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Importance: Identifying high priority pediatric conditions is important for setting a research agenda in hospital pediatrics that will benefit families, clinicians, and the health care system. However, the last such prioritization study was conducted more than a decade ago and used International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Objectives: To identify conditions that should be prioritized for comparative effectiveness research based on prevalence, cost, and variation in cost of hospitalizations using contemporary data at US children's hospitals. Design, Setting, and Participants: This retrospective cohort study of children with hospital encounters used data from the Pediatric Health Information System database. Children younger than 18 years with inpatient hospital encounters at 45 tertiary care US children's hospitals between January 1, 2016, and December 31, 2019, were included. Data were analyzed from March 2020 to April 2021. Main Outcomes and Measures: The condition-specific prevalence and total standardized cost, the corresponding prevalence and cost ranks, and the variation in standardized cost per encounter across hospitals were analyzed. The variation in cost was assessed using the number of outlier hospitals and intraclass correlation coefficient. Results: There were 2â¯882â¯490 inpatient hospital encounters (median [interquartile range] age, 4 [1-12] years; 1â¯554â¯024 [53.9%] boys) included. Among the 50 most prevalent and 50 most costly conditions (total, 74 conditions), 49 (66.2%) were medical, 15 (20.3%) were surgical, and 10 (13.5%) were medical/surgical. The top 10 conditions by cost accounted for $12.4 billion of $33.4 billion total costs (37.4%) and 592â¯815 encounters (33.8% of all encounters). Of 74 conditions, 4 conditions had an intraclass correlation coefficient (ICC) of 0.30 or higher (ie, major depressive disorder: ICC, 0.49; type 1 diabetes with complications: ICC, 0.36; diabetic ketoacidosis: ICC, 0.33; acute appendicitis without peritonitis: ICC, 0.30), and 9 conditions had an ICC higher than 0.20 (scoliosis: ICC, 0.27; hypertrophy of tonsils and adenoids: ICC, 0.26; supracondylar fracture of humerus: ICC, 0.25; cleft lip and palate: ICC, 0.24; acute appendicitis with peritonitis: ICC, 0.21). Examples of conditions high in prevalence, cost, and variation in cost included major depressive disorder (cost rank, 19; prevalence rank, 10; ICC, 0.49), scoliosis (cost rank, 6; prevalence rank, 38; ICC, 0.27), acute appendicitis with peritonitis (cost rank, 13; prevalence rank, 11; ICC, 0.21), asthma (cost rank, 10; prevalence rank, 2; ICC, 0.17), and dehydration (cost rank, 24; prevalence rank, 8; ICC, 0.18). Conclusions and Relevance: This cohort study found that major depressive disorder, scoliosis, acute appendicitis with peritonitis, asthma, and dehydration were high in prevalence, costs, and variation in cost. These results could help identify where future comparative effectiveness research in hospital pediatrics should be targeted to improve the care and outcomes of hospitalized children.
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Criança Hospitalizada/estatística & dados numéricos , Prioridades em Saúde/estatística & dados numéricos , Custos Hospitalares/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Hospitais Pediátricos/estatística & dados numéricos , Adolescente , Apendicite/economia , Apendicite/epidemiologia , Asma/economia , Asma/epidemiologia , Criança , Pré-Escolar , Pesquisa Comparativa da Efetividade , Bases de Dados Factuais , Desidratação/economia , Desidratação/epidemiologia , Transtorno Depressivo Maior/economia , Transtorno Depressivo Maior/epidemiologia , Feminino , Prioridades em Saúde/economia , Hospitalização/economia , Hospitais Pediátricos/economia , Humanos , Lactente , Recém-Nascido , Masculino , Peritonite/economia , Peritonite/epidemiologia , Prevalência , Pesquisa , Estudos Retrospectivos , Escoliose/economia , Escoliose/epidemiologia , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Tonsillectomy is one of the most common and cumulatively expensive surgical procedures in children. We determined if substantial variation in resource use, as measured by standardised costs, exists across hospitals for performing tonsillectomy and if higher resource use is associated with better quality of care, as measured by revisits to hospital. METHODS: We conducted a retrospective analysis of children undergoing routine outpatient tonsillectomy between 2011 to 2017 across