ABSTRACT
Clonidine is used for hypertension and narcotic withdrawal prophylaxis in adults and children. This study described plasma absorption of clonidine from whole and cut transdermal clonidine patches. This was a retrospective descriptive study in an 18 bed multidisciplinary pediatric intensive care unit, evaluating 15 critically ill children with a median age of 1.1 years (range 0.3-11 years) treated with transdermal clonidine for narcotic withdrawal prophylaxis, and who had plasma clonidine concentrations measured. An assessment of the relationship between clonidine dose and patch integrity (whole vs. cut) with plasma concentrations was performed, with further analysis by Spearman Correlation Coefficient. Clonidine doses averaged 7.5±4.2 µg/kg/day (range 2.3-20 µg/kg/day) for 9.8±4.3 days (range 4-20 days). There were 9 cut patches and 6 whole patches. The average prescribed dose delivered by cut patches was 6.4±3 µg/kg/day, resulting in a mean plasma concentration of 1±1.1 ng/ mL (range <0.05-3.3 ng/mL). The average prescribed dose delivered by whole patches was 7±1.7 µg/kg/day, resulting in a mean plasma concentration of 0.55±0.3 ng/mL (range 0.13-1.5 ng/mL). The Spearman Correlation Coefficient was calculated to evaluate the correlation between dose and concentration. For whole and cut patches the correlation coefficient was 0.94 (P=0.005) and 0.72 (P=0.002), respectively. Doses ranging from 1.7 to 20 µg/kg/day using whole patches resulted in no plasma concentrations >2 ng/mL. However, a plasma concentration >2 ng/mL was achieved with a dose of 8.8 µg/kg/day delivered by a cut patch. In addition, the 2 samples that resulted in undetectable concentrations were taken from patients who were treated with cut patches. The results from this pilot study suggest that critically ill children absorb clonidine from transdermal patches, but the rate and extent of absorption appears to be more predictable with the use of whole patches compared to patches that have been cut.
ABSTRACT
CONTEXT: Centers for Medicare & Medicaid Services (CMS) Health Resources and Services Administration Children's Hospitals Graduate Medical Education (GME) Payment Program now supports freestanding children's teaching hospitals. OBJECTIVE: To analyze the fair market value impact of GME payment on resident teaching efforts in our pediatric intensive care unit (PICU). DESIGN: Cost-accounting model, developed from a 1-year retrospective, descriptive, single-institution, longitudinal study, applied to physician teachers, residents, and CMS. SETTING: Sixteen-bed PICU in a freestanding, university-affiliated children's teaching hospital. PARTICIPANTS: Pediatric critical care physicians, second-year residents. MAIN OUTCOME MEASURES: Cost of physician opportunity time; CMS investment return; the teaching physicians' investment return; residents' investment return; service balance between CMS and teaching service investment margins; economic balance points; fair market value. RESULTS: GME payments to our hospital increased 4.8-fold from 577 886 dollars to 2 772 606 dollars during a 1-year period. Critical care physicians' teaching opportunity cost rose from 250 097 dollars to 262 215 dollars to provide 1523 educational hours (6853 relative value units). Residents' net financial value for service provided to the PICU rose from 245 964 dollars to 317 299 dollars. There is an uneven return on investment in resident education for CMS, critical care physicians, and residents. Economic balance points are achievable for the present educational efforts of the CMS, critical care physicians, and residents if the present direct medical education payment increases from 29.38% to 36%. CONCLUSIONS: The current CMS Health Resources and Services Administration Children's Hospitals GME Payment Program produces uneven investment returns for CMS, critical care physicians, and residents. We propose a cost-accounting model, based on perceived production capability measured in relative value units and available GME funds, that would allow a clinical service to balance and obtain a fair market value for the resident education efforts of CMS, physician teachers, and residents.
