Paediatrics (RCH) - Theses
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ItemAn evaluation of the quality of different forms of early postoperative care in children following tonsillectomy( 2004)Introduction: The perioperative care of children has undergone a revolution in recent years with the introduction of day-case care. The introduction of clay-case care as an alternative to inpatient care has predominantly been for economic reasons. The care of children in hospital by their parents has been advocated for many years and came into vogue in the 19608 with the emergence of the Care-By-Parent-Unit (CBPU) movement. Whilst reportedly successful, this form of care was poorly evaluated and succumbed to the economic pressure that led to the introduction of day-case care. This thesis describes the introduction and evaluation of a CBPU in an attempt to identify the role of CBPU care for the immediate postoperative care of children in a major paediatric tertiary referral centre. Method: A randomised, controlled trial was performed comparing inpatient and CBPU care for the management of children following tonsillectomy. A non-randomised cohort of children undergoing day-case tonsillectomy was also included for comparison. The primary outc0l11e was the quality of clinical care assessed using a composite of five clinical outcomes. Secondary outcomes included the incidence of posthospitalisalion behavioural changes assessed using the Posthospitalisation Behavioural Questionnaire (PHBQ)), parental satisfaction, and the results of an economic analysis. Results: 288 children were assessed in the randomised comparison of inpatient and CBPU care. An additional 129 children were included in the day-case cohort. The results indicated that the CBPU offered a standard of clinical care at least equivalent to both inpatient and day-case care according to prespecified criteria of equivalence (OR 0.55, 95% CI 0.34 - 0.88 and 1.03, 95% CI 0.62 - 1.71 respectively). No clinically significant difference was detected in the incidence of posthospitalisation behavioural changes between groups in children under the age of thirteen (absolute difference in effect sizes between inpatient and CBPU care groups: 0.04, 95% CI - 0.33 to 0.25 and between day-case and CBPU care groups: 0.05, 95% CI - 0.26 to 0.35). Parental satisfaction was substantially higher in the CBPU group compared to both inpatient care (effect size 1.3, 95% CI 1.1 - 1.4) and day-case care (effect size 1.2, 95% CI 0.9 - 1.3). The cost minimisation analysis estimated that CBPU care provided a 20% saving to the hospital compared with inpatient care (sensitivity analysis 4% to 43%), whilst day-case care provided a 35% saving compared with inpatient care (sensitivity analysis 20% - 58%). The Willingness-to-pay analysis indicated that a CBPU was likely to be able to sustain a $50 co-payment. Conclusion: CBPU care was demonstrated to offer a standard of clinical care at least equivalent to inpatient and day-case care, whilst being substantially more acceptable to parents. CBPU was no more costly to the hospital than inpatient care although marginally more expensive than day-case care. It is likely therefore that CBPU care does have a role as an alternative to inpatient care for a substantial group of patients in major paediatric tertiary referral centres such as the Royal Children's Hospital. CBPU care may also improve the community's acceptance of day-case care by emphasising that it is both safe and appropriate for parents to look after their own children following many medical procedures.