Medical Complexity Research Articles

School Perceptions and Attendance for Children With Medical Complexity During COVID-19 Over Time.

Disparities in school attendance exist for children with medical complexity (CMC) due to COVID-19. Longitudinal changes in family-reported school safety perceptions and predictors of full-time, in-person school attendance are unknown. This was a prospective, longitudinal cohort study with 3 survey waves (June 2021-June 2022) among English- and Spanish-speaking families of CMC aged 5 to 17 years and pre-pandemic school attendance. Changes in Health Belief Model perceptions and full-time in-person school attendance were estimated using multivariate generalized linear modeling with repeated measures. Among 1601 respondents (52.9% of 3073 invited), 86.8% participated in all 3 surveys. School safety perceptions improved with time; however, perceived susceptibility to COVID-19 increased. Full-time in-person school attendance rose from 48.4% to 90.0% from wave 1 to 3 (p < .0001), and was associated with motivation, benefits, and cues. For example, families with low compared to high motivation for in-person attendance had 76% versus 98% predicted probability for child's school attendance, respectively at wave 3 (p < .0001). Probability of full-time in-person school attendance was associated with several health belief model perceptions. School health policy and programs may benefit from promoting family motivation, benefits, and cues during future respiratory illness epidemics including COVID-19. In-person school attendance improved for CMC over time. Opportunities exist to continue optimizing in-person attendance and family-perceived safety for CMC at school.

Social Risks and Health Care Use in Medically Complex Patients

Integrated health care systems have initiated major investments to identify and address social risks, particularly for patients with multiple medical conditions. To evaluate the association of social risks with health care use among patients with complex multimorbidity. This longitudinal cohort study assessed Kaiser Permanente Northern California (KPNC) patients with (1) moderate medical complexity (defined by high comorbidity score, high risk of hospitalization, and/or prior emergency department [ED] admissions) and (2) high medical complexity (eg, meeting additional criteria, such as ≥7 medications and laboratory evidence of poor disease control). Social risks (eg, requiring medical financial assistance and self-reported social barriers to care). Inpatient and outpatient health care use during 12 months of follow-up (January 15, 2023, to January 14, 2024). The sample included 97 252 KPNC patients (mean [SD] age, 69.5 [16] years; 52.1% female; 10.6% Asian, 11.1% Black, 18.3% Hispanic, 54.6% White, and 5.5% other race or ethnicity [eg, American Indian or Alaskan Native, Native Hawaiian or Pacific Islander, multiracial, or unknown race]; and 8.8% insured by Medicaid), including 27 827 with moderate medical complexity (5074 [18.2%] with social risks) and 69 425 with high medical complexity (17 343 [25.0%] with social risks). In fully adjusted models, for moderate medical complexity, social risks were associated with higher odds of inpatient admissions (odds ratio [OR], 1.2; 95% CI, 1.1-1.4), ED visits (OR, 1.2; 95% CI, 1.1-1.3), and mental health visits (OR, 1.2; 95% CI, 1.1-1.3) vs individuals without social risks. Among individuals with high medical complexity, social risks were associated with higher odds of inpatient admissions (OR, 1.2; 95% CI, 1.1-1.2), ED visits (OR, 1.2; 95% CI, 1.1-1.2), and 30-day readmissions (OR, 1.2; 95% CI, 1.1-1.3) and higher odds of mental health visits (OR, 1.3; 95% CI, 1.2-1.3) vs individuals without social risks. In this cohort study of individuals with medical complexity, coexisting social risks were associated with substantial downstream health care use. Efforts to reduce use in individuals with complex medical comorbidity could include concurrent efforts to identify and reduce social risks.

A Coproduced Family Reporting Intervention to Improve Safety Surveillance and Reduce Disparities.

