Early Literacy Promotion Using Automated Hovering Among Young Minority Children

OBJECTIVE

To determine feasibility, acceptability, and explore outcomes of behavioral economic (BE) strategies to increase parent-child shared reading within a Reach Out and Read program.

METHODS

We conducted rapid-cycle interviews with 10 parents to assess text messages followed by an 8-week randomized controlled trial of 3 BE strategies at 2 urban primary care practices: daily text messages (texting); daily text messages and regret messaging (regret); or daily text messages, regret messaging, and lottery participation (lottery). Parent-child dyads were eligible if children were <24 months old, Medicaid-eligible, and had access to phones capable of receiving and sending text messages. Parents completed the Read Subscale of the StimQ and Parenting Stress Index-short form (PSI-SF) pre- and postintervention, MacArthur Communicative Development Inventory (CDI), Devereux Early Childhood Assessment (DECA), and a satisfaction measure postintervention. Differences between groups were assessed using intention-to-treat analysis.

RESULTS

Of 45 dyads randomized, 41 (91%) completed the study. Most participants were Black with incomes <$55,000. Parents reported reading on average 4 d/wk with no change in the reading frequency over time. StimQ scores increased over time, but there were no significant differences in StimQ, PSI-SF, CDI, and DECA scores between groups. Parents in all 3 groups reported satisfaction (3.8/5.0) with the intervention.

CONCLUSIONS

Implementation of BE strategies in 2 Reach Out and Read programs was feasible, near acceptable, and improved home reading environment scores. Future study should investigate BE strategies vis-à-vis usual care and be of sufficient duration and intensity to engage participants to assess its impact on patient and parent outcomes.

Neighborhood Social Vulnerability and Interstage Weight Gain: Evaluating the Role of a Home Monitoring Program

Background Poor interstage weight gain is a risk factor for adverse outcomes in infants with hypoplastic left heart syndrome. We sought to examine the association of neighborhood social vulnerability and interstage weight gain and determine if this association is modified by enrollment in our institution's Infant Single Ventricle Management and Monitoring Program (ISVMP). Methods and Results We performed a retrospective single-center study of infants with hypoplastic left heart syndrome before (2007-2010) and after (2011-2020) introduction of the ISVMP. The primary outcome was interstage weight gain, and the secondary outcome was interstage growth failure. Multivariable linear and logistic regression models were used to examine the association between the Social Vulnerability Index and the outcomes. We introduced an interaction term into the models to test for effect modification by the ISVMP. We evaluated 217 ISVMP infants and 111 pre-ISVMP historical controls. The Social Vulnerability Index was associated with interstage growth failure (P=0.001); however, enrollment in the ISVMP strongly attenuated this association (P=0.04). Pre-ISVMP, as well as high- and middle-vulnerability infants gained 4 g/d less and were significantly more likely to experience growth failure than low-vulnerability infants (high versus low: adjusted odds ratio [aOR], 12.5 [95% CI, 2.5-62.2]; middle versus low: aOR, 7.8 [95% CI, 2.0-31.2]). After the introduction of the ISVMP, outcomes did not differ by Social Vulnerability Index tertile. Infants with middle and high Social Vulnerability Index scores who were enrolled in the ISVMP gained 4 g/d and 2 g/d more, respectively, than pre-ISVMP controls. Conclusions In infants with hypoplastic left heart syndrome, high social vulnerability is a risk factor for poor interstage weight gain. However, enrollment in the ISVMP significantly reduces growth disparities.

Diversity in the pediatric research workforce: a scoping review of the literature

The purpose of this scoping review is to determine trends in racial and ethnic representation, identify barriers and facilitators to greater diversity, and assess strategies and interventions to advance diversity among those in the pediatric research workforce in the U.S. We conducted a scoping review of PubMed supplemented with the authors' personal library of papers published from January 1, 2010, to December 31, 2021. To be eligible, papers had to provide original data, be published in English, report information from a U.S. healthcare institution, and report on outcomes of interest relevant to the child health field. The diversity of faculty has modestly increased over the past decade but reflects a worsening representation compared to overall population trends. This slow increase reflects a loss of diverse faculty and has been referred to as a "leaky pipeline." Strategies to plug the "leaky pipeline" include greater investments in pipeline programs, implementation of holistic review and implicit bias training, development of mentoring and faculty programs targeted to diverse faculty and trainees, alleviation of burdensome administrative tasks, and creation of more inclusive institutional environments. Modest improvements in the racial and ethnic diversity of the pediatric research workforce were identified. However, this reflects worsening overall representation given changing U.S. population demographics. IMPACT: Racial and ethnic diversity in the pediatric research workforce has shown modest increases but worsening overall representation. This review identified barriers and facilitators at the intrapersonal, interpersonal, and institutional levels that impact BIPOC trainees and faculty career advancement. Strategies to improve the pathway for BIPOC individuals include greater investments in pipeline and educational programs, implementation of holistic review admissions and bias training, institution of mentoring and sponsorship, alleviation of burdensome administrative responsibilities, and creation of inclusive institutional climates. Future studies should rigorously test the effects of interventions and strategies designed to improve diversity in the pediatric research workforce.

Social Media-based Parenting Program for Women With Postpartum Depressive Symptoms: An RCT

OBJECTIVES

To test effects of a social media-based parenting program for mothers with postpartum depressive symptoms.

METHODS

We conducted a randomized controlled trial from December 2019 to August 2021 of a parenting program using Facebook. Women with mild-to-moderate depressive symptoms (Edinburgh Postnatal Depression Scale [EPDS] 10-19) were randomized to the program, plus online depression treatment or depression treatment alone for 3 months. Women completed the EPDS monthly and the Parent-Child Early Relational Assessment, Parenting Stress Index-Short Form, and Parenting Sense of Competence pre- and postintervention. Differences among groups were assessed using intention-to-treat analysis.

RESULTS

Seventy-five women enrolled and 66 (88%) completed the study. Participants were predominantly Black (69%), single (57%), with incomes <$55 000 (68%). The parenting group reported a more rapid decline in depressive symptoms than the comparison group (adjusted EPDS difference, -2.9; 95% confidence interval, -4.8 to -1.0 at 1 month). There were no significant group X time interactions for the Parent-Child Early Relational Assessment, Parenting Stress Index-Short Form, or Parenting Sense of Competence scores. Forty-one percent of women sought mental health treatment for worsening symptoms or suicidality. Women in the parenting group who exhibited greater engagement or reported mental health treatment had greater parenting responsiveness.

CONCLUSIONS

A social media-based parenting program led to more rapid declines in depressive symptoms but no differences in responsive parenting, parenting stress, or parenting competence relative to a comparison group. Social media can provide parenting support for women with postpartum depressive symptoms, but greater attention to engagement and treatment access are needed to improve parenting outcomes.

Incidence and risk factors for hypoglycemia during maintenance chemotherapy in pediatric acute lymphoblastic leukemia

BACKGROUND

Fasting hypoglycemia is a recognized occurrence among pediatric patients with acute lymphoblastic leukemia (ALL) during maintenance therapy. Existing publications describing this finding are limited to small studies and case reports. Our objective was to determine the incidence of hypoglycemia during maintenance chemotherapy and to investigate the association of age, as well as other potential risk factors, with this outcome in pediatric patients with ALL.

PROCEDURE

This retrospective cohort study included individuals 1 to 21 years of age with ALL treated with antimetabolite-containing maintenance chemotherapy at a large children's hospital between January 2011 and December 2014. The primary endpoint was time to first documented episode of hypoglycemia during maintenance therapy, defined as single measurement of plasma glucose <60 mg/dL. Cox regression was used to evaluate the association with age and identify other potential risk factors.

RESULTS

We identified 126 eligible patients, of whom 63% were documented as White, non-Hispanic, 28% as non-White, non-Hispanic, and 9% as Hispanic. Twenty-eight children (22%) had documented hypoglycemia during maintenance therapy. Younger age at the start of maintenance and hepatotoxicity documented during chemotherapy prior to maintenance initiation were associated with hypoglycemia (adjusted HR age = 0.88; 95% CI, 0.78-0.99; adjusted HR prior hepatotoxicity = 3.50; 95% CI, 1.47-8.36).

