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Berry J, Wilson K, Dumas H, Simpser E, O'Brien J, Whitford K, May R, Mittal V, Murphy N, Steinhorn D, Agrawal R, Rehm K, Marks M, Traul C, Dribbon M, Haines C, Hall M. Use of Post-Acute Facility Care in Children Hospitalized With Acute Respiratory Illness. J Hosp Med 2017; 12:626-631. [PMID: 28786428 DOI: 10.12788/jhm.2780] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Recovery from respiratory illness (RI), a common reason for hospitalization, can be protracted for some children because of high illness severity or underlying medical complexity. OBJECTIVE We assessed which children hospitalized with RI are the most likely to use post-acute facility care (PAC) for recovery. METHODS Retrospective analysis of 609,800 hospitalizations for patients in 43 US children's hospitals between 2010- 2015 for RI, identified with the Agency for Healthcare Research and Quality Clinical Classification System. Discharge to PAC was identified using Centers for Medicare & Medicaid Services Discharge Status Codes. We compared patient characteristics by PAC use with generalized estimating equations. RESULTS There were 2660 (0.4%) RI hospitalizations resulting in PAC transfer (n = 2660, 0.4%). Discharges to PAC had greater percentages of technology assistance (83.2% vs 15.1%), neuromuscular chronic condition (57.5% vs 8.9%), and mechanical ventilation (52.7% vs 9.1%), 𝑃 < 0.001 for all. The highest likelihood of PAC use occurred with ≥11 vs no chronic conditions (odds ratio [OR] 11.7 [95% CI, 8.0- 17.2]), ≥9 vs no therapeutic medication classes (OR 4.8 [95% CI, 1.8-13.0]), and existing tracheostomy (OR 3.0, 95% confidence interval [CI], 2.6-3.5). Median (interquartile range [IQR]) acute-care length of stay (LOS) for children most likely to use PAC was 19 (8-56) days; LOS remained long (median 13 [6-41] days) for children with the same attributes (n = 9448) not transferred to PAC. CONCLUSIONS Children with RI who are most likely to use PAC have a high prevalence of multiple chronic conditions, multiple medications, and medical technology. Future investigations should assess the supply of PAC against the demand of hospitalized children with RI who might need it.
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Affiliation(s)
- Jay Berry
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Franciscan Children's Hospital, Boston, Massachusetts, USA
| | - Karen Wilson
- Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Helene Dumas
- Franciscan Children's Hospital, Boston, Massachusetts, USA
| | - Edwin Simpser
- St. Mary's Healthcare System for Children, Bayside, New York, USA
| | - Jane O'Brien
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Franciscan Children's Hospital, Boston, Massachusetts, USA
| | - Kathleen Whitford
- Cleveland Clinic Children's Hospital for Rehabilitation, Cleveland, Ohio, USA
| | - Rachna May
- The Children's Hospital, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Vineeta Mittal
- UTSW Medical Center & Children's Medical Center Dallas, Dallas, Texas, USA
| | - Nancy Murphy
- Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Rishi Agrawal
- Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kris Rehm
- Monroe Carroll Jr., Children's Hospital, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Michelle Marks
- Cleveland Clinic Children's Hospital for Rehabilitation, Cleveland, Ohio, USA
| | - Christine Traul
- Cleveland Clinic Children's Hospital for Rehabilitation, Cleveland, Ohio, USA
| | - Michael Dribbon
- Children's Specialized Hospital, New Brunswick, New Jersey, USA
| | | | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas, USA
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Berry JG, Hall M, Dumas H, Simpser E, Whitford K, Wilson KM, O'Neill M, Mittal V, Agrawal R, Dribbon M, Haines CJ, Traul C, Marks M, O'Brien J. Pediatric Hospital Discharges to Home Health and Postacute Facility Care: A National Study. JAMA Pediatr 2016; 170:326-33. [PMID: 26902773 DOI: 10.1001/jamapediatrics.2015.4836] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Acute care hospitals are challenged to provide efficient, high-quality care to children who have medically complex conditions and may require weeks or months for recovery. Although the use of home health care (HHC) and facility-based postacute care (PAC) after discharge is well documented for adults, to our knowledge, little is known for children. OBJECTIVE To assess the national prevalence of, characteristics of children discharged to, and variation in use across states of HHC and PAC for children. