Visits to Pediatric Clinics by Adult Patients: A Nationwide Survey in Taiwan.
ABSTRACT: Pediatricians are trained to provide non-surgical medical care to children. Improvements in medical treatments and surgical techniques have extended the survival of children with congenital diseases and chronic illnesses. Consequently, pediatricians may provide continuous medical service to their patients into adulthood. Meanwhile, as Taiwan's birth rate has fallen to one of the lowest in the world, pediatricians are encountering growing competition. As a source of continued revenue, pediatricians could also provide medical care to adults with common diseases and patients with adult-onset chronic diseases. The aim of this study was to investigate the pattern of adult ambulatory visits to pediatric clinics recorded by Taiwan's National Health Insurance (NHI) system during 2000 to 2011. From 1/500 sampling datasets, we found that adult ambulatory visits to pediatric clinics rose steadily and statistically significantly from 16% of total visits to pediatric clinics in 2000 to 32% in 2011. Analysis of the diagnoses associated with adult ambulatory visits to pediatric clinics indicated that the most common diagnoses for such patients at academic medical centers were chronic illnesses, including epilepsy, cardiac and circulatory congenital anomalies, and diabetes. Meanwhile, at physician clinics, airway infections/diseases and gastroenteritis were the most common diagnoses. In an era of low birth rates, our findings contribute to an evidence-based discussion and provide new information that may assist in healthcare policymaking.
Project description:BACKGROUND: The utilization of medical care for gastrointestinal diseases increased over the past decade worldwide. The aim of the study was to investigate the difference between rural and urban patients in seeking medical service for gastrointestinal diseases at ambulatory sector in Taiwan. METHODS: From the one-million-people cohort datasets of the National Health Insurance Research Database, the utilization of ambulatory visits for gastrointestinal diseases in 2009 was analyzed. Rural patients were compared with urban and suburban patients as to diagnosis, locality of visits and choice of specialists. RESULTS: Among 295,056 patients who had ambulatory visits for gastrointestinal diseases in 2009, rural patients sought medical care for gastrointestinal diseases more frequently than urban and suburban patients (1.60?±?3.90 vs. 1.17?±?3.02 and 1.39?±?3.47). 83.4% of rural patients with gastrointestinal diseases were treated by non-gastroenterologists in rural areas. Rural people had lower accessibility of specialist care, especially for hepatitis, esophageal disorders and gastroduodenal ulcer. CONCLUSION: The rural-urban disparity of medical care for gastrointestinal diseases in Taiwan highlighted the importance of the well communication between rural physicians and gastroenterologists. Besides the establishment of the referral system, the medical teleconsultation system and the arrangement of specialist outreach clinics in rural areas might be helpful.
Project description:Increasing gabapentinoid use has raised concerns of misuse and abuse in the United States (US). Little is known about the characteristics of gabapentinoid use in general clinical practice over time. This cross-sectional study used data from the National Ambulatory Medical Care Survey. We examined the trends of patient and prescriber characteristics and the diagnoses associated with US ambulatory care visits involving gabapentinoids for adult visits from 2003 to 2016. Using multivariable logistic regression, we estimated the adjusted proportion of gabapentinoid-involved visits among all visits and tested for trend significance. Among the weighted estimate of 260.1 million gabapentinoid-involved visits (aged 18-64 years: 61.8%; female: 61.9%; white: 85.5%), the adjusted annual proportion of gabapentinoid-involved visits nearly quadrupled from 2003 to 2016 (9.1 to 34.9 per 1000 visits; Ptrend < 0.0001), driven mainly by gabapentin. Nearly half had concurrent use with opioids (32.9%) or benzodiazepines (15.3%). Primary care physicians (45.8%), neurologists (8.2%), surgeons (6.2%), and psychiatrists (4.8%) prescribed two-thirds of the gabapentinoids. Most (96.6%) of the gabapentinoid visits did not have an approved indication for gabapentinoids among the first three diagnoses. Among US ambulatory care visits from 2003 to 2016, gabapentinoid use increased substantially, commonly prescribed by primary care physicians.
