Transcript BePASSTA Belgian PAediatric Short STAy study RESULTS AND FINAL CONCLUSIONS 7 March 2012Prof.

BePASSTA
Belgian PAediatric Short STAy study
RESULTS AND FINAL CONCLUSIONS
7 March 2012
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Prof. Sophie Alexander, Luk Cannoodt et Alain De Wever
Researchers:
MD Cohen L, Laokri S, Seurynck N, MD PhD Zhang W-H
Trybou J, Verhaeghe N
GENERAL CONTEXT
• The hospitalized child has specific needs (Leiden 1988)
•
At least one parent present during the stay
•
Optimal treatment of pain
•
Specific needs (affective, physical and educational)
•
Hospitalization when home treatment is unavailable
RD 13th July 2006: Child Care Program
Efficiency
Quality of care
Accessibility
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GENERAL CONTEXT
• Hospitalization patterns change with time
Between 1999 and 2007…
• Mean duration of pediatric stay: stable
(from 3,7 to 3,6 days)
•
Number of traditional hospitalizations
(-3202 stays per year > -11848 days per year)
•
Number of day care hospitalizations
(+5359 admissions per year)
•
Role of the pediatric emergency dep.
• Observation units/ Observation facility
SPF/FOD data
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GOALS OF BEPASSTA
Pediatric emergency department
“…définir les paramètres pertinents pour quantifier le financement ainsi que les activités
et les caractéristiques des patients (âge, pathologie), du personnel intervenant (actes
médicaux et infirmiers, types de prestations…), de la prise en charge (traitements,
examens complémentaires, types de procédures…), ainsi que le suivi (intra- ou
extrahospitaliers des patients”.
Day care hospital
“…évaluer les avantages et les limites de la prise en charge des enfants en
hospitalisation de jour et en hospitalisation provisoire par rapport aux autres
prises en charge”
“…établir des propositions pour un financement correct de la prise en charge en
hospitalisation de jour (au sens large)” afin de “formuler des recommandations sur
la base de ces éléments”.
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RESEARCH TOOLS
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SELECTION OF THE PILOT HOSPITALS
BePASSTA
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WHAT ARE WE LOOKING FOR?
Patients
Populations
Flows
Workload
Performers
Acts
Financial
data
Consultations
Packages
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PRESENTATION METHODOLOGY
For each pole…
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COMPARAISON OF THE 3 POLES:
POPULATIONS
Emergenc
y
Medical DCH
Surgical DCH
Median age (years)
3.3
6.98
4.7
(IQR)
(1.2 - 9.1)
(3.2 - 11.96)
(2.8 - 8)
% Girls
46.7%
46.0%
40.0%
Mean nr children/family
1.5
1.7
1.5
3.7% (N=1932)
5.2% (N=385)
2.4% (N=494)
16.6%
43.9%
16.4%
(N=1931)
(N=385)
(N=494)
% Parents with disability
[CT1b=2]
Poverty : % with increased
reimbursement [CT1c=1]
IQR : Interquartile Range (Q1-Q3)
N : Size of the study population
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EMERGENCY AND OBSERVATION
FLOW CHART
 Almost 40% of all children stay longer in the hospital than a
regular consultation
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DO THEY HAVE A PRIVATE PRACTITIONER?
Distribution of patients with and without a private
practitioner
Yes
87,6%
 A majority of patients (87,6%) has a private practitioner
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HOW DO THEY DECIDED TO COME?
 A majority of patients come spontaneously and
have no prior contact with their private practitioner
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WHY DID THEY COME?
Condition felt by parents
N
%
Extreme/vital emergency
250
7,9%
Moderate emergency
1435
45,5%
•
Situation can’t wait until tomorrow
1045
33,2%
•
No doctor can see me now
390
12,4%
The child needs specialized cares
1038
32,9%
No real emergency, but I always go to the hospital
358
11,4%
Other (referred by the police, the private practitioner)
2
0,1%
Don’t know
68
2,2%
3151
100,0%
Total
 For a majority of parents (56,9%), their child’s condition is a
moderate emergency or no emergency at all
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WHEN DID THEY COME?
