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Chris Feudtner

Publications and source records attributed to Chris Feudtner.

At least 37 records · Page 2Linked to original sources
PubMed2004

Bereavement care interventions: a systematic review.

BACKGROUND: Despite abundant bereavement care options, consensus is lacking regarding optimal care for bereaved persons. METHODS: We conducted a systematic review, searching MEDLINE, PsychINFO, CINAHL, EBMR, and other databases using the terms (bereaved or bereavement) and (grief) combined with (intervention or support or counselling or therapy) and (controlled or trial or design). We also searched citations in published reports for additional pertinent studies. Eligible studies had to evaluate whether the treatment of bereaved individuals reduced bereavement-related symptoms. Data from the studies was abstracted independently by two reviewers. RESULTS: 74 eligible studies evaluated diverse treatments designed to ameliorate a variety of outcomes associated with bereavement. Among studies utilizing a structured therapeutic relationship, eight featured pharmacotherapy (4 included an untreated control group), 39 featured support groups or counselling (23 included a control group), and 25 studies featured cognitive-behavioural, psychodynamic, psychoanalytical, or interpersonal therapies (17 included a control group). Seven studies employed systems-oriented interventions (all had control groups). Other than efficacy for pharmacological treatment of bereavement-related depression, we could identify no consistent pattern of treatment benefit among the other forms of interventions. CONCLUSIONS: Due to a paucity of reports on controlled clinical trails, no rigorous evidence-based recommendation regarding the treatment of bereaved persons is currently possible except for the pharmacologic treatment of depression. We postulate the following five factors as impeding scientific progress regarding bereavement care interventions: 1) excessive theoretical heterogeneity, 2) stultifying between-study variation, 3) inadequate reporting of intervention procedures, 4) few published replication studies, and 5) methodological flaws of study design.

Journal Article↗
PubMed2004

How does an Alzheimer's disease patient's role in medical decision making change over time?

As persons with Alzheimer's disease (AD) lose their ability to make decisions, someone else has to make decisions for them. We performed a prospective cohort study of 77 AD patient-caregiver dyads to examine when this transition occurs. When dementia severity surpassed a threshold marked by a Mini-Mental State Examination (MMSE) score less than 20, the level of caregiver-reported patient involvement in the medical decision-making process declined (Moderate [MMSE = 19-12]: Odds Ratio [OR] = 2.35, 95% confidence interval [95% CI] = 1.01-5.49; P =.048; Severe [MMSE < 12]: OR = 29.38, 95% CI = 5.98-144.25, P <.001). Furthermore, older patients (OR = 1.06, 95% CI = 1.00-1.12, P =.049) and mounting caregiver burden (OR = 1.12, 95% CI = 1.04-1.26, P =.003) were significant independent predictors of transitions to the caregiver-dominated medical decision-making process. These results provide clinicians with prognostic information that can help caregivers understand how their role in decision making will change over the course of a patient's dementing illness.

Age Factors↗
PubMed2004

How do primary care physicians manage children with possible developmental delays? A national survey with an experimental design.

OBJECTIVE: Although early detection and treatment of developmental delays can improve outcome, little is known about factors that influence how primary care physicians manage young children with probable developmental delays. The objective of this study was to describe physician referral practices for children with developmental delays and to test whether the probability of referral is increased by 1) the expression of parental concern; 2) female gender in a child with language delay; 3) disruptive, as opposed to avoidant behaviors; and 4) physician characteristics, including female gender or being a pediatrician. METHODS: A cross-sectional survey was mailed to a national random sample of 800 pediatricians and 800 family practice physicians in primary care practice, using an experimental randomized block design. Recipients randomly received alternative variants of clinical vignettes, which differed only in regard to the variable specific to each of the first 3 hypotheses. Physicians answered questions about the likelihood of referral on a 5-point scale for listed referral options. Hypotheses were tested using multivariable logistic regression modeling. A total of 55% of pediatricians and 43% of family practice physicians returned the survey, for an overall response rate of 49%. RESULTS: A girl with language delay was 60% more likely to be referred to audiology than a boy (odds ratio: 1.6; 95% confidence interval: 1.1-2.3), and respondents who were female or pediatricians were more likely to refer patients. The expression of parental concern did not increase the probability of referral to diagnostic and treatment services, and avoidant rather than disruptive patient behaviors were associated with an increased probability of referral. CONCLUSIONS: Patient gender and type of behavioral presentation seem to influence referrals to diagnostic and treatment services for young children with probable developmental delays described in clinical vignettes. These findings can guide targeted educational interventions to increase rates of detection and referral for young children with developmental delays.

