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Chien AT, Spence SJ, Okumura MJ, Lu S, Chan CH, Houtrow AJ, Kuo DZ, Van Cleave JM, Shanske SA, Schuster MA, Kuhlthau KA, Toomey SL. Impairment Types and Combinations Among Adolescents and Young Adults with Disabilities: Colorado 2014-2018. Acad Pediatr 2023:S1876-2859(23)00403-5. [PMID: 37925071 DOI: 10.1016/j.acap.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/25/2023] [Accepted: 10/29/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVE Understanding the types of functional challenges faced by adolescents and young adults with disabilities (AYA-WD) can help payers, clinicians, community-based service providers, and policymakers recognize and meet needs. This paper describes state-level prevalence rates for 1) AYA-WD overall and for 2) impairment types singly and in combinations; and 3) examines how rates may differ between those insured by Medicaid versus commercial insurance. METHODS This descriptive study uses Colorado's All Payer Claims Dataset 2014-2018 to identify insured 10- to 26-year-olds (Medicaid only: 333,931; commercially only: 392,444). It then applies the previously validated Children with Disabilities Algorithm (CWDA) and its companion, the Diagnosis-to-Impairment-Type Algorithm (DITA), to compare state-level prevalence rates by insurance source for disability overall and for each of five impairment types singly and in combination. RESULTS Disability prevalence was greater among the Medicaid-insured AYA-WD by +7.6% points (pp)-Medicaid: 11.9% (47,654/333,931), commercial: 4.3% (16,907/392,444). Most AYA-WD had a single impairment, but the prevalence of AYA-WD with two or more impairments was greater among the Medicaid-insured than the commercially insured (+9.9 pp; Medicaid: 33.5% [15,963/47,654], commercial: 23.7% [3992/16, 907]), as was the prevalence of impairment types that were physical (+6.7 pp; Medicaid: 54.7% [26,054/47,654], commercial: 48.0% [8121/16,907]); developmental (+4.1 pp; Medicaid: 35.4% [16,874/47,654], commercial: 31.3% [5290/16,907]); psychiatric (+6.7 pp; Medicaid 21.3% [10,175/47,654], commercial: 14.6% [2470/16,907]), and intellectual (+9.3 pp; Medicaid: 26.2% [12,501/47,654], commercial: 16.9% [2858/16,907]). CONCLUSIONS CWDA and DITA can be used to understand the rates at which impairment types and combinations occur in a population with childhood-onset disabilities.
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Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics (AT Chien and SL Toomey), Boston Children's Hospital, Boston, Mass; Department of Pediatrics (AT Chien and SL Toomey), Harvard Medical School, Boston, Mass.
| | - Sarah J Spence
- Department of Neurology (SJ Spence), Boston Children's Hospital, Boston, Mass
| | - Megumi J Okumura
- Division of General Pediatrics (MJ Okumura), University of California San Francisco Benioff Children's Hospital
| | - Sifan Lu
- College of Medicine, State University of New York-Downstate (S Lu), Brooklyn, NY
| | - Christina H Chan
- Biostatistics and Research Design Center (CH Chan), Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Mass
| | - Amy J Houtrow
- Department of Physical Medicine and Rehabilitation (AJ Houtrow), University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Dennis Z Kuo
- Department of Pediatrics (DZ Kuo), University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Jeanne M Van Cleave
- Department of Pediatrics (JM Van Cleave), Anschutz School of Medicine, University of Colorado, Aurora, CO
| | - Susan A Shanske
- Department of Social Work (SA Shanske), Boston Children's Hospital, Boston, Mass
| | - Mark A Schuster
- Kaiser Permanent Bernard J. Tyson School of Medicine (MA Schuster), Pasadena, Calif
| | - Karen A Kuhlthau
- Center for Child and Adolescent Health Research and Policy (KA Kuhlthau), Department of General Pediatrics, Massachusetts General Hospital for Children, Boston, Mass
| | - Sara L Toomey
- Division of General Pediatrics (AT Chien and SL Toomey), Boston Children's Hospital, Boston, Mass; Department of Pediatrics (AT Chien and SL Toomey), Harvard Medical School, Boston, Mass
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Dark HE, Harnett NG, Goodman AM, Wheelock MD, Mrug S, Schuster MA, Elliott MN, Tortolero Emery S, Knight DC. Stress-induced changes in autonomic reactivity vary with adolescent violence exposure and resting-state functional connectivity. Neuroscience 2023; 522:81-97. [PMID: 37172687 DOI: 10.1016/j.neuroscience.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 04/13/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023]
Abstract
Exposure to violence during childhood can lead to functional changes in brain regions that are important for emotion expression and regulation, which may increase susceptibility to internalizing disorders in adulthood. Specifically, childhood violence exposure can disrupt the functional connectivity among brain regions that include the prefrontal cortex (PFC), hippocampus, and amygdala. Together, these regions are important for modulating autonomic responses to stress. However, it is unclear to what extent changes in brain connectivity relate to autonomic stress reactivity and how the relationship between brain connectivity and autonomic responses to stress varies with childhood violence exposure. Thus, the present study examined whether stress-induced changes in autonomic responses (e.g., heart rate, skin conductance level (SCL)) varied with amygdala-, hippocampus-, and ventromedial prefrontal cortex (vmPFC)-whole brain resting-state functional connectivity (rsFC) as a function of violence exposure. Two hundred and ninety-seven participants completed two resting-state functional magnetic resonance imaging scans prior to (pre-stress) and after (post-stress) a psychosocial stress task. Heart rate and SCL were recorded during each scan. Post-stress heart rate varied negatively with post-stress amygdala-inferior parietal lobule rsFC and positively with post-stress hippocampus-anterior cingulate cortex rsFC among those exposed to high, but not low, levels of violence. Results from the present study suggest that post-stress fronto-limbic and parieto-limbic rsFC modulates heart rate and may underlie differences in the stress response among those exposed to high levels of violence.
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Affiliation(s)
- Heather E Dark
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL
| | - Nathaniel G Harnett
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL
| | - Adam M Goodman
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL
| | - Muriah D Wheelock
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL
| | - Sylvie Mrug
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL
| | - Mark A Schuster
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | | | - Susan Tortolero Emery
- School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
| | - David C Knight
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL.
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Martino SC, Reynolds KA, Grob R, Palimaru AI, Zelazny S, Slaughter ME, Rybowski L, Parker AM, Toomey SL, Schuster MA, Schlesinger M. Evaluation of a protocol for eliciting narrative accounts of pediatric inpatient experiences of care. Health Serv Res 2023; 58:271-281. [PMID: 36645204 PMCID: PMC10012224 DOI: 10.1111/1475-6773.14134] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To evaluate the measurement properties of a set of six items designed to elicit narrative accounts of pediatric inpatient experience. DATA SOURCES Data came from 163 participants recruited from a probability-based online panel of U.S. adults. Participants were family members of a child who had an overnight hospital stay in the past 12 months. STUDY DESIGN Cross-sectional survey with follow-up phone interviews. DATA COLLECTION/EXTRACTION METHODS Participants completed an online (n = 129) or phone (n = 34) survey about their child's hospitalization experience. The survey contained closed-ended items from the Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) survey, followed by the six narrative items. Approximately 2 weeks after completing the survey, 47 participants additionally completed a one-hour, semi-structured phone interview, the results of which served as a "gold standard" for evaluating the fidelity of narrative responses. Qualitative content analysis was used to code narrative and interview responses for domains of patient experience and actionability. PRINCIPAL FINDINGS The average narrative was 248 words (SD = 319). Seventy-nine percent of narratives mentioned a topic included in the Child HCAHPS survey; 89% mentioned a topic not covered by that survey; and 75% included at least one detailed description of an actionable event. Overall, there was 66% correspondence between narrative and interview responses. Correspondence was higher on the phone than in the online condition (75% vs. 59%). CONCLUSIONS Narratives elicited from rigorously designed multi-item sets can provide detailed, substantive information about pediatric inpatient experiences that hospitals could use to improve child and family experiences during pediatric hospitalization. They add context to closed-ended survey item responses and provide information about experiences of care important to children and families that are not included in quantitative surveys.
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Affiliation(s)
| | | | - Rachel Grob
- Department of Family Medicine and Community Health, University of Wisconsin, Madison, Wisconsin, USA
| | | | | | | | | | | | - Sara L Toomey
- Boston Children's Hospital, Boston, Massachusetts, USA.,Division of General Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark A Schuster
- RAND Corporation, Santa Monica, California, USA.,Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Mark Schlesinger
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut, USA
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Progovac AM, Mullin BO, Yang X, Kibugi L(T, Mwizerwa D, Hatfield LA, Schuster MA, McDowell A, Cook BL. Despite Higher Rates of Minimally Recommended Depression Treatment, Transgender and Gender Diverse Medicare Beneficiaries with Depression Have Poorer Mental Health Outcomes: Analysis of 2009–2016 Medicare Data. Transgend Health 2023. [DOI: 10.1089/trgh.2022.0146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
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Dark HE, Harnett NG, Hurst DR, Wheelock MD, Wood KH, Goodman AM, Mrug S, Elliott MN, Emery ST, Schuster MA, Knight DC. Sex-related differences in violence exposure, neural reactivity to threat, and mental health. Neuropsychopharmacology 2022; 47:2221-2229. [PMID: 36030316 PMCID: PMC9630543 DOI: 10.1038/s41386-022-01430-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 02/06/2023]
Abstract
The prefrontal cortex (PFC), hippocampus, and amygdala play an important role in emotional health. However, adverse life events (e.g., violence exposure) affect the function of these brain regions, which may lead to disorders such as depression and anxiety. Depression and anxiety disproportionately affect women compared to men, and this disparity may reflect sex differences in the neural processes that underlie emotion expression and regulation. The present study investigated sex differences in the relationship between violence exposure and the neural processes that underlie emotion regulation. In the present study, 200 participants completed a Pavlovian fear conditioning procedure in which cued and non-cued threats (i.e., unconditioned stimuli) were presented during functional magnetic resonance imaging. Violence exposure was previously assessed at four separate time points when participants were 11-19 years of age. Significant threat type (cued versus non-cued) × sex and sex × violence exposure interactions were observed. Specifically, women and men differed in amygdala and parahippocampal gyrus reactivity to cued versus non-cued threat. Further, dorsolateral PFC (dlPFC) and inferior parietal lobule (IPL) reactivity to threat varied positively with violence exposure among women, but not men. Similarly, threat-elicited skin conductance responses varied positively with violence exposure among women. Finally, women reported greater depression and anxiety symptoms than men. These findings suggest that sex differences in threat-related brain and psychophysiological activity may have implications for mental health.
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Affiliation(s)
- Heather E Dark
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
- Laboratory of Behavioral Neuroscience, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, MD, USA
| | - Nathaniel G Harnett
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Depression and Anxiety, McLean Hospital, Belmont, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Danielle R Hurst
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Muriah D Wheelock
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Radiology, Washington University in St. Louis, St Louis, MO, USA
| | - Kimberly H Wood
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Psychology, Samford University, Homewood, AL, USA
| | - Adam M Goodman
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Neurology, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Sylvie Mrug
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Susan Tortolero Emery
- Texas Prevention Research Center, School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Mark A Schuster
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - David C Knight
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA.
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Cox JE, Bogart LM, Elliott MN, Starmer AJ, Meleedy-Rey P, Goggin K, Banerjee T, Samuels RC, Hahn PD, Epee-Bounya A, Allende-Richter S, Fu CM, Schuster MA. Improving HPV Vaccination Rates in a Racially and Ethnically Diverse Pediatric Population. Pediatrics 2022; 150:189547. [PMID: 36127315 DOI: 10.1542/peds.2021-054186] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Nationally, 54.2% of youth are fully vaccinated for human papilloma virus (HPV) with persistent gender and racial/ethnic disparities. We used a quality improvement approach to improve completion of the HPV vaccine series by age 13 years. As a secondary aim, we examined racial/ethnic and gender differences in vaccine uptake. METHODS The study setting included 2 pediatric, academic, primary care practices in Massachusetts. We designed a multilevel patient-, provider-, and systems-level intervention addressing parental hesitancy, provider communication, and clinical operations. Rates of HPV series completion by age 13 were monitored using a control p chart. Bivariate and multivariate analyses evaluated vaccine completion differences on the basis of clinic size, gender, and race/ethnicity. RESULTS Between July 1, 2014, and September 30, 2021, control p charts showed special cause variation with HPV vaccine initiation by age 9 years, increasing from 1% to 52%, and vaccine completion by 13 years, increasing from 37% to 77%. Compared with White and Black children, Hispanic children were more likely to initiate the HPV vaccine at age 9 (adjusted odds ratio [95% confidence interval] = (1.4-2.6)] and complete the series by age 13 (adjusted odds ratio [95% confidence interval] = 2.3 (1.7-3.0). CONCLUSIONS A multilevel intervention was associated with sustained HPV vaccine series completion by age 13 years. Hispanic children were more likely to be vaccinated. Qualitative family input was critical to intervention design. Provider communication training addressed vaccine hesitancy. Initiation of the vaccine at age 9 and clinicwide vaccine protocols were key to sustaining improvements.
