Rajendu Srivastava

Children With Complex Chronic Conditions in Inpatient Hospital Settings in the United States

OBJECTIVES: Hospitalized children are perceived to be increasingly medically complex, but no such trend has been documented. The objective of this study was to determine whether the proportion of pediatric inpatient use that is attributable to patients with a diagnosis of one or more complex chronic condition (CCC) has increased over time and to assess the degree to which CCC hospitalizations are associated with attributes that are consistent with heightened medical complexity. METHODS: A retrospective observational study that used the 1997, 2000, 2003, and 2006 Kids Inpatient Databases examined US hospitalizations for children. Attributes of medical complexity included hospital admissions, length of stay, total charges, technology-assistance procedures, and mortality risk. RESULTS: The proportion of inpatient pediatric admissions, days, and charges increased from 1997 to 2006 for any CCC and for every CCC group except hematology. CCCs accounted for 8.9% of US pediatric admissions in 1997 and 10.1% of admissions in 2006. These admissions used 22.7% to 26.1% of pediatric hospital days, used 37.1% to 40.6% of pediatric hospital charges, accounted for 41.9% to 43.2% of deaths, and (for 2006) used 73% to 92% of different forms of technology-assistance procedures. As the number of CCCs for a given admission increased, all markers of use increased. CONCLUSIONS: CCC-associated hospitalizations compose an increasing proportion of inpatient care and resource use. Future research should seek to improve methods to identify the population of medically complex children, monitor their increasing inpatient use, and assess whether current systems of care are meeting their needs.

Children With Medical Complexity: An Emerging Population for Clinical and Research Initiatives

Children with medical complexity (CMC) have medical fragility and intensive care needs that are not easily met by existing health care models. CMC may have a congenital or acquired multisystem disease, a severe neurologic condition with marked functional impairment, and/or technology dependence for activities of daily living. Although these children are at risk of poor health and family outcomes, there are few well-characterized clinical initiatives and research efforts devoted to improving their care. In this article, we present a definitional framework of CMC that consists of substantial family-identified service needs, characteristic chronic and severe conditions, functional limitations, and high health care use. We explore the diversity of existing care models and apply the principles of the chronic care model to address the clinical needs of CMC. Finally, we suggest a research agenda that uses a uniform definition to accurately describe the population and to evaluate outcomes from the perspectives of the child, the family, and the broader health care system.

Changes in medical errors after implementation of a handoff program

BACKGROUND Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking. METHODS We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events. RESULTS In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time. CONCLUSIONS Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).

Epidemiology, complications, and cost of hospitalization in children with laboratory-confirmed influenza infection

BACKGROUND. Influenza causes significant morbidity among children. Previous studies used indirect case ascertainment methods with little cost data. We sought to measure the burden of laboratory-confirmed influenza from hospitalized children. METHODS. We conducted a retrospective cohort study during 3 viral seasons at Primary Childrens Medical Center (Salt Lake City, UT). Children ≤18 years of age who were hospitalized with laboratory-confirmed influenza infection were included. Outcomes included hospitalization rates, complications including intensive care unit stays, mechanical ventilation, length of stay, and total hospital costs. RESULTS. A total of 325 children had hospitalizations attributable to influenza over 3 viral seasons: 28% <6 months of age, 33% between 6 and 23 months of age; and 39% >2 years of age; 37% had high-risk medical conditions. Population-based rates of hospitalization for Salt Lake County residents ranged from 6.3 to 252.7 per 100000 children. The highest rates were in children younger than 6 months, and rates decreased with increasing age. Forty-nine (15%) children had an ICU stay; 27 required mechanical ventilation, and half of these patients were >2 years of age. Total hospital cost for the cohort was

How Well Can Hospital Readmission Be Predicted in a Cohort of Hospitalized Children? A Retrospective, Multicenter Study

2 million; 55% was accounted for by children >2 years of age. Length of stay and total hospital costs were significantly higher in all children >2 years of age compared with children <6 months of age and were comparable to all children 6 to 23 months of age. CONCLUSIONS. Proven influenza infection in children results in substantial hospital resource utilization and morbidity. Nationwide, the median hospital costs may total

Prioritization of Comparative Effectiveness Research Topics in Hospital Pediatrics

55 million. Our data support the Advisory Committee on Immunizations recommendations to expand the use of influenza vaccine to children >2 years of age.

Characteristics of Hospitalizations for Patients Who Use a Structured Clinical Care Program for Children with Medical Complexity

BACKGROUND. Children with complex chronic conditions depend on both their families and systems of pediatric health care, social services, and financing. Investigations into the workings of this ecology of care would be advanced by more accurate methods of population-level predictions of the likelihood for future hospitalization. METHODS. This was a retrospective cohort study. Hospital administrative data were collected from 38 childrens hospitals in the United States for the years 2003–2005. Participants included patients between 2 and 18 years of age discharged from an index hospitalization during 2004. Patient characteristics documented during the index hospitalization or any previous hospitalization during the preceding 365 days were included. The main outcome measure was readmission to the hospital during the 365 days after discharge from the index admission. RESULTS. Among the cohort composed of 186856 patients discharged from the participating hospitals during 2004, the mean age was 9.2 years, with 54.4% male and 52.9% identified as non-Hispanic white. A total of 17.4% were admitted during the previous 365 days, and among those discharged alive (0.6% died during the admission), 16.7% were readmitted during the ensuing 365 days. The final readmission model exhibited a c statistic of 0.81 across all hospitals, with a range from 0.76 to 0.84 for each hospital. Bootstrap-based assessments demonstrated the stability of the final model. CONCLUSIONS. Accurate population-level prediction of hospital readmissions is possible, and the resulting predicted probability of hospital readmission may prove useful for health services research and planning.

