Costs and complications of hospitalizations for children with cerebral palsy

The cost of respiratory hospitalizations in children with cerebral palsy

AIM

To establish the burden of respiratory illness in cerebral palsy (CP) on the Western Australian health care system by quantifying the costs of respiratory hospitalizations in children with CP, compared with non-respiratory hospitalizations.

METHOD

A 2-year (2014-2015) retrospective study using linked hospital data (excluding emergency department visits), in a population of children with CP in Western Australia aged 18 years and under (median age at hospitalization 7 years; interquartile range 5-12 years).

RESULTS

In 671 individuals (57% male) there were 726 emergency hospitalizations, and 1631 elective hospitalizations. Although there were more elective hospitalizations, emergency hospitalizations were associated with longer stays in hospital, and more days in an intensive care unit, resulting in a higher total cost of emergency hospitalizations than elective hospitalizations (total costs: emergency AU$7 748 718 vs elective AU$6 738 187). 'Respiratory' was the leading cause of emergency hospitalizations, contributing to 36% of all emergency admission costs. For a group of high-cost inpatient users (top 5% of individuals with the highest total inpatient costs) the most common reason for hospitalization was 'respiratory'. Where non-respiratory admissions were complicated by an additional respiratory diagnosis, length of stay was greater.

INTERPRETATION

Respiratory hospitalizations in CP are a significant driver of health care costs. In the paediatric group, they are a burden for a subgroup of children with CP.

WHAT THIS PAPER ADDS

Respiratory illness is the most costly area for unplanned, emergency hospitalizations for children and young people with cerebral palsy. The top 5% of individuals with the highest total inpatient costs account for a disproportionate amount of health care costs.

Adaptive Intervention to Prevent Respiratory Illness in Cerebral Palsy: Protocol for a Feasibility Pilot Randomized Controlled Trial

BACKGROUND

This study will pilot-test an innovative just-in-time adaptive intervention to reduce severe respiratory illness among children with severe cerebral palsy (CP). Our intervention program, Respiratory Exacerbation-Plans for Action and Care Transitions (RE-PACT), delivers timely customized action planning and rapid clinical response when hospitalization risk is elevated.

OBJECTIVE

This study aims to establish RE-PACT's feasibility, acceptability, and fidelity in up to 90 children with severe CP. An additional aim is to preliminarily estimate RE-PACT's effect size.

METHODS

The study will recruit up to 90 caregivers of children with severe CP aged 0 to 17 years who are cared for by a respiratory specialist or are receiving daily respiratory treatments. Participants will be recruited from pediatric complex care programs at the University of Wisconsin-Madison (UW) and the University of California, Los Angeles (UCLA). Study participants will be randomly assigned to receive usual care through the complex care clinical program at UW or UCLA or the study intervention, RE-PACT. The intervention involves action planning, rapid clinical response to prevent and manage respiratory illness, and weekly SMS text messaging surveillance of caregiver confidence for their child to avoid hospitalization. RE-PACT will be run through 3 successively larger 6-month trial waves, allowing ongoing protocol refinement according to prespecified definitions of success for measures of feasibility, acceptability, and fidelity. The feasibility measures include recruitment and intervention time. The acceptability measures include recruitment and completion rates as well as intervention satisfaction. The fidelity measures include observed versus expected rates of intervention and data collection activities. The primary clinical outcome is a severe respiratory illness, defined as a respiratory diagnosis requiring hospitalization. The secondary clinical outcomes include hospital days and emergency department visits, systemic steroid courses, systemic antibiotic courses, and death from severe respiratory illness.

RESULTS

The recruitment of the first wave began on April 27, 2022. To date, we have enrolled 30 (33%) out of 90 participants, as projected. The final wave of recruitment will end by October 31, 2023, and the final participant will complete the study by April 30, 2024. We will start analyzing the complete responses by April 30, 2024, and the publication of results is expected at the end of 2024.

CONCLUSIONS

This pilot intervention, using adaptive just-in-time strategies, represents a novel approach to reducing the incidence of significant respiratory illness for children with severe CP. This protocol may be helpful to other researchers and health care providers caring for patients at high risk for acute severe illness exacerbations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05292365; https://clinicaltrials.gov/study/NCT05292365.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49705.

Barriers to and facilitators of a just-in-time adaptive intervention for respiratory illness in cerebral palsy: a qualitative study

OBJECTIVE

To understand caregiver, healthcare professional and national expert perspectives on implementation of a just-in-time adaptive intervention, RE-PACT (Respiratory Exacerbation-Plans for Action and Care Transitions) to prevent respiratory crises in severe cerebral palsy.

DESIGN

Qualitative research study.

SETTING

Paediatric complex care programmes at two academic medical institutions.

PARTICIPANTS

A total of n=4 focus groups were conducted with caregivers of children with severe cerebral palsy and chronic respiratory illness, n=4 with healthcare professionals, and n=1 with national experts.

METHODS

Participants viewed a video summarising RE-PACT, which includes action planning, mobile health surveillance of parent confidence to avoid hospitalisation and rapid clinical response at times of low confidence. Moderated discussion elicited challenges and benefits of RE-PACT's design, and inductive thematic analysis elicited implementation barriers and facilitators.

RESULTS

Of the 19 caregivers recruited, nearly half reported at least one hospitalisation for their child in the prior year. Healthcare professionals and national experts (n=26) included physicians, nurses, respiratory therapists, social workers and researchers. Four overarching themes and their barriers/facilitators emphasised the importance of design and interpersonal relationships balanced against health system infrastructure constraints. Intervention usefulness in crisis scenarios relies on designing action plans for intuitiveness and accuracy, and mobile health surveillance tools for integration into daily life. Trust, knowledge, empathy and adequate clinician capacity are essential components of clinical responder-caregiver relationships.

CONCLUSIONS

RE-PACT's identified barriers are addressable. Just-in-time adaptive interventions for cerebral palsy appear well-suited to address families' need to tailor intervention content to levels of experience, preference and competing demands.

Understanding and managing respiratory infections in children and young adults with neurological impairment

INTRODUCTION

Patients with neurocognitive impairment (NI) have multiple medical needs, with respiratory problems leading to an important reduction in quality of life and life expectancy. We aimed to explain that the origin of chronic respiratory symptoms in patients with NI is multifactorial.

AREAS COVERED

In people with NI there is a high prevalence of swallowing dysfunction and hypersalivation inducing aspiration; cough efficacy is decreased resulting in chronic lung infection; sleep-disordered breathing is frequent and muscle mass is abnormal due to malnutrition. Technical investigations are not always specific and sensitive enough to better diagnose the causes of the respiratory symptoms; moreover, they can sometimes be difficult to perform in this vulnerable patient population. We provide a clinical pathway to adopt to identify, prevent, and treat respiratory complications in children and young adults with NI. A holistic approach in discussion with all care providers and the parents is highly recommended.

EXPERT OPINION

The care for people with NI and chronic respiratory problems is challenging. The interplay between several causative factors may be difficult to entangle. Well-performed clinical research in this field is largely missing and should be encouraged. Only then, evidence-based clinical care will become possible for this vulnerable patient group.

