Use Of Adult-trained Medical Subspecialists By Children Seeking Medical Subspecialty Care.
Barriers To care; Consultation; Geographic Access; Pediatrics; Referral; Specialty; Subspecialty; Travel Time
OBJECTIVES:
To quantify the use of adult-trained medical subspecialists by children and to determine the association between geographic access to pediatric subspecialty care and the use of adult-trained subspecialists. Children with limited access to pediatric subspecialty care may seek care from adult-trained subspecialists, but data on this practice are limited.
STUDY DESIGN:
We identified children aged <16 years in 2007-2012 Pennsylvania Medicaid claims. We categorized outpatient visits to 9 selected medical subspecialties as either pediatric or adult-trained subspecialty visits. We used multinomial logistic regression to examine the adjusted association between travel times to pediatric referral centers and use of pediatric vs adult-trained medical subspecialists for children with and without complex chronic conditions (CCCs).
RESULTS:
Among 1.1 million children, 8% visited the examined medical subspecialists, with 10% of these children using adult-trained medical subspecialists. Compared with children with a ≤30-minute travel time to a pediatric referral center, children with a >90-minute travel time were more likely to use adult-trained subspecialists (without CCCs: relative risk ratio [RRR], 1.94, 95% CI, 1.79-2.11; with CCCs: RRR, 2.33; 95% CI, 2.10-2.59) and less likely to use pediatric subspecialists (without CCCs: RRR, 0.66; 95% CI, 0.63-0.68; with CCCs: RRR, 0.76, 95% CI, 0.73-0.79).
CONCLUSION:
Among medical subspecialty fields with pediatric and adult-trained subspecialists, adult-trained subspecialists provided 10% of care to children overall and 18% of care to children living >90 minutes from pediatric referral centers. Future studies should examine consequences of adult-trained medical subspecialist use on pediatric health outcomes and identify strategies to increase access to pediatric subspecialists.
Ray KN; Kahn JM; Miller E; Mehrotra A
Journal Of Pediatrics
2016
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
DOI: 10.1016/j.jpeds.2016.05.073
Pediatric Palliative Care And Hospice Program Development In 2016: Strategies For Success In An Ever-expanding World
Objectives
Propose pediatric program design or expansion
based on newly acquired skills of defining a
desirable and functional scope that aligns with
health system’s missions and values and identifies
areas of potential growth and collaboration
within the health system.
Discuss the creation of a formal business plan for
development of a pediatric palliative care program
to present to senior hospital leadership
that effectively highlights the benefits and challenges
of a billing revenue only strategy and
thus a need for operating dollars and philanthropic
support as a comprehensive business
plan strategy.
Develop a strategy for their community to implement
PC with limited resources and increase buyin
from stakeholders.
As with adult palliative care, pediatric palliative care is
experiencing rapid growth. Like adult palliative care,
pediatric palliative care practitioners also need to
design and sustain programs that respond to their
own institutional needs and values, that show value
added through metrics and quality improvement
research, that acknowledge the national palliative
care staffing shortage, that address the growing need
for outpatient resources in all communities, and
that have strategies embedded to prevent staff
burnout. Distinct from adult palliative care is pediatrics’
need for greater philanthropic and operational
dollar support as pediatric palliative care has not
had the patient volume to show the reduced cost savings
strategy that drives many adult palliative care
budget plans. This workshop will present strategies
for preliminary pediatric program planning and
budgeting that address these needs through the presentation
of five distinct pediatric palliative care programs.
Education will be heavily driven through case
presentations that contrast resource-rich versus
resource limited environments, newer programs
versus more established programs, and inpatient
versus outpatient arenas. After providing this platform,
the workshop will utilize these experts to assist
in small group discussions that focus on participants’
unique program needs and questions.
Humphrey L; Friebert S; Miller E; Ragsdale L; Parikh S
Journal Of Pain And Symptom Management
2016
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
DOI: http://dx.doi.org/10.1016/j.jpainsymman.2015.12.113
Impact Of A Pediatric Palliative Care Team On Limitations Of Care For Inpatients At A Free-standing, Tertiary- Care Children’s Hospital.
