Ruth A. Bush

Diagnostic imaging studies performed in children over a nine-year period.

BACKGROUND AND OBJECTIVE: Diagnostic imaging procedures (DIPs) producing radiation exposure in children have been associated with increased cancer risk. To develop effective clinical practice interventions that reduce pediatric radiation exposure, a longitudinal assessment of DIP ordering practices in the current clinical climate was performed. Our objective was to determine the prevalence and characteristics of DIPs ordered by physicians in an independent physicians association treating a general pediatric population. METHODS: DIP insurance claims from 2001 to 2009 were obtained from an independent physicians association in a large metropolitan area. Current Procedural Terminology codes, associated International Classification of Diseases, Ninth Revision codes, and patient demographics associated with DIPs were retrieved from insurance claim data and analyzed. RESULTS: Overall, 214 538 DIPs were performed on 63 116 children from 2001 to 2009 at a rate of 1 DIP associated with ionizing radiation per 21 patient-months. Over the study period, performance of computed tomography, MRI, ultrasound, and radiography all significantly increased (P < .001 for all). Higher radiation DIPs were most frequently performed in the inpatient and emergency settings on older boy patients for gastrointestinal and congenital disorders. The 3 most common International Classification of Diseases, Ninth Revision codes associated with higher radiation DIPs were abdominal pain, headache, and head injury. CONCLUSIONS: DIPs are frequently performed in children and higher radiation DIPs account for an increasing proportion of DIPs performed, especially among children evaluated in the inpatient and emergency department settings and those with gastrointestinal and neurologic symptoms, and congenital anomalies. Our findings may help guide development of clinical practice interventions to reduce DIP-related radiation exposure in youth.

Implementation of the Integrated Electronic Patient Portal in the Pediatric Population: A Systematic Review

BACKGROUND This study assessed the current state of knowledge regarding the use of the integrated electronic health record (EHR) patient portal for pediatric clinical care. A systematic examination of the research on implementation, utilization, and evaluation of the integrated EHR patient portal among pediatric patients has not been previously conducted. Therefore, the purpose of the present study was to systematically review existing research on the state of the science, describe the way others have defined the patient portal, and examine pediatric patient portal utilization. MATERIALS AND METHODS Covering a period from 1992 to 2014 a literature search was conducted on four electronic databases. Only articles in English were reviewed. Studies were included if they reported the use of a patient portal integrated with an electronic health record and captured pediatric medial encounters. Qualitative or quantitative studies of any design were eligible as long as they focused on patients (or parents) who access their health records through an electronic portal tied to an EHR and reported measures of satisfaction, attitudes on use, barriers and facilitators, adherence, or clinical and health outcomes. Content analysis of each article was performed independently by at least two authors using an extraction grid of study qualities, and quality and relevance of the studies were also assessed. RESULTS Of a total of 189 potentially relevant publications identified, 31 full-text publications were obtained after screening titles and abstracts. After a full review, 11 publications corresponding to seven studies met the inclusion criteria. The methodological approaches included cross-sectional surveys, retrospective analysis, qualitative studies, and usability testing. In general, feedback was positive. The most frequent negative comments about the portal reflected concern about teenager interaction with the portal and how that might affect communication among patient, parent, and provider. Some users were frustrated with the complexity of medical terminology used. CONCLUSIONS Reflecting the additional considerations of pediatric proxy access and fewer chronically ill patients, pediatric medicine has yet to use the patient portal as a modality for outcomes measurement. Given the paucity of studies within this age group, it is difficult to measure outcome improvements or the effect of patient record access on healthcare behaviors. This systematic review presents innovative research on the general acceptance of the patient portal among parents and highlights that the implementation of the portal is still in its early stages and has yet to be used widely in diverse populations or studies in a longitudinal manner. Further studies should confirm that protected access to health information and secure communication and information sharing with healthcare providers have an impact in the pediatric population on healthcare outcomes.

Female high-school varsity athletics: An opportunity to improve bone mineral density

The present study investigated whether moderate, organized physical activity during high school has a positive residual effect on bone mineral density (BMD) in 30-35-year-old females. Seventy-three female former high-school varsity athletes and 67 self-reported low-activity age-matched controls completed a collegiate womens health survey and participated in a one-time clinical visit with bone scan. Lumbar (L1-L4) spine BMD, total hip BMD, percentage body fat, age at menarche, history of amenorrhea, family history of osteoporosis, college alcohol consumption, number of high school varsity seasons, as well as current nutritional intake (including calcium), number of weekly weight training sessions, and caloric expenditure were assessed. Using a saturated linear regression model, current percentage body fat and number of high school seasons predicted 22% of the observed variation in total hip BMD and 25% of the observed variation of lumbar (L1-L4) spine BMD (P<0.001). High school athletes were more likely to be frequent adult exercisers (P<0.001). Athletic participants were more likely to have denser hip and spine bones than low-activity controls. Results suggest that participation in high school athletics is associated with greater BMD. Additionally, the varsity athletes continued to exercise frequently in their early 30s.

