Publications (28)111.43 Total impact
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Article: Pediatrician interventions and thirdhand smoke beliefs of parents.
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ABSTRACT: Thirdhand smoke is residual tobacco smoke contamination that remains after a cigarette is extinguished. A national study indicates that adults' belief that thirdhand smoke (THS) harms children is associated with strict household no-smoking policies. The question of whether pediatricians can influence THS beliefs has not been assessed. To identify prevalence of THS beliefs and associated factors among smoking parents, and the association of pediatrician intervention on parent belief that THS is harmful to their children. Exit interview data were collected from 1980 parents following a pediatric office visit. Parents' level of agreement or disagreement that THS can harm the health of babies and children was assessed. A multivariate logistic regression model was constructed to identify whether pediatricians' actions were independently associated with parental belief that THS can harm the health of babies and children. Data were collected from 2009 to 2011, and analyses were conducted in 2012. Ninety-one percent of parents believed that THS can harm the health of babies and children. Fathers (AOR=0.59, 95% CI=0.42, 0.84) and parents who smoked more than ten cigarettes per day (AOR=0.63, 95% CI=0.45, 0.88) were less likely to agree with this statement. In contrast, parents who received advice (AOR=1.60, 95% CI=1.04, 2.45) to have a smokefree home or car or to quit smoking and parents who were referred (AOR=3.42, 95% CI=1.18, 9.94) to a "quitline" or other cessation program were more likely to agree that THS can be harmful. Fathers and heavier smokers were less likely to believe that THS is harmful. However, pediatricians' actions to encourage smoking parents to quit or adopt smokefree home or car policies were associated with parental beliefs that THS harms children. This study is registered at NCT00664261.American journal of preventive medicine 11/2012; 43(5):533-6. · 4.24 Impact Factor -
Article: Unreadiness for Postpartum Discharge Following Healthy Term Pregnancy: Impact on Health Care Use and Outcomes.
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ABSTRACT: OBJECTIVE: To document the association between a lack of readiness, termed "unreadiness," for postpartum discharge and the health of mothers and their term newborns. METHODS: Prospective observational cohort study of 4300 mother-infant dyads in a national, pediatric, practice-based research network. The association between unreadiness for discharge and health care use, health-related behaviors, and health outcomes was analyzed by the use of bivariate, multivariate linear, and logistic models. RESULTS: Sixteen percent of mother-infant dyads were unready for discharge. Unreadiness was significantly associated with maternal and infant health care use and health outcomes but not independently associated with health-related behaviors. In multivariable analyses, after we controlled for important covariates and confounders, unready dyads had more calls to health care providers than ready dyads (13.3% increase for mothers, P = .01; 18.7% increase for infants, P < .01) during the first 2 weeks after discharge. In this same time frame, unready dyads also had more symptom days (8.5% increase for mothers, P < .01; 8.7% increase for infants, P < .01). Unready mothers had lower mean physical (5.0% decrease, P < .01) and mental (4.4% decrease, P < .01) health status scores at 4 weeks after discharge. CONCLUSIONS: Unreadiness at postpartum discharge was associated with increased health care use and poorer health outcomes in the first 2 to 4 weeks after discharge. Discharge plans should be individualized and jointly tailored to a family's needs rather than to a set timescale.Academic pediatrics 10/2012; -
Article: Pediatric research in office settings at 25: a quarter century of network research toward the betterment of children's health.
Current problems in pediatric and adolescent health care 11/2011; 41(10):286-92. -
Article: Development and validation of a tool to improve paediatric referral/consultation communication.
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ABSTRACT: To develop a template to promote brief but high-quality communication between paediatric primary care clinicians and consulting specialists. Through an iterative process with academic and community-based paediatric primary care providers and specialists, the authors identified what content elements would be of value when communicating around referrals. The authors then developed a one-page template to encourage both primary care and specialty clinicians to include these elements when communicating about referrals. Trained clinician reviewers examined a sample of 206 referrals from community primary care providers (PCPs) to specialists in five paediatric specialties at an academic medical centre, coding communication content and rating the overall value of the referral communication. The relationship between the value ratings and each content element was examined to determine which content elements contributed to perceived value. Almost all content elements were associated with increased value as rated by clinician reviewers. The most valuable communications from PCP to specialist contained specific questions for the specialist and/or physical exam features, and the most valuable from specialist to PCP contained brief education for the PCP about the condition; all three elements were found in a minority of communications reviewed. A limited set of communication elements is suitable for a brief communication template in communication from paediatric PCPs to specialists. The use of such a template may add value to interphysician communication.BMJ quality & safety 02/2011; 20(8):692-7. -
Article: Pediatric clinical research networks: current status, common challenges, and potential solutions.
