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Management and outcomes of pneumonia among children with complex chronic conditions.

ABSTRACT: Although pneumonia is a common reason for pediatric hospitalization among children with complex chronic conditions (CCC), treatment and outcomes have not been well-described. We characterized the presentation, management and outcomes of pneumonia in children with and without CCC and described how antibiotic management and outcomes vary among subgroups of children with CCC.We conducted a cohort study of children <18 years with pneumonia across a large sample of US hospitals. Children were grouped according to CCC subgroups. Differences in disease management and outcomes were assessed using multivariable regression.Of the 31,684 children in our cohort, 11.9% had CCC. Children with CCC were more likely to receive intensive investigations and therapies, were less likely to receive aminopenicillins or third generation cephalosporins and were more likely to receive antibiotics against methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa and anaerobes. Compared with children without these conditions, children with CCC had significantly increased length of stay [relative risk 1.43, 95% confidence interval (CI) 1.39-1.48] and hospital costs (relative risk 1.38, 95% CI 1.33-1.43), with increased odds of antibiotic escalation (odds ratio 1.51, 95% CI 1.35-1.70), pneumonia complications (odds ratio 1.47, 95% CI 1.24-1.75) and readmission (odds ratio 4.0, 95% CI 3.2-5.0).Children with CCC comprise a significant proportion of children hospitalized for pneumonia and are at substantially increased risk of adverse outcomes. They have high rates of treatment with broad spectrum antibiotics, both at the time of hospitalization and subsequently. Research is needed to inform decision-making and guideline development, with goals of reducing adverse outcomes and unnecessary variation in management among children with CCC.

SUBMITTER: Leyenaar JK

PROVIDER: S-EPMC4760109 | biostudies-literature | 2014 Sep

REPOSITORIES: biostudies-literature

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Management and outcomes of pneumonia among children with complex chronic conditions.

Leyenaar JoAnna K JK Lagu Tara T Shieh Meng-Shiou MS Pekow Penelope S PS Lindenauer Peter K PK

The Pediatric infectious disease journal 20140901 9

<h4>Introduction</h4>Although pneumonia is a common reason for pediatric hospitalization among children with complex chronic conditions (CCC), treatment and outcomes have not been well-described. We characterized the presentation, management and outcomes of pneumonia in children with and without CCC and described how antibiotic management and outcomes vary among subgroups of children with CCC.<h4>Methods</h4>We conducted a cohort study of children <18 years with pneumonia across a large sample o ...[more]

PMID: 24732445

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Project description:BackgroundContinuity of care has been explored largely from academic and service provider perspectives, and in relation to adult patient/client groups. We interviewed parents of children with complex chronic health conditions to examine how their experiences and perceptions of continuity of care fit with these perspectives; and to identify the salient factors in the experience of, and factors contributing to, continuity in this population.MethodsParents of 47 elementary school-aged children with spina bifida, Down syndrome, attention-deficit/hyperactivity disorder, Duchenne muscular dystrophy or cystic fibrosis participated in semi-structured interviews. Parents described and mapped the pattern of their interactions with service providers over time in all domains relevant to their child's health, well-being, and development (medical, rehabilitational, educational, and social supportive services), with particular attention paid to their perceptions of connectedness or coherency in these interactions. Verbatim transcripts were analyzed thematically using a framework approach to impose structure regarding parents' perspectives on continuity of care.ResultsExisting academic concepts of relational, informational and management continuity were all discernable in parents' narratives. A thorough knowledge of the child on the part of service providers emerged as extremely important to parents; such knowledge was underpinned by continuity of personal relationships, principally, and also by written information. For this population, notions of continuity extend to the full range of service providers these children and families need to achieve optimal health status, and are not limited to physicians and nurses. Communication among providers was seen as integral to perceived continuity. Compartmentalization of services and information led to parents assuming a necessary, though at times, uncomfortable, coordinating role. Geographic factors, institutional structures and practices, provider attitudes, and, on occasion, parent preferences and judgments, were all found to create barriers to "seamless" management and provision of care continuity across providers, settings, and sectors.ConclusionsThese findings add new perspectives to the understanding of continuity within chronically ill children's health care. They are relevant to contemporary initiatives to improve continuity of services to children with special health care needs, demonstrate the need for parental support of their important role in maintaining continuity, and suggest avenues for further research.

