A Tertiary Care-based Complex Care Program: Improving Care for Children With Medical Complexity
Infant; Child; Humans; Child Preschool; Infant Newborn; Length of Stay; Caregivers/psychology; Patient Care Team/organization & administration; Patient Acceptance of Health Care/statistics & numerical data; Hospitalization/statistics & numerical data; Emergency Service Hospital/statistics & numerical data; Patient Satisfaction; Quality Improvement/organization & administration; Case Management/organization & administration; Multiple Chronic Conditions/therapy; Tertiary Healthcare/economics/organization & administration
OBJECTIVE: Children with medical complexity (CMC) have significant health care costs, but they also experience substantial unmet health care needs, hospitalizations, and medical errors. Their parents often report psychosocial stressors and poor care satisfaction. Complex care programs can improve the care for CMC. At our tertiary care institution, we developed a consultative complex care program to improve the quality and cost of care for CMC and to improve the experience of care for patients and families. METHODS: To address the needs of CMC at our institution, we developed the Compass Care Program, a consultative complex care program across inpatient and outpatient settings. Utilization data [hospital admissions per patient month; length of stay per admission; hospital days per patient month; emergency department (ED) visits per patient month; and institutional charges per patient month] and caregiver satisfaction data (obtained via paper survey at outpatient visits) were tracked over the period of participation in the program and compared preenrollment and postenrollment for program participants. RESULTS: Participants had significant decreases in hospital admissions per patient month, length of stay per admission, hospital days per patient month, and charges per patient month following enrollment (P<0.01) without a tandem increase in readmissions within 7 days of discharge. There was no statistically significant difference in ED visits. Caregiver satisfaction scores improved in all domains. CONCLUSION: Participation in a consultative complex care program can improve utilization patterns and cost of care for CMC, as well as experience of care for patients and families.
Hogan AK; Galligan MM; Stack NJ; Leach KF; Aredas BL; English R; Dye M; Rubin D
Medical Care
2020
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<a href="http://doi.org/10.1097/mlr.0000000000001388" target="_blank" rel="noreferrer noopener">10.1097/mlr.0000000000001388</a>
Toward youth friendly services: a survey of young people in primary care
Cross-Sectional Studies; Female; Humans; Male; Physician-Patient Relations; Adult; Health Care Surveys; Age Factors; Needs Assessment; Patient Satisfaction; adolescent; Adolescent Transitions; Patient Acceptance of Health Care/statistics & numerical data; Adolescent Health Services/utilization; Health Services Needs and Demand/classification/statistics & numerical data; Primary Health Care/utilization
BACKGROUND: The World Health Organization encourages the development of youth friendly services, yet little is known on how youth currently present in general practice. OBJECTIVE: To describe the perspectives, expectations, and service receipt of young people presenting to family doctors to inform the development of youth friendly services. DESIGN: Cross-sectional survey. PARTICIPANTS AND MEASUREMENTS: Consecutive young people attending 26 randomly selected practices were recruited in the waiting rooms. Standardized instruments were used to interview them before their consultation. RESULTS: Of 501 young people who were approached, 450 participated (91% participation rate). Most had respiratory (26%) or dermatological complaints (18%). When asked to assess their health status, 59% perceived they had neither a physical nor a mental illness. However, 43% stated they had fears about their health problem and 1 in 5 feared it could be life-threatening. Although only 10% presented with psychological complaints, 24% perceived they currently had a mental illness. The most common expectations were treatment (50%) and good communication (42%). Most youth were prescribed medication (60%), but 40% of those who received a prescription had not expected to receive a treatment. A follow-up appointment was offered to 57% of participants. CONCLUSIONS: This study identifies a gap between young people's perception of illness and their presentations to family doctors. It also highlights unexpected fears, and a mismatch between expectations and service receipt. These findings have implications for family medicine training and for clinical practice. They should inform the development of youth friendly services.