Objectives
Understand the role of pediatric palliative care in
end-of-life discussions.
Identify further opportunities for do-not-resuscitate
(DNR) research and analysis of advanced
care planning in pediatrics.
Original Research Background. Discussions surrounding
limitations of care can invoke controversy,
confusion, and anxiety in both healthcare professionals
and families. Some literature exists regarding
the impact of pediatric palliative care teams on ICU
admission, cost, and family satisfaction. Limited information,
however, is available regarding the factors
involved in end-of-life decisions. Understanding these
factors may improve the process of evaluating and
placing limitation-of care orders in children.
Research Objectives. Our study aims to analyze the
timing of DNR order placement prior to death in pediatric
patients. We also aim to further delineate the
specialty of the ordering physician, demographic
data, and location of death.
Methods. We present a retrospective review of 471
deaths between 1/2009 and 10/2014. The palliative
care team was established in September, 2011. For
those patients who had a DNR order in place, we
analyzed patient and physician characteristics as well
as DNR order timing.
Results. The location of death of 49% of patients who
had a DNR in place was in an ICU setting. The death
rate in the ICU was not statistically different following
initiation of the palliative care team (PCT) (p¼0.53).
The overall DNR rate increased following initiation
of the PCT from 30.8% to 39.2% (p¼0.05). The PCT
was consulted in 77% of deaths and ordered the
DNR in 60% of children.
Conclusion. Our results emphasize the important
role of the palliative care team during end-of-life discussions
in children. The palliative care team met
with more than three quarters of families prior to
death, and they placed the DNR order in more than
half of these instances. The initiation of the palliative
care team was associated with a large increase in overall
DNR rates.
Implications for Research, Policy or
Practice. Additional studies are needed in pediatrics
to further delineate the timing of palliative care
consultation in the patient’s overall course of illness,
demographic and cultural influences, and specific patient
conditions, such as tracheostomy dependence.
Plymire C; Miller E; Frizzola M
Journal Of Pain And Symptom Management
2016
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
DOI: http://dx.doi.org/10.1016/j.jpainsymman.2015.12.080
Drug Abuse and Diversion in Pediatric Palliative Care-What You Should Know, What You Can Do, and What You Can Learn from Our Multisite Experience
Health Care Sciences & Services
Background Prescription drug abuse is an epidemic in the US, leading to increased government oversight in opioid prescribing. The issue becomes more complicated when minor children are involved. One pediatric palliative care team found that of 62 consecutive children and young adults who were stratified for opioid misuse, >60% were at either moderate or high risk. In 6 cases, the patient was weaned from opioids or the team stopped prescribing due to diversion or misuse behaviors. Thus safe opioid prescribing should be a priority for all pediatric palliative care (PPC) teams. Discussion Using a case-based discussion, we will review pediatric-specific opioid abuse data and best evidence around safe opioid prescribing. We will discuss the safe-opioid prescribing “opioid bundle” developed by the Pediatric Palliative and Comfort Care Team (PACT) at Cincinnati Children's Hospital Medical Center and how it has been rolled out at two additional children's hospitals. We will talk in-depth about caring for high risk patients, highlighting cases of confirmed diversion and the resulting de-prescribing. We will include cases of minor children with diversion by adult caregivers as well as adolescent and young adult patients participating in drug diversion. Conclusions Given the high risk of drug misuse, abuse and diversion, safe opioid prescribing is necessary for all PPC teams. The “opioid bundle” created by PACT is a practical method for PPC teams nationwide to employ in the care of their patients.
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Miller E; Humphrey L; Thienprayoon R
Journal of Pain and Symptom Management
2018
<a href="http://doi.org/10.1016/j.jpainsymman.2017.12.037" target="_blank" rel="noreferrer noopener">10.1016/j.jpainsymman.2017.12.037</a>