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Rea CJ, Toomey SL, Hauptman M, Rosen M, Samuels RC, Karpowicz K, Flanagan S, Shah SN. Predictors of Subspecialty Appointment Scheduling and Completion for Patients Referred From a Pediatric Primary Care Clinic. Clin Pediatr (Phila) 2024; 63:512-521. [PMID: 37309813 PMCID: PMC10863332 DOI: 10.1177/00099228231179673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Failure to complete subspecialty referrals decreases access to subspecialty care and may endanger patient safety. We conducted a retrospective analysis of new patient referrals made to the 14 most common referral departments at Boston Children's Hospital from January 1 to December 31, 2017. The sample included 2031 patient referrals. The mean wait time between referral and appointment date was 39.6 days. In all, 87% of referrals were scheduled and 84% of scheduled appointments attended, thus 73% of the original referrals were completed. In multivariate analysis, younger age, medical complexity, being a non-English speaker, and referral to a surgical subspecialty were associated with a higher likelihood of referral completion. Black and Hispanic/Latino race/ethnicity, living in a Census tract with Social Vulnerability Index (SVI) ≥ 90th percentile, and longer wait times were associated with a lower likelihood of appointment attendance. Future interventions should consider both health care system factors such as appointment wait times and community-level barriers to referral completion.
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Affiliation(s)
- Corinna J. Rea
- Division of General Pediatrics, Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sara L. Toomey
- Division of General Pediatrics, Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Marissa Hauptman
- Division of General Pediatrics, Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Melissa Rosen
- Division of General Pediatrics, Boston Children’s Hospital, Boston, MA, USA
| | - Ronald C. Samuels
- Division of General Pediatrics, Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of General Pediatrics, The Children’s Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Kristin Karpowicz
- Division of General Pediatrics, Boston Children’s Hospital, Boston, MA, USA
| | - Shelby Flanagan
- Division of General Pediatrics, Boston Children’s Hospital, Boston, MA, USA
| | - Snehal N. Shah
- Division of General Pediatrics, Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Warren PW, Beck AF, Zang H, Anderson J, Statile C. Inequitable access: factors associated with incomplete referrals to paediatric cardiology. Cardiol Young 2024; 34:428-435. [PMID: 35848164 DOI: 10.1017/s1047951122002037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To assess the variables associated with incomplete and unscheduled cardiology clinic visits among referred children with a focus on equity gaps. STUDY DESIGN We conducted a retrospective chart review for patients less than 18 years of age who were referred to cardiology clinics at a single quaternary referral centre from 2017 to 2019. We collected patient demographic data including race, an index of neighbourhood socio-economic deprivation linked to a patient's geocoded address, referral information, and cardiology clinic information. The primary outcome was an incomplete clinic visit. The secondary outcome was an unscheduled appointment. Independent associations were identified using multivariable logistic regression. RESULTS There were 10,610 new referrals; 6954 (66%) completed new cardiology clinic visits. Black race (OR 1.41; 95% CI 1.22-1.63), public insurance (OR 1.29; 95% CI 1.14-1.46), and a higher deprivation index (OR 1.32; 95% CI 1.08-1.61) were associated with higher odds of incomplete visit compared to the respective reference groups of White race, private insurance, and a lower deprivation index. The findings for unscheduled visit were similar. A shorter time elapsed from the initial referral to when the appointment was made was associated with lower odds of incomplete visit (OR 0.62; 95% CI 0.52-0.74). CONCLUSION Race, insurance type, neighbourhood deprivation, and time from referral date to appointment made were each associated with incomplete referrals to paediatric cardiology. Interventions directed to understand such associations and respond accordingly could help to equitably improve referral completion.
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Affiliation(s)
- Paul W Warren
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229, USA
| | - Andrew F Beck
- General and Community Pediatrics and Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Huaiyu Zang
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Jeffrey Anderson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Christopher Statile
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
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Alfonso AR, Park JJ, Kalra A, DeMitchell-Rodriguez EM, Kussie HC, Shen C, Staffenberg DA, Flores RL, Shetye PR. The Burden of Care of Nasoalveolar Molding: An Institutional Experience. J Craniofac Surg 2024:00001665-990000000-01282. [PMID: 38231199 DOI: 10.1097/scs.0000000000009960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 12/02/2023] [Indexed: 01/18/2024] Open
Abstract
Nasoalveolar molding (NAM) is an early presurgical intervention to facilitate primary cleft lip repair by reducing cleft severity and improving labial and nasal form. However, it continues to be associated with the burden of care that influences access and completion of therapy. The authors, therefore, aim to determine the burden of care of NAM therapy for families seeking treatment at a high-volume urban cleft center. A retrospective study of all patients undergoing primary cleft repair between 2012 and 2020 was performed. Patients were grouped based on whether or not NAM therapy was offered. Variables including physical, psychosocial, and financial factors were assessed. Two hundred and thirty patients underwent primary cleft repair between 2012 and 2020. Of these, 176 patients were indicated for NAM, with 4% discontinuing, and 54 patients did not undergo NAM. The 169 patients who completed NAM had a mean duration of treatment of 13.6±8.8 wks consisting of 15±6 scheduled NAM adjustment visits and 1±1 unscheduled visit made urgently to assess caregiver concerns. The mean travel distance was 28.6±37.1 miles. Eighty-four percent of caregivers were married, and 16% did not have English as a primary language. Though 57% had private insurance, 43% of patients received charity support for their treatment. NAM is a finite presurgical intervention that requires caregivers to participate in patient care for approximately three months of their early life. The decision to pursue NAM should be considered alongside the burden of care for caregivers to complete treatment.
