Child Health, Vulnerability, and Complexity: Use of Telehealth to Enhance Care for Children and Youth With Special Health Care Needs.

Telehealth, or the use of telecommunications technology and infrastructure to deliver health-related services and information that support patient care, has the potential to improve the quality of care, particularly deficiencies related to access and patient experience of care. Telehealth may also reduce disparities for children and youth with special health care needs (CYSHCN) with barriers to accessing in-person care, for example, those residing in rural areas and children with medical complexity who are particularly fragile. While important foundational work has been done to study telehealth's effectiveness and implementation, key gaps remain regarding its use for CYSHCN. The CYSHCNet national research agenda development process, described in a companion article, identified as key priority areas for future research telehealth as an innovative care delivery model for all CYSHCN and as a mechanism to address rural-urban disparities in health care access. Here, we review the current knowledge around telehealth, identify populations for whom telehealth could be especially beneficial, discuss the important gaps identified, and make recommendations for specific studies that will move the field forward. There are ample opportunities for telehealth to improve health and patient/family experience of care and quality of life for CYSHCN while requiring less time and resources from families accessing this care. Innovative research to inform best practices around incorporation and implementation of telehealth will improve its efficiency and effectiveness and achieve optimal outcomes.

Home Health Care Utilization in Children With Medicaid.

BACKGROUND: Although many children with medical complexity (CMC) use home health care (HHC), little is known about all pediatric HHC utilizers. Our objective was to assess characteristics of pediatric HHC recipients, providers, and payments. METHODS: We conducted a retrospective analysis of 5 209 525 children age 0-to-17 years enrolled Medicaid in the 2016 IBM Watson MarketScan Medicaid Database. HHC utilizers had ≥ 1 HHC claim. Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes were reviewed to codify provider types when possible: registered nurse (RN), licensed practical nurse (LPN), home health aide (HHA), certified nursing assistant (CNA), or companion/personal attendant. Enrollee clinical characteristics, HHC provider type, and payments were assessed. Chronic conditions were evaluated with Agency for Healthcare Research and Quality's Chronic Condition Indicators and Feudtner's Complex Chronic Conditions. RESULTS: Of the 0.8% of children who used HHC, 43.8% were age <1 year, 25% had no chronic condition, 38.6% had a noncomplex chronic condition, 21.5% had a complex chronic condition without technology assistance, and 15.5% had technology assistance (eg, tracheostomy). HHC for children with technology assistance accounted for 72.6% of all HHC spending. Forty-five percent of HHC utilizers received RN/LPN-level care, 7.9% companion/personal attendant care, 5.9% HHA/CNA-level care, and 36% received care from an unspecified provider. For children with technology assistance, the majority (77.2%) received RN/LPN care, 17.5% companion/personal assistant care, and 13.8% HHA/CNA care. CONCLUSIONS: Children using HHC are a heterogeneous population who receive it from a variety of providers. Future investigations should explore the role of nonnurse caregivers, particularly with CMC.

PAR2 (Protease-Activated Receptor 2) Deficiency Attenuates Atherosclerosis in Mice.

OBJECTIVE: PAR2 (protease-activated receptor 2)-dependent signaling results in augmented inflammation and has been implicated in the pathogenesis of several autoimmune conditions. The objective of this study was to determine the effect of PAR2 deficiency on the development of atherosclerosis. APPROACH AND RESULTS: PAR2 mRNA and protein expression is increased in human carotid artery and mouse aortic arch atheroma versus control carotid and aortic arch arteries, respectively. To determine the effect of PAR2 deficiency on atherosclerosis, male and female low-density lipoprotein receptor-deficient (Ldlr-/-) mice (8-12 weeks old) that were Par2+/+ or Par2-/- were fed a fat- and cholesterol-enriched diet for 12 or 24 weeks. PAR2 deficiency attenuated atherosclerosis in the aortic sinus and aortic root after 12 and 24 weeks. PAR2 deficiency did not alter total plasma cholesterol concentrations or lipoprotein distributions. Bone marrow transplantation showed that PAR2 on nonhematopoietic cells contributed to atherosclerosis. PAR2 deficiency significantly attenuated levels of the chemokines Ccl2 and Cxcl1 in the circulation and macrophage content in atherosclerotic lesions. Mechanistic studies using isolated primary vascular smooth muscle cells showed that PAR2 deficiency is associated with reduced Ccl2 and Cxcl1 mRNA expression and protein release into the supernatant resulting in less monocyte migration. CONCLUSIONS: Our results indicate that PAR2 deficiency is associated with attenuation of atherosclerosis and may reduce lesion progression by blunting Ccl2- and Cxcl1-induced monocyte infiltration.

Development of a New Care Model for Hospitalized Children With Medical Complexity.