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of 2,423,031 US acute care hospital discharges in 2012 for patients ages 0 to 21 years from the nationally representative Agency for Healthcare Research and Quality Kids' Inpatient Database. MAIN OUTCOMES AND MEASURES Discharges to HHC (eg, visiting or private-duty home nursing) and PAC (eg, rehabilitation facility) were identified from Centers for Medicare and Medicaid Services Discharge Status Codes. We compared children's characteristics (eg, race/ethnicity and number of chronic conditions) by discharge type using generalized linear regression. RESULTS The median age of participants was 3 years (interquartile range, 0-13 years), and 45.6% were female. Of 2,423,031 US acute care hospital discharges in 2012 for patients ages 0 to 21 years, 122,673 discharges (5.1%) were to HHC and 26,282 (1.1%) were to PAC facilities. Neonatal care was the most common reason (44.5%, n = 54,589) for acute care hospitalization with discharge to HHC. Nonneonatal respiratory, musculoskeletal, and trauma-related problems, collectively, were the most common reasons for discharge to PAC (42.9%, n = 11,275). When compared with PAC, more discharges to HHC had no chronic condition (34.4% vs 18.0%, P < .001) and fewer discharges to HHC had 4 or more chronic conditions (22.5% vs 37.7%, P < .001). In multivariable analysis, Hispanic children were less likely to use PAC (0.8% vs 1.1%; odds ratio [OR], 0.9 [95% CI, 0.8-0.9]) or HHC (3.3% vs 5.5%; OR, 0.8 [95% CI, 0.7-0.8]) compared with other children. Children with 4 or more chronic conditions compared with no chronic conditions had a higher likelihood of HHC use (11.0% vs 4.4%; OR, 2.9 [95% CI, 2.8-3.0]) and PAC (3.9% vs 0.8%; OR, 4.5 [95% CI, 4.3-4.9]). After case-mix adjustment, there was significant (P < .001) variation across states in HHC (range, 0.4%-24.5%) and PAC (range, 0.4%-4.9%) use. CONCLUSIONS AND RELEVANCE Home health care and PAC use after discharge for hospitalized children is infrequent, even for children with multiple chronic conditions. It varies significantly by race/ethnicity and across states. Further investigation is needed to assess reasons for this variation and to determine for which children HHC and PAC are most effective.
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Affiliation(s)
- Jay G Berry
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts2Franciscan Hospital for Children, Boston, Massachusetts
| | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas
| | - Helene Dumas
- Franciscan Hospital for Children, Boston, Massachusetts
| | - Edwin Simpser
- St Mary's Healthcare System for Children, Bayside, New York
| | - Kathleen Whitford
- Cleveland Clinic Children's Hospital for Rehabilitation, Cleveland, Ohio
| | - Karen M Wilson
- Children's Hospital Colorado, University of Colorado, Aurora
| | - Margaret O'Neill
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vineeta Mittal
- University of Texas Southwestern Medical Center and Children's Medical Center Dallas
| | - Rishi Agrawal
- Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Christine Traul
- Cleveland Clinic Children's Hospital for Rehabilitation, Cleveland, Ohio
| | - Michelle Marks
- Cleveland Clinic Children's Hospital for Rehabilitation, Cleveland, Ohio
| | - Jane O'Brien
- Franciscan Hospital for Children, Boston, Massachusetts
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O'Brien JE, Dumas HM, Nash CM, Burke SA, Holson DC, Mast J, Pelegano J, Simpser EF, Traul C, Whitford K. Pediatric post-acute care hospital transitions: an evaluation of current practice. Hosp Pediatr 2014; 4:217-21. [PMID: 24986990 DOI: 10.1542/hpeds.2013-0105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES After discharge from an acute care hospital, some children require ongoing care at a post-acute care hospital. Care transitions occur at both admission to the post-acute care hospital and again at discharge to the home/community. Our objective was to report the current practices used during the admission to and discharge from 7 pediatric