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Affiliation(s)
- Joanne E Cox
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laura M Bogart
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,RAND Corporation, Santa Monica, California
| | | | - Amy J Starmer
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Kathy Goggin
- Schools of Medicine and Pharmacy, Health Services and Outcome Research, Children's Mercy Hospital and University of Missouri, Kansas City, Missouri
| | - Taruna Banerjee
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,Organizational Quality and Patient Safety, Cambridge Health Alliance, Cambridge Massachusetts
| | - Ronald C Samuels
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,Division of General Pediatrics, Children's Hospital at Montefiore, Bronx, New York
| | - Phillip D Hahn
- Patient Safety and Quality, Boston Children's Hospital, Boston, Massachusetts
| | - Alexandra Epee-Bounya
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sophie Allende-Richter
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chong-Min Fu
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark A Schuster
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,RAND Corporation, Santa Monica, California
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Cabral P, Wallander JL, Elliott MN, Schuster MA. Longitudinal associations of parent-child communication, dating behaviors, decision-making processes, and sex initiation among United States Latina/o adolescents. Front Psychol 2022; 13:897311. [PMID: 36033077 PMCID: PMC9413066 DOI: 10.3389/fpsyg.2022.897311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 07/22/2022] [Indexed: 11/16/2022] Open
Abstract
Objective This study examined differences and identified developmental predictors of oral, vaginal, and anal intercourse initiation across generational status among Latina/o adolescents of both genders. More specifically, we compare generational status and gender differences in the longitudinal predictions from parent-child sex communication and dating behaviors to sex initiation 5 years later, and how these associations may be mediated by perceived peer norms, intentions, and attitudes regarding sex among Latina/o adolescents. Methods Using prospective longitudinal data from the Healthy Passages™ project collected in Houston and Los Angeles, Latina/o girls (n = 879) and boys (n = 885) who were identified as 1st- (18%), 2nd- (58%), or 3rd (24%)-immigrant generational status reported on their dating behaviors and parent-child communication about sex at 5th grade (M age = 11.12 years), their perceived peer norms and attitudes regarding sex at 7th grade (M age = 13.11 years), and if they had initiated oral, vaginal, or anal sexual intercourse by 10th grade (M age = 16.06 years). Results Third-generation Latina girls were more likely than 1st- and 2nd-generation Latinas to have initiated sexual intercourse by 10th grade. More advanced dating behaviors in 5th grade had a positive association with sex initiation for all generational status groups among Latino boys, but only among 1st-generation Latina girls. Moreover, mediating decision-making processes of peer norms and attitudes differed for each group. Conclusion Pre-adolescent dating behaviors are associated with long-term differences in adolescents' sexual behaviors, which may point to targets for prevention efforts. Acculturation differences may contribute to different ways in which adolescents decide to engage in sexual intercourse based on the previous dating experiences.
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Affiliation(s)
- Patricia Cabral
- Department of Psychology, Occidental College, Los Angeles, CA, United States
| | - Jan L. Wallander
- Psychological Sciences and Health Sciences Research Center, University of California, Merced, Merced, CA, United States
| | | | - Mark A. Schuster
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States
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Khan A, Baird J, Kelly MM, Blaine K, Chieco D, Haskell H, Lopez K, Ngo T, Mercer A, Quiñones-Pérez B, Schuster MA, Singer SJ, Viswanath K, Landrigan CP, Williams D, Luff D. Family Safety Reporting in Medically Complex Children: Parent, Staff, and Leader Perspectives. Pediatrics 2022; 149:188129. [PMID: 35615941 DOI: 10.1542/peds.2021-053913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite compelling evidence that patients and families report valid and unique safety information, particularly for children with medical complexity (CMC), hospitals typically do not proactively solicit patient or family concerns about patient safety. We sought to understand parent, staff, and hospital leader perspectives about family safety reporting in CMC to inform future interventions. METHODS This qualitative study was conducted at 2 tertiary care children's hospitals with dedicated inpatient complex care services. A research team conducted approximately 60-minute semistructured, individual interviews with English and Spanish-speaking parents of CMC, physicians, nurses, and hospital leaders. Audio-recorded interviews were translated, transcribed, and verified. Two researchers coded data inductively and deductively developed and iteratively refined the codebook with validation by a third researcher. Thematic analysis allowed for identification of emerging themes. RESULTS We interviewed 80 participants (34 parents, 19 nurses and allied health professionals, 11 physicians, and 16 hospital leaders). Four themes related to family safety reporting were identified: (1) unclear, nontransparent, and variable existing processes, (2) a continuum of staff and leadership buy-in, (3) a family decision-making calculus about whether to report, and (4) misaligned staff and parent priorities and expectations. We also identified potential strategies for engaging families and staff in family reporting. CONCLUSIONS Although parents were deemed experts about their children, buy-in about the value of family safety reporting among staff and leaders varied, staff and parent priorities and expectations were misaligned, and family decision-making around reporting was complex. Strategies to address these areas can inform design of family safety reporting interventions attuned to all stakeholder groups.
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Affiliation(s)
- Alisa Khan
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Departments of Pediatrics
| | - Jennifer Baird
- Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, Los Angeles, California
| | - Michelle M Kelly
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kevin Blaine
- Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, Los Angeles, California
| | - Deanna Chieco
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Mount Sinai School of Medicine, New York, New York
| | - Helen Haskell
- Mothers Against Medical Error, Columbia, South Carolina
| | - Kelleen Lopez
- Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, Los Angeles, California
| | - Tiffany Ngo
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Alexandra Mercer
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Bianca Quiñones-Pérez
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Departments of Pediatrics
| | - Mark A Schuster
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Sara J Singer
- Department of Medicine, Stanford University School of Medicine, Stanford, California.,Organizational Behavior, Stanford Graduate School of Business, Stanford, California
| | - K Viswanath
- Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,McGraw-Patterson Center for Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Christopher P Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Departments of Pediatrics.,Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - David Williams
- Orthopedic Surgery.,Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Massachusetts
| | - Donna Luff
- Anesthesia, Harvard Medical School, Boston, Massachusetts
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Bell KL, Purcell JB, Harnett NG, Goodman AM, Mrug S, Schuster MA, Elliott MN, Emery ST, Knight DC. White Matter Microstructure in the Young Adult Brain Varies with Neighborhood Disadvantage in Adolescence. Neuroscience 2021; 466:162-172. [PMID: 34004262 DOI: 10.1016/j.neuroscience.2021.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/04/2021] [Accepted: 05/10/2021] [Indexed: 01/20/2023]
Abstract
Neighborhood disadvantage and community violence are common in poor, urban communities and are risk factors for emotional dysfunction. Emotional processes are supported by neural circuitry that includes the prefrontal cortex (PFC), hippocampus, amygdala, and hypothalamus. These brain regions are connected by white matter pathways that include the cingulum bundle, uncinate fasciculus, stria terminalis, and fornix. Emotional function varies with the microstructure of these white matter pathways. However, it is not clear whether the microstructure of these pathways varies with risk factors for emotional dysfunction (e.g., neighborhood disadvantage and violence exposure). Therefore, determining the relationships between neighborhood disadvantage, violence exposure, and white matter microstructure may offer insight into the neural mechanisms by which adverse life experiences alter developing neural systems. The current study investigated the association that exposure to neighborhood disadvantage and violence have with the quantitative anisotropy (QA), a measure of the amount of directional water diffusion, of the cingulum bundle, uncinate fasciculus, stria terminalis, and fornix. Neighborhood disadvantage (Mage = 11.20) and violence exposure (MW1age = 11.20; MW2age = 13.05; MW3age = 16.20; MW4age = 19.25) were assessed during adolescence and participants returned for magnetic resonance imaging as young adults (N = 303; Mage = 20.25, SD = 1.55), during which diffusion weighted brain images were collected. The QA of the cingulum bundle, uncinate fasciculus, and stria terminalis/fornix varied negatively with neighborhood disadvantage such that the QA of these white matter tracts decreased as neighborhood disadvantage increased. Violence exposure was not related to QA in any tract (i.e., cingulum bundle, uncinate fasciculus, and stria terminalis/fornix) after correction for multiple comparisons. These results suggest that an adolescent's neighborhood may play an important role in the microstructure (i.e., QA) of white matter pathways that connect brain regions that support emotional function.
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Affiliation(s)
- Kristina L Bell
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Juliann B Purcell
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nathaniel G Harnett
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Adam M Goodman
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sylvie Mrug
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mark A Schuster
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Susan Tortolero Emery
- School of Public Health, University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - David C Knight
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA.
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MacCarthy S, Darabidian B, Elliott MN, Schuster MA, Burton C, Saliba D. Culturally Competent Clinical Care for Older Sexual Minority Adults: A Scoping Review of the Literature. Res Aging 2021; 43:274-282. [PMID: 33769144 DOI: 10.1177/01640275211004152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE As recent efforts to improve culturally competent clinical care (CCCC) have largely overlooked older LGB adults, we conducted a scoping review of position statements, empirical, and non-empirical research and suggest action steps. METHODS We followed PRISMA Extension for Scoping Reviews Guidelines and searched for articles 1/1/11-3/14/19 (n = 1210) and other resources (n = 52), deduplicating, dually screening abstracts (n = 1,156), reviewing full-text (n = 107), and conducted a content analysis to identify distinct and cross-cutting domains (n = 44). MAIN FINDINGS Most research was based on simple pre/post-training differences in provider knowledge. A majority of sources were non-empirical. We identified three distinct domains (education & staffing, physical environment, and inclusive language & communication) and three cross-cutting domains (subgroup differences, research, and policy). PRINCIPAL CONCLUSIONS Sparse empirical data that specify best approaches to improve CCCC exist; nevertheless, providers, in collaboration with researchers and policy makers, can initiate improved practices aimed at increasing CCCC for older LGB patients.
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Affiliation(s)
| | | | | | - Mark A Schuster
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | | | - Debra Saliba
- RAND Corporation, Santa Monica, CA, USA.,Los Angeles VA GRECC, Los Angeles, CA, USA.,UCLA Borun Center for Gerontological Research, Los Angeles, CA, USA
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11
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Epperson AE, Wallander JL, Song AV, Depaoli S, Peskin MF, Elliott MN, Schuster MA. Gender and racial/ethnic differences in adolescent intentions and willingness to smoke cigarettes: Evaluation of a structural equation model. J Health Psychol 2021; 26:605-619. [PMID: 30773937 PMCID: PMC6698224 DOI: 10.1177/1359105319829536] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Dual-process theories may be effective at predicting adolescent smoking; however, little is known about the effectiveness of these models across race/ethnicity and gender. Adolescents (N = 4035) completed biopsychosocial and tobacco-related perception measures in Grade 7 and reported on smoking initiation in Grade 10. Using structural equation modeling and comparing models by gender and race/ethnicity showed differences, where both intentions and willingness predicted smoking initiation for only Black and male adolescents, compared to their Latino and White and female counterparts. Intentions and willingness appear to play a role in whether an adolescent will initiate smoking in the future, but this does not apply universally across gender and race/ethnicity.
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12
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Martin-Gutierrez G, Wallander JL, Yang YJ, Depaoli S, Elliott MN, Coker TR, Schuster MA. Racial/Ethnic Differences in the Relationship Between Stressful Life Events and Quality of Life in Adolescents. J Adolesc Health 2021; 68:292-299. [PMID: 32747050 DOI: 10.1016/j.jadohealth.2020.05.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 05/26/2020] [Accepted: 05/29/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Stressful life events (SLEs) increase allostatic load and require adaptation. Experiencing SLEs has been associated with decreased health-related quality of life (HRQOL) among adolescents. This study examined racial/ethnic and developmental differences in the relationship between SLEs and HRQOL from preadolescence to midadolescence. METHODS Data were from 4,824 participants in the Healthy Passages project, a population-based prospective longitudinal survey of fifth, seventh, and 10th grade adolescents in the U.S. HRQOL was measured with Pediatric Quality of Life Inventory and SLEs with items addressing family-related SLEs (e.g., the parent's death, separation, and divorce; family member's injury/illness; residential change; new child in the household). RESULTS Adolescents, regardless of race/ethnicity, reported the highest SLEs and the lowest HRQOL in early adolescence. Analysis of an autoregressive model with cross-lagged effects showed that the concurrent relationships between SLEs and HRQOL were significantly negative across preadolescence, early adolescence, and midadolescence in African-American, Latinx, and white groups. Furthermore, adolescents had a negative cross-lagged association from SLEs in early adolescence to HRQOL in pre adolescence, but this was not the case among the other racial/ethnic groups. CONCLUSIONS Because the negative relationship between family-related SLEs and HRQOL persisted throughout stages of adolescent development, health services targeting adolescents should provide comprehensive family-centered care to alleviate the impact of family-related life stress. Relationships between family life stress and HRQOL varied by racial/ethnic groups, which should be considered by health professionals, teachers, and parents, and in prevention efforts. Latinx adolescents may be particularly vulnerable to time-lagged effects of such family-related stress.
