ABSTRACT
Eligible pediatric hospitals can purchase clinician-administered drugs at discounted rates through the 340B Drug Pricing Program and charge payers prices exceeding drug acquisition costs, but the magnitude of these markups is not known. In a study of newly approved oncology drugs at pediatric 340B hospitals, median negotiated prices ranged from 102% (interquartile range [IQR]: 91%-156%) of average sales price (ASP) at Phoenix Children's Hospital to 630% (IQR: 526%-630%) at Driscoll Children's Hospital. Pediatric hospitals participating in the federal 340B Drug Pricing Program can extract steep payments on new drugs from commercial insurers, though with wide variation between and within hospitals.
Subject(s)
Antineoplastic Agents , Drug Costs , Hospitals, Pediatric , Humans , Hospitals, Pediatric/economics , Antineoplastic Agents/economics , Child , United States , Neoplasms/drug therapy , Neoplasms/economicsABSTRACT
OBJECTIVE: To assess the financial non-medical out-of-pocket costs of hospital admissions for children with a febrile illness. DESIGN: Single-centre survey-based study conducted between March and November 2022. SETTING: Tertiary level children's hospital in the North East of England. PARTICIPANTS: Families of patients with febrile illness attending the paediatric emergency department MAIN OUTCOME MEASURES: Non-medical out-of-pocket costs for the admission were estimated by participants including: transport, food and drinks, child care, miscellaneous costs and loss of earnings. RESULTS: 83 families completed the survey. 79 families (95.2%) reported non-medical out-of-pocket costs and 19 (22.9%) reported financial hardship following their child's admission.Total costs per day of admission were median £56.25 (IQR £32.10-157.25). The majority of families reported incurring transport (N=75) and food and drinks (N=71) costs. CONCLUSIONS: A child's hospital admission for fever can incur significant financial costs for their family. One in five participating families reported financial hardship following their child's admission. Self-employed and single parents were disadvantaged by unplanned hospital admissions and at an increased risk of financial hardship. Local hospital policies should be improved to support families in the current financial climate.
Subject(s)
Fever , Hospitalization , Humans , England/epidemiology , Male , Female , Fever/economics , Fever/epidemiology , Fever/therapy , Child, Preschool , Child , Hospitalization/economics , Hospitalization/statistics & numerical data , Health Expenditures/statistics & numerical data , Infant , Cost of Illness , Adult , Surveys and Questionnaires , Adolescent , Hospitals, Pediatric/economics , Hospitals, Pediatric/statistics & numerical data , Emergency Service, Hospital/economics , Emergency Service, Hospital/statistics & numerical dataABSTRACT
OBJECTIVES: Gender-based disparities in salary exist in multiple fields of medicine. However, there is limited data examining gender inequities in salary in pediatric hospital medicine (PHM). Our primary objective was to assess whether gender-based salary differences exist in PHM. The secondary objective was to assess if, among women, the differences in salary varied on the basis of leadership positions or self-identified race and ethnicity. METHODS: We conducted a survey-based, cross-sectional study of pediatric hospitalists in December 2021. Our primary outcomes were base and total salary, adjusted for the reported number of average weekly work hours. We performed subanalyses by presence of a leadership position, as well as race. We used a weighted t test using inverse probability weighting to compare the outcomes between genders. RESULTS: A total of 559 eligible people responded to our survey (51.0%). After propensity score weighting, women's mean base salary was 87.7% of men's base (95% confidence interval [CI] 79.8%-96.4%, P < .01), and women's total salary was 85.6% of men's total (95% CI 73.2%-100.0%, P = .05) salary. On subgroup analysis of respondents with a leadership position, women's total salary was 80.6% of men's total salary (95% CI 68.7%-94.4%, P < .01). Although women who identified as white had base salaries that were 86.6% of white men's base salary (95% CI 78.5%-95.5%, P < .01), there was no gender-based difference noted between respondents that identified as nonwhite (88.4% [69.9%-111.7%] for base salary, 80.3% [57.2% to 112.7%]). CONCLUSIONS: Gender-based discrepancies in salary exists in PHM, which were increased among those with leadership roles. Continued work and advocacy are required to achieve salary equity within PHM.