Children with medical complexity are a rapidly growing inpatient population with frequent, lengthy, and costly hospitalizations. During hospitalization, these patients require care coordination among multiple subspecialties and their outpatient medical homes. At a large freestanding children's hospital, a new inpatient model of care was developed in an effort to consistently provide coordinated, family-centered, and efficient care. In addition to expanding the multidisciplinary team to include a pharmacist, dietician, and social worker, the team redesign included: (1) medication reconciliation rounds, (2) care coordination rounds, and (3) multidisciplinary weekly handoff with outpatient providers. During weekly medication reconciliation rounds, the team pharmacist reviews each patient's current medications with the team. In care coordination rounds, the team collaborates with unit care managers to identify discharge needs and complete discharge tasks. Finally, at the end of the week, the outgoing hospital medicine attending physician hands off patient care to the incoming attending with input from the team's pharmacist, dietician, and social worker. Families and providers noted improvements in care coordination with the new care model. Remaining challenges include balancing resident autonomy and attending supervision, as well as supporting providers in delivering care that can be emotionally challenging. Aspects of this care model could be tested and adapted at other hospitals that care for children with medical complexity. Additionally, future work should study the impact of inpatient complex care models on patient health outcomes and experience.

Hospital Utilization Among Children With the Highest Annual Inpatient Cost.

BACKGROUND AND OBJECTIVES: Children who experience high health care costs are increasingly enrolled in clinical initiatives to improve their health and contain costs. Hospitalization is a significant cost driver. We describe hospitalization trends for children with highest annual inpatient cost (CHIC) and identify characteristics associated with persistently high inpatient costs in subsequent years. METHODS: Retrospective study of 265 869 children age 2 to 15 years with ≥1 admission in 2010 to 39 children's hospitals in the Pediatric Health Information System. CHIC were defined as the top 10% of total inpatient costs in 2010 (n = 26 574). Multivariate regression and regression tree modeling were used to distinguish individual characteristics and interactions of characteristics, respectively, associated with persistently high inpatient costs (≥80th percentile in 2011 and/or 2012). RESULTS: The top 10% most expensive children (CHIC) constituted 56.9% ($2.4 billion) of total inpatient costs in 2010. Fifty-eight percent (n = 15 391) of CHIC had no inpatient costs in 2011 to 2012, and 27.0% (n = 7180) experienced persistently high inpatient cost. Respiratory chronic conditions (odds ratio [OR] = 3.0; 95% confidence interval [CI], 2.5-3.5), absence of surgery in 2010 (OR = 2.0; 95% CI, 1.8-2.1), and technological assistance (OR = 1.6; 95% CI, 1.5-1.7) were associated with persistently high inpatient cost. In regression tree modeling, the greatest likelihood of persistence (65.3%) was observed in CHIC with ≥3 hospitalizations in 2010 and a chronic respiratory condition. CONCLUSIONS: Most children with high children's hospital inpatient costs in 1 year do not experience hospitalization in subsequent years. Interactions of hospital use and clinical characteristics may be helpful to determine which children will continue to experience high inpatient costs over time.

Financial and psychological stressors associated with caring for children with disability.

The magnitude of stress and associated health consequences experienced by caregivers compromises their ability to effectively provide care to children, especially children with disability. We used latent class analysis of data from the 2010 Ohio Family Health Survey and identified 3 distinct classes of caregivers based on patterns of responses to 15 financial and psychological stresses they experienced. Compared with children residing in households in which caregivers experienced very little or no stress, children with disability were twice as likely to reside with caregivers with high levels of financial stress and almost 3.5 times as likely to reside with caregivers with high levels of financial stress and very high levels of psychological stress than typically developing children. Reducing caregiver stress is a critical step to ensuring the best health outcomes possible for children with disability. We identify the heterogeneity that is present in the population of caregivers by virtue of patterns of responses to various financial and psychological stressors. Children with disability are more likely to live in households in which a greater number of stressors affect caregivers. Different confounders are also associated with the latent classes of stress we identify. This is an important implication when determining the right interventions to target to the right subpopulations.

Inpatient growth and resource use in 28 children's hospitals: a longitudinal, multi-institutional study.

