51
|
Abstract
BACKGROUND Miscommunications lead to medical errors and suboptimal hospital experience. Parent-provider miscommunications are understudied. OBJECTIVES (1) Examine characteristics of parent-provider miscommunications about hospitalized children, (2) describe associations among parent-provider miscommunications, parent-reported errors, and hospital experience, and (3) compare parent and attending physician reports of parent-provider miscommunications. METHODS Prospective cohort study of 471 parents of 0- to 17-year-old medical inpatients in a pediatric hospital between May 1, 2013 and October 1, 2014. At discharge, parents reported parent-provider miscommunication and type (selecting all applicable responses), overall experience, and errors during hospitalization. During discharge billing, the attending physicians (n = 52) of a subset of patients (n = 217) also reported miscommunications, enabling comparison of parent and attending physician reports. We used logistic regression to examine characteristics of parent-reported miscommunications; McNemar's test to examine associations between miscommunications, errors, and top-box (eg, "excellent") experience; and generalized estimating equations to compare parent- and attending physician-reported miscommunication rates. RESULTS Parents completed 406 surveys (86.2% response rate). 15.3% of parents (n = 62) reported miscommunications. Parents of patients with nonpublic insurance (odds ratio: 1.99; 95% confidence interval: 1.03-3.85) and longer lengths of stay (odds ratio: 1.12; 95% confidence interval: 1.02-1.23) more commonly reported miscommunications. Parents reporting miscommunications were 5.3 times more likely to report errors and 78.6% less likely to report top-box overall experience (P < .001 for both). Among patients with both parent and attending physician surveys, 16.1% (n = 35) of parents and 3.7% (n = 8) of attending physicians reported miscommunications (P < .001). Both parents and attending physicians attributed miscommunications most often to family receipt of conflicting information. CONCLUSIONS Parent-provider miscommunications were associated with parent-reported errors and suboptimal hospital experience. Parents reported parent-provider miscommunications more often than attending physicians did.
Collapse
Affiliation(s)
- Alisa Khan
- Division of General Pediatrics, .,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and
| | | | | | - Jayne E Rogers
- Department of Nursing, Boston Children's Hospital, Boston, Massachusetts
| | - Mark A Schuster
- Division of General Pediatrics.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and
| | - Christopher P Landrigan
- Division of General Pediatrics.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and.,Division of Sleep Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
52
|
Nakamura MM, Zaslavsky AM, Toomey SL, Petty CR, Bryant MC, Geanacopoulos AT, Jha AK, Schuster MA. Pediatric Readmissions After Hospitalizations for Lower Respiratory Infections. Pediatrics 2017; 140:peds.2016-0938. [PMID: 28771405 DOI: 10.1542/peds.2016-0938] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Lower respiratory infections (LRIs) are among the most common reasons for pediatric hospitalization and among the diagnoses with the highest number of readmissions. Characterizing LRI readmissions would help guide efforts to prevent them. We assessed variation in pediatric LRI readmission rates, risk factors for readmission, and readmission diagnoses. METHODS We analyzed 2008-2009 Medicaid Analytic eXtract data for patients <18 years of age in 26 states. We identified LRI hospitalizations based on a primary diagnosis of bronchiolitis, influenza, or community-acquired pneumonia or a secondary diagnosis of one of these LRIs plus a primary diagnosis of asthma, respiratory failure, or sepsis/bacteremia. Readmission rates were calculated as the proportion of hospitalizations followed by ≥1 unplanned readmission within 30 days. We used logistic regression with fixed effects for patient characteristics and a hospital random intercept to case-mix adjust rates and assess risk factors. RESULTS Of 150 590 LRI hospitalizations, 8233 (5.5%) were followed by ≥1 readmission. The median adjusted hospital readmission rate was 5.2% (interquartile range: 5.1%-5.4%), and rates varied across hospitals (P < .0001). Infants (patients <1 year of age), boys, and children with chronic conditions were more likely to be readmitted. The most common primary diagnoses on readmission were LRIs (48.2%), asthma (10.0%), fluid/electrolyte disorders (3.4%), respiratory failure (3.3%), and upper respiratory infections (2.7%). CONCLUSIONS LRI readmissions are common and vary across hospitals. Multiple risk factors are associated with readmission, indicating potential targets for strategies to reduce readmissions. Readmission diagnoses sometimes seem related to the original LRI.
Collapse
Affiliation(s)
- Mari M Nakamura
- Divisions of General Pediatrics and .,Infectious Diseases, and.,Departments of Pediatrics and
| | | | - Sara L Toomey
- Divisions of General Pediatrics and.,Departments of Pediatrics and
| | - Carter R Petty
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts
| | | | | | - Ashish K Jha
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts.,Division of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts; and.,Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Mark A Schuster
- Divisions of General Pediatrics and.,Departments of Pediatrics and
| |
Collapse
|
53
|
Jones LC, Mrug S, Elliott MN, Toomey SL, Tortolero S, Schuster MA. Chronic Physical Health Conditions and Emotional Problems From Early Adolescence Through Midadolescence. Acad Pediatr 2017; 17:649-655. [PMID: 28215656 PMCID: PMC5545161 DOI: 10.1016/j.acap.2017.02.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 01/26/2017] [Accepted: 02/04/2017] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Chronic physical health conditions are highly prevalent in youth, frequently persisting into adulthood and contributing to the current and future health care burden in the United States. Our study evaluated associations of chronic physical health conditions with depressive and physiological anxiety symptoms in a community sample of youth and examined how those associations changed from early to midadolescence. METHODS In this longitudinal study of 5147 youth, students and their caregivers were interviewed when youth were in grades 5 (mean age = 11), 7 (mean age = 13), and 10 (mean age = 16). Caregivers reported family sociodemographics, youth race/ethnicity, and youth chronic physical health history at baseline. Youth reported their depressive symptoms at each time point and their physiological anxiety symptoms at grades 7 and 10. RESULTS At age 11, 28.5% had experienced a chronic physical health condition. Having any chronic physical health condition was related to elevated depressive symptoms at age 11 (2.05 ± 0.05 vs 1.89 ± 0.03; mean ± standard error; P < .01) and anxiety symptoms at age 16 (2.72 ± 0.06 vs 2.55 ± 0.04; P < .05). Experiencing multiple conditions was also related to experiencing more depressive symptoms (b = 0.13; P < .01) and physiological anxiety symptoms (b = 0.13; P < .05). After adjusting for previous mental health symptoms, having any condition still predicted anxiety at age 16. CONCLUSIONS Children with chronic physical health conditions have an increased risk of depressive symptoms and physiological anxiety symptoms, especially in early and midadolescence. Repeated screening for these symptoms may help identify children in need of interventions.
Collapse
Affiliation(s)
- LaRita C Jones
- Department of Psychology, University of Alabama at Birmingham, Birmingham, Ala.
| | - Sylvie Mrug
- Department of Psychology, University of Alabama at Birmingham, Birmingham, Ala
| | | | - Sara L Toomey
- Division of General Pediatrics, Boston Children's Hospital, Boston, Mass; Pediatrics, Harvard Medical School, Boston, Mass
| | - Susan Tortolero
- Center for Health Promotion and Prevention Research, University of Texas Health Science Center, Houston, Tex
| | - Mark A Schuster
- Division of General Pediatrics, Boston Children's Hospital, Boston, Mass; Pediatrics, Harvard Medical School, Boston, Mass
| |
Collapse
|
54
|
Hadland SE, Wharam JF, Schuster MA, Zhang F, Samet JH, Larochelle MR. Trends in Receipt of Buprenorphine and Naltrexone for Opioid Use Disorder Among Adolescents and Young Adults, 2001-2014. JAMA Pediatr 2017; 171. [PMID: 28628701 PMCID: PMC5649381 DOI: 10.1001/jamapediatrics.2017.0745] [Citation(s) in RCA: 184] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
IMPORTANCE Opioid use disorder (OUD) frequently begins in adolescence and young adulthood. Intervening early with pharmacotherapy is recommended by major professional organizations. No prior national studies have examined the extent to which adolescents and young adults (collectively termed youth) with OUD receive pharmacotherapy. OBJECTIVE To identify time trends and disparities in receipt of buprenorphine and naltrexone among youth with OUD in the United States. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted using deidentified data from a national commercial insurance database. Enrollment and complete health insurance claims of 9.7 million youth, aged 13 to 25 years were analyzed, identifying individuals who received a diagnosis of OUD between January 1, 2001, and June 30, 2014, with final follow-up date December 31, 2014. Analysis was conducted from April 25 to December 31, 2016. Time trends were identified and multivariable logistic regression was used to determine sociodemographic factors associated with medication receipt. EXPOSURES Sex, age, race/ethnicity, neighborhood education and poverty levels, geographic region, census region, and year of diagnosis. MAIN OUTCOMES AND MEASURES Dispensing of a medication (buprenorphine or naltrexone) within 6 months of first receiving an OUD diagnosis. RESULTS Among 20 822 youth diagnosed with OUD (0.2% of the 9.7 million sample), 13 698 (65.8%) were male and 17 119 (82.2%) were non-Hispanic white. Mean (SD) age was 21.0 (2.5) years at the first observed diagnosis. The diagnosis rate of OUD increased nearly 6-fold from 2001 to 2014 (from 0.26 per 100 000 person-years to 1.51 per 100 000 person-years). Overall, 5580 (26.8%) youth were dispensed a medication within 6 months of diagnosis, with 4976 (89.2%) of medication-treated youth receiving buprenorphine and 604 (10.8%) receiving naltrexone. Medication receipt increased more than 10-fold, from 3.0% in 2002 (when buprenorphine was introduced) to 31.8% in 2009, but declined in subsequent years (27.5% in 2014). In multivariable analyses, younger individuals were less likely to receive medications, with adjusted probability for age 13 to 15 years, 1.4% (95% CI, 0.4%-2.3%); 16 to 17 years, 9.7% (95% CI, 8.4%-11.1%); 18 to 20 years, 22.0% (95% CI, 21.0%-23.0%); and 21 to 25 years, 30.5% (95% CI, 30.0%-31.5%) (P < .001 for difference). Females (7124 [20.3%]) were less likely than males (13 698 [24.4%]) to receive medications (P < .001), as were non-Hispanic black (105 [14.8%]) and Hispanic (1165 [20.0%]) youth compared with non-Hispanic white (17 119 [23.1%]) youth (P < .001). CONCLUSIONS AND RELEVANCE In this first national study of buprenorphine and naltrexone receipt among youth, dispensing increased over time. Nonetheless, only 1 in 4 commercially insured youth with OUD received pharmacotherapy, and disparities based on sex, age, and race/ethnicity were observed.
Collapse
Affiliation(s)
- Scott E. Hadland
- Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts,Department of Pediatrics Boston Medical Center, Boston, Massachusetts,Division of Adolescent/Young Adult Medicine, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - J. Frank Wharam
- Department of Population Medicine, Harvard Medical School, Boston, Massachusetts,Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Mark A. Schuster
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts,Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Fang Zhang
- Department of Population Medicine, Harvard Medical School, Boston, Massachusetts,Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Jeffrey H. Samet
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | - Marc R. Larochelle
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
| |
Collapse
|
55
|
Bogart LM, Elliott MN, Ober AJ, Klein DJ, Hawes-Dawson J, Cowgill BO, Uyeda K, Schuster MA. Home Sweet Home: Parent and Home Environmental Factors in Adolescent Consumption of Sugar-Sweetened Beverages. Acad Pediatr 2017; 17:529-536. [PMID: 28143794 PMCID: PMC5495605 DOI: 10.1016/j.acap.2017.01.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 01/18/2017] [Accepted: 01/23/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Sugar-sweetened beverages (SSBs) are key contributors to obesity among youth. We investigated associations among parental and home-related factors (parental attitudes and consumption; home availability) regarding 3 types of SSBs-soda, sports drinks, and fruit-flavored drinks-with consumption of each type of SSB in a general school-based sample of adolescents. METHODS Data were collected across 3 school semesters, from 2009 to 2011. A total of 1313 seventh grade student-parent dyads participated. Students completed in-class surveys across 9 schools in a large Los Angeles school district; their parents completed telephone interviews. Youth were asked about their SSB consumption (soda, sports drinks, and fruit-flavored drinks), and parents were asked about their attitudes, consumption, and home availability of SSBs. RESULTS We estimated expected rates of youth SSB consumption for hypothetical parents at very low (5th) and very high (95th) percentiles for home/parental risk factors (ie, they consumed little, had negative attitudes, and did not keep SSBs in the home; or they consumed a lot, had positive attitudes, and did keep SSBs in the home). Youth of lower-risk parents (at the 5th percentile) were estimated to drink substantially less of each type of beverage than did youth of higher-risk parents (at the 95th percentile). For example, youth with higher-risk parents averaged nearly double the SSB consumption of youth of lower-risk parents (2.77 vs 1.37 glasses on the previous day; overall model significance F22,1312 = 3.91, P < .001). CONCLUSIONS Results suggest a need to focus on parental and home environmental factors when intervening to reduce youths' SSB consumption.
