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Lion KC, Arthur KC, Frías García M, Hsu C, Sotelo Guerra LJ, Chisholm H, Griego E, Ebel BE, Penfold RB, Rafton S, Zhou C, Mangione-Smith R. Pilot Evaluation of the Family Bridge Program: A Communication- and Culture-Focused Inpatient Patient Navigation Program. Acad Pediatr 2024; 24:33-42. [PMID: 37354947 DOI: 10.1016/j.acap.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 06/17/2023] [Accepted: 06/18/2023] [Indexed: 06/26/2023]
Abstract
OBJECTIVE Children with low income and minority race and ethnicity have worse hospital outcomes due partly to systemic and interpersonal racism causing communication and system barriers. We tested the feasibility and acceptability of a novel inpatient communication-focused navigation program. METHODS Multilingual design workshops with parents, providers, and staff created the Family Bridge Program. Delivered by a trained navigator, it included 1) hospital orientation; 2) social needs screening and response; 3) communication preference assessment; 4) communication coaching; 5) emotional support; and 6) a post-discharge phone call. We enrolled families of hospitalized children with public or no insurance, minority race or ethnicity, and preferred language of English, Spanish, or Somali in a single-arm trial. We surveyed parents at enrollment and 2 to 4 weeks post-discharge, and providers 2 to 3 days post-discharge. Survey measures were analyzed with paired t tests. RESULTS Of 60 families enrolled, 57 (95%) completed the follow-up survey. Most parents were born outside the United States (60%) with a high school degree or less (60%). Also, 63% preferred English, 33% Spanish, and 3% Somali. The program was feasible: families received an average of 5.3 of 6 components; all received >2. Most caregivers (92%) and providers (81% [30/37]) were "very satisfied." Parent-reported system navigation improved from enrollment to follow-up (+8.2 [95% confidence interval 2.9, 13.6], P = .003; scale 0-100). Spanish-speaking parents reported decreased skills-related barriers (-18.4 [95% confidence interval -1.8, -34.9], P = .03; scale 0-100). CONCLUSIONS The Family Bridge Program was feasible, acceptable, and may have potential for overcoming barriers for hospitalized children at risk for disparities.
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Affiliation(s)
- K Casey Lion
- Center for Child Health, Behavior and Development (K Casey Lion, KC Arthur, MF García, LJ Sotelo Guerra, H Chisholm, BE Ebel, C Zhou, and R Mangione-Smith), Seattle Children's Research Institute, Seattle, Wash; Department of Pediatrics (K Casey Lion, E Griego, BE Ebel, C Zhou, and R Mangione-Smith), University of Washington School of Medicine, Seattle, Wash.
| | - Kimberly C Arthur
- Center for Child Health, Behavior and Development (K Casey Lion, KC Arthur, MF García, LJ Sotelo Guerra, H Chisholm, BE Ebel, C Zhou, and R Mangione-Smith), Seattle Children's Research Institute, Seattle, Wash
| | - Mariana Frías García
- Center for Child Health, Behavior and Development (K Casey Lion, KC Arthur, MF García, LJ Sotelo Guerra, H Chisholm, BE Ebel, C Zhou, and R Mangione-Smith), Seattle Children's Research Institute, Seattle, Wash
| | - Clarissa Hsu
- Kaiser Permanente Washington Health Research Institute (C Hsu and RB Penfold), Seattle, Wash
| | - Laura J Sotelo Guerra
- Center for Child Health, Behavior and Development (K Casey Lion, KC Arthur, MF García, LJ Sotelo Guerra, H Chisholm, BE Ebel, C Zhou, and R Mangione-Smith), Seattle Children's Research Institute, Seattle, Wash
| | - Hillary Chisholm
- Center for Child Health, Behavior and Development (K Casey Lion, KC Arthur, MF García, LJ Sotelo Guerra, H Chisholm, BE Ebel, C Zhou, and R Mangione-Smith), Seattle Children's Research Institute, Seattle, Wash
| | - Elena Griego
- Department of Pediatrics (K Casey Lion, E Griego, BE Ebel, C Zhou, and R Mangione-Smith), University of Washington School of Medicine, Seattle, Wash
| | - Beth E Ebel
- Center for Child Health, Behavior and Development (K Casey Lion, KC Arthur, MF García, LJ Sotelo Guerra, H Chisholm, BE Ebel, C Zhou, and R Mangione-Smith), Seattle Children's Research Institute, Seattle, Wash; Department of Pediatrics (K Casey Lion, E Griego, BE Ebel, C Zhou, and R Mangione-Smith), University of Washington School of Medicine, Seattle, Wash
| | - Robert B Penfold
- Kaiser Permanente Washington Health Research Institute (C Hsu and RB Penfold), Seattle, Wash
| | - Sarah Rafton
- Center for Diversity and Health Equity, Seattle Children's Hospital (S Rafton), Seattle, Wash
| | - Chuan Zhou
- Center for Child Health, Behavior and Development (K Casey Lion, KC Arthur, MF García, LJ Sotelo Guerra, H Chisholm, BE Ebel, C Zhou, and R Mangione-Smith), Seattle Children's Research Institute, Seattle, Wash; Department of Pediatrics (K Casey Lion, E Griego, BE Ebel, C Zhou, and R Mangione-Smith), University of Washington School of Medicine, Seattle, Wash
| | - Rita Mangione-Smith
- Center for Child Health, Behavior and Development (K Casey Lion, KC Arthur, MF García, LJ Sotelo Guerra, H Chisholm, BE Ebel, C Zhou, and R Mangione-Smith), Seattle Children's Research Institute, Seattle, Wash; Department of Pediatrics (K Casey Lion, E Griego, BE Ebel, C Zhou, and R Mangione-Smith), University of Washington School of Medicine, Seattle, Wash
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Reyes MA, Etinger V, Hronek C, Hall M, Davidson A, Mangione-Smith R, Kaiser SV, Parikh K. Pediatric Respiratory Illnesses: An Update on Achievable Benchmarks of Care. Pediatrics 2023; 152:e2022058389. [PMID: 37403624 DOI: 10.1542/peds.2022-058389] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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] [Accepted: 04/24/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Pediatric respiratory illnesses (PRI): asthma, bronchiolitis, pneumonia, croup, and influenza are leading causes of pediatric hospitalizations, and emergency department (ED) visits in the United States. There is a lack of standardized measures to assess the quality of hospital care delivered for these conditions. We aimed to develop a measure set for automated data extraction from administrative data sets and evaluate its performance including updated achievable benchmarks of care (ABC). METHODS A multidisciplinary subject-matter experts team selected quality measures from multiple sources. The measure set was applied to the Public Health Information System database (Children's Hospital Association, Lenexa, KS) to cohorts of ED visits and hospitalizations from 2017 to 2019. ABC for pertinent measures and performance gaps of mean values from the ABC were estimated. ABC were compared with previous reports. RESULTS The measure set: PRI report includes a total of 94 quality measures. The study cohort included 984 337 episodes of care, and 82.3% were discharged from the ED. Measures with low performance included bronchodilators (19.7%) and chest x-rays (14.4%) for bronchiolitis in the ED. These indicators were (34.6%) and (29.5%) in the hospitalized cohort. In pneumonia, there was a 57.3% use of narrow spectrum antibiotics. In general, compared with previous reports, there was improvement toward optimal performance for the ABCs. CONCLUSIONS The PRI report provides performance data including ABC and identifies performance gaps in the quality of care for common respiratory illnesses. Future directions include examining health inequities, and understanding and addressing the effects of the coronavirus disease 2019 pandemic on care quality.
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Affiliation(s)
- Mario A Reyes
- Division of Hospital Medicine, Department of Pediatrics, Nicklaus Children's Hospital, Florida International University, Herbert Wertheim College of Medicine
| | - Veronica Etinger
- Division of Hospital Medicine, Department of Pediatrics, Nicklaus Children's Hospital, Florida International University, Herbert Wertheim College of Medicine
| | | | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | | | | | - Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, California
- Philip R. Lee Institute for Health Policy Studies, San Francisco, California
| | - Kavita Parikh
- Children's National Hospital, Washington, District of Columbia
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Hoopes AJ, Cushing-Haugen KL, Coley RY, Fuller S, White C, Ralston JD, Mangione-Smith R. Characteristics of Adolescents Who Use Secure Messaging on a Health System's Patient Portal. Pediatrics 2023:191474. [PMID: 37271795 DOI: 10.1542/peds.2022-060271] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 06/06/2023] Open
Abstract
OBJECTIVES To determine adolescent characteristics associated with patient portal secure messaging use within a health system. METHODS This study analyzed monthly data from individuals aged 13 to 17 who met study eligibility criteria from 2019 to 2021. The primary outcome was any secure messages sent from an adolescent's account during each observed month. Unadjusted and adjusted associations between adolescent characteristics and secure messaging use were assessed using generalized estimating equations with log link and binomial variance. RESULTS Of 667 678 observed months, 50.8% occurred among males who were not transgender, 51.5% among those identifying as non-Hispanic white, and 83.3% among the privately insured. The adjusted relative risks of secure messaging use were significantly higher for individuals with female sex and transgender identities (female sex, not transgender: adjusted relative risk [aRR] 1.41, 95% confidence interval [CI] 1.31-1.52; male sex, transgender: aRR 2.39, CI 1.98-2.90, female sex, transgender: aRR 3.01, 95% CI 2.63-3.46; referent male sex, not transgender), those with prior portal use (aRR 22.06, 95% CI 20.48-23.77; referent no use) and those with a recent preventive care visit (aRR 1.09, 95% CI 1.02-1.16; referent no recent visits). The adjusted relative risks of portal secure messaging use were significantly lower among those with public insurance (aRR 0.58, 95% CI 0.50-0.67; referent private). CONCLUSIONS Adolescents who sent patient portal secure messages differed from those who did not. Interventions to encourage secure messaging use may require tailoring based on patient characteristics.
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Affiliation(s)
- Andrea J Hoopes
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; and
| | | | - R Yates Coley
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; and
| | - Sharon Fuller
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; and
| | - Cicely White
- Kaiser Permanente Washington, Seattle, Washington
| | - James D Ralston
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; and
| | - Rita Mangione-Smith
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; and
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Desai AD, Tolpadi A, Parast L, Esporas M, Britto MT, Gidengil C, Wilson K, Bardach NS, Basco WT, Brittan MS, Johnson DP, Wood KE, Yung S, Dawley E, Fiore D, Gregoire L, Hodo LN, Leggett B, Piazza K, Sartori LF, Weber DE, Mangione-Smith R. Improving the Quality of Written Discharge Instructions: A Multisite Collaborative Project. Pediatrics 2023; 151:191090. [PMID: 37078242 DOI: 10.1542/peds.2022-059452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Written discharge instructions help to bridge hospital-to-home transitions for patients and families, though substantial variation in discharge instruction quality exists. We aimed to assess the association between participation in an Institute for Healthcare Improvement Virtual Breakthrough Series collaborative and the quality of pediatric written discharge instructions across 8 US hospitals. METHODS We conducted a multicenter, interrupted time-series analysis of a medical records-based quality measure focused on written discharge instruction content (0-100 scale, higher scores reflect better quality). Data were from random samples of pediatric patients (N = 5739) discharged from participating hospitals between September 2015 and August 2016, and between December 2017 and January 2020. These periods consisted of 3 phases: 1. a 14-month precollaborative phase; 2. a 12-month quality improvement collaborative phase when hospitals implemented multiple rapid cycle tests of change and shared improvement strategies; and 3. a 12-month postcollaborative phase. Interrupted time-series models assessed the association between study phase and measure performance over time, stratified by baseline hospital performance, adjusting for seasonality and hospital fixed effects. RESULTS Among hospitals with high baseline performance, measure scores increased during the quality improvement collaborative phase beyond the expected precollaborative trend (+0.7 points/month; 95% confidence interval, 0.4-1.0; P < .001). Among hospitals with low baseline performance, measure scores increased but at a lower rate than the expected precollaborative trend (-0.5 points/month; 95% confidence interval, -0.8 to -0.2; P < .01). CONCLUSIONS Participation in this 8-hospital Institute for Healthcare Improvement Virtual Breakthrough Series collaborative was associated with improvement in the quality of written discharge instructions beyond precollaborative trends only for hospitals with high baseline performance.
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Affiliation(s)
- Arti D Desai
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | | | | | - Megan Esporas
- Children's Hospital Association, Washington, District of Columbia
| | - Maria T Britto
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Karen Wilson
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Naomi S Bardach
- Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, California
| | - William T Basco
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Mark S Brittan
- Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - David P Johnson
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Kelly E Wood
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Steven Yung
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Erin Dawley
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Darren Fiore
- Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, California
| | | | - Laura N Hodo
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Brett Leggett
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Kirstin Piazza
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Laura F Sartori
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Danielle E Weber
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
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Leyenaar JK, Tolpadi A, Parast L, Esporas M, Britto MT, Gidengil C, Wilson KM, Bardach NS, Basco WT, Brittan MS, Williams DJ, Wood KE, Yung S, Dawley E, Elliott A, Manges KA, Plemmons G, Rice T, Wiener B, Mangione-Smith R. Collaborative to Increase Lethal Means Counseling for Caregivers of Youth With Suicidality. Pediatrics 2022; 150:e2021055271. [PMID: 36321386 PMCID: PMC10578326 DOI: 10.1542/peds.2021-055271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Accepted: 09/19/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The number of youth presenting to hospitals with suicidality and/or self-harm has increased substantially in recent years. We implemented a multihospital quality improvement (QI) collaborative from February 1, 2018 to January 31, 2019, aiming for an absolute increase in hospitals' mean rate of caregiver lethal means counseling (LMC) of 10 percentage points (from a baseline mean performance of 68% to 78%) by the end of the collaborative, and to evaluate the effectiveness of the collaborative on LMC, adjusting for secular trends. METHODS This 8 hospital collaborative used a structured process of alternating learning sessions and action periods to improve LMC across hospitals. Electronic medical record documentation of caregiver LMC was evaluated during 3 phases: precollaborative, active QI collaborative, and postcollaborative. We used statistical process control to evaluate changes in LMC monthly. Following collaborative completion, interrupted time series analyses were used to evaluate changes in the level and trend and slope of LMC, adjusting for covariates. RESULTS In the study, 4208 children and adolescents were included-1314 (31.2%) precollaborative, 1335 (31.7%) during the active QI collaborative, and 1559 (37.0%) postcollaborative. Statistical process control analyses demonstrated that LMC increased from a hospital-level mean of 68% precollaborative to 75% (February 2018) and then 86% (October 2018) during the collaborative. In interrupted time series analyses, there were no significant differences in LMC during and following the collaborative beyond those expected based on pre-collaborative trends. CONCLUSIONS LMC increased during the collaborative, but the increase did not exceed expected trends. Interventions developed by participating hospitals may be beneficial to others aiming to improve LMC for caregivers of hospitalized youth with suicidality.
