Showing posts with label hospital. Show all posts
Showing posts with label hospital. Show all posts

Friday, October 9, 2015

Hospital Variation on Care Utilization by Children with Medical Complexity: Does It Happen and What Do We Do about It?

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

          Thanks to the information we can get from payer claim databases, we can learn a lot about variations in care delivery regarding different patient populations. One of those populations is the group of children with medical complexity who receive care daily at our children’s hospitals.  So how consistent is the care delivery across hospitals? Ralston et al. (doi: 10.1542/peds.2014-3920), in an article being released this month in our journal, performed a retrospective population-based observational cohort study that examined payer claims of all children from 1 month to 18 years with medical complexity in Maine, New Hampshire and Vermont.  Sadly there is more variation in care across the 6 hospitals studied in these states than one might suspect.  Where are these variations occurring?  Virtually everywhere--inpatient, outpatient, in intensive care units, and in the emergency department.  Even use of ancillary tests like radiology showed substantive variation.
So what does a study like this suggest?  Drs. Thomson and Shah offer a commentary on variability in health care utilization that accompanies this study and suggest how we can learn from the results being shared in this and other care variation studies that our journal and many others seem to publishing on a frequent basis.  We encourage you to read both the study and commentary and gain a better understanding of how this data might identify best practices for these patients that can then be shared and standardized across hospitals and across states. \
 If your state has an all-payer claims database, you might want to explore what that database is saying about your utilization rates and compare them to the data in this study. If the focus of care nowadays is on managing populations with high quality and lower cost, it is studies like this one that can set the stage to make that happen. 

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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, Single day charges for the NICU range around $3,000, not including costs related to specific surgical procedures or imaging (   
      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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Wednesday, January 14, 2015

Treating Jaundice in the NICU and Lowering Cases of Readmission

By: Beth Tarini, Editorial Board Member

 Courtesy of Jim Champion
Jaundice continues to vex those who care for newborns.  The majority of babies are jaundiced to some degree.but must don't need treatment. The challenge is to identify those that need treatment without over treating the healthy or overlooking those that need treatment.

In years past, conversations about jaundiced newborns focused on our vigintiphobia – our fear that a bilirubin level of 20 mg/dL would lead to kernicterus unless treated with exchange transfusion.  Now our conversations focus on the effect of early discharge after birth.  According to the AAP, early discharge is defined as less than 48 hours for vaginal birth and more than 96 hours for Caesarean section. (1)  The conundrum is that the greatest risk for severe jaundice occurs at a time after “early discharge” babies have left the hospital.  This can create a challenge for monitoring babies – especially if they don’t have timely follow-up with a healthcare provider after discharge.

The debate over whether early discharge increases the readmission rate for jaundice among newborns is ongoing.  To this debate, Dr. Lain et al. (doi:10.1542/peds.2014-2388) add data based on the first population-based study of the issue.  The study, conducted in Australia from 2001-2010, examined the readmission rate for over 780,000 newborns, looking specifically at how factors such as gestational age might influence the readmission rate.  The authors found that 0.8% of all the infants studied were readmitted for jaundice.   However, those at highest risk for readmission were infants born early term (37 & 38 weeks gestation) and discharged less than 48 hours [aOR 9.43 (95% CI: 8.34-10.67) and 4.05 (95% CI: 3.62-4.54) respectively]. 

What is the reason for these findings?  One theory is that early discharge causes jaundice among this subset of newborns.  However, since this is a cohort study, these findings are associative and should not be viewed as causal.  It is also possible that early term infants are followed more closely after early discharge, which increases their chance of being identified as having an elevated bilirubin, which leads to a readmission.  In this study, we don’t know the bilirubin level that prompted the readmission.  We are left to assume that the level required treatment.

