Technology-dependent children

Healthcare Utilization and Costs Among Commercially Insured Infants With and Without Medically Complex Conditions

BACKGROUND

Little is known about healthcare use and costs for commercially insured infants in the first year of life following a Neonatal Intensive Care Unit (NICU) hospitalization.

PURPOSE

To evaluate healthcare utilization and costs in the 12-months after a neonatal hospitalization among commercially insured infants, comparing infants with and without medically complex conditions.

METHODS

This retrospective, cross-sectional, cohort study uses data from the IBM MarketScan Commercial database (2015-2019). The cohort included infants with and without medically complex conditions, hospitalized at birth in the NICU, discharged alive, and had 12-months continuous coverage. The primary outcomes are healthcare utilization (i.e., hospital readmissions, emergency department (ED) visits, and primary care and specialty outpatient visits) and out-of-pocket (OOP) costs.

RESULTS

The analysis included 23,940 infants, of which 84% resided in urban areas, 48% were born term (>37 weeks) and 43% had a medically complex diagnosis. Medically complex infants exhibited higher rates of readmissions, ED visits, specialist utilization, and specialty services. Average OOP costs for medically complex infants was $1893, compared to $873 for noncomplex infants. Almost half (48%) of the cohort had costs that exceeded $500 in the first year of life.

IMPLICATIONS FOR PRACTICE AND RESEARCH

This study provides insights into the financial implications of post-NICU care for infants. Findings underscore the importance of considering medical complexity over gestational age when understanding healthcare use and spending patterns. Policymakers, healthcare providers, and families can use these insights to address the financial challenges associated with caring for infants with complex medical conditions beyond the NICU.

Global trends in technology-dependent children, home care, and parental discharge education: A bibliometric analysis using Biblioshiny

BACKGROUND

Parents of technology-dependent children constitute a different population in society and face diverse problems during caregiving.

METHODS

This study aimed to identify and visualize studies conducted from 1990 to 2024 on technology-dependent children, home care, and parental discharge education and determine global trends. A descriptive and bibliometric study design was employed. Data were obtained from the Web of Science Core Collection database, and bibliometric analyses were performed with performance analysis, visualization, and mapping using the Biblioshiny interface in the R software. Screening yielded a total of 157 publications. A total of 138 publications were included.

FINDINGS

The keywords frequently used by the authors included "home care," "technology-dependent children," "palliative care," "home mechanical ventilation," "child," "family," and "pediatric." Co-author keywords with moderate centrality and density are "home mechanical ventilation" (Betw = 106.47), "technology-dependent" (Betw = 106.47), "home mechanical ventilation" (Betw = 106.47). Each article had 4.41 co-authorships, with an international co-authorship rate of 6.52 %.

CONCLUSIONS

This study provided important data on studies focusing on technology-dependent children, home care, and parental discharge education.

APPLICATION TO PRACTICE

Since the number of studies in the field is small, the findings of this study are essential in guiding researchers about gaps in the literature.

Palliative Care in the Pediatric Intensive Care Unit

The purposes of this review are to describe differences between palliative care for adult patients and palliative care for pediatric patients, both generally and in the intensive care unit; to highlight ethical considerations for pediatric intensive care unit patients by using illustrative cases; and to examine the impact of these ethical considerations on decision-making for children and their families.

Pediatric long-term noninvasive respiratory support in children with central nervous system disorders

RATIONALE

The use of long-term noninvasive respiratory support is increasing in children along with an extension of indications, in particular in children with central nervous system (CNS) disorders.

OBJECTIVE

The aim of this study was to describe the characteristics of children with CNS disorders treated with long-term noninvasive respiratory support in France.

METHODS

Data were collected from 27 French pediatric university centers through an anonymous questionnaire filled for every child treated with noninvasive ventilatory support ≥3 months on 1st June 2019.

MAIN RESULTS

The data of 182 patients (55% boys, median age: 10.2 [5.4;14.8] years old [range: 0.3-25]) were collected: 35 (19%) patients had nontumoral spinal cord injury, 22 (12%) CNS tumors, 63 (35%) multiple disabilities, 26 (14%) central alveolar hypoventilation and 36 (20%) other CNS disorders. Seventy five percent of the patients were treated with noninvasive ventilation (NIV) and 25% with continuous positive airway pressure (CPAP). The main investigations performed before CPAP/NIV initiation were nocturnal gas exchange recordings, alone or coupled with poly(somno)graphy (in 29% and 34% of the patients, respectively). CPAP/NIV was started in an acute setting in 10% of the patients. Median adherence was 8 [6;10] hours/night, with 12% of patients using treatment <4 h/day. Nasal mask was the most common interface (70%). Airway clearance techniques were used by 31% of patients.

CONCLUSION

CPAP/NIV may be a therapeutic option in children with CNS disorders. Future studies should assess treatment efficacy and patient reported outcome measures.

Initiating technology dependence to sustain a child's life: a systematic review of reasons

BACKGROUND

Decision-making in initiating life-sustaining health technology is complex and often conducted at time-critical junctures in clinical care. Many of these decisions have profound, often irreversible, consequences for the child and family, as well as potential benefits for functioning, health and quality of life. Yet little is known about what influences these decisions. A systematic review of reasoning identified the range of reasons clinicians give in the literature when initiating technology dependence in a child, and as a result helps determine the range of influences on these decisions.

