Clinical Report-Physicians' Roles in Coordinating Care of Hospitalized Children
ABSTRACT The care of hospitalized children and adolescents has become increasingly complex and often involves multiple physicians beyond the traditional primary care pediatrician. Hospitalists, medical subspecialists, surgical specialists, and hospital attending physicians may all participate in the care of hospitalized children and youth. This report summarizes the responsibilities of the pediatrician and other involved physicians in ensuring that children receive coordinated and comprehensive medical care delivered within the context of their medical homes as inpatients, and that care is appropriately continued on an outpatient basis.
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ABSTRACT: Early hospital readmission is emerging as an indicator of care quality. Some children with chronic illnesses may be readmitted on a recurrent basis, but there are limited data describing their rehospitalization patterns and impact. To describe the inpatient resource utilization, clinical characteristics, and admission reasons of patients recurrently readmitted to children's hospitals. Retrospective cohort analysis of 317,643 patients (n = 579,504 admissions) admitted to 37 US children's hospitals in 2003 with follow-up through 2008. Maximum number of readmissions experienced by each child within any 365-day interval during the 5-year follow-up period. In the sample, 69,294 patients (21.8%) experienced at least 1 readmission within 365 days of a prior admission. Within a 365-day interval, 9237 patients (2.9%) experienced 4 or more readmissions; time between admissions was a median 37 days (interquartile range [IQR], 21-63). These patients accounted for 18.8% (109,155 admissions) of all admissions and 23.2% ($3.4 billion) of total inpatient charges for the study cohort during the entire follow-up period. Tests for trend indicated that as the number of readmissions increased from 0 to 4 or more, the prevalences increased for a complex chronic condition (from 22.3% [n = 55,382/248,349] to 89.0% [n = 8225/9237]; P < .001), technology assistance (from 5.3% [n = 13,163] to 52.6% [n = 4859]; P < .001), public insurance use (from 40.9% [n = 101,575] to 56.3% [n = 5202]; P < .001), and non-Hispanic black race (from 21.8% [n = 54,140] to 34.4% [n = 3181]; P < .001); and the prevalence decreased for readmissions associated with an ambulatory care-sensitive condition (from 23.1% [62,847/272,065] to 14.0% [15,282/109,155], P < .001). Of patients readmitted 4 or more times in a 365-day interval, 2633 (28.5%) were rehospitalized for a problem in the same organ system across all admissions during the interval. Among a group of pediatric hospitals, 18.8% of admissions and 23.2% of inpatient charges were accounted for by the 2.9% of patients with frequent recurrent admissions. Many of these patients were rehospitalized recurrently for a problem in the same organ system.JAMA The Journal of the American Medical Association 02/2011; 305(7):682-90. DOI:10.1001/jama.2011.122 · 30.39 Impact Factor
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ABSTRACT: To determine the preferences for and satisfaction with communication between pediatric primary care physicians (PCPs) and hospitalists, 2 surveys (PCP and hospitalist versions with matching questions) were developed. Overall, PCPs were less satisfied than hospitalists with communication (P < .01). The 2 provider types had differing opinions on responsibility for care after hospital discharge, with hospitalists more likely than PCPs to assign responsibility to the PCP for pending labs (65% vs 49%; P < .01), adverse events (85% vs 67%; P < .01), or status changes (85% vs 69%; P < .01). Whereas satisfaction with and preferences for patient-related communication differed between hospitalists and PCPs, the incongruent views on the responsibility for care after patient discharge have major implications for safety particularly if poor communication occurs at discharge. Successful transitions from the hospital to primary care require communication between hospitalists and PCPs to be consistent, timely, and informative with responsibility for care discussed at discharge.Clinical Pediatrics 05/2011; 50(10):923-8. DOI:10.1177/0009922811407179 · 1.26 Impact Factor
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ABSTRACT: OBJECTIVE: Almost one-half of all pediatric gastrostomy tube insertions are accompanied by a fundoplication, yet little is understood about the surgical decision-making for these procedures. The objective of this study was to examine the decision-making process of surgeons about whether to perform a fundoplication in children already scheduled to have a gastrostomy tube placed. METHODS: A written questionnaire of all pediatric surgeons at a major children's hospital was completed for each planned gastrostomy procedure over the course of 1 year; the questionnaire asked about various influences on the fundoplication decision: primary care and subspecialty physicians' opinions, patient characteristics, and parent opinions. Patient demographics and clinical characteristics from the medical record, as well as questionnaire responses, were summarized for each gastrostomy occurrence. We modeled the association of questionnaire responses and patient characteristics with the outcome of having a fundoplication. RESULTS: We received questionnaires on 161 of 169 eligible patients (95%). A total of 52% of patients had fundoplication. Primary care physicians were involved in 44% of decisions, and when involved had "a lot" of influence on the fundoplication decision only 28% of time, compared with neonatologists (61%), hospitalists (44%), pediatric pulmonologists (42%), and pediatric gastroenterologists (40%). A total of 86% of patients had a subspecialist involved, and 28% had >1 subspecialist. A pH probe was performed in 7.5% of cases, and failed pharmacotherapy was noted by the surgeons in only 26.5% of the fundoplications performed. CONCLUSIONS: The decision to do a fundoplication was rarely based on definitive testing or failed medical treatment. From the surgeon's perspective, subspecialists were more influential than primary care physicians, which is at odds with current concepts of the medical home.Academic pediatrics 09/2012; DOI:10.1016/j.acap.2012.07.006 · 2.23 Impact Factor