Trends in Hospital Costs and Levels of Services Provided for Children With Bronchiolitis Treated in Children's Hospitals.

Importance: Increasing hospital costs for bronchiolitis have been associated with increasing patient complexity and mechanical ventilation. However, the associations of illness severity and diagnostic coding practices with bronchiolitis hospitalization costs have not been examined. Objective: To investigate the association of patient complexity, illness severity, and diagnostic coding practices with bronchiolitis hospitalization costs. Design, Setting, and Participants: This retrospective cross-sectional study included 385 883 infants aged 24 months or younger who were hospitalized with bronchiolitis at 39 hospitals in the Pediatric Health Information System database from January 1, 2010, to December 31, 2019. Exposure: Hospitalization for bronchiolitis. Main Outcomes and Measures: Inflation-adjusted standardized unit cost (expressed in dollar units) per hospitalization over time. A nested subgroup analysis was performed to further examine factors associated with changes in cost. Results: A total of 385 883 bronchiolitis hospitalizations were studied; the patients had a mean (SD) age of 7.5 (6.4) months and included 227 309 of 385 883 boys (58.9%) and 253 870 of 385 883 publicly insured patients (65.8%). Among patients hospitalized with bronchiolitis, the median standardized unit cost per hospitalization increased significantly during the study period (from $5636 [95% CI, $5558-$5714] in 2010 to $6973 [95% CI, $6915-$7030] in 2019; P < .001 for trend). Similar increases in cost were observed among subgroups of patients without a complex chronic condition and without the need for mechanical ventilation. However, costs for patients without a complex chronic condition or mechanical ventilation, who received care outside the intensive care unit did not change in an economically significant manner (from $4803 [95% CI, $4752-$4853] in 2010 to $4853 [95% CI, $4811-$4895] in 2019; P < .001 for trend), suggesting that intensive care unit use was a primary factor associated with cost increases. Substantial changes in coding practices were observed. Among patients hospitalized with bronchiolitis, 1.2% (95% CI, 1.1%-1.3%) were assigned an APR-DRG (All Patient Refined Diagnosis Related Group) for respiratory failure in 2010, which increased to 21.6% (95% CI, 21.2%-21.9%) in 2019 (P < .001 for trend). Increased costs and coding intensity were not accompanied by objective evidence of worsening illness severity. Conclusions and Relevance: This cross-sectional study suggests that hospitalized children with bronchiolitis are receiving costlier and more intensive care without objective evidence of increasing severity of illness. Changes in coding practices may complicate efforts to study trends in the use of health care resources using administrative data.

Identifying Continuous Quality Improvement Priorities in Maternal, Infant, and Early Childhood Home Visiting.

OBJECTIVE: The purpose of this article was to describe a methodology to identify continuous quality improvement (CQI) priorities for one state's Maternal, Infant, and Early Childhood Home Visiting program from among the 40 required constructs associated with 6 program benchmarks. The authors discuss how the methodology provided consensus on system CQI quality measure priorities and describe variation among the 3 service delivery models used within the state. DESIGN: Q-sort methodology was used by home visiting (HV) service delivery providers (home visitors) to prioritize HV quality measures for the overall state HV system as well as their service delivery model. RESULTS: There was general consensus overall and among the service delivery models on CQI quality measure priorities, although some variation was observed. Measures associated with Maternal, Infant, and Early Childhood Home Visiting benchmark 1, Improved Maternal and Newborn Health, and benchmark 3, Improvement in School Readiness and Achievement, were the highest ranked. CONCLUSIONS: The Q-sort exercise allowed home visitors an opportunity to examine priorities within their service delivery model as well as for the overall First Teacher HV system. Participants engaged in meaningful discussions regarding how and why they selected specific quality measures and developed a greater awareness and understanding of a systems approach to HV within the state. The Q-sort methodology presented in this article can easily be replicated by other states to identify CQI priorities at the local and state levels and can be used effectively in states that use a single HV service delivery model or those that implement multiple evidence-based models for HV service delivery.

[ASSESSMENT OF THE QUALITY OF INFORMATION ON THE HEALTH OF CHILDREN IN RUSSIA: INTERREGIONAL COMPARISONS AND CLASSIFICATION].

The high level of children health, according to official statistics, (about 80% of children of I and II health groups), raises doubts in quality of information. Analytical methods of processing of databases of the official state statistics, based on interregional comparisons, and also comparison of the main indices of public children's health and multidimensional classifications are offered As a result of the hierarchical cluster analysis of the main indices of children's health the poor quality of medical examinations and health survey is confirmed. The best situation concerning children's health and quality of information is noted in 19 regions, mostly European part of the country, the worst--in six national regions of the North Caucasian, Southern and Siberian Federal Districts.