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Affiliation(s)
- JoAnna K. Leyenaar
- Department of Pediatrics and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | | | | | - Megan Esporas
- Children’s Hospital Association, Washington, District of Columbia
| | - Maria T. Britto
- Department of Pediatrics and Patient Services, Cincinnati Children’s Hospital Medical Center, and the University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Karen M. Wilson
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, New York
| | - Naomi S. Bardach
- Department of Pediatrics, Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California
| | - William T. Basco
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Mark S. Brittan
- Department of Pediatrics, University of Colorado and Children’s Hospital Colorado, Aurora, Colorado
| | - Derek J. Williams
- Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Kelly E. Wood
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Steven Yung
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Erin Dawley
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Audrey Elliott
- Research Institute, Children’s Hospital Colorado, Aurora, Colorado
| | - Kirstin A. Manges
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Gregory Plemmons
- Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Timothy Rice
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Brandy Wiener
- Department of Pediatrics and Patient Services, Cincinnati Children’s Hospital Medical Center, and the University of Cincinnati College of Medicine, Cincinnati, Ohio
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Mangione-Smith R, Robinson JD, Zhou C, Stout JW, Fiks AG, Shalowitz M, Gerber JS, Burges D, Hedrick B, Warren L, Grundmeier RW, Kronman MP, Shone LP, Steffes J, Wright M, Heritage J. Fidelity evaluation of the dialogue around respiratory illness treatment (DART) program communication training. Patient Educ Couns 2022; 105:2611-2616. [PMID: 35341612 PMCID: PMC9203931 DOI: 10.1016/j.pec.2022.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 03/04/2022] [Accepted: 03/10/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To evaluate receipt fidelity of communication training content included in a multifaceted intervention known to reduce antibiotic over-prescribing for pediatric acute respiratory tract infections (ARTIs), by examining the degree to which clinicians implemented the intended communication behavior changes. METHODS Parents were surveyed regarding clinician communication behaviors immediately after attending 1026 visits by children 6 months to < 11 years old diagnosed with ARTIs by 53 clinicians in 18 pediatric practices. Communication outcomes analyzed were whether clinicians: (A) provided both a combined (negative + positive) treatment recommendation and a contingency plan (full implementation); (B) provided either a combined treatment recommendation or a contingency plan (partial implementation); or (C) provided neither (no implementation). We used mixed effects multinomial logistic regression to determine whether these 3 communication outcomes changed between baseline and the time periods following each of 3 training modules. RESULTS After completing the communication training, the adjusted probability of clinicians fully implementing the intended communication behavior changes increased by an absolute 8.1% compared to baseline (95% Confidence Interval [CI]: 2.4%, 13.8%, p = .005). CONCLUSIONS Our findings support the receipt fidelity of the intervention's communication training content. PRACTICAL IMPLICATIONS Clinicians can be trained to implement communication behaviors that may aid in reducing antibiotic over-prescribing for ARTIs.
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Affiliation(s)
| | - Jeffrey D Robinson
- Department of Communication, Portland State University, Portland, OR, USA.
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Seattle Children's Research Institute, Seattle, WA, USA.
| | - James W Stout
- Department of Pediatrics, University of Washington, Seattle, WA, USA.
| | - Alexander G Fiks
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Primary Care Research, American Academy of Pediatrics, IL, USA.
| | - Madeleine Shalowitz
- Department of Psychiatry and Behavioral Medicine, Rush University School of Medicine, Chicago, IL, USA.
| | - Jeffrey S Gerber
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Dennis Burges
- Department of Pediatrics, University of Washington, Seattle, WA, USA.
| | - Benjamin Hedrick
- Department of Pediatrics, University of Washington, Seattle, WA, USA.
| | - Louise Warren
- Department of Pediatrics, University of Washington, Seattle, WA, USA.
| | - Robert W Grundmeier
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Matthew P Kronman
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Seattle Children's Research Institute, Seattle, WA, USA.
| | - Laura P Shone
- Primary Care Research, American Academy of Pediatrics, IL, USA.
| | | | - Margaret Wright
- Primary Care Research, American Academy of Pediatrics, IL, USA.
| | - John Heritage
- Department of Sociology, University of California Los Angeles, Los Angeles, CA, USA.
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Leyenaar JK, Esporas M, Mangione-Smith R. How Does Pediatric Quality Measure Development Reflect the Real World Needs of Hospitalized Children? Acad Pediatr 2022; 22:S70-S72. [PMID: 35339245 PMCID: PMC9614710 DOI: 10.1016/j.acap.2021.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/14/2021] [Accepted: 01/31/2021] [Indexed: 12/25/2022]
Affiliation(s)
- JoAnna K. Leyenaar
- The Department of Pediatrics and The Dartmouth Institute of Health Policy & Clinical Practice, Dartmouth Hitchcock Medical Center, Lebanon, NH, 03755
| | - Megan Esporas
- Children’s Hospital Association, 600 13th Street, NW, Suite 500, Washington, DC 20005
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Parast L, Burkhart Q, Bardach NS, Thombley R, Basco WT, Barabell G, Williams DJ, Mitchel E, Machado E, Raghavan P, Tolpadi A, Mangione-Smith R. Development and Testing of an Emergency Department Quality Measure for Pediatric Suicidal Ideation and Self-Harm. Acad Pediatr 2022; 22:S92-S99. [PMID: 35339249 PMCID: PMC8969171 DOI: 10.1016/j.acap.2021.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/01/2021] [Accepted: 03/05/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To develop and test a new quality measure assessing timeliness of follow-up mental health care for youth presenting to the emergency department (ED) with suicidal ideation or self-harm. METHODS Based on a conceptual framework, evidence review, and a modified Delphi process, we developed a quality measure assessing whether youth 5 to 17 years old evaluated for suicidal ideation or self-harm in the ED and discharged to home had a follow-up mental health care visit within 7 days. The measure was tested in 4 geographically dispersed states (California, Pennsylvania, South Carolina, Tennessee) using Medicaid administrative data. We examined measure feasibility of implementation, variation, reliability, and validity. To test validity, adjusted regression models examined associations between quality measure scores and subsequent all-cause and same-cause hospital readmissions/ED return visits. RESULTS Overall, there were 16,486 eligible ED visits between September 1, 2014 and July 31, 2016; 53.5% of eligible ED visits had an associated mental health care follow-up visit within 7 days. Measure scores varied by state, ranging from 26.3% to 66.5%, and by youth characteristics: visits by youth who were non-White, male, and living in an urban area were significantly less likely to be associated with a follow-up visit within 7 days. Better quality measure performance was not associated with decreased reutilization. CONCLUSIONS This new ED quality measure may be useful for monitoring and improving the quality of care for this vulnerable population; however, future work is needed to establish the measure's predictive validity using more prevalent outcomes such as recurrence of suicidal ideation or deliberate self-harm.
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Affiliation(s)
- Layla Parast
- RAND Corporation, Statistics Group (L Parast, Q Burkhart, A Tolpadi), Santa Monica, Calif.
| | - Q Burkhart
- RAND Corporation, Statistics Group (L Parast, Q Burkhart, A Tolpadi), Santa Monica, Calif
| | - Naomi S Bardach
- University of California San Francisco (NS Bardach), San Francisco, Calif
| | - Robert Thombley
- UCSF, Institute for Health Policy Studies (R Thombley), San Francisco, Calif
| | - William T Basco
- The Medical University of South Carolina (WT Bosco), Charleston, SC
| | | | - Derek J Williams
- Division of Hospital Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Monroe Carell Jr. Children's at Vanderbilt (DJ Williams), Nashville, Tenn
| | - Ed Mitchel
- Department of Health Policy, Vanderbilt University School of Medicine (E Mitchel), Nashville, Tenn
| | - Edison Machado
- Kaiser Permanente Washington Health Research Institute (E Machado, R Mangione-Smith), Seattle, Wash
| | | | - Anagha Tolpadi
- RAND Corporation, Statistics Group (L Parast, Q Burkhart, A Tolpadi), Santa Monica, Calif
| | - Rita Mangione-Smith
- Kaiser Permanente Washington Health Research Institute (E Machado, R Mangione-Smith), Seattle, Wash
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9
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Tyler A, Bryan MA, Zhou C, Mangione-Smith R, Williams D, Johnson DP, Kenyon CC, Rasooly I, Neubauer HC, Wilson KM. Variation in Dexamethasone Dosing and Use Outcomes for Inpatient Croup. Hosp Pediatr 2022; 12:22-29. [PMID: 34846064 PMCID: PMC8882347 DOI: 10.1542/hpeds.2021-005854] [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: 01/03/2023]
Abstract
OBJECTIVES Evaluate the association between dexamethasone dosing and outcomes for children hospitalized with croup. METHODS This study was nested within a multisite prospective cohort study of children aged 6 months to 6 years admitted to 1 of 5 US children's hospitals between July 2014 and June /2016. Multivariable linear and logistic mixed-effects regression models were used to examine the association between the number of dexamethasone doses (1 vs >1) and outcomes (length of stay [LOS], cost, and 30-day same-cause reuse). All multivariable analyses included a site-specific random effect to account for clustering within hospital and were adjusted for age, sex, race and ethnicity, presenting severity, medical complexity, insurance, caregiver education, and hospital. In cost analyses, we controlled for LOS. RESULTS Among 234 children hospitalized with croup, patient characteristics did not differ by number of doses. The proportion receiving >1 dose varied by hospital (range 27.9%-57.1%). In adjusted analyses, >1 dose was not associated with same-cause reuse (odds ratio 0.87 [95% confidence interval (CI): 0.26 to 2.95]) but was associated with 45% longer LOS (relative risk = 1.45 [95% CI: 1.30 to 1.62]). When we controlled for LOS, >1 dose was not associated with differential cost ($-31.2 [95% CI $-424.4 to $362.0]). Eighty-two (35%) children received dexamethasone before presentation. CONCLUSIONS We found significant interhospital variation in dexamethasone dosing and LOS. When we controlled for severity on presentation, >1 dexamethasone dose was associated with longer LOS but not reuse. Although incomplete adjustment for severity is one possible explanation, some providers may routinely keep children hospitalized to administer multiple dexamethasone doses.
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Affiliation(s)
- Amy Tyler
- Section of Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO and Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS)
| | - Mersine A. Bryan
- Department of Pediatrics, University of Washington, Seattle, WA,Seattle Children’s Research Institute, Seattle, WA
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, WA,Seattle Children’s Research Institute, Seattle, WA
| | | | - Derek Williams
- Division of Hospital Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - David P. Johnson
- Division of Hospital Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Chén C Kenyon
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia; Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Irit Rasooly
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia; Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Hannah C. Neubauer
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Karen M. Wilson
- Kravis Children’s Hospital at the Icahn School of Medicine at Mount Sinai, New York City, NY
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10
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Connell SK, Burkhart Q, Tolpadi A, Parast L, Gidengil CA, Yung S, Basco WT, Williams D, Britto MT, Brittan M, Wood KE, Bardach N, McGalliard J, Mangione-Smith R. Quality of Care for Youth Hospitalized for Suicidal Ideation and Self-Harm. Acad Pediatr 2021; 21:1179-1186. [PMID: 34058402 PMCID: PMC8448557 DOI: 10.1016/j.acap.2021.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine performance on quality measures for pediatric inpatient suicidal ideation/self-harm care, and whether performance is associated with reutilization. METHODS Retrospective observational 8 hospital study of patients [N = 1090] aged 5 to 17 years hospitalized for suicidal ideation/self-harm between 9/1/14 and 8/31/16. Two medical records-based quality measures assessing suicidal ideation/self-harm care were evaluated, one on counseling caregivers regarding restricting access to lethal means and the other on communication between inpatient and outpatient providers regarding the follow-up plan. Multivariable logistic regression assessed associations between quality measure scores and 1) hospital site, 2) patient demographics, and 3) 30-day emergency department return visits and inpatient readmissions. RESULTS Medical record documentation revealed that, depending on hospital site, 17% to 98% of caregivers received lethal means restriction counseling (mean 70%); inpatient-to-outpatient provider communication was documented in 0% to 51% of cases (mean 16%). The odds of documenting receipt of lethal means restriction counseling was higher for caregivers of female patients compared to caregivers of male patients (adjusted odds ratio [aOR] 1.51, 95% confidence interval [CI], 1.07-2.14). The odds of documenting inpatient-to-outpatient provider follow-up plan communication was lower for Black patients compared to White patients (aOR 0.45, 95% CI, 0.24-0.84). All-cause 30-day readmission was lower for patients with documented caregiver receipt of lethal means restriction counseling (aOR 0.48, 95% CI, 0.28-0.83). CONCLUSIONS This study revealed disparities and deficits in the quality of care received by youth with suicidal ideation/self-harm. Providing caregivers lethal means restriction counseling prior to discharge may help to prevent readmission.
