Judith E. Glazner

Neonatal Outcomes After Elective Cesarean Delivery

OBJECTIVE: To examine the outcomes of neonates born by elective repeat cesarean delivery compared with vaginal birth after cesarean (VBAC) in women with one prior cesarean delivery and to evaluate the cost differences between elective repeat cesarean and VBAC. METHODS: We conducted a retrospective cohort study of 672 women with one prior cesarean delivery and a singleton pregnancy at or after 37 weeks of gestation. Women were grouped according to their intention to have an elective repeat cesarean or a VBAC (successful or failed). The primary outcome was neonatal intensive care unit (NICU) admission and measures of respiratory morbidity. RESULTS: Neonates born by cesarean delivery had higher NICU admission rates compared with the VBAC group (9.3% compared with 4.9%, P=.025) and higher rates of oxygen supplementation for delivery room resuscitation (41.5% compared with 23.2%, P<.01) and after NICU admission (5.8% compared with 2.4%, P<.028). Neonates born by VBAC required the least delivery room resuscitation with oxygen, whereas neonates delivered after failed VBAC required the greatest degree of delivery room resuscitation. The costs of elective repeat cesarean were significantly greater than VBAC. However, failed VBAC accounted for the most expensive total birth experience (delivery and NICU use). CONCLUSION: In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay. LEVEL OF EVIDENCE: II

Effectiveness and Net Cost of Reminder/Recall for Adolescent Immunizations

OBJECTIVE: To assess the effectiveness of reminder/recall (R/R) for immunizing adolescents in private pediatric practices and to describe the associated costs and revenues. METHODS: We conducted a randomized controlled trial in 4 private pediatric practices in metropolitan Denver. In each practice, 400 adolescents aged 11 to 18 years who had not received 1 or more targeted vaccinations (tetanus-diphtheria-acellular pertussis, meningococcal conjugate, or first dose of human papillomavirus vaccine for female patients) were randomly selected and randomized to intervention (2 letters and 2 telephone calls) or control (usual care) groups. Primary outcomes were receipt of >1 targeted vaccines and receipt of all targeted vaccines 6 months postintervention. We calculated net additional revenue for each additional adolescent who received at least 1 targeted vaccine and for those who received all targeted vaccines. RESULTS: Eight hundred adolescents were randomized to the intervention and 800 to the control group. Baseline rates of having already received tetanus-diphtheria-acellular pertussis, meningococcal conjugate, and first dose of human papillomavirus vaccine before R/R ranged from 33% to 54%. Postintervention, the intervention group had significantly higher proportions of receipt of at least 1 targeted vaccine (47.1% vs 34.6%, P < .0001) and receipt of all targeted vaccines (36.2% vs 25.2%, P < .0001) compared with the control group. Three practices had positive net revenues from R/R; 1 showed net losses. CONCLUSIONS: R/R was successful at increasing immunization rates in adolescents and effect sizes were comparable to those in younger children. Practices conducting R/R may benefit financially if they can generate additional well-child care visits and keep supply costs low.

Get smart Colorado: impact of a mass media campaign to improve community antibiotic use.

Context: Large-scale strategies are needed to reduce overuse of antibiotics in US communities. Objectives: To evaluate the impact of a mass media campaign—“Get Smart Colorado”—on public exposure to campaign, antibiotic use, and office visit rates. Design: Nonrandomized controlled trial. Setting: Two metropolitan communities in Colorado, United States. Subjects: The general public, managed care enrollees, and physicians residing in the mass media (2.2 million persons) and comparison (0.53 million persons) communities. Intervention: The campaign consisting of paid outdoor advertising, earned media and physician advocacy ran between November 2002 and February 2003. Principal Measures: Antibiotics dispensed per 1000 persons or managed care enrollees, and the proportion of office visits receiving antibiotics measured during 10 to 12 months before and after the campaign. Results: After the mass media campaign, there was a 3.8% net decrease in retail pharmacy antibiotic dispenses per 1000 persons (P = 0.30) and an 8.8% net decrease in managed care-associated antibiotic dispenses per 1000 members (P = 0.03) in the mass media community. Most of the decline occurred among pediatric members, and corresponded with a decline in pediatric office visit rates. There was no change in the office visit prescription rates among pediatric or adult managed care members, nor in visit rates for complications of acute respiratory tract infections. Conclusions: A low-cost mass media campaign was associated with a reduction in antibiotic use in the community, and seems to be mediated through decreases in office visits rates among children. The campaign seems to be cost-saving.

Diabetes, minor depression and health care utilization and expenditures: a retrospective database study

BackgroundTo estimate the prevalence of minor depression among US adults with diabetes, health care resource utilization, and expenditures by people with diabetes with and without minor depression.MethodsAmong adult 2003 Medical Expenditure Panel Survey respondents, diabetes was identified by diagnosis code and self-report. Depression was identified by diagnosis code plus ≥ one antidepressant prescription. Odds of having depression was estimated in people with diabetes and the general population, adjusted for sociodemographic variables (e.g., age, sex, race/ethnicity). Multivariate regressions evaluated factors associated with utilization and log-transformed expenditures for ambulatory care, hospitalizations, emergency visits, and prescriptions.ResultsIn 2003, 1932 respondents had diabetes, 435/1932 had diabetes and minor depression. Adults with diabetes were more likely than the general population to have depression (adjusted OR 1.81, 95% CI 1.56, 2.09). People with diabetes with versus without comorbid depression were more likely to be women, have lower incomes and health status, and more diabetes complications (all p < 0.05). In unadjusted analyses, ambulatory care visits were higher for those with versus without depression (17.9 vs. 11.4, p = 0.04), as were prescriptions (60.7 vs. 38.1, p = 0.05). In adjusted analyses, depression was not associated with increased resource use or higher expenditures in any category. Increased number of comorbid conditions was associated with increased resource use in all categories, and increased expenditures for ambulatory care and prescriptions.ConclusionPeople with diabetes are twice as likely to have depression as the general population. Screening for and treatment of depression is warranted, as is additional research into a causal relationship between diabetes and depression.

Cost of Vaccine Administration Among Pediatric Practices

OBJECTIVE: The goal was to describe variable costs to providers of delivering childhood immunizations. METHODS: We documented variable costs (costs that vary with the amount of services rendered), including time spent by pediatric staff members and physicians on immunization-related activities, as well as supply costs and medical waste disposal costs. Ten private pediatric practices in the Denver, Colorado, metropolitan area participated in the study. Among the 7 practices that provided us with payment data, 8 health plans were mentioned by ≥2 practices. There were 37 different agreements between the health plans and practices for vaccine administration payments. RESULTS: The total documented variable cost per injection (excluding vaccine cost) averaged

Analysis of text from injury reports improves understanding of construction falls

11.51, calculated from the following categories: nursing time,

Pediatric Telephone Call Centers: How Do They Affect Health Care Use and Costs?

1.71; billing services,

Who is paying the bills? Health care costs for musculoskeletal back disorders, Washington State Union Carpenters, 1989-2003.

2.67; nonroutine services,

Effectiveness and Cost of Immunization Recall at School-Based Health Centers

1.64; registry use,

Contractor safety practices and injury rates in construction of the Denver International Airport

0.96; physician time,