Providing a Primary Care Medical Home for Children and Youth With Cerebral Palsy

Cerebral palsy (CP) is the most common motor disorder of childhood, with prevalence estimates ranging from 1.5 to 4 in 1000 live births. This clinical report seeks to provide primary care physicians with guidance to detect children with CP; collaborate with specialists in treating the patient; manage associated medical, developmental, and behavioral problems; and provide general medical care to their patients with CP.

Healthcare utilization by children with neurological impairments and disabilities in rural Kenya: a retrospective cohort study combined with secondary analysis of audit data

Background: There is a paucity of data on healthcare utilization by children with neurological impairments (NI) in sub-Saharan Africa. We determined the rate, risk factors, causes, and outcomes of hospital admission and utilization patterns for rehabilitative care among children with NI in a defined rural area in Kenya. Methods: We designed two sub-studies to address the primary objectives. Firstly, we retrospectively observed 251 children aged 6–9 years with NI and 2162 age-matched controls to determine the rate, causes and outcomes of hospitalization in a local referral hospital. The two cohorts were identified from an epidemiological survey conducted in 2015 in a defined geographical area. Secondly, we reviewed hospital records to characterize utilization patterns for rehabilitative care. Results: Thirty-four in-patient admissions occurred in 8503 person-years of observation (PYO), yielding a crude rate of 400 admissions per 100 000 PYO (95% confidence interval (Cl): 286–560). The risk of admission was similar between cases and controls (rate ratio=0.70, 95%CI: 0.10–2.30, p = 0.31). The presence of electricity in the household was associated with reduced odds of admission (odds ratio=0.32, 95% Cl: 0.10–0.90, p < 0.01). Seizures and malaria were the main causes of admission. We confirmed six (0.3%) deaths during the follow-up period. Over 93% of outpatient paediatric visits for rehabilitative care were related to cerebral palsy and intellectual developmental delay. Health education (87%), rehabilitative exercises (79%) and assistive technology (64%) were the most common interventions. Conclusions: Surprisingly, the risk of hospitalization was not different between children with NI and those without, possibly because those with severe NI who died before this follow-up were under seclusion and restraint in the community. Evidence-based and tailored rehabilitative interventions are urgently required based on the existing secondary data.

5-year risk of “adult-onset” chronic diseases during childhood and adolescent transitioning for individuals with cerebral palsy

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“Adult-onset” chronic diseases may begin in childhood for individuals with CP.

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5-year disease risk was < 64.3-fold higher for < 1–13 year olds with vs without CP.

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5-year chronic disease risks were elevated for CP across all developmental stages.

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Patient factors impacted disease risk variably for children with CP.

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Findings may inform when to implement prevention efforts and who is more at-risk.

Epidemiologic evidence documenting risk of chronic diseases as children with cerebral palsy age throughout growth is lacking to inform prevention strategies. The objective was to characterize the 5-year risk of chronic diseases that are typically associated with advanced aging among < 1–13 year olds with cerebral palsy and effects by patient-level factors. This retrospective cohort study used nationwide commercial administrative claims from 01/01/2001–12/31/2018 from children < 1–13 years old with ≥ 5 years of mostly continuous insurance enrollment. The 5-year risk of chronic diseases was examined for the entire cohort with and without cerebral palsy and then by baseline age group (<1–2, 3–5, 6–8, 9–11, 12–13 years old), including cardiorespiratory, metabolic, kidney, and liver diseases, cancer, depression, and osteoarthritis. For cerebral palsy, the association between 5-year chronic disease rate and patient-level factors was assessed using Cox regression. Children with (n = 5,559) vs without (n = 2.3 million) cerebral palsy had a higher 5-year risk of all chronic diseases when comparing the entire cohorts (relative risk, 1.19 to 64.26, all P < 0.05) and most chronic diseases when comparing cohorts for each age group. Among children with cerebral palsy, there were effects by gender, co-occurring intellectual disabilities and/or epilepsy, and wheelchair use for some chronic diseases, which can help to identify at-risk children. This study provides novel epidemiologic evidence of 5-year risk of “adult-onset” chronic diseases for children with cerebral palsy during important developmental stages, and associated patient-level factors (to enhance clinical detection). Findings may inform when to implement prevention strategies and who may be more at risk.

Barriers to Discharge After Hip Reconstruction Surgery in Non-ambulatory Children With Neurological Complex Chronic Conditions

BACKGROUND

Hip reconstruction surgery in patients with neurological complex chronic conditions (CCC) is associated with prolonged hospitalization and extensive resource utilization. This population is vulnerable to cognitive, developmental, and medical comorbidities which can increase length of stay (LOS). The aims of this study were to characterize barriers to discharge for a cohort of children with neurological CCC undergoing hip reconstruction surgery and to identify patient risk factors for prolonged hospitalization and delayed discharge.

METHODS

Retrospective chart review of nonambulatory patients with neurological CCC undergoing hip reconstruction surgery between 2007-2016 was conducted. Hospitalization ≥1 day past medical clearance was characterized as delayed discharge. Barriers were defined as unresolved issues at the time of medical clearance and categorized as pertaining to the caregiver and patient education, durable medical equipment, postdischarge transportation/placement, and patient care needs.

RESULTS

The cohort of 116 patients was 53% male, 16% non-English speaking, and 49% Gross Motor Function Classification System (GMFCS) V with the mean age at surgery of 9.1±3.64 years. Median time from admission to medical clearance was 5 days with median LOS of 6 days. Approximately three-quarters of patients experienced delayed discharge (73%) with barriers identified for 74% of delays. Most prevalent barriers involved education (30%) and durable medical equipment (29%). Postdischarge transportation and placement accounted for 26% of barriers and 3.5 times longer delays ( P <0.001). Factors associated with delayed discharge included increased medical comorbidities ( P <0.05) and GMFCS V ( P <0.001). Longer LOS and medical clearance times were found for female ( P =0.005), older age ( P <0.001), bilateral surgery ( P =0.009), GMFCS V ( P =0.003), and non-English-speaking patients ( P <0.001).

CONCLUSIONS

Patients with neurological CCC frequently encounter postoperative barriers contributing to increased LOS and delayed discharge. Patients that may be at higher risk for prolonged hospitalization and greater resource utilization include those who are female sex, adolescent, GMFCS V, non-English speaking, have additional comorbidities, and are undergoing bilateral surgery. Standardized preoperative assessment of educational needs, perioperative equipment requirements, and posthospital transportation may decrease the LOS, reduce caregiver and patient burden/distress, cost, and ultimately reduce variation in care delivery.

LEVEL OF EVIDENCE

Level III, Retrospective Case Series.

Validation of Neurologic Impairment Diagnosis Codes as Signifying Documented Functional Impairment in Hospitalized Children

OBJECTIVE

To assess the performance of previously published high-intensity neurologic impairment (NI) diagnosis codes in identification of hospitalized children with clinical NI.

METHODS

Retrospective study of 500 randomly selected discharges in 2019 from a freestanding children's hospital. All charts were reviewed for 1) NI discharge diagnosis codes and 2) documentation of clinical NI (a neurologic diagnosis and indication of functional impairment like medical technology). Test statistics of clinical NI were calculated for discharges with and without an NI diagnosis code. A sensitivity analysis varied the threshold for "substantial functional impairment." Secondary analyses evaluated misclassified discharges and a more stringent definition for NI.