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Affiliation(s)
- Geraldy Martin-Gutierrez
- Psychological Sciences and Health Sciences Research Institute, University of California, Merced, Merced, California
| | - Jan L Wallander
- Psychological Sciences and Health Sciences Research Institute, University of California, Merced, Merced, California.
| | - Yuzhu June Yang
- Psychological Sciences and Health Sciences Research Institute, University of California, Merced, Merced, California
| | - Sarah Depaoli
- Psychological Sciences and Health Sciences Research Institute, University of California, Merced, Merced, California
| | | | - Tumaini R Coker
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Seattle Children's Research Institute, Seattle, Washington
| | - Mark A Schuster
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
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13
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Purcell JB, Goodman AM, Harnett NG, Davis ES, Wheelock MD, Mrug S, Elliott MN, Emery ST, Schuster MA, Knight DC. Stress-elicited neural activity in young adults varies with childhood sexual abuse. Cortex 2021; 137:108-123. [PMID: 33609897 DOI: 10.1016/j.cortex.2020.12.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/25/2020] [Accepted: 12/18/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Childhood physical and sexual abuse are stressful experiences that may alter the emotional response to future stressors. Stress-related emotional function is supported by brain regions that include the prefrontal cortex (PFC), hippocampus, and amygdala. The present study investigated whether childhood physical and sexual abuse are associated with stress-elicited brain activity in young adulthood. METHODS Participants (N = 300; Mage = 20.0; 151 female) completed a psychosocial stress task during functional magnetic resonance imaging (fMRI). Measures of physical and sexual abuse were included in a linear mixed effects model to estimate the unique relationship each type of childhood abuse had with stress-elicited brain activity. RESULTS Stress-elicited dorsolateral PFC, ventromedial PFC, and hippocampal activity decreased as the frequency of childhood sexual abuse increased. There were no regions in which stress-elicited activation varied with physical abuse. CONCLUSIONS The present findings suggest there is a unique relationship between childhood sexual abuse and the stress-elicited PFC and hippocampal activity of young adults that is not observed following childhood physical abuse. SIGNIFICANCE These findings may have important implications for understanding the mechanisms by which childhood sexual abuse impacts the development of future psychopathology.
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Affiliation(s)
- Juliann B Purcell
- University of Alabama at Birmingham, Department of Psychology, Birmingham, AL, USA.
| | - Adam M Goodman
- University of Alabama at Birmingham, Department of Psychology, Birmingham, AL, USA.
| | - Nathaniel G Harnett
- University of Alabama at Birmingham, Department of Psychology, Birmingham, AL, USA.
| | - Elizabeth S Davis
- University of Alabama at Birmingham, Department of Psychology, Birmingham, AL, USA.
| | - Muriah D Wheelock
- University of Alabama at Birmingham, Department of Psychology, Birmingham, AL, USA.
| | - Sylvie Mrug
- University of Alabama at Birmingham, Department of Psychology, Birmingham, AL, USA.
| | | | - Susan Tortolero Emery
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Houston, TX, USA.
| | - Mark A Schuster
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - David C Knight
- University of Alabama at Birmingham, Department of Psychology, Birmingham, AL, USA.
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14
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Mrug S, Jones LC, Elliott MN, Tortolero SR, Peskin MF, Schuster MA. Soft Drink Consumption and Mental Health in Adolescents: A Longitudinal Examination. J Adolesc Health 2021; 68:155-160. [PMID: 32636141 DOI: 10.1016/j.jadohealth.2020.05.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/28/2020] [Accepted: 05/13/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Previous studies showed associations between soft drink consumption and mental health problems in adolescents, but the direction of these effects is unknown. This study examines the hypotheses that soft drink consumption predicts aggression and depressive symptoms over time and that these mental health problems predict soft drink consumption. METHODS Interviews were conducted with 5,147 children and their caregivers from three sites at child ages 11, 13, and 16. At each time point, youth reported on their frequency of consuming soft drinks, aggressive behavior, and depressive symptoms. An autoregressive cross-lagged path model tested reciprocal relationships between soft drink consumption, aggressive behavior, and depressive symptoms over time. RESULTS More frequent consumption of soft drinks was associated with more aggressive behavior at each time point and depressive symptoms at ages 11 and 13 (r = .04 to .18, p ≤ .002). After adjusting for covariates and stability of each behavior over time, soft drink consumption at ages 11 and 13 predicted more aggressive behavior at the next time point (β = .08 and .06, p < .001). Aggressive behavior at age 13 also predicted more soft drink consumption at age 16 (β = .06, p = .002). Soft drink consumption at age 13 predicted fewer depressive symptoms (β = -.04, p = .007), but depressive symptoms did not predict soft drink consumption. CONCLUSIONS More frequent consumption of soft drinks may contribute to aggressive behavior in adolescents over time; there is some support for reciprocal relationships. There is no evidence for soft drink consumption contributing to adolescents' depression. Future research should examine longitudinal effects over shorter intervals.
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Affiliation(s)
- Sylvie Mrug
- Department of Psychology, University of Alabama at Birmingham, Birmingham, Alabama.
| | - LaRita C Jones
- Department of Psychology, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Susan R Tortolero
- Texas Prevention Research Center, University of Texas Health Science Center, Houston, Texas
| | - Melissa F Peskin
- Texas Prevention Research Center, University of Texas Health Science Center, Houston, Texas
| | - Mark A Schuster
- Office of the Dean, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
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15
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Schuster MA, Conwell WD, Connelly MT, Humphrey HJ. Building Equity, Inclusion, and Diversity Into the Fabric of a New Medical School: Early Experiences of the Kaiser Permanente Bernard J. Tyson School of Medicine. Acad Med 2020; 95:S66-S70. [PMID: 32889938 DOI: 10.1097/acm.0000000000003695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
In July 2020, the Kaiser Permanente Bernard J. Tyson School of Medicine opened in Pasadena, California, with an inaugural class of 50 students. The school endeavors to address systemic barriers that have contributed to health care and educational disparities in the United States. To realize its vision for change, equity, inclusion, and diversity (EID) have been woven throughout the school. Board members were chosen in part based on their commitment to the core values of EID. The board developed mission, vision, and values statements that explicitly avow a commitment to EID and recruited a dean (and the dean recruited leaders) who espoused and evinced these values. Leaders, faculty, and staff received training to foster an inclusive environment and ensure accountability. The school developed a curriculum that has been thoroughly evaluated for its representative and inclusive content by a team drawn from all departments. The diverse first class, selected through a holistic admissions approach, has access to student support systems that emphasize an appreciation of the distinct experiences and context of each student. The school plans a rigorous evaluation program to assess its performance in EID. Although the school may well fall short of achieving all of its EID objectives, by learning from its experiences and from evidence of others in academic medicine, the school recognizes its opportunity to continue to come closer to achieving its goals and to help shape and contribute to the national and international discourse on EID.
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Affiliation(s)
- Mark A Schuster
- M.A. Schuster is founding dean and chief executive officer, and professor, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Walter D Conwell
- W.D. Conwell is associate dean, Equity, Inclusion, and Diversity, and assistant professor, Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Maureen T Connelly
- M.T. Connelly is senior associate dean, Academic and Community Affairs, and professor, Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Holly J Humphrey
- H.J. Humphrey is president, Josiah Macy Jr. Foundation, New York, New York, and chair, Kaiser Permanente Bernard J. Tyson School of Medicine Board of Directors, Pasadena, California
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16
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Purcell JB, Orihuela CA, Elliott MN, Tortolero Emery S, Schuster MA, Mrug S. Examining Sex and Racial/Ethnic Differences in Co-use of Alcohol, Cannabis, and Cigarettes in a Community Sample of Adolescents. Subst Use Misuse 2020; 56:101-110. [PMID: 33164639 DOI: 10.1080/10826084.2020.1843056] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Although adolescents often co-use alcohol, cigarettes, and cannabis, little is known about sex and racial/ethnic differences in the co-use of these substances. Therefore, this investigation examined sex and racial/ethnic differences in alcohol, cigarette, and cannabis co-use in a large and ethnically diverse group. Methods: Participants were drawn from a large, multi-site study of adolescents from three regions in the United States (N = 4,129; Mage=16.10 years, SD = 0.59; 51% female, 49% male; 37% Black, 37% Hispanic, 25% White). Participants were categorized into eight mutually exclusive groups based on their self-reported use of alcohol, cannabis, and cigarettes in the last 30 days. Results: Unadjusted multinomial logistic regression revealed that males were more likely than females to use cannabis-only and to co-use all three substances. Additionally, Black and Hispanic adolescents were more likely to use cannabis-only, while White adolescents were more likely than Black and Hispanic adolescents to co-use alcohol and cigarettes. After adjusting for other sociodemographic variables (age, household income, parental education, and parent marital status), males were more likely to use cannabis-only than females; White youth were more likely than Hispanic youth to use cigarettes only and co-use cigarettes and alcohol. White youth were more likely than Black youth to co-use alcohol and cigarettes and co-use all three substances. Discussion: These results indicate sex and racial/ethnic differences in substance co-use that were not explained by socioeconomic factors. Results of this work suggest potential strategies for targeted prevention efforts and underscore the importance of continued efforts to better understand patterns of alcohol and substance co-use.
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Affiliation(s)
| | | | | | | | - Mark A Schuster
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sylvie Mrug
- University of Alabama at Birmingham, Birmingham, Alabama, USA
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17
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Hyderi AA, Schuster MA. Kaiser Permanente Bernard J. Tyson School of Medicine. Acad Med 2020; 95:S38-S41. [PMID: 33626640 DOI: 10.1097/acm.0000000000003471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
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18
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Affiliation(s)
- Mark A Schuster
- From the Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Artem Osherov
- From the Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Paul J Chung
- From the Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
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19
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Bucholz EM, Schuster MA, Toomey SL. Trends in 30-Day Readmission for Medicaid and Privately Insured Pediatric Patients: 2010-2017. Pediatrics 2020; 146:peds.2020-0270. [PMID: 32611808 DOI: 10.1542/peds.2020-0270] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/22/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Children insured by Medicaid have higher readmission rates than privately insured children. However, little is known about whether this disparity has changed over time. METHODS Data from the 2010 to 2017 Healthcare Cost and Utilization Project Nationwide Readmissions Database were used to compare trends in 30-day readmission rates for children insured by Medicaid and private insurers. Patient-level crude and risk-adjusted readmission rates were compared by using Poisson regression. Hospital-level risk-adjusted readmission rates were compared between Medicaid- and privately insured patients within a hospital by using linear regression. RESULTS Approximately 60% of pediatric admissions were covered by Medicaid. From 2010 to 2017, the percentage of children with a complex or chronic condition increased for both Medicaid- and privately insured patients. Readmission rates were consistently higher for Medicaid beneficiaries from 2010 to 2017. Readmission rates declined slightly for both Medicaid- and privately insured patients; however, they declined faster for privately insured patients (rate ratio: 0.988 [95% confidence interval: 0.986-0.989] vs 0.995 [95% confidence interval: 0.994-0.996], P for interaction <.001]). After adjustment, readmission rates for Medicaid- and privately insured patients declined at a similar rate (P for interaction = .87). Risk-adjusted hospital readmission rates were also consistently higher for Medicaid beneficiaries. The within-hospital difference in readmission rates for Medicaid versus privately insured patients remained stable over time (slope for difference: 0.015 [SE 0.011], P = .019). CONCLUSIONS Readmission rates for Medicaid- and privately insured pediatric patients declined slightly from 2010 to 2017 but remained substantially higher among Medicaid beneficiaries suggesting a persistence of the disparity by insurance status.
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Affiliation(s)
- Emily M Bucholz
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; .,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Mark A Schuster
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and.,Bernard J. Tyson School of Medicine, Kaiser Permanente, Pasadena, California
| | - Sara L Toomey
- Harvard Medical School, Harvard University, Boston, Massachusetts.,Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and
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20
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Affiliation(s)
- Harold C Sox
- The Patient-Centered Outcomes Research Institute, Washington, DC, USA
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Both authors contributed equally
| | - Mark A Schuster
- Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, CA, USA
- Both authors contributed equally
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21
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Orihuela CA, Mrug S, Davies S, Elliott MN, Tortolero Emery S, Peskin MF, Reisner S, Schuster MA. Neighborhood Disorder, Family Functioning, and Risky Sexual Behaviors in Adolescence. J Youth Adolesc 2020; 49:991-1004. [PMID: 32096008 DOI: 10.1007/s10964-020-01211-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 02/10/2020] [Indexed: 10/24/2022]
Abstract
Adolescent risky sexual behaviors can result in negative consequences such as sexually transmitted infection. However, much research effort has been placed on understanding individual characteristics, rather than the role of neighborhood environment. This study addressed the prospective effects of neighborhood and family functioning in preadolescence on risky sexual behaviors. Participants included 4179 youth (Mage = 11.01 years, range 8.64-13.83; 51% female) and their caregivers. Using objective and self-reported measures of neighborhood and family functioning, results from multilevel regression analyses indicated that youth residing in disordered neighborhoods or had poorer family functioning in preadolescence were more likely to initiate sexual intercourse at younger ages 5 years later. Specifically, neighborhood poverty and decay were linked to early sexual initiation, whereas neighborhood social and family processes were protective against early sexual initiation. Males were more likely to engage in risky sexual behaviors in neighborhoods with greater poverty or decay; neighborhood poverty was linked with sexual initiation in White but not African American youth. Finally, parental monitoring moderated relationships between neighborhood social resources and contraceptive use, with neighborhood social resources linked with greater contraceptive use at low levels of parental monitoring, but lower contraceptive use at high levels of parental monitoring. These findings underscore the importance of neighborhood and family contexts in adolescents' risky sexual behavior, suggesting that males and White youth are more vulnerable to the effects of neighborhood poverty and that more research is needed on the possible counterproductive function of parental monitoring in neighborhoods with greater social resources.
