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ABSTRACT: To evaluate whether admission day of the week affects the length of stay (LOS) and health care costs for failure to thrive (FTT) admissions.
Administrative data were obtained for all children aged <2 years (N = 23 332) with a primary admission diagnosis of FTT from 2003-2011 from 42 freestanding US hospitals. Demographic characteristics, day of admission, LOS, costs per stay, number of discharge diagnoses, primary discharge diagnoses, primary procedure code, number of radiologic and laboratory units billed during admission were obtained for each admission. Linear regression and zero-truncated Poisson regression were used for analysis.
Weekend admission was significantly correlated with increased LOS and increased average cost (P < .002). This finding was also true for children with both admission and discharge diagnoses of FTT (P < .001). The number of procedures for children admitted on the weekend was not significantly different compared with children admitted on the weekdays (incident rate ratio [IRR]:1.04 [95% confidence interval (CI): 0.99-1.09]). However, weekend admissions did have more radiologic studies (IRR: 1.13 [95% CI: 1.10-1.16]) and laboratory tests (IRR: 1.39 [95% CI: 1.38-1.40]) performed. If one-half of weekend admissions in 2010 with both admission and discharge diagnoses of FTT were converted to Monday admissions, total savings in health care dollars for 2010 would be $534, 145.
Scheduled FTT admissions on weekends increased LOS and health care costs compared with weekday admissions of similar levels of complexity. Reduction in planned weekend admissions for FTT could significantly reduce health care costs.
PEDIATRICS 03/2013; 131(3):e805-10. · 4.47 Impact Factor
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ABSTRACT: OBJECTIVE: To determine if automated screening and just in time delivery of testing and referral materials at the point of care promotes universal screening referral rates for maternal depression. METHODS: The Child Health Improvement through Computer Automation (CHICA) system is a decision support and electronic medical record system used in our pediatric clinics. All families of patients up to 15 months of age seen between October 2007 and July 2009 were randomized to one of three groups: (1) screening questions printed on prescreener forms (PSF) completed by mothers in the waiting room with physician alerts for positive screens, (2) everything in (1) plus 'just in time' (JIT) printed materials to aid physicians, and (3) a control group where physicians were simply reminded to screen on printed physician worksheets. RESULTS: The main outcome of interest was whether physicians suspected a diagnosis of maternal depression and referred a mother for assistance. This occurred significantly more often in both the PSF (2.4%) and JIT groups (2.4%) than in the control group (1.2%) (OR 2.06, 95% CI 1.08 to 3.93). Compared to the control group, more mothers were noted to have depressed mood in the PSF (OR 7.93, 95% CI 4.51 to 13.96) and JIT groups (OR 8.10, 95% CI 4.61 to 14.25). Similarly, compared to the control group, more mothers had signs of anhedonia in the PSF (OR 12.58, 95% CI 5.03 to 31.46) and JIT groups (OR 13.03, 95% CI 5.21 to 32.54). CONCLUSIONS: Clinical decision support systems like CHICA can improve the screening of maternal depression.
Journal of the American Medical Informatics Association 06/2012; · 3.61 Impact Factor
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ABSTRACT: Implementing US Preventive Services Task Force and American Academy of Pediatrics preventive service guidelines within the short duration of a visit is difficult because identifying which of a large number of guidelines apply to a particular patient is impractical. Clinical decision support system integrated with electronic medical records offer a good strategy for implementing screening in waiting rooms. Our objective was to determine rates of positive risk screens during typical well-care visits among children and adolescents in a primary care setting.
Child Health Improvement through Computer Automation (CHICA) is a pediatric clinical decision support system developed by our research group. CHICA encodes clinical guidelines as medical logic modules to generate scanable paper forms: the patient screening form to collect structured data from patient families in the waiting room and the physician worksheet to provide physician assessments at each visit. By using visit as a unit of analysis from CHICA's database, we have determined positive risk screen rates in our population.
From a cohort of 16 963 patients, 408 601 questions were asked in 31 843 visits. Of the questions asked, 362 363 (89%) had a response. Of those, 39 176 (11%) identified positive risk screens in both the younger children and the adolescent age groups.