Subject(s)
Hospitals, Pediatric , Salaries and Fringe Benefits , Humans , Salaries and Fringe Benefits/statistics & numerical data , Female , Male , Cross-Sectional Studies , Hospitals, Pediatric/economics , Sex Factors , Adult , Physicians, Women/economics , Physicians, Women/statistics & numerical data , Surveys and Questionnaires , Leadership , Pediatricians/statistics & numerical data , Pediatricians/economics , Hospitalists/economics , Hospitalists/statistics & numerical data , Sexism/statistics & numerical dataABSTRACT
OBJECTIVE: To estimate the direct costs of treating excess body weight in children and adolescents attending a public children's hospital. METHODS: This study analyzed the costs of the disease within the Brazilian Unified Health System (SUS) for 2,221 patients with excess body weight using a microcosting approach. The costs included operational expenses, consultations, and laboratory and imaging tests obtained from medical records for the period from 2009 to 2019. Healthcare expenses were obtained from the Table of Procedures, Medications, Orthoses/Prostheses, and Special Materials of SUS and from the hospital's finance department. RESULTS: Medical consultations accounted for 50.6% (R$703,503.00) of the total cost (R$1,388,449.40) of treatment over the period investigated. The cost of treating excess body weight was 11.8 times higher for children aged 5-18 years compared to children aged 2-5 years over the same period. Additionally, the cost of treating obesity was approximately 4.0 and 6.3 times higher than the cost of treating overweight children aged 2-5 and 5-18 years, respectively. CONCLUSION: The average annual cost of treating excess body weight was R$138,845.00. Weight status and age influenced the cost of treating this disease, with higher costs being observed for individuals with obesity and children over 5 years of age. Additionally, the important deficit in reimbursement by SUS and the small number of other health professionals highlight the need for restructuring this treatment model to ensure its effectiveness, including a substantial increase in government investment.
Subject(s)
Hospitals, Pediatric , Humans , Adolescent , Child , Brazil , Child, Preschool , Female , Male , Hospitals, Pediatric/economics , Hospitals, Public/economics , Pediatric Obesity/therapy , Pediatric Obesity/economics , Ambulatory Care/economics , Health Care Costs/statistics & numerical dataABSTRACT
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.
Subject(s)
Disposable Equipment , Operating Rooms , Humans , Operating Rooms/economics , Operating Rooms/statistics & numerical data , Disposable Equipment/economics , Disposable Equipment/statistics & numerical data , Child , Female , Male , Retrospective Studies , Child, Preschool , Hospitals, Pediatric/economics , Hospitals, Pediatric/statistics & numerical data , Surgical Procedures, Operative/economics , Surgical Procedures, Operative/statistics & numerical data , Infant , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Postoperative Complications/economicsABSTRACT
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 385â¯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 385â¯883 bronchiolitis hospitalizations were studied; the patients had a mean (SD) age of 7.5 (6.4) months and included 227â¯309 of 385â¯883 boys (58.9%) and 253â¯870 of 385â¯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.
Subject(s)
Bronchiolitis/therapy , Child Health Services/economics , Hospital Costs/statistics & numerical data , Hospitals, Pediatric/economics , Child , Child Health Services/classification , Child Health Services/statistics & numerical data , Child, Preschool , Cross-Sectional Studies , Female , Hospital Costs/standards , Hospitals, Pediatric/classification , Hospitals, Pediatric/statistics & numerical data , Humans , Infant , Male , Retrospective StudiesABSTRACT
OBJECTIVE: Pediatric patients comprise 13% of emergency medical services (EMS) transports, and most are transported to general emergency departments (ED). EMS transport destination policies may guide when to transport patients to a children's hospital, especially for medical complaints. Factors that influence EMS providers 'decisions about where to transport children are unknown. Our objective was to evaluate the factors associated with pediatric EMS transports to children's hospitals for medical complaints. METHODS: We performed a cross-sectional study of a large, urban EMS system over a 12-month period for all transports of patients 0-17 years old. We electronically queried the EMS database for demographic data, medical presentation and management, comorbidities, and documented reasons for choosing destination. Distances to the destination hospital and nearest children's and community hospital (if not the transport destination) were calculated. Univariate and multiple logistic regression analyses were conducted to determine the association between independent variables and the transport destination. RESULTS: We identified 10,065 patients, of which 6982 (69%) were for medical complaints. Of these medical complaints, 3518 (50.4%) were transported to a children's hospital ED. Factors associated with transport to a children's hospital include ALS transport, greater transport distance, protocol determination, developmental delay, or altered consciousness. Factors associated with transport to general EDs were older age, unknown insurance status, lower income, greater distance to children's or community hospital, destination determined by closest facility or diversion, abnormal respiratory rate or blood glucose, psychiatric primary impression, or communication barriers present. CONCLUSIONS: We found that younger patient age, EMS protocol requirements, and paramedic scene response may influence pediatric patient transport to both children's and community hospitals. Socioeconomic factors, ED proximity, diversion status, respiratory rate, chief complaints, and communication barriers may also be contributing factors. Further studies are needed to determine the generalizability of these findings to other EMS systems.
