Evaluation of the Effectiveness of Telemedicine Visits in a Pediatric Gastroenterology Service in the Context of COVID-19.

BACKGROUND: During the first months of COVID-19, the Gastroenterology, Hepatology and Nutrition service of the Hospital Sant Joan de Déu in Barcelona, a leading pediatric center in Spain, introduced a new model of non-face-to-face care. OBJECTIVE: To evaluate the impact of telephone consultations compared to those conducted face-to-face on healthcare utilization. METHODOLOGY: Two main indicators of effectiveness are used: the degree of resolution (percentage of first telemedicine visits that did not generate any new visits in the following 4 and 12 months) and the average number of subsequent visits. A distinction was made between visits for general pathologies (less complex) and those for pathologies treated in monographic consultations (chronic or complex pathologies). Effectiveness at 4 and 12 months was also compared. RESULTS: After 4 months from the first visit, the degree of resolution is lower in the first telemedicine visits than in face-to-face visits for both general pathologies and those of monographic agendas for chronic and complex pathologies. After twelve months, the first general telemedicine visits are less resolute than face-to-face visits, while the resolution rate is the same for chronic and complex pathology visits. Each telemedicine visit generates on average more visits than face-to-face visits. In the short term, 133.4% more in the case of general visits and 51.4% more in the case of chronic and complex visits. In the long term, general telemedicine visits generate 57.31% more visits, while no statistically significant difference is observed between chronic and complex face-to-face and telemedicine visits. CONCLUSION: The results of this study show that the resolution capacity of the non-face-to-face model in pediatric care in the pandemic context is generally lower and generates more successive visits than the face-to-face model. This lower performance of the telemedicine model should be counterbalanced with its advantages.

Pediatric Tele-Home Care Compared to Usual Care: Cost-Minimization Analysis.

BACKGROUND: Although home hospitalization has been a well-known and widespread practice for some time in the adult population, it has not been the same case in the pediatric setting. Simultaneously, telemedicine tools are a facilitator of the change in the health care model, which is increasingly focused on home care. In a pioneering way in Spain, the in-home hospitalization program of the Hospital Sant Joan de Déu in Barcelona allows the child to be in their home environment at the time they are being monitored and clinically followed by the professionals. Besides being the preferred option for families, previous experience suggests that pediatric home hospitalization reduces costs, primarily thanks to savings on the structural cost of the stay. OBJECTIVE: The aim of this study is to compare the average cost of a discharge by tele-home care with the usual care and to analyze the main drivers of the differential costs of both care models. METHODS: A cost-minimization analysis is conducted under a hospital's perspective, based on observational data, and estimated retrospectively. A historical control group of similar patients in terms of clinical casuistry to children hospitalized at home was used for comparison. RESULTS: A 24-hour stay at the hospital costs US $574.19, while the in-home hospitalization costs US $301.71 per day, representing a saving of almost half (48%) of the cost compared to usual care. The main saving drivers were the personnel costs (US $102.83/US $284.53, 35.5% of the total), intermediate noncare costs (US $6.09/US $284.53, 33.17%), and structural costs (US $55.16/US $284.53, 19.04%). Home hospitalization involves a total stay 27.61% longer, but at almost half the daily cost, and thus represents a saving of US $176.70 (9.01%) per 24-hour stay. CONCLUSIONS: The cost analysis conducted under a hospital perspective shows that pediatric tele-home care is 9% cheaper compared to regular hospital care. These results motivate the most widespread implementation of the service from the point of view of economic efficiency, adding to previous experiences that suggest that it is also preferable from the perspective of user satisfaction.

Effects of a Paediatric Antimicrobial Stewardship Program on Antimicrobial Use and Quality of Prescriptions in Patients with Appendix-Related Intraabdominal Infections.

The effectiveness of antimicrobial stewardship programs (ASP) in reducing antimicrobial use (AU) in children has been proved. Many interventions have been described suitable for different institution sizes, priorities, and patients, with surgical wards being one of the areas that may benefit the most. We aimed to describe the results on AU and length of stay (LOS) in a pre-post study during the three years before (2014-2016) and the three years after (2017-2019) implementation of an ASP based on postprescription review with feedback in children and adolescents admitted for appendix-related intraabdominal infections (AR-IAI) in a European Referral Paediatric University Hospital. In the postintervention period, the quality of prescriptions (QP) was also evaluated. Overall, 2021 AR-IAIs admissions were included. Global AU, measured both as days of therapy/100 patient days (DOT/100PD) and length of therapy (LOT), and global LOS remained unchanged in the postintervention period. Phlegmonous appendicitis LOS (p = 0.003) and LOT (p < 0.001) significantly decreased, but not those of other AR-IAI diagnoses. The use of piperacillin-tazobactam decreased by 96% (p = 0.044), with no rebound in the use of other Gram-negative broad-spectrum antimicrobials. A quasisignificant (p = 0.052) increase in QP was observed upon ASP implementation. Readmission and case fatality rates remained stable. ASP interventions were safe, and they reduced LOS and LOT of phlegmonous appendicitis and the use of selected broad-spectrum antimicrobials, while increasing QP in children with AR-IAI.

