logistic challenges. CONCLUSIONS We asked parents to be partners in guiding priorities for health care education and professional development to improve pediatric EOL care. In addition to strengthening skills in communication, confidence in the team, and compassion, parents in this study identified a need for hospital staff to anticipate financial and social stressors and provide supportive resources more readily. Additionally, parents described clinical and nonclinical staff as providing support, suggesting that a multidisciplinary and interdisciplinary curriculum be developed to improve pediatric EOL care.
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Affiliation(s)
- Gitanjli Arora
- Division of Comfort and Palliative Care .,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | | | | | | | - Daniela Obregon
- Diversity Services, Children's Hospital Los Angeles, Los Angeles, California
| | - Janet R Serwint
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Coon ER, Conroy MB, Ray KN. Posthospitalization Follow-up: Always Needed or As Needed? Hosp Pediatr 2021; 11:e270-e273. [PMID: 34479947 DOI: 10.1542/hpeds.2021-005880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Eric R Coon
- Department of Pediatrics, Primary Children's Hospital and
| | - Molly B Conroy
- Division of General Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Kristin N Ray
- Department of Pediatrics, School of Medicine, University of Pittsburgh and Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Foster CC, Chorniy A, Kwon S, Kan K, Heard-Garris N, Davis MM. Children With Special Health Care Needs and Forgone Family Employment. Pediatrics 2021; 148:e2020035378. [PMID: 34433691 PMCID: PMC9219960 DOI: 10.1542/peds.2020-035378] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Family income is known to affect child health, but this relationship can be bidirectional. We sought to characterize this relationship by quantifying forgone family employment (FFE) due to a child's health condition in families of children with special health care needs (CSHCN) with updated figures. METHODS We conducted a secondary data analysis from the 2016-2017 National Survey of Children's Health. CSHCN with previously employed caregivers were included (N = 14 050). FFE was defined as any family member having stopped work and/or reduced hours because of their child's health or health condition. Child, caregiver, and household characteristics were compared by FFE status. Logistic regression analysis was conducted to evaluate the association between hours of medical care provide by a family member and FFE. US Bureau of Labor Statistics reports were used to estimate lost earnings from FFE. RESULTS FFE occurred in 14.5% (95% confidence interval [CI] 12.9%-16.1%) of previously employed families with CSHCN and was 40.9% (95% CI 27.1%-54.7%) for children with an intellectual disability. We observed disproportionately high FFE among CSHCN who were 0 to 5 years old and of Hispanic ethnicity. We found a strong association between FFE and increasing hours of family-provided medical care, with an adjusted odds ratio (aOR) of 1.72 (95% CI 1.25-2.36) for <1 hour per week (compared with 0 hours), an aOR of 5.96 (95% CI 4.30-8.27) for 1 to 4 hours per week, an aOR of 11.89 (95% CI 6.19-22.81) for 5 to 10 hours per week, and an aOR of 8.89 (95% CI 5.26-15.01) for >10 hours per week. Lost earnings for each household with FFE were estimated at ∼$18 000 per year. CONCLUSIONS With our findings, we highlight the need to implement programs and policies that address forgone income experienced by families of CSHCN.