2007
Haller DM; Sanci LA; Patton GC; Sawyer SM
Journal Of General Internal Medicine
2007
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Journal Article
<a href="http://doi.org/10.1007/s11606-007-0177-5" target="_blank" rel="noreferrer">10.1007/s11606-007-0177-5</a>
Health care resource utilization in adults with congenital heart disease
Female; Humans; Male; Adult; Aged; Middle Aged; Length of Stay; Outcome Assessment (Health Care); Severity of Illness Index; Emergency Service; adolescent; Hospital/utilization; Adolescent Transitions; Patient Acceptance of Health Care/statistics & numerical data; Hospitalization/statistics & numerical data; Heart Defects; Age Distribution; Databases; Factual; Ambulatory Care/utilization; Congenital/epidemiology/etiology/pathology/therapy; Health Resources/utilization; Quebec/epidemiology
The number of adults with congenital heart disease (CHD) is increasing. However, rates of health care resource utilization in this population are unknown. The objectives of this study were to describe the use of general health care resources in adults with CHD and to examine the impact of CHD severity on resource utilization. The study consisted of adults alive in 1996 who had > or = 1 diagnosis of a CHD lesion conforming to the International Classification of Disease, Ninth Revision, in the physician's claims database of the province of Quebec from 1983 to 2000. From 1996 to 2000, rates of health care utilization were measured. The impact of the severity of CHD on the use of health care resources was determined using multivariate models to adjust for age, gender, Charlson co-morbidity score, and duration of follow-up. The study population consisted of 22,096 adults with CHD (42% men). From 1996 to 2000, 87% received outpatient care from specialists, 68% visited emergency rooms, 51% were hospitalized, and 16% were admitted to critical care units. Patients with severe CHD had higher adjusted rates of outpatient cardiologist care (rate ratio [RR] 2.24, 95% confidence interval [CI] 2.06 to 2.45), emergency department utilization (RR 1.09, 95% CI 1.03 to 1.17), hospitalization (RR 1.30, 95% CI 1.19 to 1.43), and days in critical care (RR 2.12, 95% CI 1.80 to 2.50) than patients with other congenital cardiac lesions. Hospitalization rates were higher than in the general Quebec adult population (RR 2.08, 95% CI 2.00 to 2.17). In conclusion, adults with CHD have high rates of health care resource utilization, particularly those with severe lesions. Appropriate resource allocation is required to serve this growing population.
2007
Mackie AS; Pilote L; Ionescu-Ittu R; Rahme E; Marelli AJ
The American Journal Of Cardiology
2007
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Journal Article
<a href="http://doi.org/10.1016/j.amjcard.2006.10.054" target="_blank" rel="noreferrer">10.1016/j.amjcard.2006.10.054</a>
The spectrum of adult congenital heart disease in Europe: morbidity and mortality in a 5 year follow-up period. The Euro Heart Survey on adult congenital heart disease
Female; Humans; Male; Pregnancy; Pregnancy Complications; Adult; Data Collection; Follow-Up Studies; Aged; Middle Aged; Survival Analysis; adolescent; Adolescent Transitions; Patient Acceptance of Health Care/statistics & numerical data; Heart Defects; Europe/epidemiology; Ambulatory Care/statistics & numerical data; Cardiovascular Agents/therapeutic use; Cardiovascular/mortality; Congenital/mortality
AIMS: To describe clinical and demographic characteristics at baseline of a European cohort of adults with congenital heart disease (CHD) and to assess mortality and morbidity in a 5 year follow-up period. METHODS AND RESULTS: Data collected as part of the Euro Heart Survey on adult CHD was analysed. This entailed information transcribed from the files of 4110 patients diagnosed with one of eight congenital heart conditions ('defects'), who consecutively visited the outpatient clinics of one of the participating centres in 1998. The patients were included retrospectively and followed until the end of 2003 for a median follow-up of 5.1 years. Notwithstanding their overall relatively good functional class and low mortality over the follow-up period, a considerable proportion of the patients had a history of endocarditis, arrhythmias, or vascular events. There were major differences between the eight defects, both in morbidity and regarding specific characteristics. Outcomes were worst in cyanotic defects and in the Fontan circulation, but a considerable proportion of the other patients also suffer from cardiac symptoms. In particular, arrhythmias are common. CONCLUSION: The spectrum of adult CHD in Europe emerging from this survey is one of a predominantly young population with substantial morbidity but relatively low mortality in a 5 year period.