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ABSTRACT: The goals were (1) to describe and to characterize pediatric clinical research networks (PCRNs) in the United States and Canada, (2) to identify PCRN strengths and weaknesses, (3) to evaluate the potential for collaboration among PCRNs, and (4) to assess untapped potential interest in PCRN participation. Data collection included (1) initial identification of PCRNs through an Internet search and word of mouth, (2) follow-up surveys of PCRN leaders, (3) telephone interviews with 21 PCRN leaders, and (4) a survey of 43 American Academy of Pediatrics specialty leaders regarding untapped interest in network research. Seventy exclusively pediatric networks were identified. Of those, specialty care networks constituted the largest proportion (50%), followed by primary care (28.6%) and disease-specific (21.4%) networks. A network profile survey (response rate: 74.3%) revealed that ∼90% held infrastructure funding. Nearly 75% of respondents viewed cross-network collaborations positively. In-depth telephone interviews corroborated the survey data, with cross-network collaboration mentioned consistently as a theme. American Academy of Pediatrics specialty leaders indicated that up to 30% of current nonparticipants might be interested in research involvement. Pediatric networks exist across the care continuum. Significant numbers of uninvolved practitioners may be interested in joining PCRNs. A strong majority of network leaders cited potential benefits from network collaboration.PEDIATRICS 10/2010; 126(4):740-5. · 4.47 Impact Factor -
Article: PROS: a research network to enhance practice and improve child health.
Pediatric Annals 06/2010; 39(6):352-61. · 0.48 Impact Factor -
Article: Effects of local institutional review board review on participation in national practice-based research network studies.
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ABSTRACT: To describe the process and outcomes of local institutional review board (IRB) review for 2 Pediatric Research in Office Settings (PROS) studies. Pediatric Research in Office Settings conducted 2 national studies concerning sensitive topics: (1) Child Abuse Recognition Experience Study (CARES), an observational study of physician decision making, and (2) Safety Check, a violence prevention intervention trial. Institutional review board approval was secured by investigators' sites, the American Academy of Pediatrics, and practices with local IRBs. Practices were queried about IRB rules at PROS enrollment and study recruitment. Pediatric Research in Office Settings practices in 29 states. Eighty-eight PROS practices (75 IRBs). Main Exposure Local IRB presence. Local IRB presence, level of PROS assistance, IRB process, study participation, data collection completion, and minority enrollment. Practices requiring additional local IRB approval agreed to participate less than those that did not (CARES: 33% vs 52%; Safety Check: 41% vs 56%). Of the 88 practices requiring local IRB approval, 55 received approval, with nearly 50% needing active PROS help, many requiring consent changes (eg, contact name additions, local IRB approval stamps), and 87% beginning data collection. Median days to obtain approval were 81 (CARES) and 109 (Safety Check). Practices requiring local IRB approval were less likely to complete data collection but more likely to enroll minority patients. Local IRB review was associated with lower participation rates, substantial effort navigating the process (with approval universally granted without substantive changes), and data collection delays. When considering future reforms, the national human subject protections system should consider the potential redundancy and effect on generalizability, particularly regarding enrollment of poor urban children, related to local IRB review.Archives of pediatrics & adolescent medicine 12/2009; 163(12):1130-4. · 3.73 Impact Factor -
Article: Assessing inter-rater reliability (IRR) of Tanner staging and orchidometer use with boys: a study from PROS.
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ABSTRACT: Few studies have systematically assessed the reliability of pubertal markers; most are flawed by limited numbers of markers and ages studied. To conduct a comprehensive examination of inter-rater reliability in the assessment of boys' sexual maturity. Eight pairs of practitioners independently rated 79 consecutive boys aged 8-14 years. Two raters in each of eight practices independently rated boys aged 8-14 years, presenting for physical examinations, on key pubertal markers: pubic hair and genitalia (both on 5-point Tanner scales), testicular size (via palpation and comparison with a four-bead Prader orchidometer), and axillary hair (via a three-point scale). Intraclass correlations assessing degree of inter-rater reliability for pubertal markers ranged from 0.61 to 0.94 (all significant at p < 0.001). Rater Kappas for signs of pubertal initiation ranged from 0.49 to 0.79. Practitioners are able to reliably stage key markers of male puberty and identify signs of pubertal initiation.Journal of pediatric endocrinology & metabolism: JPEM 04/2009; 22(4):291-9. · 0.88 Impact Factor -
Article: Office-based treatment and outcomes for febrile infants with clinically diagnosed bronchiolitis.
