Inpatient care of children with cerebral palsy as perceived by their parents

OBJECTIVES: Children with cerebral palsy (CP) have special health care needs. The aim of the study was to evaluate the inpatient care of children with CP, as perceived by their parents. METHODS: Forty parents of children with CP and 90 parents of able-bodied children completed a questionnaire designed to evaluate their perception of their child's hospital admission, including the care provided. The parents also completed the Perceived Stress Scale. RESULTS: Overall, parents of able-bodied children were more satisfied with the hospitalization than parents of children with CP (P < 0.0001). Significant differences were found in four of the five areas assessed: the admissions process (P = 0.0002); the care that their child received (P < 0.0001); their communication and confidence in doctors and nurses (P < 0.0001); and their personal experience of the hospital (P = 0.0076). Parents of disabled children displayed a much higher mean score on the Perceived Stress Scale, but no correlation was found between this scale and the satisfaction questionnaire for either group. CONCLUSION: The results of this study show that parents of children with CP were, as a group, less satisfied than parents of able-bodied children with their inpatient experience. Although these children have complex needs and often require more care than able-bodied children, it is imperative that their needs are met and that parents are satisfied with all aspects of the care they receive in hospital.     

The Parent Supervision Attributes Profile Questionnaire: a measure of supervision relevant to children''s risk of unintentional injury

OBJECTIVE: To further establish the psychometric properties of the Parent Supervision Attributes Profile Questionnaire (PSAPQ), a questionnaire measure of parent supervision that is relevant to understanding risk of unintentional injury among children 2 through 5 years of age. METHODS: To assess test-retest reliability, parents completed the PSAPQ twice, with a one month interval. Internal consistency estimates for the PSAPQ were also computed. Confirmatory factor analyses were applied to the data to assess the four factor structure of the instrument by assessing the convergent and divergent validity of the subscales and their respective items. RESULTS: Test-retest reliability and internal consistency scores were good, exceeding 0.70 for all subscales. Factor analyses confirmed the hypothesized model--namely that the 29 item questionnaire comprised four unique factors: protectiveness, supervision beliefs, risk tolerance, and fate influences on child safety. CONCLUSIONS: Previous tests comparing the PSAPQ with indices of actual supervision and children's injury history scores revealed good criterion validity. The present assessment of the PSAPQ revealed good reliability (test-retest reliability, internal consistency) and established the convergent and divergent validity of the four factors. Thus, the PSAPQ has proven to have strong psychometric properties, making it a unique and useful measure for researchers interested in studying links between supervision and young children's risks of unintentional injury.     

Parent‐perceived barriers to participation in children and adolescents with cerebral palsy

Aim: To pilot the use of the Craig Hospital Inventory of Environmental Factors (CHIEF) questionnaire to ascertain information regarding barriers to participation experienced by a sample of New Zealand children with cerebral palsy. Methods: The CHIEF questionnaire was administered to parents/caregivers of a consecutive sample of 32 children with cerebral palsy attending a paediatric tertiary clinic in Auckland. Twenty‐three children walked independently, 5 used walking aides and four used a wheelchair. Twenty‐four of the 32 parent‐respondents provided contextual feedback for their responses and wider issues relating to the topic. Results: The barriers to participation most commonly reported by parents were attitudes at school (72%) and in the community (56%), difficulties accessing personal equipment (59%), and the natural environment and built surroundings (56%). Contextual information from families generally supported their answers to the questionnaire but highlighted that some parents had confused the ‘not applicable’ and ‘never’ options. Discrepancy between scores on the policy‐related questions and later contextual feedback suggested that the policy subscale did not fully capture family concerns about limited availability of public funding for equipment, therapy, and educational support. Conclusions: The CHIEF instrument proved easy to use in a clinic setting. However, parent‐respondent feedback highlighted the difficulties in interpreting responses to some items when the instrument is used in isolation to quantify environmental barriers to participation. The results highlight the need to develop research approaches and tools that can explore barriers to participation by children with cerebral palsy taking account of socio‐economic and other relevant contextual information.     

Randomised controlled trial comparing an acute paediatric hospital at home scheme with conventional hospital care.