Source: BePASSTA
Source: UNMS
 Almost 40 to 50% of children seen during difficult hours
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WHAT DOCTOR WAS IN CHARGE?
N
%
1925
59,8%
642
19,9%
Multidisciplinary work-up without a pediatrician
445
13,8%
Multidisciplinary work-up with a pediatrician
208
6,5%
Total
3220
100,0%
Pediatrician (or assistant) only
Emergency doctor (or assistant) but not a pediatrician
 The pediatrician has a pivotal role in the emergency department
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DO ALL THE EMERGENCY CONSULTATIONS
NEED THE HOSPITAL?
An emergency consultation is called “appropriate” if…
…it mandatorily needs hospital-specific cares or technics
The selection (appropriate/inappropriate) is
• based on literature-extracted criteria
• with an a posteriori use and an epidemiological interest
only.
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DO ALL THE EMERGENCY CONSULTATIONS
NEED THE HOSPITAL?

Criteria for appropriate emergencies
•
Child sent by a doctor
•
Child is come with an ambulance
•
Child is brought by the police
•
After the visit, the child is observed or directly hospitalized
•
Child dies in the hospital after the emergency consultation
•
Cast needed
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DO ALL THE EMERGENCY CONSULTATIONS
NEED THE HOSPITAL?
Appropriate
contacts
Inappropriate
contacts
39.3%
60.7%
 Almost 40% of all the emergency consultations do not require
the hospital infrastructures
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APPROPRIATE AND INAPPROPRIATE EMERGENCY
CONSULTATIONS
A MULTIVARIATE ANALYSIS
Parents’ evaluation
Living in Flanders
age < 2 years
Night / WE / holydays
Short distance home-hospital
Having a family practitioner
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WHERE ARE THE CHILDREN OBSERVED?
3,4%
N=1209
Salle d’attente / table
d’examen dans un box
(pas dans un lit)
9,7%
Unité d’observation
dédiée aux enfants
86,9%
N=1181
Unité d’observation
avec des adultes (dans
un lit)
 The observed children remain in the Emergency department,
mostly not in a bed
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WHY ARE THE CHILDREN OBSERVED?
 69% of all children who stay longer in the hospital than a regular
consultation, are waiting for results
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DISTINGUISHING BETWEEN
LENGTHY CONSULTATIONS
AND ‘REAL’ OBSERVATIONS
 Are all observations justified?
 Probably yes (suggested by doctor and approved by parents)
 How to distinguish between lengthy consultations and ‘real’
observations?
 Criteria for a ‘real’ observation
• The child lays in a bed
• HR, RR, T°… are regularly checked
• Duration criterion?
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EMERGENCY AND OBSERVATION
CRITERIA VS. NON CRITERIA OBSERVATIONS
Observation type
N
%
Non criteria observations
1114
90%
Criteria observations
123
10%
Total
1237
100%
 10% of all observations meet the criteria
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ARE THE OBSERVATIONS USEFUL?
Diagnosis
unclear
84,3% clarification
Test the
treatment
88,3% clarification
True
observations
Prevents
unnecessary
hospitalizations
 Observations help clarifying an unclear diagnosis, testing a
treatment and preventing some hospitalizations
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DISCUSSION
 87,6% of all children
• have a private practitioner
• come spontaneously to the emergency department without a prior
contact with their doctor
 What does it mean about the first line pediatric cares?
 66,3% of all children see a pediatrician in the emergency department.
 What exactly is the role of the pediatrician in this department?
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DISCUSSION
 39,3% of the visits to the emergency department do not require
hospital-specific cares or technics
It is what we have called ‘inappropriate emergency consultation’.
 What should we do about that?
 38,6% of all children stay longer than a usual consultation (i.e.
observation), which seem to be useful.
 Should we develop the observation and how?