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ABSTRACT: The goals were to describe the (1) frequency of sepsis evaluation and empiric antibiotic treatment, (2) clinical predictors of management, and (3) serious bacterial illness frequency for febrile infants with clinically diagnosed bronchiolitis seen in office settings. The Pediatric Research in Office Settings network conducted a prospective cohort study of 3066 febrile infants (<3 months of age with temperatures >or=38 degrees C) in 219 practices in 44 states. We compared the frequency of sepsis evaluation, parenteral antibiotic treatment, and serious bacterial illness in infants with and without clinically diagnosed bronchiolitis. We identified predictors of sepsis evaluation and parenteral antibiotic treatment in infants with bronchiolitis by using logistic regression models. Practitioners were less likely to perform a complete sepsis evaluation, urine testing, and cerebrospinal fluid culture and to administer parenteral antibiotic treatment for infants with bronchiolitis, compared with those without bronchiolitis. Significant predictors of sepsis evaluation in infants with bronchiolitis included younger age, higher maximal temperature, and respiratory syncytial virus testing. Predictors of parenteral antibiotic use included initial ill appearance, age of <30 days, higher maximal temperature, and general signs of infant distress. Among infants with bronchiolitis (N = 218), none had serious bacterial illness and those with respiratory distress signs were less likely to receive parenteral antibiotic treatment. Diagnoses among 2848 febrile infants without bronchiolitis included bacterial meningitis (n = 14), bacteremia (n = 49), and urinary tract infection (n = 167). In office settings, serious bacterial illness in young febrile infants with clinically diagnosed bronchiolitis is uncommon. Limited testing for bacterial infections seems to be an appropriate management strategy.PEDIATRICS 11/2008; 122(5):947-54. · 4.47 Impact Factor -
Article: Is office-based counseling about media use, timeouts, and firearm storage effective? Results from a cluster-randomized, controlled trial.
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ABSTRACT: The objective of this study was to determine whether patients' families' violence-prevention behaviors would be affected by their primary care practitioner's use of a violence-prevention clinical intervention during the routine well-child examination. In this cluster-randomized, controlled trial (2002-2006), 137 Pediatric Research in Office Settings practices were randomly assigned and initiated patient recruitment for either an office-based violence-prevention intervention or a control group (educational handout on literacy promotion provided). Primary caregivers of children who were aged 2 to 11 years and presented for a well-child visit were surveyed at baseline and 1 and 6 months. Practitioners were trained to (1) review a parent previsit summary regarding patient-family behavior and parental concern about media use, discipline strategies, and children's exposure to firearms, (2) counsel using brief principles of motivational interviewing, (3) identify and provide local agency resources for anger and behavior management when indicated, and (4) instruct patient-families on use of tangible tools (minute timers to monitor media time/timeouts and firearm cable locks to store firearms more safely where children live or play). Main outcomes were change over time in self-reported media use <120 minutes per day, use of timeouts, and use of firearm cable locks. Generalized estimating equation analysis revealed a significant effect at 6 months for decreased media use and safer firearm storage. The intervention group compared with the control group showed an increase in limiting media use to <120 minutes per day. There was no significant effect for timeout use. There was a substantial increase in storing firearms with cable locks for the intervention group versus a decrease for the control group. This randomized, controlled trial demonstrated decreased media exposure and increased safe firearm storage as a result of a brief office-based violence-prevention approach.PEDIATRICS 08/2008; 122(1):e15-25. · 4.47 Impact Factor -
Article: Practice-based research network solutions to methodological challenges encountered in a national, prospective cohort study of mothers and newborns.
