Importance Patient-centered medical homes have not been shown to reduce adverse outcomes or costs in adults or children with chronic illness. Objective To assess whether an enhanced medical home providing comprehensive care prevents serious illness (death, intensive care unit [ICU] admission, or hospital stay >7 days) and/or reduces costs among children with chronic illness. Design, Setting, and Participants Randomized clinical trial of high-risk children with chronic illness (≥3 emergency department visits, ≥2 hospitalizations, or ≥1 pediatric ICU admissions during previous year, and >50% estimated risk for hospitalization) treated at a high-risk clinic at the University of Texas, Houston, and randomized to comprehensive care (n = 105) or usual care (n = 96). Enrollment was between March 2011 and February 2013 (when predefined stopping rules for benefit were met) and outcome evaluations continued through August 31, 2013. Interventions Comprehensive care included treatment from primary care clinicians and specialists in the same clinic with multiple features to promote prompt effective care. Usual care was provided locally in private offices or faculty-supervised clinics without modification. Main Outcomes and Measures Primary outcome: children with a serious illness (death, ICU admission, or hospital stay >7 days), costs (health system perspective). Secondary outcomes: individual serious illnesses, medical services, Medicaid payments, and medical school revenues and costs. Results In an intent-to-treat analysis, comprehensive care decreased both the rate of children with a serious illness (10 per 100 child-years vs 22 for usual care; rate ratio [RR], 0.45 [95% CI, 0.28-0.73]), and total hospital and clinic costs ($16 523 vs $26 781 per child-year, respectively; cost ratio, 0.58 [95% CI, 0.38-0.88]). In analyses of net monetary benefit, the probability that comprehensive care was cost neutral or cost saving was 97%. Comprehensive care reduced (per 100 child-years) serious illnesses (16 vs 44 for usual care; RR, 0.33 [95% CI, 0.17-0.66]), emergency department visits (90 vs 190; RR, 0.48 [95% CI, 0.34-0.67]), hospitalizations (69 vs 131; RR, 0.51 [95% CI, 0.33-0.77]), pediatric ICU admissions (9 vs 26; RR, 0.35 [95% CI, 0.18-0.70]), and number of days in a hospital (276 vs 635; RR, 0.36 [95% CI, 0.19-0.67]). Medicaid payments were reduced by $6243 (95% CI, $1302-$11 678) per child-year. Medical school losses (costs minus revenues) increased by $6018 (95% CI, $5506-$6629) per child-year. Conclusions and Relevance Among high-risk children with chronic illness, an enhanced medical home that provided comprehensive care to promote prompt effective care vs usual care reduced serious illnesses and costs. 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. Trial Registration clinicaltrials.gov Identifier:NCT02128776

https://jamanetwork.com/journals/jama/articlepdf/2084891/joi140164.pdf

Effect of an enhanced medical home on serious illness and cost of care among high-risk children with chronic illness: a randomized clinical trial.

Integrating Children's Mental Health into Primary Care.

Recent increases in the number and costs of vaccines routinely recommended for children and adolescents have raised concerns about the ability of the current vaccine financing and delivery systems to maintain access to recommended vaccines without financial barriers. Here we review the current state of US financing for vaccine delivery to children and adolescents and identify challenges that should be addressed to ensure future access to routinely recommended vaccines without financial barriers. Challenges were considered from the perspectives of vaccine providers; state and local governments; insurers, employers, and other health care purchasers; vaccine manufacturers; and consumers.

https://pediatrics.aappublications.org/content/pediatrics/124/Supplement_5/S548.full.pdf

Financing the Delivery of Vaccines to Children and Adolescents: Challenges to the Current System

BACKGROUNDStudies have demonstrated that relative value units (RVUs) do not appropriately reflect cognitive effort or time spent in patient care, but RVU continues to be used as a standardized system to track productivity. It is unknown how well RVU reflects the effort of acute care surgeons. Our ob

/pdf/does-relative-value-unit-based-compensation-shortchange-the-23d71p2604.pdf

Does relative value unit-based compensation shortchange the acute care surgeon?

Objective:To evaluate the relationship between ownership and use of ambulatory surgical centers (ASCs).Methods:From 1998 through 2002, ambulatory surgical discharges for procedures within the genitourinary system were abstracted from the Florida State Ambulatory Surgery Database. State-wide utilizat

Physician ownership of ambulatory surgery centers and practice patterns for urological surgery: evidence from the state of Florida.

The majority of public and private payers in the United States currently use the Medicare Resource-Based Relative Value Scale as the basis for physician payment Many large group and academic practices have adopted this objective system of physician work to benchmark physician productivity, including using it, wholly or in part, to determine compensation The Resource-Based Relative Value Scale survey instrument, used to value physician services, was designed primarily for procedural services, leading to current concerns that American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) surveys may undervalue nonprocedural evaluation and management services The American Academy of Pediatrics is represented on the RUC, the committee charged with maintaining accurate physician work values across specialties and age groups The Academy, working closely with other primary care and subspecialty societies, actively pursues a balanced RUC membership and a survey instrument that will ensure appropriate work relative value unit assignments, thereby allowing pediatricians to receive appropriate payment for their services relative to other services

Application of the resource-based relative value scale system to pediatrics.

Complications of Tracheostomies in the COVID-19 Era

Clinical Outcomes of Tracheostomized Patients: COVID-19 Vs Non-COVID-19

Predictors of Length of Stay, Ventilator Wean, Decannulation, and Mortality in Tracheostomized Patients

Characteristics of Tracheostomized Patients: COVID-19 Vs Non-COVID-19

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