By automating the process of screening and alerting the physician to those who screened positive, we have significantly decreased the burden of identifying relevant guidelines and screening of patient families in our clinics.
PEDIATRICS 04/2012; 129(5):e1275-81. · 4.47 Impact Factor
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ABSTRACT: The objective of this study was to take a closer look at defense-related expenses for medical malpractice cases over time. We conducted a retrospective review of medical malpractice claims reported to the Physician Insurers Association of America's Data Sharing Project with a closing date between January 1, 1985 and December 31, 2008. On average a medical malpractice claim costs more than $27,000 to defend. Claims that go to trial are much more costly to defend than are those that are dropped, withdrawn, or dismissed. However, since the overwhelming majority of claims are dropped, withdrawn, or dismissed, the total amount spent to defend them surpasses that spent on claims that go to trial. Defense attorney expenses account for the majority of defense-related expenses (74%), while expert witness expenses and other expenses split the remaining 26%. A strong association was also found between the average indemnity payment and the amount it costs to defend individual claims by specialty. Our study found that defense-related expenses for medical malpractice claims are not an insignificant cost. As state and federal governments debate how to repair the malpractice system, addressing the high cost of defending claims should not be ignored.
The Journal of Law Medicine & Ethics 03/2012; 40(1):135-42. · 1.22 Impact Factor
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ABSTRACT: Economic analyses, such as cost-utility analyses (CUAs), are dependent on the quality of the data used. Our objective was to test how health utility values (measurements of patient preference) assessed by recommended methods (classic utilities) would impact the conclusions in published pediatric CUAs.
Classic utilities for pediatric health states were obtained by recommended utility assessment methods, time trade-off, and standard gamble in 4016 parent interviews. To test the impact of these utilities on published studies, we obtained a sample of published pediatric CUAs by searching Medline, EMBASE, EconLit, Health Technology Assessment Database, Cochrane Database on Systematic Reviews, Database of Abstracts of Reviews of Effects, and the Cost Effective Analysis (CEA) Registry at Tufts Medical Center, using search terms for cost-utility analysis. Articles were included when results were presented as cost per quality adjusted life-years (QALYs), the interventions were for children <18 years of age and included at least one of the following health states: attention deficit hyperactivity disorder, asthma, gastroenteritis, hearing loss, mental retardation, otitis media, seizure disorder, or vision loss. Studies that did not include these or equivalent health states were excluded. For each CUA, we determined utilities (values for patient preference), the utility assessment method used, and presence of one-way sensitivity analyses (SAs) on utilities. When one-way SAs were conducted, we determined if using our classic utilities would change the result of the CUA. When an SA was not presented, we determined if using our classic utilities would tend to support or not support the published conclusions.
We evaluated 39 articles. Eighteen articles presented results of one-way SAs on utilities. Seven articles presented SAs over a range that included our classic utilities. In 4 of the 7, using classic utilities would change the conclusion of the study. For the 32 articles where no one-way SA were presented (n = 21), or where the classic utilities fell outside the range tested (n =11), a change to classic utility would tend against the study conclusion in 12 articles (31%).
More than a third of published CUA studies could change if pediatric utilities obtained by recommended, classic methods were used. One-way SAs on utilities are often not presented, making comparison between studies challenging.
Academic pediatrics 11/2011; 12(3):219-28.
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ABSTRACT: The diagnosis and management of urinary tract infections (UTIs) in young children are clinically challenging. This report was developed to inform the revised, evidence-based, clinical guideline regarding the diagnosis and management of initial UTIs in febrile infants and young children, 2 to 24 months of age, from the American Academy of Pediatrics Subcommittee on Urinary Tract Infection.
The conceptual model presented in the 1999 technical report was updated after a comprehensive review of published literature. Studies with potentially new information or with evidence that reinforced the 1999 technical report were retained. Meta-analyses on the effectiveness of antimicrobial prophylaxis to prevent recurrent UTI were performed.
Review of recent literature revealed new evidence in the following areas. Certain clinical findings and new urinalysis methods can help clinicians identify febrile children at very low risk of UTI. Oral antimicrobial therapy is as effective as parenteral therapy in treating UTI. Data from published, randomized controlled trials do not support antimicrobial prophylaxis to prevent febrile UTI when vesicoureteral reflux is found through voiding cystourethrography. Ultrasonography of the urinary tract after the first UTI has poor sensitivity. Early antimicrobial treatment may decrease the risk of renal damage from UTI.