AIMS: To assess the clinical effectiveness of a paediatric hospital at home service compared to conventional hospital care. METHODS: A total of 399 children suffering from breathing difficulty (n = 202), diarrhoea and vomiting (n = 125), or fever (n = 72) were randomised to Hospital at Home or in-patient paediatric care. Main outcome measures were: comparative clinical effectiveness as measured by readmission rate within three months (used as a proxy for parental coping with illness); and length of stay/care and comparative satisfaction of both patients and carers. RESULTS: Clinical effectiveness of both services was not significantly different. Length of care was one day longer in the Hospital at Home group; however, most parents and children preferred home care. CONCLUSIONS: Hospital at Home is a clinically acceptable form of care for these groups of acute paediatric illness. Readmission rates within three months failed to show any advantage in terms of parental coping. Parents and patients expressed a strong preference for hospital at home.     

Randomised controlled trial comparing an acute paediatric hospital at home scheme with conventional hospital care

Aims: To assess the clinical effectiveness of a paediatric hospital at home service compared to conventional hospital care. Methods: A total of 399 children suffering from breathing difficulty (n = 202), diarrhoea and vomiting (n = 125), or fever (n = 72) were randomised to Hospital at Home or in-patient paediatric care. Main outcome measures were: comparative clinical effectiveness as measured by readmission rate within three months (used as a proxy for parental coping with illness); and length of stay/care and comparative satisfaction of both patients and carers. Results: Clinical effectiveness of both services was not significantly different. Length of care was one day longer in the Hospital at Home group; however, most parents and children preferred home care. Conclusions: Hospital at Home is a clinically acceptable form of care for these groups of acute paediatric illness. Readmission rates within three months failed to show any advantage in terms of parental coping. Parents and patients expressed a strong preference for hospital at home.     

Parent caregiver-related predictors of health care service utilization by children with cerebral palsy enrolled in Medicaid.

INTRODUCTION: This study examined the associations between characteristics of the parent caregiver and health care service utilization by children with cerebral palsy enrolled in Medicaid. METHODS: A questionnaire was administered to the parents of children with cerebral palsy being treated in a North Carolina hospital, and the responses were linked with health services claims data from Medicaid. Data were available for 93 patients who maintained 1 year of continuous enrollment. The impact of selected demographic variables (race, years the child had the condition, employment, transportation) and behavioral variables (belief the child was receiving appropriate care, willingness to use home nursing and respite services, self-assessment of the severity of the child's condition, and use of orthopedic aids) on the frequency and costs of health care services was explored with use of multiple regression analysis. RESULTS: Parents who were willing to use home nursing and respite services were more likely to utilize these services, as well as inpatient facilities and orthopedic care, for their children (P <.05). However, parents who perceived that their child was receiving adequate care were less likely to utilize orthopedic care and home nursing for their children (P <.05). DISCUSSION: The belief of the parents in the adequacy of care received by their child, as well as their willingness to utilize supplemental health care services, were major predictors of health care service utilization by children with cerebral palsy enrolled in Medicaid. Parents who believed that their children receive enough care may need to be targeted for care management and disease management programs to ensure the continuum of treatment and care for these children.     

Quality of care at a children's hospital: the parent's perspective.

OBJECTIVES: To develop a measure of parental perceptions of pediatric inpatient quality of care, to identify processes of care that influence these perceptions, and to describe these perceptions of care. DESIGN: An interdisciplinary team modified an existing measure of inpatient care for adults using focus groups and expert review. The resulting survey was administered by telephone. SETTING: Tertiary care pediatric hospital. PATIENTS: Trained telephone interviewers obtained reports from parents of children discharged from the hospital during specified months. This report is based on the answers to 122 questions provided by 3622 (77%) of 4724 parents who responded when surveyed from 1991 through 1995. MAIN OUTCOME MEASURES: Parents provided reports about specific clinical experiences, overall ratings of care, and patient demographic and illness characteristics 2 weeks after patient discharge from the hospital. The analysis classified reports about pediatric care as either problems or not problems. Problems in different areas of care were averaged to create scores for the dimensions. RESULTS: Parents most often noted problems related to hospital discharge planning (18%) and pain management (18%) and less often reported problems concerning communication about surgery (10%) or transmission of information to children (6%). Problems in communication between clinicians and parents correlated most strongly with overall quality ratings by parents (r=0.59). Parents' specific reports of problems with care accounted for 42% of the variation in their overall assessments of the inpatient care experience. CONCLUSIONS: Parental assessment of inpatient pediatric care rests heavily on the quality of communication between the clinician and parent. Specific processes of care strongly influence overall assessments. Such reports could be used to focus the quality-improvement activities of hospitals and increase the accountability of providers of care to children and families.     

