Using consultations to reduce hospital stays of medically complex children

Being a medically complex child can mean increased time in the hospital. A report of a quality improvement at a hospital in a major metropolitan area examines whether utilizing a hospital consultation service along with the typical outpatient comprehensive care clinician could lead to a reduction in hospital use and health care costs.¹

The investigators ran a randomized quality improvement program at the University of Texas Health Science Center at Houston with an outpatient comprehensive care clinic and tertiary pediatric hospital, Children’s Memorial Hermann Hospital. Each participant was a child with medical complexity who was high risk, which mean either ≥2 hospitalizations or ≥1 admission to the pediatric intensive care unit in the year before the child was enrolled in the study. The consultation included serial discussions between the emergency department physicians, comprehensive care clinicians, and hospitalists that covered the need to admission, inpatient treatment, and the transition back to outpatient care. The participants who did not receive the intervention were given usual pediatric care.

During the study period, there were 342 children with medical complexity who were randomized to either get the intervention, 167 children, or typical care, 175 children. In the intention-to-treat analysis, the probability that hospital consultation reduced total hospital days was 91% (2.72 vs 6.01 per child-year; Bayesian rate ratio [RR], 0.61; 95% credible interval [CrI], 0.30-1.26). When compared to usual pediatric care the probability of reduction with health consultation was 98% for hospitalizations (0.60 vs 0.93 per child-year; RR, 0.68; 95% CrI, 0.48-0.97), 89% for pediatric intensive care unit days (0.77 vs 1.89 per child-year; RR, 0.59; 95% CrI, 0.26-1.38), and 94% for average total health system costs ($24 928 vs $42 276 per child-year; cost ratio, 0.67; 95% CrI, 0.41-1.10). Following a secondary analysis using a Bayesian prior centered at RR of 0.78 and reflecting the opinion of 7 clinicians who were considered experts and were knowledgeable about medically complex children, the probability that hospital consultations reduced hospital days was 96%.

The researchers concluded that among children who were considered medically complex and were receiving comprehensive outpatient, a hospital consultation would lead to likely reductions in a number of hospital outcomes such as total hospital days and health system costs. They urge further study in other centers to provide further evidence.

Reference

1. Mosquera R, Avritscher E, Pedroza C, et al. Hospital consultation from outpatient clinicians for medically complex children. JAMA Pediatr. December 1, 2020. Epub ahead of print. doi:10.1001/jamapediatrics.2020.5026