US children's hospitals using an administrative and billing data source. The primary outcome measures were the hospital tonsillectomy standardised cost and the 30-day revisit rate to hospital. We analysed the interhospital variation in standardised cost by determining the number of outlier hospitals in standardised cost and the intraclass correlation coefficient. RESULTS: 131 814 children (median age 6 years, IQR: 4,9; female sex 52.5%) underwent tonsillectomy for airway obstruction (62.9%) and infection (23.9%) across 28 hospitals. The median adjusted hospital standardised cost for tonsillectomy was $2392 (IQR: $1827, $2793; range: $1166 to $4222). There was substantial interhospital variation in costs as 11 (40%) hospitals were cost outliers, and the intraclass correlation coefficient was 0.62, suggesting that 62% of the variation in cost was attributable to variation between hospitals. The median hospital revisit rate was 9.5% (IQR: 7.8, 12.1) and higher hospital costs did not correlate with lower revisit rates (rs =0.03, 95% CI -0.36 to 0.41; p=0.87). CONCLUSIONS: There is substantial variation in hospital resource use and standardised costs for routine outpatient tonsillectomy across US children's hospitals. Higher resource use is not associated with lower revisit rates. Further study is needed to understand the practices of lower resource use hospitals who deliver high quality of care.
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Importance: As the proportion of children with Medicaid coverage increases, many pediatric health systems are searching for effective strategies to improve management of this high-risk population and reduce the need for inpatient resources. Objective: To estimate the association of a targeted population health management intervention for children eligible for Medicaid with changes in monthly hospital admissions and bed-days. Design, Setting, and Participants: This quality improvement study, using difference-in-differences analysis, deployed integrated team interventions in an academic pediatric health system with 31 in-network primary care practices among children enrolled in Medicaid who received care at the health system's hospital and primary care practices. Data were collected from January 2014 to June 2017. Data analysis took place from January 2018 to June 2019. Exposures: Targeted deployment of integrated team interventions, each including electronic medical record registry development and reporting alongside a common longitudinal quality improvement framework to distribute workflow among interdisciplinary clinicians and community health workers. Main Outcomes and Measures: Trends in monthly inpatient admissions and bed-days (per 1000 beneficiaries) during the preimplementation period (ie, January 1, 2014, to June 30, 2015) compared with the postimplementation period (ie, July 1, 2015, to June 30, 2017). Results: Of 25â¯460 children admitted to the hospital's health system during the study period, 8418 (33.1%) (3869 [46.0%] girls; 3308 [39.3%] aged ≤1 year; 5694 [67.6%] black) were from in-network practices, and 17â¯042 (67.9%) (7779 [45.7%] girls; 6031 [35.4%] aged ≤1 year; 7167 [41.2%] black) were from out-of-network practices. Compared with out-of-network patients, in-network patients experienced a decrease of 0.39 (95% CI, 0.10-0.68) monthly admissions per 1000 beneficiaries (P = .009) and 2.20 (95% CI, 0.90-3.49) monthly bed-days per 1000 beneficiaries (P = .001). Accounting for disproportionate growth in the number of children with medical complexity who were in-network to the health system, this group experienced a monthly decrease in admissions of 0.54 (95% CI, 0.13-0.95) per 1000 beneficiaries (P = .01) and in bed-days of 3.25 (95% CI, 1.46-5.04) per 1000 beneficiaries (P = .001) compared with out-of-network patients. Annualized, these differences could translate to a reduction of 3600 bed-days for a population of 93â¯000 children eligible for Medicaid. Conclusions and Relevance: In this quality improvement study, a population health management approach providing targeted integrated care team interventions for children with medical and social complexity being cared for in a primary care network was associated with a reduction in service utilization compared with an out-of-network comparison group. Standardizing the work of care teams with quality improvement methods and integrated information technology tools may provide a scalable strategy for health systems to mitigate risk from a growing population of children who are eligible for Medicaid.
