Structured Clinical Program Research Articles

Health care utilization after enrollment in an outpatient structured clinical program for children with medical complexity

Abstract Objectives Although children with medical complexity (CMC) with high health resource utilization use outpatient structured clinical programs (SCP) to optimize their health, little is known about variation in trends of their health service use shortly after enrollment. We measured these trends and assessed the utility of patient characteristics to predict them. Methods Retrospective analysis of 506 CMC newly enrolled in an outpatient, academic SCP. We measured outpatient and inpatient health service use for the first 6 months following enrollment. Using cluster analysis, we categorized CMC with similar trends by health service. We assessed patient demographic (e.g., age) and clinical [type and number of complex chronic conditions (CCC)] characteristics with the cluster categories. Results Most (90.3%) CMC enrolled had ≥1 CCCs; 53.8% had ≥3 CCCs. For all CMC, outpatient specialty visits, phone calls, and hospitalizations (not involving ICU) decreased significantly over the first 6 months after enrollment. For example, the hospitalization rate decreased from 9.7% to 4.5% in the 1st and 6th months, respectively, (P < 0.001). Cluster analysis revealed four categories of hospitalization trends, 6 months after enrollment: 72.9% of CMC had no hospital use; 16.0% had increased then decreased use; 8.3% had decreased use; and 2.8% had increased use. No patient and clinical characteristics clearly distinguished which hospitalization trend CMC experienced. Conclusions Although the overall population of CMC experienced decreased outpatient and inpatient health services utilization over time, this decrease was not uniformly experienced. Fundamental patient demographic and clinical characteristics did not predict health service trends.

Caring for Children With Medical Complexity in the Early COVID-19 Pandemic in an Ambulatory Primary Care Setting.

BackgroundChildren with medical complexity (CMC) have multiple chronic conditions and require a high level of coordinated healthcare. The risk of COVID-19 among CMC is unclear.ObjectivesWe aim to identify and describe the prevalence and experience of COVID-19 among CMC and their caregivers during the initial weeks of the COVID-19 pandemic in the NY metropolitan area.MethodsWe performed a cross-sectional study of children enrolled in a structured clinical program for CMC at a large urban, academic general pediatrics practice in NY.ResultsIn our patient population (n = 132), 16 patients had a known exposure with parents being the most common exposure in 37.5% (n = 6). Two patients were hospitalized for COVID-19 while the remainder of the confirmed or suspected COVID-19 cases were managed as an outpatient.ConclusionsCommon sources of COVID-19 exposure were family members and home care providers. Almost all of our patients experienced interruption of medical care including missed therapies and visits.

Instituting an intrathecal baclofen pump program at an academic institution.

Intrathecal baclofen (ITB) therapy via an implantable infusion system is an effective treatment for severe medical refractory spasticity and can significantly improve quality of life for patients, but it is not without risk. A structured clinical program with regular maintenance and pump failure protocols is essential to ensure patient safety. We outline two distinct institutional experiences of developing a multidisciplinary ITB program, one pediatric and one adult. At our adult institution, management is divided between the physical medicine and rehabilitation (PMR) and neurosurgical teams. PMR responsibilities include patient selection, baclofen injection and tone assessment, pump titration/maintenance, and outpatient follow-up. Neurosurgery responsibilities include inpatient management, intrathecal access, pump insertion and evaluation in cases of suspected pump failure. At our pediatric institution, PMR is responsible for patient selection, tone assessment during baclofen trial (lumbar puncture and baclofen injection is provided by interventional radiology), inpatient management/titration, pump titration/maintenance, evaluation in cases of suspected pump failure, and outpatient follow-up. Neurosurgery responsibilities include patient selection, inpatient management, pump insertion, evaluation and emergent surgical treatment in cases of suspected pump failure. ITB therapy is an effective treatment for severe medical treatment-resistant spasticity that significantly improves quality of life for many patients but is not without risk. The implementation of a structured multidisciplinary program is essential to ensure patient safety and best practice. This article is protected by copyright. All rights reserved.

