Stories about: hospital utilization

Children with medical complexity: Caught in a political and economic crossfire

What will happen to medically complex children if insurance coverage is reduced and fewer pediatricians are trained to care for them? (Image: Wikimedia Commons)

Jay Berry, MD, MPH, is a pediatrician and hospitalist in the Complex Care Service at Boston Children’s Hospital. His most recent research appears in the JAMA Pediatrics, accompanied by editorials on the findings’ implications for health care and residency training. Berry further discusses its implications in this podcast.

My first encounter with a children’s hospital was as a first grader in 1980, when my 5-year-old cousin was diagnosed with cancer. Although her family was challenged to afford her cancer treatments, St. Jude Children’s Hospital in Memphis welcomed her and treated her cancer into remission. I remember my parents saying, “Everybody in that hospital loves children. No child is turned away.”

In 1997, walking into the Children’s Hospital of Alabama as a medical student, I felt the same sense of hope and courage. Everyone on the staff believed that they could make a difference in the lives of the children and families, despite the horrific illnesses that many of the children endured. I knew, immediately, that I wanted to become a pediatrician and to learn how to care for sick children.

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BEAPPER: a Twitter-like app for emergency clinicians

Debra Weiner speaks with Emergency Department Fellow Joel Hudgins who holds one of the iPhones piloting BEAPPER

For Debra Weiner, MD, PhD, working in the Emergency Medicine Department is a numbers game. During a 12-hour shift she works with more than 50 other providers, sees up to 25 patients and analyzes multiple lab results. Every day she’s also meeting new staff members in addition to new patients.

“People don’t know each other,” Weiner said at a recent Innovators’ Forum, a monthly internal lecture series intended to showcase and encourage new developments at Children’s Hospital Boston. “We have over 100 nurses and physicians and over 200 trainees that filter in [every two to four weeks]… it’s hard to remember who everyone is and what they do.”

Coupled with the frenetic pace of Children’s Emergency Department (ED), remembering names and managing the flow of patients becomes a constant challenge.

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A rising tide of neurologic impairment: Where’s the medical home for these children?

Many doctors feel unprepared to care for children with neurologic impairment. (Photo: Lindsey Hoshaw)

Jay Berry, MD, MPH, shown here with patient Kyler Quelch, is a pediatrician and hospitalist in the Complex Care Service at Children’s Hospital Boston. He leads the multi-institutional Complex Care Quality Improvement Research Collaborative.

As a general pediatrician, albeit one with experience in complex care, I find it extremely challenging to take care of children with neurologic impairment. A child’s nervous system can be “broken” for many reasons: a congenital brain or spinal cord malformation, severe head or neck trauma, a genetic condition or, like an increasing number of children, being born prematurely.

Most of the time, we can’t “fix” a broken nervous system. We can only try to support the body functions that are impaired as a result. Functions we take for granted: breathing, eating and digesting, moving, talking. We don’t have a lot of scientific evidence to guide us when doing this,

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Reducing unnecessary care: The SCAMPs manifesto

Can we reduce health care costs without rationing? (Image: Fibonacci Blue via Flickr)

We all know the problem: The cost of health care needs to come down. About five years ago, pediatric cardiologists at Children’s Hospital Boston realized it was critical to practice more cost-effectively. “Most of the money that is going to be removed from the federal budget to reduce budgetary deficits is going to come from health care in one fashion or another,” cardiologist-in-chief James Lock told an audience of senior Children’s physicians last month. “There’s no question we were under a tremendous amount of pressure.”

Seeking to eliminate unnecessary care and testing, Lock’s team first turned to clinical practice guidelines, or CPGs, a tool meant to standardize “best practices.” But it soon became clear that CPGs were ineffective, giving no insight into how to improve care or how to deal with unexpected findings. Even worse, over time, many mandated CPGs have been shown to be wrong by subsequent data.