RESULTS

Diagnosis codes identified clinically documented NI with 88.1% (95% confidence interval [CI]: 84.7, 91) specificity, and 79.4% (95% CI: 67.3, 88.5) sensitivity; negative predictive value (NPV) was 96.7% (95% CI: 94.8, 98.0), and positive predictive value (PPV) was 49% (95% CI: 42, 56.1). Including children with milder functional impairment (lower threshold) resulted in NPV of 95.7% and PPV of 77.5%. Restricting to children with more severe functional impairment (higher threshold) resulted in NPV of 98.2% and PPV of 44.1%. Misclassification was primarily due to inclusion of children without functional impairments. A more stringent NI definition including diagnosis codes for NI and feeding tubes had a specificity of 98.4% (95% CI: 96.7-99.3) and sensitivity of 28.6% (19.4-41.3).

CONCLUSIONS

All scenarios evaluated demonstrated high NPV and low-to-moderate PPV of the diagnostic code list. To maximize clinical utility, NI diagnosis codes should be used with strategies to mitigate the risk of misclassification.

Postoperative complications in pediatric patients with cerebral palsy

BACKGROUND/PURPOSE

To assess surgical outcomes of patients with cerebral palsy (CP) and if they differ from patients without CP.

METHODS

The NSQIP-Pediatric database from 2012 to 2019 was used to compare differences in presenting characteristics and outcomes between patients with and without CP. Chi-square tests and multivariable logistic regression analysis were used to determine significance.

RESULTS

119,712 patients, 433 (0.4%) with CP, 119,279 (99.6%) without, were identified. Patients with CP had more postoperative complications (19.4% vs. 6.9%, p < 0.001) with an OR of 3.2, (95%CI 2.5-4.1, p < 0.001) on univariable analysis. They underwent fewer laparoscopic procedures (79.1% vs. 90.8%, p < 0.001), had more readmissions (10.2% vs. 3.8%, p < 0.001), reoperations (5.1% vs. 1.2%, p < 0.001), and longer length of stays (LOS) (median 3 versus 1 day, p < 0.001). On multivariable analysis, having CP did not increase the odds of postoperative morbidity (OR 0.99, 95% CI 0.7-1.3), but higher ASA class, congenital lung malformation, gastrointestinal disease, coagulopathy, preoperative inotropic support, oxygen use, nutritional support, and steroid use significantly increase the odds of morbidity, all of which were more common in patients with CP.

CONCLUSION

Patients with CP have more postoperative complications, open procedures, and longer LOS. Patient complexity may account for these differences and risk-directed perioperative planning may improve outcomes.

LEVEL OF EVIDENCE

Level IV.

Epilepsy in children with cerebral palsy: a data linkage study

AIM

To compare the prevalence of epilepsy in children with cerebral palsy (CP) to peer controls and their differences in healthcare utilization.

METHOD

The Quebec CP registry was linked to the provincial administrative health database. Two CP cohorts were identified from the registry (n=302, 168 males, 1y 2mo-14y) and administrative data (n=370, 221 males, 2y 2mo-14y). A control cohort (n=6040, 3340 males, 10-14y) was matched by age, sex, and region to the CP registry cohort. Administrative data algorithms were used to define epilepsy cases. Data on hospitalizations and emergency department presentations were obtained.

RESULTS

Using the most sensitive epilepsy definition, prevalence was 42.05% in the CP registry, 43.24% in the CP administrative data, and 1.39% in controls. Prevalence rose with increasing Gross Motor Function Classification System level. Children with CP and epilepsy had increased number and length of hospitalizations and emergency department presentations compared to children with CP or epilepsy alone. Epilepsy accounted for approximately 5% of emergency department presentations and 10% of hospitalizations in children with epilepsy, with and without CP.

INTERPRETATION

Children with CP have an increased risk of epilepsy compared to their peers. Children with CP and coexisting epilepsy represent a unique subset with complex developmental disability and increased healthcare service utilization.

Trends in Health Care Use and Spending for Young Children With Neurologic Impairment

BACKGROUND AND OBJECTIVES

Children with neurologic impairment (NI) are a growing subset of children who frequently use health care. We examined health care use and spending trends across services for children with NI during their first 5 years of life.

METHODS

This was a retrospective study of 13 947 children with NI in the multistate IBM Medicaid MarketScan Database (2009-2017). We established birth cohorts of children with NI and analyzed claims from birth to 5 years. NI, identified by using International Classification of Diseases, 9th Revision, diagnosis codes, was defined as ≥1 neurologic diagnosis that was associated with functional and/or intellectual impairment. We measured annual health care use and per-member-per-year spending by inpatient, emergency department (ED), and outpatient services. Population trends in use and spending were assessed with logistic and linear regression, respectively.

RESULTS

During their first versus fifth year, 66.8% vs 5.8% of children with NI used inpatient services, and 67.8% vs 44.4% used ED services. Annual use in both categories decreased over 0-5 years (inpatient odds ratio: 0.35, 95% confidence interval: 0.34 to 0.36; ED odds ratio: 0.78, 95% confidence interval: 0.77 to 0.79). The use of outpatient services (primary care, specialty care, home health) decreased gradually. Per-member-per-year spending on inpatient services remained the largest spending category: $83 352 (90.2% of annual spending) in the first year and $1944 (25.5%) in the fifth year.

CONCLUSIONS

For children with early-onset NI from 0-5 years, use and spending on inpatient services decreased dramatically; ED and outpatient service use decreased more gradually. These findings may help systems, clinicians, and families optimize care by anticipating and adjusting for shifting use of health care services.

Determinants of hospital-based health service utilisation in cerebral palsy: a systematic review

OBJECTIVE

To systematically review and synthesize evidence of determinants associated with hospital-based health service utilisation among individuals with cerebral palsy (CP).

DATA SOURCES

Electronic databases MEDLINE, Embase, APA Psycinfo were searched from January 2000 to April 2020.

STUDY SELECTION

Observational studies were included that described people with CP, reported quantitative measures of hospital-based health service utilisation (inpatient, outpatient, emergency department), and based in high-income countries. We excluded studies that included only subsets of people with CP, or those that only reported therapy service utilisation.

DATA EXTRACTION

After initial screen, two reviewers reviewed full texts for inclusion and performed data extraction and risk of bias assessment using the Newcastle Ottawa scale. Determinants of health service utilisation were identified and categorised using the Andersen Behavioural Model.

DATA SYNTHESIS

Seventeen studies met inclusion criteria. Study quality was high. Twenty-six determinants were reported across eight Andersen Model characteristics. Individual predisposing factors such as sex showed no difference in health service utilisation; inpatient admissions decreased with increasing age during childhood and was lower in adults. Increased health service utilisation was associated with "individual need" including severe gross motor disability, epilepsy, developmental/ intellectual disability and gastrostomy-use across inpatient, outpatient and emergency department settings. There was little information reported on socio-demographic and health system contextual determinants.

CONCLUSIONS

CP health service utilisation was associated with age, severity and comorbidities. Improved understanding of determinants of health service utilisation can support health service access for people with CP.

Outpatient healthcare use and outcomes after pediatric tracheostomy

OBJECTIVES

To 1) describe health outcomes and outpatient healthcare use after pediatric tracheostomy, and 2) identify populations with higher morbidity that may benefit from improved post-operative monitoring.