Project description:IntroductionMost pediatric emergency care occurs in general emergency departments (GED), where less pediatric experience and lower pediatric emergency readiness may compromise care. Medically vulnerable pediatric patients, such as those with chronic, severe, neurologic conditions, are likely to be disproportionately affected by suboptimal care in GEDs; however, little is known about characteristics of their care in either the general or pediatric emergency setting. In this study our objective was to compare the frequency, characteristics, and outcomes of ED visits made by children with chronic neurologic diseases between general and pediatric EDs (PED).MethodsWe conducted a retrospective analysis of the 2011-2014 Nationwide Emergency Department Sample (NEDS) for ED visits made by patients 0-21 years with neurologic complex chronic conditions (neuro CCC). We compared patient, hospital, and ED visits characteristics between GEDs and PEDs using descriptive statistics. We assessed outcomes of admission, transfer, critical procedure performance, and mortality using multivariable logistic regression.ResultsThere were 387,813 neuro CCC ED visits (0.3% of 0-21-year-old ED visits) in our sample. Care occurred predominantly in GEDs, and visits were associated with a high severity of illness (30.1% highest severity classification score). Compared to GED visits, PED neuro CCC visits were comprised of individuals who were younger, more likely to have comorbid conditions (32.9% vs 21%, P < 0.001), and technology assistance (65.4% vs. 45.9%) but underwent fewer procedures and had lower ED charges ($2,200 vs $1,520, P < 0.001). Visits to PEDs had lower adjusted odds of critical procedures (adjusted odds ratio [aOR] 0.74, 95% confidence interval [CI] 0.62-0.87), transfers (aOR 0.14, 95% CI 0.04-0.56), and mortality (aOR 0.38, 95% CI 0.19-0.75) compared to GEDs.ConclusionCare for children with neuro CCCs in a pediatric ED is associated with less resource utilization and lower rates of transfer and mortality. Identifying features of PED care for neuro CCCs could lead to lower costs and mortality for this population.

Project description:BackgroundeHealth technologies for self-management can improve quality of life, but little is known about whether the benefits gained outweigh their costs. The electronic patient-reported outcome (ePRO) mobile app and portal system supports patients with multiple chronic conditions to collaborate with primary health care providers to set and monitor health-related goals.ObjectiveThis study aims to estimate the cost of ePRO and the cost utility of the ePRO intervention compared with usual care provided to patients with multiple chronic conditions and complex needs living in the community, from the perspective of the publicly funded health care payer in Ontario, Canada.MethodsWe developed a decision tree model to estimate the incremental cost per quality-adjusted life year (QALY) gained for the ePRO tool versus usual care over a time horizon of 15 months. Resource utilization and effectiveness of the ePRO tool were drawn from a randomized clinical trial with 6 family health teams involving 45 participants. Unit costs associated with health care utilization (adjusted to 2020 Canadian dollars) were drawn from literature and publicly available sources. A series of sensitivity analyses were conducted to assess the robustness of the findings.ResultsThe total cost of the ePRO tool was CAD $79,467 (~US $ 63,581; CAD $1733 [~US $1386] per person). Compared with standard care, the ePRO intervention was associated with higher costs (CAD $1710 [~US $1368]) and fewer QALYs (-0.03). The findings were consistent with the clinical evidence, suggesting no statistical difference in health-related quality of life between ePRO and usual care groups. However, the tool would be considered a cost-effective option if it could improve by at least 0.03 QALYs. The probability that the ePRO is cost-effective was 17.3% at a willingness-to-pay (WTP) threshold of CAD $50,000 (~US $40,000)/QALY.ConclusionsThe ePRO tool is not a cost-effective technology at the commonly used WTP value of CAD $50,000 (~US $40,000)/QALY, but long-term and the societal impacts of ePRO were not included in this analysis. Further research is needed to better understand its impact on long-term outcomes and in real-world settings. The present findings add to the growing evidence about eHealth interventions' capacity to respond to complex aging populations within finite-resourced health systems.Trial registrationClinicalTrials.gov NCT02917954; https://clinicaltrials.gov/ct2/show/NCT02917954.