2005
Engelfriet P; Boersma E; Oechslin E; Tijssen J; Gatzoulis MA; Thilen U; Kaemmerer H; Moons P; Meijboom F; Popelova J; Laforest V; Hirsch R; Daliento L; Thaulow E; Mulder B
European Heart Journal
2005
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Journal Article
<a href="http://doi.org/10.1093/eurheartj/ehi396" target="_blank" rel="noreferrer">10.1093/eurheartj/ehi396</a>
Use of hospitals, physician visits, and hospice care during last six months of life among cohorts loyal to highly respected hospitals in the United States
Humans; United States; Cohort Studies; Aged; Outcome Assessment (Health Care); Hospitals; 80 and over; Non-U.S. Gov't; P.H.S.; Research Support; U.S. Gov't; retrospective studies; Patient Acceptance of Health Care/statistics & numerical data; Teaching/utilization; Hospitalization/statistics & numerical data; Terminally Ill/statistics & numerical data; Health Services Needs and Demand/statistics & numerical data; Hospice Care/utilization; General/utilization; Terminal Care/utilization
OBJECTIVE: To evaluate the use of healthcare resources during the last six months of life among patients of US hospitals with strong reputations for high quality care in managing chronic illness. DESIGN: Retrospective cohort study based on claims data from the US Medicare programme. PARTICIPANTS: Cohorts receiving most of their hospital care from 77 hospitals that appeared on the 2001 US News and World Report "best hospitals" list for heart and pulmonary disease, cancer, and geriatric services. MAIN OUTCOME MEASURES: Use of healthcare resources in the last six months of life: number of days spent in hospital and in intensive care units; number of physician visits; percentage of patients seeing 10 or more physicians; percentage enrolled in hospice. Terminal care: percentage of deaths occurring in hospital; percentage of deaths occurring in association with a stay in an intensive care unit. RESULTS: Extensive variation in each measure existed among the 77 hospital cohorts. Days in hospital per decedent ranged from 9.4 to 27.1 (interquartile range 11.6-16.1); days in intensive care units ranged from 1.6 to 9.5 (2.6-4.5); number of physician visits ranged from 17.6 to 76.2 (25.5-39.5); percentage of patients seeing 10 or more physicians ranged from 16.9% to 58.5% (29.4-43.4%); and hospice enrollment ranged from 10.8% to 43.8% (22.0-32.0%). The percentage of deaths occurring in hospital ranged from 15.9% to 55.6% (35.4-43.1%), and the percentage of deaths associated with a stay in intensive care ranged from 8.4% to 36.8% (20.2-27.1%). CONCLUSION: Striking variation exists in the utilisation of end of life care among US medical centres with strong national reputations for clinical care.
2004
Wennberg JE; Fisher ES; Stukel TA; Skinner JS; Sharp SM; Bronner KK
Bmj (clinical Research Ed.)
2004
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Journal Article
<a href="http://doi.org/10.1136/bmj.328.7440.607" target="_blank" rel="noreferrer">10.1136/bmj.328.7440.607</a>
Advice seeking and appropriate use of a pediatric emergency department
Child; Cross-Sectional Studies; Female; Humans; infant; Male; Questionnaires; Age Factors; Health Services Research; Severity of Illness Index; Sex Factors; Hospitals; Quebec; Emergency Service; adolescent; Hospital/utilization; Preschool; infant; Newborn; algorithms; Birth Order; Counseling/statistics & numerical data; Health Services Misuse/statistics & numerical data; Parents/education/psychology; Patient Acceptance of Health Care/statistics & numerical data; Pediatric/utilization; Teaching/utilization
OBJECTIVES: To determine whether seeking advice prior to an unscheduled visit to a pediatric emergency department (PED) influences appropriate use of this setting for minor illnesses. DESIGN: Cross-sectional questionnaire survey. SETTING: The medical emergency department of the Montreal (Quebec) Children's Hospital, a major referral and urban teaching hospital. PARTICIPANTS: Four hundred eighty-nine of 562 consecutive parents visiting the PED over two periods, one in February and the other in July 1989. INTERVENTIONS: None. MEASUREMENTS/MAIN RESULTS: Parents of children between 0 and 18 years of age visiting the PED were asked whether they had previously sought advice from family, friends, or a physician. Other factors possibly related to the decision to seek care were also measured. Appropriateness was rated, blind to discharge diagnosis, by two pediatricians using a structured series of questions incorporating the child's age, time of the visit, clinical state, and problem at presentation. Thirty-four percent of visits among respondents were judged appropriate. In bivariate analysis, appropriate visits occurred significantly more often when a parent spoke to both a physician and a nonphysician (47%) prior to visiting the PED than when no advice was sought (29%; P < .05). In multivariate analysis, having a regular physician and being one of two children also contributed to appropriateness. CONCLUSIONS: Appropriate use of the PED was positively influenced by seeking prior advice from both a physician and family member, having a regular physician, and having prior child care experience.