Child, Preschool↗
PubMed2004

Placement stability and mental health costs for children in foster care.

OBJECTIVE: Although prior population-based studies have found that children in foster care use more mental health services than their Medicaid peers, less is known about how different experiences in foster care impact the likelihood of mental health service use. The primary aim of this study is to test the hypothesis that instability of foster care placements is associated with higher costs for mental health care services. The secondary aim is to test the hypothesis that foster care children are also more likely to generate high costs for mental health services if they generate higher costs for non-mental health claims. METHODS: Using administrative child welfare data linked to Medicaid claims, we assembled a unique retrospective cohort of adjudicated dependent children >2 years old who entered foster care between July 1993 and June 1995, spent at least 9 months in care, and were Medicaid eligible during a 1-year follow-up period. The primary outcome was high mental health service use, defined as having costs in the top decile of the sample. The primary independent variables were the number of foster care placements during the year and whether placements were interrupted by a return home for at least 1 month during that year (episodic foster care). We used logistic regression to estimate the association between placements and service utilization, with adjustment for age and physical health care costs. RESULTS: Of the 1635 children in the study, 41% had > or = 3 foster care placements, and 5% had episodic foster care during the year of observation. The top 10% of mental health service users accounted for 83% of the 2.4 million dollars in mental health costs. Both multiple placements and episodic foster care increased the predicted probability of high mental health service use. Higher physical health care costs also increased the probability of high mental health use for all children, but this increased probability was most dramatic among children with episodic foster care (probability of high mental health use: 0.78; 95% confidence interval: 0.42-0.94). CONCLUSIONS: Foster care placement instability was associated with increased mental health costs during the first year in foster care, particularly among children with increasing general health care costs. These findings highlight the importance of interventions that address the global health of children in foster care and may permit better targeting of health care resources to subgroups of children most likely to use services.

Adolescent↗
PubMed2004

Placement changes and emergency department visits in the first year of foster care.

OBJECTIVES: Despite great needs, many children in foster care do not receive adequate medical care. Suboptimal care may be attributable in part to placement changes, which disrupt continuity of care by both a consistent surrogate parent and potentially a primary care physician. These disruptions in turn may lead to increased use of the emergency department (ED) for outpatient care. The primary aim of this study was to test whether a greater rate of placement changes was associated with increasing use of the ED among children in their first year of foster care. The secondary aim was to compare ED visit rates with rates of visits to other ambulatory care settings among children in foster care and other Medicaid-eligible children not in foster care. METHODS: Using Medicaid claims linked to foster care administrative data, we assembled a retrospective cohort of foster children in a large urban municipality from 1993 to 1996. Eligible children spent at least 9 months in a new episode of foster care and were continuously eligible for Medicaid during a 1-year follow-up period. A comparison cohort was drawn from Medicaid-eligible children not in foster care during fiscal year 1995. The dependent variable was the rate of visits to the ED or other ambulatory care settings during a 1-year follow-up period. A negative binomial model estimated visit rates to the ED and other ambulatory care settings as the number of foster care placements increased. Potential interactions were considered between age and location of service use (ED or ambulatory care setting), between age and foster care placements, and between location of service use and number of foster care placements. RESULTS: The 2358 children in the sample accounted for 1206 ED visits during the follow-up period; 38% experienced >or=2 placement changes. Children of all ages exhibited increasing reliance on the ED for ambulatory care services as the number of placements increased, with the rates of ED use more than doubling for all age groups beyond infancy. However, other ambulatory care service use increased by only 41% to 53%; there was much less utilization in these nonemergency settings for all children but particularly toddlers and infants, compared with their Medicaid-eligible peers. Although the absolute rates of all visits for younger foster children (<6 years of age) were low, older foster children had increasingly greater ED use than did their Medicaid-eligible peers, with nearly double the rate of ED visits in the adolescent age group. A temporal relationship between placements and ED visits was also identified; 75% of ED visits occurring within 3 weeks of a placement change occurred in the period after a placement change. CONCLUSIONS: Foster children received fewer overall outpatient services than did their Medicaid-eligible peers, but with age and increasing numbers of placements, had higher visit rates and received a greater proportion of their overall outpatient care in the ED. These results suggest that poor access to nonemergent ambulatory care settings might have contributed to an increasing reliance on ED settings as foster care placements increased. The temporal relationship between ED visits and placement changes underscores the need for better health care management for foster children, particularly in the period after placement changes.

Ambulatory Care↗
PubMed2004

The generation gap: differences between children and adults pertinent to economic evaluations of health interventions.