Subject(s)
Emergency Medical Services/economics , Hospitals, Pediatric/economics , Transportation of Patients/economics , Adolescent , Child , Child, Preschool , Cross-Sectional Studies , Female , Humans , Infant , Infant, Newborn , Insurance Coverage/economics , Male , Socioeconomic FactorsABSTRACT
OBJECTIVE: To evaluate the efficacy of a pediatric headache infusion center (HIC) in alleviating the symptoms and preventing future visits to the emergency department (ED). BACKGROUND: Headache is a common reason for visits to the pediatric ED. ED visits are associated with inordinate costs of care and are conceived by parents to be avoidable if adequate alternatives are available. An infusion center for acute treatment of intractable headache in children with chronic migraine may be an effective alternative to an ED visit. METHODS: This was a retrospective analysis of data from a single-center cohort of patients with a known history of chronic migraine, presenting to Dayton Children's HIC with an acute migraine from June 1, 2017 to June 1, 2020. Patients were treated according to established protocols divided into two pathways. Patient demographics, clinical characteristics, pre- and postinfusion pain scores, ED visits and inpatient admissions within 2 weeks of HIC visit, and ED visits 1 year prior and 1 year after the HIC visit were noted. RESULTS: A total of 297 HIC visits were analyzed from 201 patients. The HIC was effective in controlling symptoms with a significant reduction in pain score (median [interquartile range; IQR] 7.0 [2.0] preinfusion vs. 1.0 [2.0] postinfusion, p < 0.001). Only 25/297 (8.4%) patients came to the ED within 2 weeks of the HIC visit, and an even smaller number of patients (20/297, 6.7%) were admitted as inpatients within 2 weeks of the HIC visit. The number of ED visits was significantly reduced in the year after the HIC visit compared with the year prior (median [IQR] 1.0 [2.0] before vs. 0.0 [1.0] after, p < 0.001). CONCLUSION: A pediatric HIC is effective in alleviating the symptoms and preventing ED visits. These centers should be considered as standard of care at children's hospitals.
Subject(s)
Analgesics/administration & dosage , Emergency Service, Hospital/statistics & numerical data , Health Care Costs/statistics & numerical data , Hospitals, Pediatric/statistics & numerical data , Migraine Disorders/drug therapy , Outcome and Process Assessment, Health Care , Outpatient Clinics, Hospital/statistics & numerical data , Patient Admission/statistics & numerical data , Adolescent , Child , Chronic Disease , Emergency Service, Hospital/economics , Female , Hospitals, Pediatric/economics , Humans , Infusions, Intravenous , Male , Migraine Disorders/economics , Outpatient Clinics, Hospital/economics , Pain Measurement , Patient Admission/economics , Retrospective StudiesABSTRACT
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.
