Understanding caregiver perspectives on challenges and solutions to pediatric asthma care for children with a previous hospital admission: a multi-site qualitative study.

OBJECTIVE: Pediatric hospital admissions for asthma provide an opportunity to trigger a review of the current management with an aim of preventing readmissions. However, caregiver voices on how best to improve care are missing. METHODS: As part of a larger, mixed methods cohort study, we identified caregivers of children aged 3-18 years who had an index hospital admission to a tertiary pediatric, mixed adult and pediatric, or regional hospital in Victoria, Australia, between 1st September 2017 and 31st August 2018 with a discharge diagnosis of "Asthma" or "Wheeze" based on International Classification of Disease-10 coding. We conducted qualitative semi-structured interviews with a purposive sample of 39 caregivers. We used content analysis to identify themes from the data. RESULTS: Caregivers identified both challenges associated with asthma care for children with a previous hospital admission as well as solutions to improve care and potentially reduce readmissions. Key challenges included: unclear pathways for follow up care, inconsistent advice, lack of personalized management, delays in getting a diagnosis, delays in the prescription of a preventer medication, and difficulty accessing primary care during exacerbations. Follow up with an "asthma specialist", early access to a trial of preventer medication, personalized Written Asthma Action Plans and increased access to and quality of community-based asthma support services were identified as key solutions. CONCLUSIONS: Caregivers have identified several potential solutions that could be implemented to improve care and possibly reduce pediatric asthma hospital readmissions. The challenge now is to co-design, embed and evaluate these in healthcare systems.Supplemental data for this article can be accessed at publisher's website.

Trends in rates and inequalities in paediatric admissions for Ambulatory Care Sensitive Conditions in Victoria, Australia (2003 to 2013).

AIM: To examine 10-year trends and inequalities in paediatric admission rates for acute and chronic Ambulatory Care Sensitive Conditions (ACSCs) in Victoria, Australia. METHODS: Secondary data analysis of the Victorian Admitted Episodes Dataset of children aged 0-17 years and 11 months admitted with a principal diagnosis of acute ACSCs: gastroenteritis/dehydration, dental conditions and urinary tract infections (UTIs) or chronic ACSCs: asthma and diabetic ketoacidosis, from 2003 to 2013. Main outcome measure was trends in paediatric hospital admission rates for ACSCs (per 1000 population). RESULTS: Over the 10 years, hospital admission rates remained consistently high for asthma and dental conditions. Children from socioeconomically disadvantaged areas were more likely to be admitted for all acute conditions over time. Dental conditions were the only ACSC associated with increased rates of admissions in regional areas. CONCLUSIONS: Inequalities in paediatric hospital admissions exist for acute conditions and have not changed from 2003 to 2013; disadvantaged Victorian children were more likely to be admitted to hospital at each time point. More equitable access to medical and dental care is needed. Primary care (medical and dental) should be a critical platform to address socio-economic differences and effectively prevent avoidable hospital admissions in children.

Costs and uptake of a community model of paediatric food allergy care versus specialist hospital care: A before-and-after controlled trial.

AIM: To compare the costs of community-based food allergy model of care (intervention cohort, IC) with a tertiary-hospital, specialist allergy clinic model of care (control cohort, CC). METHODS: In this pragmatic controlled trial, children (aged 0-12 years) newly referred to the allergy clinic at Melbourne's Royal Children's Hospital with suspected/known food allergy to three or fewer foods were allocated to see either a community-based paediatrician, trained via online webinars and web-based clinical decision support tools for food allergy diagnosis and management, or a hospital allergist. Per-patient costs to the health-care system and out-of-pocket costs to families seen within 12 months (clinician time, allergy tests and medicare billing) were compared between the two models of care. RESULTS: At 12 months, 54/181 (30%) CC families had been seen in the allergy clinic and 93/115 (81%) of the IC families who chose to see a community paediatrician had been seen. In an intention-to-treat analysis (ITT), health-care system costs per IC patient were higher than the costs per CC patient (mean cost $333 versus $319, respectively; mean difference $14, 95% Confidence Interval (CI) -97 to 118, P = 0.81). Total out-of-pocket costs to family were $129 in the IC compared with $89 in the CC (mean difference $40, 95% CI $4-$77, P = 0.03). CONCLUSIONS: A community-based model of care for simple food allergy showed that costs to the health-care system were similar between the community model and hospital care but did not show reduced out-of-pocket costs to the families 12-months post-enrolment.

Parent perspectives on children and young people's mental health services in Victoria - What's wrong and how to fix it: A multi-site qualitative study.