Examine family safety-reporting after implementing a parent-nurse-physician-leader coproduced, health literacy-informed, family safety-reporting intervention for hospitalized families of children with medical complexity. We implemented an English and Spanish mobile family-safety-reporting tool, staff and family education, and process for sharing comments with unit leaders on a dedicated inpatient complex care service at a pediatric hospital. Families shared safety concerns via predischarge surveys (baseline and intervention) and mobile tool (intervention). Three physicians with patient safety expertise classified events. We compared safety-reporting baseline (via survey) versus intervention (via survey and/or mobile tool) with generalized estimating equations and sub-analyzed data by COVID-19-era and educational attainment. We also compared mobile tool-detected event rates with hospital voluntary incident reporting. 232 baseline and 208 intervention parents participated (78.2% consented); 29.5% of baseline families versus 38.2% of intervention families reported safety concerns (P = .09). Adjusted odds ratio (95% CI) of families reporting safety concerns intervention versus baseline was 1.6 (1.0-2.6) overall, 2.6 (1.3-5.4) for those with < college education, and 3.1 (1.3-7.3) in the COVID-19-era subgroup. Safety concerns reported via mobile tool (34.6% of enrolled parents) included 42 medical errors, 43 nonsafety-related quality issues, 11 hazards, and 4 other. 15% of mobile tool concerns were also detected with voluntary incident reporting. Family safety-reporting was unchanged overall after implementing a mobile reporting tool, though reporting increased among families with lower educational attainment and during the COVID-19 pandemic. The tool identified many events not otherwise captured by staff-only voluntary incident reporting. Hospitals should proactively engage families in reporting to improve safety, quality, and equity.

Nurse-led proactive mobile application in symptom management for children with medical complexity: Study protocol for a randomized controlled trial.

To investigate the effect of a nurse support using a proactive mobile app to enhance parental self-efficacy in symptom management for children with medical complexity. A single-blinded, randomized controlled trial with a two-armed repeated measures design. Eligible parents and the children will be recruited from the special schools and non-government offices. They will be randomly assigned either to the intervention or control groups. Subjects in the study group will receive nurse parental support using a symptom management mobile app for 3 months. The control group will receive the usual care that is available in the community. Data will be collected pre-intervention (T1), immediately after the intervention (T2), and three-month after intervention (T3). The primary outcome is parental self-efficacy. The secondary outcomes include child's symptom burden and their health service utilization. Primary outcome will be compared across two groups in T2 and T3 using with control for the pre-test value of parental self-efficacy. Generalized estimating equation (GEE) will be used to address secondary objectives from T1 to T3 with appropriate link function. As a result of the successful implementation of this nurse-led symptom management, parental self-efficacy will be enhanced. Both the symptoms reported by the children and their health service utilization will be reduced. Findings of this study will help in service delivery improvements because it maximizes the availability and accessibility of paediatric health service to parents and the children in local communities. The evidence produced in this study will enlarge the knowledge base that supports evidence-based paediatric home nursing service with the use of health technology in symptom management. This evidence will also contribute to the development of other symptom management programs for other paediatric patient groups. NCT05765643 (ClinicalTrials.gov identifier). Parents of children with medical complexity contributed in mobile application development by giving comments on the usability of mobile application. Improve health service delivery: Home nursing service may not be sustainable in a long run in Hong Kong, as the health care system has been facing a serious nursing workforce shortage in recent years. Besides, these services are affected or even suspended during the community outbreak of infectious disease, like recent coronavirus disease pandemic. Nurse parental support in symptom management for the CMC using a proactive mobile health application will help in service delivery improvements because it maximizes the availability and accessibility of paediatric health service to parents and their CMC in local communities. Improve physical and psychological health of parents and their CMC: The success of program implementation will help to increase parental self-efficacy in symptom management for their CMC, as a result of decrease of children's symptom burden. Improve knowledge base: The evidence produced in this study will (1) enlarge the knowledge base that supports evidence-based paediatric community nursing service related to symptom management for the CMC. This evidence will contribute to the development of other symptom management programs for other paediatric patient groups.

Falls among Pediatric Patients Receiving Home Care.

