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Shahshahani MA, Liu X, Norman M, Tilden EL, Ahlberg M. Midwifery continuity of care, breastfeeding and neonatal hyperbilirubinemia: A retrospective cohort study. Midwifery 2024; 136:104079. [PMID: 38945104 DOI: 10.1016/j.midw.2024.104079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 06/24/2024] [Accepted: 06/25/2024] [Indexed: 07/02/2024]
Abstract
AIM To examine the association between Midwifery Continuity of Care (MCoC) and exclusive breastfeeding at hospital discharge and neonatal hyperbilirubinemia. METHODS A matched cohort design was employed using data from the Swedish Pregnancy Register. The study included 12,096 women who gave birth at a university hospital in Stockholm, Sweden from January 2019 to August 2021. Women and newborns cared for in a MCoC model were compared with a propensity-score matched set receiving standard care. Risk ratios (RR) were determined with 95 % confidence intervals (CI) based on the matched cohort through modified Poisson regressions with robust standard error. A mediation analysis assessed the direct and indirect effects of MCoC on exclusive breastfeeding at hospital discharge and neonatal hyperbilirubinemia and to what extent the association was mediated by preterm birth. FINDING Findings showed that MCoC was associated with a higher chance of exclusive breastfeeding rate (RR: 1.06, 95 % CI: 1.01-1.12) and lower risk of neonatal hyperbilirubinemia (RR: 0.51, 95 % CI: 0.32-0.82) compared with standard care. Mediation analysis demonstrated that lower preterm birth accounted for approximately 28 % of total effect on the reduced risk of neonatal hyperbilirubinemia. DISCUSSION/CONCLUSION This matched cohort study provided preliminary evidence that MCoC models could be an intervention for improving exclusive breastfeeding rates at hospital discharge and reducing the risk of neonatal hyperbilirubinemia.
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Affiliation(s)
| | - Xingrong Liu
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Norman
- Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Ellen L Tilden
- Portland, Oregon, Department of Nurse-Midwifery, Oregon Health & Science University School of Nursing, United States; Portland, Oregon, Department of Obstetrics and Gynecology, Oregon Health & Science University, United States
| | - Mia Ahlberg
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden.
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Diema Konlan K, Kossi Vivor N, Gegefe I, A. Abdul-Rasheed I, Esinam Kornyo B, Peter Kwao I. The Practice of Home Visiting by Community Health Nurses as a Primary Healthcare Intervention in a Low-Income Rural Setting: A Descriptive Cross-Sectional Study in the Adaklu District of the Volta Region, Ghana. ScientificWorldJournal 2021; 2021:8888845. [PMID: 33833622 PMCID: PMC8012147 DOI: 10.1155/2021/8888845] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Home visit is an integral component of Ghana's PHC delivery system. It is preventive and promotes health practice where health professionals render care to clients in their own environment and provide appropriate healthcare needs and social support services. This study describes the home visit practices in a rural district in the Volta Region of Ghana. Methodology. This descriptive cross-sectional study used 375 households and 11 community health nurses in the Adaklu district. Multistage sampling techniques were used to select 10 communities and study respondents using probability sampling methods. A pretested self-designed questionnaire and an interview guide for household members and community health nurses, respectively, were used for data collection. Quantitative data collected were coded, cleaned, and analysed using Statistical Package for Social Sciences into descriptive statistics, while qualitative data were analysed using the NVivo software. Thematic analysis was engaged that embraces three interrelated stages, namely, data reduction, data display, and data conclusion. RESULTS Home visit is a routine responsibility of all CHNs. The factors that influence home visiting were community members' education and attitude, supervision challenges, lack of incentives and lack of basic logistics, uncooperative attitude, community inaccessibility, financial constraint, and limited number of staff. Household members (62.3%) indicated that health workers did not adequately attend to minor ailments as 78% benefited from the service and wished more activities could be added to the home visiting package (24.5%). CONCLUSION There should be tailored training of CHNs on home visits skills so that they could expand the scope of services that can be provided. Also, community-based health workers such as community health volunteers, traditional birth attendants, and community clinic attendants can also be trained to identify and address health problems in the homes.
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Affiliation(s)
- Kennedy Diema Konlan
- Department of Public Health Nursing, School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana
- College of Nursing, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Nathaniel Kossi Vivor
- Department of Public Health Nursing, School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana
| | - Isaac Gegefe
- Department of Public Health Nursing, School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana
| | - Imoro A. Abdul-Rasheed
- Department of Public Health Nursing, School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana
| | - Bertha Esinam Kornyo
- Department of Public Health Nursing, School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana
| | - Isaac Peter Kwao
- Department of Public Health Nursing, School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana
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Lee S, O'Sullivan DE, Brenner DR, Metcalfe A. Developing and validating multivariable prediction models for predicting the risk of 7-day neonatal readmission following vaginal and cesarean birth using administrative databases. J Matern Fetal Neonatal Med 2020; 35:4674-4681. [PMID: 33345657 DOI: 10.1080/14767058.2020.1860933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Approximately 3.5% of deliveries in Canada result in potentially preventable neonatal readmission, often times due to preventable morbidities. With complexities in hospital discharge planning, health care providers may benefit in identifying infants at risk of readmission for additional monitoring. OBJECTIVES To develop and validate models for predicting 7-day neonatal readmission following vaginal or cesarean births. METHODS All liveborn term singleton infants without congenital anomalies in the province of Alberta who were not admitted to the NICU were identified using perinatal and hospitalization databases. A temporal split-sample was used for model development (2012-2014, vaginal n = 63,378; cesarean n = 21,225) and external validation (2014-2015, vaginal n = 21,583, cesarean n = 7,477). Multivariable logistic regression models using backward stepwise selection were used to identify predictors of 7-day readmission. We evaluated predictors of maternal age, Apgar score, length-of-stay, birthweight, gestational age, parity, residence, and sex. Hosmer-Lemeshow test and c-statistics were used to estimate calibration and discrimination. RESULTS The rate of readmission was 3.3% (95% CI 3.1%, 3.4%) and 2.1% (95% CI 1.9%, 2.3%) following vaginal and cesarean births in the development dataset. Prediction model following vaginal birth, excluding predictors of length-of-stay and birthweight, had sub-optimal performance in development (c-statistics 0.69) and validation data (c-statistics 0.68). Prediction model following cesarean birth, excluding predictors of maternal age, birthweight, and residence, had sub-optimal performance in development (c-statistics 0.62) and validation data (c-statistics 0.64). Readmission was observed in 7.9% (95% CI 7.1%, 8.8%) and 4.9% (95% CI 3.9%, 6.1%) of infants of vaginal and cesarean births, respectively, in the top quintile for the risk of 7-day readmission. CONCLUSION Using routinely collected administrative data, we developed and validated prediction models for neonatal readmission following vaginal and cesarean births. Presently the model is sub-optimal for use in risk assessment and planning at discharge, however, additional information may improve the predictive performance.