CONCLUSIONS

Nearly one quarter of children in our cohort had hypoglycemia documented during maintenance chemotherapy. Younger age at maintenance initiation and hepatotoxicity during chemotherapy prior to maintenance initiation emerged as risk factors. These findings highlight the importance of counseling about the risk of, and monitoring for, hypoglycemia, particularly in young children.

Perspectives on Breastfeeding from Mothers with Postpartum Depression Symptoms: A Qualitative Assessment of Antecedents, Barriers, Facilitators, and Intervention Suggestions

Background: Postpartum depression (PPD) is one of the most common birthing complications, and studies negatively associate PPD with breastfeeding initiation and continuation. However, little is known about either the breastfeeding experience of mothers with PPD or what resources mothers need for sustained breastfeeding from their perspectives. This study aimed to identify the antecedents, barriers, and facilitators to breastfeeding for mothers with PPD, understand the relationship between self-efficacy and emergent themes, and generate suggestions to inform supportive interventions. Materials and Methods: Birth mothers who screened positive for PPD and reported breastfeeding were recruited to participate in semistructured interviews. Interviews were transcribed verbatim, and inter-coder discrepancies from double coding were resolved through consensus. Thematic analysis was facilitated using immersion-crystallization methods. Results: Participants identified five antecedent themes that encourage initiation (professional support, infant health, mother's health, cost-effectiveness, and faith), four facilitator themes for sustained breastfeeding (infant connection, decreased stress, personal attributes, and logistical strategies), and seven barrier themes (physical pain, infant nutrition, negative feelings, latching difficulties, medical conditions, public breastfeeding, and sleep). Participants' suggestions fell into three primary themes: supportive services, managing expectations, and respecting self-determination. Conclusion: Antecedent and facilitator themes did not overlap, indicating that factors encouraging breastfeeding initiation differ from sustaining factors. Participant suggestions, barriers, and facilitators did not largely differ from mothers without PPD in other qualitative studies. Therefore, interventions should tailor support to specific breastfeeding phase and may not need to be markedly different for mothers with PPD, in addition to depression management.

Improving Care Management in Attention-Deficit/Hyperactivity Disorder: An RCT

OBJECTIVES

To compare the effectiveness of care management combined with a patient portal versus a portal alone for communication among children with attention-deficit/hyperactivity disorder (ADHD).

METHODS

Randomized controlled trial conducted at 11 primary care practices. Children aged 5 to 12 years old with ADHD were randomly assigned to care management + portal or portal alone. The portal included parent-reported treatment preferences and goals, medication side effects, and parent- and teacher-reported ADHD symptom scales. Care managers provided education to families; communicated quarterly with parents, teachers, and clinicians; and coordinated care. The main outcome, changes in the Vanderbilt Parent Rating Scale (VPRS) score as a measure of ADHD symptoms, was assessed using intention-to-treat analysis.

RESULTS

A total of 303 eligible children (69% male; 46% Black) were randomly assigned, and 273 (90%) completed the study. During the 9-month study, parents in the care management + portal arm communicated inconsistently with care managers (mean 2.2; range 0-6) but similarly used the portal (mean 2.3 vs 2.2) as parents in the portal alone arm. In multivariate models, VPRS scores decreased over time (Adjusted β = -.015; 95% confidence interval -0.023 to -0.07) in both groups, but there were no intervention-by-time effects (Adjusted β = .000; 95% confidence interval -0.011 to 0.012) between groups. Children who received ≥2 care management sessions had greater reductions in VPRS scores than those with fewer sessions.

CONCLUSIONS

Results did not provide evidence that care management combined with a patient portal was different from portal use alone among children with ADHD. Both groups demonstrated similar reductions in ADHD symptoms. Those families with greater care management engagement demonstrated greater reductions than those with less engagement.

Promoting Early Literacy Using Digital Devices: A Pilot Randomized Controlled Trial

OBJECTIVE

To determine feasibility and explore effects of literacy promotion using e-books versus board books on the home reading environment, book reading, television use, and child development.

METHODS

Randomized controlled trial comparing digital literacy promotion (DLP) using e-books to standard literacy promotion (SLP) using board books among Medicaid-eligible infants. DLP participants received e-books on home digital devices, while SLP participants received board books at well visits between 6 and 12 months of age. Differences in StimQ Read Subscale (StimQ-Read) scores, parent-reported reading and television use, and Bayley Scales of Infant Development-3rd Edition (Bayley-3) scores between groups were assessed using intention-to-treat analysis.

RESULTS

A total of 104 Medicaid-eligible infants were enrolled and randomized from 3 pediatric practices. There were no differences in sociodemographic characteristics between groups at baseline. Children in the DLP group initially had lower StimQ-Read scores but showed similar increases in StimQ-Read scores over time as children in the SLP group. Parents in the DLP group reported greater use of digital devices to read or engage their child (65% vs 23%, P < .001) but similar board book reading and television viewing. There were no differences between groups in cognitive or motor scale scores, but DLP participants had marginally lower language scales scores (DLP 85.7 vs SLP 89.7; P = .10) at the 6-month follow-up.

CONCLUSIONS/DISCUSSION

Literacy promotion using e-books was feasible and associated with greater e-book usage but no difference in board book reading, television viewing, or home reading environment scores. A potential adverse impact of e-books on language development should be confirmed in future study.

Effect of Family Navigation on Diagnostic Ascertainment Among Children at Risk for Autism: A Randomized Clinical Trial From DBPNet

IMPORTANCE

Early identification of autism spectrum disorder (ASD) is associated with improved cognitive and behavioral outcomes. Targeted strategies are needed to support equitable access to diagnostic services to ensure that children from low-income and racial/ethnic minority families receive the benefits of early ASD identification and treatment.

OBJECTIVE

To test the efficacy of family navigation (FN), an individually tailored, culturally informed care management strategy, to increase the likelihood of achieving diagnostic ascertainment among young children at risk for ASD.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial of 249 families of children aged 15 to 27 months who had positive screening results for possible ASD was conducted in 11 urban primary care sites in 3 cities. Data collection occurred from February 24, 2015, through November 5, 2018. Statistical analysis was performed on an intent-to-treat basis from November 5, 2018, to July 27, 2020.

INTERVENTIONS

Families were randomized to FN or conventional care management (CCM). Families receiving FN were assigned a navigator who conducted community-based outreach to families to address structural barriers to care and support engagement in recommended services. Families receiving CCM were assigned to a care manager, who did limited telephone outreach. Families received FN or CCM after positive initial screening results and for 100 days after diagnostic ascertainment.

MAIN OUTCOMES AND MEASURES

The primary outcome, diagnostic ascertainment, was measured as the number of days from randomization to completion of the child's clinical developmental evaluation, when a diagnosis of ASD or other developmental disorder was determined.

RESULTS

Among 250 families randomized, 249 were included in the primary analysis (174 boys [69.9%]; mean [SD] age, 22.0 [3.5] months; 205 [82.3%] publicly insured; 233 [93.6%] non-White). Children who received FN had a greater likelihood of reaching diagnostic ascertainment over the course of 1 year (FN, 108 of 126 [85.7%]; CCM, 94 of 123 [76.4%]; unadjusted hazard ratio [HR], 1.39 [95% CI, 1.05-1.84]). Site (Boston, New Haven, and Philadelphia) and ethnicity (Hispanic vs non-Hispanic) moderated the effect of FN (treatment × site interaction; P = .03; Boston: HR, 2.07 [95% CI, 1.31-3.26]; New Haven: HR, 1.91 [95% CI, 0.94-3.89]; and Philadelphia: HR, 0.91 [95% CI, 0.60-1.37]) (treatment × ethnicity interaction; P < .001; Hispanic families: HR, 2.81 [95% CI, 2.23-3.54] vs non-Hispanic families: HR, 1.49 [95% CI, 1.45-1.53]). The magnitude of FN's effect was significantly greater among Hispanic families than among non-Hispanic families (diagnostic ascertainment among Hispanic families: FN, 90.9% [30 of 33], and CCM, 53.3% [16 of 30]; vs non-Hispanic families: FN, 89.7% [35 of 39], and CCM, 77.5% [31 of 40]).

CONCLUSIONS AND RELEVANCE

Family navigation improved the likelihood of diagnostic ascertainment among children from racial/ethnic minority, low-income families who were detected as at risk for ASD in primary care. Results suggest differential effects of FN by site and ethnicity.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02359084.

