Bergen B. Nelson

Preventing Hospitalizations in Children With Medical Complexity: A Systematic Review

BACKGROUND AND OBJECTIVES: Children with medical complexity (CMC) account for disproportionately high hospital use, and it is unknown if hospitalizations may be prevented. Our objective was to summarize evidence from (1) studies characterizing potentially preventable hospitalizations in CMC and (2) interventions aiming to reduce such hospitalizations. METHODS: Our data sources include Medline, Cochrane Central Register of Controlled Trials, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases from their originations, and hand search of article bibliographies. Observational studies (n = 13) characterized potentially preventable hospitalizations, and experimental studies (n = 4) evaluated the efficacy of interventions to reduce them. Data were extracted on patient and family characteristics, medical complexity and preventable hospitalization indicators, hospitalization rates, costs, and days. Results of interventions were summarized by their effect on changes in hospital use. RESULTS: Preventable hospitalizations were measured in 3 ways: ambulatory care sensitive conditions, readmissions, or investigator-defined criteria. Postsurgical patients, those with neurologic disorders, and those with medical devices had higher preventable hospitalization rates, as did those with public insurance and nonwhite race/ethnicity. Passive smoke exposure, nonadherence to medications, and lack of follow-up after discharge were additional risks. Hospitalizations for ambulatory care sensitive conditions were less common in more complex patients. Patients receiving home visits, care coordination, chronic care-management, and continuity across settings had fewer preventable hospitalizations. Conclusions: There were a limited number of published studies. Measures for CMC and preventable hospitalizations were heterogeneous. Risk of bias was moderate due primarily to limited controlled experimental designs. Reductions in hospital use among CMC might be possible. Strategies should target primary drivers of preventable hospitalizations.

“Eat Healthy, Stay Active!”: A Coordinated Intervention to Improve Nutrition and Physical Activity among Head Start Parents, Staff, and Children:

Purpose. Examine the effectiveness of the “Eat Healthy, Stay Active!” pilot program, a multisite, 6-month educational intervention to promote healthy nutrition and physical activity among Head Start staff, parents, and children. Design. Comparison of within-group preintervention and postintervention knowledge and behavior, along with anthropomorphic measurements. Setting. The study was conducted in a convenience sample of six large Head Start agencies in five states. Subjects. Participants included 496 staff, 438 parents, and 112 preschool children. Intervention. The 6-month intervention consisted of core trainings and reinforcing activities for staff and parents that aligned with childrens curricula. Measures. Pre-post questionnaires and anthropometric measurements examined changes in body mass index (BMI), knowledge, and behaviors related to nutrition and physical activity. Analysis. Paired t-tests to compare preintervention and postintervention weights and BMI; multiple regression analyses to examine associations between weight changes and other covariates, including knowledge and behavior changes, controlling for sociodemographic variables. Results. Each group of participants demonstrated significant reductions in BMI (mean = 30.1 to 29.2; p < .001 in adults and 17.0 to 16.6; p < 0.001 in children) and in the proportion of obese children (30% to 21%; p < .001) and adults (45% to 40%; p < .001). Child weight changes correlated with parent weight changes. Conclusion. This intervention showed promising initial results, with potential effectiveness as an intervention to promote healthier behaviors among adults and children in Head Start settings.

Cognitive Ability at Kindergarten Entry and Socioeconomic Status

OBJECTIVE: To examine how gradients in socioeconomic status (SES) impact US children’s reading and math ability at kindergarten entry and determine the contributions of family background, health, home learning, parenting, and early education factors to those gradients. METHODS: Analysis of 6600 children with cognitive assessments at kindergarten entry from the US Early Childhood Longitudinal Birth Cohort Study. A composite SES measure based on parent’s occupation, education, and income was divided into quintiles. Wald F tests assessed bivariate associations between SES and child’s cognitive ability and candidate explanatory variables. A decomposition methodology examined mediators of early cognitive gradients. RESULTS: Average reading percentile rankings increased from 34 to 67 across SES quintiles and math from 33 to 70. Children in lower SES quintiles had younger mothers, less frequent parent reading, less home computer use (27%–84%), and fewer books at home (26–114). Parent’s supportive interactions, expectations for their child to earn a college degree (57%–96%), and child’s preschool attendance (64%–89%) increased across quintiles. Candidate explanatory factors explained just over half the gradients, with family background factors explaining 8% to 13%, health factors 4% to 6%, home learning environment 18%, parenting style/beliefs 14% to 15%, and early education 6% to 7% of the gaps between the lowest versus highest quintiles in reading and math. CONCLUSIONS: Steep social gradients in cognitive outcomes at kindergarten are due to many factors. Findings suggest policies targeting levels of socioeconomic inequality and a range of early childhood interventions are needed to address these disparities.