METHODS

Optum's commercial insurance database was queried from 2003 to 2019. Children aged 0-18 who received tracheostomy identified. Mortality, decannulation, tracheostomy complications, and home ventilator dependence were determined, as well as physician office visits and specialty type. The effect that patient characteristics (age, sex, ethnicity, prematurity, and presence versus absence of chronic lung disease [CLD], congenital heart disease [CHD], neurologic impairment [NI], and upper airway obstruction [UAO]) had on outcomes were compared.

RESULTS

1231 children were identified. Infants accounted for 33% of patients and 40% of the cohort was premature. The most common comorbid conditions were NI (76%), UAO (69%), CLD (48%), and CHD (35%). Within 5 years postoperatively, 25% died, 45% had home ventilator dependence, 53% had a complication, and 10% were decannulated. CHD was associated with higher risk of death (HR,1.98; 95% CI 1.22, 3.21), while UAO was associated with lower risk of death (HR,0.51; 95% CI 0.32, 0.83) and higher probability of decannulation (HR,3.56, 95% CI 1.08, 11.74). The median number of physician office visits was 6 per year (IQR 3,10). The most common specialty types were pediatrics (32%), pulmonary medicine (10%), and otolaryngology (8%). NI was associated with greater number of office visits (mean difference/year, 4.10; 95% CI 2.00, 6.19) while Hispanic ethnicity was associated with fewer visits (mean difference/year, -2.94; 95%CI -5.42, -0.45).

CONCLUSIONS

UAO was associated with lower risk of mortality and higher probability of decannulation, while NI was associated with greater outpatient healthcare utilization. Social disparities in outpatient tracheostomy care were observed.

Taking a closer look into Crohn's disease and cerebral palsy

Inflammatory bowel disease (IBD), which includes Crohn's disease (CD), is a chronic, immune-mediated disease involving the gastrointestinal tract. Cerebral palsy (CP) has not been associated with IBD aside from a single previously published case series. In this study, we describe two cases of CD in patients with CP. Both patients had global developmental delay. They were also underweight and exclusively gastrostomy tube dependent for nutrition. By detailing their clinical courses, we illustrate the importance of becoming familiar with the extraintestinal manifestations of IBD. In the setting of developmental delay and its associated communication barriers, the evaluation of IBD might shift from assessing subjective symptoms to recognizing the subtle presentations of the disease, including anemia, weight loss, malnutrition, and failure to thrive. We also hypothesize that malnutrition and a change in the gastrointestinal microbiota associated exclusively with enteral nutrition may be linked to the development of CD in patients with CP. Overall, this study provides information for clinicians caring for patients with CP or developmental delay, and how to recognize extraintestinal manifestations of IBD.

The effect of a flexible thoracolumbar brace on neuromuscular scoliosis: A prospective observational study

Neuromuscular scoliosis is a common deformity seen in patients with neuromuscular diseases. Although rigid thoracolumbosacral orthosis is the most frequently used brace, it has low compliance rates and can lead to complications including skin ulcers. Thus, alternative methods for treating neuromuscular scoliosis are needed. The purpose of this study is to evaluate the clinical effects of a novel flexible brace to prevent the progression of neuromuscular scoliosis.This study is a prospective observational study. Twenty-three patients with neuromuscular scoliosis were enrolled in the study. Among patients diagnosed with neuromuscular disease, spine radiographs were checked for a neuromuscular scoliosis diagnosis. The participants were treated with a novel flexible brace for 6 months. The control group (n = 46) was selected using propensity score matching method from a clinical data warehouse. The Cobb angle was measured and compared between the study and control groups.In the study group, the average Cobb's angle significantly decreased from 47.22 ± 18.9° to 31.8 ± 20.0 when wearing the flexible brace (P < .001). Thus, the correction rate was 36.9%. The annual progression rate was significantly lower in the study group than in the control group (P  < .05).The flexible brace showed a significant correction rate of scoliosis in patients with severe neuromuscular diseases. The flexible brace is an alternative treatment modality for patients with neuromuscular scoliosis. Daily application of the flexible brace during the growing period can reduce the degree of fixed deformity in the long term.

Prevention and management of respiratory disease in young people with cerebral palsy: consensus statement

Respiratory illness is the leading cause of mortality in children with cerebral palsy (CP). Although risk factors for developing chronic respiratory illness have been identified, comprehensive clinical care recommendations for the prevention and management of respiratory illness do not currently exist. We invited over 200 clinicians and researchers from multiple disciplines with expertise in the management of respiratory illness in children with CP to develop care recommendations using a modified Delphi method on the basis of the RAND Corporation-University of California Los Angeles Appropriateness Method. These recommendations are intended for use by the wide range of practitioners who care for individuals living with CP. They provide a framework for recognizing multifactorial primary and secondary potentially modifiable risk factors and for providing coordinated multidisciplinary care. We describe the methods used to generate the consensus recommendations, and the overall perspective on assessment, prevention, and treatment of respiratory illness in children with CP. WHAT THIS PAPER ADDS: The first consensus statement for preventing and managing respiratory disease in cerebral palsy (CP). Risk factors for respiratory disease in CP should be identified early. Individuals with CP at risk of respiratory disease require regular assessment of risk factors. Effective partnerships between multidisciplinary teams, individuals with CP, and families are essential. Treatment of respiratory disease in individuals with CP must be proactive.

Timing of Co-occurring Chronic Conditions in Children With Neurologic Impairment

BACKGROUND

Children with neurologic impairment (NI) are at risk for developing co-occurring chronic conditions, increasing their medical complexity and morbidity. We assessed the prevalence and timing of onset for those conditions in children with NI.

METHODS

This longitudinal analysis included 6229 children born in 2009 and continuously enrolled in Medicaid through 2015 with a diagnosis of NI by age 3 in the IBM Watson Medicaid MarketScan Database. NI was defined with an existing diagnostic code set encompassing neurologic, genetic, and metabolic conditions that result in substantial functional impairments requiring subspecialty medical care. The prevalence and timing of co-occurring chronic conditions was assessed with the Agency for Healthcare Research and Quality Chronic Condition Indicator system. Mean cumulative function was used to measure age trends in multimorbidity.

RESULTS

The most common type of NI was static (56.3%), with cerebral palsy (10.0%) being the most common NI diagnosis. Respiratory (86.5%) and digestive (49.4%) organ systems were most frequently affected by co-occurring chronic conditions. By ages 2, 4, and 6 years, the mean (95% confidence interval [CI]) numbers of co-occurring chronic conditions were 3.7 (95% CI 3.7-3.8), 4.6 (95% CI 4.5-4.7), and 5.1 (95% CI 5.1-5.2). An increasing percentage of children had ≥9 co-occurring chronic conditions as they aged: 5.3% by 2 years, 10.0% by 4 years, and 12.8% by 6 years.

CONCLUSIONS

Children with NI enrolled in Medicaid have substantial multimorbidity that develops early in life. Increased attention to the timing and types of multimorbidity in children with NI may help optimize their preventive care and case management health services.

Hospitalizations in School-Aged Children with Cerebral Palsy and Population-Based Controls

OBJECTIVE

To compare hospitalizations among children with cerebral palsy (CP) and healthy controls and to identify factors associated with hospitalizations in children with CP.