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Affiliation(s)
- Sarah K Connell
- Department of Pediatrics, University of Washington (SK Connell), Seattle, Wash; Center for Child Health, Behavior, and Development, Seattle Children's Research Institute (SK Connell and J McGalliard), Seattle, Wash.
| | - Q Burkhart
- RAND Corporation (Q Burkhart, A Tolpadi, L Parast), Santa Monica, Calif
| | - Anagha Tolpadi
- RAND Corporation (Q Burkhart, A Tolpadi, L Parast), Santa Monica, Calif
| | - Layla Parast
- RAND Corporation (Q Burkhart, A Tolpadi, L Parast), Santa Monica, Calif
| | | | - Steven Yung
- Mount Sinai Hospital (S Yung), New York, NY; Maimonides Medical Center (S Yung), Brooklyn, NY
| | - William T Basco
- Medical University of South Carolina (WT Basco), Charleston, SC
| | - Derek Williams
- Vanderbilt University Medical Center (D Williams), Nashville, Tenn
| | - Maria T Britto
- Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine (MT Britto), Cincinnati, Ohio
| | - Mark Brittan
- Children's Hospital Colorado (M Brittan), Aurora, Colo
| | - Kelly E Wood
- University of Iowa Stead Family Children's Hospital (KE Wood), Iowa City, Iowa
| | - Naomi Bardach
- UCSF Department of Pediatrics (N Bardach), San Francisco, Calif
| | - Julie McGalliard
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute (SK Connell and J McGalliard), Seattle, Wash
| | - Rita Mangione-Smith
- Kaiser Permanente Washington Health Research Institute (R Mangione-Smith), Seattle, Wash
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11
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Test MR, Mangione-Smith R, Zhou C, Wright DR, Halvorson EE, Johnson DP, Williams DJ, Vachani JG, Hitt TA, Tieder JS. Obesity and Health-Related Quality of Life in Children Hospitalized for Acute Respiratory Illness. Hosp Pediatr 2021; 11:841-848. [PMID: 34266983 DOI: 10.1542/hpeds.2020-004531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Obesity has rapidly become a major problem for children that has adverse effects on respiratory health. We sought to assess the impact of obesity on health-related quality of life (HRQOL) and hospital outcomes for children hospitalized with asthma or pneumonia. METHODS In this multicenter prospective cohort study, we evaluated children (aged 2-16 years) hospitalized with an acute asthma exacerbation or pneumonia between July 1, 2014, and June 30, 2016. Subjects or their family completed surveys for child HRQOL (PedsQL Physical Functioning and Psychosocial Functioning Scales, with scores ranging from 0 to 100) on hospital presentation and 2-6 weeks after discharge. BMI categories were defined as normal weight, overweight, and obesity on the basis of BMI percentiles for age and sex per national guidelines. Multivariable regression models were used to examine associations between BMI category and HRQOL, length of stay, and 30-day reuse. RESULTS Among 716 children, 82 (11.4%) were classified as having overweight and 138 (19.3%) as having obesity. For children hospitalized with asthma or pneumonia, obesity was not associated with worse HRQOL at presentation or 2-6 weeks after discharge, hospital length of stay, or 30-day reuse. CONCLUSIONS Nearly 1 in 3 children seen in the hospital for an acute asthma exacerbation or pneumonia had overweight or obesity; however, among the population of children in our study, obesity alone does not appear to be associated with worse HRQOL or hospital outcomes.
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Affiliation(s)
- Matthew R Test
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington.,Seattle Children's Research Institute, Seattle, Washington
| | - Chuan Zhou
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington.,Seattle Children's Research Institute, Seattle, Washington
| | - Davene R Wright
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington.,Seattle Children's Research Institute, Seattle, Washington
| | - Elizabeth E Halvorson
- Department of Pediatrics, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - David P Johnson
- Division of Hospital Medicine, Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt and School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Derek J Williams
- Division of Hospital Medicine, Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt and School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Joyee G Vachani
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Talia A Hitt
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joel S Tieder
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington
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12
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Lion KC, Gritton J, Scannell J, Brown JC, Ebel BE, Klein EJ, Mangione-Smith R. Patterns and Predictors of Professional Interpreter Use in the Pediatric Emergency Department. Pediatrics 2021; 147:peds.2019-3312. [PMID: 33468598 PMCID: PMC7906072 DOI: 10.1542/peds.2019-3312] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [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] [Accepted: 10/26/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Professional interpretation for patients with limited English proficiency remains underused. Understanding predictors of use is crucial for intervention. We sought to identify factors associated with professional interpreter use during pediatric emergency department (ED) visits. METHODS We video recorded ED visits for a subset of participants (n = 50; 20% of the total sample) in a randomized trial of telephone versus video interpretation for Spanish-speaking limited English proficiency families. Medical communication events were coded for duration, health professional type, interpreter (none, ad hoc, or professional), and content. With communication event as the unit of analysis, associations between professional interpreter use and assigned interpreter modality, health professional type, and communication content were assessed with multivariate random-effects logistic regression, clustered on the patient. RESULTS We analyzed 312 communication events from 50 ED visits (28 telephone arm, 22 video arm). Professional interpretation was used for 36% of communications overall, most often for detailed histories (89%) and least often for procedures (11%) and medication administrations (8%). Speaker type, communication content, and duration were all significantly associated with professional interpreter use. Assignment to video interpretation was associated with significantly increased use of professional interpretation for communication with providers (adjusted odds ratio 2.7; 95% confidence interval: 1.1-7.0). CONCLUSIONS Professional interpreter use was inconsistent over the course of an ED visit, even for patients enrolled in an interpretation study. Assignment to video rather than telephone interpretation led to greater use of professional interpretation among physicians and nurse practitioners but not nurses and other staff.
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Affiliation(s)
- K. Casey Lion
- Department of Pediatrics and,Center for Child Health, Behavior and Development and
| | - Jesse Gritton
- Center for Child Health, Behavior and Development and
| | - Jack Scannell
- Center for Child Health, Behavior and Development and
| | - Julie C. Brown
- Department of Pediatrics and,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Beth E. Ebel
- Department of Pediatrics and,Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington; and,Center for Child Health, Behavior and Development and
| | - Eileen J. Klein
- Department of Pediatrics and,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Rita Mangione-Smith
- Department of Pediatrics and,Center for Child Health, Behavior and Development and
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13
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Foster CC, Fuentes MM, Wadlington LA, Jacob-Files E, Desai AD, Simon TD, Mangione-Smith R. Caregiver and provider experiences of physical, occupational, and speech therapy for children with medical complexity. J Pediatr Rehabil Med 2021; 14:505-516. [PMID: 33935115 DOI: 10.3233/prm-190647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Children with medical complexity (CMC) often use rehabilitative services ("therapy") to achieve optimal health outcomes. The study aims were to characterize caregiver and provider experiences with: 1) determining the suitability of therapy and 2) obtaining therapy for CMC. METHODS Primary caregivers of CMC (n = 20) and providers (n = 14) were interviewed using semi-structured questions to elicit experiences of therapy. Interviews were recorded, transcribed and coded to identify caregiver and provider reported themes. Applied thematic analysis was used to characterize themes related to study objectives. RESULTS Participants endorsed challenges setting therapy goals amongst competing patient and family priorities. They also identified logistical challenges to obtaining therapy, including transition from early intervention services to school-based years. Participants raised concerns about variability in obtaining school-based therapy and insurance coverage of community-based therapy. Overall, funding, salary, credentialing requirements, and training impacts the pediatric therapy workforce's ability to meet the need of CMC. CONCLUSION Setting the ideal "dose" of therapy within the individual and family context can be challenging for CMC. Sufficient government programming, insurance coverage, and workforce availability were barriers to obtaining services. This study adds a more detailed understanding of therapy for CMC that can be used to inform future research and policy work.
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Affiliation(s)
- Carolyn C Foster
- Department of Pediatrics, University of Washington, Seattle, WA, USA.,Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, USA
| | - Molly M Fuentes
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, USA.,Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.,Harborview Injury Prevention and Research Center, Seattle, WA, USA.,Department of Social Work, Seattle Children's Hospital, Seattle, WA, USA
| | | | - Elizabeth Jacob-Files
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, USA
| | - Arti D Desai
- Department of Pediatrics, University of Washington, Seattle, WA, USA.,Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, USA
| | - Tamara D Simon
- Department of Pediatrics, University of Washington, Seattle, WA, USA.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, WA, USA.,Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, USA
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14
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Bryan MA, Tyler A, Zhou C, Williams DJ, Johnson DP, Kenyon CC, Haq H, Simon TD, Mangione-Smith R. Associations Between Quality Measures and Outcomes for Children Hospitalized With Bronchiolitis. Hosp Pediatr 2020; 10:932-940. [PMID: 33106253 DOI: 10.1542/hpeds.2020-0175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To use adherence to the Pediatric Respiratory Illness Measurement System (PRIMES) indicators to evaluate the strength of associations for individual indicators with length of stay (LOS) and cost for bronchiolitis. METHODS We prospectively enrolled children with bronchiolitis at 5 children's hospitals between July 1, 2014, and June 30, 2016. We examined associations between adherence to each individual PRIMES indicator for bronchiolitis and LOS and cost. Sixteen indicators were included, 9 "overuse" indicators for care that should not occur and 7 "underuse" indicators for care that should occur. We performed mixed effects linear regression to examine the association between adherence to each individual indicator and LOS (hours) and cost (dollars). All models controlled for patient demographics, patient complexity, and hospital. RESULTS We enrolled 699 participants. The mean age was 8 months; 56% were male, 38% were white, and 63% had public insurance. Three indicators were significantly associated with shorter LOS and lower cost. All 3 indicators were overuse indicators and related to laboratory testing: no blood cultures (adjusted mean difference in LOS: -24.3 hours; adjusted mean cost difference: -$731, P < .001), no complete blood cell counts (LOS: -17.8 hours; cost: -$399, P < .05), and no respiratory syncytial virus testing (LOS: -16.6 hours; cost: -$272, P < .05). Two underuse indicators were associated with higher cost: documentation of oral intake at discharge ($671, P < .01) and documentation of hospital follow-up ($538, P < .05). CONCLUSIONS A subset of PRIMES quality indicators for bronchiolitis are strongly associated with improved outcomes and can serve as important measures for future quality improvement efforts.
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Affiliation(s)
- Mersine A Bryan
- Department of Pediatrics, University of Washington, Seattle, Washington; .,Seattle Children's Research Institute, Seattle, Washington
| | - Amy Tyler
- Section of Hospital Medicine, Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, Washington.,Seattle Children's Research Institute, Seattle, Washington
| | - Derek J Williams
- Division of Hospital Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt and Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - David P Johnson
- Division of Hospital Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt and Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Chén C Kenyon
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia and Department of Pediatrics, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Heather Haq
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Tamara D Simon
- Division of Hospital Medicine, Children's Hospital of Los Angeles, Los Angeles, California; and
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15
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Kronman MP, Gerber JS, Grundmeier RW, Zhou C, Robinson JD, Heritage J, Stout J, Burges D, Hedrick B, Warren L, Shalowitz M, Shone LP, Steffes J, Wright M, Fiks AG, Mangione-Smith R. Reducing Antibiotic Prescribing in Primary Care for Respiratory Illness. Pediatrics 2020; 146:e20200038. [PMID: 32747473 PMCID: PMC7461202 DOI: 10.1542/peds.2020-0038] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [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] [Accepted: 05/15/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND One-third of outpatient antibiotic prescriptions for pediatric acute respiratory tract infections (ARTIs) are inappropriate. We evaluated a distance learning program's effectiveness for reducing outpatient antibiotic prescribing for ARTI visits. METHODS In this stepped-wedge clinical trial run from November 2015 to June 2018, we randomly assigned 19 pediatric practices belonging to the Pediatric Research in Office Settings Network or the NorthShore University HealthSystem to 4 wedges. Visits for acute otitis media, bronchitis, pharyngitis, sinusitis, and upper respiratory infection for children 6 months to <11 years old without recent antibiotic use were included. Clinicians received the intervention as 3 program modules containing online tutorials and webinars on evidence-based communication strategies and antibioti c prescribing, booster video vignettes, and individualized antibiotic prescribing feedback reports over 11 months. The primary outcome was overall antibiotic prescribing rates for all ARTI visits. Mixed-effects logistic regression compared prescribing rates during each program module and a postintervention period to a baseline control period. Odds ratios were converted to adjusted rate ratios (aRRs) for interpretability. RESULTS Among 72 723 ARTI visits by 29 762 patients, intention-to-treat analyses revealed a 7% decrease in the probability of antibiotic prescribing for ARTI overall between the baseline and postintervention periods (aRR 0.93; 95% confidence interval [CI], 0.90-0.96). Second-line antibiotic prescribing decreased for streptococcal pharyngitis (aRR 0.66; 95% CI, 0.50-0.87) and sinusitis (aRR 0.59; 95% CI, 0.44-0.77) but not for acute otitis media (aRR 0.93; 95% CI, 0.83-1.03). Any antibiotic prescribing decreased for viral ARTIs (aRR 0.60; 95% CI, 0.51-0.70). CONCLUSIONS This program reduced antibiotic prescribing during outpatient ARTI visits; broader dissemination may be beneficial.
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Affiliation(s)
- Matthew P Kronman
- Department of Pediatrics, University of Washington, Seattle, Washington;
- Seattle Children's Research Institute, Seattle, Washington
| | - Jeffrey S Gerber
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert W Grundmeier
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
| | - Jeffrey D Robinson
- Department of Communication, College of Liberal Arts and Sciences, Portland State University, Portland, Oregon
| | - John Heritage
- Department of Sociology, University of California, Los Angeles, Los Angeles, California
| | - James Stout
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Dennis Burges
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Benjamin Hedrick
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Louise Warren
- Department of Pediatrics, University of Washington, Seattle, Washington
| | | | - Laura P Shone
- Primary Care Research, American Academy of Pediatrics, Itasca, Illinois; and
| | - Jennifer Steffes
- Primary Care Research, American Academy of Pediatrics, Itasca, Illinois; and
| | - Margaret Wright
- Primary Care Research, American Academy of Pediatrics, Itasca, Illinois; and
| | - Alexander G Fiks
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Primary Care Research, American Academy of Pediatrics, Itasca, Illinois; and
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16
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Dublin S, Wartko P, Mangione-Smith R. Studying Medication Safety in Pregnancy: A Call for New Approaches, Resources, and Collaborations. Pediatrics 2020; 146:peds.2020-1540. [PMID: 32513842 DOI: 10.1542/peds.2020-1540] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; and .,Departments of Epidemiology and
| | - Paige Wartko
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; and
| | - Rita Mangione-Smith
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington; and.,Health Services, University of Washington, Seattle, Washington
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17
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Foster CC, Simon TD, Qu P, Holmes P, Chang JK, Ramos JL, Koutlas A, Rivara FP, Melzer SM, Mangione-Smith R. Social Determinants of Health and Emergency and Hospital Use by Children With Chronic Disease. Hosp Pediatr 2020; 10:471-480. [PMID: 32423995 DOI: 10.1542/hpeds.2019-0248] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To evaluate the association between caregiver-reported social determinants of health (SDOH) and emergency department (ED) visits and hospitalizations by children with chronic disease. METHODS This was a nested retrospective cohort study (December 2015 to May 2017) of children (0-18 years) receiving Supplemental Security Income and Medicaid enrolled in a case management program. Caregiver assessments were coded for 4 SDOH: food insecurity, housing insecurity, caregiver health concerns, and safety concerns. Multivariable hurdle Poisson regression was used to assess the association between SDOH with ED and hospital use for 1 year, adjusting for age, sex, and race and ethnicity. ED use was also adjusted for medical complexity. RESULTS A total of 226 children were included. Patients were 9.1 years old (SD: 4.9), 60% male, and 30% Hispanic. At least 1 SDOH was reported by 59% of caregivers, including food insecurity (37%), housing insecurity (23%), caregiver health concerns (18%), and safety concerns (11%). Half of patients had an ED visit (55%) (mean: 1.5 per year [SD: 2.4]), and 20% were hospitalized (mean: 0.4 per year [SD: 1.1]). Previously unaddressed food insecurity was associated with increased ED use in the subsequent year (odds ratio: 3.43 [1.17-10.05]). Among those who had ≥1 ED visit, the annualized ED rate was higher in patients with a previously unaddressed housing insecurity (rate ratio: 1.55 [1.14-2.09]) or a safety concern (rate ratio: 2.04 [1.41-2.96]). CONCLUSIONS Over half of caregivers of children with chronic disease enrolled in a case management program reported an SDOH insecurity or concern. Patients with previously unaddressed food insecurity had higher ED rates but not hospitalization rates.