Parent satisfaction in pediatric intensive care: a critical appraisal of the literature.

OBJECTIVE: To assess the content and characteristics of satisfaction surveys for the development of a parent satisfaction questionnaire to improve clinical practice in pediatric intensive care. DESIGN: A structured literature review process. The databases PubMed and CINAHL were searched, via identified search terms, for relevant articles published between May 1994 and May 2004. Assessment and analysis of the material was related to development, content, reliability and validity, scales for scoring, and distribution of the satisfaction questionnaires. MAIN RESULTS: Twelve original studies were identified using ten different satisfaction surveys in pediatric, neonatal, or adult intensive care units or in general pediatric wards. All surveys counted a total of 248 questions or statements. Six satisfaction questionnaires categorized the questions or statements in 21 different formulated domains. Most questionnaires showed sufficient results on reliability and validity. Except for one satisfaction instrument, Likert-type scales were used for rating. One study described the distribution of the questionnaire after discharge from the hospital, whereas other questionnaires were distributed during hospital admission. CONCLUSION: The use of parent satisfaction surveys in pediatric intensive care is not well documented. Family-centered care has become widely accepted as an important issue in quality of care, and satisfaction surveys are a valuable resource for measuring and improving clinical practice. Parent satisfaction surveys need to be developed based on the needs and experiences of parents, and emphasis should be put on methodologic issues to have the results accepted as valid and effective for possible changes in clinical practice.     

Sozialmedizinische Nachsorge für schwer und chronisch kranke Kinder

Coordinated ambulatory aftercare of children and adolescents with severe and chronic conditions will improve the transition from inpatient to outpatient care. Aftercare professionals network within and outside the aftercare team, coordinating services and educating and counselling parents, family members, and professionals. They support adaptation and coping processes, accompany the parents to other welfare and health care services, and empower families to access needed services. Aftercare follows the principles of case management and includes home-based services and home visits. Social medical aftercare is supported by the German health insurances, so care providers must be certified and accredited in order to be reimbursed. The aftercare concept described here, called “Bunter Kreis” (Colourful Circle), has been scientifically evaluated, accredited by the health insurance and health boards, and serves as a model for over 47 aftercare organizations in Germany. These organisations are connected in a quality network, “Qualitätsverbund Bunter Kreis”.     

Hospital based alternatives to acute paediatric admission: a systematic review.

AIMS: To synthesise published evidence of the impacts of introducing hospital based alternatives to acute paediatric admission. METHODS: Systematic review of studies of interventions for children with acute medical problems. Main outcome measures were: admission or discharge, unscheduled returns to hospital, satisfaction of parents and general practitioners, effects on health service activity, and costs. RESULTS: Twenty five studies were included: one randomised controlled trial, 23 observational or cross-sectional studies, and one qualitative study. Many studies were of uncertain quality or were open to significant potential bias. About 40% of children attending acute assessment units in paediatric departments, and over 60% of those attending acute assessment units in A&E departments, do not require inpatient admission. There is little evidence of serious clinical consequences in children discharged from these units, although up to 7% may subsequently return to hospital. There is some evidence that users are satisfied with these services and that they are associated with reductions in inpatient activity levels and certain hospital costs. Evidence about the impact of urgent outpatient clinics is very limited. CONCLUSIONS: Current evidence supports a view that acute paediatric assessment services are a safe, efficient, and acceptable alternative to inpatient admission, but this evidence is of limited quantity and quality. Further research is required to confirm that this type of service reorganisation does not disadvantage children and their families, particularly where inpatient services are withdrawn from a hospital.     

Hospital based alternatives to acute paediatric admission: a systematic review

Aims: To synthesise published evidence of the impacts of introducing hospital based alternatives to acute paediatric admission. Methods: Systematic review of studies of interventions for children with acute medical problems. Main outcome measures were: admission or discharge, unscheduled returns to hospital, satisfaction of parents and general practitioners, effects on health service activity, and costs. Results: Twenty five studies were included: one randomised controlled trial, 23 observational or cross-sectional studies, and one qualitative study. Many studies were of uncertain quality or were open to significant potential bias. About 40% of children attending acute assessment units in paediatric departments, and over 60% of those attending acute assessment units in A&E departments, do not require inpatient admission. There is little evidence of serious clinical consequences in children discharged from these units, although up to 7% may subsequently return to hospital. There is some evidence that users are satisfied with these services and that they are associated with reductions in inpatient activity levels and certain hospital costs. Evidence about the impact of urgent outpatient clinics is very limited. Conclusions: Current evidence supports a view that acute paediatric assessment services are a safe, efficient, and acceptable alternative to inpatient admission, but this evidence is of limited quantity and quality. Further research is required to confirm that this type of service reorganisation does not disadvantage children and their families, particularly where inpatient services are withdrawn from a hospital.     