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Criança Hospitalizada/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Gestão da Saúde da População , Criança , Pré-Escolar , Feminino , Acessibilidade aos Serviços de Saúde/economia , Humanos , Masculino , Medicaid/economia , Melhoria de Qualidade/estatística & dados numéricos , Estados UnidosRESUMO
INTRODUCTION: Loss of mobility is common in advanced dementia and has important negative consequences related to fall risk, loss of independence, and lack of participation in meaningful activities. The causes of decline are multifactorial, including disease-specific changes in motor function, behavior, and cognition. To optimize clinical management of mobility, there is a need to better characterize capacity for safe and independent mobility. This study aimed to identify key factors that impact on mobility in dementia. METHODS: Expert input was gathered using a modified Delphi consensus approach. The primary criterion for participation was specialist knowledge in mobility or dementia, either as a clinician or a researcher. Participants rated elements of mobility for importance and feasibility of assessment in advanced dementia and prioritized items for inclusion in a mobility staging tool. Descriptive statistics and qualitative content analysis were used to summarize responses. RESULTS: Thirty-six experts completed the first survey with an 80% retention rate over three rounds. One-third of 61 items reached consensus for being both important and feasible to assess, representing five categories of elements. Items reaching agreement for a staging tool included walking, parkinsonism, gait, impulsivity, fall history, agitation, transfers, and posture control. DISCUSSION: This study highlights the need for a multidimensional, dementia-specific approach to mobility assessment. Results have implications for development of assessment methods and management guidelines to support the clinical care of mobility impairment in people with dementia.
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Upon publication of this article [1], it was brought to our attention that one of the 303 participants in the normative study should have been deleted from the database.
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OBJECTIVE: To determine the incidence of and risk factors for development of celiac disease (CD) in individuals with type 1 diabetes. METHODS: Cohort study using The Health Improvement Network (THIN), a UK primary care database of >13 million people. Individuals with incident type 1 diabetes diagnosed at 1 to 35 years of age between 1995 and 2015 with no previous diagnosis of CD were included. Cox regression was used to identify risk factors for CD, including age at diabetes diagnosis and sex, while adjusting for year of diagnosis to control for potential rising incidence in CD over time. RESULTS: Subjects (n = 9180; 43% female) had a median observation time of 5.1 years (interquartile range 2.0-10.1). CD was diagnosed in 196 (2%) during follow up. Median time to diagnosis was 2.1 years, but 25% were diagnosed more than 5 years after diabetes diagnosis. Incidence (per 10 000 person-years) was greater in females (43.0 [95% confidence interval [CI] 35.2-52.0]) vs males (26.8 [95% CI 21.5-32.9]). In multivariable Cox regression stratified by childhood- vs young adult-onset diabetes, younger age at diabetes diagnosis within childhood (hazard ratio [HR] 0.91 [95% CI 0.88-0.94]) and female sex among the adult-onset diabetes group (HR 3.19 [95% CI 1.39-7.34]) were associated with greater risk of CD. CONCLUSIONS: As expected, incidence of CD was higher in individuals with childhood-onset diabetes vs those with adult-onset diabetes. However, individuals with diabetes are at risk of developing CD throughout childhood and adulthood, and prolonged screening after diagnosis may be warranted. Prospective studies are needed in order to guide risk-stratified approaches to screening.
