1. RESULTS AND FINAL CONCLUSIONS 7 March 2012 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 BePASSTA Belgian PAediatric Short STAy study 1

2. G ENERAL CONTEXT 2 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

3. G ENERAL CONTEXT 3 Hospitalization patterns change with time SPF/FOD data 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

4. G OALS OF B E PASSTA 4 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”.

5. R ESEARCH TOOLS 5

6. S ELECTION OF THE PILOT HOSPITALS 6 BePASSTA

7. 7 W HAT ARE WE LOOKING FOR ? Patients Populations Flows Workload Performers Acts Financial data Consultations Packages

8. 8 Patients Workload Financia l data For each pole… P RESENTATION METHODOLOGY

9. C OMPARAISON OF THE 3 POLES : P OPULATIONS 9 IQR : Interquartile Range (Q1-Q3) N : Size of the study population Emergenc y Medical DCHSurgical DCH Median age (years) (IQR) 3.3 (1.2 - 9.1) 6.98 (3.2 - 11.96) 4.7 (2.8 - 8) % Girls46.7%46.0%40.0% Mean nr children/family 1.51.71.5 % Parents with disability [CT1b=2] 3.7% (N=1932)5.2% (N=385)2.4% (N=494) Poverty : % with increased reimbursement [CT1c=1] 16.6% (N=1931) 43.9% (N=385) 16.4% (N=494)

10. E MERGENCY AND O BSERVATION F LOW CHART 10  Almost 40% of all children stay longer in the hospital than a regular consultation

11. DO THEY HAVE A PRIVATE PRACTITIONER? 11 Yes 87,6% Distribution of patients with and without a private practitioner  A majority of patients (87,6%) has a private practitioner

12. HOW DO THEY DECIDED TO COME? 12  A majority of patients come spontaneously and have no prior contact with their private practitioner

13. WHY DID THEY COME? 13  For a majority of parents (56,9%), their child’s condition is a moderate emergency or no emergency at all Condition felt by parentsN% Extreme/vital emergency2507,9% Moderate emergency143545,5% Situation can’t wait until tomorrow104533,2% No doctor can see me now39012,4% The child needs specialized cares103832,9% No real emergency, but I always go to the hospital35811,4% Other (referred by the police, the private practitioner)20,1% Don’t know682,2% Total3151100,0%

14. WHEN DID THEY COME? 14 Source: BePASSTA Source: UNMS  Almost 40 to 50% of children seen during difficult hours

15. WHAT DOCTOR WAS IN CHARGE? 15  The pediatrician has a pivotal role in the emergency department N% Pediatrician (or assistant) only 192559,8% Emergency doctor (or assistant) but not a pediatrician 64219,9% Multidisciplinary work-up without a pediatrician 44513,8% Multidisciplinary work-up with a pediatrician 2086,5% Total3220100,0%

16. DO ALL THE EMERGENCY CONSULTATIONS NEED THE HOSPITAL? 16 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.

17. DO ALL THE EMERGENCY CONSULTATIONS NEED THE HOSPITAL? 17  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

18. DO ALL THE EMERGENCY CONSULTATIONS NEED THE HOSPITAL? 18 Appropriate contacts 60.7% Inappropriate contacts 39.3%  Almost 40% of all the emergency consultations do not require the hospital infrastructures

19. 19 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

20. WHERE ARE THE CHILDREN OBSERVED? 20  The observed children remain in the Emergency department, mostly not in a bed

21. WHY ARE THE CHILDREN OBSERVED? 21  69% of all children who stay longer in the hospital than a regular consultation, are waiting for results

22. DISTINGUISHING BETWEEN LENGTHY CONSULTATIONS AND ‘REAL’ OBSERVATIONS 22  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?

23. E MERGENCY AND O BSERVATION C RITERIA VS. NON CRITERIA OBSERVATIONS 23  10% of all observations meet the criteria Observation typeN% Non criteria observations111490% Criteria observations12310% Total1237100%

24. ARE THE OBSERVATIONS USEFUL? 24  Observations help clarifying an unclear diagnosis, testing a treatment and preventing some hospitalizations Diagnosis unclear 84,3% clarification Test the treatment 88,3% clarification True observations Prevents unnecessary hospitalizations

25. DISCUSSION 25  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?

26. 26  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? DISCUSSION

27. E MERGENCY AND O BSERVATION THE INTERESTING POPULATIONS 27 General population Observations Criteria- observations Lengthy consultations Non observations Appropriate contacts Inappropriat e contacts