1993
Oberlander T; Pless IB; Dougherty GE
American Journal Of Diseases Of Children
1993
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Journal Article
<a href="http://doi.org/10.1001/archpedi.1993.02160320065021" target="_blank" rel="noreferrer">10.1001/archpedi.1993.02160320065021</a>
Confidentiality in health care. A survey of knowledge, perceptions, and attitudes among high school students
Female; Humans; Male; Questionnaires; Massachusetts; Health Behavior; Emergency Service; Practice; adolescent; Hospital/utilization; Empirical Approach; Professional Patient Relationship; Attitudes; Adolescent Transitions; Patient Acceptance of Health Care/statistics & numerical data; Health Knowledge; Adolescent Health Services/utilization; Confidentiality; Community Health Centers/utilization; Physicians' Offices/utilization; School Health Services/utilization; Students
OBJECTIVE--To assess adolescent knowledge, perceptions, and attitudes about health care confidentiality. DESIGN--Anonymous self-report survey with 64 items addressing confidentiality issues in health care. SETTING--Rural, suburban, and urban high schools in central Massachusetts. PARTICIPANTS--Students in ninth through 12th grades from three schools. RESULTS--A total of 1295 students (87%) completed the survey: 58% had health concerns that they wished to keep private from their parents, and 69% from friends and classmates; 25% reported that they would forgo health care in some situations if their parents might find out. There were differences in response by gender, race, and school. About one third were aware of a right to confidentiality for specific health issues. Of those with a regular source of care, 86% would go to their regular physician for a physical illness, while only 57% would go there for questions about pregnancy, the acquired immunodeficiency syndrome, or substance abuse that they wished to keep private. Sixty-eight percent had concerns about the privacy of a school health center. CONCLUSIONS--A majority of adolescents have concerns they wish to keep confidential and a striking percentage report they would not seek health services because of these concerns. Interventions to address confidentiality issues are thus crucial to effective adolescent health care.
