Eric W. Fleegler

Debriefing Assessment for Simulation in Healthcare: Development and Psychometric Properties

Introduction This study examined the reliability of the scores of an assessment instrument, the Debriefing Assessment for Simulation in Healthcare (DASH), in evaluating the quality of health care simulation debriefings. The secondary objective was to evaluate whether the instrument’s scores demonstrate evidence of validity. Methods Two aspects of reliability were examined, interrater reliability and internal consistency. To assess interrater reliability, intraclass correlations were calculated for 114 simulation instructors enrolled in webinar training courses in the use of the DASH. The instructors reviewed a series of 3 standardized debriefing sessions. To assess internal consistency, Cronbach &agr; was calculated for this cohort. Finally, 1 measure of validity was examined by comparing the scores across 3 debriefings of different quality. Results Intraclass correlation coefficients for the individual elements were predominantly greater than 0.6. The overall intraclass correlation coefficient for the combined elements was 0.74. Cronbach &agr; was 0.89 across the webinar raters. There were statistically significant differences among the ratings for the 3 standardized debriefings (P < 0.001). Conclusions The DASH scores showed evidence of good reliability and preliminary evidence of validity. Additional work will be needed to assess the generalizability of the DASH based on the psychometrics of DASH data from other settings.

Chronic Ventilator Need in the Community: A 2005 Pediatric Census of Massachusetts

OBJECTIVES. The purpose of this study was to describe the population of children with chronic mechanical ventilation in Massachusetts and their patterns of medical care. PATIENTS AND METHODS. Investigators surveyed all of the Massachusetts home ventilator clinics, pediatric pulmonary services, hospital-based pediatric services for special health care needs, insurers, home care vendors, nursing agencies, the Massachusetts Department of Public Health, selected individual providers, and rehabilitation and long-term care facilities providing services to children with chronic respiratory support needs. Support was defined as daily use of noninvasive, negative-pressure, or invasive/transtracheal ventilators. Subsequent matching of demographic data, including date of birth, zip code, and gender supported maximal census yield without duplications. Geographic information systems were used to create distribution maps and estimate distances between children with chronic mechanical ventilator needs and key resources. RESULTS. A total of 197 children were identified as requiring chronic mechanical respiratory support in Massachusetts in 2005, which was a nearly threefold increase in this population in the 15-year interval since the last census. Congenital or perinatal-acquired neurologic or neuromuscular disorders constituted the majority of primary diagnoses (n = 107 [54%]). Chronic lung disease attributed to prematurity represented only 7% of the sample. CONCLUSIONS. Children receiving chronic mechanical respiratory support are a growing population. The shift in underlying diagnoses from pulmonary disease to neurogenic respiratory insufficiency has implications for hospital and community-based providers from all disciplines in extending services to the home setting. Barriers encountered when performing this study, however, reflect an overall lack of coordination among the many individuals and agencies involved in their care. Coordinated and centralized care efforts require a clear and managed flow of information; census reports such as this one are only the beginning. Direct needs assessments and quality-of-life surveys from families are needed to design and implement programmatic changes and advocacy efforts.

Youths' Health-Related Social Problems: Concerns Often Overlooked During the Medical Visit

OBJECTIVE The objectives of this study were to (1) measure the prevalence of health-related social problems among adolescent and young adult primary care patients; (2) estimate previous screening and referral experiences; and (3) examine participant attitudes toward screening and referral. METHODS Data were collected as part of a cross-sectional study conducted in an urban young adult clinic. Patients aged 15 to 25 years completed a computerized questionnaire screening for health-related social problems in nine social domains. In addition, participants answered questions about their previous screening experiences, need for referrals, and their experience using the system. RESULTS Seventy-six percent (304/401) of youth screened positive for at least one major problem, including healthcare access (37%), housing (34%), and food security (29%). Forty-seven percent (190/401) experienced major problems in two or more social domains. The prevalence of screening in the past year for each domain averaged 26%; 3% were screened in all nine domains in the previous 12 months and 33% were not screened in any domain. Overall, 75% needed a referral within the previous year, and 42% identified at least one unmet referral need. The majority (84%) of participants reported that it was acceptable to screen for these problems. CONCLUSION Prevalence of health-related social problems among youth is high. The majority needed at least one referral for a social need in the previous year. Primary care physicians would benefit from improved systems for screening and referral of health-related social problems in order to create a comprehensive medical home for their patients.