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Affiliation(s)
- Allyson R Alfonso
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY
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Aydin S, Crone MR, Siebelink BM, Numans ME, Vermeiren RRJM, Westenberg PM. Informative value of referral letters from general practice for child and adolescent mental healthcare. Eur Child Adolesc Psychiatry 2023; 32:303-315. [PMID: 34417876 PMCID: PMC9970945 DOI: 10.1007/s00787-021-01859-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 08/08/2021] [Indexed: 11/29/2022]
Abstract
Although referral letters (RLs) form a nodal point in a patient's care journey, little is known about their informative value in child and adolescent mental healthcare. To determine the informative value of RLs to child and adolescent psychiatry, we conducted a chart review in medical records of minors registered at specialized mental healthcare between January 2015 and December 2017 (The Netherlands). Symptoms indicated in RLs originating from general practice (N = 723) were coded and cross-tabulated with the best estimate clinical classifications made in psychiatry. Results revealed that over half of the minors in the sample were classified in concordance with at least one reason for referral. We found fair to excellent discriminative ability for indications made in RLs concerning the most common psychiatric classifications (95% CI AUC: 60.9-70.6 for anxiety disorders to 90.5-100.0 for eating disorders). Logistic regression analyses suggested no statistically significant effects of gender, age, severity or mental healthcare history, with the exception of age and attention deficit hyperactivity disorders (ADHD), as RLs better predicted ADHD with increasing age (OR = 1.14, 95% CI 1.03-1.27). Contextual problems, such as difficulties studying, problems with parents or being bullied were indicated frequently and associated with classifications in various disorder groups. To conclude, general practitioners' RLs showed informative value, contrary to common beliefs. Replication studies are needed to reliably incorporate RLs into the diagnostic work-up.
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Affiliation(s)
- S Aydin
- Department of Developmental and Educational Psychology, Leiden University, Wassenaarseweg 52, 2333 AK, Leiden, The Netherlands.
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands.
- Department of Child and Adolescent Psychiatry, LUMC Curium, Leiden University Medical Centre, Oegstgeest, The Netherlands.
| | - M R Crone
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - B M Siebelink
- Department of Child and Adolescent Psychiatry, LUMC Curium, Leiden University Medical Centre, Oegstgeest, The Netherlands
| | - M E Numans
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - R R J M Vermeiren
- Department of Child and Adolescent Psychiatry, LUMC Curium, Leiden University Medical Centre, Oegstgeest, The Netherlands
- Youz, Parnassia Group, Rotterdam, The Netherlands
| | - P M Westenberg
- Department of Developmental and Educational Psychology, Leiden University, Wassenaarseweg 52, 2333 AK, Leiden, The Netherlands
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Fisher AP, Lynch JD, Jacquez FM, Mitchell MJ, Kamimura-Nishimura KI, Wade SL. A systematic review examining caregivers’ of color experiences with the diagnostic process of autism spectrum disorder. AUTISM : THE INTERNATIONAL JOURNAL OF RESEARCH AND PRACTICE 2022; 27:876-889. [PMID: 36321366 DOI: 10.1177/13623613221128171] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
There are racial/ethnic disparities in the diagnosis of autism spectrum disorder, including delayed diagnosis, discrimination, and a lack of culturally responsive care. The perspectives of caregivers of color are critical in improving delivery of equitable care. We systematically reviewed articles pertaining to experiences with the diagnostic process among caregivers of color. We entered key terms into five databases to identify literature from 2000 to 2021. Fifteen qualitative studies met inclusion criteria, representing 253 caregivers. We used inductive methods to examine themes across racial and ethnic groups and assessed the quality of included studies. Families of color identified multiple factors that negatively affected the diagnostic process. Systems-level factors included long wait lists and financial concerns. Provider-level factors included minimization of caregiver concerns, a “wait and see” approach, biases, and lack of knowledge. Caregivers also described individual (e.g. knowledge) and family factors (e.g. stigma) that delayed diagnosis and complicated the diagnostic process. Communication barriers were commonly reported, which impeded understanding of autism spectrum disorder. Some families described providers, other individuals, community networks, and self-advocacy as facilitators. Interventions targeting systems- (e.g. Medicaid expansion) and provider-level (e.g. increase training in autism spectrum disorder) factors are needed to increase equity in the autism spectrum disorder diagnostic process. Lay abstract Children of color are diagnosed with autism later than White children. Caregivers of color are also more likely than White caregivers to report that their child’s healthcare providers do not treat them as a partner, spend enough time with them, or respect their culture and values. We wanted to better understand the experiences of caregivers of color with the diagnostic process of autism spectrum disorder, from the time they discuss developmental concerns with their child’s primary care provider to when the diagnosis is shared with them. We systematically reviewed the literature and found 15 articles that explored the experiences of caregivers of color. Caregivers of color described that they faced large-scale barriers, such as the cost of appointments, transportation, and long wait lists. They also reported negative experiences with providers, including providers not taking their concerns seriously, making assumptions about caregivers, and delaying referrals for an evaluation. Caregivers stated that their own lack of knowledge of autism spectrum disorder, stigma, their family’s thoughts and opinions, and cultural differences between providers and caregivers served as barriers during the diagnostic process. Communication challenges were discussed and included use of medical and technical jargon, a lack of follow-up, language barriers, and difficulty obtaining high-quality interpreters. Some families described providers, other individuals, community networks, and self-advocacy as helpful during the diagnostic process. Large-scale changes are needed, such as increases in the number of providers who are trained in diagnosing Autism. Provider-level changes (e.g. implicit bias training) are also important for improving caregivers’ experiences.