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Affiliation(s)
- Carolyn C Foster
- Division of Advanced General Pediatrics and Primary Care, Departments of Pediatrics
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Anna Chorniy
- Medical Social Sciences
- Buehler Center for Health Policy and Economics, Feinberg School of Medicine
- Institute for Policy Research, Northwestern University, Chicago, Illinois
| | - Soyang Kwon
- Division of Advanced General Pediatrics and Primary Care, Departments of Pediatrics
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Kristin Kan
- Division of Advanced General Pediatrics and Primary Care, Departments of Pediatrics
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Nia Heard-Garris
- Division of Advanced General Pediatrics and Primary Care, Departments of Pediatrics
- Institute for Policy Research, Northwestern University, Chicago, Illinois
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Matthew M Davis
- Division of Advanced General Pediatrics and Primary Care, Departments of Pediatrics
- Medical Social Sciences
- Medicine and Preventive Medicine
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Hogan AH, Carroll CL, Iverson MG, Hollenbach JP, Philips K, Saar K, Simoneau T, Sturm J, Vangala D, Flores G. Risk Factors for Pediatric Asthma Readmissions: A Systematic Review. J Pediatr 2021; 236:219-228.e11. [PMID: 33991541 DOI: 10.1016/j.jpeds.2021.05.015] [Citation(s) in RCA: 3] [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: 01/28/2021] [Revised: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To systematically review the literature on pediatric asthma readmission risk factors. STUDY DESIGN We searched PubMed/MEDLINE, CINAHL, Scopus, PsycINFO, and Cochrane Central Register of Controlled Trials for published articles (through November 2019) on pediatric asthma readmission risk factors. Two authors independently screened titles and abstracts and consensus was reached on disagreements. Full-text articles were reviewed and inclusion criteria applied. For articles meeting inclusion criteria, authors abstracted data on study design, patient characteristics, and outcomes, and 4 authors assessed bias risk. RESULTS Of 5749 abstracts, 74 met inclusion criteria. Study designs, patient populations, and outcome measures were highly heterogeneous. Risk factors consistently associated with early readmissions (≤30 days) included prolonged length of stay (OR range, 1.1-1.6) and chronic comorbidities (1.7-3.2). Risk factors associated with late readmissions (>30 days) included female sex (1.1-1.6), chronic comorbidities (1.5-2), summer discharge (1.5-1.8), and prolonged length of stay (1.04-1.7). Across both readmission intervals, prior asthma admission was the most consistent readmission predictor (1.3-5.4). CONCLUSIONS Pediatric asthma readmission risk factors depend on the readmission interval chosen. Prior hospitalization, length of stay, sex, and chronic comorbidities were consistently associated with both early and late readmissions. TRIAL REGISTRATION CRD42018107601.
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Affiliation(s)
- Alexander H Hogan
- Division of Hospital Medicine, Connecticut Children's Medical Center, Hartford, CT; Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT.
| | - Christopher L Carroll
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT; Division of Critical Care, Connecticut Children's Medical Center, Hartford, CT
| | | | - Jessica P Hollenbach
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT; Asthma Center, Connecticut Children's Medical Center, Hartford, CT
| | - Kaitlyn Philips
- Children's Hospital at Montefiore, Bronx, NY; Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY
| | - Katarzyna Saar
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT
| | - Tregony Simoneau
- Boston Children's Medical Center, Boston, MA; Department of Pediatrics, Harvard University, Cambridge, MA
| | - Jesse Sturm
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT; Department of Emergency Medicine, Connecticut Children's Medical Center, Hartford, CT
| | - Divya Vangala
- Department of Pediatrics, Duke University, Durham, NC
| | - Glenn Flores
- Department of Pediatrics, University of Miami Miller School of Medicine, and Holtz Children's Hospital, Jackson Health System, Miami, FL
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Stephens JR, Hall M, Cotter JM, Molloy MJ, Tchou MJ, Markham JL, Shah SS, Steiner MJ, Aronson PL. Trends and Variation in Length of Stay Among Hospitalized Febrile Infants ≤60 Days Old. Hosp Pediatr 2021; 11:915-926. [PMID: 34385333 DOI: 10.1542/hpeds.2021-005936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Researchers in recent studies suggest that hospitalized febrile infants aged ≤60 days may be safely discharged if bacterial cultures are negative after 24-36 hours of incubation. We aimed to describe trends and variation in length of stay (LOS) for hospitalized febrile infants across children's hospitals. METHODS We conducted a multicenter retrospective cohort study of febrile infants aged ≤60 days hospitalized from 2016 to 2019 at 39 hospitals in the Pediatric Health Information System database. We excluded infants with complex chronic conditions, bacterial infections, lower respiratory tract viral infections, and those who required ICU admission. The primary outcomes were trends in LOS overall and for individual hospitals, adjusted for patient demographics and clinical characteristics. We also evaluated the hospital-level association between LOS and 30-day readmissions. RESULTS We identified 11 868 eligible febrile infant encounters. The adjusted mean LOS for the study cohort decreased from 44.0 hours in 2016 to 41.9 hours in 2019 (P < .001). There was substantial variation in adjusted mean LOS across children's hospitals, range 33.5-77.9 hours in 2016 and 30.4-100.0 hours in 2019. The change from 2016 to 2019 in adjusted mean LOS across individual hospitals also varied widely (-23.9 to +26.7 hours; median change -1.8 hours, interquartile range: -5.4 to 0.3). There was no association between hospital-level LOS and readmission rates (P = .70). CONCLUSIONS The LOS for hospitalized febrile infants decreased marginally between 2016 and 2019, although overall LOS and change in LOS varied substantially across children's hospitals. Continued quality improvement efforts are needed to reduce LOS for hospitalized febrile infants.