Medicaid re-enrollment policies and children's risk of hospitalizations for ambulatory care sensitive conditions.

BACKGROUND: Many poor children rotate through the Medicaid program with periods of being uninsured. OBJECTIVE: To determine health and cost consequences of a Medicaid policy change that extended the Medicaid eligibility redetermination period for children in California from 3 to 12 months. RESEARCH DESIGN: A pre/postevaluation with a comparison group of a natural experiment. SUBJECTS: All California children ages 1-17 years who received a minimum of 1 month of Medicaid coverage in 1999-2000 (3,288,171) and/or 2001-2002 (3,230,120). MEASURES: The percentage of children with continuous Medicaid coverage and the hospitalization rate and costs for ambulatory care sensitive conditions in each time period. RESULTS: In the 2 years before the policy change, 49% of children had continuous Medicaid coverage compared with 62% in the 2 years afterward (P < 0.0001). After adjusting for demographic and programmatic differences in the population of children in each time period, the relative hazard of a hospitalization for an ambulatory care sensitive condition for a child with at least 1 month of Medicaid coverage decreased to 0.74 (P < 0.0001) after the extension of the Medicaid enrollment period. There was dollars 17 million less in estimated hospitalization costs for ambulatory care sensitive conditions with less frequent eligibility redetermination that partially offset the estimated dollars 150 million in additional costs to Medicaid for providing more continuous coverage. CONCLUSIONS: Reducing the frequency of eligibility redetermination for children in Medicaid was associated with higher costs to the program but more continuity of insurance coverage, improvements in health, and lower hospital spending.

How much does quality of child care vary between health workers with differing durations of training? An observational multicountry study.

BACKGROUND: Countries with high rates of child mortality tend to have shortages of qualified health workers. Little rigorous evidence has been done to assess how much the quality of care varies between types of health workers. We compared the performance of different categories of health workers who are trained in Integrated Management of Childhood Illness (IMCI). METHODS: We analysed data obtained from first-level health facility surveys in Bangladesh (2003), Brazil (2000), Uganda (2002), and Tanzania (2000). We compared the clinical performance of health workers with longer duration of preservice training (those with >4 years of post-secondary education in Brazil or >3 years in the other three countries) and shorter duration (all other health workers providing clinical care). We calculated quality of care with indicators of assessment, classification, and management of sick children according to IMCI guidelines. Every child was examined twice, by the IMCI-trained health worker being assessed and by a gold-standard supervisor. FINDINGS: 272 children were included in Bangladesh, 147 in Brazil, 231 in Tanzania, and 612 in Uganda. The proportions of children correctly managed by health workers with longer duration of preservice training in Brazil were 57.8% (n=43) versus 83.7% (n=61) for those with shorter duration of training (p=0.008), and 23.1% (n=47) versus 32.6% (n=134) (p=0.03) in Uganda. In Tanzania, those with longer duration of training did better than did those with shorter duration in integrated assessment of sick children (mean index of integrated assessment 0.94 [SD 0.15] vs 0.88 [0.13]; p=0.004). In Bangladesh, both categories of health worker did much the same in all clinical tasks. We recorded no significant difference in clinical performance in all the other clinical tasks in the four countries. INTERPRETATION: IMCI training is associated with much the same quality of child care across different health worker categories, irrespective of the duration and level of preservice training. Strategies for scaling up IMCI and other child-survival interventions might rely on health workers with shorter duration of preservice training being deployed in underserved areas.

Quality of care of children in the emergency department: association with hospital setting and physician training.

OBJECTIVE: To investigate differences in the quality of emergency care for children related to differences in hospital setting, physician training, and demographic factors. STUDY DESIGN: This was a retrospective cohort study of a consecutive sample of children presenting with high-acuity illnesses or injuries at 4 rural non-children's hospitals (RNCHs) and 1 academic urban children's hospital (UCH). Two of 4 study physicians independently rated quality of care using a validated implicit review instrument. Hierarchical modeling was used to estimate quality of care (scored from 5 to 35) across hospital settings and by physician training. RESULTS: A total of 304 patients presenting to the RNCHs and the UCH were studied. Quality was lower (difference = -3.23; 95% confidence interval [CI] = -4.48 to -1.98) at the RNCHs compared with the UCH. Pediatric emergency medicine (PEM) physicians provided better care than family medicine (FM) physicians and those in the "other" category (difference = -3.34, 95% CI = -5.40 to -1.27 and -3.12, 95% CI = -5.25 to -0.99, respectively). Quality of care did not differ significantly between PEM and general emergency medicine (GEM) physicians in general, or between GEM and PEM physicians at the UCH; however, GEM physicians at the RNCHs provided care of lesser quality than PEM physicians at the UCH (difference = -2.75; 95% CI = -5.40 to -0.05). Older children received better care. CONCLUSIONS: The quality of care provided to children is associated with age, hospital setting, and physician training.