post-acute care hospitals in the United States. METHODS Participants from 7 pediatric post-acute care hospitals completed a survey and rated the frequency of use of 20 practices to prepare and support children and their families during both admission to the hospital and at time of discharge to the home/community. For consistency with existing literature, practices were grouped into 4 previously reported categories: assessment, communication, education, and logistics. Descriptive statistics were used to report the frequency of use within practices and between hospitals. RESULTS Only 2 of 10 admission practices and 3 of 10 discharge practices were reportedly "always" used by all hospitals. Assessment and communication practices were reported to be more frequently used (57%-100% of the time) than education and logistic procedures. Between hospitals, only the reported frequency of use of the discharge practices was statistically significantly different (P = .03). CONCLUSIONS Variability exists in transition practices among 7 post-acute care pediatric hospitals. This report is the first known to detail the frequency of use of admission and discharge practices for pediatric post-acute care hospitals in the United States.
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Affiliation(s)
| | | | - Carol M Nash
- Franciscan Hospital for Children, Boston, Massachusetts
| | - Sharon A Burke
- Children's Specialized Hospital, New Brunswick, New Jersey
| | | | - Joelle Mast
- Blythedale Children's Hospital, Valhalla, New York
| | | | | | - Christine Traul
- Cleveland Clinic Children's Hospital for Rehabilitation, Cleveland, Ohio
| | - Kathleen Whitford
- Cleveland Clinic Children's Hospital for Rehabilitation, Cleveland, Ohio
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Kamal AH, Swetz KM, Liu H, Ruegg SR, Carey EC, Whitford K, Bock FA, Creagan ET, Moynihan TJ, Kaur JS. Survival trends in palliative care patients with cancer: A Mayo Clinic 5-year review. J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.9592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
9592 Background: Palliative care (PC) is an essential part of the continuum of care for cancer (CA) patients (pts). Little is known about the aggregate characteristics and survival of pts receiving inpatient palliative care consultation (PCC). Methods: We reviewed data prospectively collected on patients seen by the Palliative Care Inpatient Consult Service at Mayo Clinic - Rochester from 2003–2008. Demographics, consult characteristics, and survival were analyzed. Kaplan-Meier survival curves and a Cox model of survival were produced. Results: 1794 total patients were seen over the five year period. Cancer is the most common primary diagnosis (47%). Growth in annual PCC has risen dramatically (113 in 2003 vs. 414 in 2007) despite stable total hospital admissions. Patient are predominantly men (52% vs. 48%, p=0.02); median age is 76. General medicine, medical cardiology, and medical intensive care unit services refer most often. Most frequent issues addressed are goals of care, dismissal planning, and pain control (29%, 19%, 17%). PCC in actively dying pts have increased with 27% of all non-operating room, non-trauma in-hospital deaths being seen. Although CA pts have the highest median survival after PCC vs. other diagnoses (17 days, p = 0.018), we observed a five-year trend of decreasing survival from admission to death and PCC to death. Median time from admission to death in CA pts is 36 days in 2003 and 19 days in 2008 (p<0.01). Median time from PCC to death is 33 versus 11.5 days (p<0.01). Despite this, median hospital length of stay and time from PCC to discharge have remained fixed at 8 and 2.5 days, respectively. A Cox model of survival to discharge and <6 months survival (hospice eligibility) shows hospital length of stay, time from consult to discharge, and dismissal location from hospital are all prognostic factors. Conclusions: Survival window for PC intervention for CA pts is lessening. With the trend of shorter survival after PCC, PC professionals have little over two days to implement a comprehensive, ongoing care plan. This highlights the importance of earlier outpatient palliative care involvement with advanced cancer patients and families. No significant financial relationships to disclose.
