Inequality in early childhood chronic health conditions requiring hospitalisation: A data linkage study of health service utilisation and costs

Assessing Inequities in Hospital Outcomes for Australian Children From Underserved Populations

OBJECTIVES

Inequity in health outcomes for children and young people (CYP) from underserved populations (Indigenous, culturally and linguistically diverse, refugee and/or asylum seeking, out-of-home care backgrounds, and National Disability Insurance Scheme participants) persists. We quantify baseline inequities in health outcomes to measure the effectiveness of equity interventions.

METHODS

We analyzed electronic medical records on CYP from the Sydney Children's Hospitals Network between 2015 and 2019. The primary outcome measures were high-acuity presentations, potentially preventable hospitalizations (PPH), chronic condition hospitalizations, discharge against medical advice (DAMA), ward and critical care admission, readmission, and extended length of stay (LOS). We used generalized estimating equation models to examine the relationship between underserved population status and outcomes.

RESULTS

One third of 253 934 inpatient and 446 924 emergency department (ED) encounters were underserved CYP. Compared with nonunderserved populations, there was increased risk of PPH (relative risk [RR], 1.25; 95% CI, 1.23-1.27), chronic conditions (RR, 1.09; 95% CI, 1.07-1.10), DAMA (RR, 1.33; 95% CI, 1.19-1.49), ward admission (RR, 1.16; 95% CI, 1.15-1.18), readmission (RR, 1.48; 95% CI, 1.42-1.53), extended inpatient LOS (RR, 1.21; 95% CI, 1.18-1.24), and ED LOS (RR, 1.11; 95% CI, 1.10-1.12). As an example of cumulative risk, Indigenous CYP living with a disability had a 239% higher risk of readmission than CYP without these risk factors (RR, 3.39; 95% CI, 2.92-3.93).

CONCLUSIONS

Interventions are required to reduce health inequities for underserved CYP. We present strategies that include improved patient identification, enhanced service access, and system-wide culture change within an equity learning health system.

Fathers' Ongoing Journey When a Child in the Family Has a Chronic Condition: A Meta-Synthesis

This qualitative meta-synthesis was conducted with the aim to understand fathers' experiences and involvement when their child has a chronic condition within family context. Family nurse researchers from five countries identified 19 studies through a systematic search. Inclusion criteria were: (a) fathers as primary informant; (b) children (<19 years) with a chronic condition; (c) written in English, Spanish, French, or Portuguese. Data were synthesized using thematic analysis. Four themes reflected fathers' journey: "Juggling multiple roles" included protector, provider, and supporter; "Managing control" included relinquishing and regaining control; "Creating a new normal" addressed recovery; "Maintaining wellbeing" reflected multiple emotional responses and support found through partners, family, spirituality, and health care communities. Fathers desire to be involved in caring for their child with a chronic condition, yet involvement and experience are continually evolving due to various family needs. Health care providers should consider unconscious assumptions regarding fathers' role in child care and encourage fathers' involvement to facilitate family wellbeing.

Healthcare utilization and its association with socioeconomic status in China: Evidence from the 2011-2018 China Health and Retirement Longitudinal Study

INTRODUCTION

Healthcare utilization often favors the higher-socioeconomic status (SES) and having chronic diseases may exacerbate this inequality. This study aims to examine the trends in health service use over time, the effect of SES on healthcare utilization, and the role of chronic diseases in this association.

METHODS

Data used in this study were from the China Health and Retirement Longitudinal Study (CHARLS) in 2011, 2013, 2015, and 2018, which is the first nationally representative survey of the middle-aged and older. The sample included people aged 45 years and older who responded to all the waves. A total of 10,922 adults were included in this study. Healthcare utilization was categorized into outpatient and inpatient service use and SES was measured by per-capita household expenditure. A multilevel zero-inflated negative binomial regression model was performed to analyze outpatient and inpatient service use, separately.

RESULTS

The rates of outpatient service use in 2011, 2013, 2015, and 2018 were 19.11%, 21.45%, 20.12%, and 16.32%, respectively, while the rates of inpatient service use were 8.40%, 13.04%, 14.17%, and 18.79%, respectively. Compared to individuals in the lowest quintile of per-capita household expenditure, those in higher quintiles had higher odds of outpatient service use (Q2: odds ratio = 1.233, p < 0.0001; Q3: 1.416, p < 0.0001; Q4: 1.408, p < 0.0001; or Q5: 1.439, p < 0.0001) and higher rates of inpatient service use (Q2: incidence rate ratio = 1.273, p < 0.0001; Q3: 1.773, p < 0.0001; Q4: 2.071, p < 0.0001; or Q5: 1.992, p < 0.0001). Additionally, having morbidity generally increased healthcare utilization, but did not play a significant role in moderating the relationship between SES and healthcare utilization.

CONCLUSIONS

Healthcare utilization rates were overall low in China, but relatively high for people in higher quintiles of per-capita household expenditure or those with morbidity, compared to their counterparts. Policy actions are required to provide more health education to the public, to further optimize health insurance schemes targeting outpatient services, especially for the low-SES, and to establish new health delivery models for NCD management in the primary health care setting.