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Affiliation(s)
- John R Stephens
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas
| | - Jillian M Cotter
- Children's Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Matthew J Molloy
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Michael J Tchou
- Children's Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Jessica L Markham
- Children's Mercy Hospital and University of Missouri-Kansas City, Kansas City, Missouri
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Michael J Steiner
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Paul L Aronson
- Departments of Pediatrics and Emergency Medicine, School of Medicine, Yale University, New Haven, Connecticut
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Krager MK, Puls HT, Bettenhausen JL, Hall M, Thurm C, Plencner LM, Markham JL, Noelke C, Beck AF. The Child Opportunity Index 2.0 and Hospitalizations for Ambulatory Care Sensitive Conditions. Pediatrics 2021; 148:peds.2020-032755. [PMID: 34215676 DOI: 10.1542/peds.2020-032755] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Hospitalizations for ambulatory care sensitive conditions (ACSCs) are thought to be avoidable with high-quality outpatient care. Morbidity related to ACSCs has been associated with socioeconomic contextual factors, which do not necessarily capture the complex pathways through which a child's environment impacts health outcomes. Our primary objective was to test the association between a multidimensional measure of neighborhood-level child opportunity and pediatric hospitalization rates for ACSCs across 2 metropolitan areas. METHODS This was a retrospective population-based analysis of ACSC hospitalizations within the Kansas City and Cincinnati metropolitan areas from 2013 to 2018. Census tracts were included if located in a county where Children's Mercy Kansas City or Cincinnati Children's Hospital Medical Center had >80% market share of hospitalizations for children <18 years. Our predictor was child opportunity as defined by a composite index, the Child Opportunity Index 2.0. Our outcome was hospitalization rates for 8 ACSCs. RESULTS We included 604 943 children within 628 census tracts. There were 26 977 total ACSC hospitalizations (46 hospitalizations per 1000 children; 95% confidence interval [CI]: 45.4-46.5). The hospitalization rate for all ACSCs revealed a stepwise reduction from 79.9 per 1000 children (95% CI: 78.1-81.7) in very low opportunity tracts to 31.2 per 1000 children (95% CI: 30.5-32.0) in very high opportunity tracts (P < .001). This trend was observed across cities and diagnoses. CONCLUSIONS Links between ACSC hospitalizations and child opportunity extend across metropolitan areas. Targeting interventions to lower-opportunity neighborhoods and enacting policies that equitably bolster opportunity may improve child health outcomes, reduce inequities, and decrease health care costs.
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Affiliation(s)
- Molly K Krager
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Henry T Puls
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Jessica L Bettenhausen
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Matt Hall
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri.,Children's Hospital Association, Lenexa, Kansas
| | - Cary Thurm
- Children's Hospital Association, Lenexa, Kansas
| | - Laura M Plencner
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Jessica L Markham
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Clemens Noelke
- The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Andrew F Beck
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center and College of Medicine, University of Cincinnati, Cincinnati, Ohio
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40
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Brown CM, Williams DJ, Hall M, Freundlich KL, Johnson DP, Lind C, Rehm K, Frost PA, Doupnik SK, Ibrahim D, Patrick S, Howard LM, Gay JC. Trends in Length of Stay and Readmissions in Children's Hospitals. Hosp Pediatr 2021; 11:554-562. [PMID: 33947746 DOI: 10.1542/hpeds.2020-004044] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Patient complexity at US children's hospitals is increasing. Hospitals experience concurrent pressure to reduce length of stay (LOS) and readmissions, yet little is known about how these common measures of resource use and quality have changed over time. Our aim was to examine temporal trends in medical complexity, hospital LOS, and readmissions across a sample of US children's hospitals. METHODS Retrospective cohort study of hospitalized patients from 42 children's hospitals in the Pediatric Health Information System from 2013 to 2017. After excluding deaths, healthy newborns, obstetric care, and low volume service lines, we analyzed trends in medical complexity, LOS, and 14-day all-cause readmissions using generalized linear mixed effects models, adjusting for changes in patient factors and case-mix. RESULTS Between 2013 and 2017, a total of 3 355 815 discharges were included. Over time, the mean case-mix index and the proportion of hospitalized patients with complex chronic conditions or receiving intensive care increased (P < .001 for all). In adjusted analyses, mean LOS declined 3% (61.1 hours versus 59.3 hours from 2013 to 2017, P < .001), whereas 14-day readmissions were unchanged (7.0% vs 6.9%; P = .03). Reductions in adjusted LOS were noted in both medical and surgical service lines (3.6% and 2.0% decline, respectively; P < .001). CONCLUSIONS Across US children's hospitals, adjusted LOS declined whereas readmissions remained stable, suggesting that children's hospitals are providing more efficient care for an increasingly complex patient population.