State Variation in Posthospital Home Nursing for Commercially Insured Medically Complex Children

BACKGROUND AND OBJECTIVES

Home nursing is essential for children with medical complexity (CMC), but provision varies substantially across states. Our objectives were to quantify state-to-state variability in distribution of posthospitalization home nursing to commercially insured CMC and to rank-order states.

METHODS

Retrospective cohort study of hospitalized commercially insured children with ≥1 complex chronic condition from birth to 18 years of age in the Truven MarketScan database. Cohort eligibility criteria were hospital discharge between January 2013 and November 2016 and at least 30 days of follow-up after discharge. Two primary outcome measures were used: receipt of any home nursing within 30 days of hospital discharge (yes or no) and number of days of posthospitalization home nursing (1-30 days). A composite metric encompassing both receipt and quantity was created by evaluating the 95th percentile of days of home nursing (0-30 days).

RESULTS

Overall, 9.9% of the sample received home nursing. After we adjusted for patient characteristics, the probability of receiving home nursing varied across states, ranging from 3.4% to 19.2%. Among home nursing recipients, the adjusted median home nursing days across states ranged from 6.6 to 24.5 days. The adjusted 95th percentile of days of home nursing (across the entire of sample, including recipients and nonrecipients of home nursing) ranged from 6.8 to 22.6 days.

CONCLUSIONS

We observed striking state-to-state variability in receipt of home nursing and mean number of days of posthospitalization home nursing among commercially insured CMC after adjustment for demographic and clinical differences. This suggests opportunities for state-level improvement.

Annual Report on Children's Healthcare: Healthcare Access and Utilization by Obesity Status in the United States

OBJECTIVE

To examine access to care and utilization patterns across a set of healthcare measures by obesity status and socio-demographic characteristics among children.

METHODS

Nationally representative data from the Medical Expenditure Panel Survey (2010-2015) provides data on obesity status, well-child visits, access to a usual source of care provider, preventive dental visits, and prescription medication fills in the past year.

RESULTS

Uninsured adolescents with obesity were less likely to have a usual source of care provider relative to children without obesity (73% vs 65%). Among younger children, children with obesity were less likely to report a well-child visit (difference of 8 percentage points). Younger children with obesity who lived in the Northeast were more than twice as likely as those living in the West to have a well-child visit. Children with obesity were less likely to report preventive dental use relative to their nonobese counterparts. Obesity status was associated with more prescription medication fills for adolescents, but not for younger children.

CONCLUSIONS

Our findings provide a baseline assessment for examining obesity and utilization trends among children in the future, especially as coverage patterns change with potential changes in childhood insurance coverage access through the Child Health Insurance Programs and Medicaid programs. Our findings highlight new directions for future research, particularly regarding the lower rates of preventive dental care among children with obesity.

Latino Parents' Experiences With Literacy Promotion in Primary Care: Facilitators and Barriers

OBJECTIVE

Literacy promotion is a pediatric standard of care in which clinicians provide guidance on shared reading. Latino parents are more likely to hear advice to read with children but are less likely to do so. We sought to understand literacy promotion from the perspective of Latino parents and to identify facilitators and barriers.

METHODS

We purposively sampled Latino parents who participated in Reach Out and Read (ROR) for a qualitative, semistructured interview study. We identified themes using immersion/crystallization and achieved thematic saturation after 21 interviews.

RESULTS

Two thirds of participants had less than high school education; half of whom had not completed eighth grade. The mean child age was 16.4 months. Primary facilitators of engagement were advice from a pediatrician during a clinical encounter and receipt of the ROR book. Barriers identified included: 1) parents' perceptions that their children were not developmentally ready and that their children's behavior (eg, activity) indicated they were not interested in shared reading; 2) self-perceived limited literacy and/or English proficiency; 3) parenting demands occurring in the context of poverty; and 4) continued child media use despite advice from pediatricians to choose alternate activities such as shared reading instead.

CONCLUSIONS

Parent-clinician relationships are central to ROR's impact but clinicians need to pay more attention to factors in a child's broader environment to strengthen literacy promotion. Specifically clinicians should emphasize skill building during the clinical encounter (eg, sharing knowledge about child development and modeling) and work collaboratively with other stakeholders to address poverty-related stressors.

The risk of major bleeding in patients with suspected heparin-induced thrombocytopenia

BACKGROUND

The presence of a hypercoagulable disorder such as heparin-induced thrombocytopenia (HIT) may protect against anticoagulant-associated bleeding.

OBJECTIVES

To determine the incidence of major bleeding in patients with suspected HIT.

METHODS

We performed a retrospective analysis of 310 patients suspected of having HIT from the Hospital of the University of Pennsylvania and an affiliated community hospital. We compared the cumulative incidence of major bleeding following suspicion for HIT by ultimate HIT status (HIT+ or HIT-) and exposure to an alternative anticoagulant (Tx+ or Tx-). Secondary outcomes included the incidence of new/progressive thrombosis and 30-day mortality.

RESULTS

The incidence of major bleeding was high in the HIT+Tx+, HIT- Tx+, and HIT-Tx- groups (35.7%, 44.0%, and 37.3%, respectively). The time to first major bleeding event did not differ between groups (P = .24). Factors associated with increased risk of major bleeding included intensive care unit admission (HR 2.24, 95% CI 1.44-3.47), platelet count < 25 × 109 /L (HR 2.13, 1.10-4.12), and renal dysfunction (HR 1.56, 1.06-2.27); 35.7% of HIT+Tx+, 13.8% HIT-Tx+, and 9.3% of HIT-Tx- patients experienced new or progressive thrombosis. Mortality was similar among the three groups (26.2% HIT+Tx+, 34.5% HIT-Tx+, and 26.7% of HIT-Tx- [P = .34]).

CONCLUSIONS

Among patients with suspected HIT, major bleeding was common regardless of HIT status. Contrary to our hypothesis, HIT+ patients were not protected from major bleeding. A better understanding of bleeding risk is needed to inform management decisions in patients with suspected HIT.

Mothers' Mental Health Care Use After Screening for Postpartum Depression at Well-Child Visits

OBJECTIVE

The American Academy of Pediatrics recommends postpartum depression (PPD) screening. It is unknown whether pediatricians are effective in linking mothers to mental health services. The objectives of the current study are to determine 1) mental health care use among women with Medicaid insurance after a positive PPD screen and 2) maternal and infant factors that predict the likelihood of mental health care use.

METHODS

Retrospective cohort design of mothers attending their infants' 2-month well child visit at 1 of 5 urban primary care practices between 2011 and 2014. A linked dataset of the child's electronic health records, maternal Medicaid claims, and birth certificates was used. The primary outcome was mental health care use within 6 months of a positive PPD screen. Multivariate logistic regression was used to estimate maternal and infant clinical and sociodemographic factors that predict service use.

RESULTS

In total, 3052 mothers met study criteria, 1986 (65.1%) completed the PPD screen, and 263 (13.2%) screened positive for PPD, of whom 195 (74.1%%) were referred for services. Twenty-three women (11.8%) had at least 1 Medicaid claim for depression within 6 months of screening. In multivariate modeling, mothers with a history of depression in the previous year (odds ratio = 3.80, 1.20-12.11) were more likely to receive mental health services after a positive screen.

CONCLUSIONS

Few mothers who screened positive for PPD received mental health services. Mothers without a recent history of depression treatment may be especially at risk for inadequate care. Additional mechanisms to improve access to mental health services after PPD screening are needed.

Sharing of ADHD Information between Parents and Teachers Using an EHR-Linked Application

BACKGROUND

Appropriate management of attention-deficit/hyperactivity disorder (ADHD) involves parents, clinicians, and teachers. Fragmentation of interventions between different settings can lead to suboptimal care and outcomes. Electronic systems can bridge gaps across settings. Our institution developed an email-based software to collect ADHD information from parents and teachers, which delivered data directly to the clinician within the electronic health record (EHR).

OBJECTIVE

We sought to adapt our institution's existing EHR-linked system for ADHD symptom monitoring to support communication between parents and teachers and then to assess child characteristics associated with sharing of ADHD information.

METHODS

We updated our software to support automated sharing of ADHD information between parents and teachers. Sharing was optional for parents but obligatory for teachers. We conducted a retrospective cohort study involving 590 patients at 31 primary care sites to evaluate a system for sharing of ADHD-specific health information between parents and teachers. We used multivariable logistic regression to estimate associations between child characteristics and parental sharing. We further investigated the association between child characteristics and viewing of survey results delivered through the electronic communication system.