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Affiliation(s)
- Sangmin Lee
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Dylan E O'Sullivan
- Department of Public Health Sciences, Queen's University, Kingston, Canada
| | - Darren R Brenner
- Department of Community Health Sciences, University of Calgary, Calgary, Canada.,Department of Oncology, University of Calgary, Calgary, Canada
| | - Amy Metcalfe
- Department of Community Health Sciences, University of Calgary, Calgary, Canada.,Department of Obstetrics & Gynaecology, University of Calgary, Calgary, Canada.,Department of Medicine, University of Calgary, Calgary, Canada
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[Current status of readmission of neonates with hyperbilirubinemia and risk factors for readmission]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2020. [PMID: 32933624 PMCID: PMC7499455 DOI: 10.7499/j.issn.1008-8830.2005003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To investigate the current status of readmission of neonates with hyperbilirubinemia and risk factors for readmission. METHODS From January 2017 to December 2019, a total of 85 infants who were readmitted due to hyperbilirubinemia were enrolled as the study group. A total of 170 neonates with hyperbilirubinemia but without readmission during the same period of time were randomly selected as the control group. The medical data were compared between the two groups. Multivariate logistic regression was used to assess the risk factors for readmission due to hyperbilirubinemia. RESULTS The readmission rate was 2.30%, and the interval between readmission and initial admission was 5 days. Compared with the control group, the study group had significantly higher levels of total bilirubin and indirect bilirubin at discharge (P<0.05) and a significantly longer duration of phototherapy during the first hospitalization (P<0.05). The univariate analysis showed that compared with the control group, the study group had significantly lower birth weight, gestational age, and age on initial admission (P<0.05) and a significantly higher proportion of infants with glucose-6-phosphate dehydrogenase (G-6-PD) deficiency or hemolytic disease (P<0.05). The multivariate analysis showed that low gestational age (OR=1.792, P<0.05), young age on initial admission (OR=1.415, P<0.05), and G-6-PD deficiency (OR=2.829, P<0.05) were independent risk factors for readmission of neonates with hyperbilirubinemia. CONCLUSIONS The infants with hyperbilirubinemia who have lower gestational age, younger age on initial admission, and G-6-PD deficiency have a higher risk of readmission due to hyperbilirubinemia. It is thus important to strengthen the management during hospitalization and after discharge for these infants to prevent the occurrence of readmission.
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Abstract
Many barriers to primary healthcare accessibility in the United States exist including an increased opportunity cost associated with seeking primary care. New models of healthcare delivery aimed at addressing these problems are emerging. The potential impact that on-demand primary care physician house calls services can have on healthcare accessibility, patient care, and satisfaction by both patients and physicians is poorly characterized.We performed a retrospective observational analysis on data from 13,849 patients who utilized Heal, Inc, an application (app)-based, on-demand house calls platform between August 2016 and July 2017. We assessed house call wait time and visit duration, diagnoses by International Classification of Diseases, tenth revision, Inc (ICD10) codes, and house call outcomes by post-visit prescription and lab requests, and patient satisfaction survey.Patients who utilized this physician house call service had a bimodal age distribution peaking at age 1 year and 36 years. Same day acute sick exams (93.9% of pediatric (Ped) and 66.9% of adult requests) for fever and/or acute upper respiratory infection represented the most common use. The mean wait time for as soon as possible house calls were 96.1 minutes, with an overall mean house call duration of 27.1 minutes. A house call was primarily chosen over an Urgent Care Clinic or Doctor's office (46.2% and 41.6% of respondents, respectively), due to convenience or fastest appointment available (69.6% and 33.8% of respondents, respectively). Most survey respondents (94.2%) would schedule house calls again.On-demand physician house calls programs can expand access options to primary healthcare, primarily used by younger individuals with acute illness and preference for a smartphone app-based home visit.
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Affiliation(s)
- Shannon Fortin Ensign
- Scripps Translational Science Institute, The Scripps Research Institute
- Department of Internal Medicine, Scripps Green Hospital, La Jolla, CA
| | - Katie Baca-Motes
- Scripps Translational Science Institute, The Scripps Research Institute
| | | | - Eric J. Topol
- Scripps Translational Science Institute, The Scripps Research Institute
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Yang HJ, Jeon W, Yang HJ, Kwak JR, Seo HY, Lee JS. The Clinical Differences between Urgent Visits and Non-Urgent Visits in Emergency Department During the Neonatal Period. J Korean Med Sci 2017; 32:1870-1875. [PMID: 28960043 PMCID: PMC5639071 DOI: 10.3346/jkms.2017.32.11.1870] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 08/06/2017] [Indexed: 11/20/2022] Open
Abstract
As neonates are brought to the emergency department (ED) for various complaints, it is challenging for emergency physicians to clinically determine the urgency of the visit. We sought to explore clinical characteristics associated with urgent visits to the ED. We conducted a retrospective study by reviewing medical records of neonatal visits to a tertiary pediatric regional emergency center for 5 years. Cases of patients who were discharged after checking only chest or abdominal X-ray or discharged without workup, were classified as non-urgent visits. Cases where more examinations were performed, or when the patient was hospitalized, were classified as urgent visits. Various clinical features and process in the ED were compared between the groups. Of the 1,008 cases enrolled in this study, 856 (84.9%) were urgent and 152 (15.1%) were non-urgent visits. After adjustment by multiple logistic regression analysis, non-urgent visits were associated with self-referrals rather than physician-referrals (odds ratio [OR], 5.96), visits in the evening rather than at night or daytime (OR, 2.51), patient visits from home rather than from medical facilities (OR, 2.19; 95). Fever and jaundice were the most common complaints (25.7% and 24.5%, respectively), and their OR of non-urgent visit was relatively low (adjusted OR 0.03 and 0.03, respectively). However, other common complaints, such as vomiting and cough (7.4% and 7.1%, respectively), were more likely to be non-urgent visits (adjusted OR 2.96 and 9.83, respectively). For suspected non-urgent visits, emergency physicians need to try to reduce unnecessary workup and shorten length of stay in ED.
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Affiliation(s)
- Hyung Jun Yang
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Woochan Jeon
- Department of Emergency Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Hee Jung Yang
- Department of Preventive Medicine and Public Health, Ajou University School of Medicine, Suwon, Korea
| | - Jae Ryoung Kwak
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Hyo Yeon Seo
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Ji Sook Lee
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea.
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Abstract
QUESTIONS UNDER STUDY To investigate changes to health insurance costs for post-discharge postpartum care after the introduction of a midwife-led coordinated care model. METHODS The study included mothers and their newborns insured by the Helsana health insurance group in Switzerland and who delivered between January 2012 and May 2013 in the canton of Basel Stadt (BS) (intervention canton). We compared monthly post-discharge costs before the launch of a coordinated postpartum care model (control phase, n = 144) to those after its introduction (intervention phase, n = 92). Costs in the intervention canton were also compared to those in five control cantons without a coordinated postpartum care model (cross-sectional control group: n = 7, 767). RESULTS The average monthly post-discharge costs for mothers remained unchanged in the seven months following the introduction of a coordinated postpartum care model, despite a higher use of midwife services (increasing from 72% to 80%). Likewise, monthly costs did not differ between the intervention canton and five control cantons. In multivariate analyses, the ambulatory costs for mothers were not associated with the post-intervention phase. Cross-sectionally, however, they were positively associated with midwifery use. For children, costs in the post-intervention phase were lower in the first month after hospital discharge compared to the pre-intervention phase (difference of -114 CHF [95%CI -202 CHF to -27 CHF]), yet no differences were seen in the cross-sectional comparison. CONCLUSIONS The introduction of a coordinated postpartum care model was associated with decreased costs for neonates in the first month after hospital discharge. Despite increased midwifery use, costs for mothers remained unchanged.