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EMERGENCY AND OBSERVATION
THE INTERESTING POPULATIONS
General
population
Observations
Criteriaobservations
Non
observations
Lengthy
consultations
Appropriate
contacts
Inappropriat
e contacts
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EMERGENCY AND OBSERVATION
GENERAL POPULATION: FINANCIAL DATA
done
billed
Over-billing
Under-billing
Bill shifting
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OBSERVATION VS. NON OBSERVATION:
WORKLOAD
Observation
Non Observation
Nurse
72.32 ‘
SDO
48.9
53.48 ‘
SDNO
50.0
Test t
p<.001
Doctor
78.92 ‘
41.59
60.76 ‘
28.15
p<.001
Secretary
15.91 ‘
9.47
13.69 ‘
6.44
p<.001
Total
167.15 ‘
2.14
127.93 ‘
1.52
p<.001
Workload
Observation
 Observation means an increased workload for all
professionals working in the emergency department
Workload
NON
observation
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OBSERVATION VS. NON OBSERVATION:
DATA
Observation Non Observation
FINANCIAL
test t
(n=398)
(n=696)
Pediatrician
64,1%
53,3%
p=0,001
BMA
1,8%
2,3%
NS
SMU
32,5%
43%
p=0,001
Other specialist
3,7%
4,3%
NS
≥1 consultation
74,6%
89,7%
p< 0,001
Packages
5,8%
10,1%
p=0,015
 Observation is less funded than non observation
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Observation
CRITERIA VS. NON CRITERIA OBSERVATIONS:
WORKLOAD
Criteria
Observation
Non Criteria
Observation
SDOJ
test t
SDONJ
Nurse
100.76 ‘
58.12
71.10 ‘
48.12
p<.001
Doctor
Secretary
Total
200.53 ‘
89.63
165.72 ‘
74.14
NS
NS
p<.01
Workload
Non Criteria Obs.
Criteria
Observations
Workload
Non Criteria
Observations
for the nurses
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Criteria Obs.
CRITERIA VS. NON CRITERIA OBSERVATIONS:
FINANCIAL DATA
Criteria
Observation Non criteria
s
Observations
(n=23)
(n=375)
test t
Pediatrician
73,9%
63,5%
NS
BMA
0,0%
1,9%
NS
SMU
Other
specialists
13,0%
44,8%
0,003
8,7%
4%
NS
Packages
0,0%
6,1%
NS
≥1 consultation
87,0%
89%
NS
 Almost no billing differences between criteria and non criteria
observations
 Workload for nurses C+ obs. > C- obs.
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APPROPRIATE VS. INAPPROPRIATE EMERGENCY
CONTACTS: WORKLOAD
Appropriate
contacts
Inappropriate
contacts
SDAC
T test
SDINC
Nurse
72.94 ‘
52.92
41.83 ‘
39.44
p<.001
Doctor
74.33 ‘
38.92
57.55 ‘
24.91
p<.001
Secretary
-
-
-
-
NS
Total
161.84 ‘
76.15
113.88 ‘
57.04
p<.001
Workload (minutes per patient) for appropriate and inappropriate contacts
Workload
Appropriat
e contacts
Workload
Inappropria
te contacts
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APPROPRIATE VS. INAPPROPRIATE EMERGENCY
CONTACTS: FINANCIAL DATA
Appropriate
contacts
(n=676)
Inappropriate
contacts
(n=413)
Pediatrician
56,2%
58,9%
NS
BMA
2,2%
1,9%
NS
SMU
36,2%
36,4%
NS
Other specialists
4,4%
3,1%
NS
Packages
8,1%
9,1%
NS
≥1 consultation
80,3%
79,7%
NS
test t
 Almost no billing differences between appropriate and
inappropriate contacts
• Is it worth the money?
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APPROPRIATE VS. INAPPROPRIATE EMERGENCY
CONTACTS: WHY SHOULD WE CARE ABOUT?

Frequency:
Appropriate contacts :60,71%
Inappropriate contacts : 39,29%

Workload:
Inappropriate < Appropriate
but…

Difficult hours: Inappropriate > Appropriate

Billing:
Inappropriate = Appropriate
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PROPOSITIONS
Pediatric emergency and pediatric first line of care
1. The pediatrician is the pivotal actor of unscheduled and urgent
pediatric care (58,9% of the children seen by a pediatrician)
… but
•
the consultation codes (102071/102572) are not
suitable for emergency
•
value pediatric codes<SMU codes (risk of shift)
 We suggest to use all the existing resources of the nomenclature
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DISCUSSION AND PROPOSITIONS
Pediatric emergency and pediatric first line of care
2. Almost 50% of the children come to the Emergency
department during the night, the weekends, or public
holydays.
