Charles J. Homer

A Review of the Evidence for the Medical Home for Children With Special Health Care Needs

from stool and bronchoalveolar lavage fluid in intubated infants, and every infant who developed IC was identified and IC-related mortality was eliminated.5 All neonates with IC had a BW of 1000 g, and 15 (94%) of 16 had a gestational age of 27 weeks. Therefore, from our data, neonates with a gestational age of 27 weeks and BW of 1000 g represent the “preterm subpopulation” that would benefit most from FP. A more-precise identification of the higher-risk neonates in the NICU would be a prelude to the elaboration of more-effective prophylactic measures and should delay or prevent the emergence of resistance. Indeed, the critical question will be to find the corrected age when the immune system can face up to Candida spp to develop effective preventive strategies. Our data provide evidence that the age is somewhere around 27 weeks.

Variations in Rates of Hospitalization of Children in Three Urban Communities

Hospitalization accounts for a large portion of the expenditures for child health care, and differences in the rate of hospitalization may produce important variations in the cost of that care. We studied the rates of hospitalization in Boston, Rochester (N.Y.), and New Haven (Conn.) in 1982. We assigned the risk of hospitalization in Rochester a score of 1.00. Boston children were hospitalized at more than twice the rate of Rochester children for most medical diagnostic categories (relative risk, 2.65; 95 percent confidence interval, 2.53 to 2.78), and the rate for the New Haven group was intermediate (relative risk, 1.80; 95 percent confidence interval, 1.68 to 1.93). Rates of inpatient surgery differed less (Boston relative risk, 1.12; New Haven relative risk, 0.93). The relative risks of hospitalization (as compared with Rochester children) for Boston and New Haven children, respectively, were 3.8 and 2.3 for asthma, 6.1 and 2.9 for toxic ingestions, and 2.6 and 2.7 for head injuries. Fractures of the femur, appendicitis, and bacterial meningitis (conditions uniformly treated in the hospital) had similar rates of hospitalization across the three cities, but the relative risk of hospitalization for aseptic meningitis was 3.7 in Boston. The rates of hospitalization of children in all three communities were below the national averages in 1982. Although this study does not define the reasons for the variation in rates of hospitalization, it is possible that they were related in part to differences in socioeconomic status or access to primary care. The implications of these data for the cost and quality of pediatric care therefore remain to be determined.

Adoption of body mass index guidelines for screening and counseling in pediatric practice.

OBJECTIVE: The purpose of this study was to examine pediatrician implementation of BMI and provider interventions for childhood overweight prevention and treatment. METHODS: Data were obtained from the American Academy of Pediatrics (AAP) Periodic Survey of Fellows No. 65, a nationally representative survey of AAP members. Surveys that addressed the provision of screening and management of childhood overweight and obesity in primary care settings were mailed to 1622 nonretired US AAP members in 2006. RESULTS: One thousand five (62%) surveys were returned; 677 primary care clinicians in active practice were eligible for the survey. Nearly all respondents (99%) reported measuring height and weight at well visits, and 97% visually assess children for overweight at most or every well-child visit. Half of the respondents (52%) assess BMI percentile for children older than 2 years. Most pediatricians reported that they do not have time to counsel on overweight and obesity, that counseling has poor results, and that having simple diet and exercise recommendations would be helpful in their practice. Pediatricians in large practices and those who had attended continuing medical education on obesity were more familiar with national expert guidelines, were more likely to use BMI percentile, and had higher self-efficacy in practices related to childhood and adolescent overweight and obesity. Multivariate analysis revealed that pediatricians with better access to community and adjunct resources were more likely to use BMI percentile. CONCLUSIONS: BMI-percentile screening in primary pediatric practice is underused. Most pediatricians believe that they can and should try to prevent overweight and obesity, yet few believe there are good treatments once a child is obese. Training, time, and resource limitations affect BMI-percentile use. Awareness of national guidelines may improve rates of BMI-percentile use and recognition of opportunities to prevent childhood and adolescent obesity.