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ABSTRACT: The emergence of practice-based research networks (PBRN) has facilitated the execution of multifaceted community-based studies. As study complexity increases, so does the number of methodological barriers encountered. This paper's goal was to delineate methodological barriers and to evaluate the effectiveness of selected strategies and approaches developed and implemented in allowing a prospective, national PBRN cohort study to succeed in enrolling geographically dispersed mother/healthy term infant dyads (n = 4300) on the day of post-partum discharge. Specific methodological barriers included: (1) obtaining multiple Institutional Review Board (IRB) approvals; (2) gathering longitudinal data from multiple individuals; (3) soliciting multiple perspectives on discharge decision making; and (4) bolstering minority enrolment. The most effective strategies and approaches we employed to address these methodological challenges were: (1) preparing and distributing the 'IRB Packet'; (2) recruiting multiple practices covered by the same IRB; and (3) obtaining supplemental funding for increasing minority enrolment. We expect that other PBRN investigators can benefit from our experience and solutions in the successful conduct of this multifaceted community-based study.Paediatric and Perinatal Epidemiology 02/2008; 22(1):87-98. · 2.31 Impact Factor -
Article: Parents as information intermediaries between primary care and specialty physicians.
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ABSTRACT: In this study we assessed the views of parents of children referred to specialty care and the views of the children's primary care and specialty physicians about parents' roles as information intermediaries. We enrolled 179 patients who were newly referred from primary care pediatricians in 22 practices to 15 pediatric subspecialists in 5 specialties in a study of primary care pediatrician-specialist communication. Parents, primary care pediatricians, and specialists completed questionnaires by mail or telephone at the first visit and 6 months later. Questions included perceived responsibilities of parents as information conduits between primary care pediatricians and specialists. Opinions of parents, primary care pediatricians, and specialists about parents' roles were compared for the sample as a whole, as well as for individual cases. Agreement between parents and providers was assessed. Demographic and clinical determinants of parents reporting themselves as "comfortable with" or "acting" as primary intermediaries were assessed using logistic regression. More parents (44%) than primary care physicians (30%) felt comfortable with parents acting as primary communicators between their children's physicians; 31% of parents who reported that they were the primary communicators felt uncomfortable in that role, and there was no agreement between parents and physicians about the role of parents in individual cases. Although no demographic characteristics of children or parents were associated with parent comfort as the primary communicator, parents of children who saw the same specialist more than once during the 6-month period felt more comfortable in this role. The presence of a chronic condition was not associated with parent comfort. Although parents report more comfort with their own ability as information intermediaries than do their children's physicians, the role in which they feel comfortable is highly variable. Physicians should discuss with parents the roles they feel comfortable in assuming when specialty referrals are initiated.PEDIATRICS 01/2008; 120(6):1238-46. · 4.47 Impact Factor -
Article: Improving pediatric practice immunization rates through distance-based quality improvement: a feasibility trial from PROS.
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ABSTRACT: The feasibility and effectiveness of a distance-based quality improvement model were examined in a cohort of Pediatric Research in Office Settings (PROS) practices, with the goal of improving immunization rates and practitioner behaviors and attitudes. Of an initially assessed 82 practices, 29 with baseline rates of < or =88% for children 8 to 15 months of age were randomized into year-long paper-based education or distance-based quality improvement intervention groups. Outcomes were utility/helpfulness of quality improvement modalities, immunization rate change, and behavior/attitude change. Quality improvement participants attended approximately 75% of monthly conference calls but used the quality improvement Listserv and Web site infrequently (mean 1.09 and 0.92 uses, respectively). Helpfulness ratings of quality improvement modalities mirrored usage. Analyses revealed a 4.9% increase in quality improvement group immunization rates (P = .061), a 0.8% education group increase (P = .752), and a 4.1% difference between groups (P = .261). More quality improvement practices adopted systems identifying children behind in immunizations. A distance-based quality improvement model is feasible and may improve immunization rates.Clinical Pediatrics 01/2008; 47(1):25-36. · 1.15 Impact Factor -
Article: Firearm ownership and storage patterns among families with children who receive well-child care in pediatric offices.
