Hospital Consultation From PCPs Bests Usual Care for Medically Complex Children

By Marilynn Larkin

December 07, 2020

NEW YORK (Reuters Health) - For children with medical complexity (CMC), in-hospital consultations with their outpatient primary care providers (PCPs) likely reduced hospital days, hospitalizations and health system costs compared with usual hospital care, researchers say.

"CMCs account for only 0.4% of all children but are responsible for approximately 40% of pediatric deaths and 53% of all pediatric hospital charges," Dr. Ricardo Mosquera of the McGovern Medical School, The University of Texas Health Science Center at Houston told Reuters Health by email. "I was surprised to see how significantly an inpatient consultation from the outpatient providers reduced admissions, readmissions, and pediatric intensive care unit (PICU) days, as well as total hospital days and health system costs for CMC."

"Although (hospitalists are) highly efficient, they can often become overwhelmed with the care of patients with complex conditions whom they have just met," he noted. "On the other hand, PCPs cannot take their primary role into the hospital setting," and so the hospitalist takes the lead.

"In this situation, PCPs may feel isolated and disconnected from decision-making," he said. "Therefore, in this study, our outpatient PCPs assisted the hospitalist team as consultants...to determine admission, course of treatment and care, and discharge and transition to the outpatient setting."

"The families felt a sense of psychological relief when they received a visit from their own healthcare provider, who they trust and who knows them best," he added.

In an earlier randomized controlled trial, the team found that comprehensive care improves outcomes and reduces costs for CMC. (https://bit.ly/37JEc4u)

For the current study, published in JAMA Pediatrics, Dr. Mosquera and colleagues randomized 342 CMC to either hospital consultations (167) or usual hospital care (175). The mean patient age was six years; about 43% were girls; and most (about 80%) were Black or Hispanic. Close to half were at "very high" baseline risk.

In intention-to-treat analyses, the probability that hospital consultations reduced total hospital days was 91% (2.72 vs. 6.01 per child-year; Bayesian rate ratio, 0.61).

Further, the probability of a reduction with consultations versus usual care was 98% for hospitalizations (0.60 vs. 0.93 per child-year; RR, 0.68); 89% for PICU days (0.77 vs. 1.89 per child-year; RR, 0.59); and 94% for mean total health system costs ($24,928 vs. $42,276 per child-year; cost ratio, 0.67).

In a secondary Bayesian analysis reflecting the opinion of seven CMC experts, the probability that hospital consultations reduced hospital days was 96%.

Dr. Chris Feudtner of The Children's Hospital of Philadelphia, coauthor of an accompanying editorial, told Reuters Health by email that he and his coauthor "wished to underscore the work that the community of clinicians caring for medical complex pediatric patients need to do in order to understand the mechanisms by which our complex care programs can benefit patients and families."

"Currently, much of this detailed work is still in its infancy, as we are just starting to spell out key concepts and theories regarding complex care," he said. "We need to study these concepts and test the theories. Some concepts will prove strong, others will need to be thrown out; some theories will bear up under scrutiny and provide insight, while others will need to be revised or rejected."

"Given that some studies of complex care programs have demonstrated clear benefit while other studies have not, this nitty-gritty work of dissecting out what these programs are doing (or not doing), and how they work, is critical if we are to make steady and accumulating progress towards better, more effective care. If we don't do this, we are left with a limited black-box understanding, and then aimless or powerless to fix or improve what we don't understand," he concluded.

SOURCES: https://bit.ly/2Ik7jCR and https://bit.ly/3giR6ur JAMA Pediatrics, online November 30, 2020.

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