Children with medical complexity (CMC) often require home healthcare services to manage chronic health conditions. Evaluation of home safety is recommended when children transition from hospital to home care, though despite best efforts, safety events, such as falls, still occur. Understanding the prevalence and causal factors of falls in CMC is critical for the development of fall prevention interventions and protocols. This study aims to describe demographics and reasons for falls reported in CMC receiving home healthcare services. A retrospective analysis was performed using data from an incident reporting database from January 2019 to March 2023. Participants included CMC who received home healthcare services from a single institution and had at least one documented fall. A total of 43 falls were experienced by 31 unique participants. The participants were predominantly male (58.1%), White (71.0%), and non-Hispanic/Latino (96.8%), with a median age of 10 years at the time of the fall. Primary diagnoses of CMC with falls included neurological disorders (41.9%), congenital chromosomal abnormalities (25.8%), and oncological conditions (16.1%). The most common reasons for falls were loss of balance (32.6%), unknown factors (19.6%), and trip/slips (17.4%). Half of falls were deemed to be potentially preventable. This study provides valuable insight into falls among CMC receiving home healthcare services and emphasizes the multifactorial nature of fall risks in this population. Understanding demographic characteristics, diagnoses, and causal factors of falls is critical in the development of proactive fall prevention strategies. Responding proactively to mitigate fall risks is an important step in enhancing the safety and quality of life for CMC. Future collaborative research efforts are warranted to validate findings and evaluate potentially successful fall prevention interventions.

Resources, Workload, and Care Coordination Hours Predict Depressive Symptoms in Parents of Children with Medical Complexity

Resources, Workload, and Care Coordination Hours Predict Depressive Symptoms in Parents of Children with Medical Complexity

Barriers to auditory brainstem response testing under anesthesia

ObjectiveAuditory brainstem response (ABR) testing is the gold standard for diagnosis of hearing loss in children who cannot complete behavioral audiometry. Testing under general anesthesia is often recommended when natural sleep ABR and/or behavioral audiometry are unsuccessful. This study aims to determine which demographic and patient factors serve as barriers to receiving this diagnostic testing. MethodsA retrospective chart review from an internal database of patients who underwent ABR testing under anesthesia from 2017 to 2023 was completed. Patient demographics, clinical diagnoses, dates of initial recommendation, and dates of testing were recorded. ResultsA total of 395 patients met inclusion criteria, with a median time from initial evaluation to successful ABR under anesthesia of 5.1 months (range 0.1–209 months). This time was significantly higher in patients with public insurance compared to private insurance and in patients with the following medical complexities: cardiac disease, developmental delay, neurologic disease, eye disease, and genetic syndromes not associated with hearing loss. The interval was significantly shorter in patients with abnormal ear anatomy. ConclusionPatient factors, such as insurance type and certain medical diagnoses, may lead to delayed ABR testing under anesthesia and thus delayed diagnosis and management of hearing loss. This has implications for the timely care and treatment of children with hearing loss.

Outcomes of pediatric-focused advanced practice provider fellowship programs: An integrative review.

An increased demand for pediatric-focused advanced practice providers (APPs) exists to address the health care needs of children with medical complexity. Postlicensure advanced practice fellowship programs have been developed to help improve novice provider transition to practice, reducing attrition. The objectives of this integrative review are to (1) identify outcome measurements of pediatric-focused advanced practice fellowship programs and (2) evaluate the outcome measures to guide future implications for practice. A systematic integrative literature review was conducted in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses. PubMed, CINAHL, Embase, and Google Scholar were searched in August and September 2022. Articles met inclusion criteria if they included new graduate APPs, reported the intervention of a pediatric fellowship program, and shared outcome measurements. Studies were excluded if they did not directly report on fellowship program outcome measures. Thirteen studies met inclusion criteria and were summarized and appraised for quality using the Johns Hopkins Evidence-Based Practice Model. Four themes from the literature included the favorable impact of advanced practice fellowship programs on (a) job satisfaction, (b) retention, (c) clinical and professional performance, and (d) financial outcomes. Variable strategies were used to measure outcomes across programs. Postlicensure pediatric-focused advanced practice fellowship programs seem to improve retention and job satisfaction, increase provider confidence, and bring a favorable return on investment for the organization. Future work should include investment in developing validated, standardized assessment tools to support future development of these programs in the pediatric population.

