Elizabeth D. Cox

Problematic Internet Use Among US Youth: A Systematic Review

OBJECTIVE To investigate study quality and reported prevalence among the emergent area of problematic Internet use (PIU) research conducted in populations of US adolescents and college students. DATA SOURCES We searched PubMed, PsycINFO, and Web of Knowledge from inception to July 2010. STUDY SELECTION Using a keyword search, we evaluated English-language PIU studies with populations of US adolescents and college students. MAIN OUTCOME MEASURES Using a quality review tool based on the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement, 2 reviewers independently extracted data items including study setting, subject population, instrument used, and reported prevalence. RESULTS Search results yielded 658 articles. We identified 18 research studies that met inclusion criteria. Quality assessment of studies ranged between 14 and 29 total points of a possible 42 points; the average score was 23 (SD 5.1). Among these 18 studies, 8 reported prevalence estimates of US college student PIU; prevalence rates ranged from 0% to 26.3%. An additional 10 studies did not report prevalence. CONCLUSIONS The evaluation of PIU remains incomplete and is hampered by methodological inconsistencies. The wide range of conceptual approaches may have impacted the reported prevalence rates. Despite the newness of this area of study, most studies in our review were published more than 3 years ago. Opportunities exist to pursue future studies adhering to recognized quality guidelines, as well as applying consistency in theoretical approach and validated instruments.

A Pilot Evaluation of Associations Between Displayed Depression References on Facebook and Self-reported Depression Using a Clinical Scale

The objective of this study was to determine associations between displayed depression symptoms on Facebook and self-reported depression symptoms using a clinical screen. Public Facebook profiles of undergraduates from two universities were examined for displayed depression references. Profiles were categorized as depression symptom displayers or non-displayers. Participants completed an online PHQ-9 depression scale. Analyses examined associations between PHQ-9 score and depression symptom displayers versus non-displayers. The mean PHQ-9 score for non-displayers was 4.7 (SD = 4.0), the mean PHQ-9 score for depression symptom displayers was 6.4 (SD = 5.1; p = 0.018). A trend approaching significance was noted that participants who scored into a depression category by their PHQ-9 score were more likely to display depression symptom references. Displayed references to depression symptoms were associated with self-reported depression symptoms.

Efficacy of patient letter reminders on cervical cancer screening: a meta-analysis.

OBJECTIVE: To perform a meta-analysis on existing randomized controlled trials to investigate the efficacy of patient letter reminders on increasing cervical cancer screening using Pap smears.METHODS: A search was conducted for all relevant published and unpublished studies between the years 1966 and 2000. Eligibility criteria included randomized controlled studies that examined populations due for Pap smear screening. The intervention studied was in the form of a reminder letter. The Mantel-Haenszel method was used to measure the summary effect of the intervention. A test for homogeneity using the Mantel-Haenszel method was performed.RESULTS: Ten articles fulfilled the inclusion criteria, including one unpublished study. The test for homogeneity showed evidence of heterogeneity (x2=31, 9 df, P<.001). An analysis for causes of heterogeneity was pursued. Division into subpopulations based on socioeconomic status resolved the heterogeneity (x2=5.2, 8 df, P=.75). The studies evaluating those in lower socioeconomic groups had a smaller response (odds ratio [OR], 1.16; 95% confidence interval [CI], 0.99 to 1.35) than those studies using mixed populations (OR, 2.02; 95% CI, 1.79 to 2.28). The pooled odds ratio showed that patients who received the intervention were significantly more likely to return for screening than those who did not (OR, 1.64; 95% CI, 1.49 to 1.80).CONCLUSIONS: Patient reminders in the form of mailed letters increase the rate of cervical cancer screening. Patient letter reminders have less efficacy in lower socioeconomic groups.

Pending Laboratory Tests and the Hospital Discharge Summary in Patients Discharged To Sub-Acute Care

BackgroundPrevious studies have noted a high (41%) prevalence and poor discharge summary communication of pending laboratory (lab) tests at the time of hospital discharge for general medical patients. However, the prevalence and communication of pending labs within a high-risk population, specifically those patients discharged to sub-acute care (i.e., skilled nursing, rehabilitation, long-term care), remains unknown.ObjectiveTo determine the prevalence and nature of lab tests pending at hospital discharge and their inclusion within hospital discharge summaries, for common sub-acute care populations.DesignRetrospective cohort study.ParticipantsStroke, hip fracture, and cancer patients discharged from a single large academic medical center to sub-acute care, 2003–2005 (N = 564)Main MeasuresPending lab tests were abstracted from the laboratory information system (LIS) and from each patient’s discharge summary, then grouped into 14 categories and compared. Microbiology tests were sub-divided by culture type and number of days pending prior to discharge.Key ResultsOf sub-acute care patients, 32% (181/564) were discharged with pending lab tests per the LIS; however, only 11% (20/181) of discharge summaries documented these. Patients most often left the hospital with pending microbiology tests (83% [150/181]), particularly blood and urine cultures, and reference lab tests (17% [30/181]). However, 82% (61/74) of patients’ pending urine cultures did not have 24-hour preliminary results, and 19% (13/70) of patients’ pending blood cultures did not have 48-hour preliminary results available at the time of hospital discharge.ConclusionsApproximately one-third of the sub-acute care patients in this study had labs pending at discharge, but few were documented within hospital discharge summaries. Even after considering the availability of preliminary microbiology results, these omissions remain common. Future studies should focus on improving the communication of pending lab tests at discharge and evaluating the impact that this improved communication has on patient outcomes.