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Affiliation(s)
| | | | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | | | | | | | | | | | - Stephanie K Doupnik
- Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, and Policy Laboratory, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | | | - Stephen Patrick
- Department of Pediatrics, Vanderbilt Center for Child Health Policy, Nashville, Tennessee
| | | | - James C Gay
- General Pediatrics, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
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Desai S, Calhoun T, Sosa T, Courter JD, Letsinger A, Le M, Schubert A, Zaremba L, Shah SS, Jerardi K, Statile AM, Unaka NI. Decreasing Hospital Observation Time for Febrile Infants. J Hosp Med 2021; 16:267-273. [PMID: 33929946 DOI: 10.12788/jhm.3593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/18/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Febrile infants aged 0 to 60 days are often hospitalized for a 36-to-48 hour observation period to rule out invasive bacterial infections (IBI). Evidence suggests that monitoring blood and cerebrospinal fluid (CSF) cultures for 24 hours may be appropriate for most infants. We aimed to decrease the average culture observation time (COT) from 38 to 30 hours among hospitalized infants 0 to 60 days old over 12 months. METHODS This quality improvement initiative occurred at a large children's hospital, in conjunction with development of a multidisciplinary evidence-based guideline for the management of febrile infants. We included infants aged 0 to 60 days admitted with fever without a clear infectious source. We excluded infants who had positive blood, urine, or CSF cultures within 24 hours of incubation and infants who were hospitalized for other indications (eg, bronchiolitis). Interventions included guideline dissemination, education regarding laboratory monitoring practices, standardized order sets, and near-time identification of failures. Our primary outcome was COT, defined as time between initiation of culture incubation and hospital discharge in hours. Interventions were tracked on an annotated statistical process control chart. Our balancing measure was identification of IBI after hospital discharge. RESULTS In our cohort of 184 infants aged 0 to 60 days, average COT decreased from 38 hours to 32 hours after structured guideline dissemination and order-set standardization; this decrease was sustained over 17 months. IBI was not identified in any patients after discharge. CONCLUSIONS Implementation of an evidence-based guideline through education, transparency of laboratory procedures, creation of standardized order sets, and near-time feedback was associated with shorter COT for febrile infants aged 0 to 60 days.
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Affiliation(s)
- Sanyukta Desai
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Tara Calhoun
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Tina Sosa
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joshua D Courter
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Matthew Le
- Section of Hospital Medicine, Department of Pediatrics, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Amy Schubert
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lindsay Zaremba
- Division of Hospital Medicine, Department of Pediatrics, University Hospital Rainbow Babies and Children's Hospital, Cleveland Ohio
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Karen Jerardi
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Angela M Statile
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ndidi I Unaka
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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42
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Synhorst DC, Hall M, Bettenhausen JL, Markham JL, Macy ML, Gay JC, Morse R. Observation Status Stays With Low Resource Use Within Children's Hospitals. Pediatrics 2021; 147:peds.2020-013490. [PMID: 33707196 DOI: 10.1542/peds.2020-013490] [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] [Accepted: 12/22/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND High costs associated with hospitalization have encouraged reductions in unnecessary encounters. A subset of observation status patients receive minimal interventions and incur low use costs. These patients may contain a cohort that could safely be treated outside of the hospital. Thus, we sought to describe characteristics of low resource use (LRU) observation status hospitalizations and variation in LRU stays across hospitals. METHODS We conducted a retrospective cohort study of pediatric observation encounters at 42 hospitals contributing to the Pediatric Health Information System database from January 1, 2019, to December 31, 2019. For each hospitalization, we calculated the use ratio (nonroom costs to total hospitalization cost). We grouped stays into use quartiles with the lowest labeled LRU. We described associations with LRU stays and performed classification and regression tree analyses to identify the combination of characteristics most associated with LRU. Finally, we described the proportion of LRU hospitalizations across hospitals. RESULTS We identified 174 315 observation encounters (44 422 LRU). Children <1 year (odds ratio [OR] 3.3; 95% confidence interval [CI] 3.1-3.4), without complex chronic conditions (OR 3.6; 95% CI 3.2-4.0), and those directly admitted (OR 4.2; 95% CI 4.1-4.4) had the greatest odds of experiencing an LRU encounter. Those children with the combination of direct admission, no medical complexity, and a respiratory diagnosis experienced an LRU stay 69.5% of the time. We observed variation in LRU encounters (1%-57% of observation encounters) across hospitals. CONCLUSIONS LRU observation encounters are variable across children's hospitals. These stays may include a cohort of patients who could be treated outside of the hospital.
