Publications by authors named "Rita Mangione-Smith"

117 Publications

Patterns and Predictors of Professional Interpreter Use in the Pediatric Emergency Department.

Pediatrics 2021 Feb;147(2)

Department of Pediatrics and.

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 ( = 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2019-3312DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7906072PMC
February 2021

Associations Between Quality Measures and Outcomes for Children Hospitalized With Bronchiolitis.

Hosp Pediatr 2020 Nov;10(11):932-940

Kaiser Permanente Washington Health Research Institute, Seattle, Washington.

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, < .001), no complete blood cell counts (LOS: -17.8 hours; cost: -$399, < .05), and no respiratory syncytial virus testing (LOS: -16.6 hours; cost: -$272, < .05). Two underuse indicators were associated with higher cost: documentation of oral intake at discharge ($671, < .01) and documentation of hospital follow-up ($538, < .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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/hpeds.2020-0175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7596729PMC
November 2020

Reducing Antibiotic Prescribing in Primary Care for Respiratory Illness.

Pediatrics 2020 09 3;146(3). Epub 2020 Aug 3.

Kaiser Permanente Washington Health Research Institute, Seattle, Washington.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2020-0038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7461202PMC
September 2020

Studying Medication Safety in Pregnancy: A Call for New Approaches, Resources, and Collaborations.

Pediatrics 2020 07 8;146(1). Epub 2020 Jun 8.

Kaiser Permanente Washington Health Research Institute, Seattle, Washington; and.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2020-1540DOI Listing
July 2020

Social Determinants of Health and Emergency and Hospital Use by Children With Chronic Disease.

Hosp Pediatr 2020 06;10(6):471-480

Department of Pediatrics, School of Medicine and.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/hpeds.2019-0248DOI Listing
June 2020

Caregiver and Provider Experiences of Home Healthcare Quality for Children With Medical Complexity.

Home Healthc Now 2020 May/Jun;38(3):138-146

Carolyn C. Foster, MD, MSHS, is an Assistant Professor, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Mary Ann & J. Milburn Smith Child Health Research Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois. Molly M. Fuentes, MD, MS, is an Assistant Professor, Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, Seattle Children's Hospital, Seattle, Washington. Lauren A. Wadlington, MSW, LICSW, is a Social Work Clinical Supervisor, Department of Social Work, Seattle Children's Hospital, Seattle, Washington. Elizabeth Jacob-Files, MA, MPH, is a Qualitative Researcher, Seattle Children's Research Institute, Seattle, Washington. Arti D. Desai, MD, MSPH, is an Assistant Professor, Department of Pediatrics, University of Washington, Seattle, Washington, Seattle Children's Hospital, Seattle, Washington. Tamara D. Simon, MD, MSPH, is an Associate Professor, Department of Pediatrics, University of Washington, Seattle, Washington, Seattle Children's Hospital, Seattle, Washington. Rita Mangione-Smith, MD, MPH, is a Professor, Department of Pediatrics, University of Washington, Seattle, Washington, Seattle Children's Hospital, Seattle, Washington.

Despite a growing population of children with medical complexity, little is known about the current quality of pediatric home healthcare. The objective of this study was to characterize the quality of pediatric home healthcare experienced by primary family caregivers (parents) and healthcare providers of children with medical complexity. Semistructured, in-depth key informant interviews of 20 caregivers and 20 providers were conducted and analyzed for factors affecting home healthcare quality using the Institute of Medicine's quality framework (effective, safe, patient-centered, timely, equitable, and efficient). System complexity, insurance denials, and workforce shortages affected patients' ability to establish and maintain access to home healthcare leading to hospital discharge delays and negative family impacts. When home healthcare was accessible, respondents experienced it as effective in improving patient and family daily life and minimizing use of emergency and hospital services. However, respondents identified a need for more pediatric-specific home healthcare training and increased efficiencies in care plan communication. Overall, home healthcare was not perceived as timely or equitable due to access barriers. This study provides a new conceptual framework representing the relationship between home healthcare quality and outcomes for children with medical complexity for future evaluations of quality improvement, research, and policy initiatives.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/NHH.0000000000000857DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7199441PMC
March 2021

Social Disadvantage, Access to Care, and Disparities in Physical Functioning Among Children Hospitalized with Respiratory Illness.