Mental health services for children and adolescents in New Zealand, outcomes, and the Health of the Nation Outcome Scale for Children and Adolescents (HoNOSCA).

Patients and their families as well as communities, service providers, and funders of services would be united in their desire that children and adolescents who require mental health services should receive those services. There would also be agreement that treatment delivered by these services should be safe, effective, and (given that resources for these mental health services are limited) delivered in a timely and cost-effective manner. Furthermore, there would be a consensus that outcomes of treatment are extremely important and that there is a need to evaluate these in a valid manner. This article reviews current access to Child and Adolescent Mental Health Services (CAMHS) in New Zealand as well as issues relevant to the introduction of routine outcome measurement in these services; and critically appraises the psychometric properties and clinical utility of the first routine outcome measure introduced for CAMHS by the Ministry of Health (MOH)--the Health of the Nation Outcome Scale for Children and Adolescents (the HoNOSCA). It is argued that the evidence base for the implementation of routine outcome measurement is poor, that systematic evaluation of its introduction should occur, and that already under-funded CAMHS should be adequately resourced to support the additional work involved.

[Consultation in a baby clinic of the PMI (mother and infant welfare service): a survey in a French department]. / Consultation du nourrisson en PMI: enquête auprès des usagers et des professionnels d'un département français.

A dual survey carried out amongst the users and the professionals of PMI showed that proximity, the range of advice available, the exchanges on parenthood, and the assessment of the child's physical and mental progress and of his/her development are the key elements that parents are looking for. It is also noted that the majority of these parents deliberately consult these services. The objectives when consulting vary, going from a model based on the body and physical abilities, found especially in lower and disadvantaged groups, to one emphasising the child's psychological aspect and potential, which is the prerogative of the middle and higher classes. Indeed, although the PMI is particularly aimed at families in difficulties, all the social classes are now represented among the users. The primary role of prevention of PMI means that few parents go there specifically for the treatment of a medical disease. The majority of families maintain a parallel follow-up with another medical professional, usually a general practitioner with whom the PMI has very little contact. Given the decrease in the current medical demography and the governmental directives aimed at improving care in the prenatal period, the prospect of a closer working relationship between these two parties involved in infant welfare would seem to be a way of the future.

Attenuation of racial differences in health service utilization patterns for previously uninsured children in the Delta.

CONTEXT: A school-based health insurance program for children of the working poor was conducted in 2 isolated, rural communities in the Lower Mississippi Delta region. The larger of the 2 communities had an array of locally available health care providers, whereas the smaller community did not. In response to this lack of available care, the project designed and delivered outreach programs, including transportation to providers. PURPOSE: The purpose of this paper is to examine the role of race, age, and gender in the relationships between the utilization of care and the impact of outreach programs. METHOD: General estimating equation models are used to examine the response of utilization variables to race, age, gender, and community. Four years of insurance claims data are analyzed. FINDINGS: Race is seen to be an important component of utilization. The majority of participants were African American; however, children receiving prescription services, emergency room care, routine physician visits, and hospital outpatient services were more likely to be white. Outreach programs in vision and dental services were found to eliminate racial differences and increase utilization. A relatively strong gender effect was found in prescription, wellness, vision, and dental services. CONCLUSIONS: Previous research has shown differences by race in utilization of care. Our findings show that targeted outreach programs can significantly diminish these differences. Findings also suggest that barriers to health care for poor rural children are closely linked to transportation and availability of providers, not merely to cost of care or insurance.

Factors affecting plan choice and unmet need among supplemental security income eligible children with disabilities.

