Disparities in Oral Nutritional Supplement Usage and Dispensing Patterns across Primary Care in Ireland: ONSPres Project.

When treating malnutrition, oral nutritional supplements (ONSs) are advised when optimising the diet is insufficient; however, ONS usage and user characteristics have not been previously analysed. A retrospective secondary analysis was performed on dispensed pharmacy claim data for 14,282 anonymised adult patients in primary care in Ireland in 2018. Patient sex, age, residential status, ONS volume (units) and ONS cost (EUR) were analysed. The categories of 'Moderate' (<75th centile), 'High' (75th-89th centile) and 'Very High' ONS users (≥90th centile) were created. The analyses among groups utilised t-tests, Mann-Whitney U tests and chi-squared tests. This cohort was 58.2% female, median age was 76 years, with 18.7% in residential care. The most frequently dispensed ONS type was very-high-energy sip feeds (45% of cohort). Younger males were dispensed more ONSs than females (<65 years: median units, 136 vs. 90; p < 0.01). Patients living independently were dispensed half the volume of those in residential care (112 vs. 240 units; p < 0.01). 'Moderate' ONS users were dispensed a yearly median of 84 ONS units (median cost, EUR 153), 'High' users were dispensed 420 units (EUR 806) and 'Very High' users 892 yearly units (EUR 2402; p < 0.01). Further analyses should focus on elucidating the reasons for high ONS usage in residential care patients and younger males.

Perioperative Spending on Spinal Fusion for Scoliosis for Children With Medical Complexity.

BACKGROUND: Global payment is used with surgeries to optimize health, lower costs, and improve quality. We assessed perioperative spending on spinal fusion for scoliosis to inform how this might apply to children. METHODS: Retrospective analysis of 1249 children using Medicaid and aged ≥5 years with a complex chronic condition undergoing spinal fusion in 2013 from 12 states. From perioperative health services measured 6 months before and 3 months after spinal fusion, we simulated a spending reallocation with increased preoperative care and decreased hospital care. RESULTS: Perioperative spending was $112 353 per patient, with 77.9% for hospitalization, 12.3% for preoperative care, and 9.8% for postdischarge care. Primary care accounted for 0.2% of total spending; 15.4% and 49.2% of children had no primary care visit before and after spinal fusion, respectively. Compared with having no preoperative primary care visit, 1 to 2 visits were associated with a 12% lower surgery hospitalization cost (P = .05) and a 9% shorter length of stay (LOS) (P = .1); ≥3 visits were associated with a 21% lower hospitalization cost (P < .001) and a 14% shorter LOS (P = .01). Having ≥3 preoperative primary care visits for all children would increase total perioperative spending by 0.07%. This increased cost could be underwritten by a 0.1% reduction in hospital LOS or a 1.0% reduction in 90-day hospital readmissions. CONCLUSIONS: Hospital care accounted for most perioperative spending in children undergoing spinal fusion. Multiple preoperative primary care visits were associated with lower hospital costs and shorter hospitalizations. Modestly less hospital resource use could underwrite substantial increases in children's preoperative primary care.

Impact of Chronic Conditions on Emergency Department Visits of Children Using Medicaid.

OBJECTIVE: To assess the impact of chronic conditions on children's emergency department (ED) use. STUDY DESIGN: Retrospective analysis of 1 850 027 ED visits in 2010 by 3 250 383 children ages 1-21 years continuously enrolled in Medicaid from 10 states included in the Truven Marketscan Medicaid Database. The main outcome was the annual ED visit rate not resulting in hospitalization per 1000 enrollees. We compared rates by enrollees' characteristics, including type and number of chronic conditions, and medical technology (eg, gastrostomy, tracheostomy), using Poisson regression. To assess chronic conditions, we used the Agency for Healthcare Research and Quality's Chronic Condition Indicator system, assigning chronic conditions with ED visit rates ≥75th percentile as having the "highest" visit rates. RESULTS: The overall annual ED visit rate was 569 per 1000 enrollees. As the number of the children's chronic conditions increased from 0 to ≥3, visit rates increased by 180% (from 376 to 1053 per 1000 enrollees, P < .001). Rates were 174% higher in children assisted with vs without medical technology (1546 vs 565, P < .001). Sickle cell anemia, epilepsy, and asthma were among the chronic conditions associated with the highest ED visit rates (all ≥1003 per 1000 enrollees). CONCLUSIONS: The highest ED visit rates resulting in discharge to home occurred in children with multiple chronic conditions, technology assistance, and specific conditions such as sickle cell anemia. Future studies should assess the preventability of ED visits in these populations and identify opportunities for reducing their ED use.

Trends in Health Care Spending for Children in Medicaid With High Resource Use.