Benefits of a Pediatric Antimicrobial Stewardship Program in Antimicrobial Use and Quality of Prescriptions in a Referral Children's Hospital.

OBJECTIVES: To evaluate the results of the first 24 months of a postprescription review with feedback-based antimicrobial stewardship program in a European referral children's hospital. STUDY DESIGN: We performed a pre-post study comparing antimicrobial use between the control (2015-2016) and the intervention periods (2017-2018) expressed in days of therapy/100 days present. Quality of prescriptions was evaluated by quarterly cross-sectional point-prevalence surveys. Length of stay, readmission rates, in-hospital mortality rates, cost of systemic antimicrobial agents, and antimicrobial resistance rates were included as complementary outcomes. RESULTS: Total antimicrobial use and antibacterial use significantly decreased during the intervention period (P = .002 and P = .001 respectively), and total antifungal use remained stable. A significant decline in parenteral antimicrobial use was also observed (P < .001). In 8 quarterly point-prevalence surveys (938 prescriptions evaluated), the mean prevalence of use of any antimicrobial among inpatients was 39%. An increasing trend in the rate of optimal prescriptions was observed after the first point-prevalence survey (P = .0898). Nonoptimal prescriptions were more common in surgical than in medical departments, in antibacterial prescriptions with prophylactic intention, and in empirical more than in targeted treatments. No significant differences were observed in terms of mortality or readmission rates. Only minor changes in antimicrobial resistance rates were noted. CONCLUSIONS: Our antimicrobial stewardship program safely decreased antimicrobial use and expenditure, and a trend toward improvement in quality of prescription was also observed.

Impacto de la patología crónica en un servicio de urgencias pediátrico / Impact of chronic diseases on a pediatric emergency department

Objetivo. Describir las características clínicas de pacientes con patología crónica en un servicio de urgencias pediátrico. Método. Estudio de casos y controles realizado en un hospital pediátrico de tercer nivel. Incluye las visitas realizadas en urgencias un día a la semana durante 3 meses consecutivos. Se define como caso toda visita de pacientes con patología crónica, y como control, la visita inmediatamente posterior al caso. Resultados. De las 2.826 visitas realizadas, 278 son pacientes con patología crónica (prevalencia 9,8%; IC 95% 8,8-10,9%), que corresponden a 265 niños (12 reconsultan). Las patologías más frecuentes son respiratorias (35,2%) y neurológicas (24,9%). El 28,8% de las visitas están relacionadas con su patología crónica. La mediana de edad es mayor en casos que en controles (4 años vs 2,5; p<0,001), sin diferencias significativas en la distribución por sexos (60,8% masculino vs 52,7%, p=0,059). En los casos se realizan más análisis de sangre (16,5% vs 9%, p=0,008) y tomografías craneales (3,2% vs 0,7%, p=0,033). No encontramos diferencias en los análisis de orina (11,2% vs 9%, p=0,398), ni en las radiografías torácicas (19,1% vs 13,3%, p=0,065), ni en otras pruebas. En los casos se realizan más interconsultas a especialistas (7,6% vs 2,9%, p=0,013) y más ingresos (19,1% vs 7,6%, p<0,001). Conclusiones. Los niños con patología crónica constituyen un grupo importante de las visitas realizadas en urgencias, requieren mayor utilización de recursos hospitalarios y manejo multidisciplinario. El pediatra de urgencias debe conocer las pautas de manejo y tratamiento de estos pacientes e identificar cualquier descompensación de las enfermedades de base que sufren (AU)

Background. Childhood chronic diseases are an increasing problem for the healthcare systems. Advances made in their management have led to a marked increase in the survival of these children and thus there is a need to analyze their impact on the emergency services. Objective. To describe the clinical characteristics of patients with chronic diseases seen in a pediatric emergency department. Method. Case-control study performed in a tertiary pediatric hospital, including emergency room visits one day per week for three consecutive months. Cases were defined as any visit of patients with chronic diseases, and controls were defined as the visits immediately following the case. Results. Of the 2,826 visits, 278 were from patients with chronic diseases (prevalence 9.8%, CI 95% 8.8-10.9), corresponding to 265 children (12 revisits). The most frequent diseases were respiratory (35.2%) and neurological (24.9%) disorders; 28.8% of the visits were related to their chronic condition. The median age was higher in cases than controls (4 years vs. 2.5 years respectively, p<0.001). There were no significant differences in gender distribution (60.8% male vs. 52.7% female, p=0.059). More blood tests and CT scans were performed in cases compared to controls (16.5% vs. 9%, p=0.008, and 3.2% vs. 0.7%, p=0.033, respectively). There was no difference between cases and controls in the number of urinalysis (11.2% vs. 9% respectively, p=0.398), chest X-ray (19.1% vs. 13.3% respectively, p=0.065), or other tests performed. Compared to controls, visits of patients with chronic diseases included more consultations to specialists (7.6% vs. 2.9% respectively, p=0.013) and resulted in more admissions (19.1% vs. 7.6% respectively, p<0.001). Conclusions. Children with chronic diseases represent a large proportion of emergency room visits and require a greater utilization of hospital resources and multidisciplinary management. Pediatricians should be aware of the emergency management and treatment guidelines of these conditions and identify promptly any signs of deterioration in these children (AU)