OBJECTIVE: To evaluate factors affecting plan choice (partially capitated managed care [MC] option versus the fee-for-service [FFS] system) and unmet needs for health care services among children who qualified for supplemental security income (SSI) because of a disability. DATA SOURCES: We conducted telephone interviews during the summer and fall of 2002 with a random sample of close to 1,088 caregivers of SSI eligible children who resided in the District of Columbia. RESEARCH DESIGN: We employed a two-step procedure where we first estimated plan choice and then constructed a selectivity correction to control for the potential selection bias associated with plan choice. We included the selectivity correction, the dummy variable indicating plan choice and other exogenous regressors in the second stage equations predicting unmet need. The dependent variables in the second stage equations include: (1) having an unmet need for any service or equipment; (2) having an unmet need for physician or hospital services; (3) having an unmet need for medical equipment; (4) having an unmet need for prescription drugs; (5) having an unmet need for dental care. PRINCIPAL FINDINGS: More disabled children (those with birth defects, chronic conditions, and/or more limitations in activities of daily living) were more likely to enroll in FFS. Children of caregivers with some college education were more likely to opt for FFS, whereas children from higher income households were more prone to enroll in the partially capitated MC plan. Children in FFS were 9.9 percentage points more likely than children enrolled in partially capitated MC to experience an unmet need for any type of health care services (p<.01), while FFS children were 4.5 percentage points more likely than partially capitated MC enrollees to incur a medical equipment unmet need (p<.05). FFS children were also more likely than partially capitated MC enrollees to experience unmet needs for prescription drugs and dental care, however these differences were only marginally significant. CONCLUSIONS: We speculate that the case management services available under the MC option, low Medicaid FFS reimbursements and provider availability account for some of the differences in unmet need that exist between partially capitated MC and FFS enrollees.

Measures of strength for maternal health programs in 55 developing countries: the MNPI study.

OBJECTIVES: To measure levels and types of effort for national maternal and neonatal health programs in 55 developing countries, in 2002, as a replication of a 1999 study. METHODS: Thirteen components of program effort were covered, based on 81 items in questionnaires completed by 10-25 expert respondents in each country. RESULTS: With 100% representing maximum effort, the international average was 58-60%, and the 13 component averages varied from 48 to 72%. The components included health center and district hospital capacities, services provided, proportion of the rural and urban populations with actual access to the services, together with the support functions of policy, training, education, resources, and evaluation. Scores are high for policies but low for access, resources, training, and public education. CONCLUSIONS: National programs to improve maternal health are far from satisfactory, as assessed here, with negligible improvement from 1999-2002. Efforts fall short in general, but considerably more so for some program features than others. Literal access to basic services is poor, and is especially lacking in rural areas. Regions differ much more in the access they provide to services than in other respects.

Identifying children in need of ancillary and enabling services: a population approach.

Children with chronic or disabling conditions use health, education and social services at a higher rate than their healthy peers. Estimates of the number of children in need of these specialized services are widely varied and often depend on categorical definitions that do not account for either the diversity or commonality of their experiences. Developing methods for identifying the population in need of services, particularly children likely to use long-term ancillary (audiology, occupational, physical or speech therapy, or social work) and/or enabling services (special equipment, personal care assistance, respite care, transportation, or environmental modifications), is essential for effective policy and program implementation. This study examines several recent attempts to operationalize definitions of children with chronic conditions using a noncategorical classification approach. Particular emphasis is placed on the subgroup of children identified as having functional limitations. Proposed operational definitions of children with functional limitations are compared using data from the 1994-1995 Disability Supplement to the US National Health Interview Survey. Estimates of the number of children reported to be using ancillary and enabling services are generated and compared across operational definitions of functional limitation as well as by the number, severity, and type (i.e. mobility, self-care, communication/sensory, social cognition/learning ability) of limitation. Depending on the operational definition selected, 9-14% of US community-dwelling children are estimated to have functional limitations. Among children with limitations, 26-30% regularly use ancillary services and 11-14% use enabling services. The strengths, limitations, and potential applications for each operational definition are discussed.

Health care options in childhood ARI before hospital care.

A cross sectional study was conducted, to examine the pattern of health care options, exercised before seeking care at the district hospital in the event of ARI in under fives. One hundred fifteen under fives selected through systematic sampling technique, from two district hospitals were the subjects of study. Respondents were the care providers, who accompanied children to the Hospitals. Time delay in initiating care and reaching the district hospital was also recorded. Reasons for preferring a particular source as first choice were enquired. District Hospitals stood out as the most preferred source, as 52 (45.2%) of the children used it as the first step. Other sources of health care were Health Center (10.4%), Home Care (25.2%) General Practitioners (10.4%) and Drug Stores (8.7%). On an average a child took 1.8 steps before coming to the district hospital. Children experienced 13 unique treatment patterns. Children initially offered home care followed longer sequence and more variable pattern. Convenience (62.6%) and cost (37.4%) were the main factors in choosing a source of treatment. Children who received home care were brought to district hospital earlier than others.

