Trends in Observation‐prone Emergency Department Visits Among Michigan Children, 2007–2011

ObjectivesTo the best of the authors’ knowledge, admission of children under observation status in community hospitals has not been examined. The hypothesis of this study was that there has been an increase in observation charge code use over time and variations in the application of observation charge codes across hospital types.MethodsThis was a cross‐sectional analysis of 5 years (2007 through 2011) of administrative claims data from Michigan residents enrolled in Medicaid, Blue Cross/Blue Shield of Michigan preferred provider organization, and Blue Cross Network health maintenance organization compiled into a single data set. Emergency department (ED) visits to facilities in Michigan made by children (younger than 18 years) were selected. Observation‐prone ED visits were identified based on the presence of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM) codes. Counts of observation‐prone ED visits were determined and descriptive statistics were calculated. Changes over time in the proportion of visits with observation charge codes by hospital type were assessed with chi‐square analysis.ResultsThe observation‐prone ICD‐9‐CM codes were identified in 881,622 ED visits made by children to 142 Michigan facilities during the 5‐year study period. Overall, the vast majority of visits (n = 646,499; 91.0%) with the selected ICD‐9‐CM codes resulted in discharge from the ED without associated observation or inpatient charge codes. Among the 64,288 visits that resulted in admission for observation or inpatient care, observation charge codes without inpatient charge codes were applied to 22,933 (35.7%) admissions, observation and inpatient charge codes were applied to 4,756 (7.4%) admissions, and inpatient charge codes without observation charge codes were applied to 36,599 (56.9%) admissions. Hospitals with pediatric ED and inpatient services (Type 1 and Type 2 hospitals) had higher proportions of ED visits that went on to admission for observation or inpatient care (15.9 and 10.7%) than hospitals without pediatric ED services (Type 3 and Type 4 hospitals; 7.2 and 3.7%). The proportion of admissions that had observation charge codes for all hospital types increased over time, most prominently among Type 1 and Type 2 hospitals.ConclusionsThe application of observation charge codes to Michigan children with observation‐prone conditions has increased over time across all hospital types. There is a need to evaluate pediatric observation care in diverse settings to compare the effectiveness of different models.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/111217/1/acem12624-sup-0001-DataSupplementS1.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/111217/2/acem12624-sup-0002-DataSupplementS2.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/111217/3/acem12624.pd

The Locus Ceruleus in PTSD

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Pilot Trial of an Emergency Department–based Intervention to Promote Child Passenger Safety Best Practices

BackgroundDespite demonstrated effectiveness of child restraint systems (CRSs), use remains suboptimal. In this randomized pilot trial, we sought to determine the feasibility, acceptability, and potential efficacy of “Tiny Cargo, Big Deal” an ED‐based intervention to promote guideline‐concordant size‐appropriate CRS use.MethodsParents of children < 11 years old were recruited in two EDs and randomized in a 2 × 2 factorial design to four conditions: 1) generic information sheet, 2) tailored brochure mailed after the ED visit, 3) a single motivational interviewing‐based counseling session in the ED, and 4) full intervention (counseling session plus tailored brochure). We assessed feasibility (recruitment, completion, follow‐up rates) and acceptability (parent attitudes, uptake of information) in the ED, at 1 month and at 6 months. We obtained preliminary estimates of effect sizes of the intervention components on appropriate CRS use at 6‐month follow‐up.ResultsOf the 514 parents assessed for eligibility, 456 met inclusion criteria and 347 consented to participate. Enrolled parents were mostly mothers (88.1%); 48.7% were 18 to 29 years old; 52.5% were non‐Hispanic, white; and 65.2% reported size‐appropriate CRS use. Completion rates were 97.7% for baseline survey, 81.6% for counseling, 51.9% for 1‐month follow‐up, and 59.3% for 6‐month follow‐up. In the ED, 70.5% rated thinking about child passenger safety in the ED as very helpful. At 1 month, 70.0% expressed positive attitudes toward the study. Of 132 parents who reported receiving study mailings, 78.9% reviewed the information. Parents randomized to the full intervention demonstrated an increase (+6.12 percentage points) and other groups a decrease (–1.69 to –9.3 percentage points) in the proportion of children reported to use a size‐appropriate CRS at 6‐month follow‐up.ConclusionsSuboptimal CRS use can be identified and intervened upon during a child’s ED visit. A combined approach with ED‐based counseling and mailed tailored brochures shows promise to improve size‐appropriate CRS use.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/150596/1/acem13687_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/150596/2/acem13687.pd