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Ünver Korğalı E, Cihan MK, Oğuzalp T, Şahinbaş A, Ekici M. Hypernatremic Dehydration in Breastfed Term Infants: Retrospective Evaluation of 159 Cases. Breastfeed Med 2017; 12:5-11. [PMID: 27991839 DOI: 10.1089/bfm.2016.0077] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The aim of this study was to reveal the frequency, presenting complaints, risk factors, complications, and ways for prevention of hypernatremic dehydration (HD) among term breastfed infants. METHODS The files of 159 breastfed term infants hospitalized because of HD between the years 2009 and 2014 were examined retrospectively in the Neonatal Intensive Care Unit of Sivas State Hospital, Turkey. The patients were classified according to serum sodium (Na) levels, group 1 (Na: 146-149 mEq/L, n = 68) and group 2 (Na ≥150 mEq/L, n = 91). RESULTS The most common complaint was fever (67.9%), and the most common physical finding was oral mucosal dryness (76%). There were positive correlations between serum Na levels and weight loss, hospital stay, admission age, admission to neonatal unit after discharge, serum urea levels, and body temperature (p < 0.05). The normalization period of Na levels was significantly longer (21.7 ± 8.8 versus 29.3 ± 17.8 hours, p = 0.03), and Na reduction rate was faster in group 2 (0.41 ± 0.3 versus 0.50 ± 0.3 mEq/L/hour, p = 0.02). Bradycardia was seen more commonly in group 2 (1.5% versus 16.5%, p = 0.002). CONCLUSIONS HD is a significant condition that should be treated appropriately to avoid serious complications.
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Affiliation(s)
- Elif Ünver Korğalı
- 1 Department of Pediatrics, Cumhuriyet University Faculty of Medicine , Sivas, Turkey
| | - Meriç Kaymak Cihan
- 2 Division of Pediatric Hematology-Oncology, Department of Pediatrics, Cumhuriyet University Faculty of Medicine , Sivas, Turkey
| | - Tahir Oğuzalp
- 3 Neonatal Intensive Care Unit, Sivas State Hospital , Sivas, Turkey
| | - Ali Şahinbaş
- 3 Neonatal Intensive Care Unit, Sivas State Hospital , Sivas, Turkey
| | - Mahmut Ekici
- 1 Department of Pediatrics, Cumhuriyet University Faculty of Medicine , Sivas, Turkey
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Schreiber R, Gregoire JA, Shaha JE, Shaha SH. Think time: A novel approach to analysis of clinicians' behavior after reduction of drug-drug interaction alerts. Int J Med Inform 2016; 97:59-67. [PMID: 27919396 DOI: 10.1016/j.ijmedinf.2016.09.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 09/12/2016] [Accepted: 09/22/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Pharmacologic interaction alerting offers the potential for safer medication prescribing, but research reveals persistent concerns regarding alert fatigue. Research studies have tried various strategies to resolve this problem, with low overall success. We examined the effects of targeted alert reduction on clinician behavior in a resource constrained hospital. METHODS A physician and a pharmacy informaticist reduced alert levels of several drug-drug interactions (DDI) that clinicians almost always overrode with approval from and knowledge of the medical staff. This study evaluated the behavioral changes in prescribers and non-prescribers as measured by "think time", a new metric for evaluating the resolution time for an alert, before and after suppression of selected DDI alerts. RESULTS The user-seen DDI alert rate decreased from 9.98% of all orders to 9.20% (p=0.0001) with an overall volume reduction of 10.3%. There was no statistical difference in the reduction of cancelled (-10.00%) vs. proceed orders (-11.07%). Think time decreased overall by 0.61s (p<0.0001). Think time unexpectedly increased for cancelled orders 1.00s which while not statistically significant (p=0.28) is generally thought to be clinically noteworthy. For overrides, think time decreased 0.67s which was significant (p<0.0001). Think time lowered for both prescribers and non-prescribers. Targeted specialists had shorter think times initially, which shortened more than non-targeted specialists. CONCLUSIONS Targeted DDI alert reductions reduce alert burden overall, and increase net efficiency as measured by think time for all prescribers better than for non-prescribers. Think time may increase when cancelling or changing orders in response to DDI alerts vs. a decision to override an alert.
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Affiliation(s)
- Richard Schreiber
- Clinical Informatics, Chief Medical Informatics Officer, Holy Spirit Hospital-A Geisinger Affiliate, 431 North 21st Street, Suite 101, Camp Hill, PA 17011, United States.
| | - Julia A Gregoire
- Medication Information Systems Manager, Holy Spirit Hospital-A Geisinger Affiliate, 503 North 21st Street, Camp Hill, PA 17011, United States.
| | - Jacob E Shaha
- University of Michigan, Graduate School of Engineering & Computer Science, Ann Arbor, MI, United States.
| | - Steven H Shaha
- Center for Public Policy & Administration, Draper, UT, United States.
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Kuo MH, Wang SL, Chen WT. Using information and mobile technology improved elderly home care services. HEALTH POLICY AND TECHNOLOGY 2016. [DOI: 10.1016/j.hlpt.2016.02.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Tubbs-Cooley HL, Pickler RH, Simmons JM, Auger KA, Beck AF, Sauers-Ford HS, Sucharew H, Solan LG, White CM, Sherman SN, Statile AM, Shah SS. Testing a post-discharge nurse-led transitional home visit in acute care pediatrics: the Hospital-To-Home Outcomes (H2O) study protocol. J Adv Nurs 2016; 72:915-25. [PMID: 26817441 DOI: 10.1111/jan.12882] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2015] [Indexed: 11/30/2022]
Abstract
AIMS The aims of this study were: (1) to explore the family perspective on pediatric hospital-to-home transitions; (2) to modify an existing nurse-delivered transitional home visit to better meet family needs; (3) to study the effectiveness of the modified visit for reducing healthcare re-use and improving patient- and family-centered outcomes in a randomized controlled trial. BACKGROUND The transition from impatient hospitalization to outpatient care is a vulnerable time for children and their families; children are at risk for poor outcomes that may be mitigated by interventions to address transition difficulties. It is unknown if an effective adult transition intervention, a nurse home visit, improves postdischarge outcomes for children hospitalized with common conditions. DESIGN (1) Descriptive qualitative; (2) Quality improvement; (3) Randomized controlled trial. METHODS Aim 1 will use qualitative methods, through focus groups, to understand the family perspective of hospital-to-home transitions. Aim 2 will use quality improvement methods to modify the content and processes associated with nurse home visits. Modifications to visits will be made based on parent and stakeholder input obtained during Aims 1 & 2. The effectiveness of the modified visit will be evaluated in Aim 3 through a randomized controlled trial. DISCUSSION We are undertaking the study to modify and evaluate a nurse home visit as an effective acute care pediatric transition intervention. We expect the results will be of interest to administrators, policy makers and clinicians interested in improving pediatric care transitions and associated postdischarge outcomes, in the light of impending bundled payment initiatives in pediatric care.