Project description:Acute otitis media (AOM) occurs as a complication of viral upper respiratory tract infections in young children. AOM and respiratory viruses both display seasonal variation. Our objective was to examine the temporal association between circulating respiratory viruses and the occurrence of pediatric ambulatory care visits for AOM.This retrospective study included 9 seasons of respiratory viral activity (2002 to 2010) in Utah. We used Intermountain Healthcare electronic medical records to assess community respiratory viral activity via laboratory-based active surveillance and to identify children <18 years with outpatient visits and International Classification of Diseases, Ninth Revision codes for AOM. We assessed the strength of the association between AOM and individual respiratory viruses using interrupted time series analyses.During the study period, 96,418 respiratory viral tests were performed; 46,460 (48%) were positive. The most commonly identified viruses were respiratory syncytial virus (22%), rhinovirus (8%), influenza (8%), parainfluenza (4%), human metapneumovirus (3%) and adenovirus (3%). AOM was diagnosed during 271,268 ambulatory visits. There were significant associations between peak activity of respiratory syncytial virus, human metapneumovirus, influenza A and office visits for AOM. Adenovirus, parainfluenza and rhinovirus were not associated with visits for AOM.Seasonal respiratory syncytial virus, human metapneumovirus and influenza activity were temporally associated with increased diagnoses of AOM among children. These findings support the role of individual respiratory viruses in the development AOM. These data also underscore the potential for respiratory viral vaccines to reduce the burden of AOM.
Project description:To investigate the types of parental psychiatric and pain-related (PR) conditions that are associated with inadequate management of children's health and medical needs.The 1997-1998 Thomson/Medstat MarketScan claims and administrative dataset.A cross-sectional study that assessed the associations between parents' claims for psychiatric and PR conditions, and their children's well-child care as well as emergency department (ED) visits and hospitalizations for conditions that can be treated effectively in outpatient settings (ambulatory care sensitive [ACS] conditions).Claims were extracted for 258,313 children of ages 0-17 years and their parents, who had insurance coverage for a full 2-year period.Multiple parental psychiatric and PR diagnoses were associated with child ACS emergency services/hospitalizations. Maternal depression was negatively associated with a child having the recommended well-child visits (odds ratio [OR]: 0.92, 95 percent confidence intervals [CI]: 0.84-0.99). The combined diagnoses of maternal depression and back pain was positively associated with a child having an ACS-ED visit (OR: 1.64, 95 percent CI: 1.33-2.03) and a child having an ACS hospitalization (OR: 2.04, 95 percent CI: 1.34-3.09).Pediatricians' ability to manage child health may be enhanced with coordinated management of parental psychopathology and PR health conditions.