Recent literature agrees with most of the evidence presented in the 1999 technical report, but meta-analyses of data from recent, randomized controlled trials do not support antimicrobial prophylaxis to prevent febrile UTI. This finding argues against voiding cystourethrography after the first UTI.
PEDIATRICS 08/2011; 128(3):e749-70. · 4.47 Impact Factor
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ABSTRACT: The Child Health Improvement through Computer Automation (CHICA) system is a decision-support and electronic-medical-record system for pediatric health maintenance and disease management. The purpose of this study was to explore CHICA's ability to screen patients for disorders that have validated screening criteria--specifically tuberculosis (TB) and iron-deficiency anemia.
Children between 0 and 11 years were randomized by the CHICA system. In the intervention group, parents were asked about TB and iron-deficiency risk, and physicians received a tailored prompt. In the control group, no screens were performed, and the physician received a generic prompt about these disorders.
1123 participants were randomized to the control group and 1116 participants to the intervention group. Significantly more people reported positive risk factors for iron-deficiency anemia in the intervention group (17.5% vs 3.1%, OR 6.6, 95% CI 4.5 to 9.5). In general, far fewer parents reported risk factors for TB than for iron-deficiency anemia. Again, there were significantly higher detection rates of positive risk factors in the intervention group (1.8% vs 0.8%, OR 2.3, 95% CI 1.0 to 5.0).
It is possible that there may be more positive screens without improving outcomes. However, the guidelines are based on studies that have evaluated the questions the authors used as sensitive and specific, and there is no reason to believe that parents misunderstood them.
Many screening tests are risk-based, not universal, leaving physicians to determine who should have a further workup. This can be a time-consuming process. The authors demonstrated that the CHICA system performs well in assessing risk automatically for TB and iron-deficiency anemia.
Journal of the American Medical Informatics Association 07/2011; 18(4):485-90. · 3.61 Impact Factor
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ABSTRACT: Adolescents are developmentally in a period of transition-from children cared for by their parents to young adults capable of self-care, independent judgment, and self-directed problem solving. We wished to develop a behavioral contract for adolescent diabetes management that addresses some negotiable points of conflict within the parent-child relationship regarding self-monitoring and then assess its effectiveness in a pilot study as part of a novel cell phone-based glucose monitoring system.
In the first phase of this study we used semistructured interview techniques to determine the major sources of diabetes-related conflict in the adolescent-parent relationship, to identify factors that could facilitate or inhibit control, and to determine reasonable goals and expectations. These data were then used to inform development of a behavioral contract that addressed the negotiable sources of conflict between parents and their adolescent. The second phase of this research was a 3-month pilot study to measure how a novel cell phone glucose monitoring system would support the contract and have an effect on glucose management, family conflict, and quality of life.
Interviews were conducted with 10 adolescent-caregiver pairs. The major theme of contention was nagging about diabetes management. Two additional themes emerged as points of negotiation for the behavioral contract: glucose testing and contact with the diabetes clinical team. Ten adolescent-parent pairs participated in the pilot test of the system and contract. There was a significant improvement in the Diabetes Self-Management Profile from 55.2 to 61.1 (P < 0.01). A significant reduction in hemoglobin A1c also occurred, from 8.1% at the start of the trial to 7.6% at 3 months (P < 0.04).
This study confirms previous findings that mobile technologies do offer significant potential in improving the care of adolescents with type 1 diabetes. Moreover, behavioral contracts may be an important adjunct to reduce nagging and improve outcomes with behavioral changes.