Booster Seat Laws and Fatalities in Children 4 to 7 Years of Age

OBJECTIVE: To determine whether state booster seat laws were associated with decreased fatality rates in children 4 to 7 years of age in the United States. METHODS: Retrospective, longitudinal analysis of all motor vehicle occupant crashes involving children 4 to 7 years of age identified in the Fatality Analysis Reporting System from January 1999 through December 2009. The main outcome measure was fatality rates of motor vehicle occupants aged 4 to 7 years. Because most booster laws exclude children 6 to 7 years of age, we performed separate analyses for children 4 to 5, 6, and 7 years of age. RESULTS: When controlling for other motor vehicle legislation, temporal and economic factors, states with booster seat laws had a lower risk of fatalities in 4- to 5-year-olds than states without booster seat laws (adjusted incidence rate ratio 0.89; 95% confidence interval [CI] 0.81–0.99). States with booster seat laws that included 6-year-olds had an adjusted incidence rate ratio of 0.77 (95% CI 0.65–0.91) for motor vehicle collision fatalities of 6-year-olds and those that included 7-year-olds had an adjusted incidence rate ratio of 0.75 (95% CI, 0.62–0.91) for motor vehicle collision fatalities of 7-year-olds. CONCLUSIONS: Booster seat laws are associated with decreased fatalities in children 4 to 7 years of age, with the strongest association seen in children 6 to 7 years of age. Future legislative efforts should extend current laws to children aged 6 to 7 years.

Firearm Laws and Firearm Homicides: A Systematic Review

Importance Firearm homicide is a leading cause of injury death in the United States, and there is considerable debate over the effectiveness of firearm policies. An analysis of the effectiveness of firearm laws on firearm homicide is important to understand optimal policies to decrease firearm homicide in the United States. Objective To evaluate the association between firearm laws and preventing firearm homicides in the United States. Evidence Review We evaluated peer-reviewed articles from 1970 to 2016 focusing on the association between US firearm laws and firearm homicide. We searched PubMed, CINAHL, Lexis/Nexis, Sociological Abstracts, Academic Search Premier, the Index to Legal Periodicals and Books, and the references from the assembled articles. We divided laws into 5 categories: those that (1) curb gun trafficking, (2) strengthen background checks, (3) improve child safety, (4) ban military-style assault weapons, and (5) restrict firearms in public places and leniency in firearm carrying. The articles were assessed using the standardized Guide to Community Preventive Services data collection instrument and 5 additional quality metrics: (1) appropriate data source(s) and outcome measure(s) were used for the study, (2) the time frame studied was adequate, (3) appropriate statistical tests were used, (4) the analytic results were robust, and (5) the disaggregated results of control variables were consistent with the literature. Findings In the aggregate, stronger gun policies were associated with decreased rates of firearm homicide, even after adjusting for demographic and sociologic factors. Laws that strengthen background checks and permit-to-purchase seemed to decrease firearm homicide rates. Specific laws directed at firearm trafficking, improving child safety, or the banning of military-style assault weapons were not associated with changes in firearm homicide rates. The evidence for laws restricting guns in public places and leniency in gun carrying was mixed. Conclusions and Relevance The strength of firearm legislation in general, and laws related to strengthening background checks and permit-to-purchase in particular, is associated with decreased firearm homicide rates. High-quality research is important to further evaluate the effectiveness of these laws. Legislation is just 1 part of a multipronged approach that will be necessary to decrease firearm homicides in the United States.

Children injured by violence in the United States: emergency department utilization, 2000-2008.

OBJECTIVES Children victimized by violence are often treated in the emergency department (ED). However, our understanding of the magnitude and financial costs of this patient population is inadequate. The authors examined the scope, risk factors for, and financial cost of ED visits for intentional injury in children in the United States over time. METHODS Using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2000 through 2008, the records of children aged 0 to 17 years evaluated in an ED for intentional injuries were examined. Nationally representative rates of ED visits for intentional injuries, the proportion of ED visits accounted for by children with intentional injuries, and risk factors for intentional injury visits were calculated. The Web-based Injury Statistics Query and Reporting System (WISQARS) Cost of Injury Reports was used to generate the medical costs accrued by intentional injuries in children. RESULTS Almost 340,000 children were treated in U.S. EDs each year from 2000 through 2008 for intentional injuries, comprising 1.2% (95% confidence interval [CI] = 1.1% to 1.4%) of all U.S. pediatric ED visits. The rate of ED visits for violent injuries has not changed over time. In 2008, 49 children per 10,000 (95% CI = 36 to 61) were treated in the ED for a violent injury. In a multivariate model, increasing age, residing in a metropolitan area, African American race, and the lack of private insurance were independent predictors of intentional injury visits among children. In 2005, the aggregate medical cost of intentionally inflicted injuries in children in the United States was

Food Insecurity and the Burden of Health-Related Social Problems in an Urban Youth Population

765 million. CONCLUSIONS ED visits among children for violent injury still represent an important clinical, public health, and economic challenge. The ED could be considered as a potential venue for prevention and intervention efforts.