OBJECTIVES: To assess characteristics associated with health care spending trends among child high resource users in Medicaid. METHODS: This retrospective analysis included 48 743 children ages 1 to 18 years continuously enrolled from 2009-2013 in 10 state Medicaid programs (Truven MarketScan Medicaid Database) also in the top 5% of all health care spending in 2010. Using multivariable regression, associations were assessed between baseline demographic, clinical, and health services characteristics (using 2009-2010 data) with subsequent health care spending (ie, transiently, intermittently, persistently high) from 2011-2013. RESULTS: High spending from 2011-2013 was transient for 54.2%, persistent for 32.9%, and intermittent for 12.9%. Regarding demographic characteristics, the highest likelihood of persistent versus transient spending occurred in children aged 13 to 18 years versus 1 to 2 years in 2010 (odds ratio [OR], 3.0 [95% confidence interval (CI), 2.7-3.4]). Regarding clinical characteristics, the highest likelihoods were in children with ≥6 chronic conditions (OR, 4.8 [95% CI, 3.5-6.6]), a respiratory complex chronic condition (OR, 2.5 [95% CI, 2.2-2.8]), or a neuromuscular complex chronic condition (OR, 2.3 [95% CI, 2.2-2.5]). Hospitalization and emergency department (ED) use in 2010 were associated with a decreased likelihood of persistent spending in 2011-2013 (hospitalization OR, 0.7 [95% CI, 0.7-0.7]); ED OR, 0.8 [95% CI, 0.8-0.8]). CONCLUSIONS: Most children with high spending in Medicaid are without persistently high spending in subsequent years. Adolescent age, multiple chronic conditions, and certain complex chronic conditions increased the likelihood of persistently high spending; hospital and ED use decreased it. These data may help inform the development of new models of care and financing to optimize health and save resources in children with high resource use.

Long length of hospital stay in children with medical complexity.

BACKGROUND: Hospitalizations of children with medical complexity (CMC) account for one-half of hospital days in children, with lengths of stays (LOS) that are typically longer than those for children without medical complexity. The objective was to assess the impact of, risk factors for, and variation across children's hospitals regarding long LOS (≥10 days) hospitalizations in CMC. METHODS: A retrospective study of 954,018 CMC hospitalizations, excluding admissions for neonatal and cancer care, during 2013 to 2014 in 44 children's hospitals. CMC were identified using 3M's Clinical Risk Group categories 6, 7, and 9, representing children with multiple and/or catastrophic chronic conditions. Multivariable regression was used to identify demographic and clinical characteristics associated with LOS ≥10 days. Hospital-level risk-adjusted rates of long LOS generated from these models were compared using a covariance test of the hospitals' random effect. RESULTS: Among CMC, LOS ≥10 days accounted for 14.9% (n = 142,082) of all admissions and 61.8% ($13.7 billion) of hospital costs. The characteristics most strongly associated with LOS ≥10 days were use of intensive care unit (ICU) (odds ratio [OR]: 3.5, 95% confidence interval [CI]: 3.4-3.5), respiratory complex chronic condition (OR: 2.7, 95% CI: 2.6-2.7), and transfer from another medical facility (OR: 2.1, 95% CI: 2.0-2.1). After adjusting for severity, there was significant (P < 0.001) variation in the prevalence of LOS ≥10 days for CMC across children's hospitals (range, 10.3%-21.8%). CONCLUSIONS: Long hospitalizations for CMC are costly. Their prevalence varies significantly by type of chronic condition and across children's hospitals. Efforts to reduce hospital costs in CMC might benefit from a focus on prolonged LOS. Journal of Hospital Medicine 2016;11:750-756. © 2016 Society of Hospital Medicine.

Two-year mortality, complications, and healthcare use in children with medicaid following tracheostomy.

OBJECTIVES/HYPOTHESIS: To assess patient characteristics associated with adverse outcomes in the first 2 years following tracheostomy, and to report healthcare utilization and cost of caring for these children. STUDY DESIGN: Retrospective cohort study. METHODS: Children (0-16 years) in Medicaid from 10 states undergoing tracheostomy in 2009, identified with International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes and followed through 2011, were selected using the Truven Health Medicaid Marketscan Database (Truven Health Analytics, Inc., Ann Arbor, MI). Patient demographic and clinical characteristics were assessed with likelihood of death and tracheostomy complication using chi-square tests and logistic regression. Healthcare use and spending across the care continuum (hospital, outpatient, community, and home) were reported. RESULTS: A total of 502 children underwent tracheostomy in 2009, with 34.1% eligible for Medicaid because of disability. Median age at tracheostomy was 8 years (interquartile range 1-16 years), and 62.7% had a complex chronic condition. Two-year rates of in-hospital mortality and tracheostomy complication were 8.9% and 38.8%, respectively. In multivariable analysis, the highest likelihood of mortality occurred in children age < 1 year compared with 13+ years (odds ratio [OR] 7.3; 95% confidence interval [CI], 3.2-17.1); the highest likelihood of tracheostomy complication was in children with a complex chronic condition versus those without a complex chronic condition (OR 3.3; 95% CI, 1.1-9.9). Total healthcare spending in the 2 years following tracheostomy was $53.3 million, with hospital, home, and primary care constituting 64.4%, 9.4%, and 0.5% of total spending, respectively. CONCLUSION: Mortality and morbidity are high, and spending on primary and home care is small following tracheostomy in children with Medicaid. Future studies should assess whether improved outpatient and community care might improve their health outcomes. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:2611-2617, 2016.

