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Journal Article

Efficiency and Cost of a Hospital-Based Medical Home: Children with Special Healthcare Needs

01 Jan 2009-Florida public health review (University of South Florida College of Public Health (USF COPH))-Vol. 6, Iss: 1, pp 85-92

TL;DR: Each of the cost-effectiveness measures were found to be significantly lower post enrollment in the Hospital-Based Medical Home Model.

AbstractThe current study examined two years of pre-post hospital utilization data (the number of emergency room visits, number of unanticipated hospitalizations, and length of stay (LOS)) among forty-nine medically complex children to determine the efficiency and cost effectiveness of a comprehensive Hospital-Based Medical Home Model. Friedman nonparametric analysis was used to examine the pre-post differences for the non-normal distribution. Each of the cost-effectiveness measures (number of emergency room visits, number of unanticipated hospitalizations, and LOS) were found to be significantly lower post enrollment in the Hospital-Based Medical Home Model. Florida Public Health Review, 2009; 6, 85-92. Int tro od

Topics: Cost effectiveness (56%), Medical home (52%)

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Journal ArticleDOI
TL;DR: Although positive, the evidence supporting comprehensive hospital-based programs for children with special health care needs is restricted primarily to nonexperimental studies of children with categorical diseases and is limited by inadequate outcome measures.
Abstract: Objective To examine the effectiveness of hospital-based comprehensive care programs in improving the quality of care for children with special health care needs. Data Sources A systematic review was conducted using Ovid MEDLINE, CINAHL, EMBASE, PsycINFO, Sociological Abstracts SocioFile, and Web of Science. Study Selection Evaluations of comprehensive care programs for categorical (those with single disease) and noncategorical groups of children with special health care needs were included. Selected articles were reviewed independently by 2 raters. Data Extraction Models of care focused on comprehensive care based at least partially in a hospital setting. The main outcome measures were the proportions of studies demonstrating improvement in the Institute of Medicine's quality-of-care domains (effectiveness of care, efficiency of care, patient or family centeredness, patient safety, timeliness of care, and equity of care). Data Synthesis Thirty-three unique programs were included, 13 (39%) of which were randomized controlled trials. Improved outcomes most commonly reported were efficiency of care (64% [49 of 76 outcomes]), effectiveness of care (60% [57 of 95 outcomes]), and patient or family centeredness (53% [10 of 19 outcomes). Outcomes less commonly evaluated were patient safety (9% [3 of 33 programs]), timeliness of care (6% [2 of 33 programs]), and equity of care (0%). Randomized controlled trials occurred more frequently in studies evaluating categorical vs noncategorical disease populations (11 of 17 [65%] vs 2 of 16 [17%], P = .008). Conclusions Although positive, the evidence supporting comprehensive hospital-based programs for children with special health care needs is restricted primarily to nonexperimental studies of children with categorical diseases and is limited by inadequate outcome measures. Additional high-quality evidence with appropriate comparative groups and broad outcomes is necessary to justify continued development and growth of programs for broad groups of children with special health care needs.

64 citations


Journal ArticleDOI
TL;DR: The findings indicate that hospital-at-home for children is a good solution if the parents are well prepared and feel in control, and Norwegian policymakers should initiate more pilot testing of hospital- at- home for children.
Abstract: In recent decades, there has been a shift from hospitalisation to home care throughout the Western world, even for children. Hospital-at-home for children is in a developmental phase and represents a new service model in Norway. The aim of this pilot study conducted in a Norwegian healthcare setting was to explore how parents with a sick child experienced early hospital discharge and further care at home. The qualitative data are drawn from nine interviews with parents with a child admitted to hospital-at-home. Transcripts of interviews were analysed using a method of qualitative content analysis. In the analysis, Antonovsky's salutogenic perspective on how people cope in demanding life situations was applied. The results show that the parents experienced hospital-at-home as providing a calmer, more predictable family life compared to hospitalisation. They argued that good information and training in medical procedures prior to hospital discharge made hospital-at-home easier to master. The participants pointed out the importance of the professionals' competence and their ability to interact with the child and the parent. The certitude that they could return to the hospital at any time made them feel safe and in control. The parents associated hospital-at-home with a kind of normalisation of their family life. They had a prominent need for normalisation, and this was probably a motivation for agreeing to the hospital-at-home arrangement. The findings indicate that hospital-at-home for children is a good solution if the parents are well prepared and feel in control. In addition, certain structural conditions must be in place before this type of health care is established; there must be a certain volume of patients and the distance to the hospital must be clearly limited. Norwegian policymakers should initiate more pilot testing of hospital-at-home for children. Users and clinicians should be involved in establishing and evaluating these services.