Inside the Black (W)hole: A Queer Black Feminist Retrospective

This essay introduces a spirited cross-disciplinary and intergenerational queer black feminist dialogue about what Evelynn Hammonds’s 1994 differences essay “Black (W)holes and the Geometry of Black Female Sexuality” has meant, and continues to mean, for queer black feminist knowledge production and (academic) subject formation within and beyond the United States. Across ten essays and one poem, contributors to this special issue of differences interrogate what it means for queer black feminists to labor in a field under constant erasure; to argue for the possibilities for queer and trans and sick black women’s erotic agency in the context of hostile institutional formations such as the academic and medical industrial complexes; and to analyze the relevance of empirical black holes for theorizing polymorphous black female sexualities and erotic freedoms. From inside the black (w)hole, contributors chart the history, present, and futurity of Hammonds’s “Black (W)holes,” and, by extension, the black diasporic feminist, lesbian, queer, and trans intellectual and sociopolitical life-worlds in its wake.

Exploring What Motivates Parents of Children Living With Medical Complexity to Participate in Research

Exploring What Motivates Parents of Children Living With Medical Complexity to Participate in Research

ESKAPE Pathogens: Antimicrobial Resistance Patterns, Risk Factors, and Outcomes a Retrospective Cross-Sectional Study of Hospitalized Patients in Palestine.

Antimicrobial resistance to ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp). remains a major challenge in hospital settings. This study aimed to determine the ESKAPE antimicrobial resistance patterns and associated factors with multi-drug resistance strains among hospitalized patients in a single tertiary care medical hospital in Palestine. A single-center retrospective cross-sectional study was conducted by reviewing patients' electronic medical records and laboratory results from November 1, 2021, to November 30, 2022, at the Palestine Medical Complex in Palestine. The study included patients aged > 18 years who had been infected with ESKAPE pathogens 48 hours after hospital admission. This study included 231 patients, of whom 90.5% had MDR infections. In total, 331 clinical samples of ESKAPE pathogens were identified. A. baumannii was the most prevalent MDR pathogen (95.6%) with Carbapenem-resistant exceeding 95%, followed by K. pneumoniae (83.8%) with extended-spectrum cephalosporin resistance exceeding 90%, S. aureus (68.2) with 85% oxacillin-resistance, E. faecium (40%) with 20% vancomycin resistance, P. aeruginosa (22.6%) with 30% carbapenem resistance. Furthermore, emergent colistin resistance has been observed in A. baumannii, K. pneumoniae, and P. aerogenesis. Risk factors for MDR infection included age (p< 0.035), department (p< 0.001), and invasive procedures such as IUC (p< 0.001), CVC (p< 0.000), and MV (p< 0.008). Patients diagnosed with MDR bacteria had increased 30-day mortality (p< 0.001). The findings of this study show alarming MDR among hospitalized patients infected with ESKAPE pathogens, with resistance to first-line antimicrobial agents and emerging resistance to colistin, minimizing treatment options. Healthcare providers and the Ministry of Health must take steps, adopt policies to prevent antimicrobial resistance, adhere to infection control guidelines, implement antimicrobial stewardship programs to prevent and limit the growing health crisis, and support research to discover new treatment options.

Utilizing the determinants of healthy aging to guide the choice of social prescriptions for older adults.