Project description:Importance:The use of opioids to treat pain in pediatric patients has been viewed as necessary; however, this practice has raised concerns regarding opioid abuse and the effects of opioid use. To effectively adjust policy regarding opioids in the pediatric population, prescribing patterns must be better understood. Objective:To evaluate opioid prescribing patterns in US pediatric patients and factors associated with opioid prescribing. Design, Setting, and Participants:This cross-sectional study used publicly available data from the National Hospital Ambulatory Medical Care Survey from January 1, 2006, to December 31, 2015. Analysis included the use of bivariate and multivariate models to evaluate factors associated with opioid prescribing. Practitioners from emergency departments throughout the United States were surveyed, and data were collected using a representative sample of visits to hospital emergency departments. The study analyzed all emergency department visits included in the National Hospital Ambulatory Medical Care Survey for patients younger than 18 years. All statistical analysis was completed in June of 2018 and updated upon receiving reviewer feedback in October of 2018. Exposures:Information regarding participants' medications was collected at time of visit. Participants who reported taking 1 or more opioids were identified. Main Outcomes and Measures:Evaluation of opioid prescribing patterns across demographic factors and pain diagnoses. Results:A total of 69?152 visits with patients younger than 18 years (32?727 female) were included, which were extrapolated by the National Hospital Ambulatory Medical Care Survey to represent 293?528?632 visits nationwide, with opioid use representing 21?276?831 (7.25%) of the extrapolated visits. Factors including geographic region, race, age, and payment method were associated with statistically significant differences in opioid prescribing. The Northeast reported an opioid prescribing rate of 4.69% (95% CI, 3.69%-5.70%) vs 8.84% (95% CI, 6.82%-10.86%) in the West (P?=?.004). White individuals were prescribed an opioid at 8.11% (95% CI, 7.23%-8.99%) of visits vs 5.31% (95% CI, 4.31%-6.32%) for nonwhite individuals (P?<?.001). Those aged 13 to 17 years were significantly more likely to receive opioid prescriptions (16.20%; 95% CI, 14.29%-18.12%) than those aged 3 to 12 years (6.59%; 95% CI, 5.75%-7.43%) or 0 to 2 years (1.70%; 95% CI, 1.42%-1.98%). Patients using Medicaid for payment were less likely to receive an opioid than those using private insurance (5.47%; 95% CI, 4.79%-6.15% vs 9.73%; 95% CI, 8.56%-10.90%). There was no significant difference in opioid prescription across sexes. Opioid prescribing rates decreased when comparing 2006 to 2010 with 2011 to 2015 (8.23% [95% CI, 6.75%-9.70%] vs 6.30% [95% CI, 5.44%-7.17%]; P?<?.001); however, opioid prescribing rates remained unchanged in specific pain diagnoses, including pelvic and back pain. Conclusions and Relevance:This research demonstrated an overall reduction in opioid use among pediatric patients from 2011 to 2015 compared with the previous 5 years; however, there appear to be variations in factors associated with opioid prescribing. The association of location, race, payment method, and pain diagnoses with rates of prescribing of opioids suggests areas of potential quality improvement and further research.
Project description:Objective. We sought to determine the characteristics of children presenting to United States (US) Emergency Departments (ED) with severe sepsis. Study design. Cross-sectional analysis using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Using triage vital signs and ED diagnoses (defined by the International Classification of Diseases, Ninth Revision codes), we identified children <18 years old presenting with both infection (triage fever or ICD-9 infection) and organ dysfunction (triage hypotension or ICD-9 organ dysfunction). Results. Of 28.2 million pediatric patients presenting to US EDs each year, severe sepsis was present in 95,055 (0.34%; 95% CI: 0.29-0.39%). Fever and respiratory infection were the most common indicators of an infection. Hypotension and respiratory failure were the most common indicators of organ dysfunction. Most severe sepsis occurred in children ages 31 days-1 year old (32.1%). Most visits for pediatric severe sepsis occurred during winter months (37.4%), and only 11.1% of patients arrived at the ED by ambulance. Over half of severe sepsis cases were self-pay or insured by Medicaid. A large portion (44.1%) of pediatric severe sepsis ED visits occurred in the South census region. ED length of stay was over 3 h, and 16.5% were admitted to the hospital. Conclusion. Nearly 100,000 children annually present to US EDs with severe sepsis. The findings of this study highlight the unique characteristics of children treated in the ED for severe sepsis.