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Affiliation(s)
- Heather L Tubbs-Cooley
- Research in Patient Services/Division of Nursing & James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Ohio, USA
| | | | - Jeffrey M Simmons
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Ohio, USA
| | - Katherine A Auger
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Ohio, USA
| | - Andrew F Beck
- Divisions of General & Community Pediatrics, Cincinnati Children's Hospital Medical Center, Ohio, USA
| | - Hadley S Sauers-Ford
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Ohio, USA
| | - Heidi Sucharew
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Ohio, USA
| | - Lauren G Solan
- Division of Pediatric Hospital Medicine, University of Rochester Medical Center Golisano Children's Hospital, New York, USA
| | - Christine M White
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Ohio, USA
| | | | - Angela M Statile
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Ohio, USA
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Ohio, USA
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Tejedor-Sojo J, Singleton LM, McCormick K, Wrubel D, Chern JJ. Preventability of Pediatric 30-Day Readmissions following Ventricular Shunt Surgery. J Pediatr 2015; 167:1327-33.e1. [PMID: 26454576 DOI: 10.1016/j.jpeds.2015.09.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 08/06/2015] [Accepted: 09/03/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the preventability of 30-day pediatric ventricular shunt readmissions using clinical and administrative data review. STUDY DESIGN We performed a retrospective chart review of one hundred forty-seven 30-day ventricular shunt readmissions at a tertiary pediatric center from May 2009-April 2013 under 2 scenarios: scenario 1 considered all ventricular shunt failures preventable; and scenario 2 considered shunt failures with excellent/good catheter positioning and no contributing deficiencies in care not preventable. Three physician reviewers independently assessed readmissions to determine their preventability and whether deficiencies in care existed that contributed to the readmission. We also evaluated the degree of interrater agreement in adjudicating readmission preventability. RESULTS Only 42% of 30-day readmissions following ventricular shunt procedures were preventable when considering all shunt failures as preventable. When classifying shunts with excellent/good proximal catheter position as not preventable, 21% of ventricular shunt readmissions were deemed preventable. Interrater agreement on readmission preventability was high (kappa 0.88). Deficiencies in care existed in 29 readmissions (20%), the largest category being physician related, but not all deficiencies contributed to a readmission. CONCLUSIONS Significant discrepancy exists in the preventability adjudication of ventricular shunt readmissions between administrative and chart review. Although using administrative data has determined that a majority of readmissions following pediatric ventricular shunt procedures are preventable, our review suggests a significantly lower degree of preventability.
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Affiliation(s)
- Javier Tejedor-Sojo
- Children's Healthcare of Atlanta, Atlanta, GA; Emory University School of Medicine, Atlanta, GA; Morehouse School of Medicine, Atlanta, GA.
| | - Lori M Singleton
- Children's Healthcare of Atlanta, Atlanta, GA; Morehouse School of Medicine, Atlanta, GA
| | | | - David Wrubel
- Children's Healthcare of Atlanta, Atlanta, GA; Emory University School of Medicine, Atlanta, GA
| | - Joshua J Chern
- Children's Healthcare of Atlanta, Atlanta, GA; Emory University School of Medicine, Atlanta, GA
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Goyal NK, Folger AT, Hall ES, Ammerman RT, Van Ginkel JB, Pickler RS. Effects of home visiting and maternal mental health on use of the emergency department among late preterm infants. J Obstet Gynecol Neonatal Nurs 2015; 44:135-144. [PMID: 25782193 DOI: 10.1111/1552-6909.12538] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To describe use of the emergency department (ED) among late preterm versus term infants enrolled in a home visiting program and to determine whether home visiting frequency was associated with outcome differences. DESIGN Retrospective, cohort study. SETTING Regional home visiting program in southwest Ohio from 2007–2010. PARTICIPANTS Late preterm and term infants born to mothers enrolled in home visiting. Program eligibility requires ≥ one of four characteristics: unmarried, low income, < 18 years, or suboptimal prenatal care. METHODS Data were derived from vital statistics, hospital discharges, and home visiting records. Negative binomial regression was used to determine association of ED visits in the first year with late preterm birth and home visit frequency, adjusting for maternal and infant characteristics. RESULTS Of 1,804 infants, 9.2% were born during the late preterm period. Thirty-eight percent of all infants had at least one ED visit, 15.6% had three or more. No significant difference was found between the number of ED visits for late preterm and term infants (39.4% vs. 37.8% with at least one ED visit, p = .69). In multivariable analysis, late preterm birth combined with a maternal mental health diagnosis was associated with an ED incident rate ratio (IRR) of 1.26, p = .03; high frequency of home visits was not significant (IRR = .92, p = .42). CONCLUSIONS Frequency of home visiting service over the first year of life is not significantly associated with reduced ED visits for infants with at-risk attributes and born during the late preterm period. Research on how home visiting can address ED use, particularly for those with prematurity and maternal mental health conditions, may strengthen program impact and cost benefits.
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Dodge KA, Goodman WB, Murphy RA, O'Donnell K, Sato J, Guptill S. Implementation and randomized controlled trial evaluation of universal postnatal nurse home visiting. Am J Public Health 2013; 104 Suppl 1:S136-43. [PMID: 24354833 DOI: 10.2105/ajph.2013.301361] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES We evaluated whether a brief, universal, postnatal nurse home-visiting intervention can be implemented with high penetration and fidelity, prevent emergency health care services, and promote positive parenting by infant age 6 months. METHODS Durham Connects is a manualized 4- to 7-session program to assess family needs and connect parents with community resources to improve infant health and well-being. All 4777 resident births in Durham, North Carolina, between July 1, 2009, and December 31, 2010, were randomly assigned to intervention and control conditions. A random, representative subset of 549 families received blinded interviews for impact evaluation. RESULTS Of all families, 80% initiated participation; adherence was 84%. Hospital records indicated that Durham Connects infants had 59% fewer infant emergency medical care episodes than did control infants. Durham Connects mothers reported fewer infant emergency care episodes and more community connections, more positive parenting behaviors, participation in higher quality out-of-home child care, and lower rates of anxiety than control mothers. Blinded observers reported higher quality home environments for Durham Connects than for control families. CONCLUSIONS A brief universal home-visiting program implemented with high penetration and fidelity can lower costly emergency medical care and improve family outcomes.
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Affiliation(s)
- Kenneth A Dodge
- Kenneth A. Dodge, W. Benjamin Goodman, Robert A. Murphy, Karen O'Donnell, and Jeannine Sato are with the Center for Child and Family Policy, Duke University, Durham, NC. Susan Guptill is with the Durham County Department of Health, Durham
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15
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Lain SJ, Nassar N, Bowen JR, Roberts CL. Risk factors and costs of hospital admissions in first year of life: a population-based study. J Pediatr 2013; 163:1014-9. [PMID: 23769505 DOI: 10.1016/j.jpeds.2013.04.051] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 04/03/2013] [Accepted: 04/24/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To identify the maternal and infant risk factors associated with hospital admission in the first year and estimate the associated costs of infant hospitalization. STUDY DESIGN Data from the Perinatal Data Collection for 599753 liveborn infants born in New South Wales, Australia, 2001-2007 were linked to hospital admission data. Logistic regression models were used to investigate the association between maternal and infant characteristics and admission to hospital once, and more than once in the first year; and average costs for total hospital admissions were calculated. RESULTS Almost 15% of infants were admitted to hospital once and 4.6% had multiple admissions. Gestational age <37 weeks was most strongly associated with admission to hospital once, and severe neonatal morbidity was most strongly associated with multiple admissions (aOR 2.60; 95% CI 2.47-2.75). Infants born <39 weeks gestational age, to adolescent mothers, mothers who smoke, are not married, or had a planned delivery also have an increased risk of multiple admissions. Infants with severe neonatal morbidity contributed 27% of total infant hospital costs. With each increasing week of gestational age the mean annual cost decreased on average 10% and 27% for infants with and without neonatal morbidity respectively. CONCLUSIONS Infants born with severe neonatal morbidity have increased hospitalizations in the first year; however, the majority of burden on health system is by infants without severe neonatal morbidity. Hospitalizations, and associated costs, increased with decreasing gestational age, even for infants born at 37-38 weeks. Targeted public health strategies may reduce the burden of infant hospitalizations.