Collapse
Affiliation(s)
- Laura M. Bogart
- RAND Corporation, 1776 Main St, P.O. Box 2138, Santa Monica, CA, 90407-2138,Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA, 02115,Department of Pediatrics, Harvard Medical School, 25 Shattuck St, Boston, MA, 02115
| | - Marc N. Elliott
- RAND Corporation, 1776 Main St, P.O. Box 2138, Santa Monica, CA, 90407-2138
| | - Allison J. Ober
- RAND Corporation, 1776 Main St, P.O. Box 2138, Santa Monica, CA, 90407-2138
| | - David J. Klein
- RAND Corporation, 1776 Main St, P.O. Box 2138, Santa Monica, CA, 90407-2138,Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA, 02115
| | | | - Burton O. Cowgill
- Department of Health Policy and Management, UCLA Fielding School of Public Health, 650 Charles Young Drive South, A2-125 CHS, Box 9569000, Los Angeles, CA 90095-6900
| | - Kimberly Uyeda
- Community Partners and Medi-Cal Programs, Student Health and Human Services, Los Angeles Unified School District, 333 South Beaudry Ave, 29th floor, Los Angeles, CA 90017
| | - Mark A. Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA, 02115,Department of Pediatrics, Harvard Medical School, 25 Shattuck St, Boston, MA, 02115
| |
Collapse
|
56
|
Sawicki GS, Garvey KC, Toomey SL, Williams KA, Hargraves JL, James T, Raphael JL, Giardino AP, Schuster MA, Finkelstein JA. Preparation for Transition to Adult Care Among Medicaid-Insured Adolescents. Pediatrics 2017; 140:e20162768. [PMID: 28646002 PMCID: PMC5495532 DOI: 10.1542/peds.2016-2768] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Parents of children with chronic illness consistently report suboptimal preparation for transition from pediatric- to adult-focused health care. Little data are available on transition preparation for low-income youth in particular. METHODS We conducted a mailed survey of youth with chronic illness enrolled in 2 large Medicaid health plans to determine the quality of transition preparation using the Adolescent Assessment of Preparation for Transition (ADAPT). ADAPT is a new 26-item survey designed for 16- to 17-year-old youth to report on the quality of health care transition preparation they received from medical providers. ADAPT generates composite scores (possible range: 0%-100%) in 3 domains: counseling on transition self-management, counseling on prescription medication, and transfer planning. We examined differences in ADAPT scores based on clinical and demographic characteristics. RESULTS Among 780 and 575 respondents enrolled in the 2 health plans, respectively, scores in all domains reflected deficiencies in transition preparation. The highest scores were observed in counseling on prescription medication (57% and 58% in the 2 plans, respectively), and lower scores were seen for counseling on transition self-management (36% and 30%, respectively) and transfer planning (5% and 4%, respectively). There were no significant differences in composite scores by health plan, sex, or type of chronic health condition. CONCLUSIONS The ADAPT survey, a novel youth-reported patient experience measure, documented substantial gaps in the quality of transition preparation for adolescents with chronic health conditions in 2 diverse Medicaid populations.
Collapse
Affiliation(s)
- Gregory S. Sawicki
- Divisions of General Pediatrics,,Respiratory Diseases, and,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Katharine C. Garvey
- Divisions of General Pediatrics,,Endocrinology,,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Sara L. Toomey
- Divisions of General Pediatrics,,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Jean L. Raphael
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | - Mark A. Schuster
- Divisions of General Pediatrics,,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Jonathan A. Finkelstein
- Divisions of General Pediatrics,,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
57
|
Earnshaw VA, Elliott MN, Reisner SL, Mrug S, Windle M, Emery ST, Peskin MF, Schuster MA. Peer Victimization, Depressive Symptoms, and Substance Use: A Longitudinal Analysis. Pediatrics 2017; 139:peds.2016-3426. [PMID: 28562268 PMCID: PMC8918284 DOI: 10.1542/peds.2016-3426] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Peer victimization is common among youth and associated with substance use. Yet, few studies have examined these associations longitudinally or the psychological processes whereby peer victimization leads to substance use. The current study examined whether peer victimization in early adolescence is associated with alcohol, marijuana, and tobacco use in mid- to late adolescence, as well as the role of depressive symptoms in these associations. METHODS Longitudinal data were collected between 2004 and 2011 from 4297 youth in Birmingham, Alabama; Houston, Texas; and Los Angeles County, California. Data were analyzed by using structural equation modeling. RESULTS The hypothesized model fit the data well (Root Mean Square Error of Approximation [RMSEA] = 0.02; Comparative Fit Index [CFI] = 0.95). More frequent experiences of peer victimization in the fifth grade were associated with greater depressive symptoms in the seventh grade (B[SE] = 0.03[0.01]; P < .001), which, in turn, were associated with a greater likelihood of alcohol use (B[SE] = 0.03[0.01]; P = .003), marijuana use (B[SE] = 0.05[0.01]; P < .001), and tobacco use (B[SE] = 0.05[0.01]; P < .001) in the tenth grade. Moreover, fifth-grade peer victimization was indirectly associated with tenth-grade substance use via the mediator of seventh-grade depressive symptoms, including alcohol use (B[SE] = 0.01[0.01]; P = .006), marijuana use (B[SE] = 0.01[0.01]; P < .001), and tobacco use (B[SE] = 0.02[0.01]; P < .001). CONCLUSIONS Youth who experienced more frequent peer victimization in the fifth grade were more likely to use substances in the tenth grade, showing that experiences of peer victimization in early adolescence may have a lasting impact by affecting substance use behaviors during mid- to late adolescence. Interventions are needed to reduce peer victimization among youth and to support youth who have experienced victimization.
Collapse
Affiliation(s)
- Valerie A. Earnshaw
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts,Department of Human Development and Family Studies, University of Delaware, Newark, Delaware
| | | | - Sari L. Reisner
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts,The Fenway Institute, Fenway Health, Boston, Massachusetts
| | - Sylvie Mrug
- Department of Psychology, University of Alabama at Birmingham, Birmingham, Alabam
| | - Michael Windle
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Susan Tortolero Emery
- Center for Health Promotion and Prevention Research, The University of Texas Health Science Center at Houston School of Public Health, Houston, Texas
| | - Melissa F. Peskin
- Center for Health Promotion and Prevention Research, The University of Texas Health Science Center at Houston School of Public Health, Houston, Texas
| | - Mark A. Schuster
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
58
|
Wisk LE, Finkelstein JA, Toomey SL, Sawicki GS, Schuster MA, Galbraith AA. Impact of an Individual Mandate and Other Health Reforms on Dependent Coverage for Adolescents and Young Adults. Health Serv Res 2017; 53:1581-1599. [PMID: 28556901 DOI: 10.1111/1475-6773.12723] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To determine the effect of state-level dependent coverage expansion (DCE) with and without other state health reforms on exit from dependent coverage for adolescents and young adults (AYA). DATA SOURCES Administrative longitudinal data for 131,542 privately insured AYA in Massachusetts (DCE with other reforms) versus Maine and New Hampshire (DCE without other reforms) across three periods: prereform (1/00-12/06), poststate reform (1/07-9/10), and postfederal reform (10/10-12/12). STUDY DESIGN A difference-in-differences estimator was used to determine the rate of exit from dependent coverage, age at exit from dependent coverage, and re-uptake of dependent coverage among AYA in states with comprehensive reforms versus DCE only. PRINCIPAL FINDINGS Implementation of DCE with other reforms was significantly associated with a 23 percent reduction in exit from dependent coverage among AYA compared to the reduction observed for DCE alone. Additionally, comprehensive reforms were associated with over two additional years of dependent coverage for the average AYA and a 33 percent increase in the odds of regaining dependent coverage after a prior loss. CONCLUSIONS Findings suggest that an individual mandate and other reforms may enhance the effect of DCE in preventing loss of coverage among AYA.
Collapse
Affiliation(s)
- Lauren E Wisk
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jonathan A Finkelstein
- Department of Pediatrics, Harvard Medical School, Boston, MA.,Division of General Pediatrics, Boston Children's Hospital, Boston, MA.,Center for Healthcare Research in Pediatrics (CHeRP), Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Sara L Toomey
- Department of Pediatrics, Harvard Medical School, Boston, MA.,Division of General Pediatrics, Boston Children's Hospital, Boston, MA
| | - Gregory S Sawicki
- Department of Pediatrics, Harvard Medical School, Boston, MA.,Division of General Pediatrics, Boston Children's Hospital, Boston, MA.,Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA
| | - Mark A Schuster
- Department of Pediatrics, Harvard Medical School, Boston, MA.,Division of General Pediatrics, Boston Children's Hospital, Boston, MA
| | - Alison A Galbraith
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA.,Center for Healthcare Research in Pediatrics (CHeRP), Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| |
Collapse
|
59
|
Chien AT, Kuhlthau KA, Toomey SL, Quinn JA, Okumura MJ, Kuo DZ, Houtrow AJ, Van Cleave J, Landrum MB, Jang J, Janmey I, Furdyna MJ, Schuster MA. Quality of Primary Care for Children With Disabilities Enrolled in Medicaid. Acad Pediatr 2017; 17:443-449. [PMID: 28286057 DOI: 10.1016/j.acap.2016.10.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 09/28/2016] [Accepted: 10/28/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The quality of primary care delivered to Medicaid-insured children with disabilities (CWD) is unknown. We used the newly validated CWD algorithm (CWDA) to examine CWD prevalence among Medicaid enrollees 1 to 18 years old, primary care quality for CWD, and differences in primary care quality for CWD and non-CWD. METHODS Cross-sectional study using 2008 Medicaid Analytic eXtract claims data from 9 states, including children with at least 11 months of enrollment (N = 2,671,922 enrollees). We utilized CWDA to identify CWD and applied 12 validated or endorsed pediatric quality measures to assess preventive/screening, acute, and chronic disease care quality. We compared quality for CWD and non-CWD unmatched and matched on age, sex, and number of nondisabling chronic conditions and outpatient encounters. RESULTS CWDA identified 5.3% (n = 141,384) of our study population as CWD. Care quality levels for CWD were below 50% on 8 of 12 quality measures (eg, adolescent well visits [44.9%], alcohol/drug treatment engagement [24.9%]). CWD care quality was significantly better than the general population of non-CWD by +0.9% to +15.6% on 9 measures, but significantly worse for 2 measures, chlamydia screening (-3.4%) and no emergency department visits for asthma (-5.0%; all P < .01 to .001). Differences in care quality between CWD and non-CWD were generally smaller or changed direction when CWD were compared to a general population or matched group of non-CWD. CONCLUSIONS One in 20 Medicaid-insured children is CWD, and the quality of primary care delivered to CWD is suboptimal. Areas needing improvement include preventive/screening, acute care, and chronic disease management.
Collapse
Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass.
| | - Karen A Kuhlthau
- Department of Pediatrics, Harvard Medical School, Boston, Mass; Center for Child and Adolescent Health Research and Policy, Department of General Pediatrics, Massachusetts General Hospital for Children, Boston, Mass
| | - Sara L Toomey
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Jessica A Quinn
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass
| | - Megumi J Okumura
- Division of General Pediatrics, University of California San Francisco Beinoff Children's Hospital, San Francisco, Calif; Division of General Pediatrics, Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, Calif
| | - Dennis Z Kuo
- Department of Pediatrics, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Ark
| | - Amy J Houtrow
- Division of Pediatric Rehabilitation Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pa; Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Jeanne Van Cleave
- Department of Pediatrics, Harvard Medical School, Boston, Mass; Center for Child and Adolescent Health Research and Policy, Department of General Pediatrics, Massachusetts General Hospital for Children, Boston, Mass
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Mass
| | - Jisun Jang
- The Clinical Research Center, Boston Children's Hospital, Boston, Mass
| | - Isabel Janmey
- Case Western Reserve University School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Michael J Furdyna
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| |
Collapse
|
60
|
Toomey SL, Elliott MN, Zaslavsky AM, Klein DJ, Ndon S, Hardy S, Wu M, Schuster MA. Variation in Family Experience of Pediatric Inpatient Care As Measured by Child HCAHPS. Pediatrics 2017; 139:peds.2016-3372. [PMID: 28330970 PMCID: PMC5369678 DOI: 10.1542/peds.2016-3372] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/23/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Making national comparisons of family experience of inpatient pediatric care has been limited by the lack of a publicly available survey. The Agency for Healthcare Research and Quality and Centers for Medicare & Medicaid Services commissioned development of the Child Hospital Consumer Assessment of Healthcare Providers and Systems Survey to address this gap. Using Child Hospital Consumer Assessment of Healthcare Providers and Systems Survey, we measured performance of hospitals in a national field test. METHODS We analyzed 17 727 surveys completed from December 2012 to February 2014 by parents of children (<18 years) hospitalized at 69 hospitals in 34 states. For each of 18 survey measures, we calculated a case-mix-adjusted hospital "top-box" score (ie, percentage of respondents selecting the most positive response option). We quantified variation across hospitals by estimating hospital-level SDs for each item with a hierarchical linear probability model. We examined associations of family experience with patient, parent, and hospital characteristics. We compared aggregate performance on each measure across participating hospitals. RESULTS Mean hospital top-box scores ranged from 55% ("Preventing mistakes and helping you report concerns") to 84% ("Keeping you informed about your child's care in the emergency department"). The mean for overall rating of hospital stay was 73% (SD 7%). "Quietness of hospital room" scores varied most across hospitals (SD 8%). Overall top-box scores were higher for freestanding children's hospitals (74%) and children's hospitals within a hospital (73%) than for pediatric wards within hospitals (68%, P = .007). CONCLUSIONS Family experience of pediatric inpatient care shows substantial room for improvement and varies considerably across hospitals and measures.