Cost-effectiveness of long-term clinical management of BRCA pathogenic variant carriers

PurposeWomen who inherit a BRCA1 or BRCA2 pathogenic variant are at high risk of developing breast and ovarian cancer. Evidence for the effectiveness and cost-effectiveness of long-term management in clinical practice is lacking. The purpose of this study was to evaluate the real-world cost-effectiveness of BRCA carrier management within a structured clinical program. MethodsLifetime health outcomes and costs of clinical management for female unaffected BRCA carriers aged 20 were measured using a microsimulation model. For the intervention, women could attend a high-risk clinic, undergo risk-reducing surgery, and receive annual breast screening. Input data for the model was from a clinical database of 983 BRCA carriers. The comparator was no risk management. Outcomes were discounted at 5%. ResultsThe incremental cost-effectiveness ratio for the program was $32,359 to $48,263 per quality-adjusted life-year (QALY). Limiting uptake of risk-reducing salpingo-oophorectomy to <50% of carriers decreased cost-effectiveness by $7000–8000 per QALY. Achieving perfect adherence to guidelines was less cost-effective for BRCA2 due to increased risk-reducing mastectomy costs with smaller incremental health benefit. ConclusionLong-term management of BRCA carriers within a structured clinical program is cost-effective. Suboptimal adherence to risk management guidelines can substantially affect outcomes and is an important consideration for future studies.

Evaluation of a structured clinical program and formal coursework in breast surgeon training in Australia and New Zealand

IntroductionBreast surgeon training has been restructured since the inception of Breast Surgeons of Australia and New Zealand Inc. (BreastSurgANZ) in 2010. In 2016 a voluntary online course with a contemporary curriculum for breast surgery was initiated and taken up by the majority of post-fellowship trainees (PFTs). This article reports on PFT's perceptions of these major changes. MethodsA 46-item online survey was sent to the 56 PFTs enrolled in 2015–2017. The survey canvassed PFT's views on aspects of the two-year training program, the Graduate Certificate in Breast Surgery (GCBS) and the role of BreastSurgANZ in training. Results33/56 participants responded. The training program was rated positively with variation in satisfaction levels depending on operating experience and quality of training between clinical placements. The majority of respondents endorsed restricting numbers of training positions. GCBS students valued the clinical knowledge and structured format of the course. A range of diverse, often opposing, opinions were expressed on the appropriate role of BreastSurgANZ in training and accreditation. DiscussionThe dissonance caused by variability in training exposure and perceived mentor quality in different sites was the most important finding. The GCBS was well regarded by all students but time constraints and costs prevented some PFTs from undertaking the course. Standardisation of mandatory requirements for full BreastSurgANZ membership was identified as an issue for further consideration. ConclusionThis evaluation illuminates the challenges of providing consistently high quality breast surgical training. Many of the issues raised are being addressed by BreastSurgANZ.

Effectiveness of a structured clinical program in paediatric undergraduate training

Objective: To assess the effectiveness of a structured training program in Paediatrics during the clinical posting of final term undergraduates. Methods: 250final term undergraduate studentsdivided into 5 batchesparticipated in the study. They were given a pretest questionnaire on specific topics and scored for a maximum of 10. The answers were corrected by 2 different examiners. The overall scores were categorized as poor ( 7). A four week structured training program of 10 topics of Paediatrics was designed. It consisted traditional formats of teaching modules like general clinics, bedside clinics, ward rounds, procedures and therapeutic discussions.To maintain continuity and reinforce learning, a topic was selected as a theme of the day and various aspects of this topic were dealt with, during the interactions in the above modules.At the end of 4 weeks the post test (same questions and format of evaluation as pretest) was administered. The data was analyzed using Gamma test and McNemer’s tests. P value of <0.05 was taken as statistically significant.Results: In the pre-test, 77.7% scored poor and none of them had good scores. Post-test poor scores decreased to 8.9% and 23.13% had good scores. Astatistically significant improvement in the performance of the students’ in the post-test was noted as compared to the pre-test.Conclusions: The structured training program which was used in this study resulted in significant improvement in the clinical knowledge of students.

