The cost of a pediatric neurocritical care program for traumatic brain injury: a retrospective cohort study.

BACKGROUND: Inpatient care for children with severe traumatic brain injury (sTBI) is expensive, with inpatient charges averaging over $70,000 per case (Hospital Inpatient, Children Only, National Statistics. Diagnoses- clinical classification software (CCS) principal diagnosis category 85 coma, stupor, and brain damage, and 233 intracranial injury. Diagnoses by Aggregate charges [ https://hcupnet.ahrq.gov/#setup ]). This ranks sTBI in the top quartile of pediatric conditions with the greatest inpatient costs (Hospital Inpatient, Children Only, National Statistics. Diagnoses- clinical classification software (CCS) principal diagnosis category 85 coma, stupor, and brain damage, and 233 intracranial injury. Diagnoses by Aggregate charges [ https://hcupnet.ahrq.gov/#setup ]). The Brain Trauma Foundation developed sTBI intensive care guidelines in 2003, with revisions in 2012 (Kochanek, Carney, et. al. PCCM 3:S1-S2, 2012). These guidelines have been widely disseminated, and are associated with improved health outcomes (Pineda, Leonard. et. al. LN 12:45-52, 2013), yet research on the cost of associated hospital care is limited. The objective of this study was to assess the costs of providing hospital care to sTBI patients through a guideline-based Pediatric Neurocritical Care Program (PNCP) implemented at St. Louis Children's Hospital, a pediatric academic medical center in the Midwest United States. METHODS: This is a retrospective cohort study. We used multi-level regression to estimate pre-/post-implementation effects of the PNCP program on inflation adjusted total cost of in-hospital sTBI care. The study population included 58 pediatric patient discharges in the pre-PNCP implementation group (July 15, 1999 - September 17, 2005), and 59 post-implementation patient discharges (September 18, 2005 - January 15, 2012). RESULTS: Implementation of the PNCP was associated with a non-significant difference in the cost of care between the pre- and post-implementation periods (eß = 1.028, p = 0.687). CONCLUSIONS: Implementation of the PNCP to support delivery of guideline-based care for children with sTBI did not change the total per-patient cost of in-hospital care. A key strength of this study was its use of hospital cost data rather than charges. Future research should consider the longitudinal post-hospitalization costs of this approach to sTBI care.

Link Between Perceived Body Weight and Smoking Behavior Among Adolescents.

INTRODUCTION: This study investigates a relationship between overweight perception and smoking among adolescents. METHODS: Data were retrieved from the Youth Risk Behavior Survey (YRBS), a biennial survey of a nationally representative sample of students in grades 9 through 12 in the United States. We analyze five waves of repeated cross-sections (N = 73 376) for the years 2005-2013. We estimate a recursive simultaneous-equations system in which body weight perception, which is a function of actual weight, influences smoking status. Outcome measures are binary indicators for current smoking and frequent current smoking. Perceived weight is categorized into very overweight perception, slightly overweight perception, and about the right weight/underweight perception. RESULTS: In comparison to adolescents who perceive themselves to be the right weight or underweight, adolescents who perceive themselves to be very overweight are 6.1 percentage points (pp) (standard error [SE] = 1.6pp) more likely to currently smoking and 3.3pp (SE = 1.2pp) more likely to frequently smoke. Adolescents with slightly overweight perception are 7.9pp (SE = 1.0pp) and 2.5pp (SE = 0.6pp) more likely to currently smoke and frequently smoke, respectively, as compared to those with the right weight/underweight perception. The relationships are larger for females, and appear to be mediated by weight-loss activity. DISCUSSION: In an era of tight budgets, it is crucial to address both obesity and smoking in manners that do not work at cross purposes. Strategies to combat youth smoking may be more effective if the perception of being overweight is considered an important risk factor, especially among female adolescents. IMPLICATIONS: We find that perception of being overweight is an important causal risk factor for adolescent smoking. Main findings of this study imply that even a slight change in the perception of body weight may lead to a significant change in smoking behavior among adolescents, especially among females and that the perception of being overweight induces adolescents to smoke regularly. Unlike most prior studies, we discovered a positive effect of slight overweight perception on smoking for adolescent males. Our findings emphasize the importance of addressing both obesity and smoking in manners that do not work at cross purposes.

Oregon's experiment in health care delivery and payment reform: coordinated care organizations replacing managed care.

To control Medicaid costs, improve quality, and drive community engagement, the Oregon Health Authority introduced a new system of coordinated care organizations (CCOs). While CCOs resemble traditional Medicaid managed care, they have differences that have been deliberately designed to improve care coordination, increase accountability, and incorporate greater community governance. Reforms include global budgets integrating medical, behavioral, and oral health care and public health functions; risk-adjusted payments rewarding outcomes and evidence-based practice; increased transparency; and greater community engagement. The CCO model faces several implementation challenges. If successful, it will provide improved health care delivery, better health outcomes, and overall savings.

Oregon's coordinated care organizations: a promising and practical reform model.