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Affiliation(s)
- Catheryn A Orihuela
- The University of Alabama at Birmingham, 1300 University Blvd., Birmingham, AL, 35233, USA.
| | - Sylvie Mrug
- The University of Alabama at Birmingham, 1300 University Blvd., Birmingham, AL, 35233, USA
| | - Susan Davies
- The University of Alabama at Birmingham, 1300 University Blvd., Birmingham, AL, 35233, USA
| | - Marc N Elliott
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401-3208, USA
| | - Susan Tortolero Emery
- University of Texas Prevention Research Center, 7000 Fannin Ste. 2600, Houston, TX, 77030, USA
| | - Melissa F Peskin
- University of Texas Prevention Research Center, 7000 Fannin Ste. 2600, Houston, TX, 77030, USA
| | - Sari Reisner
- Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Mark A Schuster
- Kaiser Permanente School of Medicine, 98S. Los Robles Avenue, Pasadena, CA, 91101, USA
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22
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Feng JY, Toomey SL, Elliott MN, Zaslavsky AM, Onorato SE, Schuster MA. Factors Associated With Family Experience in Pediatric Inpatient Care. Pediatrics 2020; 145:peds.2019-1264. [PMID: 32015139 PMCID: PMC7049938 DOI: 10.1542/peds.2019-1264] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Hospitals are rapidly increasing efforts to improve the pediatric inpatient experience. However, hospitals often do not know what to target for improvement. To determine what matters most to families, we assessed which aspects of experience have the strongest relationships with parents' willingness to recommend a hospital. METHODS Cross-sectional study of 17 727 surveys completed from November 2012 to January 2014 by parents of children hospitalized at 69 hospitals in 34 states using the Child Hospital Consumer Assessment of Healthcare Providers and Systems Survey. Hierarchical logistic regressions predicted the "top box" for willingness to recommend from measures of specific care dimensions (nurse-parent communication, doctor-parent communication, communication about medicines, keeping parents informed about the child's care, privacy with providers, preparing to leave the hospital, mistakes and concerns, child comfort, cleanliness, and quietness), adjusting for parent-child characteristics. Relative importance was assessed by using partially standardized adjusted odds ratios (aORs). RESULTS Child comfort (aOR 1.50; 95% confidence interval 1.41-1.60) and nurse-parent communication (aOR 1.50; 95% confidence interval 1.42-1.58) showed the strongest relationships with willingness to recommend, followed by preparing to leave the hospital, doctor-parent communication, and keeping parents informed. Privacy and quietness were not significantly associated with willingness to recommend in multivariate analysis. CONCLUSIONS Our study uncovered highly valued dimensions that are distinct to pediatric care. Hospitals that care for children should consider using dedicated pediatric instruments to measure and track their performance. Improvement efforts should focus on creating an age-appropriate environment, improving the effectiveness of provider interactions, and engaging parents to share their values and concerns.
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Affiliation(s)
- Jeremy Y. Feng
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts;,Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts;,Medicine
| | - Sara L. Toomey
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts;,Departments of Pediatrics
| | | | | | - Sarah E. Onorato
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts;,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Mark A. Schuster
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts;,Departments of Pediatrics,,Office of the Dean, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
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23
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Bucholz EM, Toomey SL, Butala NM, Chien AT, Yeh RW, Schuster MA. Suitability of elderly adult hospital readmission rates for profiling readmissions in younger adult and pediatric populations. Health Serv Res 2020; 55:277-287. [PMID: 32037552 DOI: 10.1111/1475-6773.13269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To determine the correlation between hospital 30-day risk-standardized readmission rates (RSRRs) in elderly adults and those in nonelderly adults and children. DATA SOURCES/STUDY SETTING US hospitals (n = 1760 hospitals admitting adult patients and 235 hospitals admitting both adult and pediatric patients) in the 2013-2014 Nationwide Readmissions Database. STUDY DESIGN Cross-sectional analysis comparing 30-day RSRRs for elderly adult (≥65 years), middle-aged adult (40-64 years), young adult (18-39 years), and pediatric (1-17 years) patients. PRINCIPAL FINDINGS Hospital elderly adult RSRRs were strongly correlated with middle-aged adult RSRRs (Pearson R2 .69 [95% confidence interval (CI) 0.66-0.71]), moderately correlated with young adult RSRRs (Pearson R2 .44 [95% CI 0.40-0.47]), and weakly correlated with pediatric RSRRs (Pearson R2 .28 [95% CI 0.17-0.38]). Nearly identical findings were observed with measures of interquartile agreement and Kappa statistics. This stepwise relationship between age and strength of correlation was consistent across every hospital characteristic. CONCLUSIONS Hospital readmission rates in elderly adults, which are currently used for public reporting and hospital comparisons, may reflect broader hospital readmission performance in middle-aged and young adult populations; however, they are not reflective of hospital performance in pediatric populations.
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Affiliation(s)
- Emily M Bucholz
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Sara L Toomey
- Harvard Medical School, Boston, Massachusetts.,Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Neel M Butala
- Harvard Medical School, Boston, Massachusetts.,Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Alyna T Chien
- Harvard Medical School, Boston, Massachusetts.,Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Robert W Yeh
- Department of Cardiology, Beth Israel Deaconess Hospital, Boston, Massachusetts
| | - Mark A Schuster
- Harvard Medical School, Boston, Massachusetts.,Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
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24
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Harnett NG, Wheelock MD, Wood KH, Goodman AM, Mrug S, Elliott MN, Schuster MA, Tortolero S, Knight DC. Negative life experiences contribute to racial differences in the neural response to threat. Neuroimage 2019; 202:116086. [PMID: 31401241 PMCID: PMC6819267 DOI: 10.1016/j.neuroimage.2019.116086] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 07/11/2019] [Accepted: 08/07/2019] [Indexed: 12/12/2022] Open
Abstract
Threat-related emotional function is supported by a neural circuit that includes the prefrontal cortex (PFC), hippocampus, and amygdala. The function of this neural circuit is altered by negative life experiences, which can potentially affect threat-related emotional processes. Notably, Black-American individuals disproportionately endure negative life experiences compared to White-American individuals. However, the relationships among negative life experiences, race, and the neural substrates that support threat-related emotional function remains unclear. Therefore, the current study investigated whether the brain function that supports threat-related emotional processes varies with racial differences in negative life experiences. In the present study, adolescent violence exposure, family income, and neighborhood disadvantage were measured prospectively (i.e., at 11-19 years of age) for Black-American and White-American volunteers. Participants then, as young adults (i.e., 18-23 years of age), completed a Pavlovian fear conditioning task during functional magnetic resonance imaging (fMRI). Cued and non-cued threats were presented during the conditioning task and behavioral (threat expectancy) and psychophysiological responses (skin conductance response; SCR) were recorded simultaneously with fMRI. Racial differences were observed in neural (fMRI activity), behavioral (threat expectancy), and psychophysiological (SCR) responses to threat. These threat-elicited responses also varied with negative life experiences (violence exposure, family income, and neighborhood disadvantage). Notably, racial differences in brain activity to threat were smaller after accounting for negative life experiences. The present findings suggest that racial differences in the neural and behavioral response to threat are due, in part, to exposure to negative life experiences and may provide new insight into the mechanisms underlying racial disparities in mental health.
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Affiliation(s)
- Nathaniel G Harnett
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Muriah D Wheelock
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kimberly H Wood
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Adam M Goodman
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sylvie Mrug
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Mark A Schuster
- Harvard Medical School, Boston, MA, USA; Boston Children's Hospital, Boston, MA, USA; Kaiser Permanente School of Medicine, Pasadena, CA, USA
| | - Susan Tortolero
- Health Science Center, University of Texas, Houston, TX, USA
| | - David C Knight
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA.
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Progovac AM, Mullin BO, Creedon TB, McDowell A, Sanchez-Roman MJ, Hatfield LA, Schuster MA, Cook BL. Trends in Mental Health Care Use in Medicare from 2009 to 2014 by Gender Minority and Disability Status. LGBT Health 2019; 6:297-305. [PMID: 31436481 DOI: 10.1089/lgbt.2018.0221] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: This study examines trends in Medicare beneficiaries' mental health care use from 2009 to 2014 by gender minority and disability status. Methods: Using 2009 to 2014 Medicare claims, we modeled mental health care use (outpatient mental health care, inpatient mental health care, and psychotropic drugs) over time, adjusting for age and behavioral health diagnoses. We compared trends for gender minority beneficiaries (identified using diagnosis codes) to trends for a 5% random sample of other beneficiaries, stratified by original entitlement reason (age vs. disability). Results: Adjusted outpatient and inpatient mental health care use decreased and differences generally narrowed between gender minority and other beneficiaries over the study period. Among beneficiaries qualifying through disability, the gap in the number of outpatient and inpatient visits (among those with at least one visit in a given year) widened. Psychotropic drug use rose for all beneficiaries, but the proportion of gender minority beneficiaries in the aged cohort who had a psychotropic medication prescription rose faster than for other aged beneficiaries. Conclusions: Mental health care needs for Medicare beneficiaries may be met increasingly by using psychotropic medications rather than outpatient visits, and this pattern is more pronounced for identified gender minority (especially aged) beneficiaries. These trends may indicate a growing need for research and provider training in safe and effective psychotropic medication prescribing alongside gender-affirming treatments such as hormone therapy, especially for aged gender minority individuals who likely already experience polypharmacy.
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Affiliation(s)
- Ana M Progovac
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts.,Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Brian O Mullin
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Timothy B Creedon
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Alex McDowell
- PhD Program in Health Policy, Harvard University, Cambridge, Massachusetts.,Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Maria Jose Sanchez-Roman
- Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts.,Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Laura A Hatfield
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | | | - Benjamin Lê Cook
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts.,Health Equity Research Lab, Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts
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Nakamura MM, Toomey SL, Zaslavsky AM, Petty CR, Lin C, Savova GK, Rose S, Brittan MS, Lin JL, Bryant MC, Ashrafzadeh S, Schuster MA. Potential Impact of Initial Clinical Data on Adjustment of Pediatric Readmission Rates. Acad Pediatr 2019; 19:589-598. [PMID: 30470563 PMCID: PMC6788282 DOI: 10.1016/j.acap.2018.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 07/09/2018] [Accepted: 09/17/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Comparison of readmission rates requires adjustment for case-mix (ie, differences in patient populations), but previously only claims data were available for this purpose. We examined whether incorporation of relatively readily available clinical data improves prediction of pediatric readmissions and thus might enhance case-mix adjustment. METHODS We examined 30-day readmissions using claims and electronic health record data for patients ≤18 years and 29 days of age who were admitted to 3 children's hospitals from February 2011 to February 2014. Using the Pediatric All-Condition Readmission Measure and starting with a model including age, gender, chronic conditions, and primary diagnosis, we examined whether the addition of initial vital sign and laboratory data improved model performance. We employed machine learning to evaluate the same variables, using the L2-regularized logistic regression with cost-sensitive learning and convolutional neural network. RESULTS Controlling for the core model variables, low red blood cell count and mean corpuscular hemoglobin concentration and high red cell distribution width were associated with greater readmission risk, as were certain interactions between laboratory and chronic condition variables. However, the C-statistic (0.722 vs 0.713) and McFadden's pseudo R2 (0.085 vs 0.076) for this and the core model were similar, suggesting minimal improvement in performance. In machine learning analyses, the F-measure (harmonic mean of sensitivity and positive predictive value) was similar for the best-performing model (containing all variables) and core model (0.250 vs 0.243). CONCLUSIONS Readily available clinical variables do not meaningfully improve the prediction of pediatric readmissions and would be unlikely to enhance case-mix adjustment unless their distributions varied widely across hospitals.
