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Children with Medical Complexity: Instructions for Going Home

October 17, 2023

In a recently released article in Pediatrics, Dr. Alexander F. Glick and colleagues from NYU Langone Health conducted a systematic review that examines factors and interventions associated with caregiver understanding of and adherence to homegoing instructions for children with medical complexity (CMC) (10.1542/peds.2023-061572). This excellent review is well explained, with a comprehensive search strategy that included published and unpublished studies on the topic. The authors included studies about CMC1 aged 0-18 years who were discharged home from the inpatient setting, including the PICU. All included studies focused on factors specifically related to discharge instructions.

Fifty-one studies were ultimately included. Interestingly, the authors found no randomized clinical trials (RCTs); study types included qualitative (usually interview) studies, quality improvement trials, mixed-methods studies (meaning both qualitative and quantitative data are included) and non-randomized interventional studies. Following independent extraction of study information by two of the authors, including study characteristics and design, methods and participant descriptors, the authors assessed risk of bias and study quality, both critical to any systematic review. They used a unique tool called the Mixed Methods Appraisal Tool (MMAT)2, which is a valid and reliable checklist for appraising studies for systematic reviews like this one that include qualitative, quantitative, mixed methods and other study types. Use of the MMAT screening questions showed that all 51 studies had clear research questions with data collected adequately to answer the questions; article quality was mainly very good (24/51 met all 5 metrics on the MMAT with respect to study quality).

Although this systematic review topic initially seemed relatively narrow to me, multiple areas of discharge instruction, from technology use (tracheostomy and gastrostomy care) to medication and appointment compliance and return precautions, are included. There’s a lot covered here!

My take homes for this study included:

  1. A health literacy-informed and family-centered approach to transitioning home from the hospital appears to be key to overcoming barriers.
  2. Research and quality improvement initiatives that use objective rather than subjective measures of effective discharge teaching are needed.

Objective measures of comprehension, adherence and competency may be challenging to devise, but will potentially lead to RCTs that can inform clinical care. 

Let us know what you are doing to support great discharge teaching for children with medical complexity!


  1. Agency for Healthcare Research and Quality. Pediatric Medical Complexity Algorithm. AHRQ Publication No. 17-P006-EF June 2017 Accessed 9/26/23
  2. Hong, Q. N., Gonzalez-Reyes, A., & Pluye, P. Improving the usefulness of a tool for appraising the quality of qualitative, quantitative and mixed methods studies, the Mixed Methods Appraisal Tool (MMAT). Journal of Evaluation in Clinical Practice. 2018; 24(3): 459-467
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