Evaluating deliberation in pediatric primary care.

OBJECTIVE. Patient participation during decision-making can improve health outcomes and satisfaction, even for routine pediatric concerns. The tasks that are involved in decision-making include both information exchange and deliberation about potential options, yet deliberation (ie, the process of expressing and evaluating potential options to reach a decision) is often assessed subjectively, if at all. We objectively assessed the amount of deliberation; the involvement of parents and children in deliberation; and how deliberation is associated with child, physician, parent, and visit characteristics. METHODS. From videotapes of 101 childrens acute care visits to 1 of 15 physicians, we coded the speaker, recipient, and timing of proposed plans (ie, options) and agreements or disagreements with the plans. Reliability of measures was assessed with Cohens κ or intraclass correlation coefficients; validity was assessed with Spearman correlations. Outcome measures included number of plans proposed, deliberation length, and parent/child involvement in deliberation as either active (child or parent proposed a plan or disagreed with a plan) or passive (physician alone proposed plans). Multivariable models that accounted for clustering by physician were used to relate child, physician, parent, and visit factors to deliberation measures. RESULTS. The mean number of plans proposed was 4.1, and deliberation time averaged 2.9 minutes per visit. Passive involvement of parents/children occurred in 65% of visits. After adjustment, more plans were proposed in visits by girls, and shorter deliberations occurred with college-graduate parents. Longer visits were associated with more plans proposed, longer deliberation, and reduced odds for passive parent/child involvement. CONCLUSIONS. Using a reliable and valid technique, deliberation was demonstrated to occupy a substantial portion of the visit and include multiple proposed plans, yet passive involvement of parents and children predominated. Results support the need to develop interventions to improve parent and child participation in deliberation.

Learning to participate: effect of child age and parental education on participation in pediatric visits.

Childrens participation in health care improves outcomes, yet little is known about factors that affect participation. We examine how child age and parental education affect participation. Visit videotapes were coded to reflect key visit tasks: information giving, information gathering, and relationship building. Multivariable models were used to analyze how participation was associated with child age and parental education. For each year of child age, physicians did 3% more information gathering, incidence rate ratio (IRR) = 1.03, 95% confidence interval (95% CI) = 1.01–1.06, but reduced relationship building by 4%, IRR = 0.96, 95% CI = 0.94–0.97. Children of college-graduate parents spoke twice as much information-giving talk, IRR = 2.11, 95% CI = 1.07–4.17, and nearly 5 times as much relationship-building talk, IRR = 4.74, 95% CI = 1.45–15.52, as children with less educated parents. Results suggest physicians might attend to relationship building with older children and work to improve participation of children of less educated parents.

Internet safety education for youth: stakeholder perspectives

BackgroundInternet use is nearly ubiquitous among US youth; risks to internet use include cyberbullying, privacy violations and unwanted solicitation. Internet safety education may prevent these negative consequences; however, it is unclear at what age this education should begin and what group is responsible for teaching this topic.MethodsSurveys were distributed to key stakeholders in youth safety education including public school teachers, clinicians, parents and adolescents. Surveys assessed age at which internet safety education should begin, as well as experiences teaching and learning internet safety. Surveys of adults assessed willingness to teach internet safety. Finally, participants were asked to identify a group whose primary responsibility it should be to teach internet safety.ResultsA total of 356 participants completed the survey (93.4% response rate), including 77 teachers, 111 clinicians, 72 parents and 96 adolescents. Stakeholders felt the optimal mean age to begin teaching internet safety was 7.2 years (SD = 2.5), range 2-15. Internet safety was regularly taught by some teachers (20.8%), few clinicians (2.6%) and many parents (40.3%). The majority of teachers, clinicians and parents were willing to teach internet safety, but all groups surveyed identified parents as having primary responsibility for teaching this topic.ConclusionsFindings suggest agreement among key stakeholders for teaching internet safety at a young age, and for identifying parents as primary teachers of this topic. Clinicians have a unique opportunity to support parents by providing resources, guidance and support.

