Sanober Diaz

The onset of the COVID-19 pandemic and the public health measures instituted to mitigate its spread were associated with a dramatic reduction in circulating respiratory viruses such as respiratory syncytial virus and influenza.^1-3 Infections with respiratory viruses are common contributors to pediatric hospitalizations, either directly (eg, pneumonia) or indirectly (eg, asthma exacerbation).^4-6 Dramatic reductions in pediatric health care use were noted during the pandemic, due at least in part to the decrease in respiratory viral infections.^7-11 Children with medical complexity (CMC) are at risk of severe acute illness from respiratory infections (eg, children with cystic fibrosis,¹² congenital heart disease,¹³ or sickle cell disease¹⁴). In a Canadian evaluation, children who were admitted with SARS-CoV-2 infections during the early pandemic period often had existing comorbidities including obesity and neurologic impairment.¹⁵ Children with neurologic impairment (NI), which account for 28% of all Canadian CMC,¹⁶ are at particularly high risk due to a number of factors, including impaired cough and airway clearance, respiratory muscle weakness, bronchial hyperactivity, sleep disordered breathing, and risk of aspiration from oral secretions.¹⁷ This may result in CMC having an outsized benefit from this general decrease in burden of circulating viruses.¹⁸ Reports from multiple countries have suggested decreased emergency department visits^7,8 and admissions to hospital during the pandemic both for children with and without medical complexity,^9-11 but these findings were limited to those reporting solely on children’s hospitals, evaluations during the early pandemic period, and were not denominated on a defined at-risk population. The effect of pandemic-era suppressed respiratory viral transmission on hospitalization, intensive care unit (ICU) admission, and mortality among CMC and children without medical complexity (non-CMC) is unknown.

Introduction: A provincial strategy to expand care coordination and integration of care for children with medical complexity (CMC) was launched in Ontario, Canada in 2015. A process evaluation of the roll-out examined the processes, mechanisms of impact, and contextual factors affecting the implementation of the Complex Care for Kids Ontario (CCKO) intervention strategy. Methods: This process evaluation was conducted and analyzed according to the United Kingdom Medical Research Council (UK-MRC) process evaluation framework. To evaluate the implementation of the CCKO intervention, a multi-method study design was used, including semi-structured interviews with 38 key informants and 10 families of CMC involved in CCKO. To further understand implementation details across regional sites, provincial-level implementation plans, and process documents were reviewed. Discussion: Strengths of CCKO included novel collaborations and partnerships between complex care teams, community partners and regional sites. Issues relating to communication and coordination across care sectors created challenges to holistic care coordination objectives. Provincial system fragmentation limited the ability of CCKO to provide seamless care coordination due to the multiple care sectors involved. Conclusion: This study adds to the understanding of the processes involved in a population-level care coordination intervention for CMC. Lessons learned through CCKO can help facilitate reproducibility and necessary adjustments of the intervention in different settings.