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Affiliation(s)
- Allison P Fisher
- Cincinnati Children’s Hospital Medical Center, USA
- University of Cincinnati, USA
| | - James D Lynch
- Cincinnati Children’s Hospital Medical Center, USA
- University of Cincinnati, USA
| | | | - Monica J Mitchell
- Cincinnati Children’s Hospital Medical Center, USA
- University of Cincinnati College of Medicine, USA
| | | | - Shari L Wade
- Cincinnati Children’s Hospital Medical Center, USA
- University of Cincinnati College of Medicine, USA
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Cahan EM, Maturi J, Bailey P, Fernandes S, Addala A, Kibrom S, Krissberg JR, Smith SM, Shah S, Wang E, Saynina O, Wise PH, Chamberlain LJ. The Impact of Telehealth Adoption During COVID-19 Pandemic on Patterns of Pediatric Subspecialty Care Utilization. Acad Pediatr 2022; 22:1375-1383. [PMID: 35318159 PMCID: PMC8933868 DOI: 10.1016/j.acap.2022.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 03/13/2022] [Accepted: 03/16/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The COVID-19 pandemic prompted health systems to rapidly adopt telehealth for clinical care. We examined the impact of demography, subspecialty characteristics, and broadband availability on the utilization of telehealth in pediatric populations before and after the early period of the COVID-19 pandemic. METHODS Outpatients scheduled for subspecialty visits at sites affiliated with a single quaternary academic medical center between March-June 2019 and March-June 2020 were included. The contribution of demographic, socioeconomic, and broadband availability to visit completion and telehealth utilization were examined in multivariable regression analyses. RESULTS Among visits scheduled in 2020 compared to 2019, in-person visits fell from 23,318 to 11,209, while telehealth visits increased from 150 to 7,675. Visits among established patients fell by 15% and new patients by 36% (P < .0001). Multivariable analysis revealed that completed visits were reduced for Hispanic patients and those with reduced broadband; high income, private non-HMO insurance, and those requesting an interpreter were more likely to complete visits. Those with visits scheduled in 2020, established patients, those with reduced broadband, and patients older than 1 year were more likely to complete TH appointments. Cardiology, oncology, and pulmonology patients were less likely to complete scheduled TH appointments. CONCLUSIONS Following COVID-19 onset, outpatient pediatric subspecialty visits shifted rapidly to telehealth. However, the impact of this shift on social disparities in outpatient utilization was mixed with variation among subspecialties. A growing reliance on telehealth will necessitate insights from other healthcare settings serving populations of diverse social and technological character.