Executive summary: The age of Canada's population is increasing, necessitating innovative methods and tools for assessing the needs of older adults and identifying effective health and social prescriptions. In Alberta, a community-based, senior-serving organization undertook the development and piloting of the Healthy Aging Asset Index, an assessment tool and social prescribing guide for use by a variety of professionals within the community. Tool development was rooted in medical complexity assessment and social work practice, and adhered to the determinants of healthy aging established by Alberta's Healthy Aging Framework, which is based on the determinants of healthy aging published by the World Health Organization. Results from the pilot showed improvement in the functionality of older adults within the determinants over time, as they were supported in addressing areas of personal vulnerability. Adopting tools such as the Healthy Aging Asset Index can bring cohesiveness to the support that older adults receive across the care continuum and has the potential to shift the balance of care away from the health system and towards the community, thus improving the capacity of health systems and government to meet the needs of Canada's older adults.

The Cost-Effectiveness of Early Invasive Procedures for Acute Coronary Syndrome in Low-Income Regions: A Prospective Cohort Study in Pakistan.

Background Acute coronary syndrome (ACS) is a significant cause of mortality and morbidity globally, necessitating effective intervention strategies. Early invasive procedures such as percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are often recommended for high-risk patients. However, their cost-effectiveness in low-income regions remains uncertain, particularly in Pakistan, where healthcare resources are limited. Objective This study aims to evaluate the cost-effectiveness of early invasive procedures compared to standard care for ACS in low-income regions of Pakistan. Methods We conducted a prospective cohort study from January 1, 2021, to January 31, 2021, at four major hospitals in Pakistan: Army Cardiac Center Combined Military Hospital (CMH) Lahore, National Institute of Cardiovascular Diseases in Karachi, Lady Reading Hospital in Peshawar, and Mardan Medical Complex. The participants included 436 patients diagnosed with ACS aged 18 years or older and presenting within 24 hours of symptom onset. The patients were divided into two groups: the early invasive procedure group (n = 218) and the standard care group (n = 218). The primary outcome was the 30-day mortality rate. Secondary outcomes included recurrent myocardial infarctions, hospital readmissions, healthcare costs, and procedural complications. Data were analyzed using SPSS version 25.0 (IBM SPSS Statistics, Armonk, NY), employing descriptive statistics, chi-square tests, independent t-tests, and Kaplan-Meier survival analysis. Results The early invasive procedure group showed a mortality rate of 18 (8%) compared to 33 (15%) in the standard care group, demonstrating a significant reduction in mortality (p = 0.01). Additionally, the average healthcare cost was significantly lower in the early invasive group, with mean costs of Pakistani rupee (PKR) 187,200 (US dollar {USD} 1,200) compared to PKR 280,800 (USD 1,800) in the standard care group (p < 0.01). Recurrent myocardial infarctions occurred in 11 (5%) of the early invasive group versus 26 (12%) in the standard care group (p < 0.05). Hospital readmission rates were lower in the early invasive group, 22 (10%) compared to 39 (18%) in the standard care group (p < 0.05). Healthcare costs were significantly lower in the early invasive group, with mean costs of PKR 187,200 (USD 1,200) compared to PKR 280,800 (USD 1,800) in the standard care group (p < 0.01). Conclusion Early invasive procedures for ACS significantly improve survival rates, reduce complications, and lower healthcare costs in low-income regions of Pakistan. These findings suggest that such strategies should be considered in resource-limited settings to optimize patient outcomes and healthcare resource utilization.

Diagnostic Accuracy of Mammography and Ultrasonography Screening for Breast Cancer in Pregnant and Lactating Women