Continuing its path of Medicaid program innovation, Oregon recently embarked on a major reform that gives regional coordinated care organizations (CCOs) global budgets and accountability for the physical, behavioral, and dental care of the state's Medicaid beneficiaries (Howard et al. 2014). There are some who maintain that the state's bold reform initiative is overly aggressive in scope and unrealistically optimistic in schedule and may prove to be a costly debacle to the state of Oregon. We argue that the Oregon CCO model is not only bold in its aims and timetable but also realistically achievable.

Factors influencing maternal nutrition in rural Nepal: an exploratory research project.

In this pilot project we examined factors contributing to maternal nutrition among women of child-bearing age in the Western Region of Nepal. We found that rural women are interested in learning about nutrition regardless of educational attainment and that level of education is strongly associated with interest in learning about nutrition (p <.001). Although the majority of women with no education expressed interest in learning about nutrition (71%), a substantial percentage (22%) were not interested. Education and the teaching of basic health messages may hold important benefits for improving maternal and child health.

The role of adverse physical health events on the utilization of mental health services.

OBJECTIVE: To test the degree to which adverse physical health events may subsequently increase the utilization of mental health services. METHODS: A quasi-experimental pretest-posttest design was employed on a nationally representative sample of adults from the Medical Expenditure Panel Surveys for years 2004 and 2005. We constructed a 2-year balanced-panel dataset on 6,017 U.S. adults who did not have any adverse physical health events in 2004. We calculated difference-in-differences estimators that capture the effect of adverse physical health events on provider visits and prescription drug use for the treatment of mental health conditions. PRINCIPAL FINDINGS: Our most rigorous analytic model shows that an adverse physical health event is significantly associated with more than a threefold increase in the likelihood of provider visits and prescribed medication use for the treatment of mental health problems. These increases are mainly through office-based physician visits for nonsevere mental health conditions. This relationship is greater among those who experience more severe physical health events. CONCLUSION: An adverse physical health event substantially increases the utilization of mental health care. Mental health service use increases with the severity of a physical health condition.

Does the racial composition of the school environment influence children's body mass index?

PURPOSE: This study investigates the degree to which the racial composition of the school environment may influence the body mass index (BMI) of children aged 10 to 18 years. This research may be viewed as extending prior work that has found that the prevalence of risk behaviors among nonwhite adolescents is influenced by exposure to white adolescents. METHODS: This research used data from the Survey of Adults and Youth, which was conducted as part of the evaluation of the Robert Wood Johnson Foundation's Urban Health Initiative. The study population for this analysis is comprised of parent and child respondents in the 2004 to 2005 survey wave who lived in one of the five program cities: Baltimore, Detroit, Oakland, Philadelphia, and Richmond. We constructed two-level school random effects models and added school and census tract-level variables that describe the racial composition of the residential community and the school attended. RESULTS: Black and Hispanic adolescent girls who attend schools with a mostly nonwhite student body have higher BMIs than do their white counterparts. However, black girls in predominately white schools do not have higher BMIs than white girls. Further, black and Hispanic girls whose schoolmates are predominately white have significantly lower BMIs than black and Hispanic girls in schools where fewer than half the students are white. These associations are not found among boys, and are net of a broad variety of individual, household, and group level characteristics. CONCLUSIONS: Our findings suggest that the BMI of minority adolescent girls is influenced by the norms of the social environment.

The importance of team level tacit knowledge and related characteristics of high-performing health care teams.

Team level tacit knowledge is related to the collective knowledge of the team members. It is the shared experience that results in the ability to successfully anticipate the reactions of teammates in typical and nontypical situations. This study evaluates how tacit knowledge and related team characteristics influence the performance of cardiothoracic surgery teams.

Effect of increased ICU capacity on emergency department length of stay and ambulance diversion.

STUDY OBJECTIVE: Lack of inpatient bed availability has been identified as a major contributor to emergency department (ED) crowding. Our objective is to determine the changes in ED length of stay and ambulance diversion occurring in an urban, academic medical center after an increase in adult ICU beds. METHODS: This was a secondary analysis of 2 years of hospital administrative data, capitalizing on a natural experiment in which the number of adult ICU beds in the study hospital increased from 47 to 67 (total beds 411 to 431). We analyzed changes in ED length of stay for adults admitted to ICU, telemetry beds, and ward beds and adults discharged home. We also analyzed changes in hours per day spent on 3 types of ambulance diversion: complete diversion (all ambulances), critical care diversion (ambulances carrying patients requiring ICU beds), and diversion of ambulances carrying trauma patients. RESULTS: The average hours per day on complete ambulance diversion decreased from 3.8 hours to 1.4 hours (66% decrease). Critical care and trauma diversion showed similar decreases. Average ED length of stay for patients admitted to the ICU decreased by 25 minutes (257 to 232 minutes). Average ED length of stay did not significantly decrease for other admitted patients and increased for discharged patients. CONCLUSION: The most notable change after ICU expansion was a decrease in time spent on ambulance diversion. Increasing ICU beds appears to have shortened ED length of stay for ICU patients but has less effect on other admitted patients and apparently no effect on patients discharged home.