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Affiliation(s)
- Carolyn C Foster
- Department of Pediatrics, School of Medicine and .,Centers for Child Health, Behavior and Development and
| | - Tamara D Simon
- Department of Pediatrics, School of Medicine and.,Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Pingping Qu
- Centers for Child Health, Behavior and Development and
| | - Paula Holmes
- Seattle Children's Hospital, Seattle, Washington; and
| | - Jason K Chang
- Seattle Children's Hospital, Seattle, Washington; and
| | | | | | - Frederick P Rivara
- Department of Pediatrics, School of Medicine and.,Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington.,Centers for Child Health, Behavior and Development and.,Harborview Injury Prevention and Research Center, Seattle, Washington
| | - Sanford M Melzer
- Department of Pediatrics, School of Medicine and.,Centers for Child Health, Behavior and Development and
| | - Rita Mangione-Smith
- Department of Pediatrics, School of Medicine and.,Centers for Child Health, Behavior and Development and
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18
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Desai AD, Zhou C, Haaland W, Johnson J, Lion KC, Lopez MA, Williams DJ, Kenyon CC, Mangione-Smith R, Johnson DP. Social Disadvantage, Access to Care, and Disparities in Physical Functioning Among Children Hospitalized with Respiratory Illness. J Hosp Med 2020; 15:211-218. [PMID: 32118564 PMCID: PMC7153490 DOI: 10.12788/jhm.3359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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 AND OBJECTIVES Understanding disparities in child health-related quality of life (HRQoL) may reveal opportunities for targeted improvement. This study examined associations between social disadvantage, access to care, and child physical functioning before and after hospitalization for acute respiratory illness. METHODS From July 1, 2014, to June 30, 2016, children ages 8-16 years and/or caregivers of children 2 weeks to 16 years admitted to five tertiary care children's hospitals for three common respiratory illnesses completed a survey on admission and within 2 to 8 weeks after discharge. Survey items assessed social disadvantage (minority race/ ethnicity, limited English proficiency, low education, and low income), difficulty/delays accessing care, and baseline and follow-up HRQoL physical functioning using the Pediatric Quality of Life Inventory (PedsQL, range 0-100). We examined associations between these three variables at baseline and follow-up using multivariable, mixed-effects linear regression models with multiple imputation sensitivity analyses for missing data. RESULTS A total of 1,325 patients and/or their caregivers completed both PedsQL assessments. Adjusted mean baseline PedsQL scores were significantly lower for patients with social disadvantage markers, compared with those of patients with none (78.7 for >3 markers versus 85.5 for no markers, difference -6.1 points (95% CI: -8.7, -3.5). The number of social disadvantage markers was not associated with mean follow-up PedsQL scores. Difficulty/delays accessing care were associated with lower PedsQL scores at both time points, but it was not a significant effect modifier between social disadvantage and PedsQL scores. CONCLUSIONS Having social disadvantage markers or difficulty/delays accessing care was associated with lower baseline physical functioning; however, differences were reduced after hospital discharge.
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Affiliation(s)
- Arti D Desai
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children’s Research Institute, Seattle, Washington
- Corresponding Author: Arti D. Desai, MD, MSPH; E-mail: ; Telephone: (206) 884-1497
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children’s Research Institute, Seattle, Washington
| | - Wren Haaland
- Seattle Children’s Research Institute, Seattle, Washington
| | - Jakobi Johnson
- Division of Hospital Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - K Casey Lion
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children’s Research Institute, Seattle, Washington
| | - Michelle A Lopez
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Derek J Williams
- Division of Hospital Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Chén C Kenyon
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia and the Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children’s Research Institute, Seattle, Washington
| | - David P Johnson
- Division of Hospital Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
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19
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Bryan MA, Hofstetter AM, Simon TD, Zhou C, Williams DJ, Tyler A, Kenyon CC, Vachani JG, Opel DJ, Mangione-Smith R. Vaccination Status and Adherence to Quality Measures for Acute Respiratory Tract Illnesses. Hosp Pediatr 2020; 10:199-205. [PMID: 32041781 PMCID: PMC7041553 DOI: 10.1542/hpeds.2019-0245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To assess the relationship between vaccination status and clinician adherence to quality measures for children with acute respiratory tract illnesses. METHODS We conducted a multicenter prospective cohort study of children aged 0 to 16 years who presented with 1 of 4 acute respiratory tract illness diagnoses (community-acquired pneumonia, croup, asthma, and bronchiolitis) between July 2014 and June 2016. The predictor variable was provider-documented up-to-date (UTD) vaccination status. Our primary outcome was clinician adherence to quality measures by using the validated Pediatric Respiratory Illness Measurement System (PRIMES). Across all conditions, we examined overall PRIMES composite scores and overuse (including indicators for care that should not be provided, eg, C-reactive protein testing in community-acquired pneumonia) and underuse (including indicators for care that should be provided, eg, dexamethasone in croup) composite subscores. We examined differences in length of stay, costs, and readmissions by vaccination status using adjusted linear and logistic regression models. RESULTS Of the 2302 participants included in the analysis, 92% were documented as UTD. The adjusted mean difference in overall PRIMES scores by UTD status was not significant (adjusted mean difference -0.3; 95% confidence interval: -1.9 to 1.3), whereas the adjusted mean difference was significant for both overuse (-4.6; 95% confidence interval: -7.5 to -1.6) and underuse (2.8; 95% confidence interval: 0.9 to 4.8) composite subscores. There were no significant adjusted differences in mean length of stay, cost, and readmissions by vaccination status. CONCLUSIONS We identified lower adherence to overuse quality indicators and higher adherence to underuse quality indicators for children not UTD, which suggests that clinicians "do more" for hospitalized children who are not UTD.
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Affiliation(s)
- Mersine A Bryan
- Department of Pediatrics, University of Washington, Seattle, Washington;
- Seattle Children's Research Institute, Seattle, Washington
| | - Annika M Hofstetter
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
| | - Tamara D Simon
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
| | - Derek J Williams
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Vanderbilt University and Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Amy Tyler
- Section of Hospital Medicine, Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | - Chén C Kenyon
- Department of Pediatrics, School of Medicine, University of Pennsylvania and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Joyee G Vachani
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Douglas J Opel
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
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20
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Desai AD, Zhou C, Simon TD, Mangione-Smith R, Britto MT. Validation of a Parent-Reported Hospital-to-Home Transition Experience Measure. Pediatrics 2020; 145:peds.2019-2150. [PMID: 31969474 PMCID: PMC6993281 DOI: 10.1542/peds.2019-2150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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] [Accepted: 11/13/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The Pediatric Transition Experience Measure (P-TEM) is an 8-item, parent-reported measure that globally assesses hospital-to-home transition quality from discharge through follow-up. Our goal was to examine the convergent validity of the P-TEM with existing, validated process and outcome measures of pediatric hospital-to-home transitions. METHODS This was a prospective, cohort study of English-speaking parents and legal guardians who completed the P-TEM after their children's discharge from a tertiary children's hospital between January 2016 and October 2016. By using data from 3 surveys, we assessed convergent validity by examining associations between total and domain-specific P-TEM scores (0-100 scale) and 4 pediatric hospital-to-home transition validation measures: (1) Child Hospital Consumer Assessment of Healthcare Providers and Systems Discharge Composite, (2) Center of Excellence on Quality of Care Measures for Children With Complex Needs parent-reported transition measures, (3) change in health-related quality of life from admission to postdischarge, and (4) 30-day emergency department revisits or readmissions. RESULTS P-TEM total scores were 7.5 points (95% confidence interval: 4.6 to 10.4) higher for participants with top-box responses on the Child Hospital Consumer Assessment of Healthcare Providers and Systems Discharge Composite compared with those of participants with lower Discharge Composite scores. Participants with highet P-TEM scores (ie, top-box responses) had 6.3-points-greater improvement (95% confidence interval: 2.8 to 9.8) in health-related quality of life compared with participants who reported lower P-TEM scores. P-TEM scores were not significantly associated with 7- or 30-day reuse. CONCLUSIONS The P-TEM demonstrated convergent validity with existing hospital-to-home process and outcome validation measures in a population of hospitalized children.
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Affiliation(s)
- Arti D. Desai
- Department of Pediatrics, University of Washington, Seattle, Washington;,Seattle Children’s Research Institute, Seattle, Washington; and
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, Washington;,Seattle Children’s Research Institute, Seattle, Washington; and
| | - Tamara D. Simon
- Department of Pediatrics, University of Washington, Seattle, Washington;,Seattle Children’s Research Institute, Seattle, Washington; and
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington;,Seattle Children’s Research Institute, Seattle, Washington; and
| | - Maria T. Britto
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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Abstract
BACKGROUND Children from socially disadvantaged families experience worse hospital outcomes compared with other children. We sought to identify modifiable barriers to care to target for intervention. METHODS We conducted a prospective cohort study of hospitalized children over 15 months. Caregivers completed a survey within 3 days of admission and 2 to 8 weeks after discharge to assess 10 reported barriers to care related to their interactions within the health care system (eg, not feeling like they have sufficient skills to navigate the system and experiencing marginalization). Associations between barriers and outcomes (30-day readmissions and length of stay) were assessed by using multivariable regression. Barriers associated with worse outcomes were then tested for associations with a cumulative social disadvantage score based on 5 family sociodemographic characteristics (eg, low income). RESULTS Of eligible families, 61% (n = 3651) completed the admission survey; of those, 48% (n = 1734) completed follow-up. Nine of 10 barriers were associated with at least 1 worse hospital outcome. Of those, 4 were also positively associated with cumulative social disadvantage: perceiving the system as a barrier (adjusted β = 1.66; 95% confidence interval [CI] 1.02 to 2.30), skill barriers (β = 3.82; 95% CI 3.22 to 4.43), cultural distance (β = 1.75; 95% CI 1.36 to 2.15), and marginalization (β = .71; 95% CI 0.30 to 1.11). Low income had the most consistently strong association with reported barriers. CONCLUSIONS System barriers, skill barriers, cultural distance, and marginalization were significantly associated with both worse hospital outcomes and social disadvantage, suggesting these are promising targets for intervention to decrease disparities for hospitalized children.
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Affiliation(s)
- K Casey Lion
- Department of Pediatrics and
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington; and
| | - Chuan Zhou
- Department of Pediatrics and
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington; and
| | - Beth E Ebel
- Department of Pediatrics and
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington; and
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, Washington
| | - Robert B Penfold
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Rita Mangione-Smith
- Department of Pediatrics and
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington; and
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22
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Mangione-Smith R, Zhou C, Williams DJ, Johnson DP, Kenyon CC, Tyler A, Quinonez R, Vachani J, McGalliard J, Tieder JS, Simon TD, Wilson KM. Pediatric Respiratory Illness Measurement System (PRIMES) Scores and Outcomes. Pediatrics 2019; 144:peds.2019-0242. [PMID: 31350359 PMCID: PMC6855826 DOI: 10.1542/peds.2019-0242] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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] [Accepted: 05/15/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The Pediatric Respiratory Illness Measurement System (PRIMES) generates condition-specific composite quality scores for asthma, bronchiolitis, croup, and pneumonia in hospital-based settings. We sought to determine if higher PRIMES composite scores are associated with improved health-related quality of life, decreased length of stay (LOS), and decreased reuse. METHODS We conducted a prospective cohort study of 2334 children in 5 children's hospitals between July 2014 and June 2016. Surveys administered on admission and 2 to 6 weeks postdischarge assessed the Pediatric Quality of Life Inventory (PedsQL). Using medical records data, 3 PRIMES scores were calculated (0-100 scale; higher scores = improved adherence) for each condition: an overall composite (including all quality indicators for the condition), an overuse composite (including only indicators for care that should not be provided [eg, chest radiographs for bronchiolitis]), and an underuse composite (including only indicators for care that should be provided [eg, dexamethasone for croup]). Multivariable models assessed relationships between PRIMES composite scores and (1) PedsQL improvement, (2) LOS, and (3) 30-day reuse. RESULTS For every 10-point increase in PRIMES overuse composite scores, LOS decreased by 8.8 hours (95% confidence interval [CI] -11.6 to -6.1) for bronchiolitis, 3.1 hours (95% CI -5.5 to -1.0) for asthma, and 2.0 hours (95% CI -3.9 to -0.1) for croup. Bronchiolitis overall composite scores were also associated with shorter LOS. PRIMES composites were not associated with PedsQL improvement or reuse. CONCLUSIONS Better performance on some PRIMES condition-specific composite measures is associated with decreased LOS, with scores on overuse quality indicators being a primary driver of this relationship.
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Affiliation(s)
- Rita Mangione-Smith
- Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, Washington; .,Department of Pediatrics, University of Washington, Seattle, Washington
| | - Chuan Zhou
- Seattle Children’s Research Institute, Seattle Children’s Hospital, Seattle, Washington;,Department of Pediatrics, University of Washington, Seattle, Washington
| | - Derek J. Williams
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Vanderbilt University and Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - David P. Johnson
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Vanderbilt University and Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Chén C. Kenyon
- Department of Pediatrics, School of Medicine, University of Pennsylvania and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Amy Tyler
- Department of Pediatrics, School of Medicine, University of Colorado and Section of Hospital Medicine, Children’s Hospital Colorado, Aurora, Colorado
| | - Ricardo Quinonez
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; and
| | - Joyee Vachani
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; and
| | - Julie McGalliard
- Seattle Children’s Research Institute, Seattle Children’s Hospital, Seattle, Washington
| | - Joel S. Tieder
- Seattle Children’s Research Institute, Seattle Children’s Hospital, Seattle, Washington;,Department of Pediatrics, University of Washington, Seattle, Washington
| | - Tamara D. Simon
- Seattle Children’s Research Institute, Seattle Children’s Hospital, Seattle, Washington;,Department of Pediatrics, University of Washington, Seattle, Washington
| | - Karen M. Wilson
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, New York
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23
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Lifland B, Wright DR, Mangione-Smith R, Desai AD. The Impact of an Adolescent Depressive Disorders Clinical Pathway on Healthcare Utilization. Adm Policy Ment Health 2019; 45:979-987. [PMID: 29779180 DOI: 10.1007/s10488-018-0878-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 12/20/2022]
Abstract
Clinical pathways are known to improve the value of health care in medical and surgical settings but have been rarely studied in the psychiatric setting. This study examined the association between level of adherence to an adolescent depressive disorders inpatient clinical pathway and length of stay (LOS), cost, and readmissions. Patients in the high adherence category had significantly longer LOS and higher costs compared to the low adherence category. There was no difference in the odds of 30-day emergency department return visits or readmissions. Understanding which care processes within the pathway are most cost-effective for improving patient-centered outcomes requires further investigation.
