RESULTS AND FINAL CONCLUSIONS 7 March 2012

1. BePASSTA Belgian PAediatricShort STAy study RESULTS AND FINAL CONCLUSIONS7 March 2012 Prof. Sophie Alexander, Luk Cannoodt etAlain De Wever Researchers:MD Cohen L, Laokri S, Seurynck N, MD PhD Zhang W-H Trybou J, Verhaeghe N

2. 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

3. 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

4. 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”.

5. Researchtools

6. Selection of the pilot hospitals BePASSTA

7. What are we looking for?

8. Presentationmethodology For each pole…

9. Comparaison of the 3 poles:Populations IQR : Interquartile Range  (Q1-Q3) N : Size of the study population

10. Emergency and ObservationFlow chart • Almost 40% of all children stay longer in the hospital than a regular consultation

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

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

13. WHY DID THEY COME? • For a majority of parents (56,9%), their child’s condition is a moderateemergency or no emergency at all

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

15. WHAT DOCTOR WAS IN CHARGE? • The pediatrician has a pivotal role in the emergency department

16. 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.

17. 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 observedor directly hospitalized • Childdiesin the hospital after the emergency consultation • Castneeded

18. DO ALL THE EMERGENCY CONSULTATIONS NEED THE HOSPITAL? • Almost 40% of all the emergency consultations do not require the hospital infrastructures

19. APPROPRIATE AND INAPPROPRIATE EMERGENCY CONSULTATIONS A MULTIVARIATE ANALYSIS

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

21. WHY ARE THE CHILDREN OBSERVED? • 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 • 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°… areregularlychecked • Duration criterion?

23. Emergency and ObservationCriteria vs. non criteria observations • 10% of all observations meet the criteria

24. ARE THE OBSERVATIONS USEFUL? • Observations help clarifying an unclear diagnosis, testing a treatment and preventing some hospitalizations

25. 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?

26. 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?

27. Emergency and Observationthe interesting populations Appropriate contacts Inappropriate contacts

28. Emergency and ObservationGeneral population: financial data donebilled Over-billing Under-billing Bill shifting

29. OBSERVATION VS. NON OBSERVATION: WORKLOAD • Observation means an increased workload for all professionals working in the emergency department

30. OBSERVATION VS. NON OBSERVATION: FINANCIAL DATA • Observation is less funded than non observation Observation

31. CRITERIA VS. NON CRITERIA OBSERVATIONS: WORKLOAD Non Criteria Obs. Criteria Obs.

32. CRITERIA VS. NON CRITERIA OBSERVATIONS: FINANCIAL DATA • Almost no billing differences between criteria and non criteria observations • Workload for nurses C+ obs. > C- obs.

33. APPROPRIATE VS. INAPPROPRIATE EMERGENCY CONTACTS: WORKLOAD Workload (minutes per patient) for appropriate and inappropriate contacts

34. APPROPRIATE VS. INAPPROPRIATE EMERGENCY CONTACTS: FINANCIAL DATA • 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? • Frequency: Appropriate contacts :60,71% Inappropriate contacts : 39,29% • Workload: Inappropriate < Appropriate • but… • Difficult hours: Inappropriate > Appropriate • Billing: Inappropriate = Appropriate

36. PROPOSITIONS • Pediatric emergency and pediatric first line of care • The pediatricianis 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. Discussion and propositions • Pediatric emergency and pediatric first line of care • 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. Discussion and propositions • Pediatric emergency and pediatric first line of care • 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. Discussion and propositions • Pediatric emergency and pediatric first line of care • 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. Discussion and propositions • Pediatric emergency and pediatric first line of care • 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. Discussion and propositions • Observation • 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. Discussion and propositions Observation This regulatory frame should contain the following statements: The hospital decides to have a Observation Unit, or a more limited Observation Function Regardless of the hospital’s choice, a special area should be dedicated to children staying longer than an usual consultation Apediatrician heads the Observation Unit/Function, and is responsible for all decisions related to the child The nurses working in the Observation Unit/Function have a pediatric qualification Once the child has leaved the Observation, a report is written by the pediatrician.

43. Discussion and propositions • Observation • 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: • The child should lay in a bed(not sitting on a chair) • The child is observed more than 1 hour • A pediatrician is accountable for the child • The child is regularly checked by a nurse

44. Discussion and propositions • Observation • 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. Discussion and propositions • Observation • 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. Discussion and propositions • Observation • Clinical activity-based financing • Diagnosis-based financing Criteria-based financing • MCR analysis > BMF If criteria met, then • Admission package • Hospitalization day package • BMF

47. Dank U / Merci

48. Fin de l’exposé