Effects of In-Person Navigation to Address Family Social Needs on Child Health Care Utilization: A Randomized Clinical Trial

IMPORTANCE

While many organizations endorse screening for social risk factors in clinical settings, few studies have examined the health and utilization effects of interventions to address social needs.

OBJECTIVE

To compare the acute care utilization effects of a written resources handout vs an in-person navigation service intervention to address social needs.

DESIGN, SETTINGS, AND PARTICIPANTS

In this secondary analysis of a randomized clinical trial, 1809 adult caregivers of pediatric patients seen in primary and urgent care clinics of 2 safety-net hospitals in northern California were recruited between October 13, 2013, and August 27, 2015. Each participating family was randomly assigned to an in-person navigator intervention vs active control to address the family's social needs. Analyses were conducted between February 28, 2018, and September 25, 2019.

INTERVENTIONS

Caregivers either received written information about relevant local resources related to social needs (active control) or met with a patient navigator focused on helping them resolve social needs (navigator intervention). After an initial in-person visit, navigation services included telephone, email, and/or in-person follow-up for up to 3 months.

MAIN OUTCOME AND MEASURES

Child emergency department visit or hospitalization within 12 months of study enrollment.

RESULTS

Among the 1300 caregivers enrolled in the study without missing follow-up data, most spoke English (878 [67.5%]) and were women (1127 [86.7%]), with a mean (SD) age of 33.0 (9.33) years. Most children were aged 0 to 5 years (779 of 1300 [59.9%]), 723 children (55.6%) had Hispanic ethnicity, and 462 children (35.5%) were in excellent health; 840 families (64.6%) were recruited from urgent care. In total, 637 families (49.0%) were randomized to the in-person navigator group and 663 (51.0%) to the active control group. There was no difference in risk of an emergency department visit between the 2 groups. Children enrolled in the in-person navigator group had a decreased risk of hospitalization within 12 months (hazard ratio, 0.59; 05% CI, 0.38-0.94; P = .03), making them 69% less likely to be hospitalized.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial evaluating heath care utilization effects of programs designed to address social needs among families, children enrolled in the navigation group were significantly less likely to be hospitalized after the intervention but equally likely to have an emergency department visit. These findings strengthen our understanding of the effects of addressing social needs in clinical settings as part of a comprehensive strategy to improve health and reduce health care utilization.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01939704.

Desequilibrio de ligamiento, estratificación y patrones de ancestría en ganado Simmental

El uso masivo de pocos toros en programas de inseminación artificial afecta la composición y la estructura genética de una población. El objetivo de este estudio fue estimar la diversidad genética, estratificación genética, patrones de ancestría y el desequilibrio de ligamiento en ganado Simmental. Una muestra de 233 animales genotipados con 30106 marcadores tipo polimorfismo de nucleótido simple (SNP) fue usada. Los patrones de subdivisión genética y ancestría fueron estimados a través de análisis de componentes principales y probabilidades de asignación a grupos genéticos. El desequilibrio de ligamiento fue estimado como el cuadrado del coeficiente de correlación entre los SNP. El análisis por componentes principales no mostró patrones de subdivisión genética dentro de la población Simmental de Colombia. Sin embargo, el análisis de ancestría identificó una subdivisión genética de de tres grupos. Un valor de 0.3 para desequilibrio de ligamiento fue encontrado a una distancia de 33 kb. Los resultados permiten evidenciar el cambio en la estructura genética de una población debido al uso e importación de material genético proveniente de poblaciones que difieren en objetivos de cría y criterios de selección.

Effects of Social Needs Screening and In-Person Service Navigation on Child Health: A Randomized Clinical Trial

IMPORTANCE

Social determinants of health shape both children's immediate health and their lifetime risk for disease. Increasingly, pediatric health care organizations are intervening to address family social adversity. However, little evidence is available on the effectiveness of related interventions.

OBJECTIVE

To evaluate the effects of social needs screening and in-person resource navigation services on social needs and child health.

DESIGN, SETTING, AND PARTICIPANTS

Patients were randomized to intervention or active control conditions by the day of the week. Primary outcomes observed at 4 months after enrollment included caregivers' reports of social needs and child health status. Recruitment occurred between October 13, 2013, and August 27, 2015, in pediatric primary and urgent care clinics in 2 safety-net hospitals. Participants were English-speaking or Spanish-speaking caregivers accompanying minor children to nonacute medical visits.

INTERVENTIONS

After standardized screening, caregivers either received written information on relevant community services (active control) or received in-person help to access services with follow-up telephone calls for further assistance if needed (navigation intervention).

MAIN OUTCOMES AND MEASURES

Change in reported social needs and in caregiver assessment of child's overall health reported 4 months later.