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Affiliation(s)
| | - Matthew Hall
- Children's Mercy Hospital, Kansas City, Missouri.,Children's Hospital Association, Lenexa, Kansas
| | | | | | - Michelle L Macy
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - James C Gay
- Vanderbilt University Medical Center, Nashville, Tennessee; and
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Bassett HK, Coller RJ, Beck J, Hummel K, Tiedt KA, Flaherty B, Tchou MJ, Kapphahn K, Walker L, Schroeder AR. Financial Difficulties in Families of Hospitalized Children. J Hosp Med 2020; 15:652-658. [PMID: 33147127 DOI: 10.12788/jhm.3500] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 07/07/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND High costs of hospitalization may contribute to financial difficulties for some families. OBJECTIVE To examine the prevalence of financial distress and medical financial burden in families of hospitalized children and identify factors that can predict financial difficulties. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional survey of parents of hospitalized children at six children's hospitals between October 2017 and November 2018. MAIN OUTCOMES AND MEASURES The outcomes were high financial distress and medical financial burden. Multivariable logistic regression identified predictors of each outcome. The primary predictor variable was level of chronic disease (complex chronic disease, C-CD; noncomplex chronic disease, NC-CD; no chronic disease, no-CD). RESULTS Of 644 invited participants, 526 (82%) were enrolled, with 125 (24%) experiencing high financial distress, and 160 (30%) reporting medical financial burden. Of those, 86 (54%) indicated their medical financial burden was caused by costs associated with their hospitalized child. Neither C-CD nor NC-CD were associated with high financial distress. Child-related medical financial burden was associated with both C-CD and NC-CD (adjusted odds ratio [AOR], 4.98; 95% CI, 2.41-10.29; and AOR, 2.57; 95% CI, 1.11-5.93), compared to no-CD. Although household poverty level was associated with both measures, financial difficulties occurred in all family income brackets. CONCLUSION Financial difficulties are common in families of hospitalized children. Low-income families and those who have children with chronic conditions are at particular risk; however, financial difficulties affect all subsets of the pediatric population. Hospitalization may be a prime opportunity to identify and engage families at risk for financial distress and medical financial burden.
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Affiliation(s)
- Hannah K Bassett
- Division of Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Ryan J Coller
- Deparment of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jimmy Beck
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Kevin Hummel
- Division of Pediatric Critical Care, Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Kristin A Tiedt
- Deparment of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Brian Flaherty
- Division of Pediatric Critical Care, Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Michael J Tchou
- Section of Hospital Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado-Denver, Aurora, Colorado (current affiliation)
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio (affiliation where work was conducted)
| | | | - Lauren Walker
- Section of Hospital Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Alan R Schroeder
- Division of Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
- Division of Critical Care, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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44
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Gay JC, Hall M, Morse R, Fieldston ES, Synhorst D, Macy ML. Observation Encounters and Length of Stay Benchmarking in Children's Hospitals. Pediatrics 2020; 146:peds.2020-0120. [PMID: 33023992 DOI: 10.1542/peds.2020-0120] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Length of stay (LOS) is a common benchmarking measure for hospital resource use and quality. Observation status (OBS) is considered an outpatient service despite the use of the same facilities as inpatient status (IP) in most children's hospitals, and LOS calculations often exclude OBS stays. Variability in the use of OBS by hospitals may significantly impact calculated LOS. We sought to determine the impact of including OBS in calculating LOS across children's hospitals. METHODS Retrospective cohort study of hospitalized children (age <19 years) in 2017 from the Pediatric Health Information System (Children's Hospital Association, Lenexa, KS). Normal newborns, transfers, deaths, and hospitals not reporting LOS in hours were excluded. Risk-adjusted geometric mean length of stay (RA-LOS) for IP-only and IP plus OBS was calculated and each hospital was ranked by quintile. RESULTS In 2017, 45 hospitals and 625 032 hospitalizations met inclusion criteria (IP = 410 731 [65.7%], OBS = 214 301 [34.3%]). Across hospitals, OBS represented 0.0% to 60.3% of total discharges. The RA-LOS (SD) in hours for IP and IP plus OBS was 75.2 (2.6) and 54.3 (2.7), respectively (P < .001). For hospitals reporting OBS, the addition of OBS to IP RA-LOS calculations resulted in a decrease in RA-LOS compared with IP encounters alone. Three-fourths of hospitals changed ≥1 quintile in LOS ranking with the inclusion of OBS. CONCLUSIONS Children's hospitals exhibit significant variability in the assignment of OBS to hospitalized patients and inclusion of OBS significantly impacts RA-LOS calculations. Careful consideration should be given to the inclusion of OBS when determining RA-LOS for benchmarking, quality and resource use measurements.