Collapse
Affiliation(s)
- Sara L. Toomey
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts;,Pediatrics, Harvard Medical School, Boston, Massachusetts; and
| | | | | | - David J. Klein
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Sifon Ndon
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Shannon Hardy
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Melody Wu
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Mark A. Schuster
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts;,Pediatrics, Harvard Medical School, Boston, Massachusetts; and
| |
Collapse
|
61
|
Affiliation(s)
- Mark A Schuster
- From the Division of General Pediatrics, Boston Children's Hospital, and the Department of Pediatrics, Harvard Medical School - both in Boston (M.A.S.); and the Department of Pediatrics, University of California, San Francisco, San Francisco (E.F.-A.)
| | - Elena Fuentes-Afflick
- From the Division of General Pediatrics, Boston Children's Hospital, and the Department of Pediatrics, Harvard Medical School - both in Boston (M.A.S.); and the Department of Pediatrics, University of California, San Francisco, San Francisco (E.F.-A.)
| |
Collapse
|
62
|
Cabral P, Wallander JL, Song AV, Elliott MN, Tortolero SR, Reisner SL, Schuster MA. Generational status and social factors predicting initiation of partnered sexual activity among Latino/a youth. Health Psychol 2017; 36:169-178. [PMID: 27831707 PMCID: PMC5386886 DOI: 10.1037/hea0000435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Examine the longitudinal association of generational status (first = child and parent born outside the United States; second = child born in the United States, parent born outside the United States; third = child and parent born in the United States) and parent and peer social factors considered in 5th grade with subsequent oral, vaginal, and anal intercourse initiation by 7th and 10th grade among Latino/a youth. METHOD Using data from Latino/a participants (N = 1,790) in the Healthy Passages™ study, the authors measured generational status (first = 18.4%, second = 57.3%, third-generation = 24.3%) and parental (i.e., monitoring, involvement, nurturance) and peer (i.e., friendship quality, social interaction, peer norms) influences in 5th grade and oral, vaginal, and anal intercourse initiation by 7th and 10th (retention = 89%) grade. RESULTS Among girls, parental monitoring, social interaction, friendship quality, and peer norms predicted sexual initiation. Among boys, parental involvement, social interaction, and peer norms predicted sexual initiation (ps < .05). When ≥1 friend was perceived to have initiated sexual intercourse, third-generation Latinas were more than twice as likely as first- and second-generation Latinas (ps < .05) to initiate vaginal intercourse by 10th grade and almost 5 times as likely as first-generation Latinas to initiate oral intercourse by 7th grade. CONCLUSIONS Among Latina youth, generational status plays a role in social influences on vaginal and oral intercourse initiation. Moreover, Latinas and Latinos differ in which social influences predict sexual intercourse initiation. Preventive efforts for Latino/a youth may need to differ by gender and generational status. (PsycINFO Database Record
Collapse
Affiliation(s)
- Patricia Cabral
- Psychological Sciences and Health Sciences Research Institute, University of California, Merced
| | - Jan L Wallander
- Psychological Sciences and Health Sciences Research Institute, University of California, Merced
| | - Anna V Song
- Psychological Sciences and Health Sciences Research Institute, University of California, Merced
| | | | - Susan R Tortolero
- Prevention Research Center, University of Texas School of Public Health
| | - Sari L Reisner
- Division of General Pediatrics, Boston Children's Hospital
| | | |
Collapse
|
63
|
Chien AT, Ganeshan S, Schuster MA, Lehmann LS, Hatfield LA, Koplan KE, Petty CR, Sinaiko AD, Sequist TD, Rosenthal MB. The Effect of Price Information on the Ordering of Images and Procedures. Pediatrics 2017; 139:peds.2016-1507. [PMID: 28087684 DOI: 10.1542/peds.2016-1507] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/04/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Ordering rates for imaging studies and procedures may change if clinicians are shown the prices of those tests while they are ordering. We studied the effect of 2 forms of paid price information, single median price and paired internal/external median prices, on how often pediatric-focused and adult-oriented clinicians (most frequently general pediatricians and adult specialists caring for pediatric-aged patients, respectively) order imaging studies and procedures for 0- to 21-year-olds. METHODS In January 2014, we randomized 227 pediatric-focused and 279 adult-oriented clinicians to 1 of 3 study arms: Control (no price display), Single Median Price, or Paired Internal/External Median Prices (both with price display in the ordering screen of electronic health record). We used 1-way analysis of variance and paired t tests to examine how frequently clinicians (1) placed orders and (2) designated tests to be completed internally within an accountable care organization. RESULTS For pediatric-focused clinicians, there was no significant difference in the rates at which orders were placed or designated to be completed internally across the study arms. For adult-oriented clinicians caring for children and adolescents, however, those in the Single Price and Paired Price arms placed orders at significantly higher rates than those in the Control group (Control 3.2 [SD 4.8], Single Price 6.2 [SD 6.8], P < .001 and Paired Prices 5.2 [SD 7.9], P = .04). The rate at which adult-oriented clinicians designated tests to be completed internally was not significantly different across arms. CONCLUSIONS The effect of price information on ordering rates appears to depend on whether the clinician is pediatric-focused or adult-oriented.
Collapse
Affiliation(s)
- Alyna T Chien
- Harvard Medical School, Boston, Massachusetts; .,Division of General Pediatrics, Department of Medicine, and
| | | | - Mark A Schuster
- Harvard Medical School, Boston, Massachusetts.,Division of General Pediatrics, Department of Medicine, and
| | - Lisa Soleymani Lehmann
- Harvard Medical School, Boston, Massachusetts.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.,National Center for Ethics in Health Care, Veterans Health Administration, Washington, District of Columbia
| | - Laura A Hatfield
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | | | - Carter R Petty
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts
| | - Anna D Sinaiko
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Thomas D Sequist
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.,Partners Healthcare System, Boston, Massachusetts
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| |
Collapse
|
64
|
Hargreaves DS, Struijs JN, Schuster MA. US Children And Adolescents Had Fewer Annual Doctor And Dentist Contacts Than Their Dutch Counterparts, 2010-12. Health Aff (Millwood) 2017; 34:2113-20. [PMID: 26643632 DOI: 10.1377/hlthaff.2015.0709] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Children and adolescents in the United States have been found to be less healthy than their counterparts in other high-income countries. The contribution of pediatric health care use to health outcomes--either as an independent determinant or as a mediator of wider social factors--is not well understood. We found that, compared to their peers in the Netherlands, US children and adolescents had fewer annual doctor and dental contacts in 2012. In both countries, poorer health status was reported among low-income compared to high-income children; however, this status was accompanied by greater or equal number of doctor and dental contacts among low-income Dutch children compared to their higher-income Dutch peers. By contrast, low-income US children had 28-65 percent fewer care episodes than high-income US children. Further research is needed to investigate the potential impact of greater equity and use of pediatric services on US health outcomes. Possible policy responses might include a focus on improving the quality, coverage, and benefits of health insurance, as well as on the workforce implications of providing high-quality pediatric care to all.
Collapse
Affiliation(s)
- Dougal S Hargreaves
- Dougal S. Hargreaves is an associate professor in the Population, Policy, and Practice program at the Institute of Child Health, University College London, in England
| | - Jeroen N Struijs
- Jeroen N. Struijs is a senior researcher in the Department of Quality of Care and Health Economics at the National Institute of Public Health and the Environment (RIVM), in Bilthoven, the Netherlands
| | - Mark A Schuster
- Mark A. Schuster is the William Berenberg Professor of Pediatrics at Harvard Medical School and chief of the Division of General Pediatrics and vice chair for health policy in the Department of Medicine at Boston Children's Hospital, in Massachusetts
| |
Collapse
|
65
|
Romley JA, Shah AK, Chung PJ, Elliott MN, Vestal KD, Schuster MA. Family-Provided Health Care for Children With Special Health Care Needs. Pediatrics 2017; 139:peds.2016-1287. [PMID: 28028202 DOI: 10.1542/peds.2016-1287] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Many children with special health care needs (CSHCN) receive health care at home from family members, but the extent of this care is poorly quantified. This study's goals were to create a profile of CSHCN who receive family-provided health care and to quantify the extent of such care. METHODS We analyzed data from the 2009-2010 National Survey of Children with Special Health Care Needs, a nationally representative sample of 40 242 parents/guardians of CSHCN. Outcomes included sociodemographic characteristics of CSHCN and their households, time spent by family members providing health care at home to CSHCN, and the total economic cost of such care. Caregiving hours were assessed at (1) the cost of hiring an alternative caregiver (the "replacement cost" approach), and (2) caregiver wages (the "foregone earnings" approach). RESULTS Approximately 5.6 million US CSHCN received 1.5 billion hours annually of family-provided health care. Replacement with a home health aide would have cost an estimated $35.7 billion or $6400 per child per year in 2015 dollars ($11.6 billion or $2100 per child per year at minimum wage). The associated foregone earnings were $17.6 billion or $3200 per child per year. CSHCN most likely to receive the greatest amount of family-provided health care at home were ages 0 to 5 years, were Hispanic, lived below the federal poverty level, had no parents/guardians who had finished high school, had both public and private insurance, and had severe conditions/problems. CONCLUSIONS US families provide a significant quantity of health care at home to CSHCN, representing a substantial economic cost.
Collapse
Affiliation(s)
- John A Romley
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California.,RAND Corporation, Santa Monica, California
| | - Aakash K Shah
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Paul J Chung
- RAND Corporation, Santa Monica, California.,Departments of Pediatrics, Mattel Children's Hospital, David Geffen School of Medicine, and.,Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | | | - Katherine D Vestal
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Mark A Schuster
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts; .,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
66
|
Khan A, Baird J, Rogers JE, Furtak SL, Williams KA, Allair B, Litterer KP, Sharma M, Smith A, Schuster MA, Landrigan CP. Parent and Provider Experience and Shared Understanding After a Family-Centered Nighttime Communication Intervention. Acad Pediatr 2017; 17:389-402. [PMID: 28143793 PMCID: PMC5438159 DOI: 10.1016/j.acap.2017.01.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 01/13/2017] [Accepted: 01/22/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To assess parent and provider experience and shared understanding after a family-centered, multidisciplinary nighttime communication intervention (nurse-physician brief, family huddle, family update sheet). METHODS We performed a prospective intervention study at a children's hospital from May 2013 to October 2013 (preintervention period) and May 2014 to October 2014 (postintervention period). Participants included 464 parents, 176 nurses, and 52 resident physicians of 582 hospitalized 0- to 17-year-old patients. Pre- versus postintervention, we compared parent/provider top-box scores (eg, "excellent") for experience with communication across several domains; and level of agreement (shared understanding) between parent, nurse, and resident reports of patients' reason for admission, overnight medical plan, and overall medical plan, as rated independently by blinded clinician reviewers (agreement = 74.7%, kappa = .60). RESULTS Top-box parent experience improved for 1 of 4 domains: Experience and Communication With Nighttime Doctors (23.6% to 31.5%). Top-box provider experience improved for all 3 domains, including Communication and Shared Understanding With Families (resident rated, 16.5% to 35.1%; nurse rated, 32.2% to 37.9%) and Experience, Communication, and Shared Understanding With Other Providers (resident rated, 20.3% to 35.0%; nurse rated, 14.7% to 21.5%). Independently rated shared understanding remained unchanged for most domains but improved for parent-nurse composite shared understanding (summed agreement for reason for admission, overall plan, and overnight plan; 36.2% to 48.2%) and nurse-resident shared understanding regarding reason for admission (67.1% to 71.2%) and regarding overall medical plan (45.0% to 58.6%). All P <.05. CONCLUSIONS A family-centered, multidisciplinary nighttime communication intervention was associated with improvements in some, but not all, domains of parent/provider experience and shared understanding, particularly provider experience and nurse-family shared understanding. The intervention was promising but requires further refinement.
Collapse
Affiliation(s)
- Alisa Khan
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
| | | | - Jayne E. Rogers
- Department of Nursing, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115
| | - Stephannie L. Furtak
- Division of General Pediatrics, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115
| | - Kathryn A. Williams
- Clinical Research Center, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02215
| | - Brenda Allair
- Family Advisory Council, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115
| | - Katherine P. Litterer
- Center for Families, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115
| | | | - Alla Smith
- Division of General Pediatrics, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115
| | - Mark A. Schuster
- Division of General Pediatrics, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Christopher P. Landrigan
- Division of General Pediatrics, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115; Department of Pediatrics, Harvard Medical School, Boston, MA; Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
67
|
Abstract
Bullying of lesbian, gay, bisexual, and transgender (LGBT) youth is prevalent in the United States, and represents LGBT stigma when tied to sexual orientation and/or gender identity or expression. LGBT youth commonly report verbal, relational, and physical bullying, and damage to property. Bullying undermines the well-being of LGBT youth, with implications for risky health behaviors, poor mental health, and poor physical health that may last into adulthood. Pediatricians can play a vital role in preventing and identifying bullying, providing counseling to youth and their parents, and advocating for programs and policies to address LGBT bullying.
Collapse
Affiliation(s)
- Valerie A. Earnshaw
- Division of General Pediatrics, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115, USA,Department of Pediatrics, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA,Corresponding author. Boston Children’s Hospital, 21 Autumn Street, Room 212.1, Boston, MA 02115.
| | - Laura M. Bogart
- Division of General Pediatrics, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115, USA,Department of Pediatrics, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA,Health Unit, RAND Corporation, 1776 Main Street, P.O. Box 2138 Santa Monica, CA 90407-2138, USA
| | - V. Paul Poteat
- Counseling, Developmental, and Educational Psychology Department, Boston College, 140 Commonwealth Ave, Campion Hall 307, Chestnut Hill, MA 02467, USA
| | - Sari L. Reisner
- Division of General Pediatrics, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115, USA,Department of Pediatrics, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA,Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA,The Fenway Institute, Fenway Health, 1340 Boylston Street, Boston, MA 02215, USA
| | - Mark A. Schuster
- Division of General Pediatrics, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115, USA,Department of Pediatrics, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA
| |
Collapse
|
68
|
Jetelina KK, Reingle Gonzalez JM, Cuccaro PM, Peskin MF, Elliott MN, Coker TR, Mrug S, Davies SL, Schuster MA. The Association Between Familial Homelessness, Aggression, and Victimization Among Children. J Adolesc Health 2016; 59:688-695. [PMID: 27646498 DOI: 10.1016/j.jadohealth.2016.07.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 06/13/2016] [Accepted: 07/10/2016] [Indexed: 12/15/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the relationship between the number of periods children were exposed to familial homelessness and childhood aggression and victimization. METHODS Survey data were obtained from 4,297 fifth-grade children and their caregivers in three U.S. cities. Children and primary caregivers were surveyed longitudinally in 7th and 10th grades. Family homelessness, measured at each wave as unstable housing, was self-reported by the caregiver. Children were categorized into four mutually exclusive groups: victim only, aggressor only, victim-aggressor, and neither victim nor aggressor at each time point using validated measures. Multinomial, multilevel mixed models were used to evaluate the relationship among periods of homelessness and longitudinal victimization, aggression, and victim aggression compared to children who were nonvictims and nonaggressors. RESULTS Results suggest that children who experienced family homelessness were more likely than domiciled children to report aggression and victim aggression but not victimization only. Multivariate analyses suggested that even brief periods of homelessness were positively associated with aggression and victim aggression (relative to neither) compared to children who were never homeless. Furthermore, childhood victimization and victim aggression significantly decreased from 5th grade to 10th grade while aggression significantly increased in 10th grade. CONCLUSIONS Children who experienced family homelessness for brief periods of time were significantly more likely to be a victim-aggressor or aggressor compared to those who were never homeless. Prevention efforts should target housing security and other important factors that may reduce children's likelihood of aggression and associated victimization.