The Medical Home and Hospital Readmissions

BACKGROUND AND OBJECTIVE: Despite considerable attention, little is known about the degree to which primary care medical homes influence early postdischarge utilization. We sought to test the hypothesis that patients with medical homes are less likely to have early postdischarge hospital or emergency department (ED) encounters. METHODS: This prospective cohort study enrolled randomly selected patients during an acute hospitalization at a children’s hospital during 2012 to 2014. Demographic and clinical data were abstracted from administrative sources and caregiver questionnaires on admission through 30 days postdischarge. Medical home experience was assessed by using Maternal and Child Health Bureau definitions. Primary outcomes were 30-day unplanned readmission and 7-day ED visits to any hospital. Logistic regression explored relationships between outcomes and medical home experiences. RESULTS: We followed 701 patients, 97% with complete data. Thirty-day unplanned readmission and 7-day ED revisit rates were 12.4% and 5.6%, respectively. More than 65% did not have a medical home. In adjusted models, those with medical home component “having a usual source of sick and well care” had fewer readmissions than those without (adjusted odds ratio 0.54, 95% confidence interval 0.30–0.96). Readmissions were higher among those with less parent confidence in avoiding a readmission, subspecialist primary care providers, longer length of index stay, and more hospitalizations in the past year. ED visits were associated with lack of parent confidence but not medical home components. CONCLUSIONS: Lacking a usual source for care was associated with readmissions. Lack of parent confidence was associated with readmissions and ED visits. This information may be used to target interventions or identify high-risk patients before discharge.

How Does Incarcerating Young People Affect Their Adult Health Outcomes

BACKGROUND AND OBJECTIVES: Despite the widespread epidemic of mass incarceration in the US, relatively little literature exists examining the longitudinal relationship between youth incarceration and adult health outcomes. We sought to quantify the association of youth incarceration with subsequent adult health outcomes. METHODS: We analyzed data from 14 344 adult participants in the National Longitudinal Study of Adolescent to Adult Health. We used weighted multivariate logistic regressions to investigate the relationship between cumulative incarceration duration (none, <1 month, 1–12 months, and >1 year) before Wave IV (ages 24–34 years) and subsequent adult health outcomes (general health, functional limitations, depressive symptoms, and suicidal thoughts). Models controlled for Wave I (grades 7–12) baseline health, sociodemographics, and covariates associated with incarceration and health. RESULTS: A total of 14.0% of adults reported being incarcerated between Waves I and IV. Of these, 50.3% reported a cumulative incarceration duration of <1 month, 34.8% reported 1 to 12 months, and 15.0% reported >1 year. Compared with no incarceration, incarceration duration of < 1 month predicted subsequent adult depressive symptoms (odds ratio [OR] = 1.41; 95% confidence interval [CI], 1.11–1.80; P = .005). A duration of 1 to 12 months predicted worse subsequent adult general health (OR = 1.48; 95% CI, 1.12–1.96; P = .007). A duration of >1 year predicted subsequent adult functional limitations (OR = 2.92; 95% CI, 1.51–5.64; P = .002), adult depressive symptoms (OR = 4.18; 95% CI, 2.48–7.06; P < .001), and adult suicidal thoughts (OR = 2.34; 95% CI, 1.09–5.01; P = .029). CONCLUSIONS: Cumulative incarceration duration during adolescence and early adulthood is independently associated with worse physical and mental health later in adulthood. Potential mechanisms merit exploration.