Long-term chronic diseases and 1-year use of healthcare services by children under 18 years of age during 2018-2019: A French nationwide observational study

OBJECTIVE

Among children younger than 18 years, the prevalence of long-term chronic diseases (LTDs) is not well known in France, nor the frequency of the use of healthcare services. This nationwide observational study focused on both topics over a 1-year period following the birth or birthday of French children in 2018 and compared the LTD status and use of healthcare.

MATERIALS AND METHODS

We selected children living in mainland France from the national health data system (SNDS). It includes data concerning the LTD status, which guarantees 100% reimbursement for related healthcare expenditures. We calculated the median and interquartile range (IQR) for the prevalence of LTDs and the rate of children using healthcare services at least once during the year.

RESULTS

We included 13.211 million children (51.2% boys), of whom 4% had at least one LTD (boys: 4.6%, girls: 3.3%). Mental and behavioral disorders were the most frequent cause (1.6%). At least one visit to a general practitioner (GP) or pediatrician was found for 88% of children (median: 3, IQR: 2-6): 98% for children under 1 year of age and 81% for children aged 14-17 years. A pediatrician was visited by 17% of children, another specialist by 39%, a dentist by 37%, with peaks of about 60% at the ages of 6, 9, and 12 years; 8% visited a nurse and 7% visited a physiotherapist. At least one emergency department visit was recorded for 24% of children (42% <1 year) and one short-stay hospitalization (SSH) for 9%. Regional variations were observed. Children with LTDs more frequently used all services, such as specialist visits (50% vs. 40%), ED visits (32% vs. 23%), SSHs (26% vs. 8% and 15% vs. 4.0% for one night or more), and psychiatric hospital admissions (5% vs. 0.1%).

CONCLUSION

Most children saw a GP or pediatrician during the year and children with an LTD showed more frequent use. Nevertheless, outpatient visits appeared to be underutilized with respect to recommendations or free-of-charge prevention visits, such as for dentists. More detailed studies are required to identify factors associated with the use of healthcare services in France, for example, studies including the deprivation index and regional variations.

Strengthening Care for Children (SC4C): protocol for a stepped wedge cluster randomised controlled trial of an integrated general practitioner-paediatrician model of primary care

INTRODUCTION

Australia's current healthcare system for children is neither sustainable nor equitable. As children (0-4 years) comprise the largest proportion of all primary care-type emergency department presentations, general practitioners (GPs) report feeling undervalued as an integral member of a child's care, and lacking in opportunities for support and training in paediatric conditions. This Strengthening Care for Children (SC4C) randomised trial aims to evaluate a novel, integrated GP-paediatrician model of care, that, if effective, will improve GP quality of care, reduce burden to hospital services and ensure children receive the right care, at the right time, closer to home.

METHODS AND ANALYSIS

SC4C is a stepped wedge cluster randomised controlled trial (RCT) of 22 general practice clinics in Victoria and New South Wales, Australia. General practice clinics will provide control period data before being exposed to the 12-month intervention which will be rolled out sequentially each month (one clinic per state) until all 22 clinics receive the intervention. The intervention comprises weekly GP-paediatrician co-consultation sessions; monthly case discussions; and phone and email paediatrician support, focusing on common paediatric conditions. The primary outcome of the trial is to assess the impact of the intervention as measured by the proportion of children's (0-<18 years) GP appointments that result in a hospital referral, compared with the control period. Secondary outcomes include GP quality of care; GP experience and confidence in providing paediatric care; family trust in and preference for GP care; and the sustainability of the intervention. An implementation evaluation will assess the model to inform acceptability, adaptability, scalability and sustainability, while a health economic evaluation will measure the cost-effectiveness of the intervention.

ETHICS AND DISSEMINATION

Human research ethics committee (HREC) approval was granted by The Royal Children's Hospital Ethics Committee in August 2020 (Project ID: 65955) and site-specific HRECs. The investigators (including Primary Health Network partners) will communicate trial results to stakeholders and participating GPs and general practice clinics via presentations and publications.

TRIAL REGISTRATION NUMBER

Australia New Zealand Clinical Trials Registry 12620001299998.

Inequities in vulnerable children's access to health services in Australia

INTRODUCTION

Children born into families at risk of becoming or remaining poor are at significant risk of experiencing childhood poverty, which can impair their start to life, and perpetuate intergenerational cycles of poverty. This study sought to quantify health service utilisation, costs and funding distribution amongst children born into vulnerable compared to non-vulnerable families.

METHODS

This study used a large linked administrative dataset for all women giving birth in Queensland, Australia between July 2012 and July 2018. Health service use included inpatient, emergency department (ED), general practice, specialist, pathology and diagnostic imaging services. Costs included those paid by public hospital funders, private health insurers, Medicare and out-of-pocket costs.

RESULTS

Vulnerable children comprised 34.1% of the study cohort. Compared with non-vulnerable children, they used significantly higher average numbers of ED services during the first 5 years of life (2.52±3.63 vs 1.97±2.77), and significantly lower average numbers of specialist, pathology and diagnostic imaging services. Vulnerable children incurred significantly greater costs to public hospital funders compared with non-vulnerable children over the first 5 years of life ($16 053 vs $10 247), and significantly lower private health insurer, Medicare and out-of-pocket costs.

CONCLUSION

There are clear inequities in vulnerable children's health service utilisation in Australia. Greater examination of the uptake and cost-effectiveness of maternal and child services is needed, as these services support children's development in the critical first 1000 days of life.