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Supplemental Digital Content is available in the text., Introduction: Lower urinary tract symptoms with constipation characterize bladder and bowel dysfunction (BBD). Due to high referral volumes to hospital pediatric urology clinics and time-consuming appointments, wait times are prolonged. Initial management consists of behavioral modification strategies that could be accomplished by community pediatricians. We aimed to create a network of community pediatricians trained in BBD (BBDN) management and assess its impact on care. Methods: We distributed a survey to pediatricians, and those interested attended training consisting of lectures and clinical shadowing. Patients referred to a hospital pediatric urology clinic were triaged to the BBDN and completed the dysfunctional voiding symptom score and satisfaction surveys at baseline and follow-up. The Bristol stool chart was used to assess constipation. Results were compared between BBDN and hospital clinic patients. Results: Surveyed pediatricians (n = 100) most commonly managed BBD with PEG3350 and dietary changes and were less likely to recommend bladder retraining strategies. Baseline characteristics were similar in BBDN (n = 100) and hospital clinic patients (n = 23). Both groups had similar improvements in dysfunctional voiding symptom score from baseline to follow-up (10.1 ± 4.2 to 5.6 ± 3.3, P = 0.01, versus 10.1 ± 4.2 to 7.8 ± 4.5, P = 0.02). BBDN patients waited less time for their follow-up visit with 56 (28–70) days versus 94.5 (85–109) days for hospital clinic patients (P < 0.001). Both groups demonstrated high familial satisfaction. Conclusions: Community pediatricians may require more knowledge of management strategies for BBD. Our pilot study demonstrates that implementing a BBDN is feasible, results in shorter wait times, and similar improvement in symptoms and patient satisfaction than a hospital pediatric urology clinic.

BACKGROUND: ABO incompatibility is a major risk factor for severe jaundice. Previous small studies have suggested that increasing DAT strength is associated with higher levels of bilirubin and greater need for phototherapy. There is no Canadian published data on DAT strength and hyperbilirubinemia. DAT strength is analyzed on all positive newborn DAT tests in our center and could therefore be evaluated with respect to these high-risk infants. OBJECTIVES: To evaluate a large cohort of DAT-positive ABO incompatible Canadian newborns focusing on DAT strength, bilirubin levels and the need for phototherapy. DESIGN/METHODS: A retrospective chart review of 1,437 DAT-positive newborns over a three-year period (total births of 23,628). Infants with risk factors in addition to being DAT positive were excluded. 841 eligible infants were included. DAT strength was categorized as W, 1+, 2+, 3+ and 4+. All bilirubin test results performed from birth until 200 hours of age were analyzed. Bilirubin levels at 12 and 24 hours of age as well as the need for phototherapy was evaluated RESULTS: Of the 841 eligible infants, 594 DAT tests were weak positive, 225 were 1+, 21 were 2+, and 1 was 3+. Newborns with higher DAT strengths were more likely to need phototherapy than newborns with lower DAT strengths. Mean plasma bilirubin levels were higher at 12 and 24 hours in newborns with higher DAT strengths with the difference between 2+ and Weak being significant (P = 0.0087). Newborns with higher DAT strengths were more likely to be at or above the threshold for phototherapy initiation at 12 hours of age. Relative risk: 2+ versus weak 6.18; 2+ versus 1 + 3.34 and 1+ versus weak 1.85. Newborns with higher DAT strengths were also more likely to be in the high-risk zone on the Bhutani nomogram at 12 hours of age. Relative risk: 2+ versus weak 3.37, 2+ versus 1 + 1.96 and 1+ versus weak 1.72. CONCLUSION: ABO incompatible newborns do not exhibit the most severe form of hemolytic jaundice. Higher DAT strength newborns were more likely to require phototherapy. Higher DAT strength newborns were more likely to have bilirubin levels in the high-risk zone and be at or above the threshold for phototherapy at 12 hours of age. The majority of DAT-positive ABO-incompatible newborns with no other risk factors did not require phototherapy and many remained in the low or low intermediate risk zones

Background Primary care medical homes may improve health outcomes for children with special healthcare needs (CSHCN), by improving care coordination. However, community-based primary care practices may be challenged to deliver comprehensive care coordination to complex subsets of CSHCN such as children with medical complexity (CMC). Linking a tertiary care center with the community may achieve cost effective and high quality care for CMC. The objective of this study was to evaluate the outcomes of community-based complex care clinics integrated with a tertiary care center. Methods A before- and after-intervention study design with mixed (quantitative/qualitative) methods was utilized. Clinics at two community hospitals distant from tertiary care were staffed by local community pediatricians with the tertiary care center nurse practitioner and linked with primary care providers. Eighty-one children with underlying chronic conditions, fragility, requirement for high intensity care and/or technology assistance, and involvement of multiple providers participated. Main outcome measures included health care utilization and expenditures, parent reports of parent- and child-quality of life [QOL (SF-36®, CPCHILD©, PedsQL™)], and family-centered care (MPOC-20®). Comparisons were made in equal (up to 1 year) pre- and post-periods supplemented by qualitative perspectives of families and pediatricians. Results Total health care system costs decreased from median (IQR) $244 (981) per patient per month (PPPM) pre-enrolment to $131 (355) PPPM post-enrolment (p=.007), driven primarily by fewer inpatient days in the tertiary care center (p=.006). Parents reported decreased out of pocket expenses (p© domains [Health Standardization Section (p=.04); Comfort and Emotions (p=.03)], while total CPCHILD© score decreased between baseline and 1 year (p=.003). Parents and providers reported the ability to receive care close to home as a key benefit. Conclusions Complex care can be provided in community-based settings with less direct tertiary care involvement through an integrated clinic. Improvements in health care utilization and family-centeredness of care can be achieved despite minimal changes in parental perceptions of child health.