Project description:OBJECTIVES:Severe sepsis is a significant cause of healthcare use and morbidity among pediatric patients, but little is known about readmission diagnoses. We sought to determine the most common readmission diagnoses after pediatric severe sepsis, the extent to which post-sepsis readmissions may be potentially preventable, and whether patterns of readmission diagnoses differ compared with readmissions after other common acute medical hospitalizations. DESIGN:Observational cohort study. SETTING:National Readmission Database (2013-2014), including all-payer hospitalizations from 22 states. PATIENTS:Four-thousand five-hundred twenty-eight pediatric severe sepsis hospitalizations, matched by age, gender, comorbidities, and length of stay to 4,528 pediatric hospitalizations for other common acute medical conditions. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:We compared rates of 30-day all cause, diagnosis-specific, and potentially preventable hospital readmissions using McNemar's chi-square tests for paired data. Among 5,841 eligible pediatric severe sepsis hospitalizations with live discharge, 4,528 (77.5%) were matched 1:1 to 4,528 pediatric hospitalizations for other acute medical conditions. Of 4,528 matched sepsis hospitalizations, 851 (18.8% [95% CI, 16.0-18.2]) were rehospitalized within 30 days, compared with 775 (17.1% [95% CI, 17.1-20.0]) of matched hospitalizations for other causes (p = 0.02). The most common readmission diagnoses were chemotherapy, device complications, and sepsis, all of which were several-fold higher after sepsis versus after matched nonsepsis hospitalization. Only 11.5% of readmissions were for ambulatory care sensitive conditions compared with 23% of rehospitalizations after common acute medical conditions. CONCLUSIONS:More than one in six children surviving severe sepsis were rehospitalized within 30 days, most commonly for maintenance chemotherapy, medical device complications, or recurrent sepsis. Only a small proportion of readmissions were for ambulatory care sensitive conditions.
Project description:To investigate the utilisation of eye disorder-related ambulatory medical services prior to the diagnosis of primary Sjögren's syndrome in female Taiwanese patients.A nationwide, population-based case-control study.Taiwan's National Health Insurance Research Database.A total of 347 patients with a diagnosis of primary Sjögren's syndrome from 2005 to 2010 and 1735 controls frequency matched on 10-year age interval and index year were identified from Taiwan's National Health Insurance Research Database. Diagnoses of eye disorder (International Classification of Diseases, Ninth Revision, clinical modification (ICD-9-CM) codes from 360 to 370) were retrospectively screened to 1997.The utilisation of eye disorder-related medical service over different intervals prior to diagnosis of Sjögren's syndrome between cases and controls were compared using generalised estimating equations with negative binomial distribution and log link function.A significantly higher proportion of patients with Sjögren's syndrome (7.5%) utilised eye disorder-related ambulatory medical services over an 8-year interval prior to the diagnosis of the disease compared with controls (4.8%). The annual frequency of utilisation of eye disorder-related ambulatory medical services increased significantly faster when closer to the index date in patients with Sjögren's syndrome compared with controls (interaction effect, p=0.010). Subgroup analyses indicated that the changes over time in the utilisation of services related to disorders of lacrimal system (interaction effect, p=0.019) and conjunctiva (interaction effect, p=0.066) were significantly greater in patients with Sjögren's syndrome compared with controls.An increase in the utilisation of eye disorder-related ambulatory medical services was observed in patients with Sjögren's syndrome several years prior to the diagnosis of the disease. General practitioners and ophthalmologists can play an important role by including Sjögren's syndrome in the diagnostic evaluation of their patients afflicted with relevant symptoms.