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Affiliation(s)
- Mari M. Nakamura
- Division of General Pediatrics, Boston Children’s Hospital,Division of Infectious Diseases, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Sara L. Toomey
- Division of General Pediatrics, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Alan M. Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, Mass
| | - Carter R. Petty
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital
| | - Chen Lin
- Informatics Program, Boston Children’s Hospital
| | - Guergana K. Savova
- Informatics Program, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Sherri Rose
- Department of Health Care Policy, Harvard Medical School, Boston, Mass
| | - Mark S. Brittan
- Department of Pediatrics, Children’s Hospital Colorado, Aurora
| | - Jody L. Lin
- Department of Pediatrics, Stanford School of Medicine, Stanford, Calif
| | | | | | - Mark A. Schuster
- Division of General Pediatrics, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, Mass,Kaiser Permanente School of Medicine, Pasadena, Calif
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Jetelina KK, Reingle Gonzalez JM, Cuccaro PM, Peskin MF, Pompeii L, Atem F, Elliott MN, Earnshaw VA, Davies SL, Schuster MA. Mechanisms and Frequency of Violent Injuries Among Victims and Perpetrators of Bullying. J Adolesc Health 2019; 64:664-670. [PMID: 30612808 DOI: 10.1016/j.jadohealth.2018.10.295] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/02/2018] [Accepted: 10/26/2018] [Indexed: 01/17/2023]
Abstract
PURPOSE This article aims to (1) evaluate whether bullying typology predicts violent injury; (2) longitudinally examine whether violent injury trajectories differ across bullying typology as children age; and (3) longitudinally determine whether children who consistently reported perpetration or victimization (i.e., reported bullying at fifth, seventh, and 10th grade) were different from children who inconsistently reported perpetration or victimization. METHODS Longitudinal data were obtained from 4,297 children at three waves (fifth, seventh, and 10th grade) in three United States communities. Children were categorized into four mutually exclusive bullying typologies: neither victim nor perpetrator; victim only; perpetrator only; victim-perpetrator. Children self-reported mechanisms of violent injuries that needed medical attention in the past year. Regression models were used to evaluate the relationship between bullying group and the likelihood of violent injury over time. RESULTS Seventeen percent (n=857) of children in fifth grade reported a violent injury. Prevalence of overall violent injuries, and specifically firearm and knife injuries, increased over time. Children who reported perpetration in the absence of victimization were at increased odds for violent injury (adjusted odds ratio = 1.41, 95% confidence interval: 1.24, 1.60) compared with children who reported neither victimization nor perpetration, while children who reported victimization in the absence of perpetration were at decreased odds (adjusted odds ratio=.84, 95% confidence interval: .73, .97). A significant linear dose-response relationship was observed between duration of bullying perpetration and violent injury. CONCLUSIONS The relationship between bullying perpetration and violent injury over time was strong. Future research should investigate potential mediating behaviors, such as weapon access, which might explain the observed relationship.
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Affiliation(s)
- Katelyn K Jetelina
- University of Texas Health Science Center, School of Public Health, Dallas Campus, Dallas, Texas.
| | | | - Paula M Cuccaro
- University of Texas Health Science Center, School of Public Health, Houston, Texas
| | - Melissa F Peskin
- University of Texas Health Science Center, School of Public Health, Houston, Texas
| | - Lisa Pompeii
- University of Texas Health Science Center, School of Public Health, Houston, Texas
| | - Folefac Atem
- University of Texas Health Science Center, School of Public Health, Dallas Campus, Dallas, Texas
| | | | | | - Susan L Davies
- Department of Health Behavior, UAB Center for the Study of Community Health, Birmingham, Alabama
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Chien AT, Toomey SL, Kuo DZ, Van Cleave J, Houtrow AJ, Okumura MJ, Westfall MY, Petty CR, Quinn JA, Kuhlthau KA, Schuster MA. Care Quality and Spending Among Commercially Insured Children With Disabilities. Acad Pediatr 2019; 19:291-299. [PMID: 29932986 DOI: 10.1016/j.acap.2018.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 04/16/2018] [Accepted: 06/10/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To identify opportunities to improve care value for children with disabilities (CWD), we examined CWD prevalence within a commercially insured population and compared outpatient care quality and annual health plan spending levels for CWD relative to children with complex medical conditions without disabilities; children with chronic conditions that are not complex; and children without disabling, complex, or chronic conditions. METHODS This cross-sectional study comprised 1,118,081 person-years of Blue Cross Blue Shield Massachusetts data for beneficiaries aged 1 to 19years old during 2008 to 2012. We combined the newly developed and validated Children with Disabilities Algorithm with the Pediatric Medical Complexity Algorithm to identify CWD and non-CWD subgroups. We used 14 validated or National Quality Forum-endorsed measures to assess outpatient care quality and paid claims to examine annual plan spending levels and components. RESULTS CWD constituted 4.5% of all enrollees. Care quality for CWD was between 11% and 59% for 8 of 14 quality measures and >80% for the 6 remaining measures and was generally comparable to that for non-CWD subgroups. Annual plan spending among CWD was a median and mean 23% and 53% higher than that for children with complex medical conditions without disabilities, respectively; CWD mean and median values were higher than for all other groups as well. CONCLUSIONS CWD were prevalent in our commercially insured population. CWD experienced suboptimal levels of care, but those levels were comparable to non-CWD groups. Improving the care value for CWD involves a deeper understanding of what higher spending delivers and additional aspects of care quality.
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Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Department of Medicine; Department of Pediatrics, Harvard Medical School.
| | - Sara L Toomey
- Division of General Pediatrics, Department of Medicine; Department of Pediatrics, Harvard Medical School
| | - Dennis Z Kuo
- Division of General Pediatrics, Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, NY
| | - Jeanne Van Cleave
- Department of Pediatrics, School of Medicine, University of Colorado Denver, Anschutz Medical Campus , Aurora, Colo
| | - Amy J Houtrow
- Division of Pediatric Rehabilitation Medicine, Children's Hospital of Pittsburgh; Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine , Pittsburgh, Pa
| | - Megumi J Okumura
- Division of General Pediatrics, University of California San Francisco Benioff Children's Hospital; Division of General Pediatrics, Department of Pediatrics, University of California San Francisco School of Medicine , San Francisco
| | | | - Carter R Petty
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital
| | | | - Karen A Kuhlthau
- Department of Pediatrics, Harvard Medical School; Division of General Academic Pediatrics, Massachusetts General Hospital for Children , Boston, Mass
| | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine; Department of Pediatrics, Harvard Medical School; Kaiser Permanente School of Medicine , Pasadena, Calif
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Jetelina KK, Reingle Gonzalez JM, Cuccaro PM, Peskin MF, Pompeii L, Atem F, Elliott MN, Earnshaw VA, Davies SL, Schuster MA. Self-reporting discrepancies of bullying victimization and perpetration measures. Ann Epidemiol 2019; 32:58-63. [DOI: 10.1016/j.annepidem.2019.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 12/11/2018] [Accepted: 01/22/2019] [Indexed: 10/27/2022]
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Wallander JL, Fradkin C, Elliott MN, Cuccaro PM, Tortolero Emery S, Schuster MA. Racial/ethnic disparities in health-related quality of life and health status across pre-, early-, and mid-adolescence: a prospective cohort study. Qual Life Res 2019; 28:1761-1771. [PMID: 30927145 DOI: 10.1007/s11136-019-02157-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE To examine (1) racial/ethnic disparities in health-related quality of life (HRQOL) and overall health status among Black, Latino, and White youth during adolescence; (2) whether socioeconomic status (SES) and family contextual variables influence disparities; and (3) whether disparities are consistent from pre- to early- to mid-adolescence. METHODS A population sample of 4823 Black (1755), Latino (1812), and White (1256) youth in three US metropolitan areas was prospectively assessed in a longitudinal survey conducted on three occasions, in 5th, 7th, and 10th grades, when youth reported their HRQOL using the PedsQL™ short-form Total, Physical and Psychosocial scales and youth and parents separately reported on youth's overall health status. Parents reported their education and household income to index SES, family structure, and use of English at home. RESULTS Based on analysis conducted separately at each grade, marked racial/ethnic disparities were observed across all measures of HRQOL and health status, favoring White and disfavoring Black, and especially Latino youth. More strongly present in 5th and 7th grade, HRQOL disparities decreased by 10th grade. Most disparities between White and Black youth disappeared when adjusting for SES. However, even after adjusting for SES, family structure, and English use, overall health status disparities disfavoring Latino youth remained across all three assessments. CONCLUSIONS Racial/ethnic disparities in adolescent HRQOL and health are substantial. These disparities appear consistent from pre- to early-adolescence but diminish for HRQOL by mid-adolescence. As disparities appear influenced by SES and other family contextual variables differently in different racial/ethnic groups, efforts to reduce health disparities in youth should address culturally specific conditions impinging on health.
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Affiliation(s)
- Jan L Wallander
- Psychological Sciences and Health Sciences Research Institute, SSHA, University of California, 5200 N. Lake Rd, Merced, CA, 95343, USA.
| | - Chris Fradkin
- Psychological Sciences and Health Sciences Research Institute, SSHA, University of California, 5200 N. Lake Rd, Merced, CA, 95343, USA.,Departamento de Psicologia, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Paula M Cuccaro
- Center for Health Promotion and Prevention Research, University of Texas School of Public Health, Houston, USA
| | - Susan Tortolero Emery
- Center for Health Promotion and Prevention Research, University of Texas School of Public Health, Houston, USA
| | - Mark A Schuster
- Kaiser Permanente School of Medicine, Pasadena, CA, USA.,Division of General Pediatrics, Boston Children's Hospital, Boston, USA.,Department of Pediatrics, Harvard Medical School, Boston, USA
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MacCarthy S, Martino SC, Burkhart Q, Beckett MK, Schuster MA, Quigley DD, Ng JH, Agniel D, Elliott MN. An Integrated Approach to Measuring Sexual Orientation Disparities in Women's Access to Health Services: A National Health Interview Survey Application. LGBT Health 2019; 6:87-93. [DOI: 10.1089/lgbt.2018.0190] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | | | | | | | | | - Judy H. Ng
- National Committee for Quality Assurance, Washington, District of Columbia
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Bogart LM, Fu CM, Eyraud J, Cowgill BO, Hawes-Dawson J, Uyeda K, Klein DJ, Elliott MN, Schuster MA. Evaluation of the dissemination of SNaX, a middle school-based obesity prevention intervention, within a large US school district. Transl Behav Med 2019; 8:724-732. [PMID: 29444325 DOI: 10.1093/tbm/ibx055] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Few evidence-based school obesity-prevention programs are disseminated. We used community-based participatory research principles to disseminate an evidence-based middle-school obesity-prevention program, Students for Nutrition and eXercise (SNaX), to a large, primarily Latino, school district. In the 2014-2015 school year, we trained a district "champion" to provide training and technical assistance to schools and supplied print- and web-based materials (www.snaxinschools.org). In one district region, 18 of 26 schools agreed to participate. We evaluated the dissemination process using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. All 18 schools implemented at least one SNaX component. Of 6,410 students who attended an informational session, 1,046 registered and 472 were selected to be Student Advocates, of whom 397 attended at least one meeting. Of 60 activities observed across schools, 77% were conducted with fidelity, but local resource constraints limited most activities to a relatively small number of Student Advocates (vs. the entire student body). Qualitative data from 46 school staff and 187 students indicated positive attitudes about the program. Teachers suggested that SNaX be implemented as part of the curriculum. In the 2015-2016 school year, 6 of the original schools continued to implement SNaX, and the champion trained 94 teachers from 57 schools districtwide. Cafeteria servings overall and fruit and vegetable servings, the primary outcomes, did not increase in SNaX schools versus matched-comparison schools. Our mixed-methods evaluation of SNaX showed acceptability and fidelity, but not effectiveness. Effectiveness may be improved by providing technical assistance to community stakeholders on how to tailor core intervention components while maintaining fidelity.
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Affiliation(s)
| | - Chong-Min Fu
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Jodi Eyraud
- Student Health and Human Services, Los Angeles Unified School District, Los Angeles, CA, USA
| | - Burton O Cowgill
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | | | - Kimberly Uyeda
- Student Health and Human Services, Los Angeles Unified School District, Los Angeles, CA, USA
| | - David J Klein
- Health Unit, RAND Corporation, Santa Monica, CA, USA.,Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | | | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Kaiser Permanente School of Medicine, Pasadena, CA, USA
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Abstract
The following is an address given by the author in receipt of the Joseph W. St. Geme, Jr. Leadership Award, presented by the Federation of Pediatric Organizations at the Pediatric Academic Societies Meeting in Toronto, Canada, on May 5, 2018. Gary R. Fleisher, MD, Chairman of the Department of (Pediatric) Medicine and Physician-in-Chief at Boston Children's Hospital, and the Egan Professor of Pediatrics at Harvard Medical School, introduced the author.