Breast cancer was of significant health concern affecting women worldwide. Objective: To assess diagnostic accuracy of mammography and ultrasonography in differentiating malignant and benign breast lesions in pregnant and lactating women. Methods: A cross sectional retrospective study was conducted at Radiology department of Shahida Islam Medical Complex, Lodhran from May 2023 to April 2024. A sample size of 242 females was calculated. Electronic medical records were reviewed for radiological examination including screening ultrasound and mammography. All those pregnant and lactating females on which ultrasound and mammograms were performed were included. SPSS version 23.0 was used for data analysis. Diagnostic accuracy of both ultrasound and mammography were calculated in terms of malignant or benign and sensitivity and specificity. Mann-Whitney U test was applied between mammography, ultrasonography and BI-RADS categories. Results: Of 242 females, 110 underwent mammography and 132 underwent ultrasound. Negative mammography was observed in 71 females in which at biopsy, 24 were benign. Negative ultrasound with only benign lesion was seen in 68 females and 10 of which were confirmed at biopsy. Specificity of ultrasonography was 100 %, sensitivity 85.7 %, positive predictive value of 100 % while negative predictive value of 25 %. Specificity of mammography was 100 %, sensitivity 92.3 %, positive predictive value of 100 % while negative predictive value of 42.8 % (p&lt;0.001). Conclusions: Although both ultrasound and mammography were found to be specific, use of mammography was considered better in terms of sensitivity and diagnostic accuracy.

Historical aspects of the creation and development of university clinics (literature review)

The study is relevant due to the special role of university clinics in maintaining and strengthening public health, since these medical institutions provide training future doctors, conduct clinical and scientific activities, develop and test advanced treatment methods. A systematic review of the literature sources (original research and reviews) selected using bibliographic and semantic search in the databases MedLine, The Cochrane Library, Global Health, Cyb,erLeninka, RSCI, devoted to the historical aspects of the creation and development of university clinics. The authors studied the specifics of the activities of university clinics, searched for solutions to the problem of improving the efficiency and quality of both medical and educational processes of their life. Despite the fact that university clinics originated in different ways, the main models of their activities are highlighted in the form of a single educational, scientific, and medical complex, which allows training of medical personnel at a qualitatively different level, providing practice-oriented training, as well as the possibility of developing scientific achievements of medical science. The literature data provided by the authors indicate university clinics today to be centers of advanced practical and scientific experience in providing medical care of the population. The study of historical patterns of development of university clinics makes it possible to use the most successful experience of their management in the structure of an educational institution and develop requirements that a university clinic must meet at the present stage to ensure strategic sectoral tasks of the state health system both within the framework of training medical personnel and in ensuring the process of providing medical care of the population in the Russian Federation.

Trauma care supported through a global telemedicine initiative during the 2023–24 military assault on the Gaza Strip, occupied Palestinian territory: a case series

Hospitals, patients, and health-care workers are legally protected by international humanitarian law and the Geneva Convention. However, since Oct 7, 2023, the health-care system in the Gaza Strip, occupied Palestinian territory, has been under unprecedented direct military attacks by Israel, with support for patients proving to be challenging for the remaining health-care workers. Peer-to-peer telemedicine holds promise for assisting surgeons in high-risk, low-resource environments, but might be of reduced utility in extremely austere settings. We present a patient case series of traumatic injuries shared in an international telemedicine group by the surgical team at Nasser Medical Complex, also known as Nasser Hospital, the largest remaining partially functioning hospital in Gaza. WhatsApp (Meta; Menlo Park, CA, USA), a widely available and user-friendly end-to-end encrypted smartphone application, was used to facilitate consultations for weapon-inflicted injuries. All the presented patient cases were shared after obtaining verbal consent from the patients and discussed through a multidisciplinary team approach. The group was developed into a community with more than 15 specialty and injury-oriented subgroups and over 1000 members who joined through non-targeted social media outreach followed by snowball recruitment. Prospective registration and formal ethics approval in Gaza was impossible because the Ministry of Health, including the local Helsinki Committee, had suspended all operations. In June, 2024, we obtained ethics approval from the local Helsinki committee in Gaza. We present 12 select patient case studies from a pool of hundreds of patients admitted to Nasser Hospital between Jan 28 and Feb 12, 2024. Four (33%) of the 12 patients were female and eight (67%) were male, with four patients (33%) being children (younger than 18 years). The age range was between 3 years and 70 years, with a median age of 25 years. Most patients presented with penetrating injuries (11 [92%] of 12), with six patients presenting with wounds secondary to fragment injury, and five patients presenting with wounds due to gunshots. One patient presented with a direct blast injury. The site of reported injuries included head and neck areas (four [33%] of 12), abdomen (four [33%] of 12), chest (three [25%] of 12), pelvis (two [17%] of 12), and limbs (one [8%] of 12). Most patients were lost to follow-up (11 [92%] of 12) and were affected by the invasion of the hospital by the Israeli Defense Forces, which subsequently rendered the hospital non-functional. One patient died following their injury. The health-care team at the now non-functioning Nasser Hospital in southern Gaza adapted their allocation and distribution of extremely low resources and relied on smartphones for specialised telemedicine outreach purposes. This enhanced the capability of the medical teams in management of mass casualties of military assaults that few are trained to work in. Nonetheless, the options available to a health-care system that is under-staffed, under-served, and under siege, are extremely constrained, regardless of such telemedicine initiatives. None.