Subject(s)
Child, Hospitalized/statistics & numerical data , Health Priorities/statistics & numerical data , Hospital Costs/statistics & numerical data , Hospitalization/statistics & numerical data , Hospitals, Pediatric/statistics & numerical data , Adolescent , Appendicitis/economics , Appendicitis/epidemiology , Asthma/economics , Asthma/epidemiology , Child , Child, Preschool , Comparative Effectiveness Research , Databases, Factual , Dehydration/economics , Dehydration/epidemiology , Depressive Disorder, Major/economics , Depressive Disorder, Major/epidemiology , Female , Health Priorities/economics , Hospitalization/economics , Hospitals, Pediatric/economics , Humans , Infant , Infant, Newborn , Male , Peritonitis/economics , Peritonitis/epidemiology , Prevalence , Research , Retrospective Studies , Scoliosis/economics , Scoliosis/epidemiology , United States/epidemiologyABSTRACT
BACKGROUND AND OBJECTIVES: Laboratory testing is performed frequently in the NICU. Unnecessary tests can result in increased costs, blood loss, and pain, which can increase the risk of long-term growth and neurodevelopmental impairment. Our aim was to decrease routine screening laboratory testing in all infants admitted to our NICU by 20% over a 24-month period. METHODS: We designed and implemented a multifaceted quality improvement project using the Institute for Healthcare Improvement's Model for Improvement. Baseline data were reviewed and analyzed to prioritize order of interventions. The primary outcome measure was number of laboratory tests performed per 1000 patient days. Secondary outcome measures included number of blood glucose and serum bilirubin tests per 1000 patient days, blood volume removed per 1000 patient days, and cost. Extreme laboratory values were tracked and reviewed as balancing measures. Statistical process control charts were used to track measures over time. RESULTS: Over a 24-month period, we achieved a 26.8% decrease in laboratory tests performed per 1000 patient days (â½51 000 fewer tests). We observed significant decreases in all secondary measures, including a decrease of almost 8 L of blood drawn and a savings of $258 000. No extreme laboratory values were deemed attributable to the interventions. Improvement was sustained for an additional 7 months. CONCLUSIONS: Targeted interventions, including guideline development, dashboard creation and distribution, electronic medical record optimization, and expansion of noninvasive and point-of-care testing resulted in a significant and sustained reduction in laboratory testing without notable adverse effects.
Subject(s)
Hospitals, Pediatric/standards , Intensive Care Units, Neonatal/standards , Laboratories, Hospital/standards , Quality Improvement , Unnecessary Procedures/statistics & numerical data , Bilirubin/blood , Blood Glucose/analysis , Blood Volume , Carbon Dioxide/blood , Connecticut , Hemorrhage/etiology , Hemorrhage/prevention & control , Hospitals, Pediatric/economics , Humans , Infant, Newborn , Intensive Care Units, Neonatal/economics , Laboratories, Hospital/economics , Monitoring, Physiologic/adverse effects , Pain/etiology , Pain/prevention & control , Point-of-Care Testing , Procedures and Techniques Utilization , Unnecessary Procedures/economicsSubject(s)
Health Services Accessibility/economics , Hospital Units/economics , Hospitalization/economics , Regional Medical Programs/economics , Child , Hospital Bed Capacity , Hospital Units/statistics & numerical data , Hospitalization/statistics & numerical data , Hospitals, Pediatric/economics , Humans , Intensive Care Units, Pediatric/economics , Intensive Care Units, Pediatric/statistics & numerical data , Regional Medical Programs/statistics & numerical data , United StatesSubject(s)
Critical Care/economics , Health Care Costs , Hospitalization/economics , Hospitals, Pediatric/economics , Insurance, Health, Reimbursement/economics , Adolescent , Child , Child, Preschool , Cross-Sectional Studies , Female , Humans , Infant , Infant, Newborn , Male , Retrospective Studies , United StatesABSTRACT
OBJECTIVE: To assess the impact of geographic access to surgical center on readmission risk and burden in children after congenital heart surgery. STUDY DESIGN: Children <6 years old at discharge after congenital heart surgery (Risk Adjustment for Congenital Heart Surgery-1 score 2-6) were identified using Pediatric Health Information System data (46 hospitals, 2004-2015). Residential distance from the surgery center, calculated using ZIP code centroids, was categorized as <15, 15-29, 30-59, 60-119, and ≥120 miles. Rurality was defined using rural-urban commuting area codes. Geographic risk factors for unplanned readmissions to the surgical center and associated burden (total hospital length of stay [LOS], costs, and complications) were analyzed using multivariable regression. RESULTS: Among 59 696 eligible children, 19 355 (32%) had ≥1 unplanned readmission. The median LOS was 9 days (IQR 22) across the entire cohort. In those readmitted, median total costs were $31 559 (IQR $90 176). Distance from the center was inversely related but rurality was positively related to readmission risk. Among those readmitted, increased distance was associated with longer LOS, more complications, and greater costs. Compared with urban patients, highly rural patients were more likely to have an unplanned readmission but had fewer average readmission days. CONCLUSIONS: Geographic measures of access differentially affect readmission to the surgery center. Increased distance from the center was associated with fewer unplanned readmissions but more complications. Among those readmitted, the most isolated patients had the greatest readmission costs. Understanding the contribution of geographic access will aid in developing strategies to improve care delivery to this population.