Differences between children and adults have both technical and ethical implications for the design, interpretation and employment of economic analyses of health-related programmes. Even though policy makers increasingly turn to economic analyses to inform decisions about resource allocation, pertinent child-adult differences have received fragmented discussion in leading methodological references. Key areas warranting attention include: the ways in which a child's distinctive biology modifies the cost and effectiveness of healthcare interventions; challenges in assessing utilities for infants and young children given their limited but developing cognitive capacity; how a child's age, dependency and disability affect the selection of the appropriate time horizon and scope of the analysis; whether a child's non-wage earning productivity should be incorporated into analyses, and if so, what metric to use; what principles of equity policy makers should employ in using economic evaluations to choose between child- and adult-focused interventions; and whether special protective measures should be introduced to secure the rights and interests of children who cannot advocate for themselves.

Adult↗
PubMed2003

Hospital care for children and young adults in the last year of life: a population-based study.

BACKGROUND: To help design population-based pediatric palliative care services, we sought to describe the hospital care received in the last year of life by children and young adults who died. We also determined the proportion with complex chronic conditions (CCCs) and tested whether the use of hospital services increased as the date of death drew nearer. METHODS: For all deaths occurring under 25 years of age from 1990 to 1996 in Washington State, USA, we linked death certificate information to hospital utilization records and analyzed the timing and duration of hospitalizations and the nature of hospital procedures during the year prior to death. RESULTS: Of the 8 893 deaths, 25 % had CCCs. Among infants with CCCs, 84 % were hospitalized at the time of death and 50 % had been mechanically ventilated during their terminal admission. Among the 458 CCC neonates dying under a week of age, 92% of all days of life were spent in the hospital; among the 172 CCC neonates dying during the second to fourth weeks of life, 85 % of all days of life were spent hospitalized; among the 286 CCC infants dying during the second to twelfth month of life, 41 % of all days of life were spent hospitalized. Among children and young adults with CCCs, 55 % were hospitalized at the time of death, and 19 % had been mechanically ventilated during their terminal admission. For these older patients, the median number of days spent in the hospital during the year preceding death was 18, yet less than a third of this group was hospitalized at any point in time until the last week of their lives. The rate of hospital use increased as death drew near. For subjects who had received hospital care, 44 % had governmental insurance as the source of primary payment. CONCLUSIONS: Infants who died spent a substantial proportion of their lives in hospitals, whereas children and adolescents who died from CCCs predominantly lived outside of the hospital during the last year of life. To serve these patients, pediatric palliative and end-of-life care will have to be provided in an integrated, coordinated manner both in hospitals and home communities.

Adolescent↗
PubMed2003

Tracheotomy in pediatric patients: a national perspective.

BACKGROUND: During the past 50 years, changes in the epidemiology of infectious diseases and the capabilities of medical technology have altered the indications for, and implications of, tracheotomy in children. Given the complexity of health care that these patients subsequently require, monitoring the performance of this procedure and patient outcomes across the diverse US health care system is warranted. OBJECTIVES: To characterize children who received tracheotomies in 1997 and to determine whether disposition and mortality vary by region or health care system attributes. DESIGN: A nationally representative retrospective cohort drawn from an 80% sample of administrative hospital discharge records from all pediatric admissions in 22 states during 1997. PARTICIPANTS: Patients aged 0 to 18 years who underwent tracheotomy. METHODS: The sampling scheme of the discharge records enabled the calculation of regional and national estimates and of age-stratified population-based rates of tracheotomies. Weighted descriptive statistical and Poisson analyses were performed. RESULTS: The 2065 tracheotomy procedures recorded in the Kids' Inpatient Database yielded a national estimate of 4861 tracheotomies performed in 1997. The mean length of hospital stay was 50 days, with a mean total facilities charge exceeding $200,000. The rate of tracheotomy was highest among infants and varied significantly across regions of the United States. Adjusting for other patient and health care system attributes, patients who received their tracheotomy in a children's hospital had half the risk of dying during the admission compared with patients who were cared for in a non-children's hospital. Hospitals that performed more pediatric tracheotomies had significantly lower mortality rates than hospitals with lesser case volume. Among patients who survived to discharge, those cared for in the Northeast were discharged to long-term care facilities at twice the rate of patients in the West. Children cared for in children's hospitals or in teaching hospitals were significantly less likely to be discharged to a long-term care facility. CONCLUSIONS: Pediatric tracheotomy is associated with significant variation in rates and outcomes across the United States and across different hospital types. Further research to clarify the reasons for these associations is warranted.

