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Patrick H. Casey, MD; Robert E. Lyle, MD; Tommy M. Bird, MS; et al.
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Arch Pediatr Adolesc Med. 2011;165(5):392-398. doi:10.1001/archpediatrics.2011.5
ObjectiveTo evaluate the effect on all state Medicaid costs of a children's hospital-based multidisciplinary clinic that provides comprehensive and coordinated care for medically complex children.DesignBefore-after intervention study. Patients' health care costs for up to 1 year before enrollment in the clinic were compared with patients' health care costs for up to 1 year after enrollment in the clinic. Patients were enrolled in our study from August 2006 to May 2008.SettingTertiary care children's hospital in a rural state.ParticipantsA total of 225 medically complex children who had at least 2 chronic medical conditions and who were followed up by at least 2 pediatric subspecialists.InterventionMultidisciplinary teams ensure that each patient receives all the necessary medical, nutritional, and developmental care and that there is improved coordination of care with primary care providers, subspecialists, hospitalists, and community-based services.Main Outcome MeasuresUsing Arkansas Medicaid claims data, we examined the medical costs for all outpatient, inpatient, emergency department, and prescription drug claims. Costs were calculated on a per month per patient basis and summarized for annual costs.ResultsThe mean annual cost per patient per month decreased by $1766 for inpatient care (P聽<聽.001) and by $6.00 for emergency department care (P听&濒迟;听.001). Although the cost per patient per month for outpatient claims (P聽<聽.05) and prescriptions (P聽<聽.001) increased, the overall cost to Medicaid per patient per month decreased by $1179 (P听&濒迟;听.001).ConclusionsThis hospital-based multidisciplinary clinic resulted in a significant decrease in total Medicaid costs for medically complex children.
Jean L. Raphael, MD, MPH; Minghua Mei, PhD; David C. Brousseau, MD, MS; et al.
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Arch Pediatr Adolesc Med. 2011;165(5):399-404. doi:10.1001/archpediatrics.2011.33
Terri L. Byczkowski, PhD, MBA; Jennifer K. Munafo, MA; Maria T. Britto, MD, MPH
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Arch Pediatr Adolesc Med. 2011;165(5):405-411. doi:10.1001/archpediatrics.2011.55
Alan Shapiro, MD; Delaney Gracy, MD, MPH; Wendy Quinones, BSN, MSN, CPNP; et al.
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Arch Pediatr Adolesc Med. 2011;165(5):412-418. doi:10.1001/archpediatrics.2011.49
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Editorial
What Is the Problem With Asthma Care for Children?
Miles M. Weinberger, MD
Arch Pediatr Adolesc Med
Journal Club
Ari R. Joffe, MD; Natalie R. Anton, MD; Shauna C. Burkholder, MD
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Arch Pediatr Adolesc Med. 2011;165(5):419-423. doi:10.1001/archpediatrics.2011.47
Mary Beth Gordon, MD; Patrice Melvin, MPH; Dionne Graham, PhD; et al.
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Arch Pediatr Adolesc Med. 2011;165(5):424-428. doi:10.1001/archpediatrics.2011.54
Henry C. Lee, MD, MS; Alyna T. Chien, MD, MS; Naomi S. Bardach, MD; et al.
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Arch Pediatr Adolesc Med. 2011;165(5):429-434. doi:10.1001/archpediatrics.2011.41
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Kristen A. Copeland, MD; Susan N. Sherman, DPA; Jane C. Khoury, PhD; et al.
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Arch Pediatr Adolesc Med. 2011;165(5):435-442. doi:10.1001/archpediatrics.2010.267
ObjectivesTo examine the variability of physical activity environments and outdoor play policies in child care centers and to determine whether this variability is associated with the demographic characteristics of the child care centers surveyed.DesignEarly Learning Environments Physical Activity and Nutrition Telephone Survey.SettingChild care centers in Hamilton County (greater Cincinnati area), Ohio, during the period from 2008 to 2009.ParticipantsDirectors of all 185 licensed full-time child care centers in Hamilton County.Outcome MeasuresDescriptive measures of playground and indoor physical activity environments and weather-related outdoor play policies.ResultsOf 185 eligible child care centers, 162 (88%) responded to our survey. Of the 162 centers that responded, 151 (93%) reported an on-site playground, but slightly more than half reported that their playgrounds were large, that they were at least one-third covered in shade, or that they had a variety of portable play equipment. Only half reported having a dedicated indoor gross motor room where children could be active during inclement weather. Only 32 centers (20%) allowed children to go outside in temperatures below 32掳F (0掳C), and 70 centers (43%) reported allowing children outdoors during light rain. A higher percentage of children receiving tuition assistance was associated with lower quality physical activity facilities and stricter weather-related practices. National accreditation was associated with more physical activity鈥損romoting practices.ConclusionWe found considerable variability in the indoor and outdoor physical activity environments offered by child care centers within a single county of Ohio. Depending on the outdoor play policy and options for indoor physical activity of a child care center, children's opportunities for physical activity can be curtailed as a result of subfreezing temperatures or light rain. Policy changes and education of parents and teachers may be needed to ensure that children have ample opportunity for daily physical activity.
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Peg C. Nopoulos, MD; Amy L. Conrad, PhD; Edward F. Bell, MD; et al.