Impact of fundoplication versus gastrojejunal feeding tubes on mortality and in preventing aspiration pneumonia in young children with neurologic impairment who have gastroesophageal reflux disease.

OBJECTIVE To use information about prevalence, cost, and variation in resource utilization to prioritize comparative effectiveness research topics in hospital pediatrics. DESIGN Retrospective analysis of administrative and billing data for hospital encounters. SETTING Thirty-eight freestanding US childrens hospitals from January 1, 2004, through December 31, 2009. PARTICIPANTS Children hospitalized with conditions that accounted for either 80% of all encounters or 80% of all charges. MAIN OUTCOME MEASURES Condition-specific prevalence, total standardized cost, and interhospital variation in mean standardized cost per encounter, measured in 2 ways: (1) intraclass correlation coefficient, which represents the fraction of total variation in standardized costs per encounter due to variation between hospitals; and (2) number of outlier hospitals, defined as having more than 30% of encounters with standardized costs in either the lowest or highest quintile across all encounters. RESULTS Among 495 conditions accounting for 80% of all charges, the 10 most expensive conditions accounted for 36% of all standardized costs. Among the 50 most prevalent and 50 most costly conditions (77 in total), 26 had intraclass correlation coefficients higher than 0.10 and 5 had intraclass correlation coefficients higher than 0.30. For 10 conditions, more than half of the hospitals met outlier hospital criteria. Surgical procedures for hypertrophy of tonsils and adenoids, otitis media, and acute appendicitis without peritonitis were high cost, were high prevalence, and displayed significant variation in interhospital cost per encounter. CONCLUSIONS Detailed administrative and billing data can be used to standardize hospital costs and identify high-priority conditions for comparative effectiveness research--those that are high cost, are high prevalence, and demonstrate high variation in resource utilization.

Pediatric Hospitalists: A Systematic Review of the Literature

OBJECTIVE To describe the characteristics of hospitalizations for patients who use clinical programs that provide care coordination for children with multiple, chronic medical conditions. STUDY DESIGN Retrospective analysis of 1083 patients hospitalized between June 2006 and July 2008 who used a structured, pediatric complex-care clinical program within 4 childrens hospitals. Chronic diagnosis prevalence (ie, technology assistance, neurologic impairment, and other complex chronic conditions), inpatient resource utilization (ie, length of stay, 30-day readmission), and reasons for hospitalization were assessed across the programs. RESULTS Over the 2-year study period, complex-care program patients experienced a mean of 3.1 ± 2.8 admissions, a mean length of hospital stay per admission of 12.2 ± 25.5 days, and a 30-day hospital readmission rate of 25.4%. Neurologic impairment (57%) and presence of a gastrostomy tube (56%) were the most common clinical characteristics of program patients. Notable reasons for admission included major surgery (47.1%), medical technology malfunction (9.0%), seizure (6.4%), aspiration pneumonia (3.9%), vomiting/feeding difficulties (3.4%), and asthma (1.8%). CONCLUSIONS Hospitalized patients who used a structured clinical program for children with medical complexity experienced lengthy hospitalizations with high early readmission rates. Reducing hospital readmission may be one potential strategy for decreasing inpatient expenditures in this group of children with high resource utilization.

Death, Child Abuse, and Adverse Neurological Outcome of Infants After an Apparent Life-Threatening Event

OBJECTIVE. Aspiration pneumonia is the most common cause of death in children with neurologic impairment who have gastroesophageal reflux disease. Fundoplications and gastrojejunal feeding tubes are frequently employed to prevent aspiration pneumonia in this population. Which of these approaches is more effective in preventing aspiration pneumonia and/or improving survival is unknown. The objective of this study was to compare outcomes for children with neurologic impairment and gastroesophageal reflux disease after either a first fundoplication or a first gastrojejunal feeding tube. PATIENTS AND METHODS. This was a retrospective, observational cohort study of children with neurologic impairment who had either a fundoplication or gastrojejunal feeding tube between January 1997 and December 2005 at a tertiary care childrens hospital. Main outcome measures were postprocedure aspiration pneumonia–free survival and mortality. Propensity analyses were used to control for bias in treatment assignment and prognostic imbalances. RESULTS. Of the 366 children with neurologic impairment and gastroesophageal reflux disease, 43 had a first gastrojejunal feeding tube and 323 underwent a first fundoplication. Median length of follow-up was 3.4 years. Children who received a first fundoplication had similar rates of aspiration pneumonia and mortality after the procedure compared with those who had a first gastrojejunal feeding tube, when adjusting for the treatment assignment using propensity scores. CONCLUSIONS. Aspiration pneumonia and mortality are not uncommon events after either a first fundoplication or a first gastrojejunal feeding tube for the management of gastroesophageal reflux disease in children with neurologic impairment. Neither treatment option is clearly superior in preventing the subsequent aspiration pneumonia or improving overall survival for these children. This complex clinical scenario needs to be studied in a prospective, multicenter, randomized control trial to evaluate definitively whether 1 of these 2 management options is more beneficial.