J Hosp Med 2020 04 11;15(4):211-218. Epub 2020 Feb 11.

Division of Hospital Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nash-ville, Tennessee.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.12788/jhm.3359DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7153490PMC
April 2020

Vaccination Status and Adherence to Quality Measures for Acute Respiratory Tract Illnesses.

Hosp Pediatr 2020 03 10;10(3):199-205. Epub 2020 Feb 10.

Department of Pediatrics, University of Washington, Seattle, Washington.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/hpeds.2019-0245DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7041553PMC
March 2020

Validation of a Parent-Reported Hospital-to-Home Transition Experience Measure.

Pediatrics 2020 02;145(2)

James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2019-2150DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6993281PMC
February 2020

Identifying Modifiable Health Care Barriers to Improve Health Equity for Hospitalized Children.

Hosp Pediatr 2020 01 4;10(1):1-11. Epub 2019 Dec 4.

Department of Pediatrics and.

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% ( = 3651) completed the admission survey; of those, 48% ( = 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/hpeds.2019-0096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6931033PMC
January 2020

Pediatric Respiratory Illness Measurement System (PRIMES) Scores and Outcomes.

Pediatrics 2019 08;144(2)

Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, New York.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2019-0242DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6855826PMC
August 2019

Home Smoke Exposure and Health-Related Quality of Life in Children with Acute Respiratory Illness.

J Hosp Med 2019 04;14(4):212-217

Division of Hospital Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.12788/jhm.3164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6948779PMC
April 2019

Satisfaction With Care Coordination for Families of Children With Disabilities.

J Pediatr Health Care 2019 May - Jun;33(3):255-262. Epub 2018 Nov 16.

Introduction: Children with disabilities have significant health care needs, and receipt of care coordinator services may reduce caregiver burdens. The present study assessed caregivers' experience and satisfaction with care coordination.

Method: Caregivers of Medicaid-enrolled children with disabilities (n = 2,061) completed a survey (online or by telephone) collecting information on the caregivers' experiences and satisfaction with care coordination using the Family Experiences with Coordination of Care questionnaire.

Results: Eighty percent of caregivers with a care coordinator reported receiving help making specialist appointments, and 71% reported help obtaining community services. Caregivers who reported that the care coordinator helped with specialist appointments or was knowledgeable, supportive, and advocating for children had increased odds of satisfaction (odds ratio = 3.46, 95% confidence interval = [1.01, 11.77] and odds ratio = 1.07, 95% confidence interval = [1.03, 1.11], respectively).

Discussion: Findings show opportunities for improving care coordination in Medicaid-enrolled children with disabilities and that some specific elements of care coordination may enhance caregiver satisfaction with care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.pedhc.2018.08.010DOI Listing
July 2020

Utilizing Family-Centered Process and Outcome Measures to Assess Hospital-to-Home Transition Quality.

Acad Pediatr 2018 Nov - Dec;18(8):843-846. Epub 2018 Aug 2.

Department of Pediatrics (AD Desai, TD Simon, and R Mangione-Smith), University of Washington, Seattle; Seattle Children's Research Institute (AD Desai, TD Simon, and R Mangione-Smith).

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.acap.2018.07.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6598693PMC
November 2019

Perceived Access to Outpatient Care and Hospital Reutilization Following Acute Respiratory Illnesses.

Acad Pediatr 2019 May - Jun;19(4):370-377. Epub 2018 Jul 25.

Department of Pediatrics, University of Washington and the Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA.

Objective: Efforts to decrease hospital revisits often focus on improving access to outpatient follow-up. Our objective was to assess the relationship between perceived access to timely office-based care and subsequent 30-day revisits following hospital discharge for 4 common respiratory illnesses.

Methods: This was a prospective cohort study of children 2 weeks to 16years admitted to 5 US children's hospitals for asthma, bronchiolitis, croup, or pneumonia between July 2014 and June 2016. Hospital and emergency department (ED) (in the case of croup) admission surveys administered to caregivers included the Consumer Assessments of Healthcare Providers and Systems Timely Access to Care. Access composite scores (range 0-100, with greater scores indicating better access) were linked with 30-day ED revisits and inpatient readmissions from the Pediatric Health Information System. The relationship between access to timely care and repeat utilization was assessed using multivariable logistic regression adjusting for demographics, hospitalization, and home/outpatient factors.