Paediatric medical outpatients: are all those reviews necessary?

The value of and need for paediatric outpatient review attendance as perceived by parents, children, consultants, and general practitioners (GPs) were assessed. One hundred and ninety one parents of 239 children over 7 years of age undergoing review were randomly selected for a semistructured interview. For each parent interviewed, an audit questionnaire was completed after case note review by another paediatrician. A random sample of the patients' GPs was surveyed by postal questionnaire. Twenty per cent of parents and 26% of GPs felt that the GP could care for the child as well as or better than the hospital, whereas only 6% of consultants felt this to be so. Regarding future attendance of the child at the hospital, 48% of parents and 32% of GPs felt the child could either be discharged or seen when parents were worried, whereas consultants felt 24% of patients should have been discharged.     

Paediatric medical outpatients: are all those reviews necessary?

The value of and need for paediatric outpatient review attendance as perceived by parents, children, consultants, and general practitioners (GPs) were assessed. One hundred and ninety one parents of 239 children over 7 years of age undergoing review were randomly selected for a semistructured interview. For each parent interviewed, an audit questionnaire was completed after case note review by another paediatrician. A random sample of the patients' GPs was surveyed by postal questionnaire. Twenty per cent of parents and 26% of GPs felt that the GP could care for the child as well as or better than the hospital, whereas only 6% of consultants felt this to be so. Regarding future attendance of the child at the hospital, 48% of parents and 32% of GPs felt the child could either be discharged or seen when parents were worried, whereas consultants felt 24% of patients should have been discharged.     

Development and preliminary validation of the questionnaire on pediatric gastrointestinal symptoms to assess functional gastrointestinal disorders in children and adolescents

OBJECTIVE: The aim of this study was to develop a questionnaire assessing symptoms associated with pediatric functional gastrointestinal disorders (FGIDs) and to provide preliminary evidence for its validity and reliability in a tertiary care setting. METHODS: The Questionnaire on Pediatric Gastrointestinal Symptoms (QPGS) was designed as both a parent report and child self-report measure based on the pediatric Rome II criteria for FGIDs. It was constructed in English, translated into French, and pilot tested in both languages. Initial validation was performed using the French version. Participants were 315 consecutive new patients aged 4 to 18, and their parents, presenting to a gastroenterology clinic and classified as having a functional problem. Content validity, item discrimination capacity, and reliability (parent-child concordance and temporal stability) were examined. RESULTS: Analyses of parent and child reports indicated that all items were pertinent and variably distributed. Although children were reliable reporters, up to 42% of parents did not know about their children's gastrointestinal functioning. As many as 60% of parents of children 10 to 18 could not respond to questions about defecation and subjective symptoms. Concordance was generally fair to good, with Kappas and intraclass correlations of 0.40 to 0.70 on most items. Test-retest reliability was moderate to good for the majority of items. CONCLUSION: This study supports the content validity of the QPGS. Form A is a reliable measure for parents of children 4 to 9 years old, but the child self-report Form C appears to be more reliable for 10 to 18 year olds.     

Cross-cultural development of a child health care questionnaire on satisfaction, utilization, and needs.