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Affiliation(s)
- Brooke Lifland
- University of Washington School of Medicine, Seattle, WA, USA.,Seattle Children's Research Institute, 2001 Eighth Avenue, Suite 400, Seattle, WA, 98121, USA
| | - Davene R Wright
- Seattle Children's Research Institute, 2001 Eighth Avenue, Suite 400, Seattle, WA, 98121, USA
| | - Rita Mangione-Smith
- University of Washington School of Medicine, Seattle, WA, USA.,Seattle Children's Research Institute, 2001 Eighth Avenue, Suite 400, Seattle, WA, 98121, USA
| | - Arti D Desai
- University of Washington School of Medicine, Seattle, WA, USA. .,Seattle Children's Research Institute, 2001 Eighth Avenue, Suite 400, Seattle, WA, 98121, USA.
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24
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Johnson J, Wilson KM, Zhou C, Johnson DP, Kenyon CC, Tieder JS, Dean A, Mangione-Smith R, Williams DJ. Home Smoke Exposure and Health-Related Quality of Life in Children with Acute Respiratory Illness. J Hosp Med 2019; 14:212-217. [PMID: 30933671 PMCID: PMC6948779 DOI: 10.12788/jhm.3164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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] [Received: 09/26/2018] [Accepted: 01/06/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE This study aims to assess whether secondhand smoke (SHS) exposure has an impact on health-related quality of life (HRQOL) in children with acute respiratory illness (ARI). METHODS This study was nested within a multicenter, prospective cohort study of children (two weeks to 16 years) with ARI (emergency department visits for croup and hospitalizations for croup, asthma, bronchiolitis, and pneumonia) between July 1, 2014 and June 30, 2016. Subjects were surveyed upon enrollment for sociodemographics, healthcare utilization, home SHS exposure (0 or ≥1 smoker in the home), and child HRQOL (Pediatric Quality of Life Physical Functioning Scale) for both baseline health (preceding illness) and acute illness (on admission). Data on insurance status and medical complexity were collected from the Pediatric Hospital Information System database. Multivariable linear mixed regression models examined associations between SHS exposure and HRQOL. RESULTS Home SHS exposure was reported in 728 (32%) of the 2,309 included children. Compared with nonexposed children, SHS-exposed children had significantly lower HRQOL scores for baseline health (mean difference -3.04 [95% CI -4.34, -1.74]) and acute illness (-2.16 [-4.22, -0.10]). Associations were strongest among children living with two or more smokers. HRQOL scores were lower among SHS-exposed children for all four conditions but only significant at baseline for bronchiolitis (-2.94 [-5.0, -0.89]) and pneumonia (-4.13 [-6.82, -1.44]) and on admission for croup (-5.71 [-10.67, -0.75]). CONCLUSIONS Our study demonstrates an association between regular SHS exposure and decreased HRQOL with a dose-dependent response for children with ARI, providing further evidence of the negative impact of SHS.
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Affiliation(s)
- Jakobi Johnson
- Division of Hospital Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Karen M Wilson
- Division of General Pediatrics, Kravis Children’s Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Chuan Zhou
- Department of Pediatrics, University of Washington and the Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington
| | - David P Johnson
- Division of Hospital Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Chén C Kenyon
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia and the Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Joel S Tieder
- Division of General Pediatrics and Hospital Medicine, Department of Pediatrics, University of Washington and Seattle Children’s Hospital, Seattle, Washington
| | - Andrea Dean
- Section of Pediatric Hospital Medicine, Texas Children’s Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington and the Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington
| | - Derek J Williams
- Division of Hospital Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
- Corresponding Author: Derek J Williams, MD, MPH; E-mail: ; Telephone: 615-322-2744; Twitter: @dwillmd
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25
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Parast L, Burkhart Q, Gidengil C, Schneider EC, Mangione-Smith R, Casey Lion K, McGlynn EA, Carle A, Britto MT, Elliott MN. Validation of New Care Coordination Quality Measures for Children with Medical Complexity. Acad Pediatr 2018; 18:581-588. [PMID: 29550397 PMCID: PMC6152933 DOI: 10.1016/j.acap.2018.03.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 03/03/2018] [Accepted: 03/11/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To validate new caregiver-reported quality measures assessing care coordination services for children with medical complexity (CMC). METHODS A cross-sectional analysis of the associations between 20 newly developed Family Experiences with Coordination of Care (FECC) quality measures and 3 validation measures among 1209 caregivers who responded to a telephone or mailed survey from August to November 2013 in Minnesota and Washington. Validation measures included an access composite, a provider rating item, and a care coordination outcome measure, all derived from Consumer Assessments of Healthcare Providers and Systems (CAHPS) survey items. Multivariate regression was used to examine associations between the 3 validation measures and each of the 20 FECC quality measures. RESULTS Nineteen of the 20 FECC quality measures were significantly and positively associated with ≥1 of the validation measures. The components of care coordination demonstrating the strongest positive association with provider ratings included: 1) having a care coordinator who was knowledgeable and supportive and advocated for the child's needs (β = 26.4; 95% confidence interval [CI], 20.0-32.8, scaled to reflect change associated with a 0-100 change in the FECC measure score); and 2) receiving a written visit summary that was useful and easy to understand (β = 22.0; 95% CI, 17.1-27.0). CONCLUSIONS Nineteen newly developed FECC quality measures demonstrated convergent validity with previously validated CAHPS measures. These new measures are valid for assessing the quality of care coordination services provided to CMC and may be useful for evaluating new models of care focused on improving these services.
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Affiliation(s)
- Layla Parast
- RAND Corporation, 1776 Main St, Santa Monica, CA, 90401; ; ;
| | - Q Burkhart
- RAND Corporation, 1776 Main St, Santa Monica, CA, 90401; ; ;
| | - Courtney Gidengil
- RAND Corporation, 20 Park Plaza, Suite 920, Boston, MA, 02116;
- Division of Infectious Diseases, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115
| | | | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, 2001 Eighth Avenue, Suite 400, Seattle, WA, 98121; ,
- Seattle Children’s Research Institute, 2001 Eighth Avenue, Suite 400,Seattle, WA, 98121
| | - K. Casey Lion
- Department of Pediatrics, University of Washington, 2001 Eighth Avenue, Suite 400, Seattle, WA, 98121; ,
- Seattle Children’s Research Institute, 2001 Eighth Avenue, Suite 400,Seattle, WA, 98121
| | - Elizabeth A. McGlynn
- Kaiser Permanente Center for Effectiveness and Safety Research, 100 S Los Robles, Third Floor, Pasadena, CA 91101;
| | - Adam Carle
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, Ohio 45229; ,
- Department of Pediatrics, College of Medicine, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, Ohio 45229
- Department of Psychology, College of Arts and Sciences, University of Cincinnati, 155 B McMicken Hall, Cincinnati, OH 45221
| | - Maria T Britto
- Department of Pediatrics, College of Medicine, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, Ohio 45229
- Department of Psychology, College of Arts and Sciences, University of Cincinnati, 155 B McMicken Hall, Cincinnati, OH 45221
| | - Marc N. Elliott
- RAND Corporation, 1776 Main St, Santa Monica, CA, 90401; ; ;
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26
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Simon TD, Haaland W, Hawley K, Lambka K, Mangione-Smith R. Development and Validation of the Pediatric Medical Complexity Algorithm (PMCA) Version 3.0. Acad Pediatr 2018; 18:577-580. [PMID: 29496546 PMCID: PMC6035108 DOI: 10.1016/j.acap.2018.02.010] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 02/10/2018] [Accepted: 02/17/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To modify the Pediatric Medical Complexity Algorithm (PMCA) to include both International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification (ICD-9/10-CM) codes for classifying children with chronic disease (CD) by level of medical complexity and to assess the sensitivity and specificity of the new PMCA version 3.0 for correctly identifying level of medical complexity. METHODS To create version 3.0, PMCA version 2.0 was modified to include ICD-10-CM codes. We applied PMCA version 3.0 to Seattle Children's Hospital data for children with ≥1 emergency department (ED), day surgery, and/or inpatient encounter from January 1, 2016, to June 30, 2017. Starting with the encounter date, up to 3 years of retrospective discharge data were used to classify children as having complex chronic disease (C-CD), noncomplex chronic disease (NC-CD), and no CD. We then selected a random sample of 300 children (100 per CD group). Blinded medical record review was conducted to ascertain the levels of medical complexity for these 300 children. The sensitivity and specificity of PMCA version 3.0 was assessed. RESULTS PMCA version 3.0 identified children with C-CD with 86% sensitivity and 86% specificity, children with NC-CD with 65% sensitivity and 84% specificity, and children without CD with 77% sensitivity and 93% specificity. CONCLUSIONS PMCA version 3.0 is an updated publicly available algorithm that identifies children with C-CD, who have accessed tertiary hospital emergency department, day surgery, or inpatient care, with very good sensitivity and specificity when applied to hospital discharge data and with performance to earlier versions of PMCA.
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Affiliation(s)
- Tamara D Simon
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Wash; Seattle Children's Research Institute, Seattle, Wash.
| | - Wren Haaland
- Seattle Children's Research Institute, Seattle, Wash
| | | | - Karen Lambka
- Seattle Children's Research Institute, Seattle, Wash
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Wash; Seattle Children's Research Institute, Seattle, Wash
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27
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Desai AD, Jacob-Files EA, Wignall J, Wang G, Pratt W, Mangione-Smith R, Britto MT. Caregiver and Health Care Provider Perspectives on Cloud-Based Shared Care Plans for Children With Medical Complexity. Hosp Pediatr 2018; 8:394-403. [PMID: 29871887 DOI: 10.1542/hpeds.2017-0242] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Shared care plans play an essential role in coordinating care across health care providers and settings for children with medical complexity (CMC). However, existing care plans often lack shared ownership, are out-of-date, and lack universal accessibility. In this study, we aimed to establish requirements for shared care plans to meet the information needs of caregivers and providers and to mitigate current information barriers when caring for CMC. METHODS We followed a user-centered design methodology and conducted in-depth semistructured interviews with caregivers and providers of CMC who receive care at a tertiary care children's hospital. We applied inductive, thematic analysis to identify salient themes. Analysis occurred concurrently with data collection; therefore, the interview guide was iteratively revised as new questions and themes emerged. RESULTS Interviews were conducted with 17 caregivers and 22 providers. On the basis of participant perspectives, we identified 4 requirements for shared care plans that would help meet information needs and mitigate current information barriers when caring for CMC. These requirements included the following: (1) supporting the accessibility of care plans from multiple locations (eg, cloud-based) and from multiple devices, with alert and search features; (2) ensuring the organization is tailored to the specific user; (3) including collaborative functionality such as real-time, multiuser content management and secure messaging; and (4) storing care plans on a secure platform with caregiver-controlled permission settings. CONCLUSIONS Although further studies are needed to understand the optimal design and implementation strategies, shared care plans that meet these specified requirements could mitigate perceived information barriers and improve care for CMC.
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Affiliation(s)
- Arti D Desai
- Department of Pediatrics, University of Washington, Seattle, Washington; .,Seattle Children's Research Institute, Seattle, Washington
| | | | - Julia Wignall
- Seattle Children's Research Institute, Seattle, Washington
| | - Grace Wang
- Undergraduate Research Program, University of Washington, Seattle, Washington; and
| | - Wanda Pratt
- Department of Biomedical and Health Informatics, The Information School, and
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington.,Seattle Children's Research Institute, Seattle, Washington
| | - Maria T Britto
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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28
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Bardach NS, Burkhart Q, Richardson LP, Roth CP, Murphy JM, Parast L, Gidengil CA, Marmet J, Britto MT, Mangione-Smith R. Hospital-Based Quality Measures for Pediatric Mental Health Care. Pediatrics 2018; 141:e20173554. [PMID: 29853624 PMCID: PMC6317537 DOI: 10.1542/peds.2017-3554] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [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] [Accepted: 03/28/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with a primary mental health condition account for nearly 10% of pediatric hospitalizations nationally, but little is known about the quality of care provided for them in hospital settings. Our objective was to develop and test medical record-based measures used to assess quality of pediatric mental health care in the emergency department (ED) and inpatient settings. METHODS We drafted an evidence-based set of pediatric mental health care quality measures for the ED and inpatient settings. We used the modified Delphi method to prioritize measures; 2 ED and 6 inpatient measures were operationalized and field-tested in 2 community and 3 children's hospitals. Eligible patients were 5 to 19 years old and diagnosed with psychosis, suicidality, or substance use from January 2012 to December 2013. We used bivariate and multivariate models to examine measure performance by patient characteristics and by hospital. RESULTS Eight hundred and seventeen records were abstracted with primary diagnoses of suicidality (n = 446), psychosis (n = 321), and substance use (n = 50). Performance varied across measures. Among patients with suicidality, male patients (adjusted odds ratio: 0.27, P < .001) and African American patients (adjusted odds ratio: 0.31, P = .02) were less likely to have documentation of caregiver counseling on lethal means restriction. Among admitted suicidal patients, 27% had documentation of communication with an outside provider, with variation across hospitals (0%-38%; P < .001). There was low overall performance on screening for comorbid substance abuse in ED patients with psychosis (mean: 30.3). CONCLUSIONS These new pediatric mental health care quality measures were used to identify sex and race disparities and substantial hospital variation. These measures may be useful for assessing and improving hospital-based pediatric mental health care quality.