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Affiliation(s)
- Eli M. Cahan
- Department of Pediatrics (EM Cahan, J Maturi, P Bailey, S Fernandes, A Addala, S Kibrom, JR Krissberg, SM Smith, S Shah, E Wang, PH Wise, and LJ Chamberlain), Stanford School of Medicine, Stanford, Calif,New York University School of Medicine (EM Cahan), New York, NY,Address correspondence to Eli M. Cahan, MS, Department of Pediatrics, Stanford School of Medicine, 770 Welch Road, #100, Stanford, CA 94305
| | - Jay Maturi
- Department of Pediatrics (EM Cahan, J Maturi, P Bailey, S Fernandes, A Addala, S Kibrom, JR Krissberg, SM Smith, S Shah, E Wang, PH Wise, and LJ Chamberlain), Stanford School of Medicine, Stanford, Calif
| | - Paige Bailey
- Department of Pediatrics (EM Cahan, J Maturi, P Bailey, S Fernandes, A Addala, S Kibrom, JR Krissberg, SM Smith, S Shah, E Wang, PH Wise, and LJ Chamberlain), Stanford School of Medicine, Stanford, Calif
| | - Susan Fernandes
- Department of Pediatrics (EM Cahan, J Maturi, P Bailey, S Fernandes, A Addala, S Kibrom, JR Krissberg, SM Smith, S Shah, E Wang, PH Wise, and LJ Chamberlain), Stanford School of Medicine, Stanford, Calif,Department of Medicine (S Fernandes), Stanford School of Medicine, Stanford, Calif
| | - Ananta Addala
- Department of Pediatrics (EM Cahan, J Maturi, P Bailey, S Fernandes, A Addala, S Kibrom, JR Krissberg, SM Smith, S Shah, E Wang, PH Wise, and LJ Chamberlain), Stanford School of Medicine, Stanford, Calif
| | - Sara Kibrom
- Department of Pediatrics (EM Cahan, J Maturi, P Bailey, S Fernandes, A Addala, S Kibrom, JR Krissberg, SM Smith, S Shah, E Wang, PH Wise, and LJ Chamberlain), Stanford School of Medicine, Stanford, Calif
| | - Jill R. Krissberg
- Department of Pediatrics (EM Cahan, J Maturi, P Bailey, S Fernandes, A Addala, S Kibrom, JR Krissberg, SM Smith, S Shah, E Wang, PH Wise, and LJ Chamberlain), Stanford School of Medicine, Stanford, Calif
| | - Stephanie M. Smith
- Department of Pediatrics (EM Cahan, J Maturi, P Bailey, S Fernandes, A Addala, S Kibrom, JR Krissberg, SM Smith, S Shah, E Wang, PH Wise, and LJ Chamberlain), Stanford School of Medicine, Stanford, Calif
| | - Sejal Shah
- Department of Pediatrics (EM Cahan, J Maturi, P Bailey, S Fernandes, A Addala, S Kibrom, JR Krissberg, SM Smith, S Shah, E Wang, PH Wise, and LJ Chamberlain), Stanford School of Medicine, Stanford, Calif
| | - Ewen Wang
- Department of Pediatrics (EM Cahan, J Maturi, P Bailey, S Fernandes, A Addala, S Kibrom, JR Krissberg, SM Smith, S Shah, E Wang, PH Wise, and LJ Chamberlain), Stanford School of Medicine, Stanford, Calif,Center for Policy, Outcomes, and Prevention (E Wang, O Saynina, PH Wise, and LJ Chamberlain), Stanford School of Medicine, Stanford, Calif,Department of Emergency Medicine (E Wang), Stanford School of Medicine, Stanford, Calif
| | - Olga Saynina
- Center for Policy, Outcomes, and Prevention (E Wang, O Saynina, PH Wise, and LJ Chamberlain), Stanford School of Medicine, Stanford, Calif
| | - Paul H. Wise
- Department of Pediatrics (EM Cahan, J Maturi, P Bailey, S Fernandes, A Addala, S Kibrom, JR Krissberg, SM Smith, S Shah, E Wang, PH Wise, and LJ Chamberlain), Stanford School of Medicine, Stanford, Calif,Center for Policy, Outcomes, and Prevention (E Wang, O Saynina, PH Wise, and LJ Chamberlain), Stanford School of Medicine, Stanford, Calif
| | - Lisa J. Chamberlain
- Department of Pediatrics (EM Cahan, J Maturi, P Bailey, S Fernandes, A Addala, S Kibrom, JR Krissberg, SM Smith, S Shah, E Wang, PH Wise, and LJ Chamberlain), Stanford School of Medicine, Stanford, Calif,Center for Policy, Outcomes, and Prevention (E Wang, O Saynina, PH Wise, and LJ Chamberlain), Stanford School of Medicine, Stanford, Calif
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Cama S, Knee A, Sarvet B. Impact of Child Psychiatry Access Programs on Mental Health Care in Pediatric Primary Care: Measuring the Parent Experience. Psychiatr Serv 2020; 71:43-48. [PMID: 31551042 DOI: 10.1176/appi.ps.201800324] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study aimed to assess parents' satisfaction with the primary care provider (PCP) in the treatment of their child's mental health problems after the PCP consulted with the Massachusetts Child Psychiatry Access Program (MCPAP). It studied how parental satisfaction may vary across factors, including service utilization, parental perception of the child's illness, and parental perception of certain PCP attributes. METHODS The study analyzed 374 telephone consultations made from PCPs to MCPAP between March 2010 and June 2012. Questions in a structured telephone survey administered to parents identified the types of services participants were referred to and assessed satisfaction rates on the basis of measures reflective of the patient-doctor relationship and of illness factors. RESULTS Eighty-six percent of participants expressed satisfaction with their PCP's handling of their child's mental health problems after MCPAP consultation. Participants who agreed with statements reflective of a positive patient-doctor relationship (in terms of the PCP's empathy and knowledge) exhibited higher rates of satisfaction with the PCP's role in the treatment of their child's mental health problems than those who did not agree. The most common recommendations made to families after consultation were to follow up with the child's PCP (94%) and to obtain further MCPAP consultation (78%). CONCLUSIONS The survey results indicated high rates of parents' satisfaction with the PCP's handling of their child's mental health issues. Recommendations made to PCPs by MCPAP consultants aimed to strengthen the PCP's role as a mental health provider.