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Doença Celíaca/epidemiologia , Doença Celíaca/etiologia , Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 1/epidemiologia , Adolescente , Adulto , Criança , Pré-Escolar , Estudos de Coortes , Redes Comunitárias/organização & administração , Redes Comunitárias/estatística & dados numéricos , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Promoção da Saúde/métodos , Promoção da Saúde/organização & administração , Humanos , Incidência , Lactente , Masculino , Atenção Primária à Saúde/organização & administração , Atenção Primária à Saúde/estatística & dados numéricos , Fatores de Risco , Reino Unido/epidemiologia , Adulto JovemAssuntos
Custos de Medicamentos/estatística & dados numéricos , Preparações Farmacêuticas/economia , Serviço de Farmácia Hospitalar/economia , Agonistas Adrenérgicos beta/economia , Cardiotônicos/economia , Criança , Redução de Custos/métodos , Custos de Medicamentos/tendências , Hospitais Pediátricos/economia , Humanos , Isoproterenol/economia , PennsylvaniaRESUMO
BACKGROUND: As high-quality health care becomes increasingly expensive, improvement projects are focused on reducing cost and increasing value. To increase value by reducing operating room (OR) utilization, we studied the effect of a dedicated team approach for posterior spinal fusion (PSF) for scoliosis. METHODS: With institutional support, an interdisciplinary, dedicated team was assembled. Members developed standardized protocols for anesthetic management and patient transport, positioning, preparation, draping, imaging, and wake-up. These protocols were initially implemented with a small interdisciplinary team, including 1 surgeon (Phase 1), and then were expanded to include a second surgeon and additional anesthesiology staff (Phase 2). We compared procedures performed with a dedicated team (the Dedicated Team cases) and procedures performed without a such a team (the Casual Team cases). Because of the heterogeneous nature of PSF for scoliosis, we developed a case categorization system: Category 1 was relatively homogeneous and indicated patients with fusion of ≤12 levels, no osteotomies, and a body mass index (BMI) of <25 kg/m, and Category 2 was more heterogeneous and indicated patients with fusion of >12 levels and/or ≥1 osteotomy and/or a BMI of ≥25 kg/m. RESULTS: In total, 89 Casual Team and 78 Dedicated Team cases were evaluated: 71 were in Category 1 and 96 were in Category 2. Dedicated Team cases used significantly less OR time for both Categories 1 and 2 (p < 0.001). In Category-1 cases, the average reduction was 111.4 minutes (29.7%); in Category-2 cases, it was 76.9 minutes (18.5%). The effect of the Dedicated Team was scalable: the reduction in OR time was significant in both Phase 1 and Phase 2 (p < 0.001). The Dedicated Team cases had no complications. Cost reduction averaged approximately $8,900 for Category-1 and $6,000 for Category-2 cases. CONCLUSIONS: By creating a dedicated team and standardizing several aspects of PSFs for scoliosis, we achieved a large reduction in OR time. This increase in team efficiency was significant, consistent, and scalable. As a result, we can routinely complete 2 Category-1 PSFs in the same OR with the same team without exceeding standard block time.
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Custos e Análise de Custo , Duração da Cirurgia , Equipe de Assistência ao Paciente/economia , Escoliose/cirurgia , Fusão Vertebral/economia , Criança , Humanos , Estudos RetrospectivosRESUMO
BACKGROUND: A need exists for easily administered assessment tools to detect mild cognitive changes that are more comprehensive than screening tests but shorter than a neuropsychological battery and that can be administered by physicians, as well as any health care professional or trained assistant in any medical setting. The Toronto Cognitive Assessment (TorCA) was developed to achieve these goals. METHODS: We obtained normative data on the TorCA (n = 303), determined test reliability, developed an iPad version, and validated the TorCA against neuropsychological assessment for detecting amnestic mild cognitive impairment (aMCI) (n = 50/57, aMCI/normal cognition). For the normative study, healthy volunteers were recruited from the Rotman Research Institute registry. For the validation study, the sample was comprised of participants with aMCI or normal cognition based on neuropsychological assessment. Cognitively normal participants were recruited from both healthy volunteers in the normative study sample and the community. RESULTS: The TorCA provides a stable assessment of multiple cognitive domains. The total score correctly classified 79% of participants (sensitivity 80%; specificity 79%). In an exploratory logistic regression analysis, indices of Immediate Verbal Recall, Delayed Verbal and Visual Recall, Visuospatial Function, and Working Memory/Attention/Executive Control, a subset of the domains assessed by the TorCA, correctly classified 92% of participants (sensitivity 92%; specificity 91%). Paper and iPad version scores were equivalent. CONCLUSIONS: The TorCA can improve resource utilization by identifying patients with aMCI who may not require more resource-intensive neuropsychological assessment. Future studies will focus on cross-validating the TorCA for aMCI, and validation for disorders other than aMCI.