RESULTS

Among 1809 patients enrolled in the study, evenly split between the 2 sites, 31.6% (n = 572) were enrolled in a primary care clinic and 68.4% (n = 1237) were enrolled in an urgent care setting. The children were primarily Hispanic white individuals (50.9% [n = 921]) and non-Hispanic black individuals (26.2% [n = 473]) and had a mean (SD) age of 5.1 (4.8) years; 50.5% (n = 913) were female. The reported number of social needs at baseline ranged from 0 to 11 of 14 total possible items, with a mean (SD) of 2.7 (2.2). At 4 months after enrollment, the number of social needs reported by the intervention arm decreased more than that reported by the control arm, with a mean (SE) change of -0.39 (0.13) vs 0.22 (0.13) (P < .001). In addition, caregivers in the intervention arm reported significantly greater improvement in their child's health, with a mean (SE) change of -0.36 (0.05) vs -0.12 (0.05) (P < .001).

CONCLUSIONS AND RELEVANCE

To our knowledge, this investigation is the first randomized clinical trial to evaluate health outcomes of a pediatric social needs navigation program. Compared with an active control at 4 months after enrollment, the intervention significantly decreased families' reports of social needs and significantly improved children's overall health status as reported by caregivers. These findings support the feasibility and potential effect of addressing social needs in pediatric health care settings.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01939704.

A randomized trial on screening for social determinants of health: the iScreen study

BACKGROUND

There is growing interest in clinical screening for pediatric social determinants of health, but little evidence on formats that maximize disclosure rates on a wide range of potentially sensitive topics. We designed a study to examine disclosure rates and hypothesized that there would be no difference in disclosure rates on face-to-face versus electronic screening formats for items other than highly sensitive items.

METHODS

We conducted a randomized trial of electronic versus face-to-face social screening formats in a pediatric emergency department. Consenting English-speaking and Spanish-speaking adult caregivers familiar with the presenting child's household were randomized to social screening via tablet computer (with option for audio assist) versus a face-to-face interview conducted by a fully bilingual/bicultural researcher.

RESULTS

Almost all caregivers (96.8%) reported at least 1 social need, but rates of reporting on the more sensitive issues (household violence and substance abuse) were significantly higher in electronic format, and disclosure was marginally higher in electronic format for financial insecurity and neighborhood and school safety. There was a significant difference in the proportion of social needs items with higher endorsement in the computer-based group (70%) than the face-to-face group (30%).

CONCLUSIONS

Pediatric clinical sites interested in incorporating caregiver-reported socioeconomic, environmental, and behavioral needs screening should consider electronic screening when feasible, particularly when assessing sensitive topics such as child safety and household member substance use.

Use of grape stalk, a waste of the viticulture industry, to obtain activated carbon

Grape stalk is an organic waste produced in great amounts in the industrialization processes of grape. This work presents the results of studies carried out to use this waste as raw material to prepare activated carbon through the physical and chemical route. The physicochemical characterization of this material suggests the presence of unusually high levels of ashes. Metal content was determined and high levels of potassium, sodium, iron, calcium and magnesium in carbonized and raw grape stalk were exhibited. This characteristic made difficult physical activation at high temperatures. A leaching step was included before the activation with steam, and adsorbents with surface areas between 700 and 900 m(2)/g were obtained. Physical activation was also performed at lower temperatures using carbonized grape stalk without leaching, leading to the development of some grade of porosity, with an area of 412 m(2)/g. These results would indicate the catalytic effect of the minerals present in this raw material. Chemical activation using phosphoric acid as activating agent seemed to be a very efficient method as final products with BET areas between 1000 and 1500 m(2)/g were obtained.

Novel highly reactive and regenerable carbon/iron composites prepared from tar and hematite for the reduction of Cr(VI) contaminant

Highly reactive carbon/Fe composites were prepared from tar used as a carbon source, and hematite (alpha-Fe(2)O(3)), a widespread naturally available iron oxide. Tar was impregnated on hematite and thermally treated under N(2) atmosphere. Mössbauer, powder X-ray diffraction and magnetization data suggested that treatment at 400 and 600 degrees C produced only magnetite (Fe(3)O(4)) whereas at 800 degrees C mainly metallic iron (Fe(0)) was produced. Raman, TG and XRD analyses of the different composites revealed the presence of amorphous and graphitic carbon highly dispersed on the iron oxide surface. The composites obtained at 800 degrees C were very efficient in reducing aqueous Cr(VI), as CrO(4)(2-), even compared to finely ground commercial Fe(0). XPS and Mössbauer data showed that after five consecutive reuses, the composites deactivated, due to the surface oxidation of Fe(0). A simple treatment at 800 degrees C completely regenerated the composite by reducing Fe(3+) species allowing several reuses.