What can we do with these data?  Well, the authors themselves admit that prolonging the hospital stay is unlikely to be an economical viable solution.  It would mean that we would have to keep over 80 infants in the hospital longer just to prevent one admission.  Also noted is that unlike the U.S., Australia does not have universal bilirubin screening guidelines prior to discharge.  It would be interesting to see if these findings persist in those countries that have universal bilirubin screening.  Of course, as we already know, universal screening has been associated with increased use of phototherapy and increased readmission rates, likely due, in part, to over treatment (2).

So, in some ways, the more the conversation about jaundice has changed, the more it has stayed the same.  While we are not talking about vigintiphobia, we are still talking about fear - fear of kernicterus in the shadow of early hospital discharge.

1:American Academy of Pediatrics.Committee on Fetus and Newborn.Hospital stay for
healthy term newborns. Pediatrics.2010 Feb;125(2):405-9. doi:10.1542/peds.2009-3119.

2:Kuzniewicz MW, Escobar GJ, Newman TB. Impact of universal bilirubin screening on severe hyperbilirubinemia. Pediatrics. 2009 Oct;124(4):1031-9. Oct;124(4):1031-9. 

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Friday, December 19, 2014

Preventing Hazardous Drug-Drug Interactions in Children

Photo Courtesy of Kathea Pinto
Editorial Board Member Joann Schulte, DO, MPH

Drug-Drug interactions remind me of Haiti.  Specifically I think of the bokor (folk medicine healer vs. witch doctor) who used to sit under the flambeau trees at an outdoor market at Deschappelles, near the compound of Albert Schweitzer Hospital. He would set out a lazy susan swirl tray of capsules and tablets arranged by color. Patients would spin it like like a Vegas roulette wheel, picking a pink one and a turquoise one or some other mixture for malaria or hypertension. The hospital staff was persistent in telling patients that you couldn't take medicine that way. But the bokor always had supplies and customers, some of whom ended up admitted to the hospital.

I think about that roulette twirl these days as I’m learning more about Drug-Drug interactions in the US in a medical toxicology fellowship at the North Texas Poison Control Center in Dallas Parkland Hospital. Bad pharmaceutical consumption out of home medicine cabinets is a common history I hear. Every week or so I see patients who jiggered up their personal suicide attempts with a combination of benzodiazepines, street drugs, opioids and alcohol. Other patients are toddlers who went candy hunting in grandmother’s purse. 

Another category of drug interactions –unintended and often undetected– occurs in US hospitals. Those Drug-Drug interactions are the focus of a study published in Pediatrics this month.

Dr. Feinstein et al. (doi: 10.1542/peds.20142015) investigated potential Drug-Drug interactions (PDDI) among almost half a million hospitalizations in 2011 in forty-three pediatric hospitals.   They classified PDDI as contraindicated (shouldn’t be used together), major (life-threatening or medical intervention needed), moderate (may change the patient’s condition or require medical intervention) and minor (limited clinical effect).  They used an administrative database to calculate the potential interactions in a retrospective cohort study.

The researchers from Colorado and Philadelphia founded that 49% of the admitted children (approximately 245,000) had one or more PDDI. A contradicted PDDI occurred in 1% of admissions.  Opioids were were involved in 25% of of all PDDI, followed by anti-infective agents (17%), neurologic agents (15%), neurological agents (15%), gastrointestinal agents (13%) and cardiovascular agents (13%).

The likelihood of PDDI exposures increased with length of hospital stay. Among infants, 21.8% were exposed to a PDDI on the first day.

The authors have done a study showing potential PDDI, not actual data and have done it using an administrative database. But their work is important because it suggests how frequent Drug-Drug interactions might be. The numbers of reported adverse drug events are much lower. In 2003, 10% of pediatric hospitalizations were reported to have included an adverse drug effect.  

In short, the work done by the Colorado and Philadelphia researchers suggests that actual prevalence of Drug-Drug interactions might be under reported. More work is needed to verify how often such Drug-Drug interactions happen. There’s a big gap between the potential 49% reported here and the actual reported 10%.