Collapse
Affiliation(s)
- Katelyn K Jetelina
- Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas School of Public Health, Dallas Regional Campus, Dallas, Texas.
| | - Jennifer M Reingle Gonzalez
- Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas School of Public Health, Dallas Regional Campus, Dallas, Texas
| | - Paula M Cuccaro
- Department of Health Promotion and Behavioral Sciences, University of Texas School of Public Health, Houston, Texas
| | - Melissa F Peskin
- Department of Health Promotion and Behavioral Sciences, University of Texas School of Public Health, Houston, Texas
| | | | - Tumaini R Coker
- Department of Pediatrics, Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Sylvie Mrug
- Department of Psychology, University of Alabama Birmingham, Birmingham, Alabama
| | - Susan L Davies
- Department of Health Behavior, UAB Center for the Study of Community Health, Birmingham, Alabama
| | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
69
|
Coker TR, Elliott MN, Toomey SL, Schwebel DC, Cuccaro P, Emery ST, Davies SL, Visser SN, Schuster MA. Racial and Ethnic Disparities in ADHD Diagnosis and Treatment. Pediatrics 2016; 138:peds.2016-0407. [PMID: 27553219 PMCID: PMC5684883 DOI: 10.1542/peds.2016-0407] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We examined racial/ethnic disparities in attention-deficit/hyperactivity disorder (ADHD) diagnosis and medication use and determined whether medication disparities were more likely due to underdiagnosis or undertreatment of African-American and Latino children, or overdiagnosis or overtreatment of white children. METHODS We used a population-based, multisite sample of 4297 children and parents surveyed over 3 waves (fifth, seventh, and 10th grades). Multivariate logistic regression examined disparities in parent-reported ADHD diagnosis and medication use in the following analyses: (1) using the total sample; (2) limited to children with an ADHD diagnosis or symptoms; and (3) limited to children without a diagnosis or symptoms. RESULTS Across all waves, African-American and Latino children, compared with white children, had lower odds of having an ADHD diagnosis and of taking ADHD medication, controlling for sociodemographics, ADHD symptoms, and other potential comorbid mental health symptoms. Among children with an ADHD diagnosis or symptoms, African-American children had lower odds of medication use at fifth, seventh, and 10th grades, and Latino children had lower odds at fifth and 10th grades. Among children who had neither ADHD symptoms nor ADHD diagnosis by fifth grade (and thus would not likely meet ADHD diagnostic criteria at any age), medication use did not vary by race/ethnicity in adjusted analysis. CONCLUSIONS Racial/ethnic disparities in parent-reported medication use for ADHD are robust, persisting from fifth grade to 10th grade. These findings suggest that disparities may be more likely related to underdiagnosis and undertreatment of African-American and Latino children as opposed to overdiagnosis or overtreatment of white children.
Collapse
Affiliation(s)
- Tumaini R. Coker
- Department of Pediatrics, Mattel Children’s Hospital, David Geffen School of Medicine at UCLA, Los Angeles, California,RAND, Santa Monica, California
| | | | - Sara L. Toomey
- Division of General Pediatrics, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - David C. Schwebel
- Department of Psychology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Paula Cuccaro
- Center for Health Promotion and Prevention Research, University of Texas–Houston, School of Public Health, Houston, Texas
| | - Susan Tortolero Emery
- Center for Health Promotion and Prevention Research, University of Texas–Houston, School of Public Health, Houston, Texas
| | - Susan L. Davies
- Department of Health Behavior, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Mark A. Schuster
- RAND, Santa Monica, California,Division of General Pediatrics, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
70
|
Katz IT, Bogart LM, Fu CM, Liu Y, Cox JE, Samuels RC, Chase T, Schubert P, Schuster MA. Barriers to HPV immunization among blacks and latinos: a qualitative analysis of caregivers, adolescents, and providers. BMC Public Health 2016; 16:874. [PMID: 27558506 PMCID: PMC4997748 DOI: 10.1186/s12889-016-3529-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 08/16/2016] [Indexed: 01/05/2023] Open
Abstract
Background Despite recommendations that 11–12-year-olds receive the full three-shot Human papillomavirus (HPV) vaccine series, national HPV immunization coverage rates remain low. Disparities exist, with Blacks and Latinos being less likely than Whites to complete the series. We aimed to identify and compare barriers to HPV immunization perceived by healthcare providers, Black and Latino adolescents, and their caregivers to inform a clinic-based intervention to improve immunization rates. Methods We conducted semi-structured interviews between March and July 2014 with Black and Latino adolescents (n = 24), their caregivers (n = 24), and nurses (n = 18), and 2 focus groups with 18 physicians recruited from two pediatric primary care clinics. Qualitative protocol topics included: general perceptions and attitudes towards vaccines; HPV knowledge; and perceived individual and systems-level barriers affecting vaccine initiation and completion. Results Themes were identified and organized by individual and systems-level barriers to HPV immunization. Adolescents and their caregivers, particularly Blacks, expressed concerns about HPV being an untested, “newer” vaccine. All families felt they needed more information on HPV and found it difficult to return for multiple visits to complete the vaccine series. Providers focused on challenges related to administering multiple vaccines simultaneously, and perceptions of parental reluctance to discuss sexually transmitted infections. Conclusions Optimizing HPV immunization rates may benefit from a multi-pronged approach to holistically address provider, structural, and individual barriers to care. Further research should examine strategies for providing multiple modalities of support for providers, including a routinized system of vaccine promotion and delivery, and for addressing families’ concerns about vaccine safety and efficacy.
Collapse
Affiliation(s)
- Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA. .,Massachusetts General Hospital, Center for Global Health, Boston, MassachusettsMA, USA. .,Harvard Medical School, Boston, Massachusetts, USA. .,Division of Women's Health, 1620 Tremont Street, 3rd Floor BWH, Boston, MA, 02120, USA.
| | - Laura M Bogart
- Harvard Medical School, Boston, Massachusetts, USA.,Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,RAND Corporation, Santa Monica, California, USA
| | - Chong Min Fu
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Yingna Liu
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Joanne E Cox
- Harvard Medical School, Boston, Massachusetts, USA.,Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ronald C Samuels
- Harvard Medical School, Boston, Massachusetts, USA.,Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Tami Chase
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Pamela Schubert
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mark A Schuster
- Harvard Medical School, Boston, Massachusetts, USA.,Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
71
|
Toomey SL, Peltz A, Loren S, Tracy M, Williams K, Pengeroth L, Marie AS, Onorato S, Schuster MA. Potentially Preventable 30-Day Hospital Readmissions at a Children's Hospital. Pediatrics 2016; 138:peds.2015-4182. [PMID: 27449421 PMCID: PMC5557411 DOI: 10.1542/peds.2015-4182] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Hospital readmission rates are increasingly used to assess quality. Little is known, however, about potential preventability of readmissions among children. Our objective was to evaluate potential preventability of 30-day readmissions using medical record review and interviews. METHODS A cross-sectional study in 305 children (<18 years old) readmitted within 30 days to a freestanding children's hospital between December 2012 and February 2013. Interviews (N = 1459) were conducted with parents/guardians, patients (if ≥13 years old), inpatient clinicians, and primary care providers. Reviewers evaluated medical records, interview summaries, and transcripts, and then rated potential preventability. Multivariate regression analysis was used to identify factors associated with potentially preventable readmission. Adjusted event curves were generated to model days to readmission. RESULTS Of readmissions, 29.5% were potentially preventable. Potentially preventable readmissions occurred sooner after discharge than non-potentially preventable readmissions (5 vs 9 median days; P < .001). The odds of a readmission being potentially preventable were greatest when the index admission and readmission were causally related (adjusted odds ratio [AOR]: 2.6; 95% confidence interval [CI]: 1.0-6.8) and when hospital (AOR: 16.3; 95% CI: 5.9-44.8) or patient (AOR: 7.1; 95% CI: 2.5-20.5) factors were identified. Interviews provided new information about the readmission in 31.2% of cases. CONCLUSIONS Nearly 30% of 30-day readmissions to a children's hospital may be potentially preventable. Hospital and patient factors are associated with potential preventability and may provide targets for quality improvement efforts. Interviews contribute important information and should be considered when evaluating readmissions.
Collapse
Affiliation(s)
- Sara L. Toomey
- Division of General Pediatrics, Department of Medicine, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Alon Peltz
- Division of General Pediatrics, Department of Medicine, Boston, Massachusetts,Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut
| | - Samuel Loren
- Division of General Pediatrics, Department of Medicine, Boston, Massachusetts
| | - Michaela Tracy
- Division of General Pediatrics, Department of Medicine, Boston, Massachusetts
| | - Kathryn Williams
- Clinical Research Center, Boston Children’s Hospital, Boston, Massachusetts
| | - Linda Pengeroth
- Division of General Pediatrics, Department of Medicine, Boston, Massachusetts
| | - Allison Ste Marie
- Division of General Pediatrics, Department of Medicine, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Sarah Onorato
- Division of General Pediatrics, Department of Medicine, Boston, Massachusetts
| | - Mark A. Schuster
- Division of General Pediatrics, Department of Medicine, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
72
|
Khan A, Rogers JE, Forster CS, Furtak SL, Schuster MA, Landrigan CP. Communication and Shared Understanding Between Parents and Resident-Physicians at Night. Hosp Pediatr 2016; 6:319-29. [PMID: 27188189 DOI: 10.1542/hpeds.2015-0224] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Communication breakdowns between members of the health care team compromise patient safety and experience. Communication breakdowns with parents, an important but often overlooked part of the health care team, are understudied. Parents may play a particularly important role in nighttime care given decreased staffing and inadequate transitions of care at night. We studied communication breakdowns evidenced by lack of shared understanding between parents and night-team residents about the reason for admission and care plan. METHODS We conducted a prospective cohort study of parents (n = 286) and night-team senior residents (n = 34) from May 1, 2013 to October 31, 2013. Parents and residents rated communication and described patients' reason for admission, overall plan, and overnight plan. Two physician investigators independently reviewed (κ = 0.63) resident-parent dyads, assigned subsequently dichotomized 4-point overall agreement scores, and rated plan complexity. Using clustered logistic regression, we evaluated relationships among demographics, plan complexity, and shared understanding. We also examined resident and parent perceptions of shared understanding. RESULTS We analyzed data from 257 parent-resident dyads. Among these, 45.1% were rated as lacking shared understanding (agreement score = 1 or 2). In multivariate analysis, higher plan complexity (P < .001) and length of stay (P = .002) were associated with lack of shared understanding; lower parental education was a borderline predictor (P = .05). When surveyed, parents and residents reported that they shared an understanding with one another about care plans in 86.0% and 73.1% of cases, respectively. CONCLUSIONS Parents and night-team residents frequently lack shared understanding. Family-centered care initiatives to improve parent-provider communication and shared understanding may help empower parents as partners in safe and high-quality nighttime care.
Collapse
Affiliation(s)
- Alisa Khan
- Division of General Pediatrics, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and
| | - Jayne E Rogers
- Department of Nursing, Boston Children's Hospital, Boston, Massachusetts
| | | | | | - Mark A Schuster
- Division of General Pediatrics, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and
| | - Christopher P Landrigan
- Division of General Pediatrics, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and Division of Sleep Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
73
|
Affiliation(s)
- Mark A Schuster
- From the Division of General Pediatrics, Boston Children's Hospital (M.A.S., S.L.R., S.E.O.), the Department of Pediatrics, Harvard Medical School (M.A.S., S.L.R.), the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.L.R.), and the Fenway Institute, Fenway Health (S.L.R.) - all in Boston
| | - Sari L Reisner
- From the Division of General Pediatrics, Boston Children's Hospital (M.A.S., S.L.R., S.E.O.), the Department of Pediatrics, Harvard Medical School (M.A.S., S.L.R.), the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.L.R.), and the Fenway Institute, Fenway Health (S.L.R.) - all in Boston
| | - Sarah E Onorato
- From the Division of General Pediatrics, Boston Children's Hospital (M.A.S., S.L.R., S.E.O.), the Department of Pediatrics, Harvard Medical School (M.A.S., S.L.R.), the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.L.R.), and the Fenway Institute, Fenway Health (S.L.R.) - all in Boston
| |
Collapse
|
74
|
Nelson CP, Finkelstein JA, Logvinenko T, Schuster MA. Incidence of Urinary Tract Infection Among Siblings of Children With Vesicoureteral Reflux. Acad Pediatr 2016; 16:489-495. [PMID: 26589543 PMCID: PMC4867138 DOI: 10.1016/j.acap.2015.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 11/04/2015] [Accepted: 11/10/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Siblings of children with vesicoureteral reflux (VUR) are at elevated risk of VUR. Screening siblings may identify VUR before a clinical illness such as a urinary tract infection (UTI), but the benefit of screening has not been demonstrated. We sought to determine the incidence of UTI among siblings, and we hypothesized that the sibling UTI rate is similar between screened and unscreened siblings. METHODS We performed a retrospective cohort analysis using insurance claims data (January 1, 2000, to December 31, 2009). Within each family, we identified the index VUR patient and siblings; we included siblings who were enrolled in the insurance plan from birth for at least 1 year. We identified siblings who were screened for VUR and/or had UTI. We investigated the association of screening and UTI, controlling for patient characteristics and clustering within families. RESULTS Among 617 siblings (associated with 497 index patients), 317 (51%) were girls. Median insurance enrollment time was 53.0 months, with 424 enrolled ≥3 years. Among those with 1 or 3 years of enrollment, the proportions of siblings who experienced UTI was 8.4% (52 of 617) and 10.4% (44 of 424), respectively. Median age at initial UTI was 32.7 months. A total of 223 siblings (36.0%) underwent sibling screening. There was no significant difference in UTI between screened and unscreened siblings (odds ratio 1.57, 95% confidence interval 0.87-2.85; P = .14). In multivariate analysis, screening was not associated with sibling UTI incidence (odds ratio 1.33, 95% confidence interval 0.68-2.60; P = .40). CONCLUSIONS Although UTI is relatively common among siblings of VUR patients, there was no statistically significant difference in UTI incidence between screened and unscreened siblings.