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ABSTRACT: In this study we examined firearm storage patterns and their associations in a diverse sample of families who attended pediatric practices from both rural and nonrural areas across the United States. Parents who brought their children who were aged 2 to 11 years (N = 3745) to 96 Pediatric Research in Office Settings practices from 45 states, Canada, and Puerto Rico participated in an office-based survey before a well-child examination. The survey measured demographic variables; family history of guns in the home; and firearm types, storage behaviors, and ownership. Twenty-three percent of families reported firearm ownership. The majority (60%) of respondents reported making firearm storage decisions. Only one third of firearm owners reported safe firearm storage. Gun type owned was associated with storage habits, with long-gun owners storing their gun in places other than locked cabinets but with ammunition separate from guns and handgun users more likely to store guns loaded and to use gun locks. In a multivariate analysis, not being raised with a firearm was associated with safe storage behaviors. Families who had children aged 2 to 5 years and owned long guns were more likely to store their guns safely than families with older children. Few families reported safe firearm storage. Storage patterns are most influenced by firearm type(s) owned, family socialization with guns, and the age of the child. Primary care providers need to understand better not only whether firearms are in the home but also which types are present and whether parents were raised in homes with guns.PEDIATRICS 07/2007; 119(6):e1271-9. · 4.47 Impact Factor -
Article: Office-based motivational interviewing to prevent childhood obesity: a feasibility study.
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ABSTRACT: To determine whether pediatricians and dietitians can implement an office-based obesity prevention program using motivational interviewing as the primary intervention. Nonrandomized clinical trial. Fifteen pediatricians belonging to Pediatric Research in Office Settings, a national practice-based research network, and 5 registered dietitians were assigned to 1 of 3 groups: (1) control; (2) minimal intervention (pediatrician only); or (3) intensive intervention (pediatrician and registered dietitian). Primary care pediatric offices. Ninety-one children presenting for well-child care visits met eligibility criteria of being aged 3 to 7 years and having a body mass index (calculated as the weight in kilograms divided by the height in meters squared) at the 85th percentile or greater but lower than the 95th percentile for the age or having a normal weight and a parent with a body mass index of 30 or greater. Pediatricians and registered dietitians in the intervention groups received motivational interviewing training. Parents of children in the minimal intervention group received 1 motivational interviewing session from the physician, and parents of children in the intensive intervention group received 2 motivational interviewing sessions each from the pediatrician and the registered dietitian. Change in the body mass index-for-age percentile. At 6 months' follow-up, there was a decrease of 0.6, 1.9, and 2.6 body mass index percentiles in the control, minimal, and intensive groups, respectively. The differences in body mass index percentile change between the 3 groups were nonsignificant (P=.85). The patient dropout rates were 2 (10%), 13 (32%), and 15 (50%) for the control, minimal, and intensive groups, respectively. Fifteen (94%) of the parents reported that the intervention helped them think about changing their family's eating habits. Motivational interviewing by pediatricians and dietitians is a promising office-based strategy for preventing childhood obesity. However, additional studies are needed to demonstrate the efficacy of this intervention in practice settings.Archives of Pediatrics and Adolescent Medicine 06/2007; 161(5):495-501. · 4.14 Impact Factor -
Article: Determinants and impact of generalist-specialist communication about pediatric outpatient referrals.
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ABSTRACT: Effective communication between primary care and specialty physicians is essential for comanagement when children are referred to specialty care. We sought to determine rates of physician-reported communication between primary care physicians and specialists, the clinical impact of communication or its absence, and patient- and practice system-level determinants of communication for a cohort of children referred to specialty care. We enrolled 179 patients newly referred from general pediatricians in 30 community practices to 15 pediatric medical specialists in 5 specialties. Primary care physicians and specialists completed questionnaires at the first specialty visit and 6 months later. Questions covered communication received by primary care physicians and specialists, its impact on care provision, system characteristics of practices, and roles of physicians in treatment. We used multivariate logistic regression to determine associations between practice system and patient characteristics and the dependent variable of reported primary care physician-specialist communication. Specialists reported communication from referring primary care physicians for only 50% of initial referrals, whereas primary care physicians reported communication from specialists after 84% of initial consultations. Communication was strongly associated with physicians' reported ability to provide optimal care. System characteristics associated with reported primary care physician-specialist communication were computer access to chart notes and lack of delays in receipt of information. Associated patient characteristics included non-Medicaid insurance, no additional specialists seen, and specialty to which referred. Physicians favored comanagement of referred patients in more than two thirds of the cases. Although a prerequisite for optimal care, communication from primary care physicians to specialists is frequently absent. Interventions should promote widely accessible clinical information systems and target children with complex needs and public insurance.PEDIATRICS 11/2006; 118(4):1341-9. · 4.47 Impact Factor -
Article: Patient visits to a national practice-based research network: comparing pediatric research in office settings with the National Ambulatory Medical Care Survey.