28. E MERGENCY AND O BSERVATION G ENERAL POPULATION : FINANCIAL DATA 28 donebilled Over -billing Under -billing Bill shifting

29. OBSERVATION VS. NON OBSERVATION: WORKLOAD 29 ObservationNon Observation SD O SD NO Test t Nurse 72.32 ‘48.953.48 ‘50.0p<.001 Doctor78.92 ‘41.5960.76 ‘28.15p<.001 Secretary15.91 ‘9.4713.69 ‘6.44p<.001 Total167.15 ‘2.14 127.93 ‘ 1.52p<.001 Workload Observation Workload NON observation  Observation means an increased workload for all professionals working in the emergency department

30. OBSERVATION VS. NON OBSERVATION: FINANCIAL DATA 30 ObservationNon Observationtest t (n=398)(n=696) Pediatrician64,1%53,3%p=0,001 BMA1,8%2,3%NS SMU32,5%43%p=0,001 Other specialist3,7%4,3%NS ≥1 consultation74,6%89,7%p< 0,001 Packages5,8%10,1%p=0,015 Observation  Observation is less funded than non observation

31. CRITERIA VS. NON CRITERIA OBSERVATIONS: WORKLOAD 31 Criteria Observation Non Criteria Observation test t SD OJ SD ONJ Nurse 100.76 ‘58.1271.10 ‘48.12p<.001 Doctor----NS Secretary----NS Total200.53 ‘ 89.63165.72 ‘ 74.14p<.01 Non Criteria Obs. Criteria Obs. Workload Criteria Observations for the nurses Workload Non Criteria Observations

32. CRITERIA VS. NON CRITERIA OBSERVATIONS: FINANCIAL DATA 32 Criteria Observation s Non criteria Observations test t (n=23)(n=375) Pediatrician73,9%63,5%NS BMA0,0%1,9%NS SMU13,0%44,8%0,003 Other specialists8,7%4%NS Packages0,0%6,1%NS ≥1 consultation87,0%89%NS  Almost no billing differences between criteria and non criteria observations  Workload for nurses C+ obs. > C- obs.

33. APPROPRIATE VS. INAPPROPRIATE EMERGENCY CONTACTS: WORKLOAD 33 Appropriate contacts Inappropriate contacts T test SD AC SD INC Nurse72.94 ‘52.9241.83 ‘39.44p<.001 Doctor74.33 ‘38.9257.55 ‘24.91p<.001 Secretary----NS Total161.84 ‘ 76.15 113.88 ‘ 57.04p<.001 Workload (minutes per patient) for appropriate and inappropriate contact s Workload Appropriat e contacts Workload Inappropria te contacts

34. APPROPRIATE VS. INAPPROPRIATE EMERGENCY CONTACTS: FINANCIAL DATA 34 Appropriate contacts Inappropriate contacts test t (n=676)(n=413) Pediatrician56,2%58,9% NS BMA2,2%1,9% NS SMU36,2%36,4% NS Other specialists4,4%3,1% NS Packages8,1%9,1% NS ≥1 consultation80,3%79,7% NS  Almost no billing differences between appropriate and inappropriate contacts Is it worth the money?

35. APPROPRIATE VS. INAPPROPRIATE EMERGENCY CONTACTS: WHY SHOULD WE CARE ABOUT? 35  Frequency:Appropriate contacts :60,71% Inappropriate contacts : 39,29%  Workload: Inappropriate < Appropriate but…  Difficult hours: Inappropriate > Appropriate  Billing: Inappropriate = Appropriate

36. PROPOSITIONS 36 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

37. D ISCUSSION AND PROPOSITIONS 37 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.

38. D ISCUSSION AND PROPOSITIONS 38 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

39. D ISCUSSION AND PROPOSITIONS 39 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

40. D ISCUSSION AND PROPOSITIONS 40 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

41. D ISCUSSION AND PROPOSITIONS 41 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.

42. D ISCUSSION AND PROPOSITIONS 42 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.

43. D ISCUSSION AND PROPOSITIONS 43 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

44. D ISCUSSION AND PROPOSITIONS 44 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.

45. D ISCUSSION AND PROPOSITIONS 45 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

46. D ISCUSSION AND PROPOSITIONS 46 Observation Clinical activity-based financing Diagnosis-based financing Criteria-based financing MCR analysis > BMF If criteria met, then 1.Admission package 2.Hospitalization day package 3. BMF

47. 47 Dank U / Merci

48. F IN DE L ’ EXPOSÉ 48