Strategies for improving family engagement during family-centered rounds

BACKGROUND Family-centered rounds (FCR) are recommended as standard practice in the pediatric inpatient setting; however, limited data exist on best practices promoting family engagement during rounds. OBJECTIVE To identify strategies to enhance family engagement during FCR using a recognized systems engineering approach. METHODS In this qualitative study, stimulated recall interviews using video-recorded rounding sessions were conducted with participants representing the various stakeholders on rounds (15 parents/children and 22 healthcare team [HCT] members) from 4 inpatient services at a childrens hospital in Wisconsin. On video review, participants were asked to provide strategies that would increase family engagement on FCR. Qualitative content analysis of interview transcripts was performed in an iterative process. RESULTS We identified 21 categories of strategies corresponding to 2 themes related to the structure and process of FCR. Strategies related to the structure of FCR were associated with all five recognized work system elements: people (HCT composition), tasks (HCT roles), organization (scheduling of rounds and HCT training), environment (location of rounds and HCT positioning), and tools and technologies (computer use). Strategies related to the FCR process were associated with three rounding phases: before (HCT and family preparation), during (eg, introductions, presentation content, communication style), and after (follow-up) FCR. CONCLUSIONS We identified a range of strategies to enhance family engagement during FCR. These strategies both confirm prior work on the importance of the content and style of communication on rounds and highlight other factors within the hospital work system, like scheduling and computer use, which may affect family engagement in care.

Influence of race and socioeconomic status on engagement in pediatric primary care

OBJECTIVE To understand the association of race/ethnicity with engagement in pediatric primary care and examine how any racial/ethnic disparities are influenced by socioeconomic status. METHODS Visit videos and parent surveys were obtained for 405 children who visited for respiratory infections. Family and physician engagement in key visit tasks (relationship building, information exchange, and decision making) were coded. Two parallel regression models adjusting for covariates and clustering by physician were constructed: (1) race/ethnicity only and (2) race/ethnicity with SES (education and income). RESULTS With and without adjustment for SES, physicians seeing Asian families spoke 24% fewer relationship building utterances, compared to physicians seeing White, non-Latino families (p<0.05). Latino families gathered 24% less information than White, non-Latino families (p<0.05), but accounting for SES mitigates this association. Similarly, African American families were significantly less likely to be actively engaged in decision making (OR=0.32; p<0.05), compared to White, non-Latino families, but adjusting for SES mitigated this association. CONCLUSION While engagement during pediatric visits differed by the familys race/ethnicity, many of these differences were eliminated by accounting for socioeconomic status. PRACTICE IMPLICATIONS Effective targeting and evaluation of interventions to reduce health disparities through improving engagement must extend beyond race/ethnicity to consider socioeconomic status more broadly.

Overprescribing of lipid lowering agents

Background: Undertreatment of hyperlipidemia has received considerable attention. However, little is known about trends in overprescribing of lipid lowering agents. We examined these trends and their associations with physician, practice, and organisational factors. Methods: 2034 physicians were surveyed twice: baseline (1996–7) and follow up (1998–9). On each occasion they were asked: “For what percentage of 50 year old men without other cardiac risk factors would you recommend an oral agent for total cholesterol of 240, LDL 150, and HDL 50 after 6 months on a low cholesterol diet?” During the survey period the National Cholesterol Education Program guidelines did not recommend prescribing for these patients. Binomial and multinomial logistic regressions assessed baseline overprescribing and longitudinal changes in overprescribing, accounting for complex sampling. Results: 39% of physicians recommended prescribing at baseline (round 1), increasing at follow up (round 2) to 51% (p<0.001). Physicians who were more likely to overprescribe at baseline were less likely to be board certified (odds ratio (OR) 0.49, 95% confidence interval (CI) 0.38 to 0.63; p<0.001), were in solo or two-physician practices (OR 1.88, 95% CI 1.46 to 2.41; p<0.001), had more revenue from Medicare (OR 1.10, 95% CI 1.03 to 1.17; p = 0.004) or Medicaid (OR 1.09, 95% CI 1.01 to 1.18; p = 0.03), or were family physicians (OR 1.87, 95% CI 1.35 to 2.58; p<0.001). Physicians with large increases in overprescibing were more likely than those with small increases in overprescribing to be international medical graduates (OR 2.09, 95% CI 1.20 to 3.64; p = 0.011) and to spend more hours in patient care (OR 1.14, 95% CI 1.03 to 1.26; p = 0.016). Conclusions: Overprescribing of lipid lowering agents is commonplace and increased. At baseline and longitudinally, overprescribing was primarily associated with physician and practice characteristics and not with organisational factors.