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Affiliation(s)
- Shireen Cama
- Department of Psychiatry, Harvard Medical School and Cambridge Health Alliance, Cambridge, Massachusetts (Cama); Department of Medicine (Knee) and Department of Psychiatry (Sarvet), University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
| | - Alexander Knee
- Department of Psychiatry, Harvard Medical School and Cambridge Health Alliance, Cambridge, Massachusetts (Cama); Department of Medicine (Knee) and Department of Psychiatry (Sarvet), University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
| | - Barry Sarvet
- Department of Psychiatry, Harvard Medical School and Cambridge Health Alliance, Cambridge, Massachusetts (Cama); Department of Medicine (Knee) and Department of Psychiatry (Sarvet), University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
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Lakshmanan A, Kubicek K, Williams R, Robles M, Vanderbilt DL, Mirzaian CB, Friedlich PS, Kipke M. Viewpoints from families for improving transition from NICU-to-home for infants with medical complexity at a safety net hospital: a qualitative study. BMC Pediatr 2019; 19:223. [PMID: 31277630 PMCID: PMC6610911 DOI: 10.1186/s12887-019-1604-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 06/27/2019] [Indexed: 12/31/2022] Open
Abstract
Background We have limited information on families’ experiences during transition and after discharge from the neonatal intensive care unit. Methods Open-ended semi-structured interviews were conducted with English or Spanish- speaking families enrolled in Medicaid in an urban high-risk infant follow up clinic at a safety-net center, which serves preterm and high-risk term infants. We generated salient themes using inductive-deductive thematic analysis. Results Twenty-one participants completed the study. The infant’s median (IQR) birth weight was 1750 (1305, 2641) grams; 71% were Hispanic and 10% were Black non-Hispanic; 62% reported living in a neighborhood with 3-4th quartile economic hardship. All were classified as having chronic disease per the Pediatric Medical Complexity Algorithm and 67% had medical complexity. A conceptual model was constructed and the analysis revealed major themes describing families’ challenges and ideas to support transition centered on the parent-child role and parent self-efficacy. The challenges were: (1) comparison to normal babies, (2) caregiver mental health, (3) need for information. Ideas to support transition included, (1) support systems, (2) interventions using mobile health technology (3) improved communication to the primary care provider and (4) information regarding financial assistance programs. Specific subthemes differed in frequency counts between infants with and without medical complexity. Conclusions Families often compare their preterm or high-risk infant to their peers and mothers feel great anxiety and stress. However, families often found hope and resilience in peer support and cited that in addition to information needs, interventions using mobile health technology and transition and financial systems could better support families after discharge. Electronic supplementary material The online version of this article (10.1186/s12887-019-1604-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ashwini Lakshmanan
- Fetal and Neonatal Medicine Institute, Division of Neonatal Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, 4650 Sunset Boulevard, MS #31, Los Angeles, CA, 90027, USA. .,Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. .,Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA. .,USC Gehr Family Center for Health Systems Science, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Katrina Kubicek
- Division of Research on Children, Youth and Families, Children's Hospital Los Angeles, Los Angeles, USA
| | - Roberta Williams
- Division of Cardiology, Children's Hospital Los Angeles; Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Marisela Robles
- Division of Research on Children, Youth and Families, Children's Hospital Los Angeles, Los Angeles, USA
| | - Douglas L Vanderbilt
- Fetal and Neonatal Medicine Institute, Division of Neonatal Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, 4650 Sunset Boulevard, MS #31, Los Angeles, CA, 90027, USA.,Division of General Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Christine B Mirzaian
- Division of General Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Philippe S Friedlich
- Fetal and Neonatal Medicine Institute, Division of Neonatal Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, 4650 Sunset Boulevard, MS #31, Los Angeles, CA, 90027, USA
| | - Michele Kipke
- USC Gehr Family Center for Health Systems Science, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Saban Research Institute, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Christison AL, Vaidya S, Tinajero-Deck L, Hampl SE. Application of the Medical Neighborhood to Children with Severe Obesity. Child Obes 2018; 14:461-467. [PMID: 30109953 DOI: 10.1089/chi.2017.0342] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Growth in the prevalence of severe pediatric obesity and tertiary care pediatric weight management programs supports the application of chronic disease management models to the care of children with severe obesity. One such model, the medical neighborhood, aims to optimize care coordination between primary and tertiary care by applying principles of the Patient-Centered Medical Home to all providers. METHODS An exploration of the literature was performed describing effective programs, approaches, and coordinated care models applied to pediatric weight management and other chronic conditions. RESULTS Though there was a paucity of literature discovered with applications specific to pediatric weight management, relevant disease management and care coordination approaches were found. Proposed applications to the care of children with severe obesity can be made. CONCLUSION The application of the medical neighborhood framework, with its inclusion of healthcare and community partners, may optimize the management of children with severe obesity.