Project description:Childhood pneumonia is a major cause of childhood illness and the second leading cause of child death globally. Understanding the costs associated with the management of childhood pneumonia is essential for resource allocation and priority setting for child health.We conducted a systematic review to identify studies reporting data on the cost of management of pneumonia in children younger than 5 years old. We collected unpublished cost data on non-severe, severe and very severe pneumonia through collaboration with an international working group. We extracted data on cost per episode, duration of hospital stay and unit cost of interventions for the management of pneumonia. The mean (95% confidence interval, CI) and median (interquartile range, IQR) treatment costs were estimated and reported where appropriate.We identified 24 published studies eligible for inclusion and supplemented these with data from 10 unpublished studies. The 34 studies included in the cost analysis contained data on more than 95?000 children with pneumonia from both low- and-middle income countries (LMIC) and high-income countries (HIC) covering all 6 WHO regions. The total cost (per episode) for management of severe pneumonia was US$ 4.3 (95% CI 1.5-8.7), US$ 51.7 (95% CI 17.4-91.0) and US$ 242.7 (95% CI 153.6-341.4)-559.4 (95% CI 268.9-886.3) in community, out-patient facilities and different levels of hospital in-patient settings in LMIC. Direct medical cost for severe pneumonia in hospital inpatient settings was estimated to be 26.6%-115.8% of patients' monthly household income in LMIC. The mean direct non-medical cost and indirect cost for severe pneumonia management accounted for 0.5-31% of weekly household income. The mean length of stay (LOS) in hospital for children with severe pneumonia was 5.8 (IQR 5.3-6.4) and 7.7 (IQR 5.5-9.9) days in LMIC and HIC respectively for these children.This is the most comprehensive review to date of cost data from studies on the management of childhood pneumonia and these data should be helpful for health services planning and priority setting by national programmes and international agencies.

Project description:Interventions: This is an observational, single center investigator driven study conducted in Australia with patients who are about to start cannabinoid therapy for management of recognized chronic conditions. Patients are to be enrolled into the study no earlier than their Physician’s decision to initiate treatment with a cannabinoid therapy. It is mandatory that the prescriber’s decision to start treatment with cannabinoid therapy was taken independently and before presenting the patient the option to participate in the study. Participants will be followed monthly for a maximum of 12 months from the signing of the informed consent forms (PISCF) or until death, withdrawal of consent, loss of follow-up/record, whichever comes first. During the follow-up visits, assessments will be performed according to routine local clinical practice. Data collected at each visit for the study may include: - Change in concomitant medications and rationale - Kessler Psychological Distress Scale (K10) score - Insomnia Severity Index score - Simple Pain Index score - Kemp Quality of Life Scale score - Rationale for change in cannabinoid therapy and/or dose if applicable - Participant withdrawal from the study and/or reason for discontinuation of cannabinoid therapy - Adverse Events/Serious Adverse Events/Adverse Drug reaction that may have occurred while on the study Follow-up patient reports detailing the required information will be completed for a maximum of 12 months (Reports to coincide with patient visit for follow-up consultation and/or new cannabinoid therapy prescription). Primary outcome(s): The primary scientific objective of this project is to investigate the safety and tolerability characteristics of cannabinoid therapy prescribed to eligible patients for management of recognized chronic conditions. Safety and tolerability are measured through collection and reporting of adverse events. Information on severity, seriousness and relationship to medical cannabinoid treatment will be used to measure the tolerability and safety of any given dose. Like all prescription medicines, medicinal cannabis products can have side effects. These may include: - Fatigue and sedation - Vertigo - Nausea and vomiting - Fever - Appetite increase or decrease - Dry mouth - Diarrhoea - Convulsions - Feelings of euphoria (intense happiness) or depression confusion - Hallucinations or paranoid delusions - Psychosis or cognitive distortion (having untrue thoughts) Adverse event / serious adverse event data is collected at each visit through subject reporting of symptoms, collection of any relevant medical records / GP letters, and laboratory/pathology results. Adverse event information is documented via the observational trial specific adverse event log that is maintained by the treating physician. [Once a month for twelve months.];Participant withdrawal from the study and/or reason for discontinuation of cannabinoid therapy. This is assessed and reported by the treating physician at each visit via completion of observational trial worksheets and patient medical records. [Once a month for twelve months.];Number of doses consumed since previous visit (tolerability). This is assessed and reported by the treating physician at each visit via completion of observational trial worksheets and patient medical records [Once a month for twelve months.] Study Design: Purpose: Natural history;Duration: Longitudinal;Selection: Defined population;Timing: Prospective

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Management and outcomes of pneumonia among children with complex chronic conditions.

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Management and outcomes of pneumonia among children with complex chronic conditions.

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