4 citations


References
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Journal ArticleDOI
Abstract: Background. Children with complex chronic conditions (CCCs) might benefit from pediatric supportive care services, such as home nursing, palliative care, or hospice, especially those children whose conditions are severe enough to cause death. We do not know, however, the extent of this population or how it is changing over time. Objectives. To identify trends over the past 2 decades in the pattern of deaths attributable to pediatric CCCs, examining counts and rates of CCC-attributed deaths by cause and age (infancy: <1 year old, childhood: 1–9 years old, adolescence or young adulthood: 10–24 years old) at the time of death, and to determine the average number of children living within the last 6 months of their lives. Design/Methods. We conducted a retrospective cohort study using national death certificate data and census estimates from the National Center for Health Statistics. Participants included all people 0 to 24 years old in the United States from 1979 to 1997. CCCs comprised a broad array of International Classification of Diseases, Ninth Revision codes for cardiac, malignancy, neuromuscular, respiratory, renal, gastrointestinal, immunodeficiency, metabolic, genetic, and other congenital anomalies. Trends of counts and rates were tested using negative binomial regression. Results. Of the 1.75 million deaths that occurred in 0- to 24-year-olds from 1979 to 1997, 5% were attributed to cancer CCCs, 16% to noncancer CCCs, 43% to injuries, and 37% to all other causes of death. Overall, both counts and rates of CCC-attributed deaths have trended downward, with declines more pronounced and statistically significant for noncancer CCCs among infants and children, and for cancer CCCs among children, adolescents, and young adults. In 1997, deaths attributed to all CCCs accounted for 7242 infant deaths, 2835 childhood deaths, and 5109 adolescent deaths. Again, in 1997, the average numbers of children alive who would die because of a CCC within the ensuing 6-month period were 1097 infants, 1414 children, and 2548 adolescents or young adults. Conclusions. Population-based planning of pediatric supportive care services should use measures that best inform our need to provide care for time-limited events (perideath or bereavement care) versus care for ongoing needs (home nursing or hospice). Pediatric supportive care services will need to serve patients with a broad range of CCCs from infancy into adulthood.

499 citations


"Efficiency and Cost of a Hospital-B..." refers background in this paper

  • ...Similarly, survival prospects for children with what were once incurable malignancies or fatal genetic conditions have also increased dramatically (Feudtner et al., 2001)....

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Journal ArticleDOI
TL;DR: Families with CSHCN experience much higher expenditures, including out-of-pocket expenditures, than other children, and were best protected against inpatient hospital care expenses and most exposed to dental care expenses.
Abstract: Objectives: To provide the first nationally representative data on total health care expenses, out-of-pocket health care expenses, and information on the extent to which out-of-pocket expenses are financially burdensomeforfamiliesofchildrenwithspecialhealthcareneeds (CSHCN). To also compare utilization and expenditure patternsforchildrenwithandwithoutspecialhealthcare needs. Design: We used data from the 2000 Medical Expenditure Panel Survey (MEPS). We present univariate, bivariate, and multivariate statistics on utilization and expenditures adjusted for the complex sample design. Participants: The 2000 MEPS data set contains 6965 children younger than 18 years. Using the CSHCN definition adopted by the federal Maternal and Child Health Bureau and operationalized using the CSHCN Screener, 949children(15.6%)wereidentifiedaschildrenwithspecial health care needs. Main Outcome Measures: Compared with other children, CSHCN had 3 times higher health care expenditures ($2099 vs $628;P.01). The 15.6% of CSHCN accounted for 42.1% of total medical care costs (excluding dental costs) and 33.6% of total health care costs (includingdentalcosts)attributedtochildrenin2000.FamiliesofCSHCNwerebestprotectedagainstinpatienthospital care expenses and most exposed to dental care expenses. Families of CSHCN experiencing high out-ofpocket expenses (exceeding 5% of family income) were approximately 11 times more likely to be from households with incomes below 200% of the federal poverty level (odds ratio, 10.9; 95% confidence interval, 3.5533.76) than to be from families with incomes at or above 400% of the federal poverty level. Conclusions: Families with CSHCN experience much higher expenditures, including out-of-pocket expenditures, than other children. Insurance plays an importantprotectiveroleforfamiliesofCSHCN,butitstillprovides incomplete protection. Health policy changes that would extend the breadth and depth of insurance coverage are needed to ensure that all families of CSHCN are protected against burdensome expenses. Arch Pediatr Adolesc Med. 2005;159:10-17

436 citations


"Efficiency and Cost of a Hospital-B..." refers background in this paper

  • ...In general, costs of healthcare for children with multiple healthcare needs are approximately three times higher than for other children because of the higher need for and use of services (Newacheck & Kim, 2005)....

    [...]