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Amnésia/diagnóstico , Disfunção Cognitiva/diagnóstico , Testes Neuropsicológicos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valores de Referência , Reprodutibilidade dos TestesRESUMO
OBJECTIVE: To examine the effect of ambulatory health care processes on asthma hospitalizations. METHODS: A retrospective cohort study using electronic health records was completed. Patients aged 2-18 years receiving health care from 1 of 5 urban practices between Jan 1, 2004 and Dec 31, 2008 with asthma documented on their problem list were included. Independent variables were modifiable health care processes in the primary care setting: (1) use of asthma controller medications; (2) regular assessment of asthma symptoms; (3) use of spirometry; (4) provision of individualized asthma care plans; (5) timely influenza vaccination; (6) access to primary healthcare; and (7) use of pay for performance physician incentives. Occurrence of one or more asthma hospitalizations was the primary outcome of interest. We used a log linear model (Poisson regression) to model the association between the factors of interest and number of asthma hospitalizations. RESULTS: 5,712 children with asthma were available for analysis. 96% of the children were African American. The overall hospitalization rate was 64 per 1,000 children per year. None of the commonly used asthma-specific indicators of high quality care were associated with fewer asthma hospitalizations. Children with documented asthma who experienced a lack of primary health care (no more than one outpatient visit at their primary care location in the 2 years preceding hospitalization) were at higher risk of hospitalization compared to those children with a greater number of visits (incidence rate ratio 1.39; 95% CI 1.09-1.78). CONCLUSIONS: In children with asthma, more frequent primary care visits are associated with reduced asthma hospitalizations.
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Antiasmáticos/uso terapêutico , Asma/tratamento farmacológico , Asma/epidemiologia , Hospitalização/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Adolescente , Negro ou Afro-Americano/estatística & dados numéricos , Distribuição por Idade , Antiasmáticos/administração & dosagem , Asma/etnologia , Asma/terapia , Índice de Massa Corporal , Criança , Pré-Escolar , Continuidade da Assistência ao Paciente/estatística & dados numéricos , Registros Eletrônicos de Saúde , Feminino , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Humanos , Vacinas contra Influenza/administração & dosagem , Masculino , Grupos Minoritários/estatística & dados numéricos , Planejamento de Assistência ao Paciente/estatística & dados numéricos , Reembolso de Incentivo/estatística & dados numéricos , Estudos Retrospectivos , Índice de Gravidade de Doença , Distribuição por Sexo , Espirometria , População Urbana/estatística & dados numéricosRESUMO
BACKGROUND: A better understanding of drivers of treatment costs may help identify effective cost containment strategies and prioritize resources. We aimed to develop a method for estimating inpatient costs for pediatric patients with acute myeloid leukemia (AML) enrolled on NCI-funded Phase III trials, compare costs between AAML0531 treatment arms (standard chemotherapy ± gemtuzumab ozogamicin (GMTZ)), and evaluate primary drivers of costs for newly diagnosed pediatric AML. PROCEDURE: Patients from the AAML0531 trial were matched on hospital, sex, and dates of birth and diagnosis to the Pediatric Health Information Systems (PHIS) database to obtain daily billing data. Inpatient treatment costs were calculated as adjusted charges multiplied by hospital-specific cost-to-charge ratios. Generalized linear models were used to compare costs between treatment arms and courses, and by patient characteristics. RESULTS: Inpatient costs did not differ by randomized treatment arm. Costs varied by course with stem cell transplant being most expensive, followed by Intensification II (cytarabine/mitoxantrone) and Induction I (cytarabine/daunorubicin/etoposide). Room/board and pharmacy were the largest contributors to inpatient treatment cost, representing 74% of the total cost. Higher AML risk group (P = 0.0003) and older age (P < 0.0001) were associated with significantly higher daily inpatient cost. CONCLUSIONS: Costs from external data sources can be successfully integrated into NCI-funded Phase III clinical trials. Inpatient treatment costs did not differ by GMTZ exposure but varied by chemotherapy course. Variation in cost by course was driven by differences in duration of hospitalization through room/board charges as well as increased clinical and pharmacy charges in specific courses.