Work-related psychosocial stress and risk of preterm, low birthweight delivery

We investigated whether work-related psychologic stress--defined as work characterized by both high psychologic demands and limited control over the response to these demands--increases a womans risk of delivering a preterm, low birthweight infant. We studied 786 employed pregnant women included in the National Longitudinal Survey of Labor Market Experience, Youth Cohort (NLSY), a nationally representative sample of 12,686 young adults. Data concerning work status, job title, and other factors affecting pregnancy outcome were obtained from the NLSY. Assessment of job experience was based on job title, using an established catalogue of occupation characteristics. After accounting for the physical exertion entailed in a job, occupational psychologic stress as measured by job title was not associated with preterm, low birthweight delivery for the sample as a whole (Relative risk = 1.16, 95% confidence interval .45, 2.95). For those women who did not want to remain in the work force, work-related stress increased their risk of experiencing this outcome (RR = 8.1, 95% CI 1.5, 50.2). Personal motivation toward work, as well as the physical effort of work, should be considered in evaluating the impact of a jobs psychologic characteristics on pregnancy outcome.

Women's Health After Pregnancy and Child Outcomes at Age 3 Years: A Prospective Cohort Study

OBJECTIVES This study examined the persistence and comorbidity of womens physical and mental health conditions after pregnancy and the association of these conditions with child outcomes. METHODS A national cohort of women who recently gave birth were surveyed in 1988 and again in 1991. We examined longitudinal data on maternal poor physical health, depressive symptoms, and smoking, and maternal report of child outcomes (at age approximately 3 years). RESULTS Womens poor physical health and smoking had strong, graded associations with childrens physical health and behavior problems, whereas womens depressive symptoms were associated with childrens delayed language and behavior problems. CONCLUSIONS Substantial persistence and comorbidity of womens health conditions exist after pregnancy with adverse effects on early child outcomes. Child health professionals should support services and policies that promote womens health outside the context of pregnancy.

Sickle Cell Disease: A Question of Equity and Quality

Thirty years ago, the first major federal legislation concerning sickle cell disease treatment was passed, resulting in the development of comprehensive sickle cell centers. We are now at another watershed moment in the treatment of this illness with the passage in October 2004 of the Sickle Cell Treatment Act, designed to substantially expand specialized sickle cell treatment programs. This legislation offers a remarkable opportunity to significantly improve health outcomes for individuals with sickle cell disease if it is implemented with a specific focus on the distinct but related issues of equity and quality. Despite major advances in sickle cell disease treatment that have occurred over the past 3 decades, important gaps exist both in the equity of government and private philanthropic support for research and in the uniform provision of high quality clinical care. This article assesses the current gaps in funding support and in the implementation of improvements in clinical care in order to suggest strategies for making optimal use of the opportunity that the new legislation presents to improve the health of all individuals affected by this disease.

Health literacy and quality: focus on chronic illness care and patient safety.

Despite a heightened focus on improving quality, recent studies have suggested that children only receive half of the indicated preventive, acute, or chronic care. Two major areas in need of improvement are chronic illness care and prevention of medical errors. Recently, health literacy has been identified as an important and potentially ameliorable factor for improving quality of care. Studies of adults have documented that lower health literacy is independently associated with poorer understanding of prescriptions and other medical information and worse chronic disease knowledge, self-management behaviors, and clinical outcomes. There is also growing evidence to suggest that health literacy is important in pediatric safety and chronic illness care. Adult studies have suggested that addressing literacy can lead to improved patient knowledge, behaviors, and outcomes. Early studies in the field of pediatrics have shown similar promise. There are significant opportunities to evaluate and demonstrate the importance of health literacy in improving pediatric quality of care. Efforts to address health literacy should be made to apply the 6 Institute of Medicine aims for quality-care that is safe, effective, patient centered, timely, efficient, and equitable. Efforts should also be made to consider the distinct nature of pediatric care and address the “4 Ds” unique to child health: the developmental change of children over time; dependency on parents or adults; differential epidemiology of child health; and the different demographic patterns of children and their families.

PREPAID VERSUS TRADITIONAL MEDICAID PLANS : EFFECTS ON PREVENTIVE HEALTH CARE

Prepaid, case managed systems have been proposed as a method of controlling costs in Medicaid populations. We investigated the utilization of preventive services in two prepaid Medicaid Competition Demonstration programs in Santa Barbara County, Calif., and Jackson County, Mo. (containing the city of Kansas City). Care in the demonstration sites was compared with care given in similar counties functioning under a traditional fee-for-service Medicaid system--Ventura County, Calif., and St Louis, Mo. We tested the hypothesis that preventive care would be less in the capitated demonstrations. 2735 Childrens and 3389 adults charts were abstracted for care received during the calendar year 1985, after the prepaid demonstration had been in place for more than 1 year. No significant differences were found between the demonstration and comparison counties in the proportion of children with complete DPT or OPV immunizations at 1 year of age, with 56% complete in both California counties and 69 and 65% complete in Jackson County and St Louis, respectively. Regression analysis demonstrated a slight, but statistically significant trend towards more immunizations in the demonstration counties. Pap smear use in women of 15-44 years of age was little different in the California counties, but significantly greater in the Jackson County demonstration in Missouri (64 vs 45%). Physician breast examinations were somewhat more likely to occur in the prepaid, case managed demonstration counties. Capitated, case managed systems for the AFDC Medicaid population appear to result in no diminution of preventive services. Substantial problems exist in this, as in other poor populations, in childhood immunizations.

