Children with medical complexity (CMC) are the most vulnerable of children with chronic diseases, who have complex, multisystem chronic diseases affecting ≥3 organ systems, severe functional limitations and technology dependencies. CMC have high health care needs, and account for 40% of hospitalized children and 35% of all pediatric health care costs. Due to high medical fragility, CMC have frequent acute deteriorations superimposed on their chronic conditions, leading to recurrent emergency department (ED)/hospital admissions and affecting quality of life (QOL). To reduce ED/hospital admissions for CMC, remote monitoring is suggested, with use of mHealth apps to regularly assess their health status remotely and identify early signs of acute deterioration, allowing for early interventions to prevent ED/hospital admissions. Yet no app to support remote monitoring of CMC exists. Variable, multisystem conditions among CMC make it difficult to develop an app. Also, many CMC are at high-risk for health care inequities, with minorities having higher unmet needs, but the impacts of health care inequities and social determinants of health (SDOH) on ED/hospital admissions in CMC are rarely studied. Fortunately, ED/hospital admissions for CMC are often preceded by a limited set of shared (crosscutting) acute symptoms. These crosscutting symptoms rarely occur suddenly. Studies suggest that they usually start as subtle signs, often unnoticed by parents until they escalate to prompt an ED/hospital visit. Thus, crosscutting symptoms offer an opportunity for a novel and practical approach for developing a remote monitoring app for CMC, despite their multiple, variable underlying conditions. In a focus group, parents identified the crosscutting symptoms that most often preceded their children's hospital admissions, and conveyed their needs, preferences and key functionalities that led to MyChildCMC, the first app designed to monitor and identify early signs of crosscutting symptoms in CMC. In a pilot trial of 50 subjects, we confirmed feasibility of MyChildCMC use by parents, ability to detect early signs 2-14 days prior to ED/hospital admissions, and use leading significantly to fewer hospital days than controls. The current study will assess the efficacy and sustainability of MyChildCMC in a fully-powered 6-month, 2-arm (MyChildCMC vs usual care) trial of CMC (age 1-18 years) and their parents. Parents assigned to MyChildCMC will use the app daily for 6 months, both arms will receive financial incentive for participation, then we will stop the incentive and follow subjects for 6 more months to assess sustainability at 12 months. We will also assess if MyChildCMC use will help reduce or eliminate inequities in ED/hospital admissions. Specific Aims are: 1) Determine MyChildCMC's efficacy on 1.a. Child (ED/hospital use, hospital days and QOL) and 1.b. Parent (satisfaction, self-efficacy and stress) outcomes; 2) Compare ED/hospital use among racial/ethnic and SDOH subgroups to assess potential effect of MyChildCMC on inequities.
CMC, ages 1-18 years and their parents (or primary caregivers)
CMC (inpatients or outpatients) who receive care at participating sites (comprehensive care clinics for CMC)
Own (or provided) a smartphone or tablet with internet access
Speak English or Spanish.
Critically ill CMC and infants.
CMC exhibit similar developmental and functional abilities and typically function below expected for a 7-year-old child, allowing inclusion of a wide age range in studies.
Infants were excluded as many CMC <1 year have prematurity-related conditions that may resolve by age 2.
CMC >18 years of age were not included as some may transition to adult health care.
Parallel
MyChildCMC app (an app designed to facilitate home monitoring of CMC's health status)
Other interventionMyChildCMC is an app designed to support remote monitoring of CMC crosscutting symptoms to identify signs of CMC's health deterioration early to change their care early to avoid progression and prevent ED/hospital admissions. The app includes the following features: 1) automated reminders, 2) vital sign/symptom monitoring, 3) real-time feedback system, 4) automated and real-time summary reports with longitudinal graphs, 5) automated alerts to a care coordinator, and 6) clinic dashboard connecting patients to clinics and allowing access to patient data to support care coordination.
ED/hospital admissions
Numbers of ED and hospital admissions will be assessed pre-post enrollment.
Child's quality of life (QOL)
Child's QOL will be assessed using a survey CMC specific survey questionnaire (adapted from Ellzey et al.). This is a 7-item survey questionnaire that assesses physical health, mental health, sleep, pain, activities, and general QoL. The total QoL score will be standardized to 100 points, with highest (100) reflecting the best QOL.
Self-efficacy scale
Caregiving self-efficacy will be collected using a CMC specific questionnaire adapted from validated surveys, including the PROMIS and PhenX Toolkit self-efficacy scales, as no existing scale meets CMC needs. This is a 10-item questionnaire with scores ranging from 10 (lowest self-efficacy) to 50 (highest self-efficacy).
Caregiver stress
Caregiver stress will be assessed using the Short Form Zarit Burden Interview (ZBI-12). The ZBI-12 is a self-administered 12-item validated survey, with 5 responses ranging from 0 (never) to 4 (always), and a total score rating care-giving stress from 0 (no stress) to 48 (high/severe stress).
Parent satisfaction
Parent satisfaction will be collected using the Client Satisfaction Questionnaire. This is a 7-item questionnaire that assesses parent satisfaction with the child health care, with total scores ranging from 7 (lowest satisfaction) to 35 (highest satisfaction)
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University of Utah
Lead sponsor
National Institute of Nursing Research (NINR)
Collaborator