RESULTS

Most parents (64%) elected to share survey results with teachers at the first opportunity and the vast majority (80%) elected to share all possible information. Parents who elected to share usually continue sharing at subsequent opportunities (89%). Younger child age and performance impairments were associated with increased likelihood of sharing. However, parents viewed only 16% of teacher submitted surveys and teachers only viewed 30% of surveys shared by parents.

CONCLUSION

This study demonstrates that electronic systems to capture ADHD information from parents and teachers can be adapted to support communication between them, and that parents are amenable to sharing ADHD information with teachers. However, strategies are needed to encourage viewing of shared information.

A mixed-methods process evaluation of Family Navigation implementation for autism spectrum disorder

There is growing interest in Family Navigation as an approach to improving access to care for children with autism spectrum disorder, yet little data exist on the implementation of Family Navigation. The aim of this study was to identify potential failures in implementing Family Navigation for children with autism spectrum disorder, using a failure modes and effects analysis. This mixed-methods study was set within a randomized controlled trial testing the effectiveness of Family Navigation in reducing the time from screening to diagnosis and treatment for autism spectrum disorder across three states. Using standard failure modes and effects analysis methodology, experts in Family Navigation for autism spectrum disorder (n = 9) rated potential failures in implementation on a 10-point scale in three categories: likelihood of the failure occurring, likelihood of not detecting the failure, and severity of failure. Ratings were then used to create a risk priority number for each failure. The failure modes and effects analysis detected five areas for potential "high priority" failures in implementation: (1) setting up community-based services, (2) initial family meeting, (3) training, (4) fidelity monitoring, and (5) attending testing appointments. Reasons for failure included families not receptive, scheduling, and insufficient training time. The process with the highest risk profile was "setting up community-based services." Failure in "attending testing appointment" was rated as the most severe potential failure. A number of potential failures in Family Navigation implementation-along with strategies for mitigation-were identified. These data can guide those working to implement Family Navigation for children with autism spectrum disorder.

Annual Report on Health Care for Children and Youth in the United States: Focus on 30-Day Unplanned Inpatient Readmissions, 2009 to 2014

OBJECTIVE

To describe trends in unplanned 30-day all-condition hospital readmissions for children aged 1 to 17 years between 2009 and 2014.

METHODS

Analysis was conducted with the 2009-14 Nationwide Readmissions Database from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project. Annual hospital readmission rates, resource use, and the most common reasons for readmission were calculated for the 2009-14 period.

RESULTS

The rate of readmission for children aged 1 to 17 years was essentially stable between 2009 and 2014 (5.5% in 2009 and 5.9% in 2014). In 2009, the most common reason (principal diagnosis) for readmission was sickle cell anemia, whereas in 2014 the most common reason was epilepsy. Pneumonia fell from the second to the sixth most common reason for readmission over this period (from 3832 to 2418 stays). Other respiratory infections were among the top 10 principal readmission diagnoses in 2009, but not in 2014. Septicemia was among the 10 most common reasons for readmission in 2014, but not in 2009. Although the average cost of index (ie, initial) stays with a subsequent readmission were similar in 2009 and 2014, the average cost of index stays without a readmission and cost of readmission stays increased by approximately 23%. In both 2009 and 2014, the average cost of the index stays with a subsequent readmission was 73% to 89% higher than that of the index stays of children who were not readmitted within 30 days. The average cost of index stays preceding a readmission was 33% to 45% higher than average costs for readmitted stays. In 2014, the aggregate cost of index stays plus readmissions was $1.58 billion, with 42.9% of the costs attributable to readmissions. Regarding the average costs and lengths of stay for the 10 most common readmission diagnoses, in 2009 the average cost per stay for complications of devices, implants, or grafts was nearly 5 times greater than that of asthma ($21,200 vs $4500, respectively). In 2014, average cost per stay ranged from $5500 for asthma to $39,500 for septicemia. In 2009, the average length of stay (LOS) for complications of devices, implants, or grafts was more than 3 three times higher than that for asthma (7.8 days vs 2.5 days, respectively), and in 2014, the average LOS for septicemia was nearly 4 times higher than that for asthma (10.4 days vs. 2.6 days).

CONCLUSIONS

This study provides a baseline assessment for examining trends in 30-day unplanned pediatric readmissions, an important quality metric as the provisions of the Children's Health Insurance Program Reauthorization Act and the Affordable Care Act are changed and implemented in the future. More than 50,000 pediatric hospital stays in 2014 occurred within 30 days of a previous hospitalization, with an average cost of $13,800. This report is timely, as the health care system works to become more patient-centered and public and private payers grapple with how to pay for quality care for children. The report provides baseline information that can be used to further explore ways to reduce unplanned readmissions.

Evaluation of the PROMIS pediatric global health scale (PGH-7) in children with asthma

OBJECTIVE

To evaluate the reliability and validity of the PROMIS Pediatric Global Health scale, a 7-item measure of perceived physical, mental, and social health, in children with asthma.

METHODS

From February 2014 to February 2015, convenience samples of 8-17 year-old children (n = 182) and parents of 5-17 year-old children (n = 328) visiting an emergency department for treatment of asthma were enrolled. The Asthma Control Test was used to characterize children as controlled versus not controlled, and the PROMIS Asthma Impact Scale was used to assess asthma symptoms' impact on functional status. We conducted longitudinal analyses among 92 children and 218 parents at 3 weeks, and 74 children and 171 parents at 8 weeks after enrollment.

RESULTS

The PGH-7 reliability ranged from 0.66 to 0.81 for child-report and 0.76 to 0.82 for parent-proxy. In cross-sectional analyses, children with controlled asthma had PGH-7 scores 0.40-0.95 standard deviation units higher than those who were uncontrolled. The PGH-7 was responsive to changes in overall general health between time points, with moderate effect sizes (0.5-0.6 standard deviation units). In longitudinal analyses, PGH-7 scores were no different between those who stayed uncontrolled versus became controlled at 3 weeks of follow-up; however, by 8 weeks of follow-up, the differences between these groups were 0.7-0.8 standard deviation units, indicative of large effects.

CONCLUSIONS

The PGH-7 is a reliable and valid patient-reported outcome for assessing general health among children with asthma. It is a useful complement to other asthma-specific outcome measures.

Screening for Parental Depression in Urban Primary Care Practices: A Mixed Methods Study

We sought to determine feasibility and acceptability of parental depression screening in urban pediatric practices. We recruited seven practices to participate. Patient Health Questionnaire-2, a validated two-item screening tool, was used to screen for depressive symptoms at 1-3 year old well visits. We conducted semi-structured interviews with clinicians to identify barriers and facilitators to screening. Of 8,621 eligible parents, 21.1% completed screening with site-specific rates ranging from 10.1% to 48.5%. Among those screened, 8.1% screened positive for depressive symptoms with site-specific rates ranging from 1.2% to 16.9%. Electronic alerts improved screening rates from 45 / month to 170 / month. Fifteen clinicians completed interviews and endorsed screening to provide help for families, build stronger ties with parents, and improve outcomes for children. However, insufficient time, need to complete activities with higher priority, lack of mental health availability, few resources for parents with limited English proficiency, and discomfort addressing depression were thought to limit screening.

The Harold Amos Medical Faculty Development Program: Evaluation of a National Program to Promote Faculty Diversity and Health Equity

Purpose: The Harold Amos Medical Faculty Development Program (AMFDP), a national program of the Robert Wood Johnson Foundation, seeks to support academic physicians from historically disadvantaged backgrounds and serves as a model program for promoting faculty diversity and health equity. Our objective was to determine differences in scientific productivity, promotions and retentions, and leadership attainment among faculty applicants to this national minority faculty development program.

Methods: Final-round interview applicants from 2003 to 2008 were selected. Differences in publications, grants, promotions/retentions, and leadership positions through 2013 were compared between funded scholars and unfunded nonscholars. Semistructured interviews were conducted to identify factors that facilitated and hindered academic success.

Results: A total of 124 applicants (76 scholars and 48 nonscholars) who participated in final-round interviews from 2003 to 2008 were eligible. Scholars and nonscholars had similar number of publications. Scholars had greater number of grants and grant dollars, but differences were not significant after accounting for AMFDP program awards. Scholars were more likely to hold leadership positions (28% vs. 10%, p=0.02), but equally likely to be promoted (67% vs. 58%, p=0.32) and retained (84% vs. 75%, p=0.21). In interviews, all participants endorsed mentoring, funding, and nonscientific education to academic success, but scholars reported greater availability of leadership opportunities consequent to AMFDP.

