The medical home experience among children with sickle cell disease
Department of Pediatrics, Baylor College of Medicine, Hematology/Oncology, Houston, Texas. .Pediatric Blood & Cancer (Impact Factor: 2.39). 02/2013; 60(2). DOI: 10.1002/pbc.24184
BACKGROUND: While a large body of research documents acute care services for children with sickle cell disease (SCD), little is known about the primary care experiences of this population. The goal of this study was to determine to what extent children with SCD experienced care consistent with a patient-centered medical home (PCMH). PROCEDURE: We collected and analyzed data from 150 children, ages 1-17 years, who received care within a large children's hospital. The primary dependent variable was access to a PCMH or its four individual components (regular provider, comprehensive care, family-centered care, and coordinated care) as determined by parental report. Multivariate logistic regression was conducted to investigate associations between socio-demographic variables and having access to a PCMH. RESULTS: Only 11% (16/150) of children qualified as having a PCMH, achieving the required thresholds in all four components. Approximately half of children had access to two or fewer components. Over 90% of children were reported to have a personal provider. Two-thirds of children had access to comprehensive care. Almost 60% of children were reported to receive family-centered care. Only 20% of children had access to coordinated care. No consistent associations were found between socio-demographic variables and having access to a PCMH or its individual components. CONCLUSIONS: Within our study sample, children with SCD experienced multiple deficiencies in having access to a PCMH, particularly with respect to care coordination. However, further studies with larger samples are needed to determine associations between socio-demographic variables and having a PCMH. Pediatr Blood Cancer © 2012 Wiley Periodicals, Inc.
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ABSTRACT: Sickle cell disease (SCD) is marked by high utilization of medical services. The aim of this study was to determine whether having a patient-centered medical home (PCMH) is associated with a reduction in emergency care (ED) utilization or hospitalizations among children with SCD. We collected and analyzed data from parents of 150 children, ages 1 to 17 years, who received care within a large children's hospital. The primary dependent variables were rates of parent-reported ED visits and hospitalizations. The principal independent variable was parent-reported experience with an overall PCMH or its four individual components (regular provider, comprehensive care, family-centered care, and coordinated care). Multivariate negative binomial regression, yielding incident rate ratios (IRR), was used for analysis. Children who received comprehensive care had half the rate of ED visits (IRR 0.51, 95% confidence interval, 0.33-0.78) and nearly half the rate of hospitalizations (IRR 0.56, 95% confidence interval, 0.33-0.93) compared to children without comprehensive care. No other component of the PCMH was significantly associated with ED visits or hospitalizations. Children reported to have excellent/very good/good health status had lower odds of ED visits and hospitalizations compared to those reported to be in fair/poor condition. Children with SCD reported to experience comprehensive care had lower rates of ED encounters and hospitalizations after controlling for demographics and health status. The overall findings highlight that the provision of comprehensive care--having a usual source of care and no problems with referrals--may provide a strategy for improving pediatric SCD care.Journal of the National Medical Association 06/2013; 105(2):157-65. · 0.96 Impact Factor
- 06/2013; 4(1).
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ABSTRACT: In patients hospitalized with community-acquired pneumonia (CAP), indicators of clinical instability at discharge (fever, tachycardia, tachypnea, hypotension, hypoxia, decreased oral intake and altered mental status) are associated with poor outcomes. It is not known whether the order of indicator stabilization is associated with outcomes. To describe variation in the sequences, including whether and in what order, indicators of clinical instability resolve among patients hospitalized with CAP, and to assess associations between patterns of stabilization and patient-level outcomes. Chart review ascertained whether and when indicators stabilized and other data for 1,326 adult CAP patients in six U.S. academic medical centers. The sequences of indicator stabilization were characterized using sequence analysis and grouped using cluster analysis. Associations between sequence patterns and 30-day mortality, length of stay (LOS), and total costs were modeled using regression analysis. We found 986 unique sequences of indicator stabilization. Sequence analysis identified eight clusters of sequences (patterns) derived by the order or speed in which instabilities resolved or remained at discharge and inpatient mortality. Two of the clusters (56 % of patients) were characterized by almost complete stabilization prior to discharge alive, but differing in the rank orders of four indicators and time to maximum stabilization. Five other clusters (42 % of patients) were characterized by one to three instabilities at discharge with variable orderings of indicator stabilization. In models with fast and almost complete stabilization as the referent, 30-day mortality was lowest in clusters with slow and almost complete stabilization or tachycardia or fever at discharge [OR = 0.73, 95 % CI = (0.28-1.92)], and highest in those with hypoxia with instabilities in mental status or oral intake at discharge [OR = 3.99, 95 % CI = (1.68-9.50)]. Sequences of clinical instability resolution exhibit great heterogeneity, yet certain sequence patterns may be associated with differences in days to maximum stabilization, mortality, LOS, and hospital costs.Journal of General Internal Medicine 10/2013; 29(4). DOI:10.1007/s11606-013-2626-7 · 3.42 Impact Factor
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