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Affiliation(s)
- Amy L Christison
- 1 Department of Pediatrics, University of Illinois College of Medicine at Peoria , Peoria, IL
| | - Susma Vaidya
- 2 Department of Pediatrics, Children's National Medical Center , Washington, DC
| | | | - Sarah E Hampl
- 4 Department of Pediatrics, Children's Mercy Hospital , Kansas City, MO
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10
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Esmonde NO, Garfinkle JS, Chen Y, Lambert WE, Kuang AA. Factors Associated With Adherence to Nasoalveolar Molding (NAM) by Caregivers of Infants Born With Cleft Lip and Palate. Cleft Palate Craniofac J 2017; 55:252-258. [PMID: 29351029 DOI: 10.1177/1055665617718550] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Identify factors associated with adherence to nasoalveolar molding (NAM) therapy. DESIGN Retrospective case-control study. SETTING Tertiary referral center. PATIENTS, PARTICIPANTS Infants with cleft lip, with or without cleft palate, referred for NAM. One hundred thirty-five patients met criteria. MAIN OUTCOME MEASURE(S) Adherence to NAM therapy, defined as continuous use of the appliance and attendance of NAM adjustment visits. RESULTS Female sex (OR = 2.85, 95% CI 1.21-6.74), bilateral cleft (OR = 2.88, 95% CI 1.29-6.46), and travel distance (OR = 1.01, 95% CI 1.00-1.01) were independent predictors of nonadherence. Bilateral clefts (OR = 8.35, 95% CI 2.72-25.64) and public-payer insurance (OR = 3.67, 95% CI 1.13-11.91) for male patients were significantly associated with nonadherence, in our sex-stratified multivariate model. The majority of the families (58%) had public health insurance. Males comprised 77.0% of the cohort. CONCLUSIONS NAM treatment adherence is impaired by bilateral clefts, female sex, increased travel distance, and public insurance. Further studies are warranted to investigate how these factors affect adherence, and to develop interventions to improve adherence in families at risk due to economic or psychosocial barriers.
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Affiliation(s)
- Nick O Esmonde
- 1 Division of Plastic and Reconstructive Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Judah S Garfinkle
- 2 Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Yiyi Chen
- 3 Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland, OR, USA
| | - William E Lambert
- 3 Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Anna A Kuang
- 4 Division of Plastic & Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
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11
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Yu W, Li M, Nong X, Ding T, Ye F, Liu J, Dai Z, Zhang L. Practices and attitudes of doctors and patients to downward referral in Shanghai, China. BMJ Open 2017; 7:e012565. [PMID: 28373247 PMCID: PMC5387945 DOI: 10.1136/bmjopen-2016-012565] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 03/06/2017] [Accepted: 03/07/2017] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES In China, the rate of downward referral is relatively low, as most people are unwilling to be referred from hospitals to community health systems (CHSs). The aim of this study was to explore the effect of doctors' and patients' practices and attitudes on their willingness for downward referral and the relationship between downward referral and sociodemographic characteristics. METHODS Doctors and patients of 13 tertiary hospitals in Shanghai were stratified through random sampling. The questionnaire surveyed their sociodemographic characteristics, attitudes towards CHSs and hospitals, understanding of downward referral, recognition of the community first treatment system, and downward referral practices and willingness. Descriptive statistics, χ2 test and stepwise logistic regression analysis were employed for statistical analysis. RESULTS Only 20.8% (161/773) of doctors were willing to accept downward referrals, although this proportion was higher among patients (37.6%, 326/866). Doctors' willingness was influenced by education, understanding of downward referral, and perception of health resources in hospitals. Patients' willingness was influenced by marital status, economic factors and recognition of the community first treatment system. Well-educated doctors who do not consider downward referral would increase their workloads and those with a more comprehensive understanding of hospitals and downward referral process were more likely to make a downward referral decision. Single-injury patients fully recognising the community first treatment system were more willing to accept downward referral. Patients' willingness was significantly increased if downward referral was cost-saving. A better medical insurance system was another key factor for patients to accept downward referral decisions, especially for the floating population. CONCLUSIONS To increase the rate of downward referral, the Chinese government should optimise the current referral system and conduct universal publicity for downward referral. Doctors and patients should promote understandings of downward referral. Hospitals should realise the necessity of downward referral, effectively reduce workloads and provide continuing education for doctors. Increasing monetary reimbursement is urgent, as is improving the medical insurance system.