Collapse
Affiliation(s)
- Caleb P. Nelson
- Assistant Professor of Surgery and Pediatrics, Department of Surgery, Harvard Medical School; and Department of Urology, Boston Children’s Hospital, Boston, MA
| | - Jonathan A. Finkelstein
- Associate Professor of Pediatrics, Department of Pediatrics, Harvard Medical School; and Vice-Chair for Quality and Outcomes, Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, MA
| | - Tanya Logvinenko
- Senior Biostatistician, Clinical Research Center, Boston Children’s Hospital, Boston, MA
| | - Mark A. Schuster
- Professor of Pediatrics, Department of Pediatrics, Harvard Medical School; and Chief, Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, MA
| |
Collapse
|
75
|
Landrigan CP, Stockwell D, Toomey SL, Loren S, Tracy M, Jang J, Quinn JA, Ashrafzadeh S, Wang M, Sharek PJ, Parry G, Schuster MA. Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) Tool. Pediatrics 2016; 137:peds.2015-4076. [PMID: 27221286 DOI: 10.1542/peds.2015-4076] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Efforts to advance patient safety have been hampered by the lack of high quality measures of adverse events (AEs). This study's objective was to develop and test the Global Assessment of Pediatric Patient Safety (GAPPS) trigger tool, which measures hospital-wide rates of AEs and preventable AEs. METHODS Through a literature review and expert panel process, we developed a draft trigger tool. Tool performance was tested in 16 academic and community hospitals across the United States. At each site, a primary reviewer (nurse) reviewed ∼240 randomly selected medical records; 10% of records underwent an additional primary review. Suspected AEs were subsequently evaluated by 2 secondary reviewers (physicians). Ten percent of records were also reviewed by external expert reviewers. Each trigger's incidence and positivity rates were assessed to refine GAPPS. RESULTS In total, 3814 medical records were reviewed. Primary reviewers agreed 92% of the time on presence or absence of a suspected AE (κ = 0.69). Secondary reviewers verifying AE presence or absence agreed 92% of the time (κ = 0.81). Using expert reviews as a standard for comparison, hospital-based primary reviewers had a sensitivity and specificity of 40% and 91%, respectively. As primary reviewers gained experience, their agreement with expert reviewers improved significantly. After removing low-yield triggers, 27 and 30 (of 54) triggers met inclusion criteria to form final manual and automated trigger lists, respectively. CONCLUSIONS GAPPS reliably identifies AEs and can be used to guide and monitor quality improvement efforts. Ongoing refinement may facilitate future interhospital comparisons.
Collapse
Affiliation(s)
- Christopher P Landrigan
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachussets;
| | - David Stockwell
- Division of Critical Care Medicine, Children's National Medical Center, Washington, District of Columbia; Division of Critical Care Medicine, Department of Pediatrics, School of Medicine, George Washington University, Washington, District of Columbia
| | - Sara L Toomey
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Samuel Loren
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Michaela Tracy
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Jisun Jang
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Jessica A Quinn
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Sepideh Ashrafzadeh
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Michelle Wang
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Paul J Sharek
- Division of Pediatric Hospitalist Medicine, Department of Pediatrics, Stanford University School of Medicine; and
| | - Gareth Parry
- Institute for Healthcare Improvement, Cambridge, MA
| | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
76
|
Bogart LM, Elliott MN, Cowgill BO, Klein DJ, Hawes-Dawson J, Uyeda K, Schuster MA. Two-Year BMI Outcomes From a School-Based Intervention for Nutrition and Exercise: A Randomized Trial. Pediatrics 2016; 137:peds.2015-2493. [PMID: 27244788 PMCID: PMC4845865 DOI: 10.1542/peds.2015-2493] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES This study examined the long-term effects on BMI of a randomized controlled trial of Students for Nutrition and Exercise, a 5-week, middle school-based obesity prevention intervention combining school-wide environmental changes, encouragement to eat healthy school cafeteria foods, and peer-led education and marketing. METHODS We randomly selected schools from the Los Angeles Unified School District and assigned 5 to the intervention group and 5 to a wait-list control group. Of the 4022 seventh-graders across schools, a total of 1368 students had their height and weight assessed at baseline and 2 years' postintervention. RESULTS A multivariable linear regression was used to predict BMI percentile at ninth grade by using BMI percentile at seventh grade, school indicators, and sociodemographic characteristics (child gender, age, Latino race/ethnicity, US-born status, and National School Lunch Program eligibility [as a proxy for low-income status]). Although the Students for Nutrition and Exercise intervention did not exhibit significant effects on BMI percentile overall, intervention students who were classified as obese at baseline (in seventh grade) showed significant reductions in BMI percentile in ninth grade (b = -2.33 percentiles; SE, 0.83; P = .005) compared with control students. This outcome translated into ∼9 pounds (∼4.1 kg) lower expected body weight after 2 years for an obese student in the intervention school at the mean height and age of the sample at baseline. CONCLUSIONS Multilevel school-based interventions can have long-term effects on BMI among students who are obese. Future research should examine the mechanisms by which school-based obesity interventions can affect BMI over time.
Collapse
Affiliation(s)
- Laura M. Bogart
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;,RAND Corporation, Santa Monica, California
| | | | - Burton O. Cowgill
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California; and
| | - David J. Klein
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts;,RAND Corporation, Santa Monica, California
| | | | - Kimberly Uyeda
- Community Partners and Medi-Cal Programs, Student Health and Human Services, Los Angeles Unified School District, Los Angeles, California
| | - Mark A. Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
77
|
Ladapo JA, Bogart LM, Klein DJ, Cowgill BO, Uyeda K, Binkle DG, Stevens ER, Schuster MA. Cost and Cost-Effectiveness of Students for Nutrition and eXercise (SNaX). Acad Pediatr 2016; 16:247-53. [PMID: 26427719 PMCID: PMC4808504 DOI: 10.1016/j.acap.2015.07.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 07/17/2015] [Accepted: 07/26/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To examine the cost and cost-effectiveness of implementing Students for Nutrition and eXercise (SNaX), a 5-week middle school-based obesity-prevention intervention combining school-wide environmental changes, multimedia, encouragement to eat healthy school cafeteria foods, and peer-led education. METHODS Five intervention and 5 control middle schools (mean enrollment, 1520 students) from the Los Angeles Unified School District participated in a randomized controlled trial of SNaX. Acquisition costs for materials and time and wage data for employees involved in implementing the program were used to estimate fixed and variable costs. Cost-effectiveness was determined using the ratio of variable costs to program efficacy outcomes. RESULTS The costs of implementing the program over 5 weeks were $5433.26 per school in fixed costs and $2.11 per student in variable costs, equaling a total cost of $8637.17 per school, or $0.23 per student per day. This investment yielded significant increases in the proportion of students served fruit and lunch and a significant decrease in the proportion of students buying snacks. The cost-effectiveness of the program, per student over 5 weeks, was $1.20 per additional fruit served during meals, $8.43 per additional full-priced lunch served, $2.11 per additional reduced-price/free lunch served, and $1.69 per reduction in snacks sold. CONCLUSIONS SNaX demonstrated the feasibility and cost-effectiveness of a middle school-based obesity-prevention intervention combining school-wide environmental changes, multimedia, encouragement to eat healthy school cafeteria foods, and peer-led education. Its cost is modest and unlikely to be a significant barrier to adoption for many schools considering its implementation.
Collapse
Affiliation(s)
- Joseph A. Ladapo
- Department of Medicine, New York University School of Medicine, New York, NY,Department of Population Health, New York University School of Medicine, New York, NY
| | - Laura M. Bogart
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA,RAND Corporation, Santa Monica, CA
| | - David J. Klein
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, MA,RAND Corporation, Santa Monica, CA
| | - Burton O. Cowgill
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Kimberly Uyeda
- Student Medical Services, Los Angeles Unified School District, Los Angeles, CA
| | - David G. Binkle
- Food Services Branch, Los Angeles Unified School District, Los Angeles, CA
| | - Elizabeth R. Stevens
- Department of Population Health, New York University School of Medicine, New York, NY
| | - Mark A. Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA
| |
Collapse
|
78
|
Abstract
IMPORTANCE Limited data exist regarding the incidence and nature of patient- and family-reported medical errors, particularly in pediatrics. OBJECTIVE To determine the frequency with which parents experience patient safety incidents and the proportion of reported incidents that meet standard definitions of medical errors and preventable adverse events (AEs). DESIGN, SETTING, AND PARTICIPANTS We conducted a prospective cohort study from May 2013 to October 2014 within 2 general pediatric units at a children's hospital. Included in the study were English-speaking parents (N = 471) of randomly selected inpatients (ages 0-17 years) prior to discharge. Parents reported via written survey whether their child experienced any safety incidents during hospitalization. Two physician reviewers classified incidents as medical errors, other quality issues, or exclusions (κ = 0.64; agreement = 78%). They then categorized medical errors as harmful (ie, preventable AEs) or nonharmful (κ = 0.77; agreement = 89%). We analyzed errors/AEs using descriptive statistics and explored predictors of parent-reported errors using bivariate statistics. We subsequently reviewed patient medical records to determine the number of parent-reported errors that were present in the medical record. We obtained demographic/clinical data from hospital administrative records. MAIN OUTCOMES AND MEASURES Medical errors and preventable AEs. RESULTS The mean (SD) age of the 383 parents surveyed was 36.6 (8.9) years; most respondents (n = 266) were female. Of 383 parents surveyed (81% response rate), 34 parents (8.9%) reported 37 safety incidents. Among these, 62% (n = 23, 6.0 per 100 admissions) were determined to be medical errors on physician review, 24% (n = 9) were determined to be other quality problems, and 14% (n = 5) were determined to be neither. Thirty percent (n = 7, 1.8 per 100 admissions) of medical errors caused harm (ie, were preventable AEs). On bivariate analysis, children with medical errors appeared to have longer lengths of stay (median [interquartile range], 2.9 days [2.2-6.9] vs 2.5 days [1.9-4.1]; P = .04), more often had a metabolic (14.3% vs 3.0%; P = .04) or neuromuscular (14.3% vs 3.6%; P = .05) condition, and more often had an annual household income greater than $100,000 (38.1% vs 30.1%; P = .06) than those without errors. Fifty-seven percent (n = 13) of parent-reported medical errors were also identified on subsequent medical record review. CONCLUSIONS AND RELEVANCE Parents frequently reported errors and preventable AEs, many of which were not otherwise documented in the medical record. Families are an underused source of data about errors, particularly preventable AEs. Hospitals may wish to consider incorporating family reports into routine safety surveillance systems.
Collapse
Affiliation(s)
- Alisa Khan
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts2Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Stephannie L. Furtak
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Patrice Melvin
- Center for Patient Safety and Quality Research, Boston Children’s Hospital, Boston, Massachusetts
| | - Jayne E. Rogers
- Department of Nursing, Boston Children’s Hospital, Boston, Massachusetts
| | - Mark A. Schuster
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts2Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Christopher P. Landrigan
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts2Department of Pediatrics, Harvard Medical School, Boston, Massachusetts5Division of Sleep Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| |
Collapse
|
79
|
Chien AT, Schiavoni KH, Sprecher E, Landon BE, McNeil BJ, Chernew ME, Schuster MA. How Accountable Care Organizations Responded to Pediatric Incentives in the Alternative Quality Contract. Acad Pediatr 2016; 16:200-7. [PMID: 26523636 DOI: 10.1016/j.acap.2015.10.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 10/15/2015] [Accepted: 10/24/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVE From 2009 to 2010, 12 accountable care organizations (ACOs) entered into the alternative quality contract (AQC), BlueCross BlueShield of Massachusetts's global payment arrangement. The AQC included 6 outpatient pediatric quality measures among 64 total measures tied to pay-for-performance bonuses and incorporated pediatric populations in their global budgets. We characterized the pediatric infrastructure of these adult-oriented ACOs and obtained leaders' perspectives on their ACOs' response to pediatric incentives. METHODS We used Massachusetts Health Quality Partners and American Hospital Association Survey data to characterize ACOs' pediatric infrastructure as extremely limited, basic, and substantial on the basis of the extent of pediatric primary care, outpatient specialist, and inpatient services. After ACOs had 16 to 43 months of experience with the AQC, we interviewed 22 leaders to gain insight into how organizations made changes to improve pediatric care quality, tried to reduce pediatric spending, and addressed care for children with special health care needs. RESULTS ACOs' pediatric infrastructure ranged from extremely limited (eg, no general pediatricians in their primary care workforce) to substantial (eg, 42% of workforce was general pediatricians). Most leaders reported intensifying their pediatric quality improvement efforts and witnessing changes in quality metrics; most also investigated pediatric spending patterns but struggled to change patients' utilization patterns. All reported that the AQC did little to incentivize care for children with special health care needs and that future incentive programs should include this population. CONCLUSIONS Although ACOs involved in the AQC were adult-oriented, most augmented their pediatric quality improvement and spending reduction efforts when faced with pediatric incentives.
Collapse
Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Katherine H Schiavoni
- Harvard Medical School, Boston, Mass; Department of Medicine and Pediatrics, Massachusetts General Hospital, Boston, Mass
| | - Eli Sprecher
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass
| | - Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Mass; Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Barbara J McNeil
- Department of Health Care Policy, Harvard Medical School, Boston, Mass; Department of Radiology, Brigham and Women's Hospital, Boston, Mass
| | - Michael E Chernew
- Department of Health Care Policy, Harvard Medical School, Boston, Mass
| | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| |
Collapse
|
80
|
Ladapo JA, Elliott MN, Kanouse DE, Schwebel DC, Toomey SL, Mrug S, Cuccaro PM, Tortolero SR, Schuster MA. Firearm Ownership and Acquisition Among Parents With Risk Factors for Self-Harm or Other Violence. Acad Pediatr 2016; 16:742-749. [PMID: 27426038 PMCID: PMC5077672 DOI: 10.1016/j.acap.2016.05.145] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 05/12/2016] [Accepted: 05/20/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Recent policy initiatives aiming to reduce firearm morbidity focus on mental health and illness. However, few studies have simultaneously examined mental health and behavioral predictors within families, or their longitudinal association with newly acquiring a firearm. METHODS Population-based, longitudinal survey of 4251 parents of fifth-grade students in 3 US metropolitan areas; 2004 to 2011. Multivariate logistic models were used to assess associations between owning or acquiring a firearm and parent mental illness and substance use. RESULTS Ninety-three percent of parents interviewed were women. Overall, 19.6% of families reported keeping a firearm in the home. After adjustment for confounders, history of depression (adjusted odds ratio [aOR], 1.36; 95% confidence interval [CI], 1.04-1.77), binge drinking (aOR 1.75; 95% CI, 1.14-2.68), and illicit drug use (aOR 1.75; 95% CI, 1.12-2.76) were associated with a higher likelihood of keeping a firearm in the home. After a mean of 3.1 years, 6.1% of parents who did not keep a firearm in the home at baseline acquired one by follow-up and kept it in the home (average annual likelihood = 2.1%). No risk factors for self-harm or other violence were associated with newly acquiring a gun in the home. CONCLUSIONS Families with risk factors for self-harm or other violence have a modestly greater probability of having a firearm in the home compared with families without risk factors, and similar probability of newly acquiring a firearm. Treatment interventions for many of these risk factors might reduce firearm-related morbidity.