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Affiliation(s)
- James C Gay
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee;
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Rustin Morse
- Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Evan S Fieldston
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennyslvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Synhorst
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Michelle L Macy
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago Illinois; and.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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45
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Synhorst DC, Hall M, Harris M, Gay JC, Peltz A, Auger KA, Teufel RJ, Macy ML, Neuman MI, Simon HK, Shah SS, Lutmer J, Eghtesady P, Pavuluri P, Morse RB. Hospital Observation Status and Readmission Rates. Pediatrics 2020; 146:peds.2020-003954. [PMID: 33067343 DOI: 10.1542/peds.2020-003954] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In several states, payers penalize hospitals when an inpatient readmission follows an inpatient stay. Observation stays are typically excluded from readmission calculations. Previous studies suggest inconsistent use of observation designations across hospitals. We sought to describe variation in observation stays and examine the impact of inclusion of observation stays on readmission metrics. METHODS We conducted a retrospective cohort study of hospitalizations at 50 hospitals contributing to the Pediatric Health Information System database from January 1, 2018, to December 31, 2018. We examined prevalence of observation use across hospitals and described changes to inpatient readmission rates with higher observation use. We described 30-day inpatient-only readmission rates and ranked hospitals against peer institutions. Finally, we included observation encounters into the calculation of readmission rates and evaluated hospitals' change in readmission ranking. RESULTS Most hospitals (n = 44; 88%) used observation status, with high variation in use across hospitals (0%-53%). Readmission rate after index inpatient stay (6.8%) was higher than readmission after an index observation stay (4.4%), and higher observation use by hospital was associated with higher inpatient-only readmission rates. When compared with peers, hospital readmission rank changed with observation inclusion (60% moving at least 1 quintile). CONCLUSIONS The use of observation status is variable among children's hospitals. Hospitals that more liberally apply observation status perform worse on the current inpatient-to-inpatient readmission metric, and inclusion of observation stays in the calculation of readmission rates significantly affected hospital performance compared with peer institutions. Consideration should be given to include all admission types for readmission rate calculation.