Health Services and Health Care Needs Fulfilled by Structured Clinical Programs for Children with Medical Complexity

To describe family-reported health service needs of children with medical complexity (CMC) and to assess which needs are more often addressed in a tertiary care center-based structured clinical program for CMC. Mailed survey to families of CMC enrolled in a structured-care program providing care coordination and oversight at 1 of 3 children's hospitals. Outcomes included receipt of 14 specific health service needs. Paired t tests compared unmet health care needs prior to and following program enrollment. Four hundred forty-one of 968 (46%) surveys were returned and analyzed. Respondents reported their children had a mean age of 7 (SD 5) years. A majority of respondents reported the child had developmental delay (79%) and feeding difficulties (64%). Of the respondents, 56% regarded the primary care provider as the primary point of contact for medical issues. Respondents reported an increase in meeting all 14 health services needs after enrollment in a tertiary care center-based structured clinical program, including primary care checkups (82% vs 96%), therapies (78% vs 91%), mental health care (34% vs 58%), respite care (56% vs 75%), and referrals (51% vs 83%) (all P < .001). Tertiary care center-based structured clinical care programs for CMC may address and fulfill a broad range of health service needs that are not met in the primary care setting.

Implementing music therapy on an adolescent inpatient unit: a mixed-methods evaluation of acceptability, experience of participation and perceived impact.

We aimed to assess the feasibility of delivering a music therapy program on adolescent psychiatric wards. We undertook a mixed-methods evaluation of a pilot program. Various active and receptive techniques were employed in group music therapy sessions delivered as part of a structured clinical program. Data collected in interviews with participants and staff and feedback questionnaires were thematically and descriptively analysed and triangulated. Data from 62 questionnaires returned by 43 patients who took part in 16 music therapy sessions, and seven staff, evidenced strong support for music therapy. Patients typically reported experiencing sessions as relaxing, comforting, uplifting, and empowering; >90% would participate by choice and use music therapeutically in the future. Staff endorsed music therapy as valuable therapeutically, reporting that patients engaged enthusiastically and identified sessions as improving their own moods and ward milieu. Integration of music therapy in inpatient treatment of adolescents is feasible and acceptable, and is valued by staff and patients as a complement to 'talking therapies'. Participation is enjoyed and associated with outcomes including improvement in mood, expression of feelings and social engagement consistent with recovery.

Characteristics of Hospitalizations for Patients Who Use a Structured Clinical Care Program for Children with Medical Complexity

To describe the characteristics of hospitalizations for patients who use clinical programs that provide care coordination for children with multiple, chronic medical conditions. Retrospective analysis of 1083 patients hospitalized between June 2006 and July 2008 who used a structured, pediatric complex-care clinical program within 4 children's hospitals. Chronic diagnosis prevalence (ie, technology assistance, neurologic impairment, and other complex chronic conditions), inpatient resource utilization (ie, length of stay, 30-day readmission), and reasons for hospitalization were assessed across the programs. Over the 2-year study period, complex-care program patients experienced a mean of 3.1 ± 2.8 admissions, a mean length of hospital stay per admission of 12.2 ± 25.5 days, and a 30-day hospital readmission rate of 25.4%. Neurologic impairment (57%) and presence of a gastrostomy tube (56%) were the most common clinical characteristics of program patients. Notable reasons for admission included major surgery (47.1%), medical technology malfunction (9.0%), seizure (6.4%), aspiration pneumonia (3.9%), vomiting/feeding difficulties (3.4%), and asthma (1.8%). Hospitalized patients who used a structured clinical program for children with medical complexity experienced lengthy hospitalizations with high early readmission rates. Reducing hospital readmission may be one potential strategy for decreasing inpatient expenditures in this group of children with high resource utilization.