Pediatric Hospital Discharges to Home Health and Postacute Facility Care: A National Study.

IMPORTANCE: Acute care hospitals are challenged to provide efficient, high-quality care to children who have medically complex conditions and may require weeks or months for recovery. Although the use of home health care (HHC) and facility-based postacute care (PAC) after discharge is well documented for adults, to our knowledge, little is known for children. OBJECTIVE: To assess the national prevalence of, characteristics of children discharged to, and variation in use across states of HHC and PAC for children. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of 2,423,031 US acute care hospital discharges in 2012 for patients ages 0 to 21 years from the nationally representative Agency for Healthcare Research and Quality Kids' Inpatient Database. MAIN OUTCOMES AND MEASURES: Discharges to HHC (eg, visiting or private-duty home nursing) and PAC (eg, rehabilitation facility) were identified from Centers for Medicare and Medicaid Services Discharge Status Codes. We compared children's characteristics (eg, race/ethnicity and number of chronic conditions) by discharge type using generalized linear regression. RESULTS: The median age of participants was 3 years (interquartile range, 0-13 years), and 45.6% were female. Of 2,423,031 US acute care hospital discharges in 2012 for patients ages 0 to 21 years, 122,673 discharges (5.1%) were to HHC and 26,282 (1.1%) were to PAC facilities. Neonatal care was the most common reason (44.5%, n = 54,589) for acute care hospitalization with discharge to HHC. Nonneonatal respiratory, musculoskeletal, and trauma-related problems, collectively, were the most common reasons for discharge to PAC (42.9%, n = 11,275). When compared with PAC, more discharges to HHC had no chronic condition (34.4% vs 18.0%, P < .001) and fewer discharges to HHC had 4 or more chronic conditions (22.5% vs 37.7%, P < .001). In multivariable analysis, Hispanic children were less likely to use PAC (0.8% vs 1.1%; odds ratio [OR], 0.9 [95% CI, 0.8-0.9]) or HHC (3.3% vs 5.5%; OR, 0.8 [95% CI, 0.7-0.8]) compared with other children. Children with 4 or more chronic conditions compared with no chronic conditions had a higher likelihood of HHC use (11.0% vs 4.4%; OR, 2.9 [95% CI, 2.8-3.0]) and PAC (3.9% vs 0.8%; OR, 4.5 [95% CI, 4.3-4.9]). After case-mix adjustment, there was significant (P < .001) variation across states in HHC (range, 0.4%-24.5%) and PAC (range, 0.4%-4.9%) use. CONCLUSIONS AND RELEVANCE: Home health care and PAC use after discharge for hospitalized children is infrequent, even for children with multiple chronic conditions. It varies significantly by race/ethnicity and across states. Further investigation is needed to assess reasons for this variation and to determine for which children HHC and PAC are most effective.

Alcohol and other drug specialist treatment services and their managers: findings from a national survey.

OBJECTIVE: To examine the characteristics of alcohol and other drug (AOD) specialist treatment agencies, their workforce and workforce development issues. METHODS: A national survey of AOD specialist treatment agency managers was conducted using the Clients of Treatment Service Agencies (COTSA) database as the sampling framework. Agency managers across Australia were surveyed by phone or electronically between April and October 2002. Qualitative and quantitative data were collected. Two hundred and thirty-four managers participated, representing 318 agencies, and a response rate of 65%. More than 50% of managers from each State and Territory participated in the study. RESULTS: The study found a high prevalence of alcohol-related problems. Managers estimated 45% of clients nominated alcohol as their primary problematic drug and that 53% of poly-drug clients identified alcohol-related problems. Managers reported increasingly complex client needs such as co-occurring substance and mental health issues. A harm minimisation treatment approach was supported by more than three-quarters of AOD agencies. The majority of the AOD workforce were trained professionals and consisted of nurses (26%), general AOD workers (19%) and psychologists (9%). Approximately half the sample had been in their current managerial role for less than five years. Key workforce development issues identified were education and training, funding, and staff recruitment and retention. CONCLUSION: More information is required on the key characteristics of the AOD workforce and their workforce development needs. Such information can contribute to policies and strategies that develop the capacity of the AOD sector to manage and treat the increasingly complex needs of clients.