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Affiliation(s)
- David C Synhorst
- Department of Pediatrics, Children's Mercy Hospital and University of Missouri-Kansas City, Kansas City, Missouri;
| | - Matt Hall
- Department of Pediatrics, Children's Mercy Hospital and University of Missouri-Kansas City, Kansas City, Missouri.,Children's Hospital Association, Lenexa, Kansas
| | | | - James C Gay
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alon Peltz
- Department of Population Medicine, Harvard Medical School, Harvard University and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Katherine A Auger
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Ronald J Teufel
- Department of Pediatrics, College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Michelle L Macy
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Mark I Neuman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Harold K Simon
- Division of Pediatric Emergency Medicine, Department of Pediatrics, School of Medicine, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jeffrey Lutmer
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Pirooz Eghtesady
- Section of Pediatric Cardiothoracic Surgery, Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, Washington University in St Louis and Heart Center, St Louis Children's Hospital, St Louis, Missouri
| | - Padmaja Pavuluri
- Division of Hospitalist Medicine, Children's National Hospital, Washington, District of Columbia; and
| | - Rustin B Morse
- Children's Medical Center Dallas, Children's Health and University of Texas Southwestern Medical Center, Dallas, Texas
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46
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Markham JL, Thurm CW, Hall M, Shah SS, Quinonez R, Tchou MJ, Antoon JW, Genies MC, Parlar-Chun R, Johnson DP, Shah SP, Ittel M, Brady PW. Variation in Early Inflammatory Marker Testing for Infection-Related Hospitalizations in Children. Hosp Pediatr 2020; 10:851-858. [PMID: 32948631 DOI: 10.1542/hpeds.2020-0114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Inflammatory marker testing in children has been identified as a potential area of overuse. We sought to describe variation in early inflammatory marker (C-reactive protein and erythrocyte sedimentation rate) testing for infection-related hospitalizations across children's hospitals and to determine its association with length of stay (LOS), 30-day readmission rate, and cost. METHODS We conducted a cross-sectional study of children aged 0 to 17 years with infection-related hospitalizations using the Pediatric Health Information System. After adjusting for patient characteristics, we examined rates of inflammatory marker testing (C-reactive protein or erythrocyte sedimentation rate) during the first 2 days of hospitalization. We used k-means clustering to assign each hospital to 1 of 3 groups on the basis of similarities in adjusted diagnostic testing rates across 12 infectious conditions. Multivariable regression was used to examine the association between hospital testing group and outcomes. RESULTS We included 55 771 hospitalizations from 48 hospitals. In 7945 (14.3%), there was inflammatory marker testing in the first 2 days of hospitalization. We observed wide variation in inflammatory marker testing rates across hospitals and infections. Group A hospitals tended to perform more tests than group B or C hospitals (37.4% vs 18.0% vs 10.4%; P < .001) and had the longest adjusted LOS (3.2 vs 2.9 vs 2.8 days; P = .01). There was no significant difference in adjusted 30-day readmission rates or costs. CONCLUSIONS Inflammatory marker testing varied widely across hospitals. Hospitals with higher inflammatory testing for one infection tend to test more frequently for other infections and have longer LOS, suggesting opportunities for diagnostic stewardship.
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Affiliation(s)
- Jessica L Markham
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri;
- School of Medicine, University of Kansas, Kansas City, Kansas
| | | | - Matt Hall
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
- Children's Hospital Association, Lenexa, Kansas
| | - Samir S Shah
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ricardo Quinonez
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Michael J Tchou
- Section of Pediatric Hospital Medicine, Department of Pediatrics, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | - James W Antoon
- Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Marquita C Genies
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Raymond Parlar-Chun
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, Houston, Texas; and
| | - David P Johnson
- Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Snehal P Shah
- Division of Hospitalist Medicine, Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Molli Ittel
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
- School of Medicine, University of Kansas, Kansas City, Kansas
| | - Patrick W Brady
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Conkol KJ, Martinez-Strengel A, Coller RJ, Bergman DA, Whelan EM. Pediatric Hospitalists' Lessons Learned From an Innovation Award to Improve Care for Children With Medical Complexity. Hosp Pediatr 2020; 10:694-701. [PMID: 32651217 DOI: 10.1542/hpeds.2020-0069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Children with medical complexity experience frequent hospitalizations and pose a unique challenge for the pediatric hospitalist and their healthcare team. Pediatric hospitalists are ideally positioned to champion improved care coordination for CMC and to address the areas of need in clinical practice, quality improvement and research. Lessons learned from programs who were Healthcare Innovation Award recipients from Center for Medicare and Medicaid Innovation that were aimed at improving care for this population are presented. We focused on care coordination activities implemented during hospitalization. Through a series of meetings with the participating programs, we identified common themes across awarded programs. Programs described key aspects of care coordination during the hospital stay, beginning on admission (multidisciplinary team goal setting, family partnership and action planning), through hospitalization (integrating outpatient and inpatient care), as well as during and after discharge (linking to community-based systems and supports, expanding the transition concept). Finally, we present actionable steps for inpatient providers seeking to improve care for this patient population at the time of hospitalization.
