Wren Haaland

Validity and Responsiveness of the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales in the Pediatric Inpatient Setting

IMPORTANCE Validated patient-reported outcomes responsive to clinical change are needed to evaluate the effectiveness of quality improvement interventions. OBJECTIVES To evaluate responsiveness, construct validity, and predictive validity of the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales in the pediatric inpatient setting. DESIGN, SETTING, AND PARTICIPANTS Prospective, cohort study of parents and caregivers of patients 1 month to 18 years old (n = 4637) and patients 13 to 18 years old (n = 359) admitted to Seattle Childrens Hospital between October 1, 2011, and December 31, 2013. Of 7184 eligible participants invited to complete the survey, 4637 (64.5%) completed the PedsQL on admission, and of these 2694 (58.1%) completed the follow-up survey 2 to 8 weeks after discharge. MAIN OUTCOMES AND MEASURES Responsiveness was assessed by calculating improvement scores (difference between follow-up and admission scores). Construct validity was examined by comparing the mean improvement scores for known groups differing by medical complexity. Predictive validity was assessed using Poisson regression to examine associations among admission scores, prolonged length of stay (≥3 days), and 30-day readmissions or emergency department (ED) return visits. Similar models examined the association between improvement scores and risk for 30-day readmissions or ED return visits. RESULTS The mean (SD) PedsQL improvement scores (scale, 0-100) were 22.1 (22.7) for total, 29.4 (32.4) for physical, and 17.1 (21.0) for psychosocial. The mean PedsQL total improvement scores were lower for patients with medically complex conditions compared with patients without chronic conditions (13.7 [95% CI, 11.6-15.8] vs. 24.1 [95% CI, 22.4-25.7], P < .001). A 10-point decrement in the PedsQL total admission score below the established community-based mean was associated with an increase in risk for prolonged length of stay (15% [95% CI, 13%-17%]), 30-day readmissions (8% [95% CI, 3%-14%]), and ED return visits (13% [95% CI, 6%-20%]). A 5-point decrement in the PedsQL total improvement score below the study sample mean improvement score was associated with an increase in risk for 30-day readmissions or ED return visits (9% [95% CI, -1% to 19%]). CONCLUSIONS AND RELEVANCE The PedsQL demonstrated responsiveness, construct validity, and predictive validity in hospitalized pediatric patients. The PedsQL may be a useful patient-reported outcome for hospital-based clinical effectiveness research.

Early Prenatal Phthalate Exposure, Sex Steroid Hormones, and Birth Outcomes

Context Adequate sex steroid hormone concentrations are essential for normal fetal genital development in early pregnancy. Our previous study demonstrated an inverse relationship between third-trimester di-2-ethyl hexyl phthalate exposure and total testosterone (TT) concentrations. Here, we examine early-pregnancy phthalates, sex steroid hormone concentrations, and newborn reproductive outcomes. Design We examined associations between urinary phthalate metabolite concentrations in early pregnancy and serum free testosterone (FT), TT, estrone (E1), and estradiol (E2) in 591 woman/infant dyads in The Infant Development and Environment Study; we also examined relationships between hormones and newborn genital outcomes using multiple regression models with covariate adjustment. Results E1 and E2 concentrations were 15% to 30% higher in relation to 1-unit increases in log monoisobutyl phthalate (MiBP), mono-2-ethyl hexyl phthalate, and mono-2-ethyl-5-oxy-hexyl phthalate concentrations, and E2 was 15% higher in relation to increased log monobenzyl phthalate (MBzP). FT concentrations were 12% lower in relation to 1-unit increases in log mono(carboxynonyl) phthalate (MCNP) and mono-2-ethyl-5-carboxypentyl phthalate concentrations. Higher maternal FT was associated with a 25% lower prevalence of having a male genital abnormality at birth. Conclusions The positive relationships between MiBP, MBzP, and DEHP metabolites and E1/E2 are unique and suggest a positive estrogenic effect in early pregnancy. The inverse relationship between MCNP and DEHP metabolites and serum FT supports previous work examining phthalate/testosterone relationships later in pregnancy. Higher FT in relation to a 25% lower prevalence of male genital abnormalities confirms the importance of testosterone in early fetal development.

The costs and cost-effectiveness of collaborative care for adolescents with depression in primary care settings: a randomized clinical trial

Importance Depression is one of the most common adolescent chronic health conditions and can lead to increased health care use. Collaborative care models have been shown to be effective in improving adolescent depressive symptoms, but there are few data on the effect of such a model on costs. Objective To evaluate the costs and cost-effectiveness of a collaborative care model for treatment of adolescent major depressive disorder in primary care settings. Design, Setting, and Participants This randomized clinical trial was conducted between April 1, 2010, and April 30, 2013, at 9 primary care clinics in the Group Health system in Washington State. Participants were adolescents (age range, 13-17 years) with depression who participated in the Reaching Out to Adolescents in Distress (ROAD) collaborative care intervention trial. Interventions A 12-month collaborative care intervention included an initial in-person engagement session, delivery of evidence-based treatments, and regular follow-up by masters level clinicians. Youth in the usual care control condition received depression screening results and could access mental health services and obtain medications through Group Health. Main Outcomes and Measures Cost outcomes included intervention costs and per capita health plan costs, calculated from the payer perspective using administrative records. The primary effectiveness outcome was the difference in quality-adjusted life-years (QALYs) between groups from baseline to 12 months. The QALYs were calculated using Child Depression Rating Scale-Revised scores measured during the clinical trial. Cost and QALYs were used to calculate an incremental cost-effectiveness ratio. Results Of those screened, 105 youths met criteria for entry into the study, and 101 were randomized to the intervention (n = 50) and usual care (n = 51) groups. Overall health plan costs were not significantly different between the intervention (

Previous Antibiotic Exposure Increases Risk of Infection with Extended-Spectrum-β-Lactamase- and AmpC-Producing Escherichia coli and Klebsiella pneumoniae in Pediatric Patients.

5161; 95% CI,

Parental Predictions and Perceptions Regarding Long-Term Childhood Obesity-Related Health Risks

3564-

Auditing Access to Outpatient Rehabilitation Services for Children With Traumatic Brain Injury and Public Insurance in Washington State

7070) and usual care (

Reliable Pregnancy Testing Before Intravenous Cyclophosphamide: A Quality Improvement Study.

5752; 95% CI,

First Trimester Phthalate Exposure and Infant Birth Weight in the Infant Development and Environment Study

3814-

The Molecular and Clinical Epidemiology of Extended-Spectrum Cephalosporin– and Carbapenem-Resistant Enterobacteriaceae at 4 US Pediatric Hospitals

7952) groups. Intervention delivery cost an additional

Outcomes of a Clinical Pathway to Standardize Use of Maintenance Intravenous Fluids

1475 (95% CI,