Diabetes Technology & Therapeutics 03/2011; 13(5):543-9. · 1.93 Impact Factor
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ABSTRACT: The primary purpose of this study was to test whether recombinant human growth hormone (rhGH) supplementation would enhance protein synthesis and accretion of lean body mass. Eight adolescents (six males and two females; 17.2 +/- 2.6 years; age range, 13.7-21.2 years) participated in a randomized double-blind placebo-controlled cross-over trial of rhGH. We employed stable isotopes to measure proteolysis and protein synthesis during fasting and fed conditions during two 6-month treatment conditions. We also measured bone mineral density (BMD), markers of bone turnover, and body composition. Whole-body proteolysis, phenylalanine catabolism, and protein synthesis did not differ during treatment with rhGH vs. placebo. Enteral nutrition suppressed proteolysis and increased protein synthesis similarly during placebo and rhGH treatments. We conclude that rhGH is unlikely to provide sufficient metabolic benefit to warrant its use as an adjunct treatment in clinically stable adolescents with Crohn disease. A high prevalence of vitamin D deficiency and suboptimal BMD existed, which deserves further investigation and clinical attention.
Journal of pediatric endocrinology & metabolism: JPEM 01/2011; 24(9-10):633-40. · 0.88 Impact Factor
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ABSTRACT: Meaningful use of health information technology (HIT) requires the use of clinical decision support systems (CDSS). However, the effectiveness of CDSS depends on physician compliance with clinical reminders which is known to be highly variable. Our objective was to evaluate physician adherence to clinical reminders from a CDSS designed to maximize features known to improve practice.
We evaluated physicians' compliance with clinical reminders generated by the Child Health Improvement through Computer Automation (CHICA) system, a pediatric CDSS that generates scannable paper forms that are completed by patients, staff and physicians during routine care. The forms provide tailored reminders and collect coded clinical data during routine care. We examined CHICA's database to assess the rates of response by patients and physicians to questions and reminders generated by the system. Results showed that while patients answered, on average, 60.6% of 1,351,896 questions generated by the system over 5 years, physicians responded to only 42.9% of 343,949 alerts and reminders over the same period of time. Response rates appeared to be inversely related to both the complexity and sensitivity of the topic.
Poor physician adherence to clinical reminders in this optimized system reduces effectiveness of the system and poses some liability issues. Strategies to alert physicians to the reminders of highest import are needed.
AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium 01/2010; 2010:167-71.
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ABSTRACT: To gather and calculate utilities for a wide range of health states in the pediatric population.
The study subjects, parents or guardians at least 18 years of age with at least 1 child under age 18 years, were recruited through our Pediatric Research Network (PResNet). Recruitment locations included pediatric clinics, the Indiana State Fair, and public and private conventions. Each subject's utilities were assessed on 3 random health states out of 29 chosen for the study. Both the time trade-off and standard gamble methods were used to measure utilities.
Utilities were assessed in a total of 4016 participants (a recruitment rate of 88%). Utility values ranged from a high for acute otitis media (0.96 by standard gamble; 0.97 by time trade-off) to a low for severe mental retardation (0.59 by standard gamble; 0.51 by time trade-off).
Our extensive data set of utility assessments for a wide range of disease states can aid future economic evaluations of pediatric health care.
The Journal of pediatrics 05/2009; 155(1):21-5, 25.e1-5. · 4.02 Impact Factor
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Human Centered Design, First International Conference, HCD 2009, Held as Part of HCI International 2009, San Diego, CA, USA, July 19-24, 2009, Proceedings; 01/2009
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Archives of pediatrics & adolescent medicine 10/2008; 162(9):866-9. · 3.73 Impact Factor
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ABSTRACT: We conducted a pilot study using new technology to track adolescent "place." Using Global Positioning System (GPS)-enabled cell phones, we recruited and tracked 15 female adolescents for a 1-week period. Distance away from home was greatest in the evenings on weekends or holidays. The greatest percentage of time spent more than 1 kilometer away from home was also during these times. Such GPS technology holds promise for future adolescent health research in allowing more specific and dynamic measurement of where adolescents spend time.
Journal of Adolescent Health 05/2008; 42(4):418-20. · 3.33 Impact Factor
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ABSTRACT: Few tools exist to directly measure the microsocial and physical environments of adolescents in circumstances where participatory observation is not practical or ethical. Yet measuring these environments is important as they are significantly associated with adolescent health-risk. For example, health-related behaviors such as cigarette smoking often occur in specific places where smoking may be relatively surreptitious.
