Tuesday, July 28, 2015

Home Is Where The Heart Is: New Ways of Thinking About Discharge Planning


By: Lydia Furman, MD,  Assistant Editor 
 
      Discharging preterm infants is an arduous duty.  Both residents and supervising neonatologists are familiar with the many pitfalls that hold up the show. Coordination of care, services and appointments, and needed equipment, are massive tasks. And there is often enough angst about readiness- i.e. “will this baby ‘fly’ and “will the parents be able to meet the baby’s needs” – to put off the discharge date several days for non-medical reasons.  All that is in addition to the strong desire of parents to finally “escape” home with their baby.  Any prolongation of the hospital stay is very expensive.
Dr. Temple et al. (doi: 10.1542/peds.2015-0456) have written a highly pragmatic article that gives providers a new “crystal ball” algorithm with which to plan discharges.  Using daily progress note information, their work teaches us how to predict discharge within a 2-10 day period, giving providers and staff the information and a level of certitude with which to plan.  They emphasize that their study is not about predicting length of stay at admission, but it’s about using “real time” data to predict future discharge during the hospital stay.
      What parameters are most useful? It’s an interesting exercise to try to predict or guess ahead what information will be most useful. Will it be lab values, growth parameters, feeding information, cessation of “A’s and B’s” (apneas and bradycardias), vital signs, original birthweight or gestational age, number of medications, or some golden combination of these?
      The authors evaluated a total of 4,693 patients and 103,206 patient-days, and examined four subpopulations, including premature infants, babies with cardiac disease, babies with gastrointestinal surgery, and those with neurosurgical conditions. They used progress notes to identify qualitative and quantitative parameters, and two types of “derived” or calculated data. The retrospective data they used is clinical and intuitive, and highly available, and will likely appeal to neonatologists and trainees. Ultimately with the use of just two features (no spoiler here- please read to find out!), days to discharge of 4 days can be predicted with surprising accuracy for three of the four subpopulations (neurosurgical patients were a challenge for the algorithm). This excellent work needs prospective confirmation, but the results are highly encouraging.
       Clearly the most important thing is getting babies and parents home in a way that is comfortable and safe, but there is a huge carrot at the end for making this transition as timely as possible. A brief peek at some crude financial data suggests that the work of Temple and colleagues has the potential to create enormous societal savings. The average cost of a preterm birth in the US is $32,325, and for infants born at less than 28 weeks, the average cost of the hospital stay was $280,811 (March of Dimes Peristats, https://www.marchofdimes.org/peristats). Single day charges for the NICU range around $3,000, not including costs related to specific surgical procedures or imaging (http://www.managedcaremag.com/archives/1001/1001.preterm.html).   
      Thus any comprehensive incremental decreases in length of NICU hospital stay could have a profound impact on total health care dollars.  Kudos to the authors for their forward thinking work, since ultimately safe healthcare change must be driven and led by knowledgeable physicians, rather than by administrators or insurance companies alone.

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Monday, July 27, 2015

It’s About Time We Had HCAHPS Specifically Designed for Children!

 By: Lewis First, MD, MS; Editor-in-Chief   

          In this era of the Affordable Care Act where quality of care is sought after and rewarded through pay-for performance measures, one of those measures is patient satisfaction as reflected in Adults HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems).  Yet the adult HCAHPS system does not reliably capture what parents of hospitalized children (and older children who can respond to the survey) want to optimally experience in the quality of their care. 
      Fortunately Toomey et al. (doi: 10.1542/peds.2015-0966) reveal in a special article being released this week, the work she and her team did to develop “Child HCAHPS” and make it a highly reliable tool to determine patient engagement and satisfaction.  The authors first looked at the existing literature on pediatric quality measures, then developed their tool using interviews with experts, focus groups, pilot testing of the survey tool, leading to a national field test of 69 hospitals in 34 states—all of which is well described in this important article.   
     Child HCAHPS will hopefully be adopted in the months ahead by all children’s hospitals, and we look forward to its use, allowing even better benchmarking between and within hospitals so as to improve the quality of the care we deliver to our pediatric inpatients.  Are you using this tool?   
     Was your hospital in the national field test?  We welcome any first-hand knowledge of this survey tool by sharing your thoughts via a response to this blog, sending us an e-letter, or posting your comments on our Facebook or Twitter sites.

Friday, July 24, 2015

Antibiotic Usage and Juvenile Idiopathic Arthritis—an Interesting Association

By: Lewis First, MD, MS; Editor-in-Chief   

          We all know that drugs can have unexpected side effects.  This week, Horten et al. (doi: 10.1542/peds.2015-0036) share a possible association between antibiotic exposure and juvenile idiopathic arthritis (JIA).   In a case-control study looking at children with newly diagnosed JIA and a matched set of controls, the authors kept track of the number and timing of antibiotic courses prior to diagnosis adjusting for key confounders.  
     The results are a significant association as you might expect by the fact that we are highlighting this study—but what does it mean and why would taking antibiotics lead to an autoimmune disease like JIA?  The authors offer their take in the Discussion section of the study and so do infectious disease experts Drs. Jennifer Goldman and Mary Anne Jackson in an accompanying commentary (doi: 10.1542/peds.2015-1296).   
     There is a lot to be learned and thought about in this study and commentary.  In turn, be aware of this association and perhaps families who ask for antibiotics for what is likely something viral might be less apt to request them as a result of sharing what you learn with them from this article.

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Wednesday, July 22, 2015

Home Foreclosures as an Indicator of Increased Need for Child Protective Services Involvement


By: Lewis First, MD, MS; Editor-in-Chief   

          We are always trying to identify possible risk factors stressing parents and others living in a home with one of our patients that might increase the chance that a child might be endangered physically or emotionally by whatever the environmental stressor might be.  Yet how often do we ask about or hear about home foreclosures during health maintenance visits—and if we do, does that raise concerns for you regarding an increased risk for an abusive situation prompting possible involvement by Child Protective Services (CPS)?   
     It probably should—based on a concerning study being released this week by Berger et al. (doi: 10.1542/peds.2014-2832)  who looked at four years’ worth of foreclosure filings and then identified whether or not CPS involvement was involved in the year before, during  or after the filing.  More than 60,000 households were studied over a four period and a significant association is found between foreclosure filing and CPS involvement compared to families who did not foreclose on their homes.  The authors note that filing is only a harbinger for other financial problems in the home contributing to possible abuse and neglect but a good one when it comes to perhaps helping to provide additional services to a family in need before a child suffers.  
      Have you found similar outcomes in patients in your practice who have had to foreclose on their homes? How were you able to help these families or weren’t you?  We would welcome your comments via a response to this blog, an e-letter or by posting on our Facebook and Twitter websites.

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