Post-Trial Sustainability and Scalability of the Benefits of a Medical Home for High-Risk Children with Medical Complexity

Abstract

Objective.-To assess the sustainability of the benefits relative to usual care of a medical home providing comprehensive care for high-risk children with medical complexity (≥2 hospitalizations or ≥1 pediatric intensive care unit [PICU] admission in the year before enrollment) after we made comprehensive care our standard practice and expanded the program. Study design.-We conducted pre-post comparisons of the rate of children with serious illness (death, PICU admission, or >7-day hospitalizations) and health-system costs observed after program expansion (March 2014-June 2015) to those during the clinical trial (March 2011-August 2013) for each of the trial's treatment groups (usual care [n=96]; and comprehensive care [n=105]) (primary analyses), and among all children given comprehensive care (n Post Trial =233 [including trial usual care children who transitioned to comprehensive care post trial and newly enrolled medically complex children]; and n T Trial =105) (secondary analyses). We also analyzed the findings for the trial patients as a 2-phased stepped wedge study. Results.-In intent-to-treat analyses, rates of children with serious illness and costs were reduced or unchanged post trial vs. trial for the trial's usual care group (rate ratio [RR], 0.36 [95% Confidence Interval, 0.20-0.64]; cost ratio [CR], 0.68 [0.28-1.68]), the trial's comprehensive care group (RR, 0.74 [0.39-1.41]); CR, 0.67 [0.51-0.89]), and among all children given comprehensive care (RR, 0.97 [0.61-1.52]; CR, 0.75 [0.61-0.93]). Conservative stepped wedge analyses identified overall benefits with comprehensive care across both study periods (RR, 0.46 [0.30-0.72]; CR, 0.64 [0.43-0.99]).

Telemedicine for Children With Medical Complexity: A Randomized Clinical Trial

“…CC was provided to all trial participants to promote prompt effective care at all hours. As previously detailed, [6][7][8] CC included highly experienced PCPs and subspecialists working in the same clinic, 24/7 access to the clinic emergency cell phone that is rotated between the PCPs, same-day care on weekdays in the clinic for acute illnesses and complications, a low patient-to-PCP ratio (#100:1), weekly scrutiny of the care received before any ED visit or hospitalization, and a hospital consultation service from the CC providers during hospitalizations in our primary teaching hospital, the Children's Memorial Hermann Hospital (CMHH). 8…”

“…health system costs among medically complex children. [6][7][8] The current trial indicates that adding telemedicine to augment care in the home for medically complex children is likely to further increase these benefits and could have led to savings of $7563 per child-year for a total of $1.9 million.…”

“…on the basis of the patient's diagnoses and clinical course and prospectively validated. 6,7 We excluded medically complex children with specific disorders given primary care outside our clinic (eg, serious unrepaired congenital heart disease) or a do-not-resuscitate order.…”

“…At the study outset, telemedicine had not been used in any pediatric clinic in our center, and the parents often declined to have telemedicine visits. In addition, our PCPs who were all experienced in communicating with patients by telephone at all hours 7,8 were initially skeptical that telemedicine would add much benefit to CC. In promoting use of telemedicine, the weekly meetings between the medical director (R.M.)…”

“…As a result, CC has substantially reduced serious illnesses, hospital days, PICU days, and health system costs for medically complex children in our center. [6][7][8] Even so, their need for medical attention and the costs of care remain distressingly high.…”