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Affiliation(s)
- A. H. Kamal
- Mayo Clinic College of Medicine, Rochester, MN
| | - K. M. Swetz
- Mayo Clinic College of Medicine, Rochester, MN
| | - H. Liu
- Mayo Clinic College of Medicine, Rochester, MN
| | - S. R. Ruegg
- Mayo Clinic College of Medicine, Rochester, MN
| | - E. C. Carey
- Mayo Clinic College of Medicine, Rochester, MN
| | - K. Whitford
- Mayo Clinic College of Medicine, Rochester, MN
| | - F. A. Bock
- Mayo Clinic College of Medicine, Rochester, MN
| | | | | | - J. S. Kaur
- Mayo Clinic College of Medicine, Rochester, MN
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O'Brien JE, Haley SM, Dumas HM, Ladenheim B, Mast J, Burke SA, Birnkrant DJ, Whitford K, Coletti DJ, Simpser EF, Pelegano J, Neufeld JA, Kharasch VS. Outcomes of post-acute hospital episodes for young children requiring airway support. Dev Neurorehabil 2007; 10:241-7. [PMID: 17564864 DOI: 10.1080/17518420701302712] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In this descriptive study, we examined changes in invasive and non-invasive airway support; studied the rates of home discharge vs. long-term care or acute hospitalization; and examined the relationship between the level of airway support and discharge to home for 92 children (<3 years of age) with 104 admission-discharge episodes to a consortium of pediatric rehabilitation hospitals over a one-year period. We found a significant reduction (p < 0.001) in the level of airway support between admission and discharge. In 21 of 47 (45%) episodes, children weaned from mechanical ventilation to a less restrictive type of support. Sixty percent of the children had final discharges to home. There was a significant, though fair correlation (Spearman Rho = -0.344, p = 0.001) between home discharge and level of airway support. These outcomes data provide a multi-site baseline for understanding expected changes in airway support and home discharge rates of young children who are admitted to a post-acute inpatient program.
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Affiliation(s)
- Jane E O'Brien
- Research Centre, Franciscan Hospital for Children, Boston, MA 02135, USA
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O'Brien JE, Dumas HM, Haley SM, Ladenheim B, Mast J, Burke SA, Birnkrant DJ, Whitford K, Palazzo R, Neufeld JA, Kharasch VS. Ventilator weaning outcomes in chronic respiratory failure in children. Int J Rehabil Res 2007; 30:171-4. [PMID: 17473631 DOI: 10.1097/mrr.0b013e32813a2e24] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The purpose of this study was to describe mechanical ventilation weaning outcomes for children with chronic respiratory failure discharged from one of six post-acute rehabilitation facilities. Demographic, clinical and outcome data were collected from the medical record. Forty-four children were included in this prospective series; 20 (45%) were weaned off the ventilator at discharge. Children required significantly lower levels of ventilatory support at discharge than admission. Hourly use on the ventilator decreased from admission to discharge for the full cohort and for the subgroup who required a ventilator at discharge. Seventy-five percent of the children discharged with a ventilator had a portable unit. We conclude that nearly half of the children using mechanical ventilation achieve weaning during a postacute rehabilitation admission, whereas others have positive outcomes in severity, hours off the ventilator or portability of equipment.
