Costs of Care and Location of Death in Community-Based Pediatric Palliative Care.

Background: Children with complex chronic conditions (CCCs) are dying at home with increased frequency, yet the number of studies on the financial feasibility of community-based pediatric palliative care is limited. Objective: The objectives of this study were to (1) describe characteristics of patients who died in a community-based palliative care program and (2) evaluate cost differences associated with participant characteristics and location of death. Design: A retrospective cohort analysis of administrative and electronic medical record data was employed. Setting/Subjects: Children enrolled in the community-based pediatric palliative care program, CompassionNet, who died between 2008 and 2015 were included (N = 224). Measurements: Demographic data, program expense, and paid claims were extracted from an insurance provider database and clinical data from the electronic medical record. Results: Sixty-six (29%) of the children were <1 year old at death; 80 (36%) were 1-9 years old, and 78 (35%) were 10-22 years old. Malignancy was the most common primary CCC diagnosis for the 158 children/adolescents (n = 89, 56%), whereas neuromuscular conditions (n = 20, 30%) were most frequent for infants. Death at home occurred 21% of the time for infants, 48% for children of ages 1-9 years, and 46% for children of ages 10-22 years. The mean total cost in the final year of life for pediatric patients was significantly related to location of death, a malignancy diagnosis, and participation in Medicaid. The largest estimated difference was between costs of care associated with death at home ($121,111) versus death in the hospital ($200,050). Conclusions: Multidisciplinary community-based pediatric palliative care teams provide the opportunity for a home death to be realized as desired. Significant cost differences associated with location of death may support program replication and sustainability.

Increasing adherence to a community-based guideline for acute sinusitis through education, physician profiling, and financial incentives.

OBJECTIVES: To implement a large-scale multifaceted intervention consisting of physician education, profiling, and a financial incentive, to improve treatment quality for acute sinusitis. STUDY DESIGN: Cohort trial using a historical control of treatment patterns among approximately 500 internists, 200 family practitioners, and 200 pediatricians in a northeastern community-wide individual practice association. PARTICIPANTS AND METHODS: Episode treatment group methods were adapted to identify cases (episodes) and to assess care patterns for acute sinusitis among 420,000 health maintenance organization patients seen between January 1, 1999, and December 31, 2001. The intervention consisted of care pathway development, physician and patient education, physician profiling, and a financial incentive. RESULTS: A statistical process control chart showed a shift toward recommended treatment patterns after our intervention. The rate of exceptions per episode of acute sinusitis decreased 20%, from 326 exceptions per 1000 episodes between January 1, 1999, and October 31, 2000, to 261 between November 1, 2000, and December 31, 2001. Decreased use of less effective or inappropriate antibiotics accounted for most of the change (199 to 136 exceptions per 1000 episodes [32% change]). Azithromycin use decreased 30%, from 97 to 68 prescriptions per 1000 episodes. Firstline antibiotic (amoxicillin and doxycycline) use increased 14%, from 451 to 514 prescriptions per 1000 episodes. Inappropriate radiology use decreased 20%, from 15 to 12 per 1000 episodes. These changes were significant at P < .005. CONCLUSION: A multifaceted program, including education, physician profiling with actionable recommendations, and a financial incentive, significantly increased physicians' adherence to a community-developed care pathway and was successful at improving adherence to recommended patterns of antibiotic use in acute sinusitis.