Subject(s)
Health Services Accessibility/statistics & numerical data , Heart Defects, Congenital/surgery , Hospitals, Pediatric/supply & distribution , Patient Readmission/statistics & numerical data , Tertiary Care Centers/supply & distribution , Child , Child, Preschool , Female , Health Care Costs/statistics & numerical data , Health Services Accessibility/economics , Heart Defects, Congenital/economics , Hospitals, Pediatric/economics , Humans , Infant , Infant, Newborn , Longitudinal Studies , Male , Patient Readmission/economics , Regression Analysis , Retrospective Studies , Rural Health/economics , Rural Health/statistics & numerical data , Rural Health Services/economics , Rural Health Services/supply & distribution , Tertiary Care Centers/economics , United States , Urban Health/economics , Urban Health/statistics & numerical data , Urban Health Services/economics , Urban Health Services/supply & distributionABSTRACT
Children's hospitals responded to COVID-19 by limiting nonurgent healthcare encounters, conserving personal protective equipment, and restructuring care processes to mitigate viral spread. We assessed year-over-year trends in healthcare encounters and hospital charges across US children's hospitals before and during the COVID-19 pandemic. We performed a retrospective analysis, comparing healthcare encounters and inflation-adjusted charges from 26 tertiary children's hospitals reporting to the PROSPECT database from February 1 to June 30 in 2019 (before the COVID-19 pandemic) and 2020 (during the COVID-19 pandemic). All children's hospitals experienced similar trends in healthcare encounters and charges during the study period. Inpatient bed-days, emergency department visits, and surgeries were lower by a median 36%, 65%, and 77%, respectively, per hospital by the week of April 15 (the nadir) in 2020 compared with 2019. Across the study period in 2020, children's hospitals experienced a median decrease of $276 million in charges.
Subject(s)
COVID-19/economics , Delivery of Health Care , Health Care Costs , Hospitals, Pediatric/economics , Inpatients/statistics & numerical data , Child , Delivery of Health Care/economics , Delivery of Health Care/statistics & numerical data , Emergency Service, Hospital/economics , Emergency Service, Hospital/statistics & numerical data , Humans , Retrospective StudiesABSTRACT
OBJECTIVE: Pediatric patients undergoing surgery on the aerodigestive tract require a wide range of postoperative airway support that may be difficult predict in the preoperative period. Inaccurate prediction of postoperative resource needs leads to care inefficiencies in the form of unanticipated intensive care unit (ICU) admissions, ICU bed request cancellations, and overutilization of ICU resources. At our hospital, inefficient utilization of pediatric intensive care unit (PICU) resources was negatively impacting safety, access, throughput, and finances. We hypothesized that actionable key drivers of inefficient ICU utilization at our hospital were operative scheduling errors and the lack of predictability of intermediate-risk patients and that improvement methodology could be used in iterative cycles to enhance efficiency of care. Through testing this hypothesis, we aimed to provide a framework for similar efforts at other hospitals. STUDY DESIGN: Quality improvement initiative. METHODS: Plan, Do, Study, Act methodology (PDSA) was utilized to implement two cycles of change aimed at improving level-of-care efficiency at an academic pediatric hospital. In PDSA cycle 1, we aimed to address scheduling errors with surgical order placement restriction, creation of a standardized list of surgeries requiring PICU admission, and implementation of a hard stop for postoperative location in the electronic medical record surgical order. In the PDSA cycle 2, a new model of care, called the Grey Zone model, was designed and implemented where patients at intermediate risk of airway compromise were observed for 2-5 hours in the post-anesthesia care unit. After this observation period, patients were then transferred to the level of care dictated by their current status. Measures assessed in PDSA cycle 1 