Sarah J. Clark

Adoption of electronic health records in primary care pediatric practices.

BACKGROUND. Electronic health records may improve care delivery. Although professional organizations and federal agencies encourage widespread adoption, no national data are available regarding the penetration of electronic health records into primary care pediatric practices. METHODS. We used a national mail survey of 1000 randomly selected primary care pediatricians conducted from August to November 2005. RESULTS. The response rate was 58%. Overall, 21.3% of respondents had an electronic health record in their practice. The likelihood of having an electronic health record increased with practice size. Those in a practice network were more likely to have an electronic health record than those in other settings. Smaller and independent practices were less likely to be considering implementing an electronic health record. Although most electronic health records include some pediatric-specific functionality such as the ability to record immunizations, many do not offer decision support; only approximately one third included immunization prompts or alerts for abnormal laboratory results. Cost was a barrier for nearly all of those without an electronic health record; half of the respondents questioned whether electronic health records lead to improvement in quality of care, and many could not identify an electronic health record that would meet their practice requirements. CONCLUSIONS. Electronic health records are concentrated in larger and networked pediatric practices. Smaller and independent pediatric practices, the most common types of practice, are unlikely to adopt electronic health records until the cost of implementing and maintaining the systems decreases, developing standards for interoperability are adopted, and electronic health records are widely perceived to improve quality of care by practicing general pediatricians. The lack of decision support in current electronic health records may limit the ability of these tools to improve care delivery.

Safety and immunogenicity of a new Neisseria meningitidis serogroup C-tetanus toxoid conjugate vaccine in healthy adults.

UNLABELLED We evaluated the safety and immunogenicity of a single dose of a new serogroup C O-deacetylated meningococcal polysaccharide-tetanus toxoid conjugate vaccine in 30 healthy adult volunteers. The vaccine was well tolerated with no serious adverse events and minimal local reactions and systemic symptoms. All subjects developed a fourfold or greater increase in serum bactericidal antibody (SBA) to serogroup C meningococcus. SBA geometric mean titre increased from 11 to 3649 (p<0.001). Serogroup C-specific IgG levels increased postvaccination from 0.65 to 17.02 microg/ml (p<0.001). Bactericidal titres pre- and postimmunisation showed significant correlation with serogroup C-specific IgG (r(2)=0.693). Antibody levels fell by 6 months postvaccination, however, meningococcal C IgG avidity increased indicating the successful induction of a T-cell-dependent antibody response. CONCLUSION meningococcal C-tetanus toxoid conjugate vaccine is immunogenic and well tolerated in healthy adults.

A National Survey of Pediatric Critical Care Resources in the United States

Objective. To characterize resources available for the care of critically ill and injured children in the United States. Study Design. In January through May 2004, we conducted a cross-sectional survey of medical directors of intensive care facilities for children. Results. Pediatric critical care medical directors from 257 of 337 eligible hospitals responded to the survey (response rate: 76%). The median number of beds was 12 (interquartile range: 8–17 beds), with a median of 58 admissions per PICU bed (interquartile range: 44–70 admissions per PICU bed) in 2003. The median numbers of admissions per PICU bed were not statistically different among PICUs of different sizes. Fewer than 6% of hospitals shared PICU space with space for critically ill adults. The smallest units (1–6 beds) had higher physician and nurse staffing ratios per PICU bed. Advanced therapeutic technology, particularly renal replacement and inhaled nitric oxide therapy, was significantly more likely to be available in larger PICUs (≥7 beds). Conclusions. PICUs with the fewest beds had higher physician and nurse staffing ratios per PICU bed and lower resource capacity for high-intensity renal and respiratory therapy. The impact of PICU resource availability on referral patterns and outcomes of pediatric critical illnesses warrants additional study.

