Showing posts with label child health advocacy. Show all posts
Showing posts with label child health advocacy. Show all posts

Wednesday, October 14, 2015

A Costly, Complex Year: Examining Healthcare Cost And End of Life Care

By: Joann Schulte  DO, MPH; Editorial Board Member 

      Almost two-thirds of bankruptcy filings have a medical cause and 14.6% of those interviewed for bankruptcy in 2007 had anill child1with a complex medical condition. An estimated 2.8 to 3.3 million individuals with vast medical bills file for bankruptcy each year2.  If the percentage of filers with children has remained constant, it means between 408,800 and 481,800 people seeking bankruptcy protection each year have children with complex illnesses severe enough to prompt the filings.
      Work published this early relased recently in Pediatrics from  (doi: 10.1542/peds.2015-0260) will help provide needed information for children’s medical care and costs in the last year of life.  A group of researchers from Boston and Philadelphia used data from the forty-one free-standing children’s hospitals to describe illness and costs for such children.  The hospitals submitted data to the Pediatric Health Information System database, an administrative database that contains inpatient utilization and cost data. Children are assigned a unique identifier to track them across multiple admissions. The researchers used the data to characterize the admissions and costs incurred among a cohort of 1,252 children who were admitted and died in calendar year 2012.  Infants less than a year of age were excluded to ensure a complete one-year review.
      Those children had complex medical conditions in nine organ systems:  cardiovascular, congenital/genetic, gastrointestinal, hematologic/immunologic, malignancy, metabolic, neuromuscular, renal and respiratory. The authors converted charges to costs, using an existing ratio for each hospital and they adjusted for inflation by using the Consumer Price Index.
The authors found that the children in their last year of life had medians of two admissions, twenty-seven hospital days and $142,562 in hospital costs. Total hospital costs were $392 million, of which 58% occurred in the final admission for these children to the hospital($228 million).
      In a multivariate analysis, children diagnosed with hematological/immunologic conditions have the greatest impact on hospital resource use.  Compared to children with other complex conditions, children with hematologic/immunologic conditions spend 45 more days in the hospital and accumulated $326,844 more in hospital costs.  The vast majority of children (987, 79%) spent time in the intensive care unit and most were mechanically ventilated (946, 76 %) during their last admissions.
      These 1,252 children had an unhappy outcome, but information about their hospitalizations is an important step in painting a detailed picture about terminal pediatric illnesses.  Having such information may help economists and pediatric providers both provide needed care and figure out how to do so without bankrupting families.  


1. Himmelstein DU, Thorne D, Warren E, Woolhandler S.  Medical bankruptcy in the United States, 2007:  Results of a national study.  American Journal of Medicine  2009; 122 (8):741-746.

2. Himmelstein DU, Warren E, Thorne D, Woolhandler S.  Market Watch: Illness and injury as contributors to bankruptcy.  http://content.healthaffairs

Wednesday, August 5, 2015

Where the Streets Have No Names: Suicide In Teens Living on the Streets of Vancouver

By: Joann Schulte  DO, MPH; Editorial Board Member  
     She called herself Homey Girl in the emergency room  I work at when she came in after taking a beta blocker that wasn't hers in a suicide attempt. She said she was celebrating her 16th birthday with a final exit. She was skinny, wore dirty clothes and flashed the hard-edge stare of somebody used to the street for too long. Her given name was Alice, but I thought her street name summed up what she lacked and what she wanted.
      Homey Girl's suicide attempt is hardly an isolated case. Suicide is the cause of death in 20% of youth aged 15-24 years in the US and the numbers are even higher among adolescents and young adults living on the street. Similar figures have been published for Canada.  A new study published this month in Pediatrics assesses the link between attempted suicide and earlier abuse. Researchers from British Columbia and Boston examined the risk of attempted suicide and its association between self-reported sexual, physical, and emotional abuse and physical and emotional neglect.
      Hadland et al.  (10.1542/peds.2015-1108) enrolled a prospective cohort of street youth in Vancouver aged 14 to 26 years who had abused illicit drugs other than marijuana in the past how many months.. They assessed suicide attemtps among the 660 participants every six months.
      The participants were predominantly male (68.2%) with a median age of 21.5 years. Suicide attemtps were reported by 5.3% of the participants. In adjusted analyses using Cox proportional hazards regression, suicide attempts were associated with physical abuse, emotional abuse and emotional neglect.
      Other studies assessing attempted suicide and childhood maltreatment have focused on adult drug users in clinic settings. This study is a longitudinal assessment tracking individuals over time, a more difficult task than the cross-sectional studies. The authors suggest that the elevated risk of suicide among street youth will require prevention efforts that take the earlier abuse into account.
      This study certainly suggests that  additional work is needed to better assess the exact sequence of events in suicide attempts and the factors that might be protective in preventing suicide.  Adolescents and young adults such as Homey Girl could benefit from such work. Sadly she  reappeared in the emergency room a couple of weeks ago with another attempt.  This time it was aspirin, and she survived.  But I expect I’ll see her again under similar unhappy circumstances.

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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.

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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