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Affiliation(s)
- Samantha J Lain
- Kolling Institute of Medical Research, Clinical and Population Perinatal Health Research, University of Sydney, Sydney, Australia.
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Cost-effectiveness of recombinant human hyaluronidase-facilitated subcutaneous versus intravenous rehydration in children with mild to moderate dehydration. Am J Emerg Med 2013; 31:928-34. [DOI: 10.1016/j.ajem.2013.03.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 02/15/2013] [Accepted: 03/04/2013] [Indexed: 11/18/2022] Open
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Isetta V, Lopez-Agustina C, Lopez-Bernal E, Amat M, Vila M, Valls C, Navajas D, Farre R. Cost-effectiveness of a new internet-based monitoring tool for neonatal post-discharge home care. J Med Internet Res 2013; 15:e38. [PMID: 23419609 PMCID: PMC3636285 DOI: 10.2196/jmir.2361] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 11/15/2012] [Accepted: 01/13/2013] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The application of information and communication technologies in nursing care is becoming more widespread, but few applications have been reported in neonatal care. A close monitoring of newborns within the first weeks of life is crucial to evaluating correct feeding, growth, and health status. Conventional hospital-based postdischarge monitoring could be improved in terms of costs and clinical effectiveness by using a telemedicine approach. OBJECTIVE To evaluate the cost-effectiveness of a new Internet-based system for monitoring low-risk newborns after discharge compared to the standard hospital-based follow-up, with specific attention to prevention of emergency department (ED) visits in the first month of life. METHODS We performed a retrospective cohort study of two low-risk newborn patient groups. One group, born between January 1, 2011, and June 30, 2011, received the standard hospital-based follow-up visit within 48 hours after discharge. After implementing an Internet-based monitoring system, another group, born between July 19, 2011, and January 19, 2012, received their follow-up with this system. RESULTS A total of 18 (15.8%) out of 114 newborns who received the standard hospital-based follow-up had an ED visit in the first month of life compared with 5 (5.6%; P=.026) out of 90 infants who were monitored by the Internet-based system. The cost of the hospital-based follow-up was 182.1€ per patient, compared with 86.1€ for the Internet-based follow-up. CONCLUSION Our Internet-based monitoring approach proved to be both more effective and less costly than the conventional hospital-based follow-up, particularly through reducing subsequent ED visits.
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Affiliation(s)
- Valentina Isetta
- Unit of Biophysics and Bioengineering, Faculty of Medicine, University of Barcelona, Barcelona, Spain
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18
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Goyal N, Zubizarreta JR, Small DS, Lorch SA. Length of stay and readmission among late preterm infants: an instrumental variable approach. Hosp Pediatr 2013; 3:7-15. [PMID: 24319830 PMCID: PMC3967867 DOI: 10.1542/hpeds.2012-0027] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Evidence to guide safe discharge for late preterm infants (34-36 weeks' gestation) is lacking. Previous studies have demonstrated the increased risk of neonatal readmission for these infants compared with those born at term (> or =37 weeks' gestation). The purpose of this study was to estimate the effect of length of stay (LOS) on 7-day readmissions in this population. METHODS This was a retrospective study using hospital discharge data linked with vital records for late preterm infants delivered vaginally in California from 1993 to 2005. Exclusion criteria included complications likely requiring neonatal intensive care. The effect of LOS was assessed by using birth hour as an instrumental variable to account for unmeasured confounding. By using a matching algorithm, we created pairs of infants with different LOS based on birth hour but otherwise matched on known confounders for readmission risk, including birth year, hospital, and clinical and demographic covariates such as gestational age, birth weight, race, and insurance. RESULTS We produced 80600 matched pairs of infants with different LOS based on birth hour. In 122 pairs, both infants were readmitted within 7 days, and in 75362 pairs, neither infant was readmitted. Of the remaining 5116 matched pairs in which only 1 infant was readmitted, 2456 infants with long LOS and 2660 infants with short LOS were readmitted. We found no evidence that longer LOS reduces the odds of readmission (1-sided P value = .99). CONCLUSIONS By using an instrumental variable approach and matching algorithm, longer LOS was not associated with decreased readmission within 7 days of discharge for these late preterm infants.
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Affiliation(s)
- Neera Goyal
- Division of Neonatology and Pulmonary Biology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - José R. Zubizarreta
- Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dylan S. Small
- Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott A. Lorch
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Outcomes Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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Yang D, Yang J, Shi D, Deng R, Yan B. Scoparone potentiates transactivation of the bile salt export pump gene and this effect is enhanced by cytochrome P450 metabolism but abolished by a PKC inhibitor. Br J Pharmacol 2012; 164:1547-57. [PMID: 21649640 DOI: 10.1111/j.1476-5381.2011.01522.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Hyperbilirubinaemia and cholestasis are two major forms of liver abnormality. The Chinese herb Yin Chin has been used for thousands of years to treat liver dysfunctions. In mice, this herb and its principal ingredient scoparone were found to accelerate the clearance of bilirubin accompanied by the induction of uridine diphosphate-5'-glucuronosyltransferase-1A1 (UGT1A1), a bilirubin processing enzyme. The aim of this study was to determine whether scoparone induces the expression of human UGT1A1. In addition, the expression of the bile salt export pump (BSEP), a transporter of bile acids, was determined. EXPERIMENTAL APPROACH Primary human hepatocytes and hepatoma line Huh7 were treated with scoparone, chenodeoxycholic acid (CDCA) or both. The expression of UGT1A1 and BSEP mRNA was determined. The activation of the human BSEP promoter reporter by scoparone was determined in Huh7 cells by transient transfection and in mice by bioluminescent imaging. The metabolism of scoparone was investigated by recombinant CYP enzymes and pooled human liver microsomes. KEY RESULTS Scoparone did not enhance the expression of either human BSEP or, surprisingly, UGT1A1. However, scoparone significantly potentiated the expression of BSEP induced by CDCA. Consistent with this, scoparone potentiated the stimulant effect of CDCA on the human BSEP promoter. This potentiation was enhanced by co-transfection of cytochrome P4501A2 but abolished by the PKC inhibitor GF109203X. CONCLUSIONS AND IMPLICATIONS Scoparone and Yin Chin normalize liver function primarily by enhancing the secretion of bile acids, and this effect probably varies depending on the metabolic rate of scoparone.
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Affiliation(s)
- Dongfang Yang
- Department of Biomedical Sciences, Center for Pharmacogenomics and Molecular Therapy, University of Rhode Island, Kingston, RI 02881, USA
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20
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Xie B, da Silva O, Zaric G. Cost-effectiveness analysis of a system-based approach for managing neonatal jaundice and preventing kernicterus in Ontario. Paediatr Child Health 2012; 17:11-6. [PMID: 23277747 PMCID: PMC3276518 DOI: 10.1093/pch/17.1.11] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2010] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To evaluate the incremental cost-effectiveness of a system-based approach for the management of neonatal jaundice and the prevention of kernicterus in term and late-preterm (≥35 weeks) infants, compared with the traditional practice based on visual inspection and selected bilirubin testing. STUDY DESIGN Two hypothetical cohorts of 150,000 term and late-preterm neonates were used to compare the costs and outcomes associated with the use of a system-based or traditional practice approach. Data for the evaluation were obtained from the case costing centre at a large teaching hospital in Ontario, supplemented by data from the literature. RESULTS The per child cost for the system-based approach cohort was $176, compared with $173 in the traditional practice cohort. The higher cost associated with the system-based cohort reflects increased costs for predischarge screening and treatment and increased postdischarge follow-up visits. These costs are partially offset by reduced costs from fewer emergency room visits, hospital readmissions and kernicterus cases. Compared with the traditional approach, the cost to prevent one kernicterus case using the system-based approach was $570,496, the cost per life year gained was $26,279, and the cost per quality-adjusted life year gained was $65,698. CONCLUSION The cost to prevent one kernicterus case using the system-based approach is much lower than previously reported in the literature.