Child maltreatment and behavioral health outcomes in child welfare: Exploring the roles of severity and polyvictimization

BackgroundChild maltreatment and polyvictimization are known risk factors for long-term detrimental health and development outcomes, including behavioral health challenges. However, effects from specific types and combinations of maltreatments are unclear. This study examined the association between maltreatment or polyvictimization and behavioral health in a child welfare sample. Participants and settingMedical records of children with child welfare involvement with at least one behavioral health condition (i.e., mental, behavioral or neurodevelopmental disorder, ICD-10 F01-F99) between 1/1/2018–12/31/2021 were extracted from a large, academic hospital system. MethodsBehavioral health complexity was categorized as non-chronic, non-complex chronic, or complex chronic using the Pediatric Medical Complexity Algorithm. Partial proportional logistic regression models adjusted for age, sex, race/ethnicity, caregiver type, and physical health complexity generated odds of behavioral health complexity by maltreatment type (physical abuse, sexual abuse, neglect) and maltreatment combinations. ResultsThe analytic sample included 3992 participants (mean age 7.6 (Standard Deviation, 5.0) 44 % female, 29 % white, 32 % black, 22 % Hispanic). Participants who experienced physical abuse (Odds Ratio [OR]: 1.79, 95 % Confidence Interval [CI]: 1.10–2.91), or neglect (OR: 1.69, 95 % CI: 1.38–2.07) were more likely to have increasing behavioral health complexity versus those without maltreatment. Participants with both physical abuse and neglect were over twice as likely (OR: 2.44, 95 % CI: 1.88–3.16) to have increasing behavioral health complexity versus those who did not experience maltreatment. ConclusionResults emphasize the differential impacts of maltreatment and polyvictimization exposures on behavioral health complexity among children with child welfare involvement that can guide risk assessment and clinical care.

Caregiver and Care Team Perceptions of Online Collaborative Care Planning for CMC.

Care plans summarize a child with medical complexity's (CMC) medical history and ongoing care needs. Often, the health care team controls the care plan content, limiting caregivers' ability to edit the document in real time and potentially compromising accuracy and utility. With this study, we aimed to provide caregivers of CMC with online access and shared editing control of their child's care plan and to explore the experiences of caregivers and care team members (CTMs) after using an online collaborative care plan (OCCP). Caregivers of CMC were recruited from a tertiary complex care program to use an online, patient-facing platform for 6 months, which included the ability to edit and share their child's care plan. Caregivers and CTMs participated in semi-structured interviews to explore their experiences in using the OCCP. Consistent with grounded theory methodology, a constant comparative analysis was used, which allowed for theoretical sampling and theory generation. A total of 15 caregivers and 20 CTMs completed interviews. Interviews revealed 3 major themes and 9 subthemes, including (1) the navigation of uncharted roles (trust, responsibility), (2) the requirements for success (electronic medical record integration, online access, collaborative care plan review), and (3) cohesive care (accessibility and convenience, being on the same page, autonomy). Themes informed the creation of a theoretical model for the implementation and utility of OCCPs. Online, collaborative care plans, when implemented safely and thoughtfully, promote shared understanding, improve caregiver autonomy, and increase the accessibility of health information. Together, these benefits facilitate cohesive care and authentic partnership between caregivers and CTMs in the care of CMC.

