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J Pediatr. 2018 Dec 4. pii: S0022-3476(18)31542-7. doi: 10.1016/j.jpeds.2018.10.035. [Epub ahead of print]

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

Author information

1
Department of Pediatrics. McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX; Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, TX. Electronic address: elenir.b.caramel@uth.tmc.edu.
2
Department of Pediatrics. McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX; Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, TX.
3
Department of Pediatrics. McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX.

Abstract

OBJECTIVE:

To assess the sustainability of the benefits relative to usual care of a medical home providing comprehensive care for high-risk children with medical complexity (≥2 hospitalizations or ≥1 pediatric intensive care unit [PICU] admission in the year before enrollment) after we made comprehensive care our standard practice and expanded the program.

STUDY DESIGN:

We conducted pre-post comparisons of the rate of children with serious illness (death, PICU admission, or >7-day hospitalization) and health-system costs observed after program expansion (March 2014-June 2015) to those during the clinical trial (March 2011-August 2013) for each of the trial's treatment groups (usual care, n = 96, and comprehensive care, n = 105; primary analyses), and among all children given comprehensive care (nPost-trial = 233, including trial usual care children who transitioned to comprehensive care post-trial and newly enrolled medically complex children, and nTrial = 105; secondary analyses). We also analyzed the findings for the trial patients as a 2-phase stepped-wedge study.

RESULTS:

In intent-to-treat analyses, rates of children with serious illness and costs were reduced or unchanged post-trial vs trial for the trial's usual care group (rate ratio [RR], 0.36; 95% CI, 0.20-0.64; cost ratio [CR], 0.68; 95% CI, 0.28-1.68), the trial's comprehensive care group (RR, 0.74; 95% CI, 0.39-1.41; CR, 0.67; 95% CI, 0.51-0.89), and among all children given comprehensive care (RR, 0.97; 95% CI, 0.61-1.52; CR, 0.75; 95% CI, 0.61-0.93). Conservative stepped-wedge analyses identified overall benefits with comprehensive care across both study periods (RR, 0.46; 95% CI, 0.30-0.72; CR, 0.64; 95% CI, 0.43-0.99).

CONCLUSIONS:

Major benefits of comprehensive care did not diminish with post-trial program expansion.

KEYWORDS:

comprehensive care; health system costs; serious illness

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