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Affiliation(s)
- Bin Xie
- University of Western Ontario, London, Ontario
| | | | - Greg Zaric
- University of Western Ontario, London, Ontario
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Transitions in the early-life of late preterm infants: vulnerabilities and implications for postpartum care. J Perinat Neonatal Nurs 2012; 26:57-68. [PMID: 22293643 DOI: 10.1097/jpn.0b013e31823f8ff5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The focus of this article is on the transition of late preterm infants from hospital to home. The current state of literature related to mortality, morbidities, emergency department visits, and rehospitalization underscores the vulnerability of late preterm infants following discharge from hospital. Universal provision of postpartum care to late preterm infants is viewed as an environmental support intended to facilitate transition of these vulnerable infants from hospital to home. Gaps in provision of postpartum care of late preterm infants are situated within the discussion of guidelines and models of postpartum care (home vs clinic) of late preterm infants.
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Meier PP, Furman LM, Degenhardt M. Increased Lactation Risk for Late Preterm Infants and Mothers: Evidence and Management Strategies to Protect Breastfeeding. J Midwifery Womens Health 2010; 52:579-87. [PMID: 17983995 DOI: 10.1016/j.jmwh.2007.08.003] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Paula P Meier
- Neonatal Intensive Care Unit, and Department of Women's and Children's Health Nursing at Rush University Medical Center, Chicago, IL 60612, USA.
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23
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Feudtner C, Pati S, Goodman DM, Kahn MG, Sharma V, Hutto JH, Levin JE, Slonim AD, Hall M, Shah SS. State-level child health system performance and the likelihood of readmission to children's hospitals. J Pediatr 2010; 157:98-102.e1. [PMID: 20304421 DOI: 10.1016/j.jpeds.2010.01.049] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Revised: 12/07/2009] [Accepted: 01/27/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess the relationship between children's hospital readmission and the performance of child health systems in the states in which hospitals are located. STUDY DESIGN We conducted a retrospective cohort study of 197,744 patients 2 to 18 years old from 39 children's hospitals located in 24 states in the United States in 2005. Subjects were observed for a year after discharge for readmission to the same hospital. The odds of readmission were modeled on the basis of patient-level characteristics and state child health system performance as ranked by the Commonwealth Fund. RESULTS A total of 1.8% of patients were readmitted within a week, 4.8% within a month, and 16.3% within 365 days. After adjustment for patient-level characteristics, the probability of readmission varied significantly between states (P=.001), and the likelihood of readmission during the ensuing year increased as the states' health system performance ranking improved. States in the best ranking quartile had a 2.03% higher readmission rate than states in the lowest quartile (P=.02); the same directional relationship was observed for readmission intervals from 1 to 365 days after discharge. CONCLUSIONS Hospital readmission rates are significantly related to the performance of the surrounding health care system.
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Affiliation(s)
- Chris Feudtner
- PolicyLab, Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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Olden AM, Holloway R. Treatment of malignant pleural effusion: PleuRx catheter or talc pleurodesis? A cost-effectiveness analysis. J Palliat Med 2010; 13:59-65. [PMID: 19839739 DOI: 10.1089/jpm.2009.0220] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Malignant pleural effusions (MPEs) complicate many advanced malignancies and the median prognosis for those who develop MPEs is 6 months. These effusions lead patients to suffer from significant dyspnea, which may consequently impair mobility and lead to reduced quality of life. There are several treatment options for those with MPE. Thoracentesis may be quick and relatively easy to perform, but has a high recurrence rate; chest tube placement with talc slurry is quite effective at achieving pleurodesis, but this procedure can be quite painful and requires hospitalization. An alternative option is outpatient placement of the Pleurx catheter (Denver Biomedical Inc., Denver, CO) for home-based drainage of effusions. OBJECTIVE To determine the incremental cost effectiveness of treating MPE with talc pleurodesis versus placement of Pleurx catheter. METHODS We used decision analysis to compare treatments for the management of MPE. Cost data for Pleurx and talc treatments were obtained using Medicare reimbursement data for 2008, and outcome data (probability of treatment success and/or complication, and utility of health states) were obtained through literature review. RESULTS Under our base-case analysis, treatment with talc was less costly than Pleurx (talc, $8170.80; Pleurx, $9011.60) with similar effectiveness (talc, 0.281 quality adjusted life years [QALYs]; Pleurx, 0.276 QALYs). Pleurx became more cost effective (<$100K/QALY) when life expectancy was 6 weeks or less. CONCLUSION The treatment choice (talc pleurodesis or Pleurx catheter) for those with an MPE and a prognosis of 6 months should be based on the clinical situation and patient preferences, as well as local expertise and success rates of the procedures. A prospective study specific to the palliative care population might help to clarify which treatment is more cost effective in this population in which optimizing quality of life is essential.
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Affiliation(s)
- Aaron M Olden
- Division of Ethics, Humanities, and Palliative Care, University of Rochester, Rochester, New York 14642, USA.
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Abstract
PURPOSE To determine whether there was a relationship between postpartum psychosocial support from healthcare providers and the rate of normal newborn readmissions (NNRs), and whether there was a cost benefit to justify an intervention. STUDY DESIGN AND METHODS Data were abstracted for all normal newborn births from 1999 to 2006 (N = 14,786) at a community hospital in southern California at three different time periods: (1) at baseline prior to any intervention (1999-2000), (2) the 4 years during the comprehensive psychosocial support intervention (2001-2004), and (3) the 2 years during a limited psychosocial support intervention (2004-2006). A cost-benefit analysis was performed to analyze whether the financial benefits from the intervention matched or exceeded the costs for NNRs. RESULTS There was a significantly lower readmission rate of 1.0% (p = < .001) during the comprehensive intervention time period compared to baseline (2.3%) or to the limited intervention time period (2.3%). Although there was no significant difference in the average cost per newborn readmitted across the three study time periods, during the comprehensive intervention time period the average costs of a NNR were significantly lower ($4,180, p = .041) for the intervention group compared to those who received no intervention ($5,338). There was a cost benefit of 513,540 dollars due to fewer readmissions during the comprehensive time period, but it did not exceed the cost of the intervention. CLINICAL IMPLICATIONS Providing comprehensive follow-up for new mothers in the postpartum period can reduce NNRs, thus lowering the average newborn readmission costs for those who receive psychosocial support. Followup for new mothers should be an accepted norm rather than the exception in postpartum care, but NNRs should not be considered the sole outcome in such programs.