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Stoneman GL, Crombie DS, Whitford K, Hingston FJ, Giles R, Portlock CC, Galbraith JH, Dimmock GM. Growth and water relations of Eucalyptus marginata (jarrah) stands in response to thinning and fertilization. Tree Physiol 1997; 17:267-274. [PMID: 14759866 DOI: 10.1093/treephys/17.4.267] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
We studied the effects of five thinning treatments (T1 = 5.5, T2 = 11, T3 = 16.5, T4 = 22.5 and T5 = 28.5 m(2) ha(-1) basal area under bark) x two fertilizer treatments (F0 = unfertilized and F1 = fertilized with 400 kg ha(-1) N plus 229 kg ha(-1) P) on growth and water relations of pole-sized Eucalyptus marginata J. Donn ex Sm. trees growing in southwestern Australia. Thinning reduced leaf area index (LAI) from 2.1 in the T4 and T5 treatments to 0.8 in the T1F0 treatment. Fertilizer had no effect on LAI in the T2, T4 or T5 treatments, but increased LAI by 45 and 20% in the T1 and T3 treatments, respectively. Thinning plus fertilizing increased diameter growth most in the fastest growing trees, from 0.4 cm year(-1) for trees in the T5F0 and T5F1 treatments to 0.7 and 1.2 cm year(-1) for trees in the T1F0 and T1F1 treatments, respectively. In both fertilizer treatments, stand basal area and volume growth increased with increasing stand density up to 15 m(2) ha(-1), and thereafter declined with increasing stand density, such that the growth rate of trees in the T5 treatment was only half of that at a stand density of 15 m(2) ha(-1). In response to fertilizer, growth rates of the slowest and fastest-growing trees increased from 0.35 and 3.5 m(2) ha(-1) year(-1) (F0) to 0.56 and 5.4 m(3) ha(-1) year(-1) (F1), respectively. Stand growth efficiency (growth per unit LAI) increased in response to thinning, and fertilizer increased stand growth efficiency at all stand densities. Throughout the dry season, T5 trees had lower predawn shoot water potentials (Psi(pd)) (minimum of -1.5 MPa) than T1 or T2 trees (minimum of -0.7 MPa). Fertilizer decreased Psi(pd) in T5 trees (by -0.9 and -1.5 MPa, respectively, in F0 and F1), but not in T1 or T2 trees. Stand growth rate was closely related to cumulative midday water stress (CMWS) over the dry season, and volume growth rate declined sharply from 6 m(3) ha(-1) year(-1) at a CMWS of 130 MPa days, to zero at a CMWS of 220 MPa days. Application of fertilizer to thinned stands increased LAI, stand growth efficiency and stand growth. In unthinned stands, fertilizer increased stand growth efficiency and stand growth; however, it also increased tree water stress, which limited the fertilizer-induced increases in LAI and growth. We attribute the increase in tree and stand growth in response to application of fertilizer to increased photosynthetic rates, increased allocation to stem wood, and in thinned stands also to higher LAIs.
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Affiliation(s)
- G L Stoneman
- Department of Conservation and Land Management, Research Centre, Dwellingup, WA 6213, Australia
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Metz LC, Whitford K. Fluid delivery by pressure monitoring systems in the pediatric intensive care unit: a retrospective comparative analysis of two systems. Am J Crit Care 1996; 5:66-7. [PMID: 8680495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- L C Metz
- Rainbow Babies and Childrens Hospital, Cleveland, Ohio, USA.
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Metz LC, Whitford K. Fluid delivery by pressure monitoring systems in the pediatric intensive care unit: a retrospective comparative analysis of two systems. Am J Crit Care 1996. [DOI: 10.4037/ajcc1996.5.1.66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Abstract
The function of Class II molecules in proliferation was explored by treating human cell lines with three distinct anti-DR monoclonal antibodies (MABs). Dose-dependent, specific inhibition of eight DR+ cell lines of different origin and lineage was found. Inhibition was durable (i.e., cells did not become resistant to the anti-DR MABs despite prolonged treatment) yet reversible. The mechanism of inhibition was not due to differentiation or killing but was cytostatic. Inhibition was temporally associated with decreases in nuclear size and irregularity and appeared to be due to a non-phase-specific cell cycle arrest.
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Affiliation(s)
- L Vaickus
- Department of Medicine, University of Iowa College of Medicine, Iowa City
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