Conclusion: There were few differences in academic productivity attributable to a national faculty diversity program. However, program participants were more likely to endorse and attain leadership positions. Academic institutions should consider facilitating leadership development of minority faculty as a means of advancing health equity research and training.

Variation in Positive End-Expiratory Pressure Levels for Mechanically Ventilated Extremely Low Birth Weight Infants

OBJECTIVE

To test the hypothesis that significant positive end-expiratory pressure (PEEP) level variation exists between neonatal centers.

STUDY DESIGN

We performed a secondary analysis cohort study of the Nasal Intermittent Positive-Pressure Ventilation trial. Our study population was extremely low birth weight infants requiring mechanical ventilation within 28 days of life. The exposure was neonatal center; 34 international centers participated in the trial. Subjects from centers with fewer than 5 eligible cases were excluded. The main outcome was the maximal PEEP level used during the first course of mechanical ventilation. Infant characteristics judged a priori to directly influence clinical PEEP level selection and all characteristics associated with PEEP at P <.05 in bivariable analyses were included with and without center in multivariable linear regression models. Variation in PEEP level use between centers following adjustment for infant characteristics was assessed.

RESULTS

A total of 278 extremely low birth weight infants from 17 centers were included. Maximal PEEP ranged from 3 to 9 cm H₂O, mean = 5.7 (SD = 0.9). Significant variation between centers remained despite adjustment for infant characteristics (P < .0001). Further, center alone explained a greater proportion of the PEEP level variation than all infant characteristics combined.

CONCLUSIONS

Marked variation in PEEP levels for extremely low birth weight infants exists between neonatal centers. Research providing evidence-based guidance for this important aspect of respiratory care in preterm infants at high risk of lung injury is needed.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00433212.

Racial Disparities in Medicaid Asthma Hospitalizations

BACKGROUND AND OBJECTIVES

Black children with asthma comprise one-third of all asthma patients in Medicaid. With increasing Medicaid coverage, it has become especially important to monitor Medicaid for differences in hospital practice and patient outcomes by race.

METHODS

A multivariate matched cohort design, studying 11 079 matched pairs of children in Medicaid (black versus white matched pairs from inside the same state) admitted for asthma between January 1, 2009 and November 30, 2010 in 33 states contributing adequate Medicaid Analytic eXtract claims.

RESULTS

Ten-day revisit rates were 3.8% in black patients versus 4.2% in white patients (P = .12); 30-day revisit and readmission rates were also not significantly different by race (10.5% in black patients versus 10.8% in white patients; P = .49). Length of stay (LOS) was also similar; both groups had a median stay of 2.0 days, with a slightly lower percentage of black patients exceeding their own state's median LOS (30.2% in black patients versus 31.8% in white patients; P = .01). The mean paired difference in LOS was 0.00 days (95% confidence interval, -0.08 to 0.08). However, ICU use was higher in black patients than white patients (22.2% versus 17.5%; P < .001). After adjusting for multiple testing, only 4 states were found to differ significantly, but only in ICU use, where blacks had higher rates of use.

CONCLUSIONS

For closely matched black and white patients, racial disparities concerning asthma admission outcomes and style of practice are small and generally nonsignificant, except for ICU use, where we observed higher rates in black patients.

Auditing Practice Style Variation in Pediatric Inpatient Asthma Care

IMPORTANCE

Asthma is the most prevalent chronic illness among children, remaining a leading cause of pediatric hospitalizations and representing a major financial burden to many health care systems.

OBJECTIVE

To implement a new auditing process examining whether differences in hospital practice style may be associated with potential resource savings or inefficiencies in treating pediatric asthma admissions.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective matched-cohort design study, matched for asthma severity, compared practice patterns for patients admitted to Children's Hospital Association hospitals contributing data to the Pediatric Hospital Information System (PHIS) database. With 3 years of PHIS data on 48 887 children, an asthma template was constructed consisting of representative children hospitalized for asthma between April 1, 2011, and March 31, 2014. The template was matched with either a 1:1, 2:1, or 3:1 ratio at each of 37 tertiary care children's hospitals, depending on available sample size.

EXPOSURE

Treatment at each PHIS hospital.

MAIN OUTCOMESS AND MEASURES

Cost, length of stay, and intensive care unit (ICU) utilization.

RESULTS

After matching patients (n = 9100; mean [SD] age, 7.1 [3.6] years; 3418 [37.6%] females) to the template (n = 100, mean [SD] age, 7.2 [3.7] years; 37 [37.0%] females), there was no significant difference in observable patient characteristics at the 37 hospitals meeting the matching criteria. Despite similar characteristics of the patients, we observed large and significant variation in use of the ICUs as well as in length of stay and cost. For the same template-matched populations, comparing utilization between the 12.5th percentile (lower eighth) and 87.5th percentile (upper eighth) of hospitals, median cost varied by 87% ($3157 vs $5912 per patient; P < .001); total hospital length of stay varied by 47% (1.5 vs 2.2 days; P < .001); and ICU utilization was 254% higher (6.5% vs 23.0%; P < .001). Furthermore, the patterns of resource utilization by patient risk differed significantly across hospitals. For example, as patient risk increased one hospital displayed significantly increasing costs compared with their matched controls (comparative cost difference: lowest risk, -34.21%; highest risk, 53.27%; P < .001). In contrast, another hospital displayed significantly decreasing costs relative to their matched controls as patient risk increased (comparative cost difference: lowest risk, -10.12%; highest risk, -16.85%; P = .01).

CONCLUSIONS AND RELEVANCE

For children with asthma who had similar characteristics, we observed different hospital resource utilization; some values differed greatly, with important differences by initial patient risk. Through the template matching audit, hospitals and stakeholders can better understand where this excess variation occurs and can help to pinpoint practice styles that should be emulated or avoided.

Practice Patterns in Medicaid and Non-Medicaid Asthma Admissions

BACKGROUND AND OBJECTIVES

With American children experiencing increased Medicaid coverage, it has become especially important to determine if practice patterns differ between Medicaid and non-Medicaid patients. Auditing such potential differences must carefully compare like patients to avoid falsely identifying suspicious practice patterns. We asked if we could observe differences in practice patterns between Medicaid and non-Medicaid patients admitted for asthma inside major children's hospitals.

METHODS

A matched cohort design, studying 17 739 matched pairs of children (Medicaid to non-Medicaid) admitted for asthma in the same hospital between April 1, 2011 and March 31, 2014 in 40 Children's Hospital Association hospitals contributing data to the Pediatric Hospital Information System database. Patients were matched on age, sex, asthma severity, and other patient characteristics.

RESULTS

Medicaid patient median cost was $4263 versus $4160 for non-Medicaid patients (P < .001). Additionally, the median cost difference (Medicaid minus non-Medicaid) between individual pairs was only $84 (95% confidence interval: 44 to 124), and the mean cost difference was only $49 (95% confidence interval: -72 to 170). The 90th percentile costs were also similar between groups ($10 710 vs $10 948; P < .07). Length of stay (LOS) was also very similar; both groups had a median stay of 1 day, with a similar percentage of patients exceeding the 90th percentile of individual hospital LOS (7.1% vs 6.7%; P = .14). ICU use was also similar (10.1% vs 10.6%; P = .12).

CONCLUSIONS

For closely matched patients within the same hospital, Medicaid status did not importantly influence costs, LOS, or ICU use.

Coordinating Systems of Care Using Health Information Technology: Development of the ADHD Care Assistant

Perhaps the two principal venues for the delivery of mental health services are schools and primary care practices. Unfortunately, these systems of care are poorly connected, which may result in care that is fragmented and suboptimal. This article describes the development and implementation of an electronic health record portal, known as the ADHD Care Assistant, to facilitate the sharing of information between schools and primary care offices to promote the use of evidence-based practices for managing children with behavioral health conditions. A feasibility study was conducted across 19 diverse primary care practices with 105 participating providers. Across the practices, 67% of providers activated the system for at least one patient and 32% activated it for five or more cases. Care Assistant use was lower in practices with a relatively high percentage of Medicaid patients (≥ 25%). The article discusses challenges that have arisen among primary care providers, parents, and schools in using the Care Assistant, potential strategies for addressing the challenges, and directions for future research and practice.

