David A. Bergman

The Effect of Inhaled Steroids on the Linear Growth of Children With Asthma: A Meta-analysis

Objective. To determine whether inhaled steroid therapy causes delayed linear growth in children with asthma. Data Sources. Medline (1966–1998), Embase (1980–1998), and Cinahl (1982–1998) databases and bibliographies of included studies were searched for randomized, controlled trials of inhaled steroid therapy in children with asthma that evaluated linear growth. Study Selection. Studies were included if they met the following criteria: subjects 0 to 18 years of age with the clinical diagnosis of asthma; subjects randomized to inhaled beclomethasone, budesonide, flunisolide, fluticasone, or triamcinolone versus a nonsteroidal inhaled control for a minimum of 3 months; single- or double-blind; and outcome convertible to linear growth velocity. English- and non–English-language trials were included. Data Extraction. Data were extracted using a priori guidelines. Methodologic quality was assessed independently by both authors. Outcome was extracted as linear growth velocity. Results. Included trials were subgrouped by inhaled steroid. The beclomethasone subgroup, with 4 studies and 450 subjects, showed a decrease in linear growth velocity of 1.51 cm/year (95% confidence interval: 1.15,1.87). The fluticasone subgroup, with 1 study and 183 subjects, showed a decrease in linear growth velocity of .43 cm/year (95% confidence interval: .01,.85). Sensitivity analysis in the beclomethasone subgroup, which evaluated study quality, mode of medication delivery, control medication, and statistical model, showed similar results. Conclusions. This meta-analysis suggests that moderate doses of beclomethasone and fluticasone in children with mild to moderate asthma cause a decrease in linear growth velocity of 1.51 cm/year and .43 cm/year, respectively. The effects of inhaled steroids when given for >54 weeks, or on final adult height, remain unknown.

Urinary tract infection in infants with unexplained fever: a collaborative study.

Nine centers collaborated to determine the rate of urinary tract infection in infants with unexplained fever, to determine whether the rate is higher in febrile infants than in asymptomatic infants, and whether the yield justifies urine cultures in febrile infants. Urine cultures were done in 501 infants 0 to 2 years of age. The rate of confirmed urinary tract infections in the 193 febrile infants was 4.1%. All infections were in girls, with a rate of 7.4%. The rate of confirmed urinary tract infections in the 312 asymptomatic infants was 0.3%; again, all infections were in girls, with a rate of 0.7%. The rate in febrile girls was significantly higher than the rate in asymptomatic girls (P less than 0.01). The data support the advisability of culturing the urine of infant girls with unexplained fever.

Effectiveness of a multicomponent self-management program in at-risk, school-aged children with asthma.

BACKGROUND Improving asthma knowledge and self-management is a common focus of asthma educational programs, but most programs have had little influence on morbidity outcomes. We developed a novel multiple-component intervention that included the use of an asthma education video game intended to promote adoption of asthma self-management behaviors and appropriate asthma care. OBJECTIVE To determine the effectiveness of an asthma education video game in reducing morbidity among high-risk, school-aged children with asthma. METHODS We enrolled 119 children aged 5 to 12 years from low-income, urban areas in and around San Francisco, CA, and San Jose, CA. Children with moderate-to-severe asthma and parental reports of significant asthma health care utilization were randomized to participate in the disease management intervention or to receive their usual care (control group). Patients were evaluated for clinical and quality-of-life outcomes at weeks 8, 32, and 52 of the study. RESULTS Compared with controls, the intervention group had significant improvements in the physical domain (P = .04 and P = .01 at 32 and 52 weeks, respectively) and social activity domain (P = .02 and P = .05 at 32 and 52 weeks, respectively) of asthma quality of life on the Child Health Survey for Asthma and child (P = .02 at 8 weeks) and parent (P = .04 and .004 at 32 and 52 weeks, respectively) asthma self-management knowledge. There were no significant differences between groups on clinical outcome variables. CONCLUSIONS A multicomponent educational, behavioral, and medical intervention targeted at high-risk, inner-city children with asthma can improve asthma knowledge and quality of life.