METHODS

This retrospective cohort study linked data from a provincial CP Registry and administrative health databases. The CP cohort was comprised of children born from 1999 to 2002. Age, sex, and region-matched controls were identified from administrative health databases. Mean differences, relative risk (RR), and 95% confidence intervals (CIs) were calculated.

RESULTS

A total of 301 children with CP were linked to administrative health data and matched to 6040 controls. Mean hospitalizations per child during the study period were higher in children with CP compared to controls (raw mean difference (RMD) 5.0 95% CI 4.7 to 5.2) with longer length of stay (RMD 2.8 95% CI 1.8 to 3.8) and number of diagnoses per hospitalization (RMD 1.6 95% CI 1.4 to 1.8). Increased risk of hospitalization was observed in non-ambulant children with CP (RR 1.12 95% CI 1.01 to 1.22) compared to ambulant children and among those with spastic tri/quadriplegic CP compared to other CP subtypes (RR 1.15, 95% CI 1.05 to 1.27). Feeding difficulties (RR 1.20 95% CI 1.13 to 1.27), cortical visual (RR 1.22 95% CI 1.13 to 1.32), cognitive (RR 1.16 95% CI 1.04 to 1.30), and communication impairment (RR 1.26 95% CI 1.10 to 1.44) were associated with increased hospitalizations.

CONCLUSIONS

Children with CP face more frequent, longer hospital stays than peers, especially those with a more severe CP profile. Coordinated interdisciplinary care is needed in school-aged children with CP and medical complexity.

Nomogram for pneumonia prediction among children and young people with cerebral palsy: A population-based cohort study

BACKGROUND

Pneumonia is the leading cause of death among children and young people (CYP) with severe cerebral palsy (CP). Only a few studies used nomogram for assessing risk factors and the probability of pneumonia. Therefore, we aimed to identify risk factors and devise a nomogram for identifying the probability of severe pneumonia in CYP with severe CP.

METHODS

This retrospective nationwide population-based cohort study examined CYP with newly diagnosed severe CP before 18 years old between January 1st, 1997 and December 31st, 2013 and followed them up through December 31st, 2013. The primary endpoint was defined as the occurrence of severe pneumonia with ≥ 5 days of hospitalization. Logistic regression analysis was used for determining demographic factors and comorbidities associated with severe pneumonia. These factors were assigned integer points to create a scoring system to identify children at high risk for severe pneumonia.

RESULTS

Among 6,356 CYP with newly diagnosed severe CP, 2,135 (33.59%) had severe pneumonia. Multivariable logistic regression analysis revealed that seven independent predictive factors, namely age <3 years, male sex, and comorbidities of pressure ulcer, gastroesophageal reflux, asthma, seizures, and perinatal complications. A nomogram was devised by employing these seven significant predictive factors. The prediction model presented favorable discrimination performance.

CONCLUSIONS

The nomogram revealed that age, male sex, history of pressure ulcer, gastroesophageal reflux, asthma, seizures, and perinatal complications were potential risk factors for severe pneumonia among CYP with severe CP.

Effects of salivary gland botulinum Toxin-A on drooling and respiratory morbidity in children with neurological dysfunction

OBJECTIVE

To describe the effects of salivary gland Botulinum Toxin-A (SG BoNT-A) on children with drooling due to neurological dysfunction.

METHODS

This was a 3½-year prospective observational case series design of children referred for SG BoNT-A injections at a pediatric hospital (2010-2014). Outcomes were parent-reported severity, frequency, impact of drooling, and respiratory morbidity; and, from hospital records, number of respiratory hospital admissions.

RESULTS

Out of 17 children treated, complete data were available for 15 (including 8 boys) aged 3-14 years (Mean = 9.9 years; SD = 3.4), with a combined total of 71 injections. Most had cerebral palsy (n = 11), classified as Level V (n = 10) or IV (n = 1) on the Gross Motor Function Classification Scale (GMFCS). In almost all instances, parents reported reductions in severity, frequency, and impact of drooling, and parent-reported respiratory morbidity. Among those with posterior drooling (n = 12), most children (n = 10) did not have advanced respiratory disease. A trend towards reduced respiratory-related hospital admissions was observed during SG BoNT-A treatment periods.

CONCLUSION

SG BoNT-A can improve severity, frequency, and impact of drooling. It can also reduce respiratory-related hospital admissions in children with posterior drooling without advanced respiratory disease. For children with advanced respiratory disease, it may reduce severity and impact of drooling.

Interventions for management of respiratory disease in young people with cerebral palsy: A systematic review

BACKGROUND

Respiratory disease is a leading cause of hospitalizations and deaths in young people with cerebral palsy (CP). It is insidious and multifactorial. Clinical management can be complex. This systematic review describes effects of interventions for the prevention and management of respiratory disease in young people with CP.

METHODS

Nine databases (Cochrane, CINAHL, Embase, EMCare, MEDLINE, PEDro, OpenGrey, ScienceDirect, and SpeechBITE) were searched. Eligibility criteria were as follows: the population included at least 50% individuals with CP aged under 26 years, the intervention was for chronic respiratory illness, the outcomes were any measurable indicators of respiratory health or morbidity; the study design could be any original study reporting effects of an intervention on measurable outcomes, and the study was published January 1998 or later. The American Academy for Cerebral Palsy and Developmental Medicine methodology guided study appraisal and synthesis. The review was registered with PROSPERO (reference number CRD42018086314).

RESULTS

The search yielded 3,347 papers; 37 papers (reporting 34 studies) of these met the eligibility criteria. They included 582 participants with CP (ranging from 1 to 77 across studies) with ages from 5 months to 25 years. Interventions were diverse and included: airway clearance techniques, exercise, positioning, mealtime management, salivary management, upper airway interventions, antibiotics, gastro-intestinal interventions, and spinal surgery. There were no interventions aimed at prevention of respiratory disease in this population. Research designs were classified as Levels 2 (n = 3), 3 (n = 2), 4 (n = 25), and 5 (n = 4).

CONCLUSIONS

Evidence for most respiratory interventions for young people with CP is absent or weak. No controlled trials demonstrated significant effects on respiratory morbidity, owing to their scarcity, weak designs, and inadequate power. There is an urgent need for well-designed prospective controlled studies investigating prevention and management of respiratory disease in young people with CP.

Prolonged length of stay for acute hospital admissions as the increasing of age: A nationwide population study for Taiwan's patients with cerebral palsy

BACKGROUND

Studies investigating reasons for the admission and the associated lengths of stay (LOSs) among cerebral palsy (CP) patients are limited. This study determined common reasons for acute hospitalizations and the LOSs among children, adolescents, and young adults with CP.

METHODS

We performed a secondary analysis of data. CP patients aged 4-32.9 years were identified by CP registry in the catastrophic illness patient registry of the 2010 Taiwan National Health Insurance Research Database. Data of admission claims from 2010 to 2011 were analyzed. Reasons for admissions were identified according to International Classification of Diseases codes. Common reasons, frequencies of admissions for each reason, and LOSs were reported.

RESULTS

Pneumonia, other respiratory problems, and epilepsy were the top three reasons for admissions in all groups. Other common reasons in all groups were sepsis, other respiratory infections, and gastrointestinal problems. The reasons specific to children included orthopedic issues; ear, nose, and throat problems; and urinary tract infections (UTIs). In youths, scoliosis, and contractures, were unique reasons. In young adults, UTIs, blood problems, and mental illness, were special reasons. Most admission reasons appeared to prolong LOS, and the LOS exhibited an increasing trend as age increased.