Avaliaçäo de serviços de saúde: um desenho epidemiológico / Health services evaluation: an epidemiologic approach

Inicialmente, a partir da revisäo da literatura sobre avaliaçäo de serviços de saúde e epidemiologia da saúde materno-infantil, justificamos a importância de avaliar os serviços de saúde, públicos e privados, utilizados pela populaçäo materno-infantil, enquanto impacto das açöes de saúde (resultados), a partir de indicadores do processo de assistência à saúde, guardadas as devidas dimensöes próprias da epidemiologia de modo a incorporar o conceito de risco/proteçäo ("marcador"). Em decorrência, fornecer subsídios para o planejamento em saúde a fim de contribuir para a consolidaçäo de Sistema Unico de Saúde, conforme consta dos nossos objetivos. A metodologia usada é o estudo tipo coorte junto à populaçäo materno-infantil do Jardim Campos Elíseos, periferia do município de Campinas, caracterizada conforme a situaçäo social (condiçöes de vida, condiçöes de moradia e condiçöes de saneamento), nutricional (antropometria, alimentaçäo e amamentaçäo) e assistencial (demanda de saúde, processo de assistência, impacto das açöes de saúde e participaçäo popular no sistema de saúde) no que se refere aos equipamentos de saúde, conforme o tipo de serviço utilizado. Encontrou-se diferença significativa, entre as populaçöes dos diferentes serviços, quanto às variáveis sociais para renda, anos de estudo materno e localizaçäo damoradia, quanto às variáveis sociais para renda, anos de estudo materno e localizaçäo damoradia, quanto às variáveis nutricionais para estado nutricional pré-gestacional, ganho de peso na gestaçäo e consumo de frutas para as gestantes e idade de introduçäo de frutas para as crianças. Quanto aos indicadores de processo, observou-se diferença para idade na primeira consulta de pré-natal e puericultura, tempo de espera, número de serviços de saúde utilizados pela criança e satisgaçäo com o atendimento, negativamente para o serviço público. No que se refere aos indicadores de impacto, encontrou-se diferença para tipo de parto e tipo de alojamento ao nascer, negativamente para o serviço privado. Sugere-se a adoçäo destes indicadores na monitorizaçäo da avaliaçäo de serviços de saúde, buscando a melhoria do atendimento público e o direito à saúde de alta qualidade para todos os cidadäos

Missed opportunities for childhood vaccinations in office practices and the effect on vaccination status.

To determine the rate of childhood under-vaccination, rate and types of missed opportunities (MOs) for vaccinations, and the contribution of MOs to the undervaccination of preschool-age children, the authors conducted a retrospective medical chart review in seven primary care settings in the Rochester, NY, area: a hospital clinic, a neighborhood health center, a group-model health maintenance organization, an urban group practice, a suburban group practice, a rural health center, and a rural private practice. The random sample included 1124 children having birth dates between March 15, 1988, and September 15, 1989. The main outcome measures were cumulative undervaccination rate, defined as the proportion of patients from each practice who were ever > 60 days past-due for a vaccination by 12, 18, or 24 months of age; undervaccination time, defined as the median number of months during which children were undervaccinated; number of MOs; visit types and conditions associated with the MOs; and the duration of undervaccination time attributable to MOs. The cumulative undervaccination rate by 12 months was at least 20% in each practice except for the suburban practice, where it was 4%. The frequency of MOs varied from a high of 1.8 MO per patient per year at the rural private practice to a low of 0.3 MO per patient per year at the suburban practice. More than one quarter of MOs occurred during either health supervision or follow-up visits in all practices. In 28% of visits during which an MO occurred, patients had no fever or acute illness.(ABSTRACT TRUNCATED AT 250 WORDS)

Service needs of families of children with severe physical disability.

Service contacts, perceived helpfulness of services and needs for help were investigated in a sample of 107 families of young children with severe physical disability. Many families were in contact with a multiplicity of different services and overall frequency of contact was high. Despite this, there was evidence of considerable unmet need, particularly in the provision of information to families. Families with the highest levels of unmet need were likely to have experienced high levels of strain from life events and to have children with mental retardation as well as physical disability, fathers in those families were more likely to be unemployed and mothers were more likely to use passive optimism in coping with child problems. The findings indicate the importance of services which are easily accessible to parents, the provision of information to parents about such services, the co-ordination of services through a 'link' person and the accurate and individual assessment of family needs.