Effect of an Evidence-Based Hand Washing Policy on Hand Washing Rates and False-Positive Coagulase Negative Staphylococcus Blood and Cerebrospinal Fluid Culture Rates in a Level III NICU

OBJECTIVE: To determine the effect of implementing an evidence-based hand washing policy on between-patient hand washing compliance and on blood and cerebrospinal fluid (CSF) culture rates in a level III neonatal intensive care unit (NICU).METHODS: An evidence-based hand washing policy, supported by an intensive education program, was introduced in a regional NICU. A total of 2009 preintervention neonates (16,168 patient days) over 17 months were compared to 676 postintervention neonates (5779 patient days) over 6 months. Hand washing compliance and rates of blood and CSF cultures yielding coagulase negative staphylococci (CONS) were compared before and after intervention.RESULTS: Compliance with appropriate between-patient hand washing improved (from 47.4% to 85.4%, p=0.001) after the hand washing policy was introduced. The rate of cultures positive for CONS declined from 6.1±2.3 to 3.2±1.6 per 1000 patient days (p=0.005). Most of this reduction was attributable to a reduction in false-positive cultures, from 4.2±2.4 to 1.9±1.8 per 1000 patient days (p=0.042), but there was a trend toward decreased true-positive cultures (from 2.1±1.2 to 1.2±1.0 per 1000 patient days, p=0.074) as well. Potential confounders and demographics factors were similar between the control and intervention subjects.CONCLUSION: Implementation of an evidence-based hand washing policy resulted in a significant increase in hand washing compliance and a significant decrease in false-positive coagulase negative staphylococcal blood and CSF culture rates. Exploratory data analysis revealed a possible effect on true-positive coagulase negative staphylococcal blood and CSF culture rates, but these results need to be confirmed in future studies.

The Use of Internet-Based Technology to Tailor Well-Child Care Encounters

OBJECTIVE: The goal was to evaluate the feasibility and acceptance of a new model for well-child care (WCC) in a large health maintenance organization. METHODS: We designed a new model of WCC that engages families in Internet-based developmental and behavioral screening, allows for review of the results before the visit, and allows for selection of the appropriate visit type (e-visit, e-visit with brief provider visit, or extended encounter). The new model was pilot-tested in 2 practices within a large health maintenance organization. Seven providers and 70 parents participated in the study. Parents and providers were surveyed regarding their experience and satisfaction with the encounter. RESULTS: Seventy-five percent of parents thought that the online previsit assessment improved or very much improved the WCC visit. However, 12% of parents found the online assessment somewhat or very difficult to use. All of the parents found the e-visit or the e-visit with brief provider visit acceptable or very acceptable, compared with a standard WCC visit. All 7 providers thought that use of the new model helped focus the visit and that they would continue or definitely continue to use the model. CONCLUSIONS: We demonstrated the feasibility of a new model of WCC that engaged parents in previsit assessment and used alternative visit types to tailor care to the needs of the family. Future research will be needed to examine the impact of this model on important WCC outcomes.

A High-Performing System for Well-Child Care: A Vision for the Future

Standardization of well-child care services is intended to ensure that families receive core services and key information. But standardization also encourages a “one-size-fits-all” approach that subjects many families to unnecessary office visits. At the same time, many children at risk for physical, developmental, or behavioral problems fail to get needed services due to time and resource constraints. This report presents a vision for a high performing system of well-child care and a guide for future policy and research efforts. Based on their extensive research, the authors conclude that an ideal system would be characterized by advanced access to services, teambased care, individualized developmental and behavioral screening, care coordination through a medical home, electronic health records, and tools for information and knowledge transfer. Some reforms are ready to be implemented, while others would require additional resources, new technology, and/or policy changes. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. This report and other Fund publications are available online at www.cmwf.org. To learn more about new publications when they become available, visit the Fund’s Web site and register to receive e-mail alerts. Commonwealth Fund pub. no. 959. iii CONTENTS List of Tables and Figures iv About the Authors v Executive Summary v

The use of telemedicine access to schools to facilitate expert assessment of children with asthma

Research has shown that access to an asthma specialist improves asthma outcomes. We hypothesized that we could improve access to expert asthma care through a telemedicine link between an asthma specialist and a school-based asthma program. We conducted a prospective cohort study in 3 urban schools to ascertain the feasibility of using an asthma-focused telemedicine solution. Each subject was seen by an asthma expert at 0, 8, and 32 weeks. The assessment and recommendations for care were sent to the primary care physician (PCP) and parents were told to contact their physician for follow-up care. Eighty three subjects participated in the study. Subjects experienced improvement (P < .05) in family social activities and the number of asthma attacks. Ninety four percent of subjects rated the program as good or excellent. This study demonstrates the feasibility and acceptance of a school-based asthma program using a telemedicine link to an asthma specialist.