were unanticipated ICU admissions and ICU bed request cancellations. In addition to continued analysis of these measures, PDSA cycle 2 measures were ICU beds avoided, safety events, and secondary transfers from extended observation to ICU. RESULTS: In PDSA cycle 1, no significant decrease in unanticipated ICU admissions was observed; however, there was an increase in average monthly ICU bed cancellations from 36.1% to 45.6%. In PDSA cycle 2, average monthly unanticipated ICU admissions and cancelled ICU bed requests decreased from 1.3% to 0.42% and 45.6% to 33.8%, respectively. In patients observed in the Grey Zone, 229/245 (93.5%) were transferred to extended observation, avoiding admission to the ICU. Financial analysis demonstrated a charge differential to payers of $1.1 million over the study period with a charge differential opportunity to the hospital of $51,720 for each additional hospital transfer accepted due to increased PICU bed availability. CONCLUSIONS: Implementation of the Grey Zone model of care improved efficiency of ICU resource utilization through reducing unanticipated ICU admissions and ICU bed cancellations while simultaneously avoiding overutilization of ICU resources for intermediate-risk patients. This was achieved without compromising safety of patient care, and was financially sound in both fee-for-service and value-based reimbursement models. While such a model may not be applicable in all healthcare settings, it may improve efficiency at other pediatric hospitals with high surgical volume and acuity. LEVEL OF EVIDENCE: N/A Laryngoscope, 131:S1-S10, 2021.
Subject(s)
Health Care Rationing/methods , Hospitals, Pediatric/organization & administration , Intensive Care Units, Pediatric/organization & administration , Otorhinolaryngologic Diseases/surgery , Otorhinolaryngologic Surgical Procedures , Postoperative Care/economics , Child , Health Care Rationing/economics , Health Care Rationing/statistics & numerical data , Health Plan Implementation/organization & administration , Hospitals, Pediatric/economics , Hospitals, Pediatric/statistics & numerical data , Humans , Intensive Care Units, Pediatric/economics , Intensive Care Units, Pediatric/statistics & numerical data , Otorhinolaryngologic Diseases/economics , Postoperative Care/statistics & numerical data , Program Evaluation , Quality ImprovementABSTRACT
Although pharmacogenetic testing is becoming increasingly common across medical subspecialties, a broad range of utilization and implementation exists across pediatric centers. Large pediatric institutions that routinely use pharmacogenetics in their patient care have published their practices and experiences; however, minimal data exist regarding the full spectrum of pharmacogenetic implementation among children's hospitals. The primary objective of this nationwide survey was to characterize the availability, concerns, and barriers to pharmacogenetic testing in children's hospitals in the Children's Hospital Association. Initial responses identifying a contact person were received from 18 institutions. Of those 18 institutions, 14 responses (11 complete and 3 partial) to a more detailed survey regarding pharmacogenetic practices were received. The majority of respondents were from urban institutions (72%) and held a Doctor of Pharmacy degree (67%). Among all respondents, the three primary barriers to implementing pharmacogenetic testing identified were test reimbursement, test cost, and money. Conversely, the three least concerning barriers were potential for genetic discrimination, sharing results with family members, and availability of tests in certified laboratories. Low-use sites rated several barriers significantly higher than the high-use sites, including knowledge of pharmacogenetics (P = 0.03), pharmacogenetic interpretations (P = 0.04), and pharmacogenetic-based changes to therapy (P = 0.03). In spite of decreasing costs of pharmacogenetic testing, financial barriers are one of the main barriers perceived by pediatric institutions attempting clinical implementation. Low-use sites may also benefit from education/outreach in order to reduce perceived barriers to implementation.