Project description:Importance:Pediatric hospital medicine is a relatively new and growing specialty. However, research remains inconclusive on outcomes for inpatients cared for by pediatric hospitalists compared with those cared for by general pediatricians. Objective:To analyze outcomes, adverse events (AEs), and types of AEs associated with care provided for pediatric patients by hospitalists vs general pediatricians. Design, Setting, and Participants:This cross-sectional study used data from the medical records of a US urban academic children's hospital comprising 1423 hospitalizations between January 1, 2009, and August 31, 2015, for 57 diagnoses of patients cared for by either a hospitalist or general pediatrician. General pediatricians worked primarily in the hospital's outpatient clinic, serving a few inpatient weeks per year, and were not the patients' primary care physician. Data analysis was performed from July 1, 2017, to October 10, 2018. Main Outcomes and Measures:Outcomes were length of stay, total costs, 30-day readmission rates, and AEs. Adverse events were documented by International Classification of Diseases, Ninth Revision, Clinical Modification codes determined by review of medical records. Adverse event categories were drug events, infections, and device-related AEs. Generalized linear models were used to analyze patient outcomes, with standard errors clustered by physician. Models were adjusted for patient characteristics, including Chronic Condition Indicators. Models were estimated with and without adjustment for physician characteristics. Results:The data set contained 1423 hospitalizations among 726 female patients and 697 male patients (mean [SD] age, 6.1 [6.3] years). Hospitalists cared for 870 patients, and general pediatricians cared for 553 patients. Among the physicians, there were 57 women and 38 men; physicians were a mean (SD) 11.1 (8.1) years out of medical school. Patients cared for by general pediatricians were younger than those cared for by hospitalists (mean [SD] age, 5.4 [6.0] vs 6.5 [6.4] years; P?=?.001) but had similar mean (SD) Chronic Condition Indicator scores (1.5 [1.0] vs 1.5 [1.0]). A total of 33 of 56 general pediatricians (58.9%) and 24 of 39 hospitalists (61.5%) were women (P?=?.006), and general pediatricians were in practice twice as long as hospitalists on average (mean [SD], 16.0 [10.3] vs 7.9 [3.8] years out of medical school; P?<?.001). In multivariate models adjusting for patient-level features, there were no significant differences between general pediatricians and hospitalists for mean length of stay (4.7 vs 4.6 days), total costs ($14?490 vs $15?200), and estimated 30-day readmission rate (8.9% vs 6.4%), and results were similar with adjustments for physician characteristics. Device-related AEs were higher among hospitalists (3.0% vs 1.1%; odds ratio, 0.34; 95% CI, 0.12-1.00); this association became nonsignificant after adjusting for physician experience. Conclusions and Relevance:General pediatrician and hospitalist inpatient care had similar length of stay, total costs, and readmission rates. However, AEs differed between hospitalists and general pediatricians, with device-related AEs more common among hospitalists, which may be associated with hospitalists' fewer years in practice. Such findings can inform hospitals in planning their inpatient staffing and patient safety oversight.
Project description:Background:Acute otitis media (AOM) and otitis media with effusion (OME) occur primarily in children, whereas acute otitis externa (AOE) occurs with similar frequency in children and adults. Data on the incidence and management of otitis in adults are limited. This study characterizes the incidence, antibiotic management, and outcomes for adults with otitis diagnoses. Methods:A retrospective cohort of ambulatory adult veterans who presented with acute respiratory tract infection (ARI) diagnoses at 6 VA Medical Centers during 2014-2018 was created. Then, a subcohort of patients with acute otitis diagnoses was developed. Patient visits were categorized with administrative diagnostic codes for ARI (eg, sinusitis, pharyngitis) and otitis (OME, AOM, and AOE). Incidence rates for each diagnosis were calculated. Proportions of otitis visits with antibiotic prescribing, complications, and specialty referral were summarized. Results:Of 46 634 ARI visits, 3898 (8%) included an otitis diagnosis: OME (22%), AOM (44%), AOE (31%), and multiple otitis diagnoses (3%). Incidence rates were otitis media 4.0 (95% confidence interval [CI], 3.9-4.2) and AOE 2.0 (95% CI, 1.9-2.1) diagnoses per 1000 patient-years. By comparison, the incidence rates for pharyngitis (8.4; 95% CI, 8.2-8.6) and sinusitis (15.2; 95% CI, 14.9-15.5) were higher. Systemic antibiotics were prescribed in 75%, 63%, and 21% of AOM, OME, and AOE visits, respectively. Complications for otitis visits were low irrespective of antibiotic treatment. Conclusions:Administrative data indicated that otitis media diagnoses in adults were half as common as acute pharyngitis, and the majority received antibiotic treatment, which may be inappropriate. Prospective studies verifying diagnostic accuracy and antibiotic appropriateness are warranted.