OBJECTIVE: To compare inpatient resource use trends for healthy children and children with chronic health conditions of varying degrees of medical complexity. DESIGN: Retrospective cohort analysis. SETTING: Twenty-eight US children's hospitals. PATIENTS: A total of 1 526 051 unique patients hospitalized from January 1, 2004, through December 31, 2009, who were assigned to 1 of 5 chronic condition groups using 3M's Clinical Risk Group software. INTERVENTION: None. MAIN OUTCOME MEASURES: Trends in the number of patients, hospitalizations, hospital days, and charges analyzed with linear regression. RESULTS: Between 2004 and 2009, hospitals experienced a greater increase in the number of children hospitalized with vs without a chronic condition (19.2% vs 13.7% cumulative increase, P < .001). The greatest cumulative increase (32.5%) was attributable to children with a significant chronic condition affecting 2 or more body systems, who accounted for 19.2% (n = 63 203) of patients, 27.2% (n = 111 685) of hospital discharges, 48.9% (n = 1.1 million) of hospital days, and 53.2% ($9.2 billion) of hospital charges in 2009. These children had a higher percentage of Medicaid use (56.5% vs 49.7%; P < .001) compared with children without a chronic condition. Cerebral palsy (9179 [14.6%]) and asthma (13 708 [21.8%]) were the most common primary diagnosis and comorbidity, respectively, observed among these patients. CONCLUSIONS: Patients with a chronic condition increasingly used more resources in a group of children's hospitals than patients without a chronic condition. The greatest growth was observed in hospitalized children with chronic conditions affecting 2 or more body systems. Children's hospitals must ensure that their inpatient care systems and payment structures are equipped to meet the protean needs of this important population of children.

Hospital utilization and characteristics of patients experiencing recurrent readmissions within children's hospitals.

CONTEXT: Early hospital readmission is emerging as an indicator of care quality. Some children with chronic illnesses may be readmitted on a recurrent basis, but there are limited data describing their rehospitalization patterns and impact. OBJECTIVES: To describe the inpatient resource utilization, clinical characteristics, and admission reasons of patients recurrently readmitted to children's hospitals. DESIGN, SETTING, AND PATIENTS: Retrospective cohort analysis of 317,643 patients (n = 579,504 admissions) admitted to 37 US children's hospitals in 2003 with follow-up through 2008. MAIN OUTCOME MEASURE: Maximum number of readmissions experienced by each child within any 365-day interval during the 5-year follow-up period. RESULTS: In the sample, 69,294 patients (21.8%) experienced at least 1 readmission within 365 days of a prior admission. Within a 365-day interval, 9237 patients (2.9%) experienced 4 or more readmissions; time between admissions was a median 37 days (interquartile range [IQR], 21-63). These patients accounted for 18.8% (109,155 admissions) of all admissions and 23.2% ($3.4 billion) of total inpatient charges for the study cohort during the entire follow-up period. Tests for trend indicated that as the number of readmissions increased from 0 to 4 or more, the prevalences increased for a complex chronic condition (from 22.3% [n = 55,382/248,349] to 89.0% [n = 8225/9237]; P < .001), technology assistance (from 5.3% [n = 13,163] to 52.6% [n = 4859]; P < .001), public insurance use (from 40.9% [n = 101,575] to 56.3% [n = 5202]; P < .001), and non-Hispanic black race (from 21.8% [n = 54,140] to 34.4% [n = 3181]; P < .001); and the prevalence decreased for readmissions associated with an ambulatory care-sensitive condition (from 23.1% [62,847/272,065] to 14.0% [15,282/109,155], P < .001). Of patients readmitted 4 or more times in a 365-day interval, 2633 (28.5%) were rehospitalized for a problem in the same organ system across all admissions during the interval. CONCLUSIONS: Among a group of pediatric hospitals, 18.8% of admissions and 23.2% of inpatient charges were accounted for by the 2.9% of patients with frequent recurrent admissions. Many of these patients were rehospitalized recurrently for a problem in the same organ system.

Public perception of climate change voluntary mitigation and barriers to behavior change.

Mitigating global climate change requires not only government action but also cooperation from consumers. Population-based, cross-sectional surveys were conducted among 1202 respondents in Portland OR and Houston TX between June and September 2007 regarding awareness, concern, and behavior change related to climate change. The data were subjected to both quantitative and qualitative analyses. Awareness about climate change is virtually universal (98% in Portland and 92% in Houston) with the vast majority reporting some level of concern (90% in Portland and 82% in Houston). A multivariate analysis revealed significant predictors of behavior change: individuals with heightened concern about climate change (p<0.001); respondents with higher level of education (p= 0.03); younger compared with older individuals (p<0.001); and Portlanders more likely to change behavior compared with Houstonians (p<0.001). Of those who changed behavior, 43% reported having reduced their energy usage at home, 39% had reduced gasoline consumption, and 26% engaged in other behaviors, largely recycling. Qualitative data indicate a number of cognitive, behavioral, and structural obstacles to voluntary mitigation. Although consumers are interested in global climate change-mitigation strategies and willing to act accordingly, considerable impediments remain. Government policy must eliminate economic, structural, and social barriers to change and advance accessible and economical alternatives. Individual-level mitigation can be a policy option under favorable contextual conditions, as these results indicate, but must be accompanied by mitigation efforts from industry, commerce, and government.