Collapse
Affiliation(s)
- Joseph A. Ladapo
- Departments of Medicine and Population Health, New York University School of Medicine, New York, NY
| | | | | | | | - Sara L. Toomey
- Division of General Pediatrics, Boston Children’s Hospital, Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Sylvie Mrug
- Department of Psychology, University of Alabama, Birmingham, AL
| | | | | | - Mark A. Schuster
- Division of General Pediatrics, Boston Children’s Hospital, Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA
| |
Collapse
|
81
|
Bogart LM, Babey SH, Patel AI, Wang P, Schuster MA. Lunchtime School Water Availability and Water Consumption Among California Adolescents. J Adolesc Health 2016; 58:98-103. [PMID: 26552740 PMCID: PMC4695239 DOI: 10.1016/j.jadohealth.2015.09.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 09/01/2015] [Accepted: 09/01/2015] [Indexed: 11/19/2022]
Abstract
PURPOSE To examine the potential impact of California SB 1413, which required school districts to provide free, fresh drinking water during mealtimes in food service areas by July 1, 2011, on greater water consumption among California adolescents. METHODS Data were drawn from the 2012 and 2013 state-representative California Health Interview Survey. A total of 2,665 adolescents aged 12-17 years were interviewed regarding their water consumption and availability of free water during lunchtime at their school. RESULTS Three-fourths reported that their school provided free water at lunchtime, mainly via fountains. In a multivariate model that controlled for age, gender, income, race/ethnicity, body mass index, and school type, adolescents in schools that provided free water consumed significantly more water than adolescents who reported that water was not available, bivariate (standard error) = .67 (.28), p = .02. School water access did not significantly vary across the 2 years. CONCLUSIONS Lunchtime school water availability was related to water consumption, but a quarter of adolescents reported that their school did not provide free water at lunch. Future research should explore what supports and inducements might facilitate provision of drinking water during school mealtimes.
Collapse
Affiliation(s)
- Laura M Bogart
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Health Unit, RAND Corporation, Santa Monica, California.
| | - Susan H Babey
- UCLA Center for Health Policy Research, University of California, Los Angeles, Los Angeles, California
| | - Anisha I Patel
- Department of Pediatrics, University of California, San Francisco, San Francisco, California; Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California
| | - Pan Wang
- UCLA Center for Health Policy Research, University of California, Los Angeles, Los Angeles, California
| | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
82
|
Dudovitz RN, Chung PJ, Elliott MN, Davies SL, Tortolero S, Baumler E, Banspach SW, Schuster MA. Relationship of Age for Grade and Pubertal Stage to Early Initiation of Substance Use. Prev Chronic Dis 2015; 12:E203. [PMID: 26583575 PMCID: PMC4655482 DOI: 10.5888/pcd12.150234] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Introduction Studies suggest students who are substantially older than the average age for their grade engage in risky health behaviors, including substance use. However, most studies do not account for the distinct reasons why students are old for their grade (ie, grade retention vs delayed school entry) or for their pubertal stage. Thus, whether the association between age for grade and substance use is confounded by these factors is unknown. We sought to determine whether age, grade, or pubertal stage were associated with early substance use. Methods Cross-sectional Healthy Passages Wave I survey data from 5,147 fifth graders and their caregivers in Alabama, California, and Texas from 2004 through 2006 were analyzed in 2014. Logistic regressions examined whether older age for grade, grade retention, delayed school entry, or pubertal stage were associated with use of any substance, cigarettes, alcohol, or other drugs. Results Seventeen percent of fifth graders reported trying at least 1 substance. Among boys, advanced pubertal stage was associated with increased odds of cigarette, alcohol, or other drug use, whereas delayed school entry was associated with lower odds of any substance, alcohol, or other drug use. Among girls, advanced pubertal stage was associated only with higher odds of alcohol use, and delayed school entry was not associated with substance use. Neither older age for grade or grade retention was independently associated with substance use after controlling for potential confounders. Conclusion Advanced pubertal stage may be a more important risk factor for substance use than age for grade. Pediatricians should consider initiating substance use screening earlier for patients with advanced pubertal stage.
Collapse
Affiliation(s)
- Rebecca N Dudovitz
- Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, 10833 Le Conte Ave, 12-358 CHS, MC: 175217, Los Angeles, CA 90095.
| | - Paul J Chung
- University of California Los Angeles, Los Angeles, California, and RAND Corp, Santa Monica, California
| | | | | | | | | | - Stephen W Banspach
- Division of Adolescent and School Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mark A Schuster
- Division of General Pediatrics, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
83
|
Khan A, Rogers JE, Melvin P, Furtak SL, Faboyede GM, Schuster MA, Landrigan CP. Physician and Nurse Nighttime Communication and Parents' Hospital Experience. Pediatrics 2015; 136:e1249-58. [PMID: 26504131 PMCID: PMC5439977 DOI: 10.1542/peds.2015-2391] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Night teams of hospital providers have become more common in the wake of resident physician duty hour changes. We sought to examine relationships between nighttime communication and parents' inpatient experience. METHODS We conducted a prospective cohort study of parents (n = 471) of pediatric inpatients (0-17 years) from May 2013 to October 2014. Parents rated their overall experience, understanding of the medical plan, quality of nighttime doctors' and nurses' communication with them, and quality of nighttime communication between doctors and nurses. We tested the reliability of each of these 5 constructs (Cronbach's α for each >.8). Using logistic regression models, we examined rates and predictors of top-rated hospital experience. RESULTS Parents completed 398 surveys (84.5% response rate). A total of 42.5% of parents reported a top overall experience construct score. On multivariable analysis, top-rated overall experience scores were associated with higher scores for communication and experience with nighttime doctors (odds ratio [OR] 1.86; 95% confidence interval [CI], 1.12-3.08), for communication and experience with nighttime nurses (OR 6.47; 95% CI, 2.88-14.54), and for nighttime doctor-nurse interaction (OR 2.66; 95% CI, 1.26-5.64) (P < .05 for each). Parents provided the highest percentage of top ratings for the individual item pertaining to whether nurses listened to their concerns (70.5% strongly agreed) and the lowest such ratings for regular communication with nighttime doctors (31.4% excellent). CONCLUSIONS Parent communication with nighttime providers and parents' perceptions of communication and teamwork between these providers may be important drivers of parent experience. As hospitals seek to improve the patient-centeredness of care, improving nighttime communication and teamwork will be valuable to explore.
Collapse
Affiliation(s)
- Alisa Khan
- Division of General Pediatrics, Department of Medicine, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and
| | - Jayne E. Rogers
- Department of Nursing, Boston Children’s Hospital, Boston, Massachusetts
| | - Patrice Melvin
- Center for Patient Safety and Quality Research, Boston Children’s Hospital, Boston, Massachusetts
| | - Stephannie L. Furtak
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - G. Mayowa Faboyede
- Clinical Research Center, Boston Children’s Hospital, Boston, Massachusetts
| | - Mark A. Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Christopher P. Landrigan
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts,Division of Sleep Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| |
Collapse
|
84
|
Abstract
IMPORTANCE Health care systems, payers, and hospitals use hospital readmission rates as a measure of quality. Although hospitals can track readmissions back to themselves (hospital A to hospital A), they lack information when their patients are readmitted to different hospitals (hospital A to hospital B). Because hospitals lack different-hospital readmission (DHR) data, they may underestimate all-hospital readmission (AHR) rates (hospital A to hospital A or B). OBJECTIVES To determine the prevalence of 30-day pediatric DHRs; to assess the effect of DHR on readmission performance; and to identify patient and hospital characteristics associated with DHR. DESIGN, SETTING, AND PARTICIPANTS We analyzed all-payer inpatient claims for 701,263 pediatric discharges (patients aged 0-17 years) from 177 acute care hospitals in New York State from January 1, 2005, through November 30, 2009, to identify 30-day same-hospital readmissions (SHRs), DHRs, and AHRs. Data analysis was performed from March 12, 2013, through April 6, 2015. We compared excess readmission ratios (calculated per the Medicare formula) using SHRs and AHRs to determine what might happen if the federal formula were applied to a specific state and to evaluate how often hospitals might accurately anticipate-using data available to them--whether they would incur penalties (excess readmission ratio >1) for readmissions. Using multivariate logistic regression, we identified patient- and hospital-level predictors of DHR vs SHR. MAIN OUTCOMES AND MEASURES The proportion of DHRs vs SHRs, AHR and SHR rates, and excess readmissions. RESULTS Different-hospital readmissions constituted 13.9% of 31,325 AHRs. At the individual hospital level, the median (interquartile range) percentage of DHRs was 21.6% (12.8%-39.1%). The median (interquartile range) adjusted AHR rate was 3.4% (3.0%-4.1%), 38.9% higher than the median adjusted SHR rate of 2.5% (2.0%-3.4%) (P < .001). Excess readmission ratios using SHRs inaccurately anticipated penalties (changed from >1 to ≤ 1 or vice versa) for 20 of the 177 hospitals (11.3%); all were nonchildren's hospitals and 18 of 20 (90.0%) were nonteaching hospitals. Characteristics associated with higher odds ratios (ORs) (reported with 95% CIs) of DHR in multivariate analyses included being younger (compared with age <1 year, ORs [95% CIs] for the other age categories ranged from 0.76 [0.66-0.88] to 0.85 [0.73-0.99]); being white (ORs [95% CIs] for nonwhite race/ethnicity ranged from 0.74 [0.65-0.84] to 0.88 [0.79-0.99]); having private insurance (1.14 [1.04-1.24]); having a chronic condition indicator for a mental disorder (1.33 [1.13-1.56]) or a disease of the nervous system (1.37 [1.20-1.57]) or circulatory system (1.20 [1.00-1.43]); and admission to a nonchildren's (1.62 [1.01-2.60]), urban (ORs for nonurban hospitals ranged from 0.35 [0.24-0.52] to 0.36 [0.21-0.64]), or lower-volume (0.73 [0.64-0.84]) hospital (P < .05 for each). CONCLUSIONS AND RELEVANCE Different-hospital readmissions differentially affect hospitals' pediatric readmission rates and anticipated performance, making SHRs an incomplete surrogate for AHRs-particularly for certain hospital types. Failing to incorporate DHRs into readmission measurement may impede quality assessment, anticipation of penalties, and quality improvement.
Collapse
Affiliation(s)
- Alisa Khan
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts2Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Mari M. Nakamura
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts2Department of Pediatrics, Harvard Medical School, Boston, Massachusetts3Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts
| | - Alan M. Zaslavsky
- Department of Healthcare Policy, Harvard Medical School, Boston, Massachusetts
| | - Jisun Jang
- Clinical Research Center, Boston Children’s Hospital, Boston, Massachusetts
| | - Jay G. Berry
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts2Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Jeremy Y. Feng
- currently a medical student at Harvard Medical School, Boston, Massachusetts
| | - Mark A. Schuster
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts2Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
85
|
Chien AT, Kuhlthau KA, Toomey SL, Quinn JA, Houtrow AJ, Kuo DZ, Okumura MJ, Van Cleave JM, Johnson CK, Mahoney LL, Martin J, Landrum MB, Schuster MA. Development of the Children With Disabilities Algorithm. Pediatrics 2015; 136:e871-8. [PMID: 26416938 DOI: 10.1542/peds.2015-0228] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND A major impediment to understanding quality of care for children with disabilities (CWD) is the lack of a method for identifying this group in claims databases. We developed the CWD algorithm (CWDA), which uses International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes to identify CWD. METHODS We conducted a cross-sectional study that (1) ensured each of the 14,567 codes within the 2012 ICD-9-CM codebook was independently classified by 3 to 9 pediatricians based on the code's likelihood of indicating CWD and (2) triangulated the resulting CWDA against parent and physician assessment of children's disability status by using survey and chart abstraction, respectively. Eight fellowship-trained general pediatricians and 42 subspecialists from across the United States participated in the code classification. Parents of 128 children from a large, free-standing children's hospital participated in the parent survey; charts of 336 children from the same hospital were included in the abstraction study. RESULTS CWDA contains 669 ICD-9-CM codes classified as having a ≥75% likelihood of indicating CWD. Examples include 318.2 Profound intellectual disabilities and 780.72 Functional quadriplegia. CWDA sensitivity was 0.75 (95% confidence interval 0.63-0.84) compared with parent report and 0.98 (0.95-0.99) compared with physician assessment; its specificity was 0.86 (0.72-0.95) and 0.50 (0.41-0.59), respectively. CONCLUSIONS ICD-9-CM codes can be classified by their likelihood of indicating CWD. CWDA triangulates well with parent report and physician assessment of child disability status. CWDA is a new tool that can be used to assess care quality for CWD.
Collapse
Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; Departments of Pediatrics, and
| | - Karen A Kuhlthau
- Departments of Pediatrics, and Center for Child and Adolescent Health Research and Policy, Department of General Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Sara L Toomey
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; Departments of Pediatrics, and
| | - Jessica A Quinn
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Amy J Houtrow
- Division of Pediatric Rehabilitation Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Dennis Z Kuo
- Department of Pediatrics, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas; and
| | - Megumi J Okumura
- Division of General Pediatrics, Beinoff Children's Hospital, and Department of Pediatrics, Division of General Pediatrics, School of Medicine, University of California San Francisco, San Francisco, California
| | - Jeanne M Van Cleave
- Departments of Pediatrics, and Center for Child and Adolescent Health Research and Policy, Department of General Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Chelsea K Johnson
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Lindsey L Mahoney
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Julia Martin
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | | | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; Departments of Pediatrics, and
| |
Collapse
|
86
|
Affiliation(s)
- Mark A Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Mass.
| |
Collapse
|
87
|
Windle M, Wiesner M, Elliott MN, Wallander JL, Kanouse DE, Schuster MA. The Abbreviated Dimensions of Temperament Survey: Factor Structure and Construct Validity Across Three Racial/Ethnic Groups. J Pers Assess 2015; 97:515-24. [PMID: 25932505 PMCID: PMC4942113 DOI: 10.1080/00223891.2015.1034868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The factor structure, reliability, and construct validity of an abbreviated version of the Revised Dimensions of Temperament Survey (DOTS-R) were evaluated across Black, Hispanic, and White early adolescents. Primary caregivers reported on 5 dimensions of temperament for 4,701 children. Five temperament dimensions were identified via maximum likelihood exploratory factor analysis and were labeled flexibility, general activity level, positive mood, task orientation, and sleep rhythmicity. Multigroup mean and covariance structures analysis provided partial support for strong factorial invariance across these racial/ethnic groups. Mean level comparisons indicated that relative to Hispanics and Blacks, Whites had higher flexibility, greater sleep regularity, and lower activity. They also reported higher positive mood than Blacks. Blacks, relative to Hispanics, had higher flexibility and lower sleep regularity. Construct validity was supported as the 5 temperament dimensions were significantly correlated with externalizing problems and socioemotional competence. This abbreviated version of the DOTS-R could be used across racial/ethnic groups of early adolescents to assess significant dimensions of temperament risk that are associated with mental health and competent (healthy) functioning.
