Lack of Association of Pediatric Surgical Patient Outcomes With Increased Disposable Operating Room Supply Costs.

INTRODUCTION: There is wide variation in the cost of disposable operating room supplies between surgeons performing the same operation at the same institution. The general relationship between variation in disposable supply cost and patient outcomes is unknown. We aimed to evaluate the relationship between disposable supply cost and patient outcomes for sixteen common operations. METHODS: Cost data were reviewed for the most common procedures performed by five surgical divisions at a single children's hospital over a six-month period in 2021. For procedure, the median disposable OR costs were calculated. Each operation performed was categorized as low cost (below the group median) or high cost (above the group median. We compared the rates of adverse events (clinic visit within 5 days, 30-day emergency department visit, unplanned reoperation, unplanned readmission, anesthesia complications, prolonged hospital length of stay, need for blood product transfusion, or death) between procedures with low and high disposable supply costs. RESULTS: 1139 operations performed by 48 unique surgeons from five specialties were included; 596 (52%) were low-cost and 543 (48%) high-cost. The low and high-cost groups did not differ regarding most demographic characteristics. Overall, 21.9% of children suffered any adverse outcome; this rate did not differ between the low and high-cost groups when evaluated individually or in aggregate (20.5% vs 23.6%, p = 0.23). CONCLUSION: Our data demonstrate that across a wide range of pediatric surgical procedures, the cost of disposable operating room supplies was not associated with the risk of adverse outcomes. LEVEL OF EVIDENCE: Level 3.

Using Implementation Mapping to develop protocols supporting the implementation of a state policy on screening children for Adverse Childhood Experiences in a system of health centers in inland Southern California.

Adverse Childhood Experiences (ACEs) are defined as traumatic events occurring before age 18, such as maltreatment, life-threatening accidents, harsh migration experiences, or violence. Screening for ACEs includes asking questions about an individual's early exposure to these types of events. ACEs screenings have potential value in identifying children exposed to chronic and significant stress that produces elevated cortisol levels (i.e., toxic stress), and its associated physical and mental health conditions, such as heart disease, diabetes, depression, asthma, ADHD, anxiety, and substance dependence. However, ACEs screenings are seldom used in primary care settings. The Surgeon General of California has addressed this care gap by introducing ACEs Aware, an ACEs screening fee-for-service healthcare policy signed into law by Gov. Gavin Newsom. Since January 2020, Medi-Cal, California's Medicaid health care program, has reimbursed primary care providers for using the Pediatric ACEs and Related Life-events Screener (PEARLS) tool to screen children and adults for ACEs during wellness visits. To achieve the goals set by the ACEs Aware state policy, it is essential to develop and test implementation strategies that are informed by the values, priorities, and resources of clinical settings, healthcare professionals, and end-users. To address this need, we partnered with a system of federally qualified health centers in Southern California on a pilot study to facilitate the implementation of ACEs screenings in five community-based clinics. The health centers had broad ideas for an implementation strategy, as well as best practices to improve adoption of screenings, such as focusing on staff training to improve clinic workflow. This knowledge was incorporated into the development of an implementation strategy template, used at the outset of this study. We used the Exploration, Preparation, Implementation and Sustainment (EPIS) framework to guide the study and inform a participatory planning process called Implementation Mapping. In this paper, we describe how Implementation Mapping was used to engage diverse stakeholders and guide them through a systematic process that resulted in the development of the implementation strategy. We also detail how the EPIS framework informed each Implementation Mapping Task and provide recommendations for developing implementation strategies using EPIS and Implementation Mapping in health-care settings.

Nurse and case manager views on improving access and use of healthcare for adults living in permanent supportive housing.

Housing is one of the social determinants of health, and homelessness is associated with health inequalities including increased morbidity and decreased life expectancy. Services to improve access to and use of primary healthcare are provided to formerly homeless individuals (hereafter residents) who live in permanent supportive housing (PSH). Residents do not always utilize services, nor receive adequate healthcare, and often have poor health outcomes. The study aims were to explore nurse and case manager (hereafter participants) views on the challenges of providing healthcare to residents, and strategies to address challenges. This descriptive, qualitative study used thematic analysis. Five nurses and eight case managers working with residents of PSH agencies were interviewed using semistructured interviews. Five main themes emerged. The first theme of context of healthcare use included how the residents' history of homelessness, trauma, and survival affected using services. The second theme was how aspects of relationships (communication issues and mistrust) were barriers to care. The third theme was how residents' health issues (physical chronic diseases, mental health, and substance dependency) affected care. Community level barriers (insurance, financial hardship, and transportation) was the fourth theme. The final theme highlighted recommendations to improve access and use of healthcare by building rapport, addressing mistrust, and using effective communication techniques. Participants noted that barriers to healthcare use were often influenced by residents' previous homeless experience. Nurses noted that chronic physical health issues were problematic for residents. Participants expressed the need to take time to form an authentic relationship to increase trust with residents.

Disparities in Shared Decision Making and Service Receipt Among Children With Special Health Care Needs and Developmental Delay: A National Survey Analysis.