Primary care physician perspectives on reimbursement for childhood immunizations

OBJECTIVES. The purpose of this research was to explore physicians’ attitudes and behaviors related to vaccine financing issues within their practice. Amid the increasing number of vaccine doses recommended for children and adolescents, anecdotal reports suggest that physicians are facing increasing financial pressures from vaccine purchase and administration and may stop providing vaccines altogether to privately insured children. Whether these sentiments are widely held among immunization providers is unknown. METHODS. We conducted a cross-sectional mail survey from July to September 2007 of a random sample of 1280 US pediatricians and family physicians engaged in direct patient care. Main outcome measures included delay in the purchase of specific vaccines for financial reasons; reported decrease in profit margin from immunizations; and practice consideration of whether to stop providing all vaccines to privately insured children. RESULTS. The response rate was 70% for pediatricians and 60% for family physicians. Approximately half of the respondents reported that their practice had delayed the purchase of specific vaccines for financial reasons (49%) and experienced decreased profit margin from immunizations (53%) in the previous 3 years. Twenty-one percent of respondents strongly disagreed that “reimbursement for vaccine purchase is adequate,” and 17% strongly disagreed that “reimbursement for vaccine administration is adequate.” Eleven percent of respondents said their practice had seriously considered whether to stop providing all vaccines to privately insured children in the previous year. CONCLUSIONS. Physicians who provide vaccines to children and adolescents report dissatisfaction with reimbursement levels and increasing financial strain from immunizations. Although large-scale withdrawal of immunization providers does not seem to be imminent, efforts to address root causes of financial pressures should be undertaken.

Incremental hospital charges associated with obesity as a secondary diagnosis in children

Objective: The objective was to evaluate the association of obesity as a comorbidity with hospital charges, by comparing charges for pediatric hospitalizations with vs. without obesity as a secondary diagnosis.

Primary care physicians' attitudes regarding follow-up care for children with positive newborn screening results.

BACKGROUND. Although primary care physicians are responsible for providing follow-up care after a positive newborn screen, little is known about their willingness or ability to do so. METHODS. A national mail survey of a random sample of 350 general pediatricians and 350 family physicians was conducted from April to June 2006. RESULTS. The response rate was 63% among pediatricians and 50% among family physicians. Most pediatricians (89.7%) and nearly one half of family physicians (44.1%) had had a patient with a positive newborn screen within the past 5 years. Most respondents thought that primary care physicians should be responsible for informing families about a positive newborn screen (73.2%), arranging confirmatory testing (66.0%), and coordinating subspecialty referral (85.3%). However, more than one half (56.2%) would prefer newborn screening programs to provide the initial evaluation of positive newborn screening results. Some respondents (but fewer pediatricians than family physicians) reported that they were not competent to discuss conditions included in newborn screening panels (eg, 22.6% of pediatricians and 53.2% of family physicians for phenylketonuria and 8.8% of pediatricians and 40.4% of family physicians for congenital hypothyroidism). More than one half (58.3%) thought that families with a child diagnosed as having congenital hypothyroidism should receive formal genetic counseling. Respondents were less likely to think that families with a child with sickle cell trait, compared with families with a child who is a cystic fibrosis carrier, should receive formal genetic counseling (69.3% vs 84.1%). CONCLUSIONS. Many primary care physicians are not prepared to manage the follow-up care of children with a positive newborn screen, including initial counseling, diagnosis, and subspecialty referral. New strategies are needed to ensure appropriate and equitable health care delivery.

Breast-feeding education of obstetrics-gynecology residents and practitioners☆

OBJECTIVE Our purpose was to assess breast-feeding education, knowledge, attitudes, and practices among resident and practicing obstetrician-gynecologists. STUDY DESIGN A mailed survey was administered to a national sample of resident and practicing obstetrician-gynecologists. RESULTS Response rates were 64% for residents and 69% for practitioners. Residency training included limited opportunity for direct patient interaction regarding breast-feeding; 60% of practitioners recommended that training devote more time to breast-feeding counseling skills. Only 38% of residents reported that obstetric faculty presented breast-feeding topics; more common sources were nursing staff and other residents. Practitioners rated themselves as more effective in meeting the needs of breast-feeding patients than were residents; prior personal breast-feeding experience was a significant influence on perceived effectiveness. Almost all respondents agreed that obstretician-gynecologists have a role in breast-feeding promotion, but significant deficits in knowledge of breast-feeding benefits and clinical management were found. CONCLUSION Residency training and continuing education programs should create opportunities to practice breast-feeding promotion skills and emphasize management of common lactation problems.

