Evaluation of community wide, in-home hospital level care for reduction of pediatric hospitalization. Hospitalization accounts for almost 50% of child health expenditures, estimated at $49.8 billion for the U.S. in 1987. Adverse psychosocial effects of hospitalization are widely recognized. Wide variation in hospitalization rates for much common, acute childhood illness suggests that admission is often highly dependent on physician discretion and that many admissions are avoidable. Discretionary hospitalizations in Monroe County (Rochester), NY account for 53% of admissions in children ages 1 month - 18 years. Admitting pediatricians elsewhere have judged 28% of acute, general pediatric hospitalizations to be potentially avoidable, had alternative services they identified been available. In-Home Hospital level Care (IHHC) as a new, highly cost-effective alternative to hospitalization for care of selected episodes of acute childhood illness. Program characteristics will include: 1) immediate accessibility; 2) capacity to provide a broad range of services, comparable to those provided in the hospital for selected illness episodes; 3) ability to adjust to the unique and changing needs of different families and illnesses; and 4) integration in both primary care and hospital care systems. Several studies, some of which are underway, have been designed to address the following research questions. 1) What is the potential for implementing IHHC on a community wide basis, including inner city, other urban and suburban areas? 2) How well will IHHC be accepted by (a) families and (b) providers? 3) What is the net impact of IHHC on hospitalization of IHHC-eligible episodes and on overall community hospitalization rates? 4) What will be the cost of care for eligible episodes on IHHC enrollment days vs non-enrollment days? 5) Will quality of care for illness episodes managed with IHHC be comparable to that for eligible episodes hospitalized? 6) Is family satisfaction with IHHC high?
Hospitalization of infants with lower respiratory tract illness. Lower respiratory tract illness (LRI) is the most common reason for hospitalization of infants beyond the neonatal period. Wide inter-community variation in hospitalization rates suggests that admission is highly dependent on physician discretion and that reduction in hospitalization is possible. The ultimate goal of this research program is to reduce unnecessary hospitalization for LRI in infants. Objectives follow. (1) To develop and validate a physiologically-based measure of respiratory illness termed the Acute Infant Respiratory Dysfunction Index (AIR-DI). Development of the AIR-DI will be based on physiologic variables recognized as indicators of respiratory dysfunction. (2) To develop a prediction rule for peak AIR-DI (worst dysfunction during the illness) based on observations available to physicians when hospitalization decisions are made. (3) To analyze the decision to hospitalize, specifying the cost-effectiveness of basing decisions on the prediction rule. The decision model will be structured to address decision alternatives (hospitalize or not) considering the proximate clinical outcome (severe respiratory dysfunction) and final outcomes (e.g, recovery, death, vulnerable child syndrome). Utilities for decision analysis will be based on preferences of physicians and parents. (4) To identify family, health system and physician determinants of hospitalization. Decision analysis will suggest how physicians should make decisions when hospitalization is based entirely on physiologic risk. Family, health system, and physician factors influence how physicians actually make decisions, and they may constitute barriers to use of a prediction rule.
References
McConnochie KM, Roghmann KJ, Liptak GS. Hospitalization for lower respiratory tract illness in infants: Variation in rates among counties in New York State and areas in Monroe County. J Pediatr 1995;126:220- 229.
McConnochie KM, Roghmann KJ, Kitzman HJ, Liptak GS, McBride JT.
Review and Commentary: Ensuring high quality alternatives while ending
pediatric inpatient care as we know it. Arch Pediatrics & Adol Med,
1997;151:341-349
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