Collapse
Affiliation(s)
- Michael Windle
- Department of Behavioral Sciences and Health Education, Emory University
| | - Margit Wiesner
- Department of Educational Psychology, University of Houston
| | | | | | | | - Mark A. Schuster
- Division of General Pediatrics, Boston Children’s Hospital/Harvard Medical School
| |
Collapse
|
88
|
Hargreaves DS, Elliott MN, Viner RM, Richmond TK, Schuster MA. Unmet Health Care Need in US Adolescents and Adult Health Outcomes. Pediatrics 2015; 136:513-20. [PMID: 26283778 DOI: 10.1542/peds.2015-0237] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/02/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Adolescence is a formative period when health care services have a unique opportunity to influence later health outcomes. Unmet health care need in adolescence is known to be associated with poor contemporaneous health outcomes; it is unknown whether it predicts poor adult health outcomes. METHODS We used nationally representative data from 14 800 subjects who participated in Wave I (mean age: 15.9 years [1994/1995]) and Wave IV (mean age: 29.6 years [2008]) of the National Longitudinal Study of Adolescent to Adult Health. Logistic regression models were used to estimate the association between unmet health care need in adolescence and 5 self-reported measures of adult health (fair/poor general health, functional impairment, time off work/school, depressive symptoms, and suicidal ideation). Models were adjusted for baseline health, insurance category, age, gender, race/ethnicity, household income, and parental education. RESULTS Unmet health care need was reported by 19.2% of adolescents and predicted worse adult health: fair/poor general health (adjusted odds ratio [aOR]: 1.27 [95% confidence interval (CI): 1.00-1.60]); functional impairment (aOR: 1.52 [95% CI: 1.23-1.87]); depressive symptoms (aOR: 1.36 [95% CI: 1.13-1.64]); and suicidal ideation (aOR: 1.30 [95% CI: 1.03-1.68]). There was no significant association between unmet health care need and time off work/school (aOR: 1.13 [95% CI: 0.93-1.36]). Cost barriers accounted for only 14.8% of unmet health care need. The reason for unmet need was not significantly related to the likelihood of poor adult health outcomes. CONCLUSIONS Reported unmet health care need in adolescence is common and is an independent predictor of poor adult health. Strategies to reduce unmet adolescent need should address health engagement and care quality, as well as cost barriers to accessing services.
Collapse
Affiliation(s)
- Dougal S Hargreaves
- Division of General Pediatrics, Department of Medicine, and Population, Policy and Practice Programme, UCL Institute of Child Health, London, United Kingdom;
| | | | - Russell M Viner
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, United Kingdom
| | - Tracy K Richmond
- Division of Adolescent and Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
89
|
Lewis T, Schwebel DC, Elliott MN, Visser SN, Toomey SL, McLaughlin KA, Cuccaro P, Tortolero Emery S, Banspach SW, Schuster MA. The association between youth violence exposure and attention-deficit/hyperactivity disorder (ADHD) symptoms in a sample of fifth-graders. Am J Orthopsychiatry 2015; 85:504-13. [PMID: 26460708 DOI: 10.1037/ort0000081] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The purpose of the current study was to examine the association between violence exposures (no exposure, witness or victim only, and both witness and victim) and attention-deficit/hyperactivity disorder (ADHD) symptoms, as well as the potential moderating role of gender. Data from 4,745 5th graders and their primary caregivers were drawn from the Healthy Passages study of adolescent health. Parent respondents completed the DISC Predictive Scales for ADHD, and youth provided information about exposure to violence. Results indicated that youth who reported both witnessing and victimization had more parent-reported ADHD symptoms and were more likely to meet predictive criteria for ADHD. Among those with both exposures, girls exhibited a steeper increase in ADHD symptoms and higher probability of meeting predictive criteria than did boys. Findings indicate that being both victim-of and witness-to violence is significantly associated with ADHD symptoms particularly among girls.
Collapse
Affiliation(s)
- Terri Lewis
- Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, Department of Pediatrics, University of Colorado, Anschutz Medical Campus, School of Medicine
| | | | | | - Susanna N Visser
- National Center on Birth Defects and Disabilities, Centers for Disease Control and Prevention
| | - Sara L Toomey
- Division of General Pediatrics, Boston Children's Hospital
| | | | - Paula Cuccaro
- School of Public Health, University of Texas Health Science Center at Houston
| | | | - Stephen W Banspach
- National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention
| | | |
Collapse
|
90
|
Sawicki GS, Garvey KC, Toomey SL, Williams KA, Chen Y, Hargraves JL, Leblanc J, Schuster MA, Finkelstein JA. Development and Validation of the Adolescent Assessment of Preparation for Transition: A Novel Patient Experience Measure. J Adolesc Health 2015; 57:282-7. [PMID: 26299555 PMCID: PMC4548278 DOI: 10.1016/j.jadohealth.2015.06.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 06/05/2015] [Accepted: 06/05/2015] [Indexed: 11/17/2022]
Abstract
PURPOSE Significant gaps exist in health care transition (HCT) preparation that can impact care and outcomes in young adults with chronic illness. No quality measure exists to directly assess adolescent experiences of HCT preparation. Our objective was to develop an adolescent-reported measure of the quality of HCT preparation received from pediatric health care providers. METHODS The Adolescent Assessment of Preparation for Transition (ADAPT) is a 26-item mailed survey designed for completion by 16- and 17-year-old adolescents with a chronic health condition. Adolescents from three samples (two large Medicaid insurance plans [n = 3,000 each] and one large tertiary care pediatric hospital [n = 623]) were mailed the survey. An iterative developmental process included focus groups and cognitive interviews, and validity was assessed using confirmatory factor analysis and ordinal reliability coefficients. RESULTS Reliability and validity was evaluated for the following three prespecified composite measures: (1) counseling on transition self-management; (2) counseling on prescription medication; and (3) transfer planning. Across the three samples, all but one measure had good internal consistency (ordinal reliability coefficient ≥ .7). Confirmatory factor analysis using tetrachoric correlation coefficients was stable across samples and supported the construct validity of the first two composite measures. CONCLUSIONS ADAPT is a reliable, validated instrument measuring the quality of HCT preparation experiences reported by adolescents with chronic disease. ADAPT will enable clinical programs and health care delivery systems to assess the quality of HCT preparation and provide targets for improvement in adolescent counseling related to transition.
Collapse
Affiliation(s)
- Gregory S Sawicki
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts; Division of Respiratory Diseases, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
| | - Katharine C Garvey
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Sara L Toomey
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Kathryn A Williams
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts
| | - Yuefan Chen
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - J Lee Hargraves
- Center for Survey Research, University of Massachusetts, Boston, Massachusetts
| | - Jessica Leblanc
- Center for Survey Research, University of Massachusetts, Boston, Massachusetts
| | - Mark A Schuster
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Jonathan A Finkelstein
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
91
|
Berry JG, Zaslavsky AM, Toomey SL, Chien AT, Jang J, Bryant MC, Klein DJ, Kaplan WJ, Schuster MA. Recognizing Differences in Hospital Quality Performance for Pediatric Inpatient Care. Pediatrics 2015; 136:251-62. [PMID: 26169435 PMCID: PMC4516938 DOI: 10.1542/peds.2014-3131] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/28/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Hospital quality-of-care measures are publicly reported to inform consumer choice and stimulate quality improvement. The number of hospitals and states with enough pediatric hospital discharges to detect worse-than-average inpatient care remains unknown. METHODS This study was a retrospective analysis of hospital discharges for children aged 0 to 17 years from 3974 hospitals in 44 states in the 2009 Kids' Inpatient Database. For 11 measures of all-condition or condition-specific quality, we assessed the number of hospitals and states that met a "power standard" of 80% power for a 5% level significance test to detect when care is 20% worse than average over a 3-year period. For this assessment, we approximated volume as 3 times actual 2009 admission volumes. RESULTS For all-condition quality, 1380 hospitals (87% of all pediatric discharges) and all states met the power standard for the family experience-of-care measure; 1958 hospitals (95% of discharges) and all states met the standard for adverse drug events. For condition-specific quality measures of asthma, birth, and mental health, 203 to 482 hospitals (52%-90% of condition-specific discharges) met the power standard and 40 to 44 states met the standard. One hospital and 16 states met the standard for sickle cell disease. No hospital and ≤27 states met the standard for the remaining measures studied (appendectomy, cerebrospinal fluid shunt surgery, gastroenteritis, heart surgery, and seizure). CONCLUSIONS Most children are admitted to hospitals in which all-condition measures of quality have adequate power to show modest differences in performance from average, but most condition-specific measures do not. Policies regarding incentives for pediatric inpatient quality should take these findings into account.
Collapse
Affiliation(s)
- Jay G. Berry
- Division of General Pediatrics, and,Division of General Pediatrics, Department of Medicine, and
| | - Alan M. Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Sara L. Toomey
- Division of General Pediatrics, and,Division of General Pediatrics, Department of Medicine, and
| | - Alyna T. Chien
- Division of General Pediatrics, and,Division of General Pediatrics, Department of Medicine, and
| | - Jisun Jang
- Clinical Research Center, Boston Children’s Hospital, Boston, Massachusetts; and
| | | | | | | | - Mark A. Schuster
- Division of General Pediatrics, and,Division of General Pediatrics, Department of Medicine, and
| |
Collapse
|
92
|
Nelson CP, Routh JC, Logvinenko T, Rosoklija I, Kokorowski PJ, Prosser LA, Schuster MA. Utility scores for vesicoureteral reflux and anti-reflux surgery. J Pediatr Urol 2015; 11:177-82. [PMID: 25975732 PMCID: PMC4540632 DOI: 10.1016/j.jpurol.2015.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 03/17/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Management of vesicoureteral reflux (VUR) continues to be controversial. In conditions of uncertainty, decision analytic techniques such as cost-utility analysis (CUA) can help to structure the decision-making process. However, CUA analyses require a "utility," a value between 0 (death) and 1 (perfect health) corresponding to the quality of life associated with a health state. Ideally, utility values are elicited directly from representative community samples, but utilities have not been rigorously measured for pediatric urology conditions. OBJECTIVES To elicit utility scores for VUR and open anti-reflux surgery (ARS) from a representative, well-characterized community sample of adults who have been parents. METHODS Cross-sectional survey of nationally representative adults who had ever been parents. Each respondent saw one of four descriptions of VUR, with or without continuous antibiotic prophylaxis (CAP) and occurrence of febrile urinary tract infection (UTI). A 6-week postoperative health state following ARS was also assessed. We used the time trade-off (TTO) method to elicit utility scores. Factors associated with utility score were assessed with a multivariate linear regression model. RESULTS The survey was completed by 1200 individuals. Data were weighted to adjust for demographic differences between responders and non-responders. Mean age was 52 ± 15 years, 44% were male, and 68% were White. In terms of education, 29% had a college degree or higher. The mean utility score for VUR overall was 0.82 ± 0.28. VUR utility scores did not differ significantly based on inclusion of CAP or UTI in the health state description (p = 0.21). The 6-week postoperative period garnered a utility of 0.71 ± 0.43. DISCUSSION Our results showed that VUR has a mean utility score of 0.82, which indicates that the community perceives this condition to be a substantial burden. For comparison, conditions with similar utility scores include compensated hepatitis B-related cirrhosis (0.80) and glaucoma (0.82); conditions with higher utilities include neonatal jaundice (0.99) and transient neonatal neurological symptoms (0.95); and conditions with lower utility scores include severe depression (0.43) and major stroke (0.30). Our results suggest that parents consider the burden associated with VUR to be significant, and that the impact of the condition on families and children is substantial. CONCLUSIONS VUR is perceived as having a substantial impact on health-related quality of life, with a utility value of 0.82. However, use of CAP and occurrence of UTI do not seem to affect significantly the community perspective on HRQOL associated with living with VUR.
Collapse
Affiliation(s)
- Caleb P Nelson
- Department of Urology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Division of General Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Jonathan C Routh
- Division of Urology, Duke University Medical Center, Durham, NC, USA
| | - Tanya Logvinenko
- Department of Urology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Clinical Research Center, Boston Children's Hospital, Boston, MA, USA
| | - Ilina Rosoklija
- Department of Urology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Paul J Kokorowski
- Division of Urology, Children's Hospital of Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Lisa A Prosser
- CHEAR Unit, General Pediatrics, University of Michigan Health System, Ann Arbor, MI, USA
| | - Mark A Schuster
- Division of General Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| |
Collapse
|
93
|
Toomey SL, Zaslavsky AM, Elliott MN, Gallagher PM, Fowler FJ, Klein DJ, Shulman S, Ratner J, McGovern C, LeBlanc JL, Schuster MA. The Development of a Pediatric Inpatient Experience of Care Measure: Child HCAHPS. Pediatrics 2015; 136. [PMID: 26195542 PMCID: PMC5036167 DOI: 10.1542/peds.2015-0966] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The Centers for Medicare and Medicaid Services (CMS) uses Adult Hospital Consumer Assessment of Healthcare Providers and Systems (Adult HCAHPS) scores for public reporting and pay-for-performance for most US hospitals, but no publicly available standardized survey of inpatient experience of care exists for pediatrics. To fill the gap, CMS and the Agency for Healthcare Research and Quality commissioned the development of a pediatric version (Child HCAHPS), a survey of parents/guardians of pediatric patients (<18 years old) who were recently hospitalized. This article describes the development of Child HCAHPS, which included an extensive review of the literature and quality measures, expert interviews, focus groups, cognitive testing, pilot testing of the draft survey, a national field test with 69 hospitals in 34 states, psychometric analysis, and end-user testing of the final survey. We conducted extensive validity and reliability testing to determine which items would be included in the final survey instrument and develop composite measures. We analyzed national field test data of 17,727 surveys collected in November 2012 to January 2014 from parents of recently hospitalized children. The final Child HCAHPS instrument has 62 items, including 39 patient experience items, 10 screeners, 12 demographic/descriptive items, and 1 open-ended item. The 39 experience items are categorized based on testing into 18 composite and single-item measures. Our composite and single-item measures demonstrated good to excellent hospital-level reliability at 300 responses per hospital. Child HCAHPS was developed to be a publicly available standardized survey of pediatric inpatient experience of care. It can be used to benchmark pediatric inpatient experience across hospitals and assist in efforts to improve the quality of inpatient care.
