Comprehensive care for high-risk, chronically ill children reduces serious illnesses

High-risk children with chronic illness who received care at a clinic that provided both primary and specialty care and features to promote prompt effective care had an increase in access to care and parent satisfaction and a reduction in serious illnesses and costs, according to a study in the December 24/31 issue of JAMA.

Although the patient-centered or family-centered medical home is widely recommended, its value in improving clinical outcomes or reducing health care costs remains to be demonstrated. Medical homes are potentially the most cost-effective for high-risk patients, particularly high-risk children with chronic illness whose care is often fragmented, costly, and ineffective. "With the inadequate current payments for outpatient pediatric care and the necessity to restrain health care spending, the payments required to develop and sustain such medical homes may not be forthcoming unless they are shown to improve outcomes with minimal or no increase in costs," the authors write.

Ricardo A. Mosquera, M.D., of the University of Texas Medical School, Houston, and colleagues randomly assigned 201 high-risk children with chronic illness to receive comprehensive care (n = 105; included treatment from primary care clinicians and specialists in the same clinic with multiple features to promote prompt effective care) or usual care (n = 96; provided locally in private offices or faculty-supervised clinics without modification). Patients were defined as high-risk with chronic illness if they had three or more emergency department visits, two or more hospitalizations, or one or more pediatric intensive care unit admissions during the previous year, and a greater than 50 percent estimated risk for hospitalization. The children were treated at a high-risk clinic at the University of Texas in Houston.

Comprehensive care (or enhanced medical home), compared to usual care, reduced the number of children with a serious illness (by 55 percent) and total hospital and clinic costs ($16,523 vs. $26,781 per child-year respectively). Rates were also reduced for emergency department visits, hospitalizations, number of days in the hospital, intensive care unit (ICU) admissions and days in the ICU.

"In this randomized clinical trial, the triple aim of improved care, improved health, and lower costs was achieved in an enhanced medical home providing comprehensive care to high- risk children with chronic illness compared with usual care," the authors write.

"These findings from a single site of selected patients with a limited number of clinicians require study in larger, broader populations before conclusions about generalizability to other settings can be reached."

James M. Perrin, M.D., of Harvard Medical School and MassGeneral Hospital for Children, Boston, writes in an accompanying editorial that lessons from this study and the dual-eligible accountable care organizations can inform the development of medical home programs for patients with complex conditions.

"First, regular, almost daily, contact with the patient is critical. It is more difficult to reduce hospitalization rates once a patient enters the emergency department. Second, care must be comprehensive and responsive to the needs of the patient. What may seem a trivial problem to physicians may be important to patients. Third, care teams should have intimate knowledge of the patient (and their families)."

Dr. Perrin adds that although not a part of the current study, new technologies also can enhance management of complex chronic conditions. "Equipping families with mobile technologies that would allow them to enter data about their child's health and wellness status could provide clinic staff real-time information and encourage scheduling of follow-up visits based mainly on the child's clinical status and less on arbitrary prearranged follow-up times."