Shared decision making (SDM) is associated with increased service satisfaction among pediatric patients. Our objective was to examine the association between SDM and service use experiences across racial/ethnic child groups. This secondary data analysis used the 2009-2010 National Survey of Children with Special Health Care Needs (CSHCN) and 2011 Pathways to Diagnosis and Services Survey. We used a rank-and-replace matching approach consistent with Institute of Medicine recommendations for health disparities research. We included CSHCN aged 6 to 17 years. The exposure of interest was parents of CSHCN reporting engagement in SDM with clinicians. There were 4032 CSHCN included in analysis. CSHCNs experiencing SDM had a 16% higher probability of reporting service use compared to those not experiencing it (95% CI, 14.24-19.42). Black children experiencing SDM reported seeing all needed care providers at a lower rate than whites (79% and 87.6% respectively; 95% CI, -14.05-3.27). The benefit of SDM over not experiencing it for blacks was 12.2% less than for whites for the outcome of seeing all needed care providers. For the outcome of receiving all needed treatments and services, the SDM benefit was 9.1% lower for Hispanics compared with whites. SDM can improve service experiences but implementation flexibility may be needed.

Conversations between Latina mothers and their child's mental health provider: An observational study of shared decision-making regarding pediatric patient mental health needs.

OBJECTIVE: To evaluate shared decision-making (SDM) and delineate SDM processes in audio-recorded conversations between language congruent Spanish-/English-speaking clinicians and parents of pediatric mental health patients. METHODS: Transcripts from audio-recorded consultations were rated using the 5-Item Observing Patient Involvement in Decision Making (Observer OPTION5) instrument. One hundred encounters between seventeen clinicians and 100 parents were rated. Interrater reliability for total score was 0.98 between two trained coders (ICC range: 0.799-0.879). RESULTS: Scores ranged between 0 and 70 on a 100-point scale, with an average total Observer OPTION5 score of 33.2 (SD = 17.36). This corresponded to modest success at mutual shared decision-making. Clinicians and parents both showed effort at identifying a problem with treatment options and engaging in team talk. However, preference elicitation and integration were largely lacking. CONCLUSION: The present sample performed on par with other populations studied to date. It expands the evaluation of observed SDM to include Latino patients and new clinician populations. PRACTICE IMPLICATIONS: Use of the Observer OPTION5 Item instrument highlights that eliciting and integrating parent/patient preferences is a skill that requires attention when delivering culturally competent interventions.

Minority patient preferences, barriers, and facilitators for shared decision-making with health care providers in the USA: A systematic review.

OBJECTIVES: This systematic review of contemporary literature sought to better understand racial and ethnic minority patients' shared decision-making (SDM) preferences, challenges and facilitators. METHODS: Data sources were PubMed, CINAHL, Embase, Google Scholar, PsycINFO, Sociological Abstracts, and Web of Science databases for publications between 2011 and 2016. Publications were included if they studied SDM during the clinical encounter for minority adults in clinical care in the United States. We conducted a narrative, descriptive synthesis of each study. RESULTS: From over 5000 publications identified through the search strategy, 18 met eligibility criteria following an abstract and full text (n = 685) review in Covidence. Studies focused on SDM in developing treatment plans (n = 10), and were conducted in primary care (n = 6) or hospital/health system settings (n = 6). Patients' decision preferences ranged from physician-driven altogether or initially, to patient-driven style. A comprehensive list of SDM facilitators and barriers was developed. CONCLUSION: Despite strong policy and research SDM support to increase patient communication and a growing published literature, results suggest lack of representation of minority populations in contemporary literature. PRACTICE IMPLICATIONS: Provider training may be needed to facilitate patient-provider transition from a passive toward a more active SDM engagement over time while confidence, trust and rapport is established.

Disparities in Self-reported Access to Patient-centered Medical Home Care for Children With Special Health Care Needs.

BACKGROUND: Efforts to transform primary care have been underway for over a decade. Yet, we lack understanding of the progress made in scaling up this care model nationwide and on whether patient-centered medical home (PCMH) has benefited every group of children with special health care needs (CSHCNs). OBJECTIVE: The main objective of this study was to examine variation in caregiver service experience concordant with PCMH care over time and by child characteristics. RESEARCH DESIGN: This was a cross-sectional pooled data analysis using the 2003-2012 Medical Expenditures Panel Survey data for CSHCNs, aged 5-17 years. Logistic regressions were implemented, accounting for child and parent sociodemographic, child's health insurance, and contextual characteristics. PCMH concordant care and each component were constructed as binary variables and child functional impairment was measured with the Columbia Impairment Scale. RESULTS: Thirty-one percent of children reported medical home concordant care; comprehensive (83%) and compassionate (82%) care were most prevalent, and the least common were accessible care (59%) and patient-centered care (60%). PCMH concordant care significantly increased nationwide between 2003 and 2012, but disparities remained based on child needs and sociodemographic characteristics. Multivariate regressions showed variation across medical home components. CONCLUSIONS: Despite increased parent perception of care that is concordant with medical home care over time, disparities remain among high-need CSHCNs. Future research may focus on better understanding how clinical settings tailor this care model, particularly on providing increased access and patient-centered care, to better serve children at the highest need.