Gastric Acid Suppressant Prophylaxis in Pediatric Intensive Care: Current Practice as Reflected in a Large Administrative Database

OBJECTIVES

Stress-related gastrointestinal bleeding may occur in PICU patients. Raising gastric pH with acid suppressant medications is the accepted treatment. We describe the use of histamine 2 receptor blockers and proton pump inhibitors and associated factors among a national sample of PICU patients.

DESIGN

Retrospective cohort analysis using Pediatric Health Information System clinically detailed administrative database.

SETTING

Forty-two children's hospitals throughout the United States.

PATIENTS

All hospitalizations for all patients 20 years old or younger, admitted directly to a PICU, from January 1, 2007, through December 31, 2011.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The exposure of interest was treatment with a histamine 2 receptor blocker, proton pump inhibitor, or both on the first day of PICU admission. Demographics, principal and additional diagnoses, and procedure codes were assessed. For each hospitalization, principal diagnosis, coagulation disorder, head trauma, spinal trauma, severe burns, sepsis, gastrointestinal hemorrhage, mechanical ventilation, blood product transfusion, and 10 complex chronic conditions were identified. The frequency of principal diagnoses was determined to identify the most prevalent PICU diseases. Acid suppressant use was categorized as high or low. Three hundred and thirty-six thousand ten inpatient hospitalizations were sampled. Histamine 2 receptor blocker or proton pump inhibitor was used in 60.0%, with histamine 2 receptor blocker alone in 70.4%, proton pump inhibitor alone in 17.8%, and both agents in 11.8%. Use increased over the sample years 2007 through 2011. Gastrointestinal bleeding occurred in 1.32% of hospitalizations with transfusion needed in 0.1%. Among most prevalent diagnoses, histamine 2 receptor blocker and proton pump inhibitor use ranged from 33% to 87%. Sepsis, coagulopathy, and mechanical ventilation identified higher use. Use of histamine 2 receptor blocker or proton pump inhibitor among hospitals varied considerably ranging from 28% to 87%.

CONCLUSIONS

Histamine 2 receptor blocker and proton pump inhibitor are prescribed in most PICU patients, but significant variation exists across health conditions and hospitals. Institutional preferences likely influence variation. Gastrointestinal hemorrhage is infrequent in the current era. Study data limitations prevent examination of associations between medication use and patient outcomes.

Factors associated with early intervention referral and evaluation: a mixed methods analysis

OBJECTIVE

To identify parent, child, community, and health care provider characteristics associated with early intervention (EI) referral and multidisciplinary evaluation (MDE) by EI.

METHODS

We conducted a mixed methods secondary analysis of data from a randomized controlled trial of a developmental screening program in 4 urban primary care practices. Children <30 months of age not currently enrolled in EI and their parents were included. Using logistic regression, we tested whether parent, child, community, and health care provider characteristics were associated with EI referral and MDE completion. We also conducted qualitative interviews with 9 pediatricians. Interviews were recorded, transcribed, and coded. We identified themes using modified grounded theory.

RESULTS

Of 2083 participating children, 434 (21%) were identified with a developmental concern. A total of 253 children (58%) with a developmental concern were referred to EI. A total of 129 children (30%) received an MDE. Failure in 2 or more domains on developmental assessments was associated with EI referral (adjusted odds ratio [AOR] 3.15, 95% confidence interval [CI] 1.89-5.24) and completed MDE (AOR 2.16, 95% CI 1.19-3.93). Faxed referral to EI, as opposed to just giving families a phone number to call was associated with MDE completion (AOR 2.94, 95% CI 1.48-5.84). Pediatricians reported that office processes, family preference, and whether they thought parents understood the developmental screening tool influenced the EI referral process.

CONCLUSIONS

In an urban setting, one third of children with a developmental concern were not referred to EI, and two thirds of children with a developmental concern were not evaluated by EI. Our results suggest that practice-based strategies that more closely connect the medical home with EI such as electronic transmission of referrals (e.g., faxing referrals) may improve completion rates of EI evaluation.

Challenges to implementation of developmental screening in urban primary care: a mixed methods study

Background

Research is needed to identify challenges to developmental screening and strategies for screening in an urban pediatric setting.

Methods

Parents of young children and clinicians at four urban pediatric practices participated in focus groups prior to implementation of screening. Participants were queried regarding attitudes, social norms, and barriers to developmental screening. Using information from the focus groups, workflow strategies were developed for implementing screening. Referral rates and satisfaction with screening were gathered at the conclusion.

Results

Six focus groups of parents and clinicians were conducted. Major themes identified included 1) parents desired greater input on child development and increased time with physicians, 2) physicians did not fully trust parental input, 3) physicians preferred clinical acumen over screening tools, and 4) physicians lacked time and training to conduct screening. For the intervention, developmental screening was implemented at the 9-, 18-, 24-, and 30-month well visits using the Ages & Stages Questionnaire-II and the Modified Checklist for Toddlers. 1397 (98% of eligible) children under 36 months old were enrolled, and 1184 (84%) were screened at least once. 1002 parents (85%) completed a survey at the conclusion of the screening trial. Most parents reported no difficulty completing the screens (99%), felt the screens covered important areas of child development (98%), and felt they learned about their child’s strengths and limitations (88%).

Conclusions

Developmental screening in urban low-income practices is feasible and acceptable, but requires strategies to capture parental input, provide training, facilitate referrals, and develop workflow procedures and electronic decision support.

Minority Faculty Development Programs and Underrepresented Minority Faculty Representation at US Medical Schools

IMPORTANCE

Diversity initiatives have increased at US medical schools to address underrepresentation of minority faculty.

OBJECTIVE

To assess associations between minority faculty development programs at US medical schools and underrepresented minority faculty representation, recruitment, and promotion.

DESIGN

Secondary analysis of the Association of American Medical Colleges Faculty Roster, a database of US medical school faculty.

PARTICIPANTS

Full-time faculty at schools located in the 50 US states or District of Columbia and reporting data from 2000-2010.

EXPOSURE

Availability of school-wide programs targeted to underrepresented minority faculty in 2010.

MAIN OUTCOMES AND MEASURES

Percentage of underrepresented minority faculty, defined as self-reported black, Hispanic, Native American, Alaskan Native, Native Hawaiian, or Pacific Islander faculty. Percentage of underrepresented minority faculty was computed by school and year for all faculty, newly appointed faculty, and newly promoted faculty. Panel-level analyses that accounted for faculty clustering within schools were conducted and adjusted for faculty- and school-level variables.

RESULTS

Across all schools, the percentage of underrepresented minority faculty increased from 6.8% (95% CI, 6.7%-7.0%) in 2000 to 8.0% (95% CI, 7.8%-8.2%) in 2010. Of 124 eligible schools, 36 (29%) were identified with a minority faculty development program in 2010. Minority faculty development programs were heterogeneous in composition, number of components, and duration. Schools with minority faculty development programs had a similar increase in percentage of underrepresented minority faculty as schools without minority faculty development programs (6.5%-7.4% vs 7.0%-8.3%; odds ratio [OR], 0.91 [95% CI, 0.72-1.13]). After adjustment for faculty and school characteristics, minority faculty development programs were not associated with greater representation of minority faculty (adjusted OR, 0.99 [95% CI, 0.81-1.22]), recruitment (adjusted OR, 0.97 [95% CI, 0.83-1.15]), or promotion (adjusted OR, 1.08 [95% CI, 0.91-1.30]). In subgroup analyses, schools with programs of greater intensity (present for ≥5 years and with more components) were associated with greater increases in underrepresented minority representation than schools with minority faculty development programs of less intensity.

CONCLUSIONS AND RELEVANCE

The percentage of underrepresented minority faculty increased modestly from 2000 to 2010 at US medical schools. The presence of a minority faculty development program targeted to underrepresented minority faculty was not associated with greater underrepresented minority faculty representation, recruitment, or promotion. Minority faculty development programs that were of greater intensity were associated with greater increases in underrepresented minority faculty representation.