 For security reasons (for the patient and for the pediatrician),
we suggest to…
•
regulate the duration of uninterrupted work
•
adapt payment for work during nights, weekends and public
holydays
•
promote the collaboration between GP’s, private
pediatricians and the hospital.
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DISCUSSION AND PROPOSITIONS
Pediatric emergency and pediatric first line of care
3. Almost 40% of the visits to the Emergency department were
considered inappropriate.
Those ‘inappropriate’ visits are
•
more frequent
•
•
•
•
•
during the tough hours
when the child is less than 2 years
When the distance to the hospital is small
when they have a GP or a private pediatrician
(?)
not less expensive than appropriate contacts.
 Is this a suitable use for the Emergency department?
 We suggest an a posteriori answer based on efficiency
measurement, rather an a priori answer based on ideology
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DISCUSSION AND PROPOSITIONS
Pediatric emergency and pediatric first line of care
4. Before coming to the Emergency department, more than 2/3 of
children have no prior contact with their doctor (parents'
decision only)
…but 87.6% have a family doctor or a private pediatrician.
 Why is the first line so regularly bypassed?
 What should be the ideal distribution between the GP, the private
pediatrician, the hospital and other structures?
 Is this a suitable use for the first line in Belgium?
 We suggest an a posteriori answer based on efficiency
measurement, rather an a priori answer based on ideology
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DISCUSSION AND PROPOSITIONS
Pediatric emergency and pediatric first line of care
5. There are frequent pricing errors, which are armful for
•
•
•
•
parents
physicians
the hospital
the Social Security
 What could be done to lower the number of errors?
 We suggest the hospitals
•
to check the coding procedures and
•
to control their paper pathways
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DISCUSSION AND PROPOSITIONS
Observation
1. Almost 40% of the children stay longer than a usual
consultation.
It has been called “Observation”.
 Is the Observation useful?
•
•
•
Observation helps making a diagnosis: 84,3%
Observation helps testing a treatment: 88,3%
Observation prevents unnecessary hospitalizations
Yes, Observation is useful for patients, doctors and the Social
Security.
 Therefore, we suggest to create a regulatory frame to help the
development of the Observation Unit or Function.
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DISCUSSION AND PROPOSITIONS
Observation
This regulatory frame should contain the following statements:
1. The hospital decides to have a Observation Unit, or a more
limited Observation Function
2. Regardless of the hospital’s choice, a special area should be
dedicated to children staying longer than an usual consultation
3. A pediatrician heads the Observation Unit/Function, and is
responsible for all decisions related to the child
4. The nurses working in the Observation Unit/Function have a
pediatric qualification
5. Once the child has leaved the Observation, a report is written by
the pediatrician.
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DISCUSSION AND PROPOSITIONS
Observation
2. Not all the children staying in the hospital longer than un usual
consultation should be considered observed. Therefore, a group of
experts has suggested for an observational stay to be defined
according to the following cumulative criteria:
1. The child should lay in a bed (not sitting on a chair)
2. The child is observed more than 1 hour
3. A pediatrician is accountable for the child
4. The child is regularly checked by a nurse
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DISCUSSION AND PROPOSITIONS
Observation
3. BePASSTA has shown that Observation means more work than
an usual consultation.
 For the pediatrician , we suggest to…
•
create an “Observation fee” , which value would be equal to
the ‘supervision day 1 fee’ (code: 598802)
•
This Observation fee would be related to the supervision of
the child during the Observation (including the writing of
the medical report)
•
All the cumulative criteria must be met for the Observation
fee to be due.
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DISCUSSION AND PROPOSITIONS
Observation
4. Observation needs an additional budget and a specific
financing.
We suggest that for the Observation…
…financing should be based
on the clinical activity
Diagnosis-based financing
Criteria-based financing
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DISCUSSION AND PROPOSITIONS
Observation
Clinical activity-based financing
Diagnosis-based financing
MCR analysis >
BMF
Criteria-based financing
If criteria met, then
1. Admission package
2. Hospitalization day package
3.
BMF
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Dank U / Merci
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FIN DE L’EXPOSÉ
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