METHODS

Medline, EMBASE, CINAHL, PsychINFO, Web of Science, ASSIA and Global Health Library databases were searched to identify all reasons given for the initiation of technology dependence in a child. Each reason was coded as a broad and narrow reason type, and whether it supported or rejected technology dependence.

RESULTS

53 relevant papers were retained from 1604 publications, containing 116 broad reason types and 383 narrow reason types. These were grouped into broad thematic categories: clinical factors, quality of life factors, moral imperatives and duty and personal values; and whether they supported, rejected or described the initiation of technology dependence. The majority were conceptual or discussion papers, less than a third were empirical studies. Most discussed neonates and focused on end-of-life care.

CONCLUSIONS

There is a lack of empirical studies on this topic, scant knowledge about the experience of older children and their families in particular; and little written on choices made outside 'end-of-life' care. This review provides a sound basis for empirical research into the important influences on a child's potential technology dependence.

SARS-CoV-2 infection in technology-dependent children: a multicenter case series

Purpose

The objective of this study was to describe the clinical course and outcomes in children with technology dependence (TD) hospitalized with SARS-CoV-2 infection.

Methods

Seventeen pediatric hospitals (15 Canadian and one each in Iran and Costa Rica) included children up to 17 years of age admitted February 1, 2020, through May 31, 2021, with detection of SARS-CoV-2. For those with TD, data were collected on demographics, clinical course and outcome.

Results

Of 691 children entered in the database, 42 (6%) had TD of which 22 had feeding tube dependence only, 9 were on supplemental oxygen only, 3 had feeding tube dependence and were on supplemental oxygen, 2 had a tracheostomy but were not ventilated, 4 were on non-invasive ventilation, and 2 were on mechanical ventilation prior to admission. Three of 42 had incidental SARS-CoV-2 infection. Two with end-stage underlying conditions were transitioned to comfort care and died. Sixteen (43%) of the remaining 37 cases required increased respiratory support from baseline due to COVID-19 while 21 (57%) did not. All survivors were discharged home.

Conclusion

Children with TD appear to have an increased risk of COVID-19 hospitalization. However, in the absence of end-stage chronic conditions, all survived to discharge.

Indication-based timing of tracheostomy and its effects on outcome in the pediatric intensive care unit

OBJECTIVES

The objective of study was to find an association between the timing of tracheostomy with duration of mechanical ventilation (MV) and length of stay (LOS) in pediatric intensive care unit (PICU) and hospital.

METHODS

The data were collected prospectively from 2000 to 2018 and were analyzed retrospectively. Data included clinical diagnosis, indication, and duration (days) of MV, LOS in PICU and hospital before and after tracheostomy. Patients who did not receive MV or underwent MV for <24 h were excluded. According to the indication of tracheostomy enrolled patients were divided into four groups-airways anomalies (AA), central neurological impairment (CNI), cardiopulmonary insufficiency (CPI), and neuromuscular disorders (NMD). Patients in each group were divided into early (ET) and late tracheostomy (LT) category based on the median (interquartile range interquartile range [IQR]) days of pretracheostomy MV.

RESULTS

Two hundred and fifty six patients were analyzed. The frequency and median [IQR] days of pretracheostomy MV were -AA 54 [7(3,16)], CNI 120 [12(9,16)], CPI 51 [25(16.5,30.5)], and NMD 31[12(8,16.5)]. In AA patients, median (IQR) durations of posttracheostomy MV [2(1,5.2) versus 3.5(2,12); p = 0.032], PICU [7(5,8.2) versus11(7,18); p = 0.004] and hospital [12(9.7,21) versus 21.5(12,28); p = 0.027] stays were lower in ET as compared with LT group. Posttracheostomy MV duration was significantly short in ET patients with CNI and NMD (p < 0.005). The total days of MV, PICU and hospital stay were significantly lower in ET as compared with LT patients in all four groups (p < 0.01).

CONCLUSION

As compared with LT, ET patient had shorter durations of total MV and PICU and hospital stay.

Death review of children receiving medical care at home

BACKGROUND

Children receiving home medical care need special attention to prevent unexpected death. The aim of this study was to clarify the factors contributing to death in children receiving home medical care from the child death review database.

METHODS

Children receiving home medical care were enrolled from the child death review database from 2014 to 2016 in Aichi prefecture, Japan, with a population of one million children. Types of medical care and factors contributing to death were examined.

RESULTS

Of the 631 children who died, 40 children (6%) were receiving home medical care (21: tracheostomy; 19: ventilator; 26: suctioning of naso-oral secretions; 19: oxygen inhalation; 32: tube feeding; 6: urethral catheterization; and 1: peritoneal dialysis). The death rate was 50 times that in the general population of children. Ten children had contributory factors that seemed to be preventable. In four children, the families could not replace the tracheostomy tubes during an accident. In three, oxygen saturation or ventilator alarms were not set appropriately. In two, an oxygen cylinder became empty. One child fell down from a seat in a car.

CONCLUSIONS

Improvement of devices and correct guidance to caregivers may reduce the death rate in children receiving home medical care.

IMPACT

Children receiving home medical care, such as tracheostomy care, mechanical ventilation, or tube feeding, need special attention to prevent unexpected death. In this population-based child death review, 6% of children received home medical care, and it was estimated that 1 of 100 children receiving home medical care died per year. One-quarter of the deaths could be preventable by caregiver education or development of devices.