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False-negative results of pre-discharge neonatal bilirubin screening to predict severe hyperbilirubinemia: a need for caution. Eur J Pediatr 2009; 168:1461-6. [PMID: 19255782 DOI: 10.1007/s00431-009-0950-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 02/16/2009] [Indexed: 10/21/2022]
Abstract
Routine bilirubin screening prior to newborn hospital discharge, using an hour-specific bilirubin nomogram, has been advocated to assess risk for subsequent severe hyperbilirubinemia. However, the false-negative rate has never been adequately studied. Our objective was to determine false-negative results of pre-discharge bilirubin screening. After routine pre-discharge, bilirubin screening was in place for over 4 years, we performed a retrospective chart review to identify infants readmitted for total bilirubin levels > 17 mg/dl (>290.7 micromol/l). We documented each infant's pre-discharge bilirubin level, risk-zone assignment by nomogram, the presence or absence of risk factors for severe hyperbilirubinemia, co-morbidities upon readmission, treatment received, and ultimate disposition. Readmitted infants whose pre-discharge bilirubin was in the low-risk (<40th percentile) and low-intermediate (40-75th percentile) risk zones of the nomogram, were considered false-negatives. Of the 6,220 infants discharged from the newborn nursery during the 51-month study period, 28 (0.45%) were readmitted for treatment of serum bilirubin levels > 17 mg/dl (>290.7 micromol/l). All received phototherapy and none required exchange transfusion. Pre-discharge bilirubin values were <40th percentile (low-risk zone) in one infant (3.6%), and between 40-75th percentiles (low-intermediate risk zone) in twelve infants (43%). Risk factors for the development of severe hyperbilirubinemia were present in 27 (96%) readmitted infants. In conclusion, nearly half of readmitted infants had pre-discharge bilirubin values in zones considered at lower risk. The use of pre-discharge bilirubin screening alone to assign future risk for severe hyperbilirubinemia may provide false reassurance. Rigorous research is required to determine the test characteristics of pre-discharge bilirubin screening before widespread acceptance and implementation. Universal early post-discharge follow-up should remain the cornerstone of preventing severe hyperbilirubinemia.
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Konetzny G, Bucher HU, Arlettaz R. Prevention of hypernatraemic dehydration in breastfed newborn infants by daily weighing. Eur J Pediatr 2009; 168:815-8. [PMID: 18818944 DOI: 10.1007/s00431-008-0841-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Accepted: 09/10/2008] [Indexed: 11/25/2022]
Abstract
UNLABELLED Hypernatraemic dehydration, which predominantly appears in breastfed neonates, can cause serious complications, such as convulsions, permanent brain damage and death, if recognised late. Weight loss > or = 10% of birth weight could be an early indicator for this condition. In this prospective cohort study from October 2003 to June 2005 in the postnatal ward of the University Hospital Zurich, Switzerland, all term newborns with birth weight > or = 2,500 g were weighed daily until discharge. When the weight loss was > or = 10% of birth weight, serum sodium was measured from a heel prick. Infants with moderate hypernatraemia (serum sodium = 146-149 mmol/l) were fed supplementary formula milk or maltodextrose 10%. Infants with severe hypernatraemia (serum sodium > or = 150 mmol/l) were admitted to the neonatal unit and treated in the same way, with or without intravenous fluids, depending on the severity of the clinical signs of dehydration. A total of 2,788 breastfed healthy term newborns were enrolled. Sixty-seven (2.4%) newborns had a weight loss > or = 10% of birth weight; 24 (36%) of these had moderate and 18 (27%) severe hypernatraemia. Infants born by caesarean section had a 3.4 times higher risk for hypernatraemia than those born vaginally. All newborns regained weight 24 h after additional fluids. CONCLUSION In our study, one out of 66 healthy exclusively breastfed term neonates developed hypernatraemic dehydration. Daily weight monitoring and supplemental fluids in the presence of weight loss > or = 10% of birth weight allows early detection and intervention, thereby preventing the severe sequellae of hypernatraemic dehydration.
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Affiliation(s)
- Gabriel Konetzny
- Clinic of Neonatology, University Hospital Zurich, Zurich, Switzerland.
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Ogbuanu CA, Jones CA, McTigue JF, Baker SL, Heim M, Baek J, Smith LU. A program evaluation of postpartum/newborn home visitation services in aiken county, South Carolina. Public Health Nurs 2009; 26:39-47. [PMID: 19154191 DOI: 10.1111/j.1525-1446.2008.00752.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Home visiting programs for very young children seek to promote their health and development. We conducted a process and outcome evaluation of the Postpartum/Newborn Home Visit (PPNBHV) service in 1 county. DESIGN A retrospective study of Aiken County Health records of live infant births in 2004 was conducted. SAMPLE A random sample of 176 infants who were born in 2004 and enrolled in the women, infants, and children's (WIC) program in the same year was selected. MEASURES Process measures include timeliness of the home visit, and appropriateness of revisits. Outcome measures include age at WIC enrollment and immunization status at 6/9 months. RESULTS Of the 176 infants, 76 (43%) received a home visit. Of these, 13 (17%) received the visit within the stipulated time frame. After controlling for potential confounders, infants who received a home visit were 4 times (95% CI 1.92-8.36) as likely to enroll early in the WIC program compared with those who did not. CONCLUSION The PPNBHV service may contribute to early enrollment in the WIC program. Improvement in the timeliness of the visits is needed. Program monitoring and evaluation are necessary to ensure adherence, measure outcomes, and provide feedback for continuous quality improvement.
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Affiliation(s)
- Chinelo A Ogbuanu
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC 29208, USA.
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Abstract
Access to perinatal healthcare services for women living in poverty is complicated by many barriers and directly affects rates of premature births, low birthweight infants, and maternal and infant deaths. Health and social services delivered in the home can help improve pregnancy outcomes. Home visiting programs need sustainable funding and support from physicians and other healthcare providers. Ongoing research is needed to develop, refine, and evaluate systems of care that integrate home visiting components and different service delivery models that address pregnancies complicated by various psychosocial and medical complications.
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Nichols LO, Chang C, Lummus A, Burns R, Martindale-Adams J, Graney MJ, Coon DW, Czaja S. The cost-effectiveness of a behavior intervention with caregivers of patients with Alzheimer's disease. J Am Geriatr Soc 2008; 56:413-20. [PMID: 18179480 PMCID: PMC2575686 DOI: 10.1111/j.1532-5415.2007.01569.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine the cost-effectiveness of a randomized, clinical trial of a home-based intervention for caregivers of people with dementia. DESIGN This cost-effectiveness analysis examined Resources for Enhancing Alzheimer's Caregivers Health (REACH II), a multisite, randomized, clinical trial, from June 2002 through December 2004, funded by the National Institute on Aging and the National Institute of Nursing Research, of a behavioral intervention to decrease caregivers' stress and improve management of care recipient behavioral problems. SETTING Community-dwelling dementia caregiving dyads from the Memphis REACH II site. PARTICIPANTS Of Memphis' random sample of 55 intervention and 57 control black and white dyads, 46 in each arm completed without death or discontinuation. Family caregivers were aged 21 and older, lived with the care recipient, and had provided 4 or more hours of care per day for 6 months or longer. Care recipients were cognitively and functionally impaired. INTERVENTION(S) Twelve individual sessions (9 home sessions and 3 telephone sessions) supplemented by five telephone support-group sessions. Control caregivers received two "check in" phone calls. MEASUREMENTS Incremental cost-effectiveness ratio (ICER), the additional cost to bring about one additional unit of benefit (hours per day of providing care). RESULTS At 6 months, there was a significant difference between intervention caregivers and control caregivers in hours providing care (P=.01). The ICER showed that intervention caregivers had 1 extra hour per day not spent in caregiving, at a cost of $5 per day. CONCLUSION The intervention provided that most scarce of caregiver commodities--time. The emotional and physical costs of dementia caregiving are enormous, and this intervention was able to alleviate some of that cost.
