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Decreasing Hospital Utilization among Medically Complex Children
Project Number: R40 MC 25677
Project Date: 2/1/2013
Thomas Klitzner, MD
B2-427 MDCC, 10833 Le Conte Ave.
Los Angeles, CA 900951743
Phone: (310) 825-5296
- Perinatal/Infancy (0-12 months)
- Toddlerhood (13-35 months)
- Early Childhood (3-5 years)
- Middle Childhood (6-11 years)
- Adolescence (12-18 years)
The number of children who are medically complex is increasing due to advances in pediatric care that have led to increased survival in previously high-mortality conditions. This population accounts for a substantial proportion of overall pediatric hospital utilization, despite its relatively low prevalence. Little is known about how to decrease utilization in this group. Based on MCHB Strategic Issue III - services and systems to assure quality of care for MCH populations - our project hypothesizes that significant reductions in hospital utilization may be achieved in a medical home setting through better understanding modifiable factors leading to hospitalization and designing activities to decrease them. Through an innovative, mixed-methods design, this study aims first to identify modifiable risks for hospitalization among medically complex children (Phase 1), and then to examine whether a randomized controlled pilot intervention within an existing patient-centered medical home can decrease hospital utilization in this population (Phase 2). This study will occur within the Pediatric Medical Home Program at UCLA, a primary care program that serves medically complex children. During 2008-2010, patients in the program averaged over 2 admissions per year, a 30-day readmission rate over 32%, and a 6-month readmission rate over 60%. Phase 1 will be accomplished through in-depth interviews among parents of hospitalized patients who receive their primary care within the UCLA Medical Home. Two strata, consisting of Spanish- vs. English-speaking families and child less than 13 years vs. 13 years or older, will be used among approximately 20 interviewees. Based on themes emerging from the analysis combined with existing literature, the most relevant 8 modifiable risks for hospitalization will be identified, and a candidate set of 5 possible medical home interventions will be created for each modifiable risk. Using the RAND/UCLA Appropriateness Method, the effectiveness of these 40 medical home interventions will be rated by a panel of national experts in caring for medically complex children. During Phase 2, patients enrolled within the Medical Home Program will be randomized to either a usual care control group, or a pilot intervention group, with the set of interventions drawn from those rated highly by the expert panel in Phase 1. Primary outcomes include number of all-cause admissions and preventable admissions. Secondary utilization outcomes include 30-day readmissions and emergency department visits. Negative binomial regression will be used to analyze count data in intervention vs. control groups, while controlling for relevant confounding variables. This study will advance the field of child health services and improve the quality of systems of care for a very high-utilizing population. It will address important research and clinical gaps through its rigorous design, and develop generalizable and feasible interventions which can be integrated into a primary care patient-centered medical home.
Listed is descending order by year published.
Coller RJ, Klitzner TS, Saenz AA, Lerner CF, et al. The medical home and hospital readmissions. Pediatrics. 2015;136:e1550.
Coller RJ, Nelson BB, Sklansky DJ, et al. Preventing hospitalizations in children with medical complexity: a systematic review. Pediatrics. 2014;134(6):e1628-47.
Chronic Illness, Coordination of Services, Health Care Utilization, Infant Illness & Hospitalization, Medical Home, Primary Care, Special Health Care Needs, Health Care Quality