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Affiliation(s)
- Naomi S Bardach
- Department of Pediatrics, University of California San Francisco, San Francisco, California;
| | - Q Burkhart
- RAND Corporation, Santa Monica, California
| | - Laura P Richardson
- Department of Pediatrics, University of Washington, Seattle, Washington
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | | | - J Michael Murphy
- Division of Child and Adolescent Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | | | - Courtney A Gidengil
- Harvard Medical School, Harvard University, Boston, Massachusetts
- RAND Corporation, Boston, Massachusetts
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
| | - Jordan Marmet
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota; and
| | - Maria T Britto
- Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
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Desai AD, Jacob-Files EA, Lowry SJ, Opel DJ, Mangione-Smith R, Britto MT, Howard WJ. Development of a Caregiver-Reported Experience Measure for Pediatric Hospital-to-Home Transitions. Health Serv Res 2018; 53 Suppl 1:3084-3106. [PMID: 29740810 DOI: 10.1111/1475-6773.12864] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 11/29/2022] Open
Abstract
OBJECTIVE To develop and test a caregiver-reported experience measure for pediatric hospital-to-home transitions. DATA SOURCES/STUDY SETTING Primary data were collected between 07/2014 and 05/2015 from caregivers within 2-8 weeks of their child's discharge from a tertiary care children's hospital. STUDY DESIGN/DATA COLLECTION We used a step-wise approach to developing the measure that included drafting de novo survey items based on caregiver interviews (n = 18), pretesting items using cognitive interviews (n = 18), and pilot testing revised items among an independent sample of caregivers (n = 500). Item reduction statistics and confirmatory factor analysis (CFA) were performed on a test sample of the pilot data to refine the measure, followed by CFA on the validation sample to test the final measure model fit. PRINCIPAL FINDINGS Of 46 initial survey items, 19 were removed after pretesting and 19 were removed after conducting item statistics and CFA. This resulted in an eight-item measure with two domains: transition preparation (four items) and transition support (four items). Survey items assess the quality of discharge instructions, access to needed support and resources, care coordination, and follow-up care. Practical fit indices demonstrated an acceptable model fit: χ2 = 28.3 (df = 19); root-mean-square error of approximation = 0.04; comparative fit index = 0.99; and Tucker-Lewis index = 0.98. CONCLUSIONS An eight-item caregiver-reported experience measure to evaluate hospital-to-home transition outcomes in pediatric populations demonstrated acceptable content validity and psychometric properties.
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Affiliation(s)
- Arti D Desai
- Department of Pediatrics, University of Washington, Seattle Children's Research Institute, Seattle, WA
| | | | | | - Douglas J Opel
- Department of Pediatrics, University of Washington, Seattle Children's Research Institute, Seattle, WA
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle Children's Research Institute, Seattle, WA
| | - Maria T Britto
- Department of Pediatrics, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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30
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Opel DJ, Zhou C, Robinson JD, Henrikson N, Lepere K, Mangione-Smith R, Taylor JA. Impact of Childhood Vaccine Discussion Format Over Time on Immunization Status. Acad Pediatr 2018; 18:430-436. [PMID: 29325912 PMCID: PMC5936647 DOI: 10.1016/j.acap.2017.12.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 12/28/2017] [Accepted: 12/30/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Presumptive formats to initiate childhood vaccine discussions (eg, "Well, we have to do some shots") have been associated with increased vaccine acceptance after one visit compared to participatory formats (eg, "How do you feel about vaccines?"). We characterize discussion format patterns over time and the impact of their repeated use on vaccine acceptance. METHODS We conducted a longitudinal prospective cohort study of children of vaccine-hesitant parents enrolled in a Seattle-based integrated health system. After the child's 2-, 4-, and 6-month visits, parents reported the format their child's provider used to begin the vaccine discussion (presumptive, participatory, or other). Our outcome was the percentage of days underimmunized of the child at 8 months old for 6 recommended vaccines. We used linear regression and generalized estimating equations to test the association of discussion format and immunization status. RESULTS We enrolled 73 parent-child dyads and obtained data from 82%, 73%, and 53% after the 2-, 4-, and 6-month visits, respectively. Overall, 65% of parents received presumptive formats at ≥1 visit and 42% received participatory formats at ≥1 visit. Parental receipt of presumptive formats at 1 and ≥2 visits (vs no receipt) was associated with significantly less underimmunization of the child, while receipt of participatory formats at ≥2 visits was associated with significantly more underimmunization. Visit-specific use of participatory (vs presumptive) formats was associated with a child being 10.1% (95% confidence interval, 0.3, 19.8; P = .04) more days underimmunized (amounting to, on average, 98 more days underimmunized for all 6 vaccines combined). CONCLUSIONS Presumptive (vs participatory) discussion formats are associated with increased immunization.
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Affiliation(s)
- Douglas J Opel
- Department of Pediatrics, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, Wash.
| | - Chuan Zhou
- Department of Pediatrics, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, Wash
| | | | - Nora Henrikson
- Kaiser Permanente Washington Health Research Institute, Seattle, Wash
| | - Katherine Lepere
- Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, Wash
| | - Rita Mangione-Smith
- Department of Pediatrics, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, Wash
| | - James A Taylor
- Department of Pediatrics, Child Health Institute, University of Washington School of Medicine, Seattle, Wash
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31
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Parast L, Bardach NS, Burkhart Q, Richardson LP, Murphy JM, Gidengil CA, Britto MT, Elliott MN, Mangione-Smith R. Development of New Quality Measures for Hospital-Based Care of Suicidal Youth. Acad Pediatr 2018; 18:248-255. [PMID: 29100860 DOI: 10.1016/j.acap.2017.09.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 09/09/2017] [Accepted: 09/23/2017] [Indexed: 01/16/2023]
Abstract
OBJECTIVES To develop, validate, and test the feasibility of implementation of 4 new quality measures assessing emergency department (ED) and inpatient care for suicidal youth. METHODS Four quality measures were developed to assess hospital-based care for suicidal youth. These measures, focused on counseling caregivers about restricting access to lethal means of self-harm and benefits and risks of antidepressant medications, were operationalized into 2 caregiver surveys that assessed ED and inpatient quality, respectively. Survey field tests included caregivers of youth who received inpatient and/or ED care for suicidality at 1 of 2 children's hospitals between July 2013 and June 2014. We examined the feasibility of obtaining measure scores and variation in scores. Multivariate models examined associations between quality measure scores and 4 validation metrics: modified Child Hospital Consumer Assessments of Health Care Providers and Systems, communication composites, hospital readmissions, and ED return visits. RESULTS Response rates were 35% (ED) and 31% (inpatient). Most caregivers reported receiving counseling to restrict their child's access to lethal means of self-harm (90% in the ED and 96% in the inpatient setting). In the inpatient setting, caregivers reported higher rates of counseling on benefits (95%) of newly prescribed antidepressants than risks (physical adverse effects 85%, increased suicidality 72%). Higher scores on the latter measure were associated with higher nurse (P < .001) and doctor (P < .01) communication composite scores. Measure scores were not associated with readmissions or ED return visits. CONCLUSIONS These new quality measures evaluate key aspects of care for suicidal youth, and they may facilitate assessing quality of care for this vulnerable population.
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Affiliation(s)
| | | | | | - Laura P Richardson
- Seattle Children's Research Institute, Seattle, Wash; Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Wash
| | - J Michael Murphy
- Department of Psychiatry, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Courtney A Gidengil
- Harvard Medical School, Boston, Mass; RAND Corporation, Boston, Mass; Division of Infectious Diseases, Boston Children's Hospital, Boston, Mass
| | - Maria T Britto
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Rita Mangione-Smith
- Seattle Children's Research Institute, Seattle, Wash; Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Wash
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Desai AD, Simon TD, Leyenaar JK, Britto MT, Mangione-Smith R. Utilizing Family-Centered Process and Outcome Measures to Assess Hospital-to-Home Transition Quality. Acad Pediatr 2018; 18:843-846. [PMID: 30077673 PMCID: PMC6598693 DOI: 10.1016/j.acap.2018.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/13/2018] [Accepted: 07/28/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Arti D. Desai
- Department of Pediatrics University of Washington, Seattle,Seattle Children’s Research Institute
| | - Tamara D. Simon
- Department of Pediatrics University of Washington, Seattle,Seattle Children’s Research Institute
| | - JoAnna K. Leyenaar
- Department of Pediatrics & The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Maria T. Britto
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Ohio
| | - Rita Mangione-Smith
- Department of Pediatrics University of Washington, Seattle,Seattle Children’s Research Institute
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33
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Arthur KC, Lucenko BA, Sharkova IV, Xing J, Mangione-Smith R. Using State Administrative Data to Identify Social Complexity Risk Factors for Children. Ann Fam Med 2018; 16:62-69. [PMID: 29311178 PMCID: PMC5758323 DOI: 10.1370/afm.2134] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 04/25/2017] [Accepted: 06/14/2017] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Screening for social determinants of health is challenging but critically important for optimizing child health outcomes. We aimed to test the feasibility of using an integrated state agency administrative database to identify social complexity risk factors and examined their relationship to emergency department (ED) use. METHODS We conducted a retrospective cohort study among children younger than 18 years with Washington State Medicaid insurance coverage (N = 505,367). We linked child and parent administrative data for this cohort to identify a set of social complexity risk factors, such as poverty and parent mental illness, that have either a known or hypothesized association with suboptimal health care use. Using multivariate analyses, we examined associations of each risk factor and of number of risk factors with the rate of ED use. RESULTS Nine of 11 identifiable social complexity risk factors were associated with a higher rate of ED use. Additionally, the rate increased as the number of risk factors increased from 0 to 5 or more, reaching approximately twice the rate when 5 or more risk factors were present in children aged younger than 5 years (incidence rate ratio = 1.92; 95% CI, 1.85-2.00) and in children aged 5 to 17 years (incidence rate ratio = 2.06; 95% CI, 1.99-2.14). CONCLUSIONS State administrative data can be used to identify social complexity risk factors associated with higher rates of ED use among Medicaid-insured children. State agencies could give primary care medical homes a social risk flag or score to facilitate targeted screening and identification of needed resources, potentially preventing future unnecessary ED use in this vulnerable population of children.
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Affiliation(s)
| | - Barbara A Lucenko
- Washington State Department of Social and Health Services, Division of Research and Data Analysis, Olympia, Washington
| | - Irina V Sharkova
- Washington State Department of Social and Health Services, Division of Research and Data Analysis, Olympia, Washington
| | - Jingping Xing
- Washington State Department of Social and Health Services, Division of Research and Data Analysis, Olympia, Washington
| | - Rita Mangione-Smith
- Seattle Children's Research Institute, Seattle, Washington.,University of Washington Department of Pediatrics, Seattle, Washington
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34
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Lifland BE, Mangione-Smith R, Palermo TM, Rabbitts JA. Agreement Between Parent Proxy Report and Child Self-Report of Pain Intensity and Health-Related Quality of Life After Surgery. Acad Pediatr 2018; 18:376-383. [PMID: 29229566 PMCID: PMC5936667 DOI: 10.1016/j.acap.2017.12.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 11/27/2017] [Accepted: 12/02/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Monitoring patient-centered health outcomes after hospital discharge is important for identifying patients experiencing poor recovery after surgery. Utilizing parent reports may improve the feasibility of monitoring recovery when children are not available to provide self-report. We therefore aimed to examine agreement between parent and child reports of child pain and health-related quality of life (HRQOL) in children after hospital discharge from inpatient surgery. METHODS A total of 295 children aged 8 to 18 years and their parents reported on child pain intensity using an 11-point numerical rating scale and on HRQOL using the 0- to 100-point Pediatric Quality of Life Inventory Version 4.0 Generic Core Scales by phone or online, 4 to 8 weeks after surgery. Agreement between parent and child ratings was assessed by absolute discrepancy scores, Pearson product-moment correlations, 2-way mixed effects intraclass correlation coefficient models, and linear regression models. RESULTS We found good to excellent agreement between child and parent reports of pain intensity and HRQOL. Average absolute discrepancy scores of pain intensity and HRQOL were 0.6 and 7.8 points, respectively. Pearson product-moment correlation coefficients were 0.74 and 0.80, and intraclass correlation coefficients were 0.72 and 0.79, for pain intensity and HRQOL, respectively. Regression coefficients for models examining pain intensity and HRQOL were 0.93 to 0.98 and 1.0, respectively. CONCLUSIONS Although child and parent reports may both contribute important information, parent report is a valid proxy for child self-reported pain intensity and HRQOL after discharge from inpatient pediatric surgery, which may prove important for better understanding pain experiences and intervention needs.
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Affiliation(s)
- Brooke E. Lifland
- University of Washington School of Medicine, Seattle, WA, USA,Seattle Children’s Research Institute, Seattle, WA, USA
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, WA, USA,Seattle Children’s Research Institute, Seattle, WA, USA
| | - Tonya M. Palermo
- Department of Pediatrics, University of Washington, Seattle, WA, USA,Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA,Seattle Children’s Research Institute, Seattle, WA, USA
| | - Jennifer A. Rabbitts
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA,Seattle Children’s Research Institute, Seattle, WA, USA
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35
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Leyenaar JK, Rizzo PA, Khodyakov D, Leslie LK, Lindenauer PK, Mangione-Smith R. Importance and Feasibility of Transitional Care for Children With Medical Complexity: Results of a Multistakeholder Delphi Process. Acad Pediatr 2018; 18:94-101. [PMID: 28739535 PMCID: PMC5756674 DOI: 10.1016/j.acap.2017.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 07/14/2017] [Accepted: 07/18/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Children with medical complexity (CMC) account for disproportionate hospital utilization and adverse outcomes after discharge, and several gaps exist regarding the quality of hospital to home transitional care for this population. We conducted an expert elicitation process to identify important and feasible hospital to home transitional care interventions for CMC from the perspectives of parents and health care professionals. METHODS We conducted a 2-round electronic Delphi process to identify important and feasible transitional care interventions. Panelists included parents of CMC and multidisciplinary health care professionals. In the first round, panelists rated the importance and feasibility of 39 transitional care interventions on a 9-point Likert scale; agreement between panelists was defined according to RAND/UCLA Appropriateness Methods. The second round of data collection evaluated 16 interventions that panelists did not agree on in the first round and 8 new or revised interventions, accompanied by quantitative and qualitative data summaries. RESULTS A total of 29 parents of CMC and 37 health care professionals participated in the Delphi process (response rate 75%). Both stakeholder panels endorsed most interventions as important; health care professionals were less likely to rate several interventions as feasible compared with the parent panel. Over 2 rounds of data collection, the 2 stakeholder panels endorsed 25 interventions as important as well as feasible. These interventions related to family engagement during the hospitalization, care coordination and social support assessment, predischarge education, and written materials. CONCLUSIONS Parents and health care professionals considered several transitional care interventions important as well as feasible. This research might inform hospitals' transitional care programs and policies.