AIM: The number of children and young people presenting to emergency departments (EDs) with anxiety and depression is increasing. We aimed to determine parent perspectives on: (i) barriers to accessing non-ED mental health services; and (ii) improving access in the paediatric mental health service system. METHODS: Qualitative study with parents of children and young people aged 0-19 years who attended one of four EDs across Victoria between October 2017 and September 2018 and received a primary diagnosis of anxiety or depression. EXCLUSION CRITERIA: child or young person without a parent/guardian, or presented with self-harm or suicide attempt. Eligible participants completed semi-structured phone interviews. Interviews were recorded and transcripts were coded and analysed using content analysis. RESULTS: A total of 72 parents completed interviews. The average child age was 14 years (standard deviation 2.5) and two thirds identified as female (64%). A total of 57% of children and young people presented with a primary diagnosis of anxiety. Parents reported barriers in accessing care including: service shortages and inaccessibility, underresourced schools, lack of clinician mental health expertise, lack of child-clinician rapport, inconsistent care, financial constraints, lack of mental health awareness among parents, and stigma. Parents want expanded and improved access to services, more respite and support services, supportive schools, and improved mental health education for parents. CONCLUSIONS: Parents of children and young people attending the ED for anxiety and depression are generally dissatisfied with services for child mental health. Solutions that enable parents to better care for their child in the community are needed to improve care.

Understanding parent-reported factors that influence children and young people's anxiety and depression presentations to emergency departments: A multi-site study.

OBJECTIVE: Victorian ED data show increased presentations for anxiety and depression in children. We aimed to determine parent-reported factors contributing to these presentations. METHODS: Qualitative study with parents of children and young people aged 0-17 years who attended one of four EDs across Victoria between October 2017 and September 2018 and received a primary diagnosis of anxiety or depression (excluding self-harm or suicide attempt). Eligible parents completed semi-structured phone interviews, which were audio-recorded and transcribed. Transcripts were coded and qualitatively analysed using thematic analysis. RESULTS: Seventy parents completed interviews. The average age of children and young people was 14 years (standard deviation 2.4) and 63% (n = 44) identified as female. Thirty (43%) children received a primary diagnosis of depression, compared to 40 (57%) children who received a primary diagnosis of anxiety. The majority of respondents were mothers (n = 59; 84%). Key themes as to why families presented to EDs included: listening to trusted professionals, desperation, a feeling of no alternative, respecting their child's need to feel safe and to rule out a potentially serious medical condition. CONCLUSIONS: Parents bring their children to the ED for many reasons. Policy makers, managers and clinicians should work with parents to develop alternative approaches that provide families with community-based support, particularly for younger children and after hours, in order to provide an appropriate source of care for children and young people with anxiety and depression.

Trends in paediatric practice in Australia: 2008 and 2013 national audits from the Australian Paediatric Research Network.

AIM: In adult medicine, rates of investigation and prescribing appear to be increasing. Such information is lacking for paediatrics. We audited Australian paediatricians' practices in 2013 to determine changes since 2008 in: (i) conditions seen; (ii) consultation duration; (iii) imaging and pathology ordered; and (iv) prescribing. METHODS: This is a patient-level prospective audit of paediatricians' secondary care practice. Between November and December 2013, members of the Australian Paediatric Research Network were invited to complete standardised forms for 100 consecutive patients or all patients seen over 2 weeks, whichever was completed first. MAIN MEASURES: diagnoses, consultation duration, pathology and/or imaging investigations ordered, rate of medication prescription. ANALYSES: hierarchical linear modelling clustered at the paediatrician level. RESULTS: One hundred and eighty paediatricians (48% of those eligible) contributed 7102 consultations. The proportion of developmental/behavioural conditions rose from 48% (SD 31%) to 60% (SD 30%) in new and 54% (SD 28%) to 66% (SD 28%) in review consultations in 2013 compared with 2008. More paediatricians reported diagnoses of autism spectrum disorder (39-56%, P = 0.002), attention-deficit/hyperactivity disorder (47-55%, P = 0.05) and intellectual disability (18-36%, P = 0.001) in first consultations. Mean consultation duration and pathology/imaging ordering rates were stable. Prescribing rates increased from 39 to 45% of consultations for the top 10 new diagnoses and from 57 to 68% of consultations for the top 10 review diagnoses. CONCLUSIONS: Paediatricians are seeing more children with developmental-behavioural conditions, prescribing more and demonstrating wide variation in their practice. The latter suggests both over- and under-treatment.