Predictors of Poor School Readiness in Children Without Developmental Delay at Age 2

BACKGROUND AND OBJECTIVES: Current recommendations emphasize developmental screening and surveillance to identify developmental delays (DDs) for referral to early intervention (EI) services. Many young children without DDs, however, are at high risk for poor developmental and behavioral outcomes by school entry but are ineligible for EI. We developed models for 2-year-olds without DD that predict, at kindergarten entry, poor academic performance and high problem behaviors. METHODS: Data from the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B), were used for this study. The analytic sample excluded children likely eligible for EI because of DDs or very low birth weight. Dependent variables included low academic scores and high problem behaviors at the kindergarten wave. Regression models were developed by using candidate predictors feasibly obtainable during typical 2-year well-child visits. Models were cross-validated internally on randomly selected subsamples. RESULTS: Approximately 24% of all 2-year-old children were ineligible for EI at 2 years of age but still had poor academic or behavioral outcomes at school entry. Prediction models each contain 9 variables, almost entirely parental, social, or economic. Four variables were associated with both academic and behavioral risk: parental education below bachelor’s degree, little/no shared reading at home, food insecurity, and fair/poor parental health. Areas under the receiver-operating characteristic curve were 0.76 for academic risk and 0.71 for behavioral risk. Adding the mental scale score from the Bayley Short Form–Research Edition did not improve areas under the receiver-operating characteristic curve for either model. CONCLUSIONS: Among children ineligible for EI services, a small set of clinically available variables at age 2 years predicted academic and behavioral outcomes at school entry.

Out of the classroom and into the community: medical students consolidate learning about health literacy through collaboration with Head Start.

BackgroundMedical schools need to teach future physicians about health literacy and patient-doctor communication, especially when working with vulnerable communities, but many fall short. In this article, we present a community-based, service learning experience over one academic year during the pre-clerkship portion of medical school as an innovative and successful model for medical students to learn about health literacy and practice effective communication strategies. “Eat Healthy, Stay Active!” (EHSA) is a 5-month pediatric obesity intervention designed for Head Start children, their parent (s), and staff. We hypothesized students’ attitudes, knowledge, and skills confidence regarding healthy literacy and patient communication would improve from baseline after receiving training and serving as family mentors in the EHSA intervention.MethodsFirst- and second-year medical students were trained through a series of didactics and then partnered with Head Start children, parents, and staff to help educate and set goals with families during the EHSA intervention. Medical students were given a pre- and post-intervention survey designed to measure their attitudes, knowledge, and skills confidence regarding health literacy. The pre-survey was administered before the first didactic session and the post-survey was administered after the conclusion of the EHSA intervention. We compared students’ pre- and post-intervention responses using paired t-tests. Throughout the project, the medical students were asked to complete a set of open-ended journal questions about their experiences. These responses were examined using qualitative, thematic analyses. Additionally, the Head Start parents and staff were asked to complete a survey about their experience working with the medical students.ResultsParticipant (n=12) pre- and post-surveys revealed that medical students’ attitudes about the importance of health literacy were ranked highly both pre- and post- intervention. However, knowledge and skills confidence regarding health literacy showed statistically significant improvement from baseline. Journal entries were categorized qualitatively to demonstrate medical students’ insight about their growth and development throughout the project. Survey results from Head Start parents showed medical student participation to be highly valued.ConclusionProviding medical students with a service learning opportunity to work with individuals with low health literacy in their pre-clerkship years increased students’ knowledge and skills confidence regarding health literacy and communication.

A Structured Management Approach to Implementation of Health Promotion Interventions in Head Start

Improving the health and health literacy of low-income families is a national public health priority in the United States. The federal Head Start program provides a national infrastructure for implementation of health promotion interventions for young children and their families. The Health Care Institute (HCI) at the Anderson School of Management at the University of California, Los Angeles, developed a structured approach to health promotion training for Head Start grantees using business management principles. This article describes the HCI approach and provides examples of implemented programs and selected outcomes, including knowledge and behavior changes among Head Start staff and families. This prevention-focused training platform has reached 60,000 Head Start families in the United States since its inception in 2001. HCI has demonstrated consistent outcomes in diverse settings and cultures, suggesting both scalability and sustainability.