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Chest X-rays: Learning forbearance

"Round" pneumonia in a 15-year-old with cough and fever. (Image: Nevit Dilmen/Wikimedia Commons)

In emergency situations involving children, it’s tempting for doctors to do everything possible to get information, especially when anxious parents are at hand. Unfortunately, that can mean a lot of unnecessary imaging and radiation exposure, and sometimes fruitless exploratory surgery.

This has spurred a search for biomarkers that can reliably make or rule out a diagnosis, as in appendicitis, and the creation of decision rules about the need for imaging, as in minor head trauma and blunt abdominal trauma, based on physical examination and limited testing, and validated by a large volume of clinical experience.

Emergency physicians Mark Neuman and Rich Bachur at Children’s Hospital Boston have been looking to reduce the use of chest X-rays in children with suspected pneumonia, where chest X-ray is usually considered the diagnostic testing modality of choice.

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Using health-records technology to bring value

The shelves that used to hold Children's Hospital Boston's paper medical records now stand empty.

What does paperlessness mean? It’s about helping patients, says Daniel Nigrin, Chief Information Officer at Children’s Hospital Boston. This approach helps explain why he was named one of the InformationWeek Healthcare 25, a short list of leaders driving the healthcare IT revolution.

“The integration of a patient’s data has to be one of the topmost national priorities,” Nigrin says. “It will eventually lead to better care, and hopefully a reduction in cost.”

This need is becoming critical as healthcare reform rolls out and primary-care practices become patients’ medical homes, integrating information from

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Keeping frequent flyers safe at home – with good detective work

Photo: PhylB/Flickr

Jay Berry is a pediatrician and hospitalist within the Complex Care Service at Children’s Hospital Boston. He leads the multi-institutional Complex Care Quality Improvement Research Collaborative (CC-QIRC). This is the final post in a 3-part series.

Imagine a child and family going through four hospital readmissions in a row — one right after the other — and how disruptive those hospitalizations are to their lives. I recently was involved in a study that demonstrated that patients experiencing frequent, potentially avoidable readmissions – so-called “frequent flyers” — are a major driver of pediatric healthcare costs. These children often have very complex, chronic health conditions.  It’s now our duty to take action on these findings.

So how can we help prevent these repeated readmissions?

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Gauging the impact of pediatric “frequent flyers”

Jay Berry, MD, MPH, is a pediatrician and hospitalist in the Complex Care Service at Children’s Hospital Boston. He leads the multi-institutional Complex Care Quality Improvement Research Collaborative. This post is second of a three-part series.

Emerging evidence suggests that small groups of adult patients who are frequently readmitted to the hospital are responsible for a large proportion of health care costs. Is this also true in pediatrics? What impact do our young “frequent flyers” have on the inpatient health care system?

I’m fortunate to be part of a multi-state collaborative, supported by the Child Health Corporation of America, that is trying understand how to best deliver care to the neediest children. These patients have complex medical needs, who are fragile and predisposed to getting very, very sick. Often, they have multiple, chronic health conditions, neurodevelopmental/intellectual disabilities and impaired functional status, requiring feeding tubes, breathing tubes and other technology to maintain their health.

Many of them, like Jim, seem to be falling through the cracks.

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My first “frequent flyer”

Photo: Lars Plougmann/Flickr

Jay Berry, MD, MPH, is a pediatrician and hospitalist in the Complex Care Service at Children’s Hospital Boston. He leads the multi-institutional Complex Care Quality Improvement Research Collaborative (CC-QIRC). This post is first of a three-part series.

Everywhere you turn these days, there’s an airline, grocery store or coffee shop pushing a “frequent flyer” or “rewards” program. You know the gist – the more money you give these businesses, the more discounts they give back to you and the more money you “save.” In theory, these programs are win-win: customers like frequenting the same business; businesses love holding onto satisfied customers.

But when I was a medical student, and overheard a nurse call my patient a “frequent flyer,” I wondered, “Who gets the ‘reward’ in that frequent flyer deal?” I hoped this child, a 4-year-old boy with cerebral palsy, was benefiting from being admitted over and over again.

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