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ABSTRACT: Our objective with this study was to assess the extent to which patients who are seen by practitioners in Pediatric Research in Office Settings, a national primary care practice-based research network, are representative of those who are seen in ambulatory office-based pediatric primary care in the United States. Pediatric Research in Office Settings patient data were collected from the offices of 57 randomly selected network practitioners as part of an Agency for Healthcare Research and Quality-funded effort to describe primary care visits and replicate the National Ambulatory Medical Care Survey in primary care practice-based research networks. These data were from 1706 randomly selected pediatric patient visits that occurred between March and June 2002. National comparison data were 948 randomly selected pediatric patient visits that occurred between March and June 2000 in the offices of the 33 primary care pediatric practitioners who had participated in the National Ambulatory Medical Care Survey. The groups were compared on patient demographics (age, gender, race, ethnicity, and socioeconomic status, as represented by Medicaid status), visit characteristics (percentages of patients referred, practitioner designation of visit as acute versus nonacute, and continuity of care), the top patient/parent-articulated reasons for visit, and the top practitioner diagnoses. Comparisons revealed substantial similarities between Pediatric Research in Office Settings and national data, including gender, ethnicity, socioeconomic status, and visit characteristics. Differences were noted for age and race, with Pediatric Research in Office Settings children approximately 1 year older and comprising a significantly lower proportion of black patients than their National Ambulatory Medical Care Survey counterparts. Although the top 6 reasons that were articulated by parents for outpatient visits in the 2 groups were remarkably similar in rank order and proportions, there were overall differences, mostly attributable to a larger number of the "other" category in the Pediatric Research in Office Settings cases. There were no significant differences among the top 5 practitioner visit diagnoses between the Pediatric Research in Office Settings and National Ambulatory Medical Care Survey data. The Pediatric Research in Office Settings patient population is reasonably representative of patients who are seen in US ambulatory office-based pediatric primary care practices; therefore, the Pediatric Research in Office Settings is an appropriate laboratory for studies of care in such settings.PEDIATRICS 09/2006; 118(2):e228-34. · 4.47 Impact Factor -
Article: Does clinical presentation explain practice variability in the treatment of febrile infants?
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ABSTRACT: Previous studies documented considerable variability in the treatment of febrile infants, despite the existence of practice guidelines for this condition. None of those studies documented the extent to which this variability is accounted for by differences in clinical severity. To quantify the individual effects of the patient's clinical presentation, demographic, provider, and practice characteristics, and regional variables on practice variability in the evaluation and treatment of febrile infants. With data collected through the Pediatric Research in Office Settings network, we analyzed data on the treatment of 2712 febrile infants examined by 484 pediatricians located in 194 practices. We analyzed hospitalization, lumbar puncture, urinalysis and/or urine culture, blood work, and initial antibiotic administration. We obtained a summary score for evaluation and treatment intensity (ranging from no tests or treatments to comprehensive testing, hospitalization, and antibiotic therapy) by performing principal-components analysis with these 5 variables. This summary score was regressed with respect to patients' clinical presentation, demographic and practice/practitioner features, and geographic region. Provider fixed effects were also included in the model. Although the overall model explained 46.5% of the variance, the clinical characteristics of the patient alone explained 29.7% of the overall variance. Practice site fixed effects explained nearly 15% of the overall variance. Provider and practitioner characteristics and geographic region had minimal explanatory power. Our results show that measures of the patient's clinical presentation account for nearly one third of the variability that our model explains. This suggests that differences in clinical presentation and severity of illness underlie much of the observed practice variability among pediatricians evaluating and treating febrile infants. These findings demonstrate that the management of this common and potentially serious condition depends more on the clinical presentation of the patient than on the characteristics of the provider/practice and the residential region.PEDIATRICS 04/2006; 117(3):787-95. · 4.47 Impact Factor -
Article: Choice of urine collection methods for the diagnosis of urinary tract infection in young, febrile infants.