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Affiliation(s)
- Wenya Yu
- Institute of Military Health Management, Second Military Medical University, Shanghai, China
| | - Meina Li
- Institute of Military Health Management, Second Military Medical University, Shanghai, China
| | - Xin Nong
- Maternal and Child Service Center of Rizhao City, Rizhao, China
| | - Tao Ding
- Institute of Military Health Management, Second Military Medical University, Shanghai, China
| | - Feng Ye
- Institute of Military Health Management, Second Military Medical University, Shanghai, China
- No 187th hospital of PLA, Haikou, China
| | - Jiazhen Liu
- Institute of Military Health Management, Second Military Medical University, Shanghai, China
- Shanghai Sixth People's Hospital, Shanghai, China
| | - Zhixing Dai
- Institute of Military Health Management, Second Military Medical University, Shanghai, China
| | - Lulu Zhang
- Institute of Military Health Management, Second Military Medical University, Shanghai, China
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12
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Emerson ND, Morrell HER, Neece C. Predictors of Age of Diagnosis for Children with Autism Spectrum Disorder: The Role of a Consistent Source of Medical Care, Race, and Condition Severity. J Autism Dev Disord 2016; 46:127-138. [PMID: 26280401 DOI: 10.1007/s10803-015-2555-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Having a consistent source of medical care may facilitate diagnosis of autism spectrum disorders (ASD). This study examined predictors of age of ASD diagnosis using data from the 2011-2012 National Survey of Children's Health. Using multiple linear regression analysis, age of diagnosis was predicted by race, ASD severity, having a consistent source of care (CSC), and the interaction between these variables after controlling for birth cohort, birth order, poverty level, parental education, and health insurance. While African American children were diagnosed earlier than Caucasians, this effect was moderated by ASD severity and CSC. Having a CSC predicted earlier diagnosis for Caucasian but not African American children. Both physician and parent behaviors may contribute to diagnostic delays in minority children.
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Affiliation(s)
- Natacha D Emerson
- Department of Psychology, Loma Linda University, 11130 Anderson Street, Loma Linda, CA, 92354, USA.
| | - Holly E R Morrell
- Department of Psychology, Loma Linda University, 11130 Anderson Street, Loma Linda, CA, 92354, USA
| | - Cameron Neece
- Department of Psychology, Loma Linda University, 11130 Anderson Street, Loma Linda, CA, 92354, USA
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13
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Hoilette LK, Blumkin AK, Baldwin CD, Fiscella K, Szilagyi PG. Community health centers: medical homes for children? Acad Pediatr 2013; 13:436-42. [PMID: 24011746 DOI: 10.1016/j.acap.2013.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 05/27/2013] [Accepted: 06/17/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To explore medical home attributes of community health centers (CHCs) that provide care to low-income children nationwide compared to other providers for the poor. METHODS Cross-sectional study of children aged 0 to 17 years in the Medical Expenditure Panel Survey (MEPS; 2003 to 2009) who resided in families living at <200% of the federal poverty level (FPL) and had visits to a primary care setting. CHC visits were defined as a visit to a neighborhood/family health center, rural health clinic, or community health center. Independent measures included provider type, age, gender, race/ethnicity, insurance, FPL, number of parents at home, language, maternal education, health status, and special health care need. Dependent measures included 4 medical home attributes: accessibility, and family-centered, comprehensive, and compassionate care. RESULTS CHCs typically serve low-income children who are publicly insured or uninsured, come from racial/ethnic minority groups, and have poorer health status. Eighty percent to 90% of parents visiting both CHCs and other primary care providers rated high levels of family-centered, comprehensive, and compassionate care. However, CHCs had a 10% to 18% lower rating of accessibility (after-hours care, telephone access) even after controlling for sociodemographic characteristics. Racial/ethnic disparities existed at both settings, but these patterns did not differ between CHCs and other settings. CONCLUSIONS On the basis of parental reports, CHCs received similar ratings to other primary care providers for family-centered, comprehensive, and compassionate care, but lower ratings for accessibility. Further studies should examine strategies for practice transformation in CHCs to improve patient satisfaction and accessibility to optimize child health outcomes.
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Affiliation(s)
- Leesha K Hoilette
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY.
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14
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The effect of medical malpractice liability on rate of referrals received by specialist physicians. HEALTH ECONOMICS POLICY AND LAW 2013; 8:453-75. [PMID: 23527533 DOI: 10.1017/s1744133113000157] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Using nationally representative data from the United States, this paper analyzed the effect of a state’s medical malpractice environment on referral visits received by specialist physicians. The analytic sample included 12,839 ambulatory visits to specialist care doctors in office-based settings in the United States during 2003–2007. Whether the patient was referred for the visit was examined for its association with the state’s malpractice environment, assessed by the frequency and severity of paid medical malpractice claims, medical malpractice insurance premiums and an indicator for whether the state had a cap on non-economic damages. After accounting for potential confounders such as economic or professional incentives within practices, the analysis showed that statutory caps on non-economic damages of $250,000 were significantly associated with lower likelihood of a specialist receiving referrals, suggesting a potential impact of a state’s medical malpractice environment on physicians’ referral behavior.