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Affiliation(s)
- Linda O Nichols
- Veterans Affairs Medical Center Memphis, Memphis, Tennessee 38104, USA.
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Abstract
AIMS To investigate the characteristics of neonates presenting to a metropolitan Mixed Emergency Department (MED). To examine whether there are maternal and neonatal characteristics which increase the risk of presentation to the ED in the neonatal period. METHODS A retrospective chart review was performed of all neonatal presentations occurring between July 2002 and June 2003 to Liverpool Hospital Emergency Department, a Level 6 MED located in south-western Sydney, New South Wales, Australia, seeing approximately 45,000 presentations annually of which 20% are paediatric. Comparisons of maternal and neonatal characteristics were made with Liverpool Hospital, Area Health Service and New South Wales Mothers and Babies data, and with other paediatric presentations to the MED. RESULTS 179 neonates made 194 neonatal presentations. Compared with all paediatric presentations, the neonatal triage category assignment, admission and transfer proportions were significantly higher, although just over half had 'primary care type illnesses'. Mothers of neonates presenting to this MED were more likely to be younger and first time mothers in comparison to the general population of mothers and newborns. This study did not find an over-representation of neonates who were discharged within 48 h after birth. CONCLUSION The implications of these results for practice include a consideration of the availability and appropriateness of after-hours service available to new mothers. Further studies investigating parental reasons for neonatal ED presentation are recommended.
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Affiliation(s)
- Setthy Ung
- Liverpool Hospital, Sydney, NSW, Australia
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Paul IM, Lehman EB, Hollenbeak CS, Maisels MJ. Preventable newborn readmissions since passage of the Newborns' and Mothers' Health Protection Act. Pediatrics 2006; 118:2349-58. [PMID: 17142518 DOI: 10.1542/peds.2006-2043] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Congress passed the Newborns' and Mothers' Health Protection Act in 1996, reversing the trend of shorter newborn nursery lengths of stay. Hope existed that morbidities would lessen for this vulnerable population, but some reports indicate that the timeliness and quality of postdischarge care may have worsened in recent years. OBJECTIVE Our goal was to determine risk factors for the potentially preventable readmissions because of jaundice, dehydration, or feeding difficulties in the first 10 days of life in Pennsylvania since passage of the Newborns' and Mothers' Health Protection Act. PATIENTS AND METHODS Birth records from 407,826 newborns > or = 35 weeks' gestation from 1998 to 2002 were merged with clinical discharge records. A total of 2540 newborns rehospitalized for jaundice, dehydration, or feeding difficulties in the first 10 days of life were then compared with 5080 control infants. Predictors of readmission were identified by using multiple logistic regression analysis. RESULTS An unadjusted comparison of baseline characteristics revealed numerous predictors of readmission. Subsequent adjusted analysis revealed that Asian mothers, those 30 years of age or older, nonsmokers, and first-time mothers were more likely to have a readmitted newborn, as were those with diabetes and pregnancy-induced hypertension. For neonates, female gender and delivery via cesarean section were protective for readmission, whereas vacuum-assisted delivery, gestational age < 37 weeks, and nursery length of stay < 72 hours were predictors of readmission in the first 10 days of life. CONCLUSIONS Although readmissions for jaundice, dehydration, and feeding difficulties may be less common for some minority groups and Medicaid recipients in the era of the Newborns' and Mothers' Health Protection Act compared with nonminorities or privately insured patients, several predictors of newborn readmission have established associations with inexperienced parenting and/or breastfeeding difficulty. This is one indication that this well-intentioned legislation and current practice may not be sufficiently protecting the health of newborns and suggests that additional support for mothers and newborns during the vulnerable postdelivery period may be indicated.
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Affiliation(s)
- Ian M Paul
- Penn State College of Medicine, Pediatrics H085, 500 University Dr, Hershey, PA 17033, USA.
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35
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Abstract
PURPOSE To describe the concept of Nurse Dose. METHODS The concept of nurse dose has been identified from decades of clinical research as a concept essential in the delivery of safe and high quality health care. The components of nurse dose were conceptualized through review of the literature from nursing, medicine, and health services research. FINDINGS Nurse dose is conceptualized as having three equally essential components: dose, nurse, and host and host response. Dose in the macro view includes the number of nurses per patient or per population in cities, states, regions, or countries. Dose in a micro view includes the amount of nurse time and the number of contacts. The nurse component consists of the education, expertise, and experience of the nurse. Host is represented by an organization and its characteristics (culture, autonomy, practice control) in a macro view and by the patient and characteristics (beliefs, values, culture) in a micro view. Host response includes response to the autonomy and acceptability of the nurse. CONCLUSIONS Greater nurse dose has been associated with decreases in patient mortality, morbidity, and healthcare costs.
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Affiliation(s)
- Dorothy Brooten
- School of Nursing, Florida International University, Miami 33181, USA.
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Abstract
This article reviews outcomes, indicators, and challenges for building evidence-based practice in community maternal-child health (MCH), and includes promising new design and analytical strategies. In addition, 10 topic areas are listed, which are the foundation of community MCH evidence: (1) evidence of health behavior on mortality/morbidity; (2) theoretical underpinnings of public policy interventions; (3) evidence of growing health disparities; (4) the potential of exploding information technologies; (5) data on aging, maternity, employment, and lactation; (6) data on the changing face of HIV/AIDS; (7) data on the changing way we give birth; (8) drug safety registries; (9) antibiotic-resistant organisms; and (10) environmental pollutants and health. In addition, evidence of indirect and global influences on community MCH is reviewed and the principles of lifestyle change and health promotion are emphasized.
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Affiliation(s)
- Linda Beth Tiedje
- Department of Epidemiology, School of Human Medicine, Michigan State University, East Lansing, USA.
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Abstract
PURPOSE OF REVIEW To concisely review data published over the past year on three topics pertinent to the practicing pediatrician: immunizations, neonatal jaundice, and animal-induced injuries. RECENT FINDINGS Updates on immunizations, including varicella and pneumococcus in the post-vaccine era, use of a polyvalent conjugated meningococcal vaccine, and influenza vaccination during a vaccine shortage are discussed. Mortality and morbidity from varicella, and risk of invasive disease from pneumococcal infections have declined. The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention released guidelines for the use of a tetravalent meningococcal conjugate vaccine in adolescents 11 years and older. Infants at younger gestational age are at higher risk for developing hyperbilirubinemia. The American Academy of Pediatrics has released new guidelines emphasizing breastfeeding, systematic pre-discharge assessment for risk factors, early follow-up and intervention. Use of home nursing services in the postnatal period is cost-effective. Although the incidence of rabies is low, many receive postexposure prophylaxis. Spider bites cause fewer systemic effects in children than adults. Pet reptile carriage of salmonella necessitates handwashing after handling of animals. SUMMARY Recommendations for adolescent meningococcal vaccination, and the impact of varicella and pneumococcal immunization on our communities reflect an evolution in our management of infectious diseases. The latest practice guidelines on hyperbilirubinemia emphasize close follow-up of all newborns after postpartum discharge and even more careful evaluation of those infants near term. Education on rabies prophylaxis, spider bites, and salmonella from pet reptiles should focus on judicious use of resources and the proper handling of pets.
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Affiliation(s)
- Melissa S Lee
- Harvard Combined Program in Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
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