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Affiliation(s)
- JoAnna K Leyenaar
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Tufts University School of Medicine, Boston, Mass.
| | | | | | - Laurel K Leslie
- Departments of Medicine and Pediatrics, Tufts Medical Center, Boston, Mass; Department of Research, American Board of Pediatrics, Chapel Hill, NC
| | - Peter K Lindenauer
- Department of Quantitative Health Sciences, University of Massachusetts Medial School, Worcester; Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle Children's Research Institute, Seattle
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36
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Simon TD, Whitlock KB, Haaland W, Wright DR, Zhou C, Neff J, Howard W, Cartin B, Mangione-Smith R. Effectiveness of a Comprehensive Case Management Service for Children With Medical Complexity. Pediatrics 2017; 140:peds.2017-1641. [PMID: 29192004 DOI: 10.1542/peds.2017-1641] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [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] [Accepted: 07/25/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To assess whether children with medical complexity (CMC) exposed to a hospital-based comprehensive case management service (CCMS) experience improved health care quality, improved functional status, reduced hospital-based utilization, and/or reduced overall health care costs. METHODS Eligible CMC at Seattle Children's Hospital were enrolled in a cluster randomized controlled trial between December 1, 2010, and September 29, 2014. Participating primary care providers (PCPs) were randomly assigned, and CMC either had access to an outpatient hospital-based CCMS or usual care directed by their PCP. The CCMS included visits to a multidisciplinary clinic ≥ every 6 months for 1.5 years, an individualized shared care plan, and access to CCMS providers. Differences between control and intervention groups in change from baseline to 12 months and baseline to 18 months (difference of differences) were tested. RESULTS Two hundred PCPs caring for 331 CMC were randomly assigned. Intervention group (n = 181) parents reported more improvement in the Consumer Assessment of Healthcare Providers and Systems version 4.0 Child Health Plan Survey global health care quality ratings than control group parents (6.7 [95% confidence interval (CI): 3.5-9.8] vs 1.3 [95% CI: 1.9-4.6] at 12 months). We did not detect significant differences in child functional status and most hospital-based utilization between groups. The difference in change of overall health care costs was higher in the intervention group (+$8233 [95% CI: $1701-$16 937]) at 18 months). CCMS clinic costs averaged $3847 per child-year. CONCLUSIONS Access to a CCMS generally improved health care quality, but was not associated with changes in child functional status or hospital-based utilization, and increased overall health care costs among CMC.
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Affiliation(s)
- Tamara D Simon
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and .,Centers for Clinical and Translational Research and
| | - Kathryn B Whitlock
- Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Wren Haaland
- Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Davene R Wright
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and.,Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and.,Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - John Neff
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and
| | - Waylon Howard
- Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Brian Cartin
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and.,Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
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37
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Gidengil C, Parast L, Burkhart Q, Brown J, Elliott MN, Lion KC, McGlynn EA, Schneider EC, Mangione-Smith R. Development and Implementation of the Family Experiences With Coordination of Care Survey Quality Measures. Acad Pediatr 2017; 17:863-870. [PMID: 28373108 DOI: 10.1016/j.acap.2017.03.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 03/10/2017] [Accepted: 03/20/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Ensuring high-quality care coordination for children with medical complexity (CMC) could yield significant health and economic benefits because they account for one-third of pediatric health care expenditures. The objective of this study was to develop and field test the Family Experiences with Coordination of Care (FECC) survey, which facilitates assessment of 20 new caregiver-reported quality measures for CMC. METHODS We identified caregivers of Medicaid-insured CMC aged 0 to 17 years in Minnesota and Washington state, categorized by the Pediatric Medical Complexity Algorithm as having complex chronic disease. Eligible caregivers had CMC with at least 4 visits to health care providers participating in Medicaid in 2012. Caregivers were randomized to telephone or mixed mode (mail with telephone follow-up). Survey administration and data were collected in 2013. RESULTS Twelve hundred nine caregivers responded to the FECC survey (response rate, 41%; 36% via telephone only, 46% via mixed mode; P < .001). Among CMC with a hospitalization, caregivers were invited to join hospital rounds in 51% of cases. Seventy-two percent of caregivers reported their child had a care coordinator; among these, 96% reported knowing how to access the care coordinator. Few children had written shared care plans (44%) or emergency care plans (20%). Only 10% of adolescents had a written transition care plan. Scores were lower from mixed mode respondents than from telephone-only respondents for some measures. CONCLUSIONS The FECC survey enables the evaluation of care coordination quality for CMC. Both survey modes were feasible to implement, but mixed mode administration produced a higher response rate.
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Affiliation(s)
- Courtney Gidengil
- RAND Corporation, Boston, Mass; Division of Infectious Diseases, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
| | | | | | | | | | - K Casey Lion
- Department of Pediatrics, University of Washington/Seattle Children's Hospital; Seattle Children's Research Institute
| | - Elizabeth A McGlynn
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, Calif
| | | | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington/Seattle Children's Hospital; Seattle Children's Research Institute
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38
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Mangione-Smith R. Academic Pediatric Association Research Award Acceptance Speech May 2017, San Francisco, California. Acad Pediatr 2017; 17:805-806. [PMID: 28693977 DOI: 10.1016/j.acap.2017.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 07/04/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Rita Mangione-Smith
- Division of General Pediatrics and Hospital Medicine University of Washington Department of Pediatrics, and the Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Wash.
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39
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Foster CC, Jacob-Files E, Arthur KC, Hillman SA, Edwards TC, Mangione-Smith R. Provider Perspectives of High-Quality Pediatric Hospital-to-Home Transitions for Children and Youth With Chronic Disease. Hosp Pediatr 2017; 7:649-659. [PMID: 29038132 DOI: 10.1542/hpeds.2017-0031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The objective of this study was to describe health care providers' and hospital administrators' perspectives on how to improve pediatric hospital-to-home transitions for children and youth with chronic disease (CYCD). METHODS Focus groups and key informant interviews of inpatient attending physicians, primary care physicians, pediatric residents, nurses, care coordinators, and social workers were conducted at a tertiary care children's hospital. Key informant interviews were performed with hospital administrators. Semistructured questions were used to elicit perceptions of transitional care quality and to identify key structures and processes needed to improve transitional care outcomes. Transcripts of discussions were coded to identify emergent themes. RESULTS Participants (N = 22) reported that key structures needed to enhance transitional care were a multidisciplinary team, inpatient provider-patient continuity, hospital resource availability, an interoperative electronic health record, and availability of community resources. Key processes needed to achieve high-quality transitional care included setting individualized transition goals, involving parents in care planning, establishing parental competency with home care tasks, and consistently communicating with primary care physicians. Providers identified a lack of reliable roles and processes, insufficient assessment of patient and/or family psychosocial factors, and consistent 2-way communication with community providers as elements to target to improve transitional care outcomes for CYCD. CONCLUSIONS Many key structures and processes of care perceived as important to achieving high-quality transitional care outcomes for CYCD have the opportunity for improvement at the institution studied. Engaging key stakeholders in designing quality improvement interventions to address these deficits in the current care model may improve transitional care outcomes for this vulnerable population.
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Affiliation(s)
- Carolyn C Foster
- Departments of Pediatrics and .,Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington; and
| | - Elizabeth Jacob-Files
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington; and
| | - Kimberly C Arthur
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington; and
| | - Stephanie A Hillman
- Department of Patient and Family Experience, Seattle Children's Hospital, Seattle, Washington
| | - Todd C Edwards
- Health Services, University of Washington, Seattle, Washington
| | - Rita Mangione-Smith
- Departments of Pediatrics and.,Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington; and
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Abstract
BACKGROUND AND OBJECTIVES The Pediatric Medical Complexity Algorithm (PMCA) was developed to stratify children by level of medical complexity. We sought to refine PMCA and evaluate its performance based on the duration of eligibility and completeness of Medicaid data. METHODS PMCA version 1.0 was applied to a cohort of 299 children insured by Washington State Medicaid with ≥1 Seattle Children's Hospital outpatient, emergency department, and/or inpatient encounter in 2012. Blinded assessment of the validation cohort's PMCA category was performed by using medical records. In-depth review of discrepant cases was performed and informed the development of PMCA version 2.0. The sensitivity and specificity of PMCA version 2.0 were assessed. RESULTS Using Medicaid data, the sensitivity of PMCA version 2.0 was 74% for complex chronic disease (C-CD), 60% for noncomplex chronic disease (NC-CD), and 87% for those without chronic disease (CD). Specificity was 84% to 91% in Medicaid data for all 3 groups. Medicaid data were most complete for children that had primarily fee-for-service claims and were less complete for those with some managed care encounter data. PMCA version 2.0 performed optimally when children had a longer duration of coverage (25 to 36 months) with fee-for-service reimbursement, identifying children with C-CD with 85% sensitivity and 75% specificity, children with NC-CD with 55% sensitivity and 88% specificity, and children without CD with 100% sensitivity and 97% specificity. CONCLUSIONS PMCA version 2.0 identifies children with C-CD with good sensitivity and very good specificity when applied to Medicaid data. Data quality is a critical consideration when using PMCA.
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Affiliation(s)
- Tamara D Simon
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Washington; .,Seattle Children's Research Institute, Seattle, Washington; and
| | - Mary Lawrence Cawthon
- Research and Data Analysis Division, Washington Department of Social and Health Services, Olympia, Washington
| | - Jean Popalisky
- Seattle Children's Research Institute, Seattle, Washington; and
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Washington.,Seattle Children's Research Institute, Seattle, Washington; and
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Parast L, Burkhart Q, Desai AD, Simon TD, Allshouse C, Britto MT, Leyenaar JK, Gidengil CA, Toomey SL, Elliott MN, Schneider EC, Mangione-Smith R. Validation of New Quality Measures for Transitions Between Sites of Care. Pediatrics 2017; 139:peds.2016-4178. [PMID: 28557755 PMCID: PMC9534578 DOI: 10.1542/peds.2016-4178] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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] [Accepted: 02/22/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Assessing and improving the quality of transitions to home from the emergency department (ED) or hospital is critical for patient safety. Our objective was to validate 8 newly developed caregiver-reported measures of transition quality. METHODS This prospective observational study included 1086 caregiver survey respondents whose children had an ED visit (n = 523) or hospitalization (n = 563) at Seattle Children's Hospital in 2014. Caregivers were contacted to complete 2 surveys. The first survey included the newly developed transition quality measures and multiple validation measures including modified versions of Child Hospital Consumer Assessments of Healthcare Providers and Systems (HCAHPS) composites, assessing communication and discharge planning. The second survey (administered 30 days later) included questions about follow-up appointments and ED return visits and readmissions. Using multivariate regression, we examined associations between the newly developed transition quality measures and each validation measure. RESULTS All transition quality measures were significantly associated with ≥1 validation measures. The hospital-to-home transition measure assessing whether discharge instructions were easy to understand, were useful, and contained necessary follow-up information had the largest association with the Child HCAHPS nurse-parent and doctor-parent communication composites (β = 55.6; 95% confidence interval, 43 to 68.3; and β = 48.3; 95% confidence interval, 36.3 to 60.3, respectively, scaled to reflect change associated with a 0 to 100 change in the transition measure score). CONCLUSIONS Newly developed quality measures for pediatric ED- and hospital-to-home transitions were significantly and positively associated with previously validated measures of caregiver experience. These new measures may be useful for assessing and improving on the quality of ED- and hospital-to-home transitions.
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Affiliation(s)
| | | | - Arti D. Desai
- Seattle Children’s Research Institute, Seattle, Washington,Department of Pediatrics, University of Washington, Seattle, Washington
| | - Tamara D. Simon
- Seattle Children’s Research Institute, Seattle, Washington,Department of Pediatrics, University of Washington, Seattle, Washington
| | | | - Maria T. Britto
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | | | - Courtney A. Gidengil
- RAND Corporation, Boston, Massachusetts,Boston Children’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Sara L. Toomey
- Boston Children’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | | | | | - Rita Mangione-Smith
- Seattle Children’s Research Institute, Seattle, Washington,Department of Pediatrics, University of Washington, Seattle, Washington
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42
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Affiliation(s)
- Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington; and Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
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Foster CC, Mangione-Smith R, Simon TD. Caring for Children with Medical Complexity: Perspectives of Primary Care Providers. J Pediatr 2017; 182:275-282.e4. [PMID: 27916424 DOI: 10.1016/j.jpeds.2016.11.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 10/12/2016] [Accepted: 11/03/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To describe typical care experiences and key barriers and facilitators to caring for children with medical complexity (CMC) from the perspective of community primary care providers (PCPs). STUDY DESIGN PCPs participating in a randomized controlled trial of a care-coordination intervention for CMC were sent a 1-time cross-sectional survey that asked PCPs to (1) describe their experiences with caring for CMC; (2) identify key barriers affecting their ability to care for CMC; and (3) prioritize facilitators enhancing their ability to provide care coordination for CMC. PCP and practice demographics also were collected. RESULTS One hundred thirteen of 155 PCPs sent the survey responded fully (completion rate = 73%). PCPs endorsed that medical characteristics such as polypharmacy (88%), multiorgan system involvement (84%), and rare/unfamiliar diagnoses (83%) negatively affected care. Caregivers with high needs (88%), limited time with patients and caregivers (81%), and having a large number of specialists involved in care (79%) were also frequently cited. Most commonly endorsed strategies to improve care coordination included more time with patients/caregivers (84%), summative action plans (83%), and facilitated communication (eg, e-mail, phone meetings) with specialists (83%). CONCLUSIONS Community PCPs prioritized more time with patients and their families, better communication with specialists, and summative action plans to improve care coordination for this vulnerable population. Although this study evaluated perceptions rather than actual performance, it provides insights to improve understanding of which barriers and facilitators ideally might be targeted first for care delivery redesign.
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Affiliation(s)
- Carolyn C Foster
- Department of Pediatrics, University of Washington, Seattle, WA; Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, WA; Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA
| | - Tamara D Simon
- Department of Pediatrics, University of Washington, Seattle, WA; Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA
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Bryan MA, Desai AD, Wilson L, Wright DR, Mangione-Smith R. Association of Bronchiolitis Clinical Pathway Adherence With Length of Stay and Costs. Pediatrics 2017; 139:peds.2016-3432. [PMID: 28183732 DOI: 10.1542/peds.2016-3432] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [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] [Accepted: 12/07/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To examine the associations between the level of adherence to bronchiolitis clinical pathway recommendations, health care use, and costs. METHODS We conducted a retrospective cohort study of 267 patients ≤24 months old diagnosed with bronchiolitis from 12/2009 to 7/2012. Clinical pathway adherence was assessed by using a standardized scoring system (0-100) for 18 quality measures obtained by medical record review. Level of adherence was categorized into low, middle, and high tertiles. Generalized linear models were used to examine relationships between adherence tertile and (1) length of stay (LOS) and (2) costs. Logistic regression was used to examine the associations between adherence tertile and probability of inpatient admission and 7-day readmissions. RESULTS Mean adherence scores were: ED, 78.8 (SD, 18.1; n = 264), inpatient, 95.0 (SD, 6.3; n = 216), and combined ED/inpatient, 89.1 (SD, 8.1; n = 213). LOS was significantly shorter for cases in the highest versus the lowest adherence tertile (ED, 90 vs 140 minutes, adjusted difference, -51 [95% confidence interval (CI), -73 to -29; P <.05]; inpatient, 3.1 vs 3.8 days, adjusted difference, -0.7 [95% CI, -1.4 to 0.0; P <.05]). Costs were less for cases in the highest adherence tertile (ED, -$84, [95% CI, -$7 to -$161; P <.05], total, -$1296 [95% CI, -126.43 to -2466.03; P <.05]). ED cases in the highest tertile had a lower odds of admission (odds ratio, 0.38 [95% CI, 0.15-0.97; P < .05]). Readmissions did not differ by tertile. CONCLUSIONS High adherence to bronchiolitis clinical pathway recommendations across care settings was associated with shorter LOS and lower cost.