Healthcare utilization and spending by children with cancer on Medicaid

BackgroundChildren with cancer are a unique patient population with high resource, complex healthcare needs. Understanding their healthcare utilization could highlight areas for care optimization.ProcedureWe performed a retrospective, cross‐sectional analysis of the 2014 Truven Marketscan Medicaid Database to explore clinical attributes, utilization, and spending among children with cancer who were Medicaid enrollees. Eligible patients included children (ages 0–18 years) with cancer (Clinical Risk Group 8). Healthcare utilization and spending (per member per month, PMPM) were assessed overall and across specific healthcare services.ResultsChildren with cancer (n = 5,405) represent less than 1% of the 1,516,457 children with medical complexity in the dataset. Children with cancer had high services use: laboratory/radiographic testing (93.0%), outpatient specialty care (83.4%), outpatient therapy/treatment (53.4%), emergency department (43.7%), hospitalization (31.5%), home healthcare (9.5%). PMPM spending for children with cancer was $3,706 overall and$2,323 for hospital care.ConclusionChildren with cancer have high healthcare resource use and spending. Differences in geographic distribution of services for children with cancer and the trajectory of spending over the course of therapy are areas for future investigation aimed at lowering costs of care without compromising on health outcomes.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/138316/1/pbc26569_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/138316/2/pbc26569.pd

Frequent Emergency Department Utilizers Among Children with Cancer

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/136404/1/pbc25929.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/136404/2/pbc25929_am.pd

Rounding frequency and hospital length of stay for children with respiratory illnesses: A simulation study

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/102158/1/jhm2097.pd

Characteristics of Children With Cancer Discharged or Admitted From the Emergency Department

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/136395/1/pbc25872_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/136395/2/pbc25872.pd

Characteristics of Children With Cancer Discharged or Admitted From the Emergency Department

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/136395/1/pbc25872_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/136395/2/pbc25872.pd

Integrating Assertive Community Treatment and Illness Management and Recovery for Consumers with Severe Mental Illness

This study examined the integration of two evidence-based practices for adults with severe mental illness: Assertive community treatment (ACT) and illness management and recovery (IMR) with peer specialists as IMR practitioners. Two of four ACT teams were randomly assigned to implement IMR. Over 2 years, the ACT–IMR teams achieved moderate fidelity to the IMR model, but low penetration rates: 47 (25.7%) consumers participated in any IMR sessions and 7 (3.8%) completed the program during the study period. Overall, there were no differences in consumer outcomes at the ACT team level; however, consumers exposed to IMR showed reduced hospital use over time

Differences in designations of observation care in US freestanding children's hospitals: Are they virtual or real?

OBJECTIVE: To characterize practices related to observation care and to examine the current models of pediatric observation medicine in US children's hospitals. DESIGN: We utilized 2 web‐based surveys to examine observation care in the 42 hospitals participating in the Pediatric Health Information System database. We obtained information regarding the designation of observation status, including the criteria used to admit patients into observation. From hospitals reporting the use of observation status, we requested specific details relating to the structures of observation care and the processes of care for observation patients following emergency department treatment. RESULTS: A total of 37 hospitals responded to Survey 1, and 20 hospitals responded to Survey 2. Designated observation units were present in only 12 of 31 (39%) hospitals that report observation patient data to the Pediatric Health Information System. Observation status was variably defined in terms of duration of treatment and prespecified criteria. Observation periods were limited to <48 hours in 24 of 31 (77%) hospitals. Hospitals reported that various standards were used by different payers to determine observation status reimbursement. Observation care was delivered in a variety of settings. Most hospitals indicated that there were no differences in the clinical care delivered to virtual observation status patients when compared with other inpatients. CONCLUSIONS: Observation is a variably applied patient status, defined differently by individual hospitals. Consistency in the designation of patients under observation status among hospitals and payers may be necessary to compare quality outcomes and costs, as well as optimize models of pediatric observation care. Journal of Hospital Medicine 2012;. © 2011 Society of Hospital Medicine.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/91108/1/949_ftp.pd