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15
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Zuckerman KE, Perrin JM, Hobrecker K, Donelan K. Barriers to specialty care and specialty referral completion in the community health center setting. J Pediatr 2013; 162:409-14.e1. [PMID: 22929162 PMCID: PMC3752985 DOI: 10.1016/j.jpeds.2012.07.022] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 05/24/2012] [Accepted: 07/12/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To assess the frequency of barriers to specialty care and to assess which barriers are associated with an incomplete specialty referral (not attending a specialty visit when referred by a primary care provider) among children seen in community health centers. STUDY DESIGN Two months after their child's specialty referral, 341 parents completed telephone surveys assessing whether a specialty visit was completed and whether they experienced any of 10 barriers to care. Family/community barriers included difficulty leaving work, obtaining childcare, obtaining transportation, and inadequate insurance. Health care system barriers included getting appointments quickly, understanding doctors and nurses, communicating with doctors' offices, locating offices, accessing interpreters, and inconvenient office hours. We calculated barrier frequency and total barriers experienced. Using logistic regression, we assessed which barriers were associated with incomplete referral, and whether experiencing ≥ 4 barriers was associated with incomplete referral. RESULTS A total of 22.9% of families experienced incomplete referral. 42.0% of families encountered 1 or more barriers. The most frequent barriers were difficulty leaving work, obtaining childcare, and obtaining transportation. On multivariate analysis, difficulty getting appointments quickly, difficulty finding doctors' offices, and inconvenient office hours were associated with incomplete referral. Families experiencing ≥ 4 barriers were more likely than those experiencing ≤ 3 barriers to have incomplete referral. CONCLUSION Barriers to specialty care were common and associated with incomplete referral. Families experiencing many barriers had greater risk of incomplete referral. Improving family/community factors may increase satisfaction with specialty care; however, improving health system factors may be the best way to reduce incomplete referrals.
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Affiliation(s)
- Katharine E Zuckerman
- Division of General Pediatrics, Child and Adolescent Health Measurement Initiative, Oregon Health and Science University, Portland, OR 97239, USA.
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16
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Leslie LK, Rodday AM, Saunders TS, Cohen JT, Wong JB, Sheldrick RC, Parsons SK. Survey of United States child and adolescent psychiatrists' cardiac screening practices prior to starting patients on stimulants. J Child Adolesc Psychopharmacol 2012; 22:375-84. [PMID: 23083024 PMCID: PMC3482376 DOI: 10.1089/cap.2011.0141] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The purpose of this study was to determine psychiatrists' barriers, attitudes, and practices regarding cardiac screening prior to initiating stimulants in children with attention-deficit/hyperactivity disorder. BACKGROUND Professional and federal oversight organizations recently have debated the evidence regarding sudden cardiac death (SCD) risk with stimulants, and have published guidelines recommending cardiac screening. It is not known how psychiatrists have responded. METHODS This study was a cross-sectional survey of 1,600 randomly-selected U.S. members of the American Academy of Child and Adolescent Psychiatry. Analyses included descriptive statistics and logistic regression. RESULTS Response rate was 40%; 96% met eligibility criteria. Barriers to identifying cardiac disorders in general included ability to perform a routine physical examination (74%) and care coordination with primary care providers (35%). Only 27% agreed that SCD risk warranted cardiac assessment. Prior to starting a patient on stimulants, 95% of psychiatrists obtained a routine history. The majority either conducted (9%), or relied on primary care providers to conduct (67%) a physical examination; 26% did not obtain a physical examination. Nineteen percent of psychiatrists ordered an electrocardiogram (ECG), of those, non-mutually exclusive reasons for ordering an ECG included standard practice procedure (62%), clinical findings (27%), medicolegal considerations (25%), and guideline adherence (24%). On multivariate modeling, psychiatrists were less likely to conduct cardiac screening themselves if in private practice (referent: academic medical center), if >50% of their patients had private insurance, or if they believed their ability to perform a physical examination to be a barrier. When modeling cardiac screening performed by any healthcare professional (e.g., psychiatrist, primary care practitioner), screening was less likely if the psychiatrist was practicing in a community mental health center (referent: academic medical center), was male, or if >50% of that psychiatrist's patients had private insurance. CONCLUSION Findings suggest the tacit interplay between primary care and psychiatry for the assessment and management of medical risks associated with psychotropic medications should be improved, and solutions prioritized.
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Affiliation(s)
- Laurel K. Leslie
- The Institute of Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.,Floating Hospital for Children, Tufts Medical Center, Boston, Massachusetts.,Tufts University School of Medicine, Boston, Massachusetts
| | - Angie Mae Rodday
- The Institute of Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Tully S. Saunders
- The Institute of Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.,Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, Massachusetts
| | - Joshua T. Cohen
- The Institute of Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.,Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, Massachusetts
| | - John B. Wong
- Tufts University School of Medicine, Boston, Massachusetts
| | - R. Christopher Sheldrick
- The Institute of Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.,Department of Pediatrics, Tufts Medical Center, Boston, Massachusetts
| | - Susan K. Parsons
- The Institute of Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.,Floating Hospital for Children, Tufts Medical Center, Boston, Massachusetts.,Tufts University School of Medicine, Boston, Massachusetts
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