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Aminoglicosídeos/economia , Anticorpos Monoclonais Humanizados/economia , Antineoplásicos/economia , Leucemia Mieloide Aguda/economia , Adolescente , Aminoglicosídeos/uso terapêutico , Anticorpos Monoclonais Humanizados/uso terapêutico , Antineoplásicos/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/economia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Criança , Pré-Escolar , Feminino , Gemtuzumab , Humanos , Lactente , Recém-Nascido , Pacientes Internados , Leucemia Mieloide Aguda/tratamento farmacológico , Masculino , Transplante de Células-Tronco/economia , Adulto JovemRESUMO
OBJECTIVES: Medical emergency teams (METs) can reduce adverse events in hospitalized children. We aimed to model the financial costs and benefits of operating an MET and determine the annual reduction in critical deterioration (CD) events required to offset MET costs. METHODS: We performed a single-center cohort study between July 1, 2007 and March 31, 2012 to determine the cost of CD events (unplanned transfers to the ICU with mechanical ventilation or vasopressors in the 12 hours after transfer) as compared with transfers to the ICU without CD. We then performed a cost-benefit analysis evaluating varying MET compositions and staffing models (freestanding or concurrent responsibilities) on the annual reduction in CD events needed to offset MET costs. RESULTS: Patients who had CD cost $99,773 (95% confidence interval, $69,431 to $130,116; P < .001) more during their post-event hospital stay than transfers to the ICU that did not meet CD criteria. Annual MET operating costs ranged from $287,145 for a nurse and respiratory therapist team with concurrent responsibilities to $2,358,112 for a nurse, respiratory therapist, and ICU attending physician freestanding team. In base-case analysis, a nurse, respiratory therapist, and ICU fellow team with concurrent responsibilities cost $350,698 per year, equivalent to a reduction of 3.5 CD events. CONCLUSIONS: CD is expensive. The costs of operating a MET can plausibly be recouped with a modest reduction in CD events. Hospitals reimbursed with bundled payments could achieve real financial savings by reducing CD with an MET.
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Equipe de Respostas Rápidas de Hospitais/economia , Hospitais Pediátricos/economia , Adolescente , Criança , Pré-Escolar , Redução de Custos , Efeitos Psicossociais da Doença , Análise Custo-Benefício , Estado Terminal/economia , Estado Terminal/terapia , Feminino , Custos Hospitalares , Humanos , Lactente , Unidades de Terapia Intensiva Pediátrica/economia , Tempo de Internação/economia , Masculino , Transferência de Pacientes , Respiração Artificial/economiaAssuntos
Atitude do Pessoal de Saúde , Criança Hospitalizada , Família , Equipe de Respostas Rápidas de Hospitais/organização & administração , Médicos/psicologia , Criança , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Unidades de Terapia Intensiva/organização & administração , Masculino , Grupos Raciais , Fatores SexuaisRESUMO
OBJECTIVE: We sought to characterize variation in hospital resource utilization and readmission for diabetic ketoacidosis (DKA) across US children's hospitals. METHODS: The study sample included a retrospective cohort of children aged 2 to 18 years with a diagnosis of DKA at 38 children's hospitals between 2004 and 2009. The main outcomes were resource utilization as determined by total standardized cost per hospitalization, overall and non-ICU length of stay (LOS), and readmission for DKA within 30 and 365 days. RESULTS: There were 24,890 DKA admissions, and 20.3% of these were readmissions within 1 year. The mean hospital-level total standardized cost was $7142 (range $4125-$11,916). The mean hospital-level LOS was 2.5 days (1.5-3.7), and the non-ICU portion was 1.9 days (0.7-2.7). The mean hospital-level readmission within 365 days was 18.7% (6.5%-41.1%) and within 30 days was 2.5% (0.0%-7.1%). Hospital bed days overall, and in particular the non-ICU portion, accounted for the majority of the total standardized cost per hospitalization (overall 57%; non-ICU 36%) and explained most of the variation in resource use. Even after adjusting for difference in patient characteristics across hospitals, widespread differences existed across hospitals in total standardized cost, LOS, and readmission rates (P < .001). CONCLUSIONS: Readmission for DKA within a year of hospitalization is common. US children's hospitals vary widely in resource use, hospital LOS, and readmission rates for patients with DKA. Our study highlights the need for additional research to understand these differences and to identify the most cost-effective strategies for managing diabetes across the continuum of care.