Synthesis of α 1 -Antichymotrypsin and α 1 -Antitrypsin by Human Trophoblast

ABSTRACT: α1-Antichymotrypsin (α1-ACHY) and α1-an-titrypsin (α1-AT) are closely related glycoprotein protease inhibitors, present in plasma and other extracellular fluids, that neutralize proteases released by leukocytes in response to trauma and inflammatory stimuli. Both inhibitors are synthesized primarily by hepatocytes, although lower levels of synthesis by monocytes and breast and intestinal epithelial cells have been demonstrated. Recently, the immunohistochemical localization of α1-AT and α1-ACHY in intrauterine and extrauterine human trophoblastic tissue has been reported. In the present study, we have sought to determine whether human trophoblast is also able to synthesize α1-AT and α1-ACHY. Messenger RNA for both inhibitors was found by Northern blotting in chorionic villi obtained from first trimester and term placenta. Substantial differences in messenger levels for both inhibitors among individual placentas were noted. α1-ACHY and α1-AT messenger was also present in trophoblast cells in primary culture. Synthesis of α1-AT and α1-ACHY protein was demonstrated by SDS-PAGE after immunoprecipitation of [35S]-labeled α1-AT and α1-ACHY from conditioned media of trophoblast cells in culture metabolically labeled with [35SJ-methionine. It is of some interest that the Mr of the α1-AT and α1-ACHY secreted by trophoblast were 50 000 and 49 000, respectively, compared with 54 000 and 68 000 for these proteins in plasma (or secreted by HepG2 human hepatoma and MCF-7 human breast cancer cells). After enzymatic deglycosylation, the Mr of the α1-AT and α1-ACHY secreted by trophoblast and HepG2 cells were all approximately 46 000, suggesting incomplete glycosylation of the inhibitors released by trophoblast.

Moving From Research to Large-Scale Change in Child Health Care

There is a large and persistent failure to achieve widespread dissemination of evidence-based practices in child health care. Too often studies demonstrating evidence for effective child health care practices are not brought to scale and across different settings and populations. This failure is not due to a lack of knowledge, but rather a failure to bring to bear proven methods in dissemination, diffusion, and implementation (DD&I) science that target the translation of evidence-based medicine to everyday practice. DD&I science offers a framework and a set of tools to identify innovations that are likely to be implemented, and provides methods to better understand the capabilities and preferences of individuals and organizations and the social networks within these organizations that help facilitate widespread adoption. Successful DD&I is dependent on making the intervention context sensitive without losing fidelity to the core components of the intervention. The achievement of these goals calls for new research methods such as pragmatic research trials that combine hypothesis testing with quality improvement, participatory research that engages the target community at the beginning of research design, and other quasi-experimental designs. With the advent of health care reform, it will be extremely important to ensure that the ensuing large demonstration projects that are designed to increase integrated care and better control costs can be rapidly brought to scale across different practices settings, and health plans and will be able to achieve effectiveness in diverse populations.

Managed Care and the Quality of Children's Health Services

Managed care has changed the practice of medicine. The choice of health care providers has been narrowed, physicians are being held financially accountable for the number of services they use, and a new emphasis is being placed on the cost and quality of the care provided. The transition to managed care has occurred with little attention to its impact on access to health care services or the quality of services provided. There is an absence of information about how children fare in these new systems. What little is known indicates that children in managed care arrangements are less likely to be able to be seen by pediatric specialists, and that families and providers are less satisfied under managed care. The impact of these changes on childrens health status, however, is yet to be determined. For children with special needs, the problems of coordination of care, coverage of needed services, and the choice of the appropriate pediatric subspecialists, many of which existed in traditional fee-for-service systems, persist under managed care. In spite of all of the negative anecdotes about managed health care, managed cares focus on its population of enrollees and its heightened sense of a need for health care accountability bring exciting new opportunities to measure and improve the health care children receive. A new emphasis is being placed on practicing evidence-based medicine; the focus is on closing the gap between what is known (effective, evidence-based care) and what is done (current practice). Improved health outcomes and reduced health care costs have been documented in demonstration projects in neonatal intensive care units and in pediatric offices. Applying the principles of these learning collaboratives and employing the tools of continuous quality improvement in health care are urgent challenges that deserve to be met. Health plans, physicians, health care purchasers, regulators, families, and their children must work together to assure that children receive the highest-quality care possible--care that is technically excellent and medically appropriate, and that improves the health of our children.