Continuity of Public Insurance Coverage

Publicly financed insurance programs are tasked with maintaining coverage for eligible children, but published measures to assess coverage have not been evaluated. Therefore, we sought to identify and categorize measures of health insurance continuity for children and adolescents. We conducted a systematic review of Medline and HealthStar databases, review of reference lists of eligible articles, and contact with experts. We categorized measures into 8 domains based on a conceptual framework. We identified 147 measures from 84 eligible articles. Most measures evaluated the following domains: always insured (41%), repeatedly uninsured (36%), and transition out of coverage (29%), while fewer assessed single gap in coverage, always uninsured, transition into coverage, change in coverage, and eligibility. Only 18% of measures assessed associations between continuity of coverage and child and adolescent health outcomes. These results suggest that a number of measures of continuity of coverage exist, but few measures have assessed impact on outcomes.

Parental preferences and goals regarding ADHD treatment

OBJECTIVES

To describe the association between parents' attention-deficit/hyperactivity disorder (ADHD) treatment preferences and goals and treatment initiation.

METHODS

Parents/guardians of children aged 6 to 12 years diagnosed with ADHD in the past 18 months and not currently receiving combined treatment (both medication and behavior therapy [BT]) were recruited from 8 primary care sites and an ADHD treatment center. Parents completed the ADHD Preference and Goal Instrument, a validated measure, and reported treatment receipt at 6 months. Logistic regression was used to analyze the association of baseline preferences and goals with treatment initiation. Using linear regression, we compared the change in preferences and goals over 6 months for children who initiated treatment versus others.

RESULTS

The study included 148 parents/guardians. Baseline medication and BT preference were associated with treatment initiation (odds ratio [OR]: 2.6 [95% confidence interval (CI):1.2-5.5] and 2.2 [95% CI: 1.0-5.1], respectively). The goal of academic achievement was associated with medication initiation (OR: 2.1 [95% CI: 1.3-3.4]) and the goal of behavioral compliance with initiation of BT (OR: 1.6 [95% CI: 1.1-2.4]). At 6 months, parents whose children initiated medication or BT compared with others had decreased academic and behavioral goals, suggesting their goals were attained. However, only those initiating BT had diminished interpersonal relationship goals.

CONCLUSIONS

Parental treatment preferences were associated with treatment initiation, and those with distinct goals selected different treatments. Results support the formal measurement of preferences and goals in practice as prioritized in recent national guidelines for ADHD management.

Amphetamines, atomoxetine and the risk of serious cardiovascular events in adults

Main Objective

To compare the incidence rates of serious cardiovascular events in adult initiators of amphetamines or atomoxetine to rates in non-users.

Methods

This was a retrospective cohort study of new amphetamines (n = 38,586) or atomoxetine (n = 20,995) users. Each medication user was matched to up to four non-users on age, gender, data source, and state (n = 238,183). The following events were primary outcomes of interest 1) sudden death or ventricular arrhythmia, 2) stroke, 3) myocardial infarction, 4) a composite endpoint of stroke or myocardial infarction. Cox proportional hazard regression was used to calculate propensity-adjusted hazard ratios for amphetamines versus matched non-users and atomoxetine versus matched non-users, with intracluster dependence within matched sets accounted for using a robust sandwich estimator.

Results

The propensity-score adjusted hazard ratio for amphetamines use versus non-use was 1.18 (95% CI: 0.55–2.54) for sudden death/ventricular arrhythmia, 0.80 (95% CI: 0.44–1.47) for stroke, 0.75 (95% CI: 0.42–1.35) for myocardial infarction, and 0.78 (95% CI: 0.51–1.19) for stroke/myocardial infarction. The propensity-score adjusted hazard ratio for atomoxetine use versus non-use was 0.41 (95% CI: 0.10–1.75) for sudden death/ventricular arrhythmia, 1.30 (95% CI: 0.52–3.29) for stroke, 0.56 (95% CI: 0.16–2.00) for myocardial infarction, and 0.92 (95% CI: 0.44–1.92) for stroke/myocardial infarction.

Conclusions

Initiation of amphetamines or atomoxetine was not associated with an elevated risk of serious cardiovascular events. However, some of the confidence intervals do not exclude modest elevated risks, e.g. for sudden death/ventricular arrhythmia.

Coordinating Mental Health Care Across Primary Care and Schools: ADHD as a Case Example

Although primary care practices and schools are major venues for the delivery of mental health services to children, these systems are disconnected, contributing to fragmentation in service delivery. This paper describes barriers to collaboration across the primary care and school systems, including administrative and fiscal pressures, conceptual and linguistic differences between healthcare and educational professionals, role restrictions among professionals, and privacy laws. Strategies for overcoming these barriers that can be applied in both primary care and school settings are described. The paper has a primary focus on children with ADHD, but the principles and strategies described are applicable to children with a range of mental health and health conditions.

Effectiveness of developmental screening in an urban setting

OBJECTIVE

To determine the effectiveness of developmental screening on the identification of developmental delays, early intervention (EI) referrals, and EI eligibility.

METHODS

This randomized controlled, parallel-group trial was conducted from December 2008 to June 2010 in 4 urban pediatric practices. Children were eligible if they were <30 months old, term, without congenital malformations or genetic syndromes, not in foster care, and not enrolled in EI. Children were randomized to receive 1 of the following: (1) developmental screening using Ages and Stages Questionnaire-II (ASQ-II and Modified Checklist for Autism in Toddlers (M-CHAT) with office staff assistance, (2) developmental screening using ASQ-II and M-CHAT without office staff assistance, or (3) developmental surveillance using age-appropriate milestones at well visits. Outcomes were assessed using an intention-to-treat analysis.

RESULTS

A total of 2103 children were enrolled. Most were African-American with family incomes less than $30,000. Children in either screening arm were more likely to be identified with delays (23.0% and 26.8% vs 13.0%; P < .001), referred to EI (19.9% and 17.5% vs 10.2%; P < .001), and eligible for EI services (7.0% and 5.3% vs 3.0%; P < .001) than children in the surveillance arm. Children in the screening arms incurred a shorter time to identification, EI referral, and EI evaluation than children in the surveillance arm.

CONCLUSIONS

Children who participated in a developmental screening program were more likely to be identified with developmental delays, referred to EI, and eligible for EI services in a timelier fashion than children who received surveillance alone. These results support policies endorsing developmental screening.

An environmental scan of faculty diversity programs at U.S. medical schools

PURPOSE

To update the information available on the number and type of faculty diversity programs at U.S. MD-degree-granting medical schools.

METHOD

The authors conducted an environmental scan of the 124 MD-degree-granting medical schools included in the 2010 Faculty Roster. They interviewed key informants in the faculty affairs and/or minority affairs offices and conducted Web site searches to identify relevant schoolwide programs. Using a conceptual framework, they categorized the faculty programs that they identified into four domains: mentorship, career development, social climate, and financial support.

RESULTS

Of 124 eligible schools, the authors interviewed key informants from 84 schools (67.7%) and conducted Web site searches for 40 schools (32.2%). They identified diversity programs at 36 schools (29.0%) including mentoring (20/36; 16.1%), career development (20/36; 16.1%), social climate (17/36; 13.7%), and financial support programs (15/36; 12.1%). Schools with diversity programs were similar to schools without diversity programs in terms of year established, public/private status, and designation as historically black but were more likely to rank in the highest quartile and have a greater number of total faculty, and less likely to be located in the South.

CONCLUSIONS

Less than a third of medical schools had programs targeting underrepresented minority (URM) faculty, and those programs that existed differed in scope and goals. These findings suggest that a lack of resources and a preference for programs that target all faculty may limit the development of programs targeting URM faculty. Future research should examine whether diversity programs contribute to URM faculty recruitment and retention.

Barriers to evaluation for early intervention services: parent and early intervention employee perspectives

OBJECTIVE

To explore barriers to early intervention (EI) evaluation among referred infants and toddlers.

METHODS

We conducted semistructured interviews with parents of children referred for EI services and with EI staff. We purposively sampled families according to whether they received an EI evaluation. Families were recruited from a randomized controlled trial testing implementation of developmental screening. Parents filled out demographic surveys. Interviews were recorded, transcribed, and coded. We identified themes within and across respondent groups using modified grounded theory.