OBJECTIVE: The instrument Child Health Care-Satisfaction, Utilization and Needs (CHC-SUN) has been developed cross-culturally to evaluate pediatric health care services for children with special health care needs (CSHCN) from the proxy perspective of parents. METHODS: The children of the participating parents received treatment in pediatric specialty clinics in 7 European countries for asthma, cystic fibrosis, diabetes, epilepsy, cerebral palsy, rheumatoid arthritis, and atopic dermatitis. The instrument was developed through a process including literature review, expert consensus, and item generation through focus groups. The pilot instrument was extensively tested to assess psychometric properties, support item reduction, and evaluate clinical validity. The final field version was tested in a new sample of 795 parents in 7 countries. RESULTS: Pilot testing and item reduction resulted in a practical 40-item instrument with 14 single items related to provision of services (module 1), and 26 items related to 6 scales on satisfaction with care (module 2), and 1 item on general satisfaction with care. Satisfaction with care scales showed very good psychometric properties, both initially and in the field version, with Cronbach's alpha ranging between .80 and .95 in the revised scales. Both modules discriminated well between functional status and diagnosis across countries. CONCLUSIONS: A new instrument is available to measure provision of services and satisfaction with care for children with chronic conditions from the perspective of parents. Cross-cultural analysis reveals that the measure is useful in multinational studies evaluating health services against the background of different health systems.     

The experience of parents in Ronald McDonald houses in France

BackgroundRonald McDonald houses are located close to children's hospitals. They enable the hospitalized child to benefit from their family's presence, while helping the family to cope better with their child's hospital stay. This study aimed to describe the experience of parents staying in Ronald McDonald houses in France, identify their needs, and study the psychological impact of their child being in hospital.MethodThis cross-sectional observational epidemiological study was conducted in 2016, using anonymous self-administered questionnaires offered to parents staying in one of the nine Ronald McDonald houses in France. The questionnaire had two sections: a general section about the hospitalized child, and a 62 questions section to be completed by each parent, including a Hospital Anxiety and Depression Scale (HADS).ResultsThe participation rate was 62.9%: 71% of mothers completed the questionnaire (n = 320), and 54.7% of fathers did so (n = 246). They were the parents of 333 children (53.9% boys, 46.1% girls), under 1 year old (44.1%), hospitalized in the following three departments: intensive care (24%), pediatric oncology (23.1%), and neonatal care (20.1%). The mothers on average spent 11 h a day at their child's bedside, while the fathers spent 8 h 47 min. The parents tended to be employees or manual workers, and mostly lived together, with an average 2-h journey to hospital. They reported financial problems in 42.1% of cases, significant sleep deprivation (>90 min) in 73.2% of cases, and anxiety and depressive disorders: anxiety (59%) and depression (26%). There were some significant differences between the experiences of mothers and fathers: mothers lost out on their sleep and lost more appetite, and spent more time at their child's bedside, while the fathers encountered twice as many work-related difficulties (p<0.01). Additionally, their perception of the Ronald McDonald House was similar, as over 90% of them stated that this family accommodation allowed them to feel closer to their child and supported them in their role as parents.ConclusionThe parents of children in hospital were 6–8 times more anxious than the general population, while clinical symptoms of depression were twice as common as in the overall population. Despite this suffering linked to their child's illness, the parents rated highly the support provided by the Ronald McDonald House in helping them cope with their child's time in hospital.     

Short-term psychiatric adjustment of children and their parents following meningococcal disease.

OBJECTIVE: To assess short-term changes in child and parent psychiatric status following meningococcal disease. DESIGN: Prospective cohort study; 3-month follow-up using parent, teacher, and child questionnaires. SETTING: Hospital admissions to three pediatric intensive care units and 19 general pediatric wards. PATIENTS: Sixty children aged 3-6 yrs, 60 mothers, and 45 fathers. INTERVENTIONS: We administered measures of illness severity (Glasgow Meningococcal Septicaemia Prognostic Score, days in hospital) and psychiatric morbidity (Strengths and Difficulties Questionnaires, parent and teacher versions; Impact of Event scales; General Health Questionnaire-28). MEASUREMENTS AND MAIN RESULTS: In children admitted to pediatric intensive care units, parental reports at 3-month follow-up showed a significant increase in emotional and hyperactivity symptoms and in related impairment; symptoms of posttraumatic stress disorder were present in four of 26 (15%) children >8 yrs old. Regarding the parents, 26 of 60 (43%) mothers in the total sample had questionnaire scores indicative of high risk for psychiatric disorder and 22 of 58 (48%) for posttraumatic stress disorder. In fathers there was high risk for psychiatric disorder in 11 of 45 (24%) and for posttraumatic stress disorder in 8 of 43 (19%). Severity of the child's physical condition on admission was significantly associated with hyperactivity and conduct symptoms at follow-up. Length of hospital admission was associated with psychiatric symptoms in the child and posttraumatic stress disorder symptoms in parents. There were also significant associations between psychiatric symptoms in children and parents. CONCLUSIONS: Admission of children to pediatric intensive care units for meningococcal disease is associated with an increase in and high levels of psychiatric and posttraumatic stress disorder symptoms in children and parents. Length of admission is associated with psychiatric symptoms in children and posttraumatic stress disorder symptoms in parents. Pediatric follow-up should explore psychiatric as well as physical sequelae in children and parents.     