CONCLUSION

The results implied that patients with CP are more susceptible to most disease invasions. Our results also suggest that the current care system in Taiwan is unsuitable for patients with CP. These results can be used as guidance for planning effective multidisciplinary assessments in the future.

Perioperative management of patients with cerebral palsy undergoing scoliosis surgery: Survey of surgeon practices

PURPOSE

Progressive scoliosis significantly impacts the quality of life in patients with cerebral palsy (CP). Spinal fusion is the mainstay of treatment of progressive spinal curves. The current study aims to identify approaches used by pediatric spine surgeons to optimize care of patients with CP undergoing scoliosis surgery.

METHODS

A 33-question survey was distributed electronically to 181 POSNA/SRS members with an established interest in pediatric spinal deformity surgery. Eighty one responses were obtained (45%). Using the Delphi consensus guidelines, agreement > 75% was considered as consensus.

RESULTS

There was a consensus on 15 out of 33 questions (46%). 97% of responders identified nutrition status as a comorbidity which could be optimized. However, the timing and method of obtaining nutritional assessment varied. 92% of the surgeons stated that they used shared decision making with the family but only 22% used a formal decision aid. 83% use antifibrinolytics routinely, 81% used a surgical site infection prevention protocol, 78% obtained preoperative pulmonary consult, and 88% took steps postoperatively to prevent pulmonary complications.

CONCLUSION

There is significant variability in the current practices of perioperative management of patients with CP undergoing scoliosis surgery. This data can be used in future studies to create a standardized integrated care pathway.

Predicting respiratory hospital admissions in young people with cerebral palsy

OBJECTIVE

To determine the early predictors of respiratory hospital admissions in young people with cerebral palsy (CP).

DESIGN

A 3-year prospective cohort study using linked data.

PATIENTS

Children and young people with CP, aged 1 to 26 years.

MAIN OUTCOME MEASURES

Self-reported and carer-reported respiratory symptoms were linked to respiratory hospital admissions (as defined by the International Statistical Classification of Diseases and Related Health Problems 10th Revision codes) during the following 3 years.

RESULTS

482 participants (including 289 males) were recruited. They were aged 1 to 26 years (mean 10 years, 10 months; SD 5 years, 11 months) at the commencement of the study, and represented all Gross Motor Function Classification Scale (GMFCS) levels. During the 3-year period, 55 (11.4%) participants had a total of 186 respiratory hospital admissions, and spent a total of 1475 days in hospital. Statistically significant risk factors for subsequent respiratory hospital admissions over 3 years in univariate analyses were GMFCS level V, at least one respiratory hospital admission in the year preceding the survey, oropharyngeal dysphagia, seizures, frequent respiratory symptoms, gastro-oesophageal reflux disease, at least two courses of antibiotics in the year preceding the survey, mealtime respiratory symptoms and nightly snoring.

CONCLUSIONS

Most risk factors for respiratory hospital admissions are potentially modifiable. Early identification of oropharyngeal dysphagia and the management of seizures may help prevent serious respiratory illness. One respiratory hospital admission should trigger further evaluation and management to prevent subsequent respiratory illness.

Systematic review of the economic impact of cerebral palsy

BACKGROUND

Cerebral palsy (CP) and its associated conditions can pose a significant economic burden on families, the health care system and the general economy. The boundary for inclusion of costs in research can vary substantially across studies.

AIMS

To summarize the evidence for burden of disease for CP including the impacts on the health system, the community and carers.

METHODS

Literature was identified from Ovid Medline, Embase, CINHAL, PsyInfo, Econlit, Health Economic Evaluation Database (HEED) and NHS Economic Evaluation Database (NHS EED) in the Cochrane Library. The search was restricted to articles published in English between 1970 and April 2016. All costs were converted to $USD 2016 price.

RESULTS

Twenty-two articles were included. Studies varied from snapshot cost descriptions to more complex lifetime estimates, from prevalence-based to incidence-based studies, and from inclusion to exclusion of non-medical costs. There was a strong positive relationship between CP severity and expenditure. Significant costs were incurred by families and the welfare system to facilitate school and community engagement.

CONCLUSION

Facilitating participation for people with CP involves substantial expense. The size, nature and distribution of the economic burden emphasises the importance of finding effective strategies to reduce the risk and severity of CP, together with how it is financed.

Factors Associated with Respiratory Illness in Children and Young Adults with Cerebral Palsy

OBJECTIVE

To describe associations between respiratory illness and its potential predictors in children and young adults with cerebral palsy (CP).

STUDY DESIGN

Cross-sectional survey of self- and caregiver-reported respiratory symptoms for individuals aged up to 26 years with CP. Respiratory illness was indicated by 2 outcomes: (1) ≥1 respiratory hospitalizations in the past year; and (2) ≥2 courses of antibiotics for respiratory symptoms in the past year. ORs were calculated using univariate and multivariate logistic regression.

RESULTS

There were 551 participants, aged 1-26 years, distributed across all gross motor function classification scale (GMFCS) levels. In univariate analyses, factors significantly associated with respiratory hospitalizations were weekly respiratory symptoms (OR 2.31, 95% CI 1.78-3.00), respiratory symptoms during meals (OR 3.23, 95% CI 1.50-5.80), gastroesophageal reflux (OR 3.01, 95% CI 1.71-5.31), coughing or choking on saliva (OR 4.36, 95% CI 2.38-8.01), current asthma (OR 3.56, 95% CI 1.97-6.42), age (0-3 years) (OR 3.24, 95% CI 1.19-8.80, compared with 13-17 years), seizures (OR 3.45, 95% CI 1.96-6.08), and scoliosis (OR 2.14, 95% CI 1.16-3.97). Nonambulatory individuals (GMFCS IV-V) were at significantly increased risk of hospitalizations only if they had food modifications and/or nasogastric or gastrostomy tube feeds (OR 5.36, 95% CI 2.89-9.96, compared with GMFCS I-III with no food modifications and no tube). All factors, except seizures and scoliosis, were significantly associated with multiple courses of antibiotics in univariate analyses.

CONCLUSIONS

Oromotor dysfunction is strongly associated with respiratory illness in patients with CP.

Supporting communication for children with cerebral palsy in hospital: views of community and hospital staff

OBJECTIVE

We aimed to investigate the views of allied health and nursing staff on supporting the communication of children with cerebral palsy (CP) and complex communication needs (CCN) in hospital.

METHOD

We conducted 12 focus groups with 49 community- and hospital-based allied health professionals and hospital nurses.

RESULTS

Participants reported having active roles in supporting children's seating, mobility, equipment, mealtime management and psychosocial needs, but not in supporting the children's communication in hospital. Participants described several environmental barriers to supporting children's augmentative and alternative communication (AAC) in hospital, and suggested a range of strategies to ease communication difficulties at the bedside.

CONCLUSION

Results indicate a potential new role for community- and hospital-based health professionals in supporting nurses to implement AAC strategies at the bedside. Supporting nursing staff to remove environmental barriers and use communication technologies might create a more communicatively accessible hospital ward for children with CP and CCN.

Parents and children with cerebral palsy discuss communication needs in hospital

OBJECTIVE

The aim of this study was to understand the communication needs and experiences of parents and children with cerebral palsy (CP) and complex communication needs (CCN) in hospital.