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Affiliation(s)
- Mark A Schuster
- Kaiser Permanente School of Medicine, Pasadena, California; Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Abstract
BACKGROUND Health reform and policy initiatives over the last 2 decades have led to significant changes in pediatric clinical practice. However, little is known about recent trends in pediatric hospitalizations and readmissions at a national level. METHODS Data from the 2010-2016 Healthcare Cost and Utilization Project Nationwide Readmissions Database and National Inpatient Sample were analyzed to characterize patient-level and hospital-level trends in annual pediatric (ages 1-17 years) admissions and 30-day readmissions. Poisson regression was used to evaluate trends in pediatric readmissions over time. RESULTS From 2010 to 2016, the total number of index admissions decreased by 21.3%, but the percentage of admissions for children with complex chronic conditions increased by 5.7%. Unadjusted pediatric 30-day readmission rates increased over time from 6.26% in 2010 to 7.02% in 2016 with a corresponding increase in numbers of admissions for patients with complex chronic conditions. When stratified by complex or chronic conditions, readmission rates declined or remained stable across patient subgroups. Mean risk-adjusted hospital readmission rates increased over time overall (6.46% in 2010 to 7.14% in 2016) and in most hospital subgroups but decreased over time in metropolitan teaching hospitals. CONCLUSIONS Pediatric admissions declined from 2010 to 2016 as 30-day readmission rates increased. The increase in readmission rates was associated with greater numbers of admissions for children with chronic conditions. Hospitals serving pediatric patients need to account for the rising complexity of pediatric admissions and develop strategies for reducing readmissions in this high-risk population.
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Affiliation(s)
- Emily M. Bucholz
- Department of Cardiology Boston Children’s Hospital, Boston, Massachusetts,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Sara L. Toomey
- Harvard Medical School, Harvard University, Boston, Massachusetts,Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Mark A. Schuster
- Harvard Medical School, Harvard University, Boston, Massachusetts,Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts,Kaiser Permanente School of Medicine, Pasadena, California
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Kim KW, Wallander JL, Felt JM, Elliott MN, Schuster MA. Associations of Parental General Monitoring with Adolescent Weight-Related Behaviors and Weight Status. Obesity (Silver Spring) 2019; 27:280-287. [PMID: 30597754 DOI: 10.1002/oby.22372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 10/25/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study examined how parental general monitoring (PGM), which refers to parental awareness of adolescents' activities in various domains, is associated with adolescents' weight status and related behaviors and whether these relationships differ among racial/ethnic groups. METHODS Data are from 4,088 Black, Latino, and White youth assessed in seventh grade (mean age = 13.06). BMI percentile based on measured height and weight indicated weight status. PGM was assessed by adolescent report of parents' awareness of money spending, friends, and whereabouts. Adolescents reported both healthy and unhealthy dietary intake (DI), physical activity, and screen time over the past 7 days. Total sample and multigroup structural models were estimated. RESULTS PGM was associated with lower weight status for the total sample, as well as being positively associated with healthy DI and physical activity and inversely associated with screen time across racial/ethnic groups. PGM was also inversely associated with unhealthy DI, except for in Black adolescents. There was an indirect effect from PGM to lower weight status via reduced screen time among Latino and White adolescents. CONCLUSIONS Positive outcomes associated with PGM are extended to weight status and related behaviors. Efforts at improving weight status and related behaviors could benefit from addressing general parenting practices with their children.
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Affiliation(s)
- Kay W Kim
- Psychological Sciences and Health Sciences Research Institute, University of California, Merced, Merced, California, USA
| | - Jan L Wallander
- Psychological Sciences and Health Sciences Research Institute, University of California, Merced, Merced, California, USA
| | - John M Felt
- Psychological Sciences and Health Sciences Research Institute, University of California, Merced, Merced, California, USA
| | | | - Mark A Schuster
- Kaiser Permanente School of Medicine, Pasadena, California, USA
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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Atkinson MK, Schuster MA, Feng JY, Akinola T, Clark KL, Sommers BD. Adverse Events and Patient Outcomes Among Hospitalized Children Cared for by General Pediatricians vs Hospitalists. JAMA Netw Open 2018; 1:e185658. [PMID: 30646280 PMCID: PMC6324330 DOI: 10.1001/jamanetworkopen.2018.5658] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Pediatric hospital medicine is a relatively new and growing specialty. However, research remains inconclusive on outcomes for inpatients cared for by pediatric hospitalists compared with those cared for by general pediatricians. OBJECTIVE To analyze outcomes, adverse events (AEs), and types of AEs associated with care provided for pediatric patients by hospitalists vs general pediatricians. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data from the medical records of a US urban academic children's hospital comprising 1423 hospitalizations between January 1, 2009, and August 31, 2015, for 57 diagnoses of patients cared for by either a hospitalist or general pediatrician. General pediatricians worked primarily in the hospital's outpatient clinic, serving a few inpatient weeks per year, and were not the patients' primary care physician. Data analysis was performed from July 1, 2017, to October 10, 2018. MAIN OUTCOMES AND MEASURES Outcomes were length of stay, total costs, 30-day readmission rates, and AEs. Adverse events were documented by International Classification of Diseases, Ninth Revision, Clinical Modification codes determined by review of medical records. Adverse event categories were drug events, infections, and device-related AEs. Generalized linear models were used to analyze patient outcomes, with standard errors clustered by physician. Models were adjusted for patient characteristics, including Chronic Condition Indicators. Models were estimated with and without adjustment for physician characteristics. RESULTS The data set contained 1423 hospitalizations among 726 female patients and 697 male patients (mean [SD] age, 6.1 [6.3] years). Hospitalists cared for 870 patients, and general pediatricians cared for 553 patients. Among the physicians, there were 57 women and 38 men; physicians were a mean (SD) 11.1 (8.1) years out of medical school. Patients cared for by general pediatricians were younger than those cared for by hospitalists (mean [SD] age, 5.4 [6.0] vs 6.5 [6.4] years; P = .001) but had similar mean (SD) Chronic Condition Indicator scores (1.5 [1.0] vs 1.5 [1.0]). A total of 33 of 56 general pediatricians (58.9%) and 24 of 39 hospitalists (61.5%) were women (P = .006), and general pediatricians were in practice twice as long as hospitalists on average (mean [SD], 16.0 [10.3] vs 7.9 [3.8] years out of medical school; P < .001). In multivariate models adjusting for patient-level features, there were no significant differences between general pediatricians and hospitalists for mean length of stay (4.7 vs 4.6 days), total costs ($14 490 vs $15 200), and estimated 30-day readmission rate (8.9% vs 6.4%), and results were similar with adjustments for physician characteristics. Device-related AEs were higher among hospitalists (3.0% vs 1.1%; odds ratio, 0.34; 95% CI, 0.12-1.00); this association became nonsignificant after adjusting for physician experience. CONCLUSIONS AND RELEVANCE General pediatrician and hospitalist inpatient care had similar length of stay, total costs, and readmission rates. However, AEs differed between hospitalists and general pediatricians, with device-related AEs more common among hospitalists, which may be associated with hospitalists' fewer years in practice. Such findings can inform hospitals in planning their inpatient staffing and patient safety oversight.
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Affiliation(s)
- Mariam Krikorian Atkinson
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | | | - Jeremy Y. Feng
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital/Harvard Medical School, Boston
| | - Temilola Akinola
- Department of Radiology, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Kathryn L. Clark
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Benjamin D. Sommers
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
- Division of General Medicine & Primary Care, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
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Stockwell DC, Landrigan CP, Toomey SL, Westfall MY, Liu S, Parry G, Coopersmith AS, Schuster MA. Racial, Ethnic, and Socioeconomic Disparities in Patient Safety Events for Hospitalized Children. Hosp Pediatr 2018; 9:1-5. [PMID: 30509900 DOI: 10.1542/hpeds.2018-0131] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Previous studies have revealed racial/ethnic and socioeconomic disparities in quality of care and patient safety. However, these disparities have not been examined in a pediatric inpatient environment by using a measure of clinically confirmed adverse events (AEs). In this study, we do so using the Global Assessment of Pediatric Patient Safety (GAPPS) Trigger Tool. METHODS GAPPS was applied to medical records of randomly selected pediatric patients discharged from 16 hospitals in the Pediatric Research in Inpatient Settings Network across 4 US regions from January 2007 to December 2012. Disparities in AEs for hospitalized children were identified on the basis of patient race/ethnicity (black, Latino, white, or other; N = 17 336 patient days) and insurance status (public, private, or self-pay/no insurance; N = 19 030 patient days). RESULTS Compared with hospitalized non-Latino white children, hospitalized Latino children experienced higher rates of all AEs (Latino: 30.1 AEs per 1000 patient days versus white: 16.9 AEs per 1000 patient days; P ≤ .001), preventable AEs (Latino: 15.9 AEs per 1000 patient days versus white: 8.9 AEs per 1000 patient days; P = .002), and high-severity AEs (Latino: 12.6 AEs per 1000 patient days versus white: 7.7 AEs per 1000 patient days; P = .02). Compared with privately insured children, publicly insured children experienced higher rates of preventable AEs (public: 12.1 AEs per 1000 patient days versus private: 8.5 AEs per 1000 patient days; P = .02). No significant differences were observed among other groups. CONCLUSIONS The GAPPS analysis revealed racial and/or ethnic and socioeconomic disparities in rates of AEs experienced by hospitalized children across a broad range of geographic and hospital settings. Further investigation may reveal underlying mechanisms of these disparities and could help hospitals reduce harm.
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Affiliation(s)
- David C Stockwell
- Children's National Medical Center, Washington, District of Columbia.,Division of Critical Care Medicine, Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia
| | - Christopher P Landrigan
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sara L Toomey
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Matthew Y Westfall
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Shanshan Liu
- Institutional Centers for Clinical and Translational Research and
| | - Gareth Parry
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Institute for Healthcare Improvement, Cambridge, Massachusetts; and
| | - Ari S Coopersmith
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts.,Kaiser Permanente School of Medicine, Pasadena, California
| | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; .,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Kaiser Permanente School of Medicine, Pasadena, California
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Abstract
Background Research suggests that an immigrant paradox exists where those who were not born in the United States (1st generation) have significantly better health than those who were born in the U.S. (2nd generation or more). The aim of the current study was to examine the immigrant paradox with respect to tobacco-related perceptions and parenting influences in smoking initiation among Latinx adolescents. Methods Data came from the 7th and 10th grade Healthy Passages™ assessments of Latinx participants in three U.S. urban areas (N = 1536) who were first (18%), second (60%), and third (22%) generation. In addition to demographics, measures included perceived cigarette availability and peer smoking, intentions and willingness to smoke, and general monitoring by parents. Parents reported on generational status and their own tobacco use. The primary outcome was participant’s reported use of cigarettes. Results By 10th grade, 31% of Latinx youth had tried a cigarette, compared to 8% in 7th grade. After controlling for age, gender, and socioeconomic status, regression analyses indicated that there were no significant differences related to generational status in cigarette smoking initiation in either 7th or 10th grade. Youth tobacco-related perceptions, general parental monitoring, and parental tobacco use predicted Latinx adolescent cigarette use initiation by 10th grade. Conclusions Latinx adolescents might not have deferential smoking rates based on generation status, suggesting that the immigrant paradox concept may not hold for smoking initiation among Latinx adolescents. Rather, factors influencing cigarette initiation generally in adolescents as a group appear to apply to Latinxs as well.
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Affiliation(s)
- Anna E Epperson
- Stanford Prevention Research Center, Department of Medicine, Stanford University, 1265 Welch Road, Suite 300, Palo Alto, CA, 94305, USA.
| | - Jan L Wallander
- Psychological Sciences and Health Sciences Research Institute, University of California, Merced, 5200 Lake Rd, Merced, CA, 95340, USA
| | - Marc N Elliott
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA
| | - Mark A Schuster
- Division of General Pediatrics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA.,Department of Pediatrics, Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA.,Kaiser Permanente School of Medicine, 100 S. Los Robles Avenue, Pasadena, CA, 91101, USA
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39
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Correnti CM, Klein DJ, Elliott MN, Veledar E, Saraiya M, Chien AT, Schwebel DC, Mrug S, Tortolero SR, Cuccaro PM, Schuster MA, Chen SC. Racial disparities in fifth-grade sun protection: Evidence from the Healthy Passages study. Pediatr Dermatol 2018; 35:588-596. [PMID: 29962040 PMCID: PMC6168341 DOI: 10.1111/pde.13550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES Despite rising skin cancer rates in children, multiple studies reveal inadequate youth sun-protective behavior (eg, sunscreen use). Using Healthy Passages data for fifth-graders, we set out to determine sunscreen adherence in these children and investigated factors related to sunscreen performance. METHODS Survey data were collected from 5119 fifth-graders and their primary caregivers. Logistic regression was used to assess associations between sunscreen adherence and performance of other preventive health behaviors (eg, flossing, helmet use) and examine predictors of sunscreen adherence. Analyses were repeated in non-Hispanic black, Hispanic, and non-Hispanic white subgroups. RESULTS Five thousand one hundred nineteen (23.4%) children almost always used sunscreen, 5.9% of non-Hispanic blacks (n = 1748), 23.7% of Hispanics (n = 1802), and 44.8% of non-Hispanic whites (n = 1249). Performing other preventive health behaviors was associated with higher odds of sunscreen adherence (all P < .001), with the greatest association with flossing teeth (odds ratio = 2.41, 95% confidence interval = 1.86-3.13, P < .001). Factors for lower odds of sunscreen adherence included being male and non-Hispanic black or Hispanic and having lower socioeconomic status. School-based sun-safety education and involvement in team sports were not significant factors. CONCLUSION Our data confirm low use of sun protection among fifth-graders. Future research should explore how public health success in increasing prevalence of other preventive health behaviors may be applied to enhance sun protection messages. Identifying risk factors for poor adherence enables providers to target patients who need more education. Improving educational policies and content in schools may be an effective way to address sun safety.