Reliability and validity of health status measurement by the TAPQOL

Background: In addition to clinical measures in the evaluation of paediatric interventions, health related quality of life (HRQoL) is an important outcome. The TAPQOL (TNO-AZL Preschool children Quality of Life) was developed to measure HRQoL in preschool children. It is a generic instrument consisting of 12 scales that cover the domains physical, social, cognitive, and emotional functioning. Aims: To evaluate the feasibility, score distribution, internal consistency, test-retest reliability, and discriminative and concurrent validity of the TAPQOL multi-item scales in preschool children, aged 2–48 months. Also to evaluate the feasibility, reliability, and validity separately for infants (2–12 months old) and toddlers (12–48 months old). Methods: Parents of a random general population sample of 500 preschool children were sent a questionnaire by mail. A random subgroup of 159 parents who participated received a retest after two weeks. Results: The response rate was 83% at the test and 75% at the retest. There were few missing answers. Six scales showed ceiling effects. Nine scales had Cronbach''s alphas >0.70. In general, score distributions and Cronbach''s alphas were comparable for infants and toddlers. Test-retest showed no significant differences in mean scale scores; two scales had intra-class correlations <0.50. Five scales showed significant differences between children with no conditions versus children with two or more parent reported chronic conditions. Conclusion: Results showed that the TAPQOL is a feasible instrument to measure HRQoL and support the reliability and discriminative validity of the majority of its scales for infants as well as toddlers.     

Reliability and validity of health status measurement by the TAPQOL.

BACKGROUND: In addition to clinical measures in the evaluation of paediatric interventions, health related quality of life (HRQoL) is an important outcome. The TAPQOL (TNO-AZL Preschool children Quality of Life) was developed to measure HRQoL in preschool children. It is a generic instrument consisting of 12 scales that cover the domains physical, social, cognitive, and emotional functioning. AIMS: To evaluate the feasibility, score distribution, internal consistency, test-retest reliability, and discriminative and concurrent validity of the TAPQOL multi-item scales in preschool children, aged 2-48 months. Also to evaluate the feasibility, reliability, and validity separately for infants (2-12 months old) and toddlers (12-48 months old). METHODS: Parents of a random general population sample of 500 preschool children were sent a questionnaire by mail. A random subgroup of 159 parents who participated received a retest after two weeks. RESULTS: The response rate was 83% at the test and 75% at the retest. There were few missing answers. Six scales showed ceiling effects. Nine scales had Cronbach's alphas >0.70. In general, score distributions and Cronbach's alphas were comparable for infants and toddlers. Test-retest showed no significant differences in mean scale scores; two scales had intra-class correlations <0.50. Five scales showed significant differences between children with no conditions versus children with two or more parent reported chronic conditions. CONCLUSION: Results showed that the TAPQOL is a feasible instrument to measure HRQoL and support the reliability and discriminative validity of the majority of its scales for infants as well as toddlers.     

Economic evaluation of an acute paediatric hospital at home clinical trial.

AIMS: To compare the privately borne and NHS costs of hospital at home (HAH) and conventional inpatient care for children with selected acute conditions. METHODS: Prospective economic evaluation using cost minimisation analysis within a randomised controlled trial, in paediatric wards of a district general hospital, and private homes in the local catchment area in Wirral, Merseyside. Subjects were children who fulfilled the criteria for admission to HAH, suffering from breathing difficulties (n = 202), diarrhoea and vomiting (n = 125), or fever (n = 72). RESULTS: Direct costs borne by families are reduced by 41% for HAH patients ( pound 23.31 v pound 13.76, p = 0.001). There is no evidence that HAH transfers the burden of care to parents, and there is no difference in absence rates from paid employment. Patients and their careers expressed a strong preference for HAH. Comparison of NHS costs is equivocal, depending on how HAH is implemented alongside the conventional hospital service. CONCLUSION: Paediatric HAH schemes are unlikely to reduce NHS costs and do not increase privately borne costs. They will, however, significantly increase patient and career satisfaction with care provision for sick children with appropriate conditions.