Results: Of the 2438 children enrolled, 2179 (89%) reported an office visit in the previous 6 months. Average access composite score was 52.0 (standard deviation, 36.3). In adjusted analyses, greater access scores were associated with greater odds of 30-day ED revisits (odds ratio [OR] = 1.07; 95% confidence interval [CI], 1.02-1.13)-particularly for croup (OR = 1.17; 95% CI, 1.02-1.36)-but not inpatient readmissions (OR = 1.02; 95% CI, 0.96-1.09).

Conclusions: Perceived access to timely office-based care was associated with significantly greater odds of subsequent ED revisit. Focusing solely on enhancing timely access to care following discharge for common respiratory illnesses may be insufficient to prevent repeat utilization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.acap.2018.07.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6347552PMC
May 2020

Caregiver and Health Care Provider Perspectives on Cloud-Based Shared Care Plans for Children With Medical Complexity.

Hosp Pediatr 2018 07 5;8(7):394-403. Epub 2018 Jun 5.

Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/hpeds.2017-0242DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6692073PMC
July 2018

Hospital-Based Quality Measures for Pediatric Mental Health Care.

Pediatrics 2018 06;141(6)

Department of Pediatrics, University of Washington, Seattle, Washington.

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 ( = 446), psychosis ( = 321), and substance use ( = 50). Performance varied across measures. Among patients with suicidality, male patients (adjusted odds ratio: 0.27, < .001) and African American patients (adjusted odds ratio: 0.31, = .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%; < .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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2017-3554DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6317537PMC
June 2018

The Impact of an Adolescent Depressive Disorders Clinical Pathway on Healthcare Utilization.

Adm Policy Ment Health 2018 11;45(6):979-987

University of Washington School of Medicine, Seattle, WA, USA.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10488-018-0878-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6590677PMC
November 2018

Development of a Caregiver-Reported Experience Measure for Pediatric Hospital-to-Home Transitions.

Health Serv Res 2018 08 8;53 Suppl 1:3084-3106. Epub 2018 May 8.

Seattle Children's Research Institute, Seattle, WA.

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: χ  = 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/1475-6773.12864DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6056575PMC
August 2018

Quality of Care for Children With Medical Complexity: An Analysis of Continuity of Care as a Potential Quality Indicator.

Acad Pediatr 2018 08 25;18(6):669-676. Epub 2018 Apr 25.

The Commonwealth Fund, New York, NY.

Objective: To examine the relationship between continuity of care for children with medical complexity (CMC) and emergency department (ED) utilization, care coordination quality, and family effects related to care coordination.

Methods: We measured ED utilization and primary care continuity with the Bice-Boxerman continuity of care index for 1477 CMC using administrative data from Minnesota and Washington state Medicaid agencies. For a subset of 186 of these CMC a caregiver survey was used to measure care coordination quality (using items adapted from the Consumer Assessment of Healthcare Providers and System Adult Health Plan Survey) and family impact (using items adapted from the National Survey of Children with Special Health Care Needs). Multivariable regression was used to examine the relationship between continuity, entered as a continuous variable ranging from 0 to 1, and the outcomes.

Results: The median continuity was 0.27 (interquartile range [IQR], 0.12-0.48) in the administrative data cohort and 0.27 (IQR, 0.14-0.43) in the survey cohort. Compared with children with a continuity score of 0, children with a score of 1 had lower odds of having ≥1 ED visit (odds ratio, 0.65; 95% confidence interval [CI], 0.46-0.93; P = .017) and their caregivers reported higher scores for the measure of receipt of care coordination (β = 35.2 on a 0-100 scale; 95% CI, 11.5-58.9; P = .004). There was no association between continuity and family impact.

Conclusions: Continuity of care holds promise as a quality measure for CMC because of its association with lower ED utilization and more frequent receipt of care coordination.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.acap.2018.04.009DOI Listing
August 2018

Validation of New Care Coordination Quality Measures for Children with Medical Complexity.

Acad Pediatr 2018 07 14;18(5):581-588. Epub 2018 Mar 14.