Role of reputation in top pediatric specialties rankings.

OBJECTIVE: Although the role of reputation in determining the relative standings in the U.S. News & World Report (USNWR) annual rankings of the top 50 hospitals has received analytical attention, the role of reputation in the best childrens hospitals pediatric specialty rankings has not been quantified. Our goal was to quantify the role of reputation in determining the relative standings of the top-ranked pediatric specialties and their associated hospitals in the 2008–2010 editions of the USNWR best childrens hospital rankings. METHODS: A cross-sectional study of USNWR data collected from the top 30 hospitals in each of 6 (and later 10) specialties was performed. The main outcome measures were rankings based on total USNWR scores and subjective reputation scores. RESULTS: On average, rankings based on reputation scores alone correlated with USNWR overall rankings; correlation coefficients ranged from 0.80 to 0.98 (Spearman Correlation; mean P < .001). This relationship was consistent over all 3 survey years. CONCLUSIONS: The relative standings of the top 30 pediatric hospitals in each of 10 specialties are largely explained by the compelling correlation between subjective reputation scores and ranking scores.

Exploring perceptions and use of the electronic health record by parents of children with autism spectrum disorder: A qualitative study

This qualitative project used structured interviews with nine parents to examine perceptions of the electronic health record (EHR) and associated patient portal in the treatment of their child’s autism spectrum disorder. Thematic analysis identified six complementary themes including: Familiarity and exposure to the EHR, changing experience of care (streamlining appointments, providing more rapid medical record access, increasing clinician awareness of the complexity of their child’s medical treatment, and facilitating prescriptions), portal use, patient/EHR/portal interaction, interoperability, and mother as care coordinator. While aware of the patient portal, only one-third had registered to use it and these parents reported only limited use. In general, perceptions of the electronic health record are positive, but the patient portal has yet to have needed consumer adoption. Further research and functionality are needed to increase portal registration and greater portal integration in patient care.

Can we predict a national profile of non-attendance paediatric urology patients: a multi-institutional electronic health record study

BACKGROUND Non-attendance at paediatric urology outpatient appointments results in the patients failure to receive medical care and wastes health care resources. OBJECTIVE To determine the utility of using routinely collected electronic health record (EHR) data for multi-centre analysis of variables predictive of patient noshows (NS) to identify areas for future intervention. METHODS Data were obtained from Childrens Hospital Colorado, Rady Childrens Hospital San Diego and University of Virginia Hospital paediatric urology practices, which use the Epic® EHR system. Data were extracted for all urology outpatient appointments scheduled from 1 October 2010 to 30 September 2011 using automated electronic data extraction techniques. Data included appointment type; date; provider type and days from scheduling to appointment. All data were de-identified prior to analysis. Predictor variables identified using χ(2) and analysis of variance were modelled using multivariate logistic regression. RESULTS A total of 2994 NS patients were identified within a population of 28,715, with a mean NS rate of 10.4%. Multivariate logistic regression determined that an appointment with mid-level provider (odds ratio (OR) 1.70 95% CI (1.56, 1.85)) and an increased number of days between scheduling and appointment (15-28 days OR 1.24 (1.09, 1.41); 29+ days OR 1.70 (1.53, 1.89)) were significantly associated with NS appointments. CONCLUSION We demonstrated sufficient interoperability among institutions to obtain data rapidly and efficiently for use in 1) interventions; 2) further study and 3) more complex analysis. Demographic and potentially modifiable clinic characteristics were associated with NS to the outpatient clinic. The analysis also demonstrated that available data are dependent on the clinical data collection systems and practices.