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Arch Pediatr Adolesc Med. 2011;165(5):443-450. doi:10.1001/archpediatrics.2010.269
ObjectiveTo assess the long-term outcome of brain structure in preterm infants, at an average age of 12 years, who received a red blood cell transfusion for anemia of prematurity.DesignAs neonates, this cohort of infants participated in a clinical trial in which they received red blood cell transfusions based on a high pretransfusion hematocrit threshold (liberal group) or a low hematocrit threshold (restricted group). These 2 preterm groups were compared with a group of full-term healthy control children.SettingTertiary care hospital.ParticipantsMagnetic resonance imaging scans for 44 of the original 100 subjects were obtained.InterventionLiberal vs restricted transfusion.Main Outcome MeasuresIntracranial volume, total brain tissue, total cerebrospinal fluid, cerebral cortex and cerebral white matter volume, subcortical nuclei volume, and cerebellum volume.ResultsIntracranial volume was substantially smaller in the liberal group compared with controls. Intracranial volume in the restricted group was not different from controls. Whole-cortex volume was not different in either preterm group compared with controls. Cerebral white matter was substantially reduced in both preterm groups, more so for the liberal group. The subcortical nuclei were substantially decreased in volume, equally so for both preterm groups compared with controls. When sex effects were evaluated, the girls in the liberal group had the most significant abnormalities.ConclusionRed blood cell transfusions affected the long-term outcome of premature infants as indicated by reduced brain volumes at 12 years of age for neonates who received transfusions using liberal guidelines.
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Cade M. Nylund, MD; Anthony Goudie, PhD; Jose M. Garza, MD; et al.
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Arch Pediatr Adolesc Med. 2011;165(5):451-457. doi:10.1001/archpediatrics.2010.282
ObjectivesTo evaluate the trend in Clostridium difficile infection (CDI) among hospitalized children in the United States and to evaluate the severity of and risk factors associated with these cases of CDI.DesignA retrospective cohort study using the triennial Healthcare Cost and Utilization Project Kids' Inpatient Database for the years 1997, 2000, 2003, and 2006.SettingHospitalized children in the United States.ParticipantsA nationally weighted number of patients (10聽474聽454) discharged from the hospital, 21聽274 of whom had CDI.Main ExposureDischarge diagnosis of CDI.Main Outcome MeasuresTrend in cases of CDI; effect and severity were measured by length of hospital stay, hospitalization charges, colectomy rate, and death rate.ResultsThere was an increasing trend in cases of CDI, from 3565 cases in 1997 to 7779 cases in 2006 (P听&濒迟;听.001). Patients with CDI had an increased risk of death (adjusted odds ratio [OR], 1.20; 95% confidence interval [95% CI], 1.01-1.43), colectomy (adjusted OR, 1.36; 95% CI, 1.04-1.79), a longer length of hospital stay (adjusted OR, 4.34; 95% CI, 3.97-4.83), and higher hospitalization charges (adjusted OR, 2.12; 95% CI, 1.98-2.26). There was no trend in death, colectomy, length of hospital stay, or hospitalization charges during the 4 time periods (ie, 1997, 2000, 2003, and 2006). The risk of comorbid diagnoses associated with CDI included inflammatory bowel disease, with an OR of 11.42 (95% CI, 10.16-12.83), and other comorbid diagnoses associated with immunosuppression or antibiotic administration.ConclusionsThere is an increasing trend in CDI among hospitalized children, and this disease is having a significant effect on these children. In contrast to adults, there is no increasing trend in the severity of CDI in children. Children with medical conditions (including inflammatory bowel disease and immunosuppression) or conditions requiring antibiotic administration are at high risk of CDI.
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Adam L. Dorfman, MD; Reza Fazel, MD, MSc; Andrew J. Einstein, MD, PhD; et al.
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Arch Pediatr Adolesc Med. 2011;165(5):458-464. doi:10.1001/archpediatrics.2010.270
ObjectiveTo determine population-based rates of the use of diagnostic imaging procedures with ionizing radiation in children, stratified by age and sex.DesignRetrospective cohort analysis.SettingAll settings using imaging procedures with ionizing radiation.PatientsIndividuals younger than 18 years, alive, and continuously enrolled in UnitedHealthcare between January 1, 2005, and December 31, 2007, in 5 large US health care markets.Main Outcome MeasuresNumber and type of diagnostic imaging procedures using ionizing radiation in children.ResultsA total of 355聽088 children were identified; 436聽711 imaging procedures using ionizing radiation were performed in 150聽930 patients (42.5%). The highest rates of use were in children older than 10 years, with frequent use in infants younger than 2 years as well. Plain radiography accounted for 84.7% of imaging procedures performed. Computed tomographic scans鈥攁ssociated with substantially higher doses of radiation鈥攚ere commonly used, accounting for 11.9% of all procedures during the study period. Overall, 7.9% of children received at least 1 computed tomographic scan and 3.5% received 2 or more, with computed tomographic scans of the head being the most frequent.ConclusionsExposure to ionizing radiation from medical diagnostic imaging procedures may occur frequently among children. Efforts to optimize and ensure appropriate use of these procedures in the pediatric population should be encouraged.