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Affiliation(s)
- Mersine A Bryan
- Department of Pediatrics, University of Washington, Seattle, Washington; and .,Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Arti D Desai
- Department of Pediatrics, University of Washington, Seattle, Washington; and.,Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Lauren Wilson
- Department of Pediatrics, University of Washington, Seattle, Washington; and
| | - Davene R Wright
- Department of Pediatrics, University of Washington, Seattle, Washington; and.,Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington; and.,Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
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Mangione-Smith R, Roth CP, Britto MT, Chen AY, McGalliard J, Boat TF, Adams JL, McGlynn EA. Development and Testing of the Pediatric Respiratory Illness Measurement System (PRIMES) Quality Indicators. Hosp Pediatr 2017; 7:125-133. [PMID: 28223319 DOI: 10.1542/hpeds.2016-0182] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To develop and test quality indicators for assessing care in pediatric hospital settings for common respiratory illnesses. PATIENTS A sample of 2796 children discharged from the emergency department or inpatient setting at 1 of the 3 participating hospitals with a primary diagnosis of asthma, bronchiolitis, croup, or community-acquired pneumonia (CAP) between January 1, 2010, and December 31, 2011. SETTING Three tertiary care children's hospitals in the United States. METHODS We developed evidence-based quality indicators for asthma, bronchiolitis, croup, and CAP. Expert panel-endorsed indicators were included in the Pediatric Respiratory Illness Measurement System (PRIMES). This new set of pediatric quality measures was tested to assess feasibility of implementation and sensitivity to variations in care. Medical records data were extracted by trained abstractors. Quality measure scores (0-100 scale) were calculated by dividing the number of times indicated care was received by the number of eligible cases. Score differences within and between hospitals were determined by using the Student's t-test or analysis of variance. RESULTS CAP and croup condition-level PRIMES scores demonstrated significant between-hospital variations (P < .001). Asthma and bronchiolitis condition-level PRIMES scores demonstrated significant within-hospital variation with emergency department scores (means [SD] 82.2(6.1)-100.0 (14.4)] exceeding inpatient scores (means [SD] 71.1 (2.0)-90.8 (1.3); P < .001). CONCLUSIONS PRIMES is a new set of measures available for assessing the quality of hospital-based care for common pediatric respiratory illnesses.
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Affiliation(s)
- Rita Mangione-Smith
- Seattle Children Research Institute, Center for Child Health, Behavior and Development, Seattle, Washington; .,Department of Pediatrics, University of Washington, Seattle, Washington
| | | | - Maria T Britto
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alex Y Chen
- AltaMed Health Services, Los Angeles, California; and
| | - Julie McGalliard
- Seattle Children Research Institute, Center for Child Health, Behavior and Development, Seattle, Washington
| | - Thomas F Boat
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - John L Adams
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, California
| | - Elizabeth A McGlynn
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, California
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Lion KC, Wright DR, Desai AD, Mangione-Smith R. Costs of Care for Hospitalized Children Associated With Preferred Language and Insurance Type. Hosp Pediatr 2017; 7:70-78. [PMID: 28073815 DOI: 10.1542/hpeds.2016-0051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The study goal was to determine whether preferred language for care and insurance type are associated with cost among hospitalized children. METHODS A retrospective cohort study was conducted of inpatients at a freestanding children's hospital from January 2011 to December 2012. Patient information and hospital costs were obtained from administrative data. Cost differences according to language and insurance were calculated using multivariate generalized linear model estimates, allowing for language/insurance interaction effects. Models were also stratified according to medical complexity and length of stay (LOS) ≥3 days. RESULTS Of 19 249 admissions, 8% of caregivers preferred Spanish and 6% preferred another language; 47% of admissions were covered by public insurance. Models controlled for LOS, medical complexity, home-to-hospital distance, age, asthma diagnosis, and race/ethnicity. Total hospital costs were significantly higher for publicly insured Spanish speakers ($20 211 [95% confidence interval (CI), 7781 to 32 641]) and lower for privately insured Spanish speakers (-$16 730 [95% CI, -28 265 to -5195]) and publicly insured English speakers (-$4841 [95% CI, -6781 to -2902]) compared with privately insured English speakers. Differences were most pronounced among children with medical complexity and LOS ≥3 days. CONCLUSIONS Hospital costs varied significantly according to preferred language and insurance type, even adjusting for LOS and medical complexity. These differences in the amount of billable care provided to medically similar patients may represent either underprovision or overprovision of care on the basis of sociodemographic factors and communication, suggesting problems with care efficiency and equity. Further investigation may inform development of effective interventions.
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Affiliation(s)
- K Casey Lion
- Department of Pediatrics, University of Washington, Seattle, Washington; and .,Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Davene R Wright
- Department of Pediatrics, University of Washington, Seattle, Washington; and.,Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Arti D Desai
- Department of Pediatrics, University of Washington, Seattle, Washington; and.,Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington; and.,Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington
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Mangione-Smith R, Zhou C, Corwin MJ, Taylor JA, Rice F, Stout JW. Effectiveness of the Spirometry 360 Quality Improvement Program for Improving Asthma Care: A Cluster Randomized Trial. Acad Pediatr 2017; 17:855-862. [PMID: 28693976 PMCID: PMC5673551 DOI: 10.1016/j.acap.2017.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/18/2017] [Accepted: 06/24/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the effectiveness of the Spirometry 360 distance learning quality improvement (QI) program for enhancing the processes and outcomes of care for children with asthma. METHODS Cluster randomized controlled trial involving 25 matched pairs of pediatric primary care practices. Practices were recruited from 2 practice-based research networks: the Slone Center Office-based Research Network at Boston University, Boston, Mass, and the Puget Sound Pediatric Research Network, Seattle, Wash. Study participants included providers from one of the 50 enrolled pediatric practices and 626 of their patients with asthma. Process measures assessed included spirometry test quality and appropriate prescription of asthma controller medications. Outcome measures included asthma-specific health-related quality of life, and outpatient, emergency department, and inpatient utilization for asthma. RESULTS At baseline, 25.4% of spirometry tests performed in control practices and 50.4% of tests performed in intervention practices were of high quality. During the 6-month postintervention period, 28.7% of spirometry tests performed in control practices and 49.9% of tests performed in intervention practices were of high quality. The adjusted difference-of-differences analysis revealed no intervention effect on spirometry test quality. Adjusted differences-of-differences analysis also revealed no intervention effect on appropriate use of controller medications or any of the parent- or patient-reported outcomes examined. CONCLUSIONS In this study, the Spirometry 360 distance learning QI program was ineffective in improving spirometry test quality or parent- or patient-reported outcomes. QI programs like the one assessed here may need to focus on practices with lower baseline performance levels or may need to be tailored for those with higher baseline performance.
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Affiliation(s)
- Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Wash; Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Wash.
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, WA,Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA
| | | | - James A. Taylor
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Fiona Rice
- Slone Epidemiology Center, Boston University
| | - James W. Stout
- Department of Pediatrics, University of Washington, Seattle, WA
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Rutman L, Atkins RC, Migita R, Foti J, Spencer S, Lion KC, Wright DR, Leu MG, Zhou C, Mangione-Smith R. Modification of an Established Pediatric Asthma Pathway Improves Evidence-Based, Efficient Care. Pediatrics 2016; 138:peds.2016-1248. [PMID: 27940683 DOI: 10.1542/peds.2016-1248] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [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] [Accepted: 06/30/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE In September 2011, an established pediatric asthma pathway at a tertiary care children's hospital underwent significant revision. Modifications included simplification of the visual layout, addition of evidence-based recommendations regarding medication use, and implementation of standardized admission criteria. The objective of this study was to determine the impact of the modified asthma pathway on pathway adherence, percentage of patients receiving evidence-based care, length of stay, and cost. METHODS Cases were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Data were analyzed for 24 months before and after pathway modification. Statistical process control was used to examine changes in processes of care, and interrupted time series was used to examine outcome measures, including length of stay and cost in the premodification and postmodification periods. RESULTS A total of 5584 patients were included (2928 premodification; 2656 postmodification). Pathway adherence was high (79%-88%) throughout the study period. The percentage of patients receiving evidence-based care improved after pathway modification, and the results were sustained for 2 years. There was also improved efficiency, with a 30-minute (10%) decrease in emergency department length of stay for patients admitted with asthma (P = .006). There was a nominal (<10%) increase in costs of asthma care for patients in the emergency department (P = .04) and no change for those admitted to the hospital. CONCLUSIONS Modification of an existing pediatric asthma pathway led to sustained improvement in provision of evidence-based care and patient flow without adversely affecting costs. Our results suggest that continuous re-evaluation of established clinical pathways can lead to changes in provider practices and improvements in patient care.
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Affiliation(s)
- Lori Rutman
- University of Washington, Seattle, Washington; .,Seattle Children's Hospital, Seattle, Washington; and
| | | | - Russell Migita
- University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington; and
| | - Jeffrey Foti
- University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington; and
| | | | - K Casey Lion
- University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington; and
| | - Davene R Wright
- University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington; and
| | - Michael G Leu
- University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington; and
| | - Chuan Zhou
- University of Washington, Seattle, Washington
| | - Rita Mangione-Smith
- University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington; and
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Leyenaar JK, Ralston SL, Shieh MS, Pekow PS, Mangione-Smith R, Lindenauer PK. Epidemiology of pediatric hospitalizations at general hospitals and freestanding children's hospitals in the United States. J Hosp Med 2016; 11:743-749. [PMID: 27373782 PMCID: PMC5467435 DOI: 10.1002/jhm.2624] [Citation(s) in RCA: 159] [Impact Index Per Article: 19.9] [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] [Received: 11/24/2015] [Revised: 03/31/2016] [Accepted: 04/18/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND Children may be hospitalized at general hospitals or freestanding children's hospitals. Knowledge about how inpatient care differs at these hospitals is important to inform national research and quality efforts. OBJECTIVE To describe the volume and characteristics of pediatric hospitalizations at acute care general and freestanding children's hospitals in the United States. DESIGN, PATIENTS, AND SETTING Cross-sectional study of hospitalizations in the United States among children <18 years, excluding in-hospital births, using the Healthcare Cost and Utilization Project's 2012 Kids' Inpatient Database. MEASUREMENT We examined differences between hospitalizations at general and freestanding children's hospitals, applying weights to generate national estimates. Reasons for hospitalization were categorized using a pediatric grouper, and differences in hospital volumes were assessed for common diagnoses. RESULTS A total of 1,407,822 (standard deviation 50,456) hospitalizations occurred at general hospitals, representing 71.7% of pediatric hospitalizations. Hospitalizations at general hospitals accounted for 63.6% of hospital days and 50.0% of pediatric inpatient healthcare costs. Median volumes of pediatric hospitalizations, per hospital, were significantly lower at general hospitals than freestanding children's hospitals for common medical and surgical diagnoses. Although the most common reasons for hospitalization were similar, the most costly conditions differed. CONCLUSIONS In 2012, more than 70% of pediatric hospitalizations occurred at general hospitals in the United States. Differences in patterns of care at general hospitals and freestanding children's hospitals may inform clinical programs, research, and quality improvement efforts. Journal of Hospital Medicine 2016;11:743-749. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- JoAnna K Leyenaar
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Tufts Medical Center, Boston, Massachusetts.
| | - Shawn L Ralston
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Meng-Shiou Shieh
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts
| | - Penelope S Pekow
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts
- School of Public Health and Health Sciences, University of Massachusetts, Amherst, Massachusetts
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle Children's Research Institute, Seattle, Washington
| | - Peter K Lindenauer
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts
- Tufts University School of Medicine, Department of Medicine, Boston, Massachusetts
- Division of General Medicine, Baystate Medical Center, Springfield, Massachusetts
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Schrager SM, Arthur KC, Nelson J, Edwards AR, Murphy JM, Mangione-Smith R, Chen AY. Development and Validation of a Method to Identify Children With Social Complexity Risk Factors. Pediatrics 2016; 138:peds.2015-3787. [PMID: 27516527 DOI: 10.1542/peds.2015-3787] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [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] [Accepted: 06/30/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We sought to develop and validate a method to identify social complexity risk factors (eg, limited English proficiency) using Minnesota state administrative data. A secondary objective was to examine the relationship between social complexity and caregiver-reported need for care coordination. METHODS A total of 460 caregivers of children with noncomplex chronic conditions enrolled in a Minnesota public health care program were surveyed and administrative data on these caregivers and children were obtained. We validated the administrative measures by examining their concordance with caregiver-reported indicators of social complexity risk factors using tetrachoric correlations. Logistic regression analyses subsequently assessed the association between social complexity risk factors identified using Minnesota's state administrative data and caregiver-reported need for care coordination, adjusting for child demographics. RESULTS Concordance between administrative and caregiver-reported data was moderate to high (correlation range 0.31-0.94, all P values <.01), with only current homelessness (r = -0.01, P = .95) failing to align significantly between the data sources. The presence of any social complexity risk factor was significantly associated with need for care coordination before (unadjusted odds ratio = 1.65; 95% confidence interval, 1.07-2.53) but not after adjusting for child demographic factors (adjusted odds ratio = 1.53; 95% confidence interval, 0.98-2.37). CONCLUSIONS Social complexity risk factors may be accurately obtained from state administrative data. The presence of these risk factors may heighten a family's need for care coordination and/or other services for children with chronic illness, even those not considered medically complex.
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Affiliation(s)
- Sheree M Schrager
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California;
| | - Kimberly C Arthur
- Seattle Children's Hospital and Seattle Children's Research Institute, Seattle, Washington
| | - Justine Nelson
- Minnesota Department of Human Services, St. Paul, Minnesota
| | | | - J Michael Murphy
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Rita Mangione-Smith
- Seattle Children's Hospital and Seattle Children's Research Institute, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; and
| | - Alex Y Chen
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, California
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