We assessed the feasibility of using GPS-enabled cell phones to track adolescent travel patterns and gather daily diary data. We enrolled 15 adolescent women from a clinic-based setting and asked them to carry the phones for 1 week. We found that these phones can accurately and reliably track participant locations, as well as record diary information on adolescent behaviors. Participants had variable paths extending beyond their immediate neighborhoods, and denied that GPS-tracking influenced their activity.
GPS-enabled cell phones offer a feasible and, in many ways, ideal modality of monitoring the location and travel patterns of adolescents. In addition, cell phones allow space- and time-specific interaction, probing, and intervention which significantly extends both research and health promotion beyond a clinical setting. Future studies can employ GPS-enabled cell phones to better understand adolescent environments, how they are associated with health-risk behaviors, and perhaps intervene to change health behavior.
International Journal of Health Geographics 02/2008; 7:22. · 2.62 Impact Factor
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BMJ (Clinical research ed.). 02/2008; 337:a2769.
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BMJ (Clinical research ed.). 01/2008; 335(7633):1288-9.
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ABSTRACT: Recently, academic medical centers have been asked to take the lead in voluntarily instituting more stringent regulations regarding pharmaceutical industry interactions not only with physicians but also with medical trainees.
Our goal was to summarize the recent literature regarding the impact of educational interventions and regulatory policies on trainee perceptions of pharmaceutical industry interactions and/or pharmaceutical industry-related trainee behavior.
We searched Medline and the bibliographies of review articles for relevant studies. Articles published before the Accreditation Council for Continuing Medical Education standards for commercial support of continuing medical education were issued in 1991 were excluded. Two reviewers selected empiric studies that (1) reported empiric data about educational interventions that were meant to shape trainee knowledge, attitudes, or practices concerning the pharmaceutical industry or (2) evaluated the impact of regulatory policies on trainee attitudes or behaviors.
From 247 identified articles, 12 met the inclusion criteria. In 2 of these studies, the impact of regulatory policies on trainee attitudes and/or behaviors was assessed. In the remaining 10 studies, the impact of various educational interventions developed by training programs or schools to shape trainee knowledge, attitudes, or practices concerning the pharmaceutical industry were evaluated.
Although modest in size, a body of empirical research exists that might inform medical educators. Beyond institutional policy that excludes the pharmaceutical industry, the evidence reviewed suggests that well-designed seminars, role playing, and focused curricula can affect trainee attitudes and behavior, although it is not entirely clear whether these changes are sustainable over the long-term.
PEDIATRICS 01/2008; 120(6):e1528-35. · 4.47 Impact Factor
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Diabetes care 12/2007; 30(11):2859-60. · 8.09 Impact Factor
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ABSTRACT: Our goals were to examine malpractice claims data that are specific to the specialty of pediatrics and to provide a better understanding of the effect that malpractice has on this specialty.
The Physician Insurers Association of America is a trade association of medical malpractice insurance companies. The data contained in its data-sharing project represent approximately 25% of the medical malpractice claims in the United States at a given time. Although this database is not universally comprehensive, it does contain information not available in the National Practitioner Data Bank, such as information on claims that are not ultimately paid and specialty of the defendant. We asked the Physician Insurers Association of America to perform a query of its data-sharing project database to find malpractice claims reported between January 1, 1985, and December 31, 2005, in which the defendant's medical specialty was coded as pediatrics. Comparison data were collected for 27 other specialties recorded in the database.
During a 20-year period (1985-2005), there were 214,226 closed claims reported to the Physician Insurers Association of America data-sharing project. Pediatricians account for 2.97% of these claims, making it 10th among the 28 specialties in terms of the number of closed claims. Pediatrics ranks 16th in terms of indemnity payment rate (28.13%), with dentistry ranked highest at 43.35%, followed by obstetrics and gynecology at 35.50%. Indemnity payment refers to settlements or awards made directly to plaintiffs as a result of claim-resolution process. Data are presented on changes over time, claim-adjudication status, expenses on claims, the causes of claims, and injuries sustained.
Malpractice is a serious issue. Some will read the results of this analysis and draw comfort; others will view the same data with alarm and surprise. Regardless of how one interprets these findings, they are important in truly informing the debate with generalizable facts.
PEDIATRICS 08/2007; 120(1):10-7. · 4.47 Impact Factor