Adolescent↗
PubMed2003

How do primary care physicians identify young children with developmental delays? A national survey.

Little is known about the current practices of primary care physicians regarding developmental surveillance and screening during pediatric preventive care visits. We conducted a mailed survey of a random national sample of pediatricians and family physicians to describe their practices and identify factors that predict use of developmental screening tools, an efficacious way of identifying children with developmental delays. Most physicians reviewed developmental milestones and prompted parents for developmental concerns at preventive care visits. Approximately half of the physicians used a formal developmental screening instrument. Female physician gender predicted higher rates of use of screening tools for family physicians, but not for pediatricians. Most physicians seemed committed to the early diagnosis of developmental delays. Substantial variability in surveillance and screening practices, barriers of time and reimbursement, and under-reliance on parent-completed questionnaires underscore areas for improvement.

Adult↗
PubMed2003

Spiritual care needs of hospitalized children and their families: a national survey of pastoral care providers' perceptions.

OBJECTIVE: Although spirituality is viewed as a vital aspect of the illness experience by most Americans, little is known about this domain of pediatric health care. The objective of this study was to profile pastoral care providers' perceptions of the spiritual care needs of hospitalized children and their parents, barriers to better pastoral care, and quality of spiritual care in children's hospitals. METHODS: A cross-sectional mail survey was conducted of pastoral care providers at children's hospitals throughout the United States, with a 67% response rate from 115 institutions. RESULTS: Respondents estimated that, among patients they visited, 34% were chronically ill and 21% were clearly dying. Half or more of patients were thought to have spiritual care needs regarding feeling fearful or anxious, coping with pain or other physical symptoms, and regarding their relationship to their parents or the relationship between their parents. Among patients' parents, 60% to 80% were estimated to have felt fearful or anxious, had difficulty coping with their child's pain or other symptoms, sought more medical information about their child's illness, questioned why they and their child were going through this experience, asked about the meaning or purpose of suffering, and felt guilty. Respondents agreed on 3 barriers to providing spiritual care: inadequate staffing of the pastoral care office, inadequate training of health care providers to detect patients' spiritual needs, and being called to visit with patients and families too late to provide all the care that could have been provided. Overall, respondents judged that their hospitals were providing 60% of what they deemed as ideal spiritual care. CONCLUSIONS: Pastoral care providers believe that the spiritual care needs of hospitalized children and their parents are diverse and extensive. With system-level barriers cited as limiting the quality of spiritual care, considerable improvement may be possible.

Adaptation, Psychological↗
PubMed2002

Where do children with complex chronic conditions die? Patterns in Washington State, 1980-1998.

OBJECTIVE: Little is known about factors that influence whether children with chronic conditions die at home. We sought to test whether deaths attributable to underlying complex chronic conditions (CCCs) were increasingly occurring at home and to determine what features were associated with home deaths. DESIGN: A retrospective case series was conducted of all deaths that occurred to children age 0 to 18 years in Washington state from 1980 to 1998 using death certificate data, augmented with 1990 US Census data regarding median household income by zip code in 1989, to determine the site of death. RESULTS: Of the 31 455 deaths identified in infants, children, and adults younger than 25 years, 52% occurred in the hospital, 17.2% occurred at home, 8.5% occurred in the emergency department or during transportation, 0.4% occurred in nursing homes, and 21.7% occurred at other sites. Among children who died as a result of some form of CCC (excluding injury, sudden infant death syndrome, and non-CCC medical conditions), the percentage of cases younger than 1 year who died at home rose slightly from 7.8% in 1980 to 11.6% in 1998, whereas the percentage of older children and young adults who had a CCC and died at home rose substantially from 21% in 1980 to 43% in 1998. Children who had lived in more affluent neighborhoods were more likely to have died at home. Using leukemia-related deaths as a benchmark, deaths as a result of congenital, genetic, neuromuscular, and metabolic conditions and other forms of cancer all were more likely to have occurred at home. Significant variation in the likelihood of home death, not explained by the individual attributes of the cases, also existed across the 39 counties in Washington state. CONCLUSIONS: Children who die with underlying CCCs increasingly do so at home. Age at death, specific condition, local area affluence, and the location of home all influence the likelihood of home death. These findings warrant additional study, as they have implications for how we envision pediatric palliative care, hospice, and other supportive services for the future.

Adolescent↗
PubMed2002

Lactobacillus therapy for acute infectious diarrhea in children: a meta-analysis.