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Affiliation(s)
- Christina M Correnti
- Department of Dermatology, School of Medicine, University of Maryland, Baltimore, ML, USA.,Department of Dermatology, School of Medicine, Emory University, Atlanta, GA, USA
| | - David J Klein
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.,RAND Corporation, Santa Monica, CA, USA
| | | | - Emir Veledar
- Department of Dermatology, School of Medicine, Emory University, Atlanta, GA, USA
| | - Mona Saraiya
- Epidemiology and Applied Research Branch, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alyna T Chien
- Department of Dermatology, School of Medicine, Emory University, Atlanta, GA, USA.,Department of Pediatrics, School of Medicine, Harvard University, Boston, MA, USA
| | - David C Schwebel
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sylvie Mrug
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Susan R Tortolero
- Center for Health Promotion and Prevention Research, School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Paula M Cuccaro
- Center for Health Promotion and Prevention Research, School of Public Health, University of Texas Health Science Center, Houston, TX, USA
| | - Mark A Schuster
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, School of Medicine, Harvard University, Boston, MA, USA.,School of Medicine, Kaiser Permanente, Pasadena, CA, USA
| | - Suephy C Chen
- Department of Dermatology, School of Medicine, Emory University, Atlanta, GA, USA.,Division of Dermatology, Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA
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Stockwell DC, Landrigan CP, Toomey SL, Loren SS, Jang J, Quinn JA, Ashrafzadeh S, Wang MJ, Wu M, Sharek PJ, Classen DC, Srivastava R, Parry G, Schuster MA. Adverse Events in Hospitalized Pediatric Patients. Pediatrics 2018; 142:peds.2017-3360. [PMID: 30006445 PMCID: PMC6317760 DOI: 10.1542/peds.2017-3360] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2018] [Indexed: 11/24/2022] Open
Abstract
UNLABELLED : media-1vid110.1542/5789657761001PEDS-VA_2017-3360Video Abstract BACKGROUND: Patient safety concerns over the past 2 decades have prompted widespread efforts to reduce adverse events (AEs). It is unclear whether these efforts have resulted in reductions in hospital-wide AE rates. We used a validated safety surveillance tool, the Global Assessment of Pediatric Patient Safety, to measure temporal trends (2007-2012) in AE rates among hospitalized children. METHODS We conducted a retrospective surveillance study of randomly selected pediatric inpatient records from 16 teaching and nonteaching hospitals. We constructed Poisson regression models with hospital random intercepts, controlling for patient age, sex, insurance, and chronic conditions, to estimate changes in AE rates over time. RESULTS Examining 3790 records, reviewers identified 414 AEs (19.1 AEs per 1000 patient days; 95% confidence interval [CI] 17.2-20.9) and 210 preventable AEs (9.5 AEs per 1000 patient days; 95% CI 8.2-10.8). On average, teaching hospitals had higher AE rates than nonteaching hospitals (26.2 [95% CI 23.7-29.0] vs 5.1 [95% CI 3.7-7.1] AEs per 1000 patient days, P < .001). Chronically ill children had higher AE rates than patients without chronic conditions (33.9 [95% CI 24.5-47.0] vs 14.0 [95% CI 11.8-16.5] AEs per 1000 patient days, P < .001). Multivariate analyses revealed no significant changes in AE rates over time. When stratified by hospital type, neither teaching nor nonteaching hospitals experienced significant temporal AE rate variations. CONCLUSIONS AE rates in pediatric inpatients are high and did not improve from 2007 to 2012. Pediatric AE rates were substantially higher in teaching hospitals as well as in patients with more chronic conditions.
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Affiliation(s)
- David C. Stockwell
- Children’s National Medical Center,
Washington, District of Columbia;,Division of Critical Care Medicine, Department of
Pediatrics, School of Medicine and Health Sciences, George Washington
University, Washington, District of Columbia
| | - Christopher P. Landrigan
- Division of General Pediatrics, Department of
Medicine, Boston Children’s Hospital, Boston, Massachusetts;,Harvard Medical School, Harvard University, Boston,
Massachusetts;,Division of Sleep Medicine, Department of Medicine,
Brigham and Women’s Hospital, Boston, Massachusetts
| | - Sara L. Toomey
- Division of General Pediatrics, Department of
Medicine, Boston Children’s Hospital, Boston, Massachusetts;,Harvard Medical School, Harvard University, Boston,
Massachusetts
| | - Samuel S. Loren
- Division of General Pediatrics, Department of
Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Jisun Jang
- Division of General Pediatrics, Department of
Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Jessica A. Quinn
- Division of General Pediatrics, Department of
Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Sepideh Ashrafzadeh
- Division of General Pediatrics, Department of
Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Michelle J. Wang
- Division of General Pediatrics, Department of
Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Melody Wu
- Division of General Pediatrics, Department of
Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Paul J. Sharek
- Division of Pediatric Hospitalist Medicine,
Department of Pediatrics, School of Medicine, Stanford University, Stanford,
California
| | - David C. Classen
- Division of Clinical Epidemiology, Department of
Internal Medicine and
| | - Rajendu Srivastava
- Division of Inpatient Medicine, Department of
Pediatrics, University of Utah, Salt Lake City, Utah;,Primary Children’s Hospital and,Institute for Healthcare Delivery Research,
Intermountain Healthcare, Salt Lake City, Utah; and
| | - Gareth Parry
- Harvard Medical School, Harvard University, Boston,
Massachusetts;,Institute for Healthcare Improvement, Cambridge,
Massachusetts
| | - Mark A. Schuster
- Division of General Pediatrics, Department of
Medicine, Boston Children’s Hospital, Boston, Massachusetts;,Harvard Medical School, Harvard University, Boston,
Massachusetts
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41
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Abstract
Youth living with socially devalued characteristics (e.g., minority sexual orientation, race, and/or ethnicity; disability; obesity) experience frequent bullying. This stigma-based bullying undermines youths' wellbeing and academic achievement, with lifelong consequences. The National Academies of Sciences, Engineering, and Medicine recommends developing, implementing, and evaluating evidence-based interventions to address stigma-based bullying. To characterize the existing landscape of these interventions, we conducted a systematic review of stigma-based bullying interventions targeting youth in any country published in the peer-reviewed literature between 2000 and 2015. Our analysis was guided by a theoretical framework of stigma-based bullying, which describes stigma-related factors at the societal, structural, interpersonal, and individual levels that lead to stigma-based bullying. We screened 8,240 articles and identified 22 research studies describing 21 interventions addressing stigma-based bullying. We found that stigma-based bullying interventions are becoming more numerous, yet are unevenly distributed across stigmas, geographic locations, and types of organizations. We further found that these interventions vary in the extent to which they incorporate theory and have been evaluated with a wide range of research designs and types of data. We recommend that future work address stigma-based bullying within multicomponent interventions, adopt interdisciplinary and theory-based approaches, and include rigorous and systematic evaluations. Intervening specifically on stigma-related factors is essential to end stigma-based bullying and improve the wellbeing of youth living with socially devalued characteristics.
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Affiliation(s)
- Valerie A. Earnshaw
- Department of Human Development and Family Sciences, University of Delaware, Newark, Delaware, USA
| | - Sari L. Reisner
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - David Menino
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - V. Paul Poteat
- Counseling, Developmental, and Educational Psychology Department, Boston College, Chestnut Hill, Massachusetts, USA
| | - Laura M. Bogart
- Health Unit, RAND Corporation, Santa Monica, California, USA
| | - Tia N. Barnes
- Department of Human Development and Family Sciences, University of Delaware, Newark, Delaware, USA
| | - Mark A. Schuster
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Kaiser Permanente School of Medicine, Pasadena, CA
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Hargreaves DS, Sizmur S, Pitchforth J, Tallett A, Toomey SL, Hopwood B, Schuster MA, Viner RM. Children and young people's versus parents' responses in an English national inpatient survey. Arch Dis Child 2018; 103:486-491. [PMID: 29434020 PMCID: PMC5916103 DOI: 10.1136/archdischild-2017-313801] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 11/28/2017] [Accepted: 12/14/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Despite growing interest in children and young people's (CYP) perspectives on healthcare, they continue to be excluded from many patient experience surveys. This study investigated the feasibility of, and additional information gained by, measuring CYP experiences of a recent hospital admission. DESIGN Cross-sectional analysis of national survey data. SETTING Inpatients aged 8-15 years in eligible National Health Service hospitals, July-September 2014. PARTICIPANTS 6204 parents/carers completed the parent section of the survey. The CYP section of the survey was completed by CYP themselves (n=3592), parents (n=849) or jointly (n=1763). MAIN OUTCOME MEASURES Pain relief, involvement, quality of staff communication, perceived safety, ward environment, overall experience. ANALYSES Single-measures intraclass correlations (ICCs) were used to assess the concordance between CYP and parent responses about the same inpatient episode. Multilevel logistic regression models, adjusted for individual characteristics, were used to compare the odds of positive responses when the CYP section of the survey was completed by parents, by CYP themselves or jointly. RESULTS The CYP section of the survey was completed independently by 57.8% of CYP. Agreement between CYP and parent responses was reasonably good for pain relief (ICC=0.61 (95% CI 0.58 to 0.63)) and overall experience (ICC=0.70 (95% CI 0.68 to 0.72)), but much lower for questions comparing professionals' communication with CYP and with their parents (ICC range=0.28 (95% CI 0.24 to 0.32) to 0.51 (95% CI 0.47 to 0.54)). In the regression models, CYP were significantly less likely than parents to report feeling safe (adjusted OR (AOR)=0.54 (95% CI 0.38 to 0.76)), involvement in decisions (AOR=0.66 (95% CI 0.46 to 0.94)) or adequate privacy (AOR=0.68 (95% CI 0.52 to 0.89)). CONCLUSIONS Including CYP (8-15 years) in patient experience surveys is feasible and enhances what is known from parents' responses.
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Affiliation(s)
- Dougal S Hargreaves
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK,The Nuffield Trust, London, UK
| | | | - Jacqueline Pitchforth
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Sara L Toomey
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, UK
| | | | - Mark A Schuster
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, UK,Kaiser Permanente School of Medicine, Pasadena, USA
| | - Russell M Viner
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
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Progovac AM, Cook BL, Mullin BO, McDowell A, Sanchez R MJ, Wang Y, Creedon TB, Schuster MA. Identifying Gender Minority Patients' Health And Health Care Needs In Administrative Claims Data. Health Aff (Millwood) 2018; 37:413-420. [PMID: 29505378 PMCID: PMC5942884 DOI: 10.1377/hlthaff.2017.1295] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Health care utilization patterns for gender minority Medicare beneficiaries (those who are transgender or gender nonbinary people) are largely unknown. We identified gender minority beneficiaries using a diagnosis-code algorithm and compared them to a 5 percent random sample of non-gender minority beneficiaries from the period 2009-14 in terms of mental health and chronic diseases, use of preventive and mental health care, hospitalizations, and emergency department (ED) visits. Gender minority beneficiaries experienced more disability and mental illness. When we adjusted for age and mental health, we found that they used more mental health care. And when we adjusted for age and chronic conditions, we found that they were more likely to be hospitalized and to visit the ED. There were several small but significant differences in preventive care use. Findings were similar for disabled and older cohorts. These findings underscore the need to capture gender identity in health data to better address this population's health needs.