Discharge handoff communication and pediatric readmissions

BACKGROUND: Improvement in hospital transitional care has become a major national priority, although the impact on childrens postdischarge outcomes is unclear. OBJECTIVE: To characterize common handoff practices between hospital and primary care providers (PCPs), and test the hypothesis that common handoff practices would be associated with fewer unplanned readmissions. DESIGN, SETTING, AND PATIENTS: This prospective cohort study enrolled randomly selected pediatric patients during an acute hospitalization at a tertiary childrens hospital in 2012‐2014. MEASUREMENTS: Primary care and patient data were abstracted from administrative, caregiver, and PCP questionnaires on admission through 30 days postdischarge. The primary outcome was 30‐day unplanned readmission to any hospital. Logistic regression assessed relationships between readmissions and 11 handoff communication practices. RESULTS: We enrolled 701 children, from which 685 identified PCPs. Complete data were collected from 84% of PCPs. Communication practices varied widely—verbal handoffs occurred rarely (10.7%); PCP notification of admission occurred for 50.8%. Caregiver experience scores, using an adapted Care Transitions Measure‐3, were high but were unrelated to readmissions. Thirty‐day unplanned readmissions to any hospital were unrelated to most handoff practices. Having PCP follow‐up appointments scheduled prior to discharge was associated with more readmissions (adjusted odds ratio, 2.20; 95% confidence interval, 1.08‐4.46). CONCLUSION: Despite their presumed value, common handoff practices between hospital providers and PCPs may not lead to reductions in postdischarge utilization for children. Addressing broader constructs like caregiver self‐efficacy or social determinants is likely necessary.

Healthy sleep in young children: missed opportunity in early childhood programs and policies?

The evidence is clear: healthy sleep in early childhood promotes optimal development. Inadequate sleep, both in terms of quantity and quality, is associated with increased risks of obesity, emotional and behavioral problems, and suboptimal cognitive development. Long-term sleep problems have detrimental effects on brain development that may last into adulthood. Disparities in sleep health are closely associated with socioeconomic factors and may contribute to long-term health disparities. In addition, many parents of young children crave better sleep for their children and themselves and are willing to pay a growing number of private sleep coaches to help. In spite of compelling evidence that healthy sleep helps lay the foundation for early childhood development and long-term health, major systems of care for young children—namely, pediatric primary care and early care and education (ECE)—lack clear guidance for how to promote sleep health. Both primary care and ECE settings present important opportunities for promoting healthy sleep and preventing sleep disorders. The American Academy of Pediatrics (AAP) and its Bright Futures guidelines for child health providers recommend developmentally-staged anticipatory guidance for parents on a wide range of health promotion topics, including sleep. Even with AAP guidance, evidence suggests that many childhood sleep problems are underrecognized and undertreated by pediatricians. The Institute of Medicine recommends that state child care regulations promote age-appropriate sleep duration and healthy sleep practices to prevent early childhood obesity, yet few states have regulations that do. Caring for Our Children, the most comprehensive set of national recommendations for ECE health and safety standards, mentions sleep only with regard to sudden infant death syndrome (SIDS) and cot spacing. Similarly, the discussion of sleep in the Head Start Program Performance Standards is limited to SIDS prevention and crib safety. Meanwhile, there are ample discussions in all of these documents about recommended policies to prevent obesity, identify early developmental concerns, and address behavioral problems—all of which may be caused, in part, by inadequate sleep. Early care and education settings are increasingly becoming venues for health promotion and disease prevention. There are major gaps, however, between evidence-based practices and the programs with the potential to implement them on a large scale. Mistry et al presented a useful framework that links early childhood programs and policies to improved child health outcomes in a social-ecological context, building the capacities of families and communities to care for children. Based on this thoughtful conceptual framework, a clear research and policy agenda for sleep health in ECE should (1) identify effective programs and practices; (2) build