OBJECTIVE: Childhood diarrhea accounts for substantial morbidity and mortality worldwide. Multiple studies in children have shown that Lactobacillus, administered orally, may have antidiarrheal properties. We conducted a meta-analysis of randomized, controlled studies to assess whether treatment with Lactobacillus improves clinical outcomes in children with acute infectious diarrhea. METHODS: Studies were sought in bibliographic databases of traditional biomedical as well as complementary and alternative medicine literature published from 1966 to 2000. Search terms were "competitive inhibition," "diarrhea," "gastroenteritis," "Lactobacillus," "probiotic," "rotavirus," and "yog(h)urt." We included studies that were adequately randomized, blinded, controlled trials in which the treatment group received Lactobacillus and the control group received an adequate placebo and that reported clinical outcome measures of diarrhea intensity. These inclusion criteria were applied by blind review and consensus. The original search yielded 26 studies, 9 of which met the criteria. Multiple observers independently extracted study characteristics and clinical outcomes. Data sufficient to perform meta-analysis of the effect of Lactobacillus on diarrhea duration and diarrhea frequency on day 2 were contained in 7 and 3 of the included studies, respectively. RESULTS: Summary point estimates indicate a reduction in diarrhea duration of 0.7 days (95% confidence interval: 0.3-1.2 days) and a reduction in diarrhea frequency of 1.6 stools on day 2 of treatment (95% confidence interval: 0.7-2.6 fewer stools) in the participants who received Lactobacillus compared with those who received placebo. Details of treatment protocols varied among the studies. A preplanned subanalysis suggests a dose-effect relationship. CONCLUSION: The results of this meta-analysis suggest that Lactobacillus is safe and effective as a treatment for children with acute infectious diarrhea.

Administration, Oral↗
PubMed2002

Characteristics of deaths occurring in children's hospitals: implications for supportive care services.

CONTEXT: End-of-life care is an important yet underdeveloped component of pediatric hospital services. OBJECTIVES: We sought 1) to describe the demographics of children who die in children's hospitals, 2) to describe the prevalence of complex chronic conditions (CCCs) among these cases, and 3) to test the hypotheses that cases with a greater number of CCC diagnoses experience longer periods both of mechanical ventilation and of hospitalization before death. Design and Methods. We identified all deaths of patients 0 to 24 years old that occurred in the 60 hospitals contributing discharge data to the National Association of Children's Hospitals and Related Institutions data consortium for the years 1991, 1994, and 1997. We classified discharge diagnoses into 9 major categories of CCCs (cardiovascular, neuromuscular, malignancy, respiratory, renal, metabolic, gastrointestinal, hematologic/immunologic, and other congenital/genetic). RESULTS: Of the 13 761 deaths identified, 42% had been admitted between 0 and 28 days of life, 18% between 1 and 12 months, 25% between 1 and 9 years, and 15% between 10 and 24 years. Fifty-three percent were white, 20% were black, and 9% were Hispanic. The principal payer was listed as a governmental source for 42% and a private insurance company for 35%. Based on all the discharge diagnoses recorded for each case, 40% had no CCC diagnosis, 44% had diagnoses representing 1 major CCC category, 13% had diagnoses representing 2 CCC categories, and 4% had diagnoses representing 3 or more CCC categories. Among cases that had no CCC diagnoses, the principal diagnoses were related to prematurity and newborn disorders for 32% of these cases, injuries and poisoning for 26%, and an assortment of acute and infectious processes for the remaining 42%. Mechanical ventilation was provided to 66% of neonates, 40% of infants, 36% of children, and 36% of adolescents. Cases with CCCs were more likely than non-CCC cases to have been mechanically ventilated (52% vs 46%), and to have been ventilated longer (mean: 11.7 days for CCC cases vs 4.8 days for non-CCC cases). The median duration of hospitalization was 4 days, while the mean was 16.4 days. After adjustment for age, sex, year, and principal payer, compared with patients with no CCC diagnoses, those with 1 major CCC category had a significantly lower hazard of dying soon after admission (hazard ratio [HR]: 0.60; 95% confidence interval [CI]: 0.57-0.62), those with 2 CCC categories even lower (HR: 0.53; 95% CI: 0.50-0.57), and those with 3 or more CCC categories the lowest hazard of rapid death (HR: 0.51; 95% CI: 0.46-0.57). This trend of diminishing hazard of rapid death was significant across the 3 groups of children with 1 or more CCCs. CONCLUSIONS: Children's hospitals care for a substantial number of dying patients, who differ widely by age and medical conditions. Children who die in the hospital with CCCs are more likely to experience longer periods of mechanical ventilation and hospitalization before death.

Child↗