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Affiliation(s)
- Ana M Progovac
- Ana M. Progovac ( ) is a senior scientist in the Health Equity Research Lab in the Department of Psychiatry, Cambridge Health Alliance, in Cambridge, and an instructor in the Department of Psychiatry, Harvard Medical School, in Boston, both in Massachusetts
| | - Benjamin Lê Cook
- Benjamin Lê Cook is director of the Health Equity Research Lab and director of research in the Department of Psychiatry, Cambridge Health Alliance, and an assistant professor in the Department of Psychiatry, Harvard Medical School
| | - Brian O Mullin
- Brian O. Mullin is a senior analyst in Health Equity Research Lab and the Children's Health Initiative in the Department of Psychiatry, Cambridge Health Alliance
| | - Alex McDowell
- Alex McDowell is a PhD student in the Department of Health Care Policy, Harvard Medical School, and a research assistant at the Health Equity Research Lab in the Department of Psychiatry, Cambridge Health Alliance
| | - Maria Jose Sanchez R
- Maria Jose Sanchez R. is a research assistant in the Health Equity Research Lab in the Department of Psychiatry, Cambridge Health Alliance
| | - Ye Wang
- Ye Wang is a research scientist in the Disparities Research Unit, Massachusetts General Hospital, in Boston
| | - Timothy B Creedon
- Timothy B. Creedon is a researcher at IBM Watson Health in Cambridge, Massachusetts. At the time this work was conducted, he was a research associate in the Health Equity Research Lab in the Department of Psychiatry, Cambridge Health Alliance
| | - Mark A Schuster
- Mark A. Schuster is founding dean and CEO of the Kaiser Permanente School of Medicine, in Pasadena, California. At the time this work was conducted, he was chief of the Division of General Pediatrics, Boston Children's Hospital, and the William Berenberg Professor of Pediatrics in the Department of Pediatrics, Harvard Medical School
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44
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Schuster MA, Onorato SE, Meltzer DO. Costs of Quality Measurement-Reply. JAMA 2018; 319:615-616. [PMID: 29450520 DOI: 10.1001/jama.2017.20292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Sarah E Onorato
- Division of General Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - David O Meltzer
- Department of Medicine, University of Chicago, Chicago, Illinois
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Abstract
BACKGROUND AND OBJECTIVES Reducing readmissions is a major health care system goal. There is a gap in our understanding of pediatric readmission patterns after mental health (MH) admissions. With this study, we aimed to characterize the prevalence of readmissions after MH admissions, to identify patient-level factors and costs associated with readmissions, and to assess variation in readmission rates across hospitals. METHODS Using the 2014 Healthcare Cost and Utilization Project all-payer Nationwide Readmissions Database, we conducted a retrospective cohort analysis of 253 309 admissions for 5- to 17-year-olds at acute-care hospitals in 22 states. We calculated 30-day unplanned readmission rates, lengths of stay, and costs by primary admission diagnosis. We used hierarchical regression models to assess differences in readmission rates by patient characteristics, primary diagnoses, and comorbid chronic conditions, and to estimate the variation in case mix-adjusted rates across hospitals. RESULTS MH stays accounted for 18.7% (n = 47 397) of index admissions. The 30-day readmission rate for MH admissions was higher than for non-MH admissions (8.0% vs 6.2%; P < .001). Children who were ≤14 years old, had non-MH chronic conditions, and/or had public insurance were more likely to be readmitted than their peers (P < .001 for each). Adjusted rates varied across hospitals (P < .001) and were 97.9% greater for hospitals 1 SD above versus below (11.2% vs 5.6%) the mean. Adjusted readmission rates, lengths of stay, and costs differed by diagnosis (P < .001). CONCLUSIONS The 30-day readmission rate was significantly higher after MH than non-MH admissions. Adjusted MH readmission rates varied substantially among hospitals, suggesting potential room for improvement.
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Affiliation(s)
- Jeremy Y Feng
- Divisions of General Pediatrics and .,Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Sara L Toomey
- Divisions of General Pediatrics and.,Departments of Pediatrics and
| | - Alan M Zaslavsky
- Health Care Policy, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Mari M Nakamura
- Divisions of General Pediatrics and.,Departments of Pediatrics and.,Infectious Diseaseas, Boston Children's Hospital, Boston, Massachusetts
| | - Mark A Schuster
- Divisions of General Pediatrics and.,Departments of Pediatrics and.,Kaiser Permanente School of Medicine, Pasadena, California
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46
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Kim KW, Wallander JL, Peskin M, Cuccaro P, Elliott MN, Schuster MA. Associations Between Parental SES and Children’s Health-Related Quality of Life: The Role of Objective and Subjective Social Status. J Pediatr Psychol 2017; 43:534-542. [DOI: 10.1093/jpepsy/jsx139] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 10/27/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kay W Kim
- Psychological Sciences and Health Sciences Research Institute, University of California, Merced
| | - Jan L Wallander
- Psychological Sciences and Health Sciences Research Institute, University of California, Merced
| | - Melissa Peskin
- Prevention Research Center, University of Texas School of Public Health
| | - Paula Cuccaro
- Prevention Research Center, University of Texas School of Public Health
| | | | - Mark A Schuster
- Division of General Pediatrics, Boston Children’s Hospital
- Department of Pediatrics, Harvard Medical School
- Kaiser Permanente School of Medicine, Pasadena, CA, USA
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47
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Chien AT, Newhouse JP, Iezzoni LI, Petty CR, Normand SLT, Schuster MA. Socioeconomic Background and Commercial Health Plan Spending. Pediatrics 2017; 140:peds.2017-1640. [PMID: 28974535 PMCID: PMC5654394 DOI: 10.1542/peds.2017-1640] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Risk-adjustment algorithms typically incorporate demographic and clinical variables to equalize compensation to insurers for enrollees who vary in expected cost, but including information about enrollees' socioeconomic background is controversial. METHODS We studied 1 182 847 continuously insured 0 to 19-year-olds using 2008-2012 Blue Cross Blue Shield of Massachusetts and American Community Survey data. We characterized enrollees' socioeconomic background using the validated area-based socioeconomic measure and calculated annual plan payments using paid claims. We evaluated the relationship between annual plan payments and geocoded socioeconomic background using generalized estimating equations (γ distribution and log link). We expressed outcomes as the percentage difference in spending and utilization between enrollees with high and low socioeconomic backgrounds. RESULTS Geocoded socioeconomic background had a significant, positive association with annual plan payments after applying standard adjusters. Every 1 SD increase in socioeconomic background was associated with a 7.8% (95% confidence interval, 7.2% to 8.3%; P < .001) increase in spending. High socioeconomic background enrollees used higher-priced outpatient and pharmacy services more frequently than their counterparts from low socioeconomic backgrounds (eg, 25% more outpatient encounters annually; 8% higher price per encounter; P < .001), which outweighed greater emergency department spending among low socioeconomic background enrollees. CONCLUSIONS Higher socioeconomic background is associated with greater levels of pediatric health care spending in commercially insured children. Including socioeconomic information in risk-adjustment algorithms may address concerns about adverse selection from an economic perspective, but it would direct funds away from those caring for children and adolescents from lower socioeconomic backgrounds who are at greater risk of poor health.
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Affiliation(s)
- Alyna T. Chien
- Division of General Pediatrics, Department of Medicine and,Departments of Pediatrics
| | - Joseph P. Newhouse
- Health Care Policy, and,Departments of Health Policy and Management and,John F. Kennedy School of Government, Harvard University, Cambridge, Massachusetts;,National Bureau of Economic Research, Cambridge, Massachusetts; and
| | - Lisa I. Iezzoni
- Medicine, Harvard Medical School,,Mongan Institute Health Policy Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Carter R. Petty
- Clinical Research Center, Boston Children’s Hospital, Boston, Massachusetts
| | | | - Mark A. Schuster
- Division of General Pediatrics, Department of Medicine and,Departments of Pediatrics
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Fenton AT, Elliott MN, Schwebel DC, Berkowitz Z, Liddon NC, Tortolero SR, Cuccaro PM, Davies SL, Schuster MA. Unequal interactions: Examining the role of patient-centered care in reducing inequitable diffusion of a medical innovation, the human papillomavirus (HPV) vaccine. Soc Sci Med 2017; 200:238-248. [PMID: 29157686 DOI: 10.1016/j.socscimed.2017.09.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 09/07/2017] [Accepted: 09/14/2017] [Indexed: 11/19/2022]
Abstract
RATIONALE Studies of inequities in diffusion of medical innovations rarely consider the role of patient-centered care. OBJECTIVE We used uptake of the human papillomavirus (HPV) vaccine shortly after its licensing to explore the role of patient-centered care. METHODS Using a longitudinal multi-site survey of US parents and adolescents, we assessed whether patient-centered care ratings might shape racial/ethnic and socioeconomic gaps at two decision points in the HPV vaccination process: (1) Whether a medical provider recommends the vaccine and (2) whether a parent decides to vaccinate. RESULTS We did not find evidence that the association of patient-centeredness with vaccination varies by parent education. In contrast, parent ratings of providers' patient-centeredness were significantly associated with racial/ethnic disparities in parents' reports of receiving a HPV vaccine recommendation from a provider: Among parents who rate patient-centered care as low, white parents' odds of receiving such a recommendation are 2.6 times higher than black parents' odds, but the racial/ethnic gap nearly disappears when parents report high patient-centeredness. Moderated mediation analyses suggest that patient-centeredness is a major contributor underlying vaccination uptake disparities: Among parents who report low patient-centeredness, white parents' odds of vaccinating their child are 8.1 times higher than black parents' odds, while both groups are equally likely to vaccinate when patient-centeredness is high. CONCLUSION The results indicate that patient-centered care, which has been a relatively understudied factor in the unequal diffusion of medical innovations, deserves more attention. Efforts to raise HPV vaccination rates should explore why certain patient groups may be less likely to receive recommendations and should support providers to consistently inform all patient groups about vaccination.
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Affiliation(s)
- Anny T Fenton
- Department of Sociology, Harvard University, 33 Kirkland Street, Cambridge, MA 02138, USA.
| | - Marc N Elliott
- 1776 Main Street, RAND Corporation, Santa Monica, CA 90401, USA.
| | - David C Schwebel
- Department of Psychology, University of Alabama at Birmingham, Campbell Hall 415, 1530 3rd Avenue South, Birmingham, AL 35294, USA.
| | - Zahava Berkowitz
- Division of Cancer Prevention and Control, Epidemiology and Applied Research Branch, CDC, 1600 Clifton Road Atlanta, GA 30329, USA.
| | - Nicole C Liddon
- Division of Adolescent and School Health, CDC, 1600 Clifton Road Atlanta, GA 30329, USA.
| | - Susan R Tortolero
- Department of Health Promotion and Behavioral Sciences, University of Texas School of Public Health, 1200 Pressler Street, Houston, TX 77030, USA.
| | - Paula M Cuccaro
- Department of Health Promotion and Behavioral Sciences, University of Texas School of Public Health, 1200 Pressler Street, Houston, TX 77030, USA.
| | - Suzy L Davies
- Department of Health Behavior, UAB Center for the Study of Community Health, 1665 University Boulevard, Birmingham, AL 35294, USA.
| | - Mark A Schuster
- Division of General Pediatrics, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Enders, 300 Longwood Avenue, Boston, MA 02115, USA; Kaiser Permanente School of Medicine, 100 South Los Robles Avenue, Pasadena, CA 91106, USA.
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Affiliation(s)
- Mark A Schuster
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Sarah E Onorato
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - David O Meltzer
- Department of Medicine, University of Chicago, Chicago, Illinois
- Harris School of Public Policy, University of Chicago, Chicago, Illinois
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Earnshaw VA, Reisner SL, Juvonen J, Hatzenbuehler ML, Perrotti J, Schuster MA. LGBTQ Bullying: Translating Research to Action in Pediatrics. Pediatrics 2017; 140:peds.2017-0432. [PMID: 28947607 PMCID: PMC5613818 DOI: 10.1542/peds.2017-0432] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2017] [Indexed: 11/24/2022] Open
Abstract
Lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth experience significant bullying that undermines their mental and physical health. National health organizations have called for the development of innovative strategies to address LGBTQ bullying. Pediatricians and other clinicians, medical and public health students, interdisciplinary researchers, government officials, school leaders, community members, parents, and youth from around the country came together at a national symposium entitled "LGBTQ Bullying: Translating Research to Action to Improve the Health of All Youth" in May 2016 to generate strategies to prevent LGBTQ bullying and meet the needs of LGBTQ youth experiencing bullying. This article describes key scientific findings on bullying, LGBTQ stigma, and LGBTQ bullying interventions that were shared at the symposium and provides recommendations for pediatricians to address LGBTQ bullying via clinical care, research, interventions, and policy. Symposium participants recommended that pediatricians engage in efforts to foster inclusive and affirming health care environments wherein LGBTQ youth feel comfortable discussing their identities and experiences, identify youth experiencing LGBTQ bullying, and prevent the negative health consequences of bullying among youth. Moreover, pediatricians can attend to how multiple identities (eg, sexual orientation, gender identity, race and/or ethnicity, disability, and others) shape youth experiences of bullying and expand intervention efforts to address LGBTQ bullying in health care settings. Pediatricians can further advocate for evidence-based, antibullying policies prohibiting bullying on the basis of sexual orientation and gender identity. Collaboration between pediatricians and diverse stakeholders can contribute to the development and implementation of lasting change in all forms of bullying, including LGBTQ bullying.
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Affiliation(s)
- Valerie A. Earnshaw
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;,Department of Human Development and Family Sciences, University of Delaware, Newark, Delaware
| | - Sari L. Reisner
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts;,The Fenway Institute, Fenway Health, Boston, Massachusetts
| | - Jaana Juvonen
- Department of Psychology, University of California, Los Angeles, Los Angeles, California
| | - Mark L. Hatzenbuehler
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York; and
| | - Jeff Perrotti
- Safe Schools Program for LGBTQ Students, Massachusetts Department of Elementary and Secondary Education, Malden, Massachusetts
| | - Mark A. Schuster
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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