METHODS

Focus groups with 10 parents and interviews with seven children with CP and CCN were analysed for content themes.

RESULTS

Results demonstrated that children often want to communicate directly with hospital staff to: gain attention, answer yes/no, convey basic physical needs, give and receive information, control their environment and participate in preferred activities. Barriers to communication included lack of access to augmentative and alternative communication (AAC), staff preferring to communicate with parents and lack of time to communicate.

CONCLUSIONS

Results highlight strategies for successful communication, the role of the parents in supporting communication and provision of AAC systems for children in hospital. Policy and practice implications in the preparation of children with CP and CCN for communication in hospital are discussed.

Variations in hospitalization outcomes in children admitted with seizures between 2003 and 2006

Economic factors play an increasingly important role in the management of medical conditions. This study evaluated the economic impact of seizures in children in the United States using a large national data set known as the Kids' Inpatient Database (KID). The aim of this study was to characterize hospitalizations including total costs, length of stay, and variations in care. There were 63,719 pediatric seizure discharges in the 2003 and 2006 Kids' Inpatient Database. The mean hospital cost was $4105 in 2003 and $4553 in 2006. Patients with government insurance as the primary payer had a significantly longer length of stay compared with private insurance or self-pay patients (P < .0001); however, there was no significant difference in the total costs of hospitalization between the different payer groups. This analysis highlights multiple disparities of health care utilization in pediatric seizure management. In a stressful economic climate, all health care entities must focus on cost management of pediatric seizure.

Trends in resource utilization by children with neurological impairment in the United States inpatient health care system: a repeat cross-sectional study

BACKGROUND

Care advances in the United States (US) have led to improved survival of children with neurological impairment (NI). Children with NI may account for an increasing proportion of hospital resources. However, this assumption has not been tested at a national level.

METHODS AND FINDINGS

We conducted a study of 25,747,016 US hospitalizations of children recorded in the Kids' Inpatient Database (years 1997, 2000, 2003, and 2006). Children with NI were identified with International Classification of Diseases, 9th Revision, Clinical Modification diagnoses resulting in functional and/or intellectual impairment. We assessed trends in inpatient resource utilization for children with NI with a Mantel-Haenszel chi-square test using all 4 y of data combined. Across the 4 y combined, children with NI accounted for 5.2% (1,338,590) of all hospitalizations. Epilepsy (52.2% [n = 538,978]) and cerebral palsy (15.9% [n = 164,665]) were the most prevalent NI diagnoses. The proportion of hospitalizations attributable to children with NI did not change significantly (p = 0.32) over time. In 2006, children with NI accounted for 5.3% (n = 345,621) of all hospitalizations, 13.9% (n = 3.4 million) of bed days, and 21.6% (US$17.7 billion) of all hospital charges within all hospitals. Over time, the proportion of hospitalizations attributable to children with NI decreased within non-children's hospitals (3.0% [n = 146,324] in 1997 to 2.5% [n = 113,097] in 2006, p<.001) and increased within children's hospitals (11.7% [n = 179,324] in 1997 to 13.5% [n = 209,708] in 2006, p<0.001). In 2006, children with NI accounted for 24.7% (2.1 million) of bed days and 29.0% (US$12.0 billion) of hospital charges within children's hospitals.

CONCLUSIONS

Children with NI account for a substantial proportion of inpatient resources utilized in the US. Their impact is growing within children's hospitals. We must ensure that the current health care system is staffed, educated, and equipped to serve this growing segment of vulnerable children.

Reasons for hospital admissions among youth and young adults with cerebral palsy

OBJECTIVE

To identify the most common reasons for acute care hospital admissions among youth (age range, 13-17.9y) and young adults (age range, 23-32.9y) with cerebral palsy (CP).

DESIGN

We completed a secondary analysis of data from the Canadian Institute for Health Information (CIHI) to determine the most frequently observed reasons for admissions and the associated lengths of stay (LOS).

SETTING

Participants were identified from 6 children's treatment centers in Ontario, Canada.

PARTICIPANTS

Health records data from youth with CP (n=587) and young adults with CP (n=477) contributed to this study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The most common reasons for hospital admission, relative frequencies of admissions for each reason, and mean LOS were reported.

RESULTS

The analysis of CIHI records identified epilepsy and pneumonia as the top 2 reasons for admissions in both age groups. Both age groups were commonly admitted because of infections other than pneumonia and urinary tract infections (UTIs), gastrointestinal (GI) problems such as malabsorption, and mental illness. The reasons that were unique to youth included orthopedic and joint-related issues, other respiratory problems, and scoliosis. In young adults, mental illness was the third most common reason for admission, followed by lower GI or constipation problems, malnutrition or dehydration, upper GI problems, fractures, and UTIs.

CONCLUSIONS

This article provides important clinical information that can be used in the training of physicians and health care providers, and to guide future planning of ambulatory care services to support the clinical management of persons with CP over their lifespan.

State-level child health system performance and the likelihood of readmission to children's hospitals

OBJECTIVES

To assess the relationship between children's hospital readmission and the performance of child health systems in the states in which hospitals are located.

STUDY DESIGN

We conducted a retrospective cohort study of 197,744 patients 2 to 18 years old from 39 children's hospitals located in 24 states in the United States in 2005. Subjects were observed for a year after discharge for readmission to the same hospital. The odds of readmission were modeled on the basis of patient-level characteristics and state child health system performance as ranked by the Commonwealth Fund.

RESULTS

A total of 1.8% of patients were readmitted within a week, 4.8% within a month, and 16.3% within 365 days. After adjustment for patient-level characteristics, the probability of readmission varied significantly between states (P=.001), and the likelihood of readmission during the ensuing year increased as the states' health system performance ranking improved. States in the best ranking quartile had a 2.03% higher readmission rate than states in the lowest quartile (P=.02); the same directional relationship was observed for readmission intervals from 1 to 365 days after discharge.

CONCLUSIONS

Hospital readmission rates are significantly related to the performance of the surrounding health care system.

Selective percutaneous myofascial lengthening of the lower extremities in children with spastic cerebral palsy

Children with spastic cerebral palsy commonly acquire lower extremity musculoskeletal deformities that at some point may need surgical correction. The authors present 58 children with spastic cerebral palsy who underwent selective percutaneous myofascial lengthening of the hip adductor group and the medial or the lateral hamstrings. All the patients were spastic diplegic, hemiplegic, or quadriplegic. The indications for surgery were a primary contracture that interfered with the patients' walking or sitting ability or joint subluxation. Gross motor ability and gross motor function of the children were evaluated using the gross motor function classification system (GMFCS) and the gross motor function measure (GMFM), respectively. The mean time of the surgical procedure was 14 minutes (range, 1 to 27 minutes). All patients were discharged from the hospital setting the same day after the operation. There were no infections, overlengthening, nerve palsies, or vascular complications. Three patients required repeat procedures for relapsed hamstring and adductor contractures at 8, 14, and 16 months postoperatively. At 2 years after the initial operation, all the children improved on their previous functional level; 34 children improved by one GMFCS level, and 5 children improved by two GMFCS levels. The overall improvement in mean GMFM scores was from 71.19 to 83.19.