RESULTS

We reached thematic saturation after interviewing 22 parents whose child was evaluated by EI, 22 not evaluated, and 14 EI employees. Mean child age at first referral was 16.7 months, and 80% were referred as the result of language concerns. We identified 5 primary themes: (1) Parents reported communication problems with their pediatrician, including misinterpreting reassurance and not understanding the referral process; (2) Many parents saw themselves as experts on their child's development and felt they should decide whether their child pursues EI services; (3) Some families preferred to wait for the developmental concern to resolve or work with their child on their own prior to seeking EI services; (4) For ambivalent parents, practical obstacles especially limited completion of evaluation, but highly motivated parents overcame obstacles; and (5) EI employees perceived that families avoid evaluation because they mistake EI for child protective services.

CONCLUSIONS

Communication between pediatricians and families that addresses practical logistics, families' perceptions of their child's development and EI, and motivation to address developmental concerns may improve the completion of EI referrals.

Shared decision making and behavioral impairment: a national study among children with special health care needs

Background

The Institute of Medicine has prioritized shared decision making (SDM), yet little is known about the impact of SDM over time on behavioral outcomes for children. This study examined the longitudinal association of SDM with behavioral impairment among children with special health care needs (CSHCN).

Method

CSHCN aged 5-17 years in the 2002-2006 Medical Expenditure Panel Survey were followed for 2 years. The validated Columbia Impairment Scale measured impairment. SDM was measured with 7 items addressing the 4 components of SDM. The main exposures were (1) the mean level of SDM across the 2 study years and (2) the change in SDM over the 2 years. Using linear regression, we measured the association of SDM and behavioral impairment.

Results

Among 2,454 subjects representing 10.2 million CSHCN, SDM increased among 37% of the population, decreased among 36% and remained unchanged among 27%. For CSHCN impaired at baseline, the change in SDM was significant with each 1-point increase in SDM over time associated with a 2-point decrease in impairment (95% CI: 0.5, 3.4), whereas the mean level of SDM was not associated with impairment. In contrast, among those below the impairment threshold, the mean level of SDM was significant with each one point increase in the mean level of SDM associated with a 1.1-point decrease in impairment (0.4, 1.7), but the change was not associated with impairment.

Conclusion

Although the change in SDM may be more important for children with behavioral impairment and the mean level over time for those below the impairment threshold, results suggest that both the change in SDM and the mean level may impact behavioral health for CSHCN.

Development of an instrument to measure parents' preferences and goals for the treatment of attention deficit-hyperactivity disorder

OBJECTIVES

To describe the development and validation of an instrument to measure parents' attention deficit-hyperactivity disorder (ADHD) treatment preferences and goals.

METHODS

Parents of children 6 to 12 years of age diagnosed with ADHD in the past 18 months were recruited from 8 primary care sites and an ADHD treatment center (autism excluded). A 16-item medication, 15-item behavior therapy preference scale and a 23-item goal scale, were developed after a review of the literature, 90 parent and clinician semistructured interviews, and input from parent advocates and professional experts were administered to parents. Parent cognitive interviews confirmed item readability, clarity, content, and response range. We conducted an exploratory factor analysis and assessed internal consistency and test-retest reliability and construct and concurrent validity.

RESULTS

We recruited 237 parents (mean child age 8.1 years, 51% black, 59% from primary care, 61% of children medication naive). Factor analyses identified 4 medication preference subscales (treatment acceptability, feasibility, stigma, and adverse effects, Cronbach's α 0.74-0.87); 3 behavior therapy subscales (treatment acceptability, feasibility, and adverse effects, α 0.76-0.83); and 3 goal subscales (academic achievement, behavioral compliance, and interpersonal relationships, α 0.83-0.86). The most strongly endorsed goal was academic achievement. The scales demonstrated construct validity, concurrent validity (r = 0.3-0.6) compared with the Treatment Acceptability Questionnaire and Impairment Rating Scale and moderate to excellent test-retest reliability (intraclass coefficient = 0.7-0.9).

CONCLUSIONS

We developed a valid and reliable instrument for measuring preferences and goals for ADHD treatment, which may help clinicians more easily comply with new national treatment guidelines for ADHD that emphasize shared decision making.

Methylphenidate and risk of serious cardiovascular events in adults

OBJECTIVE

The authors sought to determine whether use of methylphenidate in adults is associated with elevated rates of serious cardiovascular events compared with rates in nonusers.

METHOD

This was a cohort study of new users of methylphenidate based on administrative data from a five-state Medicaid database and a 14-state commercial insurance database. All new methylphenidate users with at least 180 days of prior enrollment were identified. Users were matched on data source, state, sex, and age to as many as four comparison subjects who did not use methylphenidate, amphetamines, or atomoxetine. A total of 43,999 new methylphenidate users were identified and matched to 175,955 nonusers. Events of primary interest were 1) sudden death or ventricular arrhythmia, 2) stroke, 3) myocardial infarction, and 4) a composite endpoint of stroke or myocardial infarction.

RESULTS

The age-standardized incidence rate per 1,000 person-years of sudden death or ventricular arrhythmia was 2.17 (95% CI=1.63-2.83) in methylphenidate users and 0.98 (95% CI=0.89-1.08) in nonusers, for an adjusted hazard ratio of 1.84 (95% CI=1.33-2.55). Dosage was inversely associated with risk. Adjusted hazard ratios for stroke, myocardial infarction, and the composite endpoint of stroke or myocardial infarction did not differ statistically from 1.

CONCLUSIONS

Although initiation of methylphenidate was associated with a 1.8-fold increase in risk of sudden death or ventricular arrhythmia, the lack of a dose-response relationship suggests that this association may not be a causal one.

Shared decision-making and health care expenditures among children with special health care needs

BACKGROUND AND OBJECTIVES

To understand the association between shared decision-making (SDM) and health care expenditures and use among children with special health care needs (CSHCN).

METHODS

We identified CSHCN <18 years in the 2002-2006 Medical Expenditure Panel Survey by using the CSHCN Screener. Outcomes included health care expenditures (total, out-of-pocket, office-based, inpatient, emergency department [ED], and prescription) and utilization (hospitalization, ED and office visit, and prescription rates). The main exposure was the pattern of SDM over the 2 study years (increasing, decreasing, or unchanged high or low). We assessed the impact of these patterns on the change in expenditures and utilization over the 2 study years.

RESULTS

Among 2858 subjects representing 12 million CSHCN, 15.9% had increasing, 15.2% decreasing, 51.9% unchanged high, and 17.0% unchanged low SDM. At baseline, mean per child total expenditures were $2131. Over the 2 study years, increasing SDM was associated with a decrease of $339 (95% confidence interval: $21, $660) in total health care costs. Rates of hospitalization and ED visits declined by 4.0 (0.1, 7.9) and 11.3 (4.3, 18.3) per 100 CSHCN, and office visits by 1.2 (0.3, 2.0) per child with increasing SDM. Relative to decreasing SDM, increasing SDM was associated with significantly lower total and out-of-pocket costs, and fewer office visits.

CONCLUSIONS

We found that increasing SDM was associated with decreased utilization and expenditures for CSHCN. Prospective study is warranted to confirm if fostering SDM reduces the costs of caring for CSHCN for the health system and families.

Performance measures of the specialty referral process: a systematic review of the literature

BACKGROUND

Performance of specialty referrals is coming under scrutiny, but a lack of identifiable measures impedes measurement efforts. The objective of this study was to systematically review the literature to identify published measures that assess specialty referrals.

METHODS

We performed a systematic review of the literature for measures of specialty referral. Searches were made of MEDLINE and HealthSTAR databases, references of eligible papers, and citations provided by content experts. Measures were eligible if they were published from January 1973 to June 2009, reported on validity and/or reliability of the measure, and were applicable to Organization for Economic Cooperation and Development healthcare systems. We classified measures according to a conceptual framework, which underwent content validation with an expert panel.

RESULTS

We identified 2,964 potentially eligible papers. After abstract and full-text review, we selected 214 papers containing 244 measures. Most measures were applied in adults (57%), assessed structural elements of the referral process (60%), and collected data via survey (62%). Measures were classified into non-mutually exclusive domains: need for specialty care (N = 14), referral initiation (N = 73), entry into specialty care (N = 53), coordination (N = 60), referral type (N = 3), clinical tasks (N = 19), resource use (N = 13), quality (N = 57), and outcomes (N = 9).

CONCLUSIONS

Published measures are available to assess the specialty referral process, although some domains are limited. Because many of these measures have been not been extensively validated in general populations, assess limited aspects of the referral process, and require new data collection, their applicability and preference in assessment of the specialty referral process is needed.