The International Caries Detection and Assessment System (ICDAS): an integrated system for measuring dental caries

This paper describes early findings of evaluations of the International Caries Detection and Assessment System (ICDAS) conducted by the Detroit Center for Research on Oral Health Disparities (DCR-OHD). The lack of consistency among the contemporary criteria systems limits the comparability of outcomes measured in epidemiological and clinical studies. The ICDAS criteria were developed by an international team of caries researchers to integrate several new criteria systems into one standard system for caries detection and assessment. Using ICDAS in the DCR-OHD cohort study, dental examiners first determined whether a clean and dry tooth surface is sound, sealed, restored, crowned, or missing. Afterwards, the examiners classified the carious status of each tooth surface using a seven-point ordinal scale ranging from sound to extensive cavitation. Histological examination of extracted teeth found increased likelihood of carious demineralization in dentin as the ICDAS codes increased in severity. The criteria were also found to have discriminatory validity in analyses of social, behavioral and dietary factors associated with dental caries. The reliability of six examiners to classify tooth surfaces by their ICDAS carious status ranged between good to excellent (kappa coefficients ranged between 0.59 and 0.82). While further work is still needed to define caries activity, validate the criteria and their reliability in assessing dental caries on smooth surfaces, and develop a classification system for assessing preventive and restorative treatment needs, this early evaluation of the ICDAS platform has found that the system is practical; has content validity, correlational validity with histological examination of pits and fissures in extracted teeth; and discriminatory validity.

[Spontaneous bacterial peritonitis from Campylobacter fetus]

A patient with cirrhosis and ascites who developed spontaneous bacterial peritonitis due to Campylobacter fetus is described herein. This organism has been increasingly associated with bacteremia and localized infections in patients with cirrhosis and other immunocompromised states, but spontaneous bacterial peritonitis has been rarely reported. We review Campylobacter fetus infections and their relationship to development of spontaneous bacterial peritonitis, and we emphasize that prolonged antimicrobial therapy is required.

[Value of laparoscopy in ascites of undetermined origin]

OBJECTIVE

To assess the diagnostic accuracy of laparoscopy in the study of patients with ascites of unknown cause, and the frequency of laparoscopy use for that indication after the advent of ultrasonography and computed tomography.

DESIGN

A retrospective study of 4.536 laparoscopies performed in 16 years, in two periods of 8 years, and the correlation with the pathologic diagnosis.

PATIENTS

137 patients in whom laparoscopy was indicated for the study of ascites of unknown cause.

RESULTS

63.5% of laparoscopies were performed over the first 8-year period, and 36.5% in the second (p = 0.0001), and for the study of ascites 2.6 and 3.8% respectively. Laparoscopy and biopsy were diagnostic in 98.5% of cases; 51% carcinomatosis, 17.5% liver cirrhosis, 11.7% hepatic neoplasm and others. Two of five cases of peritoneal tuberculosis were considered carcinomatosis at laparoscopy. There were no serious complications.

CONCLUSIONS

The advent of new imaging method has reduced the use of laparoscopy, although it is still employed frequently for the study of ascites. Laparoscopy with biopsy when necessary has an excellent effectiveness and accuracy for the diagnosis of ascites of unknown cause.

Cryptic adenosine triphosphatase activities in plasma membranes of CCl4-cirrhotic rats. Its modulation by changes in cholesterol/phospholipid ratios

The activities of Na+,K+-, and Ca2+-ATPases were determined in plasma membranes obtained from livers of rats treated acutely and chronically with CCl4. Twenty-four hours after a single oral dose of CCl4 the ATPases decreased below 50% of control values. The activity of Ca2+-ATPase returned to normal after 4 days, and Na+,K+-ATPase activity returned to normal values after 12 days. One week after initiation of the chronic intraperitoneal treatment with CCl4, the Na,K+-ATPase decreased to 40% of control values and continued to decrease further until reaching values below 1%. Ca2+-ATPase followed a pattern similar to that obtained with Na+,K+-ATPase, except that the decrease was not as severe. Colchicine treatment prevented the modifications in ATPases when given simultaneously with CCl4 and reverted the alterations in ATPase activities of the CCl4-cirrhotic animals. Because ATPases are known to be modulated by the lipid composition of the membrane, we also determined the cholesterol to phospholipid ratio in all the isolated membranes. The ratios were increased in membranes with low ATPase activity due to an increase in the total concentration of cholesterol. Plasma membranes of cirrhotic rats treated with colchicine showed a low concentration of cholesterol, a decreased cholesterol to phospholipid ratio, and Na+,K+-ATPase activity was almost normal. When plasma membranes of cirrhotic rats were fused with phosphatidyl serine-containing liposomes, the cholesterol to phospholipid ratio decreased and the ATPase activity increased. The ATPase activity of normal plasma membranes decreased below 20% of control values when enriched with cholesterol. Our results suggest that the decrease in the plasma membrane Na+,K+-ATPase activity of the cirrhotic rat is due in part to an increase in its cholesterol concentration and in the cholesterol to phospholipid ratio.