Not without my permission: Parents' willingness to permit use of newborn screening samples for research

Background: State newborn screening (NBS) programs are considering the storage and use of NBS blood samples for research. However, no systematic assessment of parents’ attitudes exists. Methods: We conducted an Internet-based survey of a nationally representative parent sample. We examined parents’ willingness (1) to permit use of their children’s NBS samples for research with/without their permission and (2) to allow NBS sample storage. Using bivariate and multinomial logistic regression, we examined the association of parent and child characteristics with parents’ willingness to permit NBS sample storage and use for research, respectively. Results: The response rate was 49.5%. If permission is obtained, 76.2% of parents were ‘very or somewhat willing’ to permit use of the NBS sample for research. If permission is not obtained, only 28.2% of parents were ‘very or somewhat willing’. Of parents surveyed, 78% would permit storage of their children’s NBS sample. Parents who refused NBS sample storage were also less willing to permit use of the NBS sample for research. Conclusions: Three-quarters of parents would permit use of their children’s NBS samples for research – if their permission is obtained. Parents not in favor of storing NBS samples often opposed the use of NBS samples for research.

Influenza vaccination attitudes and practices among US registered nurses

BACKGROUND The influenza vaccination rate among US health care personnel (HCP) remains low and may vary by occupational categories. The objective of this study was to explore knowledge, attitudes, and beliefs associated with influenza vaccination in a broad population of registered nurses. METHODS The study used a cross-sectional mail survey, administered January-March 2006, of 2000 registered nurses in 4 US states. RESULTS Of the 2000 surveys sent, 1310 (72%) were returned, and 1017 (67%) were eligible for analysis. The majority of respondents (59%) reported receiving influenza vaccine during the 2005-2006 influenza season. The most common reason for being vaccinated was protecting oneself from illness (95%), and the most common reason for not being vaccinated was concern about adverse reactions (39%). Respondents who reported their patient population as high risk related to influenza were more likely to be vaccinated and to agree with statements regarding influenza disease and influenza vaccination of HCP. CONCLUSION Concerns about adverse reactions and vaccine effectiveness continue to be barriers to influenza vaccination among registered nurses. Those most knowledgeable about influenza vaccination of HCP have higher vaccination rates. Future efforts to improve vaccination rates should include data on vaccine effectiveness and adverse effects, as well as descriptions of high-risk populations.

A national survey of physician practices regarding influenza vaccine.

AbstractOBJECTIVE: To characterize U.S. physicians’ practices regarding influenza vaccine, particularly regarding the capacity to identify high-risk patients, the use of reminder systems, and the typical period of administration of vaccine. DESIGN: Cross-sectional mail survey administered in October and November 2000. PARTICIPANTS: National random sample of internists and family physicians (N=1,606). RESULTS: Response rate was 60%. Family physicians are significantly more likely than internists to administer influenza vaccine in their practices (82% vs 76%; P<.05). Eighty percent of physicians typically administer influenza vaccine for 3 to 5 months, but only 27% continue administering vaccine after the typical national peak of influenza activity. Only one half of physicians said their practices are able to generate lists of patients with chronic illnesses at high risk for complications of influenza, and only one quarter had used mail or telephone reminder systems to contact high-risk patients. Physicians working in a physician network (including managed care organizations) are more than twice as likely to use reminders as physicians in other practice settings (odds ratio, 2.04; 95% confidence interval, 1.17 to 3.55). CONCLUSIONS: Over three quarters of U.S. internists and family physicians routinely administer influenza vaccine, but few continue immunization efforts past the typical national peak of influenza activity. Many physicians may be limited by their practice data systems’ capacity to identify high-risk patients. Despite the known effectiveness and cost-effectiveness of reminder systems, few physicians use reminders for influenza vaccination efforts. These findings raise concerns about meeting domestic influenza vaccination goals—especially for individuals with chronic illness and during periods of delayed vaccine availability—and the possibility of increased morbidity and mortality attributable to influenza as a result.