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Cetoacidose Diabética/economia , Cetoacidose Diabética/epidemiologia , Recursos em Saúde/economia , Recursos em Saúde/estatística & dados numéricos , Hospitais Pediátricos/economia , Hospitais Pediátricos/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Custos Hospitalares/estatística & dados numéricos , Humanos , Lactente , Tempo de Internação/economia , Masculino , Estudos Retrospectivos , Estados UnidosRESUMO
IMPORTANCE: A child's health, positive perceptions of the research team and consent process, and altruistic motives play significant roles in the decision-making process for parents who consent for their child to enroll in clinical research. This study identified that nonconsenting parents were better educated, had private insurance, showed lower levels of altruism, and less understanding of study design. OBJECTIVE: To determine the factors associated with parental consent for their child's participation in a randomized, placebo-controlled trial. DESIGN: Cross-sectional survey conducted from July 2008 to May 2011. The survey was an ancillary study to the Randomized Intervention for Children with VesicoUreteral Reflux Study. SETTING: Seven children's hospitals participating in a randomized trial evaluating management of children with vesicoureteral reflux. PARTICIPANTS: Parents asked to provide consent for their child's participation in the randomized trial were invited to complete an anonymous online survey about factors influencing their decision. A total of 120 of the 271 (44%) invited completed the survey; 58 of 125 (46%) who had provided consent and 62 of 144 (43%) who had declined consent completed the survey. MAIN OUTCOMES AND MEASURES: A 60-question survey examining child, parent, and study characteristics; parental perception of the study; understanding of the design; external influences; and decision-making process. RESULTS Having graduated from college and private health insurance were associated with a lower likelihood of providing consent. Parents who perceived the trial as having a low degree of risk, resulting in greater benefit to their child and other children, causing little interference with standard care, or exhibiting potential for enhanced care, or who perceived the researcher as professional were significantly more likely to consent to participate. Higher levels of understanding of the randomization process, blinding, and right to withdraw were significantly positively associated with consent to participate. CONCLUSIONS AND RELEVANCE Parents who declined consent had a relatively higher socioeconomic status, had more anxiety about their decision, and found it harder to make their decision compared with consenting parents, who had higher levels of trust and altruism, perceived the potential for enhanced care, reflected better understanding of randomization, and exhibited low decisional uncertainty. Consideration of the factors included in the conceptual model should enhance the quality of the informed consent process and improve participation in pediatric clinical trials.
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Consentimento dos Pais/psicologia , Pais/psicologia , Ensaios Clínicos Controlados Aleatórios como Assunto/psicologia , Recusa de Participação/psicologia , Adulto , Altruísmo , Anti-Infecciosos/uso terapêutico , Ansiedade , Criança , Pré-Escolar , Estudos Transversais , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Lactente , Seguro Saúde , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Prevenção Secundária , Fatores Socioeconômicos , Inquéritos e Questionários , Confiança , Infecções Urinárias/prevenção & controleRESUMO
OBJECTIVE: To determine whether racial differences exist in antibiotic prescribing among children treated by the same clinician. METHODS: Retrospective cohort study of 1,296,517 encounters by 208,015 children to 222 clinicians in 25 practices in 2009. Clinical, antibiotic prescribing, and demographic data were obtained from a shared electronic health record. We estimated within-clinician associations between patient race (black versus nonblack) and (1) antibiotic prescribing or (2) acute respiratory tract infection diagnosis after adjusting for potential patient-level confounders. RESULTS: Black children were less likely to receive an antibiotic prescription from the same clinician per acute visit (23.5% vs 29.0%, odds ratio [OR] 0.75; 95% confidence interval [CI]: 0.72-0.77) or per population (0.43 vs 0.67 prescriptions/child/year, incidence rate ratio 0.64; 95% CI 0.63-0.66), despite adjustment for age, gender, comorbid conditions, insurance, and stratification by practice. Black children were also less likely to receive diagnoses that justified antibiotic treatment, including acute otitis media (8.7% vs 10.7%, OR 0.79; 95% CI 0.75-0.82), acute sinusitis (3.6% vs 4.4%, OR 0.79; 95% CI 0.73-0.86), and group A streptococcal pharyngitis (2.3% vs 3.7%, OR 0.60; 95% CI 0.55-0.66). When an antibiotic was prescribed, black children were less likely to receive broad-spectrum antibiotics at any visit (34.0% vs 36.9%, OR 0.88; 95% CI 0.82-0.93) and for acute otitis media (31.7% vs 37.8%, OR 0.75; 95% CI 0.68-0.83). CONCLUSIONS: When treated by the same clinician, black children received fewer antibiotic prescriptions, fewer acute respiratory tract infection diagnoses, and a lower proportion of broad-spectrum antibiotic prescriptions than nonblack children. Reasons for these differences warrant further study.