Subject(s)
Hospitals, Pediatric/statistics & numerical data , Pharmacogenomic Testing/statistics & numerical data , Practice Patterns, Physicians'/statistics & numerical data , Hospitals, Pediatric/economics , Humans , Pharmacogenomic Testing/economics , Practice Patterns, Physicians'/economics , Reimbursement Mechanisms , United StatesABSTRACT
BACKGROUND: An effective pediatric emergency care (PEC) system is key to reduce pediatric mortality in low-income countries. While data on pediatric emergencies from these countries can drive the development and adjustment of such a system, they are very scant, especially from Africa. We aimed to describe the characteristics and outcomes of presentations to a tertiary-care Pediatric Emergency Department (PED) in Mozambique. METHODS: We retrospectively reviewed PED presentations to the "Hospital Central da Beira" between April 2017 and March 2018. Multivariable logistic regression was used to identify predictors of hospitalization and death. RESULTS: We retrieved 24,844 presentations. The median age was 3 years (IQR 1-7 years), and 92% lived in the urban area. Complaints were injury-related in 33% of cases and medical in 67%. Data on presenting complaints (retrieved from hospital paper-based registries) were available for 14,204 (57.2%) records. Of these, respiratory diseases (29.3%), fever (26.7%), and gastrointestinal disorders (14.2%) were the most common. Overall, 4,997 (20.1%) encounters resulted in hospitalization. Mortality in the PED was 1.6% (62% ≤4 hours from arrival) and was the highest in neonates (16%; 89% ≤4 hours from arrival). A younger age, especially younger than 28 days, living in the extra-urban area and being referred to the PED by a health care provider were all significantly associated with both hospitalization and death in the PED at the multivariable analysis. CONCLUSIONS: Injuries were a common presentation to a referral PED in Mozambique. Hospitalization rate and mortality in the PED were high, with neonates being the most vulnerable. Optimization of data registration will be key to obtain more accurate data to learn from and guide the development of PEC in Mozambique. Our data can help build an effective PEC system tailored to the local needs.
Subject(s)
Emergency Medical Services/organization & administration , Fever/therapy , Gastrointestinal Diseases/therapy , Hospitals, Pediatric/organization & administration , Respiratory Tract Diseases/therapy , Wounds and Injuries/therapy , Adolescent , Age Factors , Child , Child, Preschool , Emergencies/epidemiology , Emergency Medical Services/economics , Emergency Medical Services/statistics & numerical data , Emergency Service, Hospital/economics , Emergency Service, Hospital/organization & administration , Emergency Service, Hospital/statistics & numerical data , Female , Fever/diagnosis , Fever/mortality , Gastrointestinal Diseases/diagnosis , Gastrointestinal Diseases/mortality , Hospital Mortality , Hospitalization/economics , Hospitalization/statistics & numerical data , Hospitals, Pediatric/economics , Hospitals, Pediatric/statistics & numerical data , Humans , Infant , Male , Mozambique/epidemiology , Respiratory Tract Diseases/diagnosis , Respiratory Tract Diseases/mortality , Retrospective Studies , Treatment Outcome , Wounds and Injuries/diagnosis , Wounds and Injuries/mortalityABSTRACT
BACKGROUND: Even before seeing a physician, patients must first gain access to the hospital system. At large hospitals with high patient volumes, access to specialty care can pose a particular challenge. This study examines the effects of specific initiatives to increase clinic capacity, appointment use, and ease of scheduling on both patient satisfaction and hospital revenue. METHODS: In 2017, a task force at a large, multidisciplinary pediatric hospital instituted a number of initiatives to increase patient access to ambulatory specialty clinics. Clinic sessions were standardized to a 4-hour template, and unscheduled, "held" appointment slots were required to be made available ("flipped") 72 hours before the appointment. A patient-centered electronic scheduling platform was also implemented. Patient satisfaction was assessed using Press Ganey scores. Revenue estimates were calculated for increases in "new" and "return" patient appointments. RESULTS: Total new appointment slots increased by over 44 percent, with over 53,000 appointments added annually. The number of held appointment slots declined by 93 percent. A total of 17,996 annual appointments were added in surgical subspecialties, and an additional 14,756 more surgical appointments were completed. Over 2000 appointments were scheduled by means of the online patient portal. Press Ganey "ease-of-scheduling" scores increased from 57 percent to 72 percent over the intervention period. Hospitalwide, these initiatives generated an estimated $8.3 million in revenue opportunity. CONCLUSION: Standardizing clinic sessions and optimizing clinic availability generates new appointment opportunities, improves patient experience, and increases hospital revenue.