National risk factors and estimated costs for redo ureteroneocystostomy after pediatric renal transplant

Approximately 800 pediatric renal transplants are performed annually in the United States. VUR or obstruction may cause graft failure requiring redo ureteroneocystostomy. We examined possible risk factors and cost using the PHIS national database. We examined the PHIS for 8.5 yr to determine the association between redo ureteroneocystostomy following pediatric renal transplant to demographics, comorbidities, GU conditions, insurance status, and hospital characteristics, and looked at relative costs using descriptive and comparative statistics. A total of 2390 pediatric renal transplants were identified, of which 69 (2.3%) underwent redo ureteroneocystostomy (median 11.6 months post‐transplant). Risk factors for redo ureteroneocystostomy are younger age (p = 0.048), PUVs (p < 0.001), female gender (p = 0.005), race (p = 0.014), insurance type (p < 0.027), region (p = 0.045), and transplant surgery volume (p = 0.048). Redo ureteroneocystostomy after transplant does not significantly increase the overall cost of transplant (p = 0.175). We confirmed previous findings that younger age and PUVs increase the risk of post‐transplant redo ureteroneocystostomy, with a five‐yr plateau. We found an association with gender, race, insurance status, and hospital characteristics. Redo ureteroneocystostomy, which increases costs, does not statistically significantly increase overall cost of individual treatment in this database, although costs may be underreported.

“Minimally invasive research?” Use of the electronic health record to facilitate research in pediatric urology

BACKGROUND The electronic health record (EHR) was designed as a clinical and administrative tool to improve clinical patient care. Electronic healthcare systems have been successfully adopted across the world through use of government mandates and incentives. METHODS Using electronic health record, health information system, electronic medical record, health information systems, research, outcomes, pediatric, surgery, and urology as initial search terms, the literature focusing on clinical documentation data capture and the EHR as a potential resource for research related to clinical outcomes, quality improvement, and comparative effectiveness was reviewed. Relevant articles were supplemented by secondary review of article references as well as seminal articles in the field as identified by the senior author. FINDINGS US federal funding agencies, including the Agency for Healthcare Research and Quality, the Patient-Centered Outcomes Research Institute, the National Institutes of Health, and the Food and Drug Administration have recognized the EHRs role supporting research. The main approached to using EHR data include enhanced lists, direct data extraction, structured data entry, and unstructured data entry. The EHRs potential to facilitate research, overcoming cost and time burdens associated with traditional data collection, has not resulted in widespread use of EHR-based research tools. CONCLUSION There are strengths and weaknesses for all existing methodologies of using EHR data to support research. Collaboration is needed to identify the method that best suits the institution for incorporation of research-oriented data collection into routine pediatric urologic clinical practice.

A systematic review of the use of the electronic health record for patient identification, communication, and clinical support in palliative care

Abstract Objectives Globally, healthcare systems are using the electronic health record (EHR) and elements of clinical decision support (CDS) to facilitate palliative care (PC). Examination of published results is needed to determine if the EHR is successfully supporting the multidisciplinary nature and complexity of PC by identifying applications, methodology, outcomes, and barriers of active incorporation of the EHR in PC clinical workflow. Methods A systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The data sources PubMed, CINAL, EBSCOhost, and Academic Search Premier were used to identify literature published 1999–2017 of human subject peer-reviewed articles in English containing original research about the EHR and PC. Results The search returned 433 articles, 30 of which met inclusion criteria. Most studies were feasibility studies or retrospective cohort analyses; one study incorporated prospective longitudinal mixed methods. Twenty-three of 30 (77%) were published after 2014. The review identified five major areas in which the EHR is used to support PC. Studies focused on CDS to: identify individuals who could benefit from PC; electronic advanced care planning (ACP) documentation; patient-reported outcome measures (PROMs) such as rapid, real-time pain feedback; to augment EHR PC data capture capabilities; and to enhance interdisciplinary communication and care. Discussion Beginning in 2015, there was a proliferation of articles about PC and EHRs, suggesting increasing incorporation of and research about the EHR with PC. This review indicates the EHR is underutilized for PC CDS, facilitating PROMs, and capturing ACPs.

Correlates of Perinatal Post-Traumatic Stress Among Culturally Diverse Women with Depressive Symptomatology

Abstract Post-traumatic stress disorder (PTSD) is an important and often neglected comorbidity of pregnancy; left untreated, it can lead to serious health complications for the mother and developing fetus. Structured interviews were conducted to identify risk factors of PTSD among culturally diverse women with depressive symptomatology receiving perinatal services at community obstetric/gynecologic clinics. Women abused as adults, with two or more instances of trauma, greater trauma severity, insomnia, and low social support were more likely to present perinatal PTSD symptoms. Perinatal PTSD is prevalent and has the potential for chronicity. It is imperative healthcare providers recognize salient risk factors and integrate culturally sensitive screening, appropriate referral, and treatment services for perinatal PTSD.