RAND Corporation, Santa Monica, Calif.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.acap.2018.03.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6152933PMC
July 2018

Development and Validation of the Pediatric Medical Complexity Algorithm (PMCA) Version 3.0.

Acad Pediatr 2018 07 26;18(5):577-580. Epub 2018 Feb 26.

Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Wash; Seattle Children's Research Institute, Seattle, Wash.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.acap.2018.02.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6035108PMC
July 2018

Impact of Childhood Vaccine Discussion Format Over Time on Immunization Status.

Acad Pediatr 2018 May - Jun;18(4):430-436. Epub 2018 Jan 8.

Department of Pediatrics, Child Health Institute, University of Washington School of Medicine, Seattle, Wash.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.acap.2017.12.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5936647PMC
June 2019

Using State Administrative Data to Identify Social Complexity Risk Factors for Children.

Ann Fam Med 2018 01;16(1):62-69

Seattle Children's Research Institute, Seattle, Washington.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1370/afm.2134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5758323PMC
January 2018

Agreement Between Parent Proxy Report and Child Self-Report of Pain Intensity and Health-Related Quality of Life After Surgery.

Acad Pediatr 2018 May - Jun;18(4):376-383. Epub 2017 Dec 8.

Centers for Clinical and Translational Research and Child Health Behavior and Development, Seattle Children's Research Institute, Seattle, Wash; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Wash. Electronic address:

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.acap.2017.12.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5936667PMC
June 2019

Kawasaki Disease Substantially Impacts Health-Related Quality of Life.

J Pediatr 2018 02 1;193:155-163.e5. Epub 2017 Dec 1.

Division of Pediatric Cardiology, Department of Pediatrics, University of Washington, Seattle, WA; Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA.

Objective: To prospectively evaluate the acute impact of Kawasaki disease (KD) on health-related quality of life (HRQoL) and to assess deterioration in the HRQoL experienced by children with KD compared with other childhood diseases.

Study Design: We merged the Outcomes Assessment Program database obtained prospectively with the existing KD database and queried for KD admissions between 1 month and 13 years of age. HRQoL was evaluated with the parent-proxy Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core and Infant Scales. We compared the KD HRQoL results with those obtained from newly diagnosed patients with cancer and pneumonia, matched for age, sex and race. PedsQL total scores over time were assessed with ANCOVA models, adjusted for matching variables and PedsQL score prior to admission.

Results: We identified 89 patients with KD and compared 65 subjects with an equal number with pneumonia and with 67 subjects with newly diagnosed cancer. Patients with demonstrated lower PedsQL total score on admission and suffered a significantly greater HRQoL decline from baseline to admission than the other groups. KD diagnostic subtype (complete or incomplete) and coronary artery dilatation were not associated with HRQoL outcomes. However, non-intravenous immunoglobulin responders showed greater HRQoL decline than responders (P = .03).

Conclusions: Children with KD suffer acute and significant HRQoL impairment exceeding that of children newly diagnosed with cancer. Lack of immediate treatment response may exert an additional HRQoL burden, whereas KD subtype and coronary artery dilatation do not.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpeds.2017.09.070DOI Listing
February 2018

Effectiveness of a Comprehensive Case Management Service for Children With Medical Complexity.

Pediatrics 2017 Dec;140(6)

Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and.

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 ( = 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2017-1641DOI Listing
December 2017

Effectiveness of a Comprehensive Case Management Service for Children With Medical Complexity.

Pediatrics 2017 Dec;140(6)

Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and.

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 ( = 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2017-1641DOI Listing
December 2017

Provider Perspectives of High-Quality Pediatric Hospital-to-Home Transitions for Children and Youth With Chronic Disease.

Hosp Pediatr 2017 11;7(11):649-659

Departments of Pediatrics and.

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 ( = 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/hpeds.2017-0031DOI Listing
November 2017

Importance and Feasibility of Transitional Care for Children With Medical Complexity: Results of a Multistakeholder Delphi Process.

Acad Pediatr 2018 Jan - Feb;18(1):94-101. Epub 2017 Jul 21.

Department of Pediatrics, University of Washington, Seattle Children's Research Institute, Seattle.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.acap.2017.07.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5756674PMC
June 2019