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Antibacterianos/uso terapêutico , Negro ou Afro-Americano , Disparidades em Assistência à Saúde/etnologia , Pediatria , Padrões de Prática Médica/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Infecções Respiratórias/tratamento farmacológico , Doença Aguda , Adolescente , Criança , Pré-Escolar , Estudos de Coortes , Registros Eletrônicos de Saúde , Feminino , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Modelos Logísticos , Masculino , Análise Multivariada , Otite Média/diagnóstico , Otite Média/tratamento farmacológico , Otite Média/etnologia , Infecções Respiratórias/diagnóstico , Infecções Respiratórias/etnologia , Estudos Retrospectivos , População BrancaRESUMO
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 children's 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.
Assuntos
Pesquisa Comparativa da Efetividade/métodos , Prioridades em Saúde , Recursos em Saúde/estatística & dados numéricos , Custos Hospitalares/estatística & dados numéricos , Hospitais Pediátricos , Pediatria , Procedimentos Cirúrgicos Operatórios , Criança , Estudos de Coortes , Pesquisa Comparativa da Efetividade/economia , Prioridades em Saúde/economia , Prioridades em Saúde/estatística & dados numéricos , Recursos em Saúde/economia , Hospitais Pediátricos/economia , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Modelos Estatísticos , Pediatria/economia , Pediatria/estatística & dados numéricos , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/economia , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Estados UnidosRESUMO
Canadians with dementia have access to Medicare, a universal, single payer healthcare program. Implementation of Medicare is through the provinces and territories, giving variation in the level of care available. At present, there is no national strategy for dementia, although a recent report from the Alzheimer Society of Canada is expected to catalyze one. Most dementia care is provided by primary care practitioners, with three specialties (geriatric psychiatry, geriatric medicine and neurology) providing consultant expertise. Primary care reforms are aimed at developing a more coordinated approach to the complex needs of people with dementia, and have especially emphasized education of providers. Any national strategy is expected to underscore prevention and research, the latter building on Canada's strong contribution to this international undertaking.
Assuntos
Atenção à Saúde/organização & administração , Demência/terapia , Serviços de Saúde para Idosos/organização & administração , Serviços de Saúde Mental/organização & administração , Programas Nacionais de Saúde/organização & administração , Idoso , Canadá , Atenção à Saúde/economia , Demência/economia , Acessibilidade aos Serviços de Saúde , Serviços de Saúde para Idosos/economia , HumanosRESUMO
OBJECTIVE: Alzheimer's disease (AD) burdens not only the person, but also the person's caregiver(s). This burden has been linked to negative health effects for caregivers. To that end, a survey of Canadian caregivers of persons with AD/other dementias was conducted to investigate the social, physical, psychological and financial impact of AD and/or dementia-related conditions on caregivers' quality of life. METHODS: A web-based survey, the Canadian Alzheimer's Disease Caregiver survey, was made available through the Canadian Alzheimer's Society website and 50plus.com, an internet portal for baby boomers (BB) (people aged 50 years or older), as well as through HarrisDecima Research's e-Vox panel. A total of 398 individuals completed the survey between 15 September and 5 November 2006. RESULTS: Of the 398 total respondents, 221 were identified as baby boomers who provided care to an individual with AD/dementia. Respondents identified several areas of burden of care. These included negative effects on emotional health (such as increased depression, more stress and greater fatigue), financial costs and a need to change a working situation (e.g. by retiring early, reducing work hours or refusing a promotion). CONCLUSION: Caregivers of persons with AD/related dementia face important social, physical, psychological and financial pressures. These negatively affect the quality of life of caregivers with a significant increased burden being placed on live-in caregivers versus caregivers who do not co-reside with their care recipients. Interventions that address these pressures will not only improve the health and well-being of caregivers, but likely also the care of persons with AD/dementia.