Scoliosis in cerebral palsy

Spinal deformity is a common musculoskeletal problem for individuals with cerebral palsy. Severe scoliosis may impair physical function and may be a source of pain. Spine braces and carefully constructed seating arrangements may moderate the behavior of these deformities but do not seem capable of stopping progression, which often continues in adulthood. Spine fusion surgery can produce a stable, durable trunk shape that improves sitting and positioning but the process of surgery is arduous and outcomes can be compromised by numerous serious complications. Despite complications, many families and caregivers express satisfaction with the results of surgery. Careful patient evaluation, studious attention to surgical planning and performance, and a good relationship with patients, family members, and other providers is essential.

Management of motor problems in cerebral palsy: a critical update for the clinician

Currently there is no specific treatment for the brain insults leading to motor dysfunction in cerebral palsy. The available symptomatic therapeutic options place cerebral palsy among the costliest chronic childhood conditions. Therefore, it is necessary to make well-informed decisions in an effort to match cost-effectiveness with patient and family needs. This presentation aims to analyze the efficacy of rehabilitation therapy, orthoses, oral medications, botulinum toxin, intrathecal baclofen, complementary or alternative treatments and discuss guidelines for a goal oriented approach. Despite insufficient reporting of trials, physiotherapy has shifted from traditional to goal oriented approaches, based on principles of motor learning, strength and fitness training. Correct choice and use of orthoses is stressed, yet evidence from primary studies is limited. Pharmacological treatments of spasticity (oral agents, botulinum toxin, intrathecal baclofen) may be alternatives or supplements to orthopaedic surgery. There is evidence that botulinum toxin combined with conservative treatments reduces the number of complex orthopaedic interventions. Intrathecal baclofen effectively reduces spasticity; criteria describing the ideal candidate are needed. Complementary or alternative treatment use is widespread; research needs to determine what factors make these modalities desirable and effective in cerebral palsy. It is concluded that the introduction of new therapies facilitates an individualized management plan. Multimodal treatment is optimized with a multidisciplinary team. Outcome measurement according to the World Health Organization's new International Classification of Functioning, Disability and Health is emphasized.

Predictors of clinical outcomes and hospital resource use of children after tracheotomy

OBJECTIVES

The objectives are to describe health outcomes and hospital resource use of children after tracheotomy and identify patient characteristics that correlate with outcomes and hospital resource use.

PATIENTS AND METHODS

A retrospective analysis of 917 children aged 0 to 18 years undergoing tracheotomy from 36 children's hospitals in 2002 with follow-up through 2007. Children were identified from ICD-9-CM tracheotomy procedure codes. Comorbid conditions (neurologic impairment [NI], chronic lung disease, upper airway anomaly, prematurity, and trauma) were identified with ICD-9-CM diagnostic codes. Patient characteristics were compared with in-hospital mortality, decannulation, and hospital resource use by using generalized estimating equations.

RESULTS

Forty-eight percent of children were <or=6 months old at tracheotomy placement. Chronic lung disease (56%), NI (48%), and upper airway anomaly (47%) were the most common underlying comorbid conditions. During hospitalization for tracheotomy placement, children with an upper airway anomaly experienced less mortality (3.3% vs 11.7%; P < .001) than children without an upper airway anomaly. Five years after tracheotomy, children with NI experienced greater mortality (8.8% vs 3.5%; P <or= .01), less decannulation (5.0% vs 11.0%; P <or= .01), and more total number of days in the hospital (mean [SE]: 39.5 [4.0] vs 25.6 [2.6] days; P <or= .01) than children without NI. These findings remained significant (P < .01) in multivariate analysis after controlling for other significant cofactors.

CONCLUSIONS

Children with upper airway anomaly experienced less mortality, and children with NI experienced higher mortality rates and greater hospital resource use after tracheotomy. Additional research is needed to explore additional factors that may influence health outcomes in children with tracheotomy.

Retained foreign bodies during surgery in pediatric patients: a national perspective

BACKGROUND

Attention has been placed on surgical and medical errors, though there is a lack of data on the frequency of some complications.

METHODS

International Classification of Diseases, Ninth Revision, Clinical Modification, code 998.4 and E code 871.0 were used to search a database from the United States.

RESULTS

In the Kids' Inpatient Database 2003, there were 103 reports of retained foreign bodies after surgery (incidence, 0.0031%) with a mean age of 11.5 years. There was a wide range between the 36 states sampled. Total charges for a patient with this complication are $56,683 (95% confidence interval, $41,327-$72,039); mean length of stay is 10.5 days. There is an increased charge of $42,077 in patients who have this complication (P < .0001). Of the cases, 74% occurred at teaching institutions.

CONCLUSIONS

On a national perspective in the United States, the rate of a retained foreign body is 0.0031% or approximately 1 in 32,672 cases and is associated with an increased charge of $42,077 for this complication. Comparative data demonstrate that pediatric surgery in the United States is exceptionally safe with regard to retained foreign bodies.

Resource utilization in the management of subglottic stenosis

OBJECTIVE: The purpose of this study was to determine resource utilization in managing subglottic stenosis.

STUDY DESIGN: The Kids' Inpatient Database (KID) 2003 was analyzed.

SUBJECTS AND METHODS: International Classification of Diseases, Ninth Revision code 478.74 was the inclusion criteria.

RESULTS: Two thousand forty-six admissions with subglottic stenosis were sampled; there were 10 deaths (0.49%). States with the most admissions were Ohio, California, and Illinois; these did not have the highest spending per admission. Two hundred eighteen (10.7%) underwent a laryngeal graft procedure; states with the most were Ohio (35.8%), Texas, California, and Florida. Indicators of increased resource utilization include length of stay, nonelective admission, race, primary payer, hospital location, and type.

CONCLUSIONS: For subglottic stenosis, three states account for 37% of admissions, and four states account for 56% of laryngeal graft procedures in 2003. The mean total charges were $53,787; 90% of admissions had total charges less than $139,253. Patients who underwent surgical procedures had total charges of $76,409.

Youth and Young Adults With Cerebral Palsy: Their Use of Physician and Hospital Services

OBJECTIVES

To examine patterns of health care utilization among youth and young adults who have cerebral palsy (CP) and to provide information to guide the development of health services for adults who have CP.

DESIGN

This study analyzed health insurance data for outpatient physician visits and hospital admissions for a 4-year period.

SETTING

Six children's treatment centers in Ontario, Canada.

PARTICIPANTS

The sample included 587 youth and 477 adults with CP identified from health records. Youths were 13 to 17 years of age, and adults were 23 to 32 years of age at the end of the data range.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

We computed the annual rates of outpatient physician visits and hospitalizations per 1000 persons and compared these with rates for the general population.

RESULTS

Annual rates of outpatient physician visits were 6052 for youth and 6404 for adults with CP, 2.2 times and 1.9 times higher, respectively, than rates for age-matched peers (P<.01). Specialists provided 28.4% of youth visits but only 18.8% of adult visits. Annual hospital admission rates were 180 for youth and 98 for adults with CP, 4.3 times and 10.6 times higher, respectively, than rates for age-matched peers (P<.01).

CONCLUSIONS

It appears that youth and adults with CP continue to have complex care needs and rely heavily on the health care system. Comprehensive services are essential to support their health as they move into youth and adulthood. However, there appear to be gaps in the adult health care system, such as limited access to specialist physicians.