Collapse
Affiliation(s)
- Sara L. Toomey
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts;,Harvard Medical School, Boston, Massachusetts;,Address correspondence Sara L. Toomey, MD, MPhil, MPH, MSc, Division of General Pediatrics, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail:
| | - Alan M. Zaslavsky
- Harvard Medical School, Boston, Massachusetts;,Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | | | | | - Floyd J. Fowler
- Center for Survey Research, University of Massachusetts Boston, Massachusetts
| | - David J. Klein
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Shanna Shulman
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Jessica Ratner
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Caitriona McGovern
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts;,Harvard Medical School, Boston, Massachusetts
| | - Jessica L. LeBlanc
- Center for Survey Research, University of Massachusetts Boston, Massachusetts
| | - Mark A. Schuster
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts;,Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
94
|
Wisk LE, Finkelstein JA, Sawicki GS, Lakoma M, Toomey SL, Schuster MA, Galbraith AA. Predictors of timing of transfer from pediatric- to adult-focused primary care. JAMA Pediatr 2015; 169:e150951. [PMID: 26030515 PMCID: PMC4862601 DOI: 10.1001/jamapediatrics.2015.0951] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE A timely, well-coordinated transfer from pediatric- to adult-focused primary care is an important component of high-quality health care, especially for youths with chronic health conditions. Current recommendations suggest that primary-care transfers for youths occur between 18 and 21 years of age. However, the current epidemiology of transfer timing is unknown. OBJECTIVE To examine the timing of transfer to adult-focused primary care providers (PCPs), the time between last pediatric-focused and first adult-focused PCP visits, and the predictors of transfer timing. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of patients insured by Harvard Pilgrim Health Care (HPHC), a large not-for-profit health plan. Our sample included 60 233 adolescents who were continuously enrolled in HPHC from 16 to at least 18 years of age between January 2000 and December 2012. Pediatric-focused PCPs were identified by the following provider specialty types, but no others: pediatrics, adolescent medicine, or pediatric nurse practitioner. Adult-focused PCPs were identified by having any provider type that sees adult patients. Providers with any specialty provider designation (eg, gastroenterology or gynecology) were not considered PCPs. MAIN OUTCOMES AND MEASURES We used multivariable Cox proportional hazards regression to model age at first adult-focused PCP visit and time from the last pediatric-focused to the first adult-focused PCP visit (gap) for any type of office visit and for those that were preventive visits. RESULTS Younger age at transfer was observed for female youths (hazard ratio [HR], 1.32 [95% CI, 1.29-1.36]) who had complex (HR, 1.06 [95% CI, 1.01-1.11]) or noncomplex (HR, 1.08 [95% CI, 1.05-1.12]) chronic conditions compared with those who had no chronic conditions. Transfer occurred at older ages for youths who lived in lower-income neighborhoods compared with those who lived in higher-income neighborhoods (HR, 0.89 [95% CI, 0.83-0.95]). The gap between last pediatric-focused to first adult-focused PCP visit was shorter for female youths than male youths (HR, 1.57 [95% CI, 1.53-1.61]) and youths with complex (HR, 1.35 [95% CI, 1.28-1.41]) or noncomplex (HR, 1.24 [95% CI, 1.20-1.28]) chronic conditions. The gap was longer for youths living in lower-income neighborhoods than for those living in higher-income neighborhoods (HR, 0.80 [95% CI, 0.75-0.85]). Multivariable models showed an adjusted median age at transfer of 21.8 years for office visits and 23.1 years for preventive visits and an adjusted median gap length of 20.5 months for office visits and 41.6 months for preventive visits. CONCLUSIONS AND RELEVANCE Most youths are transferring care later than recommended and with gaps of more than a year. While youths with chronic conditions have shorter gaps, they may need even shorter transfer intervals to ensure continuous access to care. More work is needed to determine whether youths are experiencing clinically important lapses in care or other negative health effects due to the delayed timing of transfer.
Collapse
Affiliation(s)
- Lauren E. Wisk
- Center for Child Health Care Studies, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts2Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Ma
| | - Jonathan A. Finkelstein
- Center for Child Health Care Studies, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts2Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Ma
| | - Gregory S. Sawicki
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts3Department of Pediatrics, Harvard Medical School, Boston, Massachusetts4Division of Pulmonary and Respiratory Diseases, Boston Children’s Hospital, B
| | - Matthew Lakoma
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Sara L. Toomey
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts3Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Mark A. Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts3Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Alison A. Galbraith
- Center for Child Health Care Studies, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts2Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Ma
| |
Collapse
|
95
|
Stockwell DC, Bisarya H, Classen DC, Kirkendall ES, Landrigan CP, Lemon V, Tham E, Hyman D, Lehman SM, Searles E, Hall M, Muething SE, Schuster MA, Sharek PJ. A trigger tool to detect harm in pediatric inpatient settings. Pediatrics 2015; 135:1036-42. [PMID: 25986015 DOI: 10.1542/peds.2014-2152] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES An efficient and reliable process for measuring harm due to medical care is needed to advance pediatric patient safety. Several pediatric studies have assessed the use of trigger tools in varying inpatient environments. Using the Institute for Healthcare Improvement's adult-focused Global Trigger Tool as a model, we developed and pilot tested a trigger tool that would identify the most common causes of harm in pediatric inpatient environments. METHODS After formal training, 6 academic children's hospitals used this novel pediatric trigger tool to review 100 randomly selected inpatient records per site from patients discharged during the month of February 2012. RESULTS From the 600 patient charts evaluated, 240 harmful events ("harms") were identified, resulting in a rate of 40 harms per 100 patients admitted and 54.9 harms per 1000 patient days across the 6 hospitals. At least 1 harm was identified in 146 patients (24.3% of patients). Of the 240 total events, 108 (45.0%) were assessed to have been potentially or definitely preventable. The most common patient harms were intravenous catheter infiltrations/burns, respiratory distress, constipation, pain, and surgical complications. CONCLUSIONS Consistent with earlier rates of all-cause harm in adult hospitals, harm occurs at high rates in hospitalized children. Availability and use of an all-cause harm identification tool will establish the epidemiology of harm and will provide a consistent approach to assessing the effect of interventions on harms in hospitalized children.
Collapse
Affiliation(s)
- David C Stockwell
- Division of Critical Care Medicine, Department of Pediatrics, School of Medicine, The George Washington University, Washington, District of Columbia; Center for Quality and Improvement Science, Children's National Medical Center, Washington, District of Columbia;
| | | | - David C Classen
- Department of Infectious Disease, School of Medicine, University of Utah, Salt Lake City, Utah; Chief Medical Information Officer, Pascal Metrics, Washington, District of Columbia
| | - Eric S Kirkendall
- Division of Biomedical Informatics, Division of Hospital Medicine, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio; James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Christopher P Landrigan
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Valere Lemon
- Departments of Performance Improvement, Children's National Health System, Washington, District of Columbia
| | - Eric Tham
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Research Institute and
| | - Daniel Hyman
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Department of Quality and Patient Safety, Children's Hospital Colorado, Aurora, Colorado
| | | | - Elizabeth Searles
- Department of Quality, Children's Hospital Central California, Madera, California
| | - Matt Hall
- Division of Analytics, Children's Hospital Association, Overland Park, Kansas
| | - Stephen E Muething
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Paul J Sharek
- Division of Hospitalist Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California; and Center for Quality and Clinical Effectiveness, Lucile Packard Children's Hospital, Palo Alto, California
| |
Collapse
|
96
|
|
97
|
Affiliation(s)
- Mark A Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
98
|
Wiesner M, Windle M, Kanouse DE, Elliott MN, Schuster MA. DISC Predictive Scales (DPS): Factor structure and uniform differential item functioning across gender and three racial/ethnic groups for ADHD, conduct disorder, and oppositional defiant disorder symptoms. Psychol Assess 2015; 27:1324-36. [PMID: 25774639 DOI: 10.1037/pas0000101] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The factor structure and potential uniform differential item functioning (DIF) among gender and three racial/ethnic groups of adolescents (African American, Latino, White) were evaluated for attention deficit/hyperactivity disorder (ADHD), conduct disorder (CD), and oppositional defiant disorder (ODD) symptom scores of the DISC Predictive Scales (DPS; Leung et al., 2005; Lucas et al., 2001). Primary caregivers reported on DSM-IV ADHD, CD, and ODD symptoms for a probability sample of 4,491 children from three geographical regions who took part in the Healthy Passages study (mean age = 12.60 years, SD = 0.66). Confirmatory factor analysis indicated that the expected 3-factor structure was tenable for the data. Multiple indicators multiple causes (MIMIC) modeling revealed uniform DIF for three ADHD and 9 ODD item scores, but not for any of the CD item scores. Uniform DIF was observed predominantly as a function of child race/ethnicity, but minimally as a function of child gender. On the positive side, uniform DIF had little impact on latent mean differences of ADHD, CD, and ODD symptomatology among gender and racial/ethnic groups. Implications of the findings for researchers and practitioners are discussed.
Collapse
Affiliation(s)
- Margit Wiesner
- Department of Educational Psychology, University of Houston
| | - Michael Windle
- Department of Behavioral Sciences and Health Education, Emory University
| | | | | | - Mark A Schuster
- Division of General Pediatrics, Boston Children's Hospital/ Harvard Medical School
| |
Collapse
|
99
|
Coker TR, Elliott MN, Schwebel DC, Windle M, Toomey SL, Tortolero SR, Hertz MF, Peskin MF, Schuster MA. Media violence exposure and physical aggression in fifth-grade children. Acad Pediatr 2015; 15:82-8. [PMID: 25441652 PMCID: PMC10683669 DOI: 10.1016/j.acap.2014.09.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 09/09/2014] [Accepted: 09/12/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To examine the association of media violence exposure and physical aggression in fifth graders across 3 media types. METHODS We analyzed data from a population-based, cross-sectional survey of 5,147 fifth graders and their parents in 3 US metropolitan areas. We used multivariable linear regression and report partial correlation coefficients to examine associations between children's exposure to violence in television/film, video games, and music (reported time spent consuming media and reported frequency of violent content: physical fighting, hurting, shooting, or killing) and the Problem Behavior Frequency Scale. RESULTS Child-reported media violence exposure was associated with physical aggression after multivariable adjustment for sociodemographics, family and community violence, and child mental health symptoms (partial correlation coefficients: TV, 0.17; video games, 0.15; music, 0.14). This association was significant and independent for television, video games, and music violence exposure in a model including all 3 media types (partial correlation coefficients: TV, 0.11; video games, 0.09; music, 0.09). There was a significant positive interaction between media time and media violence for video games and music but not for television. Effect sizes for the association of media violence exposure and physical aggression were greater in magnitude than for most of the other examined variables. CONCLUSIONS The association between physical aggression and media violence exposure is robust and persistent; the strength of this association of media violence may be at least as important as that of other factors with physical aggression in children, such as neighborhood violence, home violence, child mental health, and male gender.
Collapse
Affiliation(s)
- Tumaini R Coker
- Department of Pediatrics, Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, Calif; RAND, Santa Monica, Calif.
| | | | - David C Schwebel
- Department of Psychology, University of Alabama at Birmingham, Birmingham, Ala
| | - Michael Windle
- Department of Behavioral Sciences and Health Education, Emory University, Atlanta, Ga
| | - Sara L Toomey
- Division of General Pediatrics, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Susan R Tortolero
- Center for Health Promotion and Prevention Research, University of Texas-Houston, School of Public Health, Houston, Tex
| | - Marci F Hertz
- Centers for Disease Control and Prevention, Atlanta, Ga
| | - Melissa F Peskin
- Center for Health Promotion and Prevention Research, University of Texas-Houston, School of Public Health, Houston, Tex
| | - Mark A Schuster
- Division of General Pediatrics, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| |
Collapse
|
100
|
Fields EL, Bogart LM, Smith KC, Malebranche DJ, Ellen J, Schuster MA. "I Always Felt I Had to Prove My Manhood": Homosexuality, Masculinity, Gender Role Strain, and HIV Risk Among Young Black Men Who Have Sex With Men. Am J Public Health 2015; 105:122-131. [PMID: 24832150 DOI: 10.2105/ajph.2013.301866] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. We explored gender role strain (GRS) arising from conflict between homosexuality and cultural conceptions of masculinity among young Black men who have sex with men (MSM). Methods. We conducted a categorical analysis (a qualitative, 3-stage, iterative analysis) of data from studies conducted in 2001 to 2006, which interviewed 35 men aged 18 to 24 years in 3 New York cities and Atlanta, Georgia. Results. Participants described rigid, often antihomosexual expectations of masculinity from their families, peers, and communities. Consistent with GRS, this conflict and pressure to conform to these expectations despite their homosexuality led to psychological distress, efforts to camouflage their homosexuality, and strategies to prove their masculinity. Participants believed this conflict and the associated experience of GRS might increase HIV risk through social isolation, poor self-esteem, reduced access to HIV prevention messages, and limited parental-family involvement in sexuality development and early sexual decision-making. Conclusions. Antihomosexual expectations of masculinity isolate young Black MSM during a developmental stage when interpersonal attachments are critical. GRS may influence sexual risk behavior and HIV risk and be an important target for HIV prevention.
Collapse
Affiliation(s)
- Errol Lamont Fields
- Errol L. Fields and Jonathan Ellen are with the Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, School of Medicine, and Katherine C. Smith is with the Department of Health Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Laura M. Bogart and Mark A. Schuster are with the Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, and the Department of Pediatrics, Harvard Medical School, Boston, MA. David J. Malebranche is with Student Health Services, University of Pennsylvania, Philadelphia
| | | | | | | | | | | |
Collapse
|