Expert survey for the management of adolescent depression in primary care

OBJECTIVE. Primary care clinics have become the “de facto” mental health clinics for teens with mental health problems such as depression; however, there is little guidance for primary care professionals who are faced with treating this population. This study surveyed experts on key management issues regarding adolescent depression in primary care where empirical literature was scant or absent. METHODS. Participants included experts from family medicine, pediatrics, nursing, psychology, and child psychiatry, identified through nonprobability sampling. The expert survey was developed on the basis of information from focus groups with patients, families, and professionals and from the research literature and included sections on early identification, assessment and diagnosis, initial management, treatment, and ongoing management. Means, standard deviations, and confidence intervals were calculated for each survey item. RESULTS. Seventy-eight of 81 experts agreed to participate (return rate of 96%). Fifty-three percent of the experts (n = 40) were primary care professionals. Experts endorsed routine surveillance for youth at high risk for depression, as well as the use of standardized measures as diagnostic aids. For treatment, “active monitoring” was deemed appropriate in mild depression with recent onset. Medication and psychotherapy were considered acceptable options for treatment of moderate depression without complicating factors such as comorbid illness. Fluoxetine was rated as the most appropriate antidepressant for use in this population. Finally, experts agreed that patients who are started on antidepressants should be followed within 2 weeks after initiation. CONCLUSIONS. Survey results support the identification and management of adolescent depression in the primary care setting and, in specific situations, referral and co-management with specialty mental health professionals. Even with the recent controversies around treatment, experts across primary care and specialty mental health alike agreed that active monitoring, pharmacotherapy with selective serotonin reuptake inhibitors, and psychotherapy can be appropriate under certain clinical circumstances when initiated within primary care settings.

Interventions to improve screening and follow-up in primary care: a systematic review of the evidence.

BACKGROUND The American Academy of Pediatrics and other organizations recommend several screening tests as part of preventive care. The proportion of children who are appropriately screened and who receive follow-up care is low. OBJECTIVE To conduct a systematic review of the evidence for practice-based interventions to increase the proportion of patients receiving recommended screening and follow-up services in pediatric primary care. DATA SOURCE Medline database of journal citations. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS We developed a strategy to search MEDLINE to identify relevant articles. We selected search terms to capture categories of conditions (eg, developmental disabilities, obesity), screening tests, specific interventions (eg, quality improvement initiatives, electronic records enhancements), and primary care. We searched references of selected articles and reviewed articles suggested by experts. We included all studies with a distinct, primary care-based intervention and post-intervention screening data, and studies that focused on children and young adults (≤21 years of age). We excluded studies of newborn screening. STUDY APPRAISAL AND SYNTHESIS METHODS Abstracts were screened by 2 reviewers and articles with relevant abstracts received full text review and were evaluated for inclusion criteria. A structured tool was used to abstract data from selected articles. Because of heterogeneous interventions and outcomes, we did not attempt a meta-analysis. RESULTS From 2547 returned titles and abstracts, 23 articles were reviewed. Nine were pre-post comparisons, 5 were randomized trials, 3 were postintervention comparisons with a control group, 3 were postintervention cross-sectional analyses only, and 3 reported time series data. Of 14 articles with preintervention or control group data and significance testing, 12 reported increases in the proportion of patients appropriately screened. Interventions were heterogeneous and often multifaceted, and several types of interventions, such as provider/staff training, electronic medical record templates/prompts, and learning collaboratives, appeared effective in improving screening quality. Few articles described interventions to track screening results or referral completion for those with abnormal tests. Data were often limited by single-site, nonrandomized design. CONCLUSIONS Several feasible, practice- and provider-level interventions appear to increase the quality of screening in pediatric primary care. Evidence for interventions to improve follow-up of screening tests is scant. Future research should focus on which specific interventions are most effective, whether effects are sustained over time, and what interventions improve follow-up of abnormal screening tests.