Journal ArticleDOI
TL;DR: Lower continuity of primary care is associated with higher risk of ED utilization and hospitalization and efforts to improve and maintain continuity may be warranted.
Abstract: Context. The benefits of continuity of pediatric care remain controversial. Objective. To determine whether there is an association between having a continuous relationship with a primary care pediatric provider and decreased risk of emergency department (ED) visitation and hospitalization. Design. Retrospective cohort study. Setting and Population. We used claims data from 46 097 pediatric patients enrolled at Group Health Cooperative, a large staff-model health maintenance organization, between January 1, 1993, and December 31, 1998, for our analysis. To be eligible, patients had to have been continuously enrolled for at least a 2-year period or since birth and to have made at least 4 visits to one of the Group Health Cooperative clinics. Main Exposure Variable. A continuity of care (COC) index that quantifies the degree to which a patient has experienced continuous care with a provider. Main Outcome Measures. ED utilization and hospitalization. Results. Compared with children with the highest COC, children with medium continuity were more likely to have visited the ED (hazard ratio [HR]: 1.28 [1.20–1.36]) and more likely to be hospitalized (HR: 1.22 [1.09–1.38]). Children with the lowest COC were even more likely to have visited the ED (HR: 1.58 [1.49–1.66]) and to be hospitalized (HR: 1.54 [1.33–1.75]). These risks were even greater for children on Medicaid and those with asthma. Conclusions. Lower continuity of primary care is associated with higher risk of ED utilization and hospitalization. Efforts to improve and maintain continuity may be warranted.

424 citations


Journal ArticleDOI
TL;DR: A current national profile of the prevalence and impact of chronic conditions causing childhood disability is provided, which has profound impacts on children, the education system, and the health care system.
Abstract: OBJECTIVES: This study provides a current national profile of the prevalence and impact of chronic conditions causing childhood disability. Disability is defined as a long-term reduction in ability to conduct social role activities, such as school or play, because of a chronic physical or mental condition. METHODS: A cross-sectional descriptive analysis was performed on data from 99513 children younger than 18 years who were included in the 1992-1994 National Health Interview Survey. The response rate exceeded 93% during each year. RESULTS: A significant proportion of children, estimated at 6.5% of all US children, experienced some degree of disability. The most common causes of childhood disability were respiratory diseases and mental impairments. Prevalence of disability was higher for older children, boys, and children from low-income and single-parent families. Childhood disability is estimated to result in 66 million restricted activity days annually, including 24 million days lost from school. Furth...

381 citations


"Efficiency and Cost of a Hospital-B..." refers background in this paper

  • ...Children with special healthcare needs form a relatively small, but growing group, of approximately 15%–18% of all children (Newacheck & Halfon, 1998; Newacheck et al., 1998)....

    [...]


Journal ArticleDOI
TL;DR: The interactive seminar based on theories of self-regulation led to patient-physician encounters that were of shorter duration, had significant impact on the prescribing and communications behavior of physicians, led to more favorable patient responses to physicians' actions, and led to reductions in health care utilization.
Abstract: Objectives. This study was conducted to assess the impact of an interactive seminar based on self-regulation theory on 1) the treatment practices and communications and education behavior of physicians, 2) the health status and medical care utilization of their pediatric patients with asthma, and 3) the satisfaction with care of the subjects9 parents. Methods. A total of 74 general practice pediatricians were assigned to either a program or a control group in a randomized controlled study. Data were collected from physicians at baseline, and 69 (93%) provided follow-up data 5 months after the program. Data were also collected from 637 of their patients at baseline, and in a 22-month window after the intervention, 472 (74%) of this number provided follow-up data. Results. After the seminar, physicians in the program group were more likely than were control group physicians to address patients9 fears about medicines, review written instructions, provide a sequence of educational messages, write down how to adjust the medicines at home when symptoms change, and report that they spent less time with their patients. Parents of the children treated by program physicians were significantly more likely than were control group parents to report that the physician had been reassuring, described as a goal that the child be fully active, and gave information to relieve specific worries. After a visit with the physician, these parents were also more likely to report that they knew how to make management decisions at home. After the intervention compared to controls, patients of physicians in the program group were more likely to have received a prescription for inhaled antiinflammatory medicine and to have been asked by the physician to demonstrate how to use a metered-dose inhaler. After the intervention, children seen by program physicians made significantly fewer nonemergency office visits and visits for follow-up of an episode of symptoms; however, there were no differences in emergency department visits and hospitalizations. Among children who were placed on inhaled corticosteroids during this study, however, children treated by physicians who had received education had significantly fewer symptoms and fewer follow-up office visits, nonemergency physician office visits, emergency department visits, and hospitalizations. Conclusions. The interactive seminar based on theories of self-regulation led to patient–physician encounters that were of shorter duration, had significant impact on the prescribing and communications behavior of physicians, led to more favorable patient responses to physicians9 actions, and led to reductions in health care utilization.

340 citations