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Affiliation(s)
| | - Angela Martinez-Strengel
- Department of Internal Medicine, National Clinician Scholars Program, School of Medicine, Yale University, New Haven, Connecticut
| | - Ryan J Coller
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - David A Bergman
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
| | - Ellen-Marie Whelan
- Center for Medicaid and Children's Health Insurance Program Services, Centers for Medicare and Medicaid Services, Baltimore, Maryland
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48
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Implementation of Febrile Infant Management Guidelines Reduces Hospitalization. Pediatr Qual Saf 2020; 5:e252. [PMID: 32190797 PMCID: PMC7056289 DOI: 10.1097/pq9.0000000000000252] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 12/18/2019] [Indexed: 12/21/2022] Open
Abstract
Supplemental Digital Content is available in the text. The clinical management of well-appearing febrile infants 7−60 days of age remains variable due in part to multiple criteria differentiating the risk of a serious bacterial infection. The purpose of this quality improvement study was to standardize risk stratification in the emergency department and length of stay in the inpatient unit by implementing an evidence-based clinical practice guideline (CPG).
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49
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Andrist E, Riley CL, Brokamp C, Taylor S, Beck AF. Neighborhood Poverty and Pediatric Intensive Care Use. Pediatrics 2019; 144:peds.2019-0748. [PMID: 31676680 PMCID: PMC6889973 DOI: 10.1542/peds.2019-0748] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Disparities in health service use have been described across a range of sociodemographic factors. Patterns of PICU use have not been thoroughly assessed. METHODS This was a population-level, retrospective analysis of admissions to the Cincinnati Children's Hospital Medical Center PICU between 2011 and 2016. Residential addresses of patients were geocoded and spatially joined to census tracts. Pediatric patients were eligible for inclusion if they resided within Hamilton County, Ohio. PICU admission and bed-day rates were calculated by using numerators of admissions and bed days, respectively, over a denominator of tract child population. Relationships between tract-level PICU use and child poverty were assessed by using Spearman's ρ and analysis of variance. Analyses were event based; children admitted multiple times were counted as discrete admissions. RESULTS There were 4071 included admissions involving 3129 unique children contributing a total of 12 297 PICU bed days. Child poverty was positively associated with PICU admission rates (r = 0.59; P < .001) and bed-day rates (r = 0.47; P < .001). When tracts were grouped into quintiles based on child poverty rates, the PICU bed-day rate ranged from 23.4 days per 1000 children in the lowest poverty quintile to 81.9 days in the highest poverty quintile (P < .001). CONCLUSIONS The association between poverty and poor health outcomes includes pediatric intensive care use. This association exists for children who grow up in poverty and around poverty. Future efforts should characterize the interplay between patient- and neighborhood-level risk factors and explore neighborhood-level interventions to improve child health.
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Affiliation(s)
- Erica Andrist
- Department of Critical Care Medicine, C.S. Mott Children's Hospital, Ann Arbor, Michigan; .,Department of Pediatrics, Medical School, University of Michigan, Ann Arbor, Michigan
| | - Carley L. Riley
- Divisions of Critical Care Medicine,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Cole Brokamp
- Biostatistics and Epidemiology,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Stuart Taylor
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Andrew F. Beck
- General and Community Pediatrics, and,Hospital Medicine;,James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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50
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Beck AF, Anderson KL, Rich K, Taylor SC, Iyer SB, Kotagal UR, Kahn RS. Cooling The Hot Spots Where Child Hospitalization Rates Are High: A Neighborhood Approach To Population Health. Health Aff (Millwood) 2019; 38:1433-1441. [DOI: 10.1377/hlthaff.2018.05496] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Andrew F. Beck
- Andrew F. Beck is an associate professor of pediatrics at the University of Cincinnati College of Medicine and Cincinnati Children’s Hospital Medical Center, in Ohio
| | - Kristy L. Anderson
- Kristy L. Anderson is a clinical manager for social services at Cincinnati Children’s Hospital Medical Center
| | - Kate Rich
- Kate Rich is a data analyst at the James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center
| | - Stuart C. Taylor
- Stuart C. Taylor is a data analyst at the James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center
| | - Srikant B. Iyer
- Srikant B. Iyer is director of pediatric emergency medicine at Emory University School of Medicine and Children’s Healthcare of Atlanta, in Georgia. At the time this work was conducted, he was an associate professor of pediatrics at the University of Cincinnati College of Medicine and Cincinnati Children’s Hospital Medical Center
| | - Uma R. Kotagal
- Uma R. Kotagal is executive leader of population and community health and a professor of pediatrics at the University of Cincinnati College of Medicine and Cincinnati Children’s Hospital Medical Center
| | - Robert S. Kahn
- Robert S. Kahn is the associate chair of community health and a professor of pediatrics at the University of Cincinnati College of Medicine and Cincinnati Children’s Hospital Medical Center
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