Firearm Ownership and Violent Crime in the U.S. An Ecologic Study

PURPOSE Our study objectives were to (1) determine the prevalence of food insecurity; (2) examine the association between presence and level of food insecurity with other health-related social problems; and (3) assess the predictive values of a two-item food insecurity screen in an urban youth population. METHODS Patients aged 15-25 years completed a Web-based screening tool. Validated questions were used to identify problems in seven health-related social domains (food insecurity, health care access, education, housing, income insecurity, substance use, and intimate partner violence). Chi-square and Kruskal-Wallis tests and logistic regression models controlled for age, sex, and race/ethnicity, assessed the association between food insecurity and health-related social problems. Predictive values of a two-item food insecurity screen compared with the United States Department of Agriculture Food Security Survey were calculated. RESULTS Among 400 patients (mean age 18 years; 69.2% female; 54.6% black; 58.9% public insurance), 32.5% screened positive for food insecurity. Increasing food insecurity level was significantly associated with cumulative burden of social problems (p < .001). In adjusted analyses, food insecurity was associated with problems with health care access (aOR = 2.6, 95% confidence interval [CI] 1.7-4.1), education (aOR = 2.8, 95% CI 1.6-5.1), housing (aOR = 2.8, 95% CI 1.8-4.4), income insecurity (aOR = 2.3, 95% CI 1.2-4.5), and substance use (aOR = 2.5, 95% CI 1.5-4.3). The two-item screen demonstrated sensitivity of 88.5% and specificity of 84.1%. CONCLUSIONS One-third of youth in sample experienced food insecurity, which was strongly associated with presence of other health-related social problems. The two-item screen effectively detected food insecurity. Food insecurity screening may lead to identification of other health-related social problems that when addressed early may improve adolescent health.

Community Asthma Initiative to Improve Health Outcomes and Reduce Disparities Among Children with Asthma

INTRODUCTION Although some view the ownership of firearms as a deterrent to crime, the relationship between population-level firearm ownership rates and violent criminal perpetration is unclear. The purpose of this study is to test the association between state-level firearm ownership and violent crime. METHODS State-level rates of household firearm ownership and annual rates of criminal acts from 2001, 2002, and 2004 were analyzed in 2014. Firearm ownership rates were taken from a national survey and crime data were taken from the Federal Bureau of Investigation Uniform Crime Reports. Rates of criminal behavior were estimated as a function of household gun ownership using negative binomial regression models, controlling for several demographic factors. RESULTS Higher levels of firearm ownership were associated with higher levels of firearm assault and firearm robbery. There was also a significant association between firearm ownership and firearm homicide, as well as overall homicide. CONCLUSIONS The findings do not support the hypothesis that higher population firearm ownership rates reduce firearm-associated criminal perpetration. On the contrary, evidence shows that states with higher levels of firearm ownership have an increased risk for violent crimes perpetrated with a firearm. Public health stakeholders should consider the outcomes associated with private firearm ownership.

Adherence to guidelines for managing the well-appearing febrile infant: assessment using a case-based, interactive survey.

Black and Hispanic children are hospitalized with complications of asthma at much higher rates than white children. The Boston Childrens Hospital Community Asthma Initiative (CAI) provides asthma case management and home visits for children from low-income neighborhoods in Boston, Massachusetts, to address racial/ethnic health disparities in pediatric asthma outcomes. CAI objectives were to evaluate 1) case management data by parent/guardian report for health outcomes and 2) hospital administrative data for comparison between intervention and comparison groups. Data from parent/guardian reports indicate that CAI decreased the number of children with any (one or more) asthma-related hospitalizations (decrease of 79% at 12 months) and any asthma-related emergency department visits (decrease of 56% at 12 months) among children served, most of whom were non-Hispanic black or Hispanic. Hospital administrative data also indicate that the number of asthma-related hospitalizations per child significantly decreased among CAI participants compared with a comparison group. The CAI model has been replicated in other cities and states with adaptations to local cultural and systems variations. Health outcome and cost data have been used to contribute to a business case to educate legislators and insurers about outcomes and costs for this enhanced approach to care. Strong partnerships with public health, community, and housing agencies have allowed CAI to leverage its outcomes to expand systemic changes locally and statewide to reduce asthma morbidity.