Collaborative practices for children with medical complexities and their families: A scoping review

Objective This scoping review aimed to provide an overview of collaborative practices for children with medical complexities and their families by life stage.Methods This scoping review was conducted based on the JBI scoping review manual using the PubMed, CINAHL, and Medical Journal databases. Search terms included "collaboration," "intersectoral collaboration," "children with medical complexity," and "children with special healthcare needs," whereas control words included "children with special healthcare needs," "children with medical care," "children with severe mental and physical disabilities," and "children with severe mental and physical disabilities." The inclusion criteria were articles in Japan that reported on practices for children (aged 0-18 years) with medical care needs and collaboration among other multiple professions, research articles, excluding review and protocol articles, and English or Japanese articles. For the analysis, collaboration-related practices were extracted from selected papers, categorized based on similarities in content, and further summarized according to the life stage. Three researchers discussed the selection of papers, data extraction, and analysis until a consensus was reached.Results The analysis included 30 papers (27 Japanese and three English papers). Regarding publication year, 14 papers were published within the last 3 years. Additionally, 19 case and 26 practice reports and 11 studies (quantitative research; one, qualitative research; 10) were published by professionals. Regarding collaborative practices, 160 cases were extracted and classified into nine. In "discharge support," practices in all subcategories were reported for preschoolers, whereas only two of the five subcategories were reported for school-aged children. Contrastingly, in the "maintenance phase in preschool, daycare, and school," preschoolers reported practices in two of the seven subcategories. Additionally, various professionals from the fields of medicine, welfare, education, and administration were involved in the collaboration.Conclusion There were differences in the reporting of collaborative practices at each life stage. Although numerous professionals were involved, reports of collaborative practices among them were unevenly distributed. Eventually, it will be necessary to investigate the nature of collaborative practices among various professionals, focusing on children and their families.

The association between medication use and health-related quality of life in multimorbid older patients with polypharmacy.

To explore the association between medication use-related factors and health-related quality of life (HRQoL) in older hospitalised multimorbid patients with polypharmacy. This cross-sectional study used the intervention arm data of the OPERAM trial (hospitalised patients ≥ 70years with polypharmacy). HRQoL was assessed using the visual analogue scale (EQ-VAS) and the EQ-5D index score of the EuroQol questionnaire (EQ-5D-5L). Lower or higher EQ-VAS/EQ-5D was based on the median of the study population. Medication use-related factors included hyperpolypharmacy (≥ 10 medications), anticholinergic and sedative burden, appropriateness of medication (STOPP/START criteria), high-risk medication for hospital (re)admission, medication complexity and adherence. Multivariable logistic regression analysis was used to assess the association between medication use-related factors and HRQoL. A total of 955 patients were included (mean age 79years, 46% female, median EQ-VAS of 60, median EQ-5D of 0.60). Opioids use was associated with lower EQ-5D and EQ-VAS (aOR EQ-5D: 2.10; 95% CI 1.34-3.32, EQ-VAS: 1.59; 1.11-2.30). Hyperpolypharmacy (aOR 1.37; 1.05-1.80), antibiotics (aOR 1.64; 1.01-2.68) and high medication complexity (aOR 1.53; 1.10-2.15) were associated with lower EQ-VAS. A high anticholinergic and sedative burden (aOR 1.73; 1.11-2.69), presence of multiple prescribing omissions (aOR 1.94; 1.19-3.17) and benzodiazepine use (aOR 2.01; 1.22-3.35) were associated with lower EQ-5D. Especially in hyperpolypharmacy patients, high anticholinergic and sedative burden and medication complexity were associated with a lower HRQoL. Several medication use-related factors are significantly associated with a lower HRQoL in hospitalised older patients. Medication complexity is a novel factor, which should be considered when evaluating medication use of older patients with hyperpolypharmacy.