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ABSTRACT: The optimal method of urine collection in febrile infants is debatable; catheterization, considered more accurate, is technically difficult and invasive. To determine predictors of urethral catheterization in febrile infants and to compare bag and catheterized urine test performance characteristics. Prospective analysis of infants enrolled in the Pediatric Research in Office Settings' Febrile Infant Study. A total of 219 practices from within the Pediatric Research in Office Settings' network, including 44 states, the District of Columbia, and Puerto Rico. A total of 3066 infants aged 0 to 3 months with temperatures of 38 degrees C or higher. We calculated adjusted odds ratios for predictors of catheterization. Diagnostic test characteristics were compared between bag and catheterization. Urinary tract infection was defined as pure growth of 100 000 CFU/mL or more (bag) and 20 000 CFU/mL or more (catheterization). Seventy percent of urine samples were obtained by catheterization. Predictors of catheterization included female sex, practitioner older than 40 years, Medicaid, Hispanic ethnicity, nighttime evaluation, and severe dehydration. For leukocyte esterase levels, bag specimens demonstrated no difference in sensitivity but somewhat lower specificity (84% [bag] vs 94% [catheterization], P<.001) and a lower area under the receiver operating characteristic curve for white blood cells (0.71 [bag] vs 0.86 [catheterization], P = .01). Infection rates were similar in bag and catheterized specimens (8.5% vs 10.8%). Ambiguous cultures were more common in bag specimens (7.4% vs 2.7%, P<.001), but 21 catheterized specimens are needed to avoid each ambiguous bag result. Most practitioners obtain urine from febrile infants via catheterization, but choice of method is not related to the risk of urinary tract infection. Although both urine cultures and urinalyses are more accurate in catheterized specimens, the magnitude of difference is small but should be factored into clinical decision making.Archives of Pediatrics and Adolescent Medicine 11/2005; 159(10):915-22. · 4.14 Impact Factor -
Chapter: Learning from Errors in Ambulatory Pediatrics
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ABSTRACT: Background: Approximately 70 percent of pediatric care occurs in ambulatory settings, yet there has been little research on errors and harm in these settings. Given the importance of understanding harm in ambulatory pediatrics, this study was funded by the Agency for Healthcare Research and Quality (AHRQ) as part of the University of North Carolina (UNC) Center for Education and Research on Therapeutics (CERTs), in partnership with the American Academy of Pediatrics (AAP) Pediatric Research in Office Settings (PROS) Network. Purpose: Learning from Errors in Ambulatory Pediatrics (LEAP) was designed to (1) develop a secure, Web-based tool for reporting errors; (2) identify the types and range of errors; and (3) identify errors that can be generalized across multiple practices. Methods: Data collection was pilot-tested in five pediatric practices in March 2003, using a secure, Web-based tool. After revising the tool, 14 sites collected data from June to September 2003. Three members of the research team (one pediatrician and two patient safety researchers) independently coded the qualitative error reports using the constant comparative method. Reports were coded by medical domain, problem types, and child-specific factors. Coding discrepancies were reconciled by consensus. Results: Study participants reported 136 errors. Data collection via the Web-based tool was very successful; participating practitioners reported a high degree of satisfaction and a minimal number of problems. Errors were reported in several domains: prevention, diagnosis, treatment, patient identification, communication, falls, equipment, and administration. For example, one reported treatment error was “prescription changed from liquid to capsule form of anticonvulsant. Mom misunderstood directions and gave both meds for one week. Child developed blurred vision, stuttering, and ataxia.” Conclusions and implications: Physicians reported errors, yet various members of the care team (parents, nurses, pharmacists) discovered the errors. This suggests that everyone has a role in preventing errors from reaching the child. Information learned from this study will be instrumental in the subsequent design of interventions to reduce errors and improve pediatric patient safety. The success of the Web-based, data collection tool points the way for future online data collection efforts. Further research will clarify the categories of harm observed in ambulatory settings, and explore venues for presenting errors and collaboratively designing and testing solutions.01/2005;
Top co-authors
Top Journals
Institutions
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2008–2011
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American Academy of Pediatrics
Elk Grove Village, IL, USA -
University of Massachusetts Amherst
Amherst Center, MA, USA -
University of Vermont
- Department of Pediatrics
Burlington, VT, USA -
Harvard University
- Department of Pediatrics
Boston, MA, USA -
Vanderbilt University
- Department of Pediatrics
Nashville, MI, USA
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2006
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Stanford University
- Division of General Pediatrics
Stanford, CA, USA -
University of Massachusetts Medical School
- Department of Pediatrics
Worcester, MA, USA
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2004
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University of California, San Francisco
- Division of Hospital Medicine
San Francisco, CA, USA
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2002
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University of Washington Seattle
- Department of Pediatrics
Seattle, WA, USA -
University of Pittsburgh
- Center for Research on Health Care
Pittsburgh, PA, USA
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