1993
Cheng TL; Savageau JA; Sattler AL; DeWitt TG
Jama
1993
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Journal Article
<a href="http://doi.org/10.1001/jama.269.11.1404" target="_blank" rel="noreferrer">10.1001/jama.269.11.1404</a>
Adolescent girls' and boys' preferences for provider gender and confidentiality in their health care
Child; Female; Humans; Male; United States; Physician-Patient Relations; Ethnic Groups; Health Care Surveys; Parent-Child Relations; Logistic Models; Health Services Accessibility; Age Factors; Socioeconomic Factors; Health Status; Sex Factors; adolescent; Adolescent Transitions; Risk-Taking; Patient Acceptance of Health Care/statistics & numerical data; Confidentiality; Patient Satisfaction/statistics & numerical data; Prejudice
PURPOSE: To assess the influence of demographic variables and health risk status on adolescents' preferences and actual receipt of services regarding provider gender, sharing a physician with parents, and private examinations. METHODS: Data from students participating in the Commonwealth Fund 1997 Survey of the Health of Adolescent Girls were analyzed. The weighted sample included 6748 students from grades 5-12. The influence of demographic variables and health risk status on preferences regarding physician gender, sharing a physician with parents, and parental presence during examinations and on actual physician gender, sharing a physician with parents, and receipt of confidential care was assessed for the 5067 students who indicated that they had a health check-up or physical examination within the past 2 years. Associations were examined using SAS to determine preliminary estimates of significance and correlation coefficients, and SUDAAN to generate proportions and Cochran Mantel-Haenszel Chi-squared values. A multiple logistic regression procedure in SUDAAN was used to assess interaction among demographic variables. RESULTS: Gender, race/ethnicity, grade level, and risk status were associated with preferences regarding provider gender and sharing a physician with parents. 50% of girls preferred a female provider; 48% had no preference. 23% of boys preferred a male provider; 65% had no preference. Most adolescents had no preference regarding whether they shared a physician with parents. Gender, race/ethnicity, grade level, and risk status were associated with preference regarding parental presence during examinations. Most younger girls preferred to have a parent present; most younger boys had no preference. Most older girls and boys preferred private examinations. For actual care situation, most adolescents were cared for by male health providers and did not share a physician with parents. 57% of girls and 66% of boys spoke privately with their health provider. Girls who had a female physician were more likely to have private time than were girls receiving care from a male physician. Gender, grade level, and risk status were associated with having private time with a physician. CONCLUSIONS: Gender was a significant variable in adolescents' preferences regarding health care. Preferences were also influenced by race/ethnicity, grade level, and risk status. A substantial proportion of adolescents, including those involved in health risk activities, report not having private time with their health provider.
1999
Kapphahn CJ; Wilson KM; Klein JD
The Journal Of Adolescent Health : Official Publication Of The Society For Adolescent Medicine
1999
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Journal Article
<a href="http://doi.org/10.1016/s1054-139x(99)00050-6" target="_blank" rel="noreferrer">10.1016/s1054-139x(99)00050-6</a>
Factors Influencing The Uptake Of Neonatal Bereavement Support Services – Findings From Two Tertiary Neonatal Centres In The Uk
Autopsy; Bereavement; England; Female; Humans; Infant; Infant Death; Infant Newborn; Intensive Care Units Neonatal; Male; Parents/psychology; Patient Acceptance Of Health Care/statistics & Numerical Data; Perinatal Care/utilization; Referral And Consultation/utilization; Social Support; Socioeconomic Factors; Stillbirth/psychology
Neonatal; Bereavement Follow Up; Death; Ethnicity; Socio-economic; Autopsy
Background
Research on perinatal bereavement services is limited. The aim of the study was to compare the uptake of bereavement support services between two tertiary neonatal units (NNU), and to investigate influencing factors.
Method
The medical and bereavement records of all neonatal deaths were studied from January 2006 to December 2011. Data collected included parent and baby characteristics, mode of death, consent for autopsy and bereavement follow-up. The categorical data were compared by chi-square or Fisher’s exact test and continuous data by Wilcoxon signed-rank test; a multivariable regression analysis was performed using STATA 12.0.
Results
The neonatal deaths of 297 babies (182 in NNU1 and 115 in NNU2) with full datasets were analysed. Baby characteristics were similar between units except for lower median gestational age in NNU1 (p = 0.03). Significantly more NNU1 parents were non-Caucasian (p < 0.01), from lower socio-economic status (p = 0.01) and had previous stillbirth/miscarriage (p = 0.03). More babies had care withdrawn in NNU2 (p < 0.01). A significantly higher proportion of parents from NNU1 (61 %) attended bereavement follow-up compared to NNU2 (34 %; p < 0.01).
On multivariable analysis, significantly more parents who were married or co-habiting (p = 0.02) and consented for an autopsy (p = 0.01) attended bereavement services.
Conclusion
Uptake of bereavement services varied between the two NNUs, which could be due to differences in the ethnic and socio-economic mix of the population. Significantly more parents who were married or co-habiting, or consented for autopsy, attended bereavement follow up services.
Jayanta Banerjee; Charanjit Kaur; Sridhar Ramaiah; Rahul Roy; Narendra Aladangady
Bmc Palliative Care
2016
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doi: 10.1186/s12904-016-0126-3