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Importance: Delayed diagnosis of appendicitis is associated with worse outcomes than timely diagnosis, but clinical features associated with diagnostic delay are uncertain, and the extent to which delays are preventable is unclear., Objective: To determine clinical features associated with delayed diagnosis of pediatric appendicitis, assess the frequency of preventable delay, and compare delay outcomes., Design, Setting, and Participants: This case-control study included 748 children treated at 5 pediatric emergency departments in the US between January 1, 2010, and December 31, 2019. Participants were younger than 21 years and had a diagnosis of appendicitis., Exposures: Individual features of appendicitis and pretest likelihood of appendicitis were measured by the Pediatric Appendicitis Risk Calculator (pARC)., Main Outcomes and Measures: Case patients had a delayed diagnosis of appendicitis, defined as 2 emergency department visits leading to diagnosis and a case review showing the patient likely had appendicitis at the first visit. Control patients had a single emergency department visit yielding a diagnosis. Clinical features and pARC scores were compared by case-control status. Preventability of delay was assessed as unlikely, possible, or likely. The proportion of children with indicated imaging based on an evidence-based cost-effectiveness threshold was determined. Outcomes of delayed diagnosis were compared by case-control status, including hospital length of stay, perforation, and multiple surgical procedures., Results: A total of 748 children (mean [SD] age, 10.2 [4.3] years; 392 boys [52.4%]; 427 White children [57.1%]) were included in the study; 471 (63.0%) had a delayed diagnosis of appendicitis, and 277 (37.0%) had no delay in diagnosis. Children with a delayed diagnosis were less likely to have pain with walking (adjusted odds ratio [aOR], 0.16; 95% CI, 0.10-0.25), maximal pain in the right lower quadrant (aOR, 0.12; 95% CI, 0.07-0.19), and abdominal guarding (aOR, 0.33; 95% CI, 0.21-0.51), and were more likely to have a complex chronic condition (aOR, 2.34; 95% CI, 1.05-5.23). The pretest likelihood of appendicitis was 39% to 52% lower in children with a delayed vs timely diagnosis. Among children with a delayed diagnosis, 109 cases (23.1%) were likely to be preventable, and 247 (52.4%) were possibly preventable. Indicated imaging was performed in 104 (22.0%) to 289 (61.3%) children with delayed diagnosis, depending on the imputation method for missing data on white blood cell count. Patients with delayed diagnosis had longer hospital length of stay (mean difference between the groups, 2.8 days; 95% CI, 2.3-3.4 days) and higher perforation rates (OR, 7.8; 95% CI, 5.5-11.3) and were more likely to undergo 2 or more surgical procedures (OR, 8.0; 95% CI, 2.0-70.4)., Conclusions and Relevance: In this case-control study, delayed appendicitis was associated with initially milder symptoms but worse outcomes. These findings suggest that a majority of delayed diagnoses were at least possibly preventable and that many of these patients did not undergo indicated imaging, suggesting an opportunity to prevent delayed diagnosis of appendicitis in some children.

Objective: To create definitions for complications for 16 serious pediatric conditions using the International Classification of Diseases, 10th Revision, Clinical Modification or Procedure Coding System (ICD-10-CM/PCS), and to assess whether complication rates are similar to those measured with ICD-9-CM/PCS., Data Sources: The Healthcare Cost and Utilization Project State Emergency Department and Inpatient Databases from five states between 2014 and 2017 were used to identify cases and assess complication rates. Incidences were calculated using population counts from the 5-year American Community Survey., Data Collection/extraction Methods: Patients were identified by the presence of a diagnosis code for one of the 16 serious conditions. Only the first encounter for a given condition by a patient was included. Encounters resulting in transfer were excluded as the presence of complications was unknown., Study Design: We defined complications using data elements routinely available in administrative databases including ICD-10-CM/PCS codes. The definitions were adapted from ICD-9-CM/PCS using general equivalence mappings and refined using consensus opinion. We included 16 serious conditions: appendicitis, bacterial meningitis, compartment syndrome, new-onset diabetic ketoacidosis (DKA), ectopic pregnancy, empyema, encephalitis, intussusception, mastoiditis, myocarditis, orbital cellulitis, ovarian torsion, sepsis, septic arthritis, stroke, and testicular torsion. Using data from children under 18 years, we compared incidences and complication rates across the ICD-10-CM/PCS transition for each condition using interrupted time series., Principal Findings: There were 61 314 ED visits for a serious condition; the most common was appendicitis (n = 37 493). Incidence rates for each condition were not significantly different across the ICD-10-CM/PCS transition for 13/16 conditions. Three differed: empyema (increased 42%), orbital cellulitis (increased 60%), and sepsis (increased 26%). Complication rates were not significantly different for each condition across the ICD-10-CM/PCS transition, except appendicitis (odds ratio 0.62, 95% CI 0.57-0.68), DKA (OR 3.79, 95% CI 1.92-7.50), and orbital cellulitis (OR 0.53, 95% CI 0.30-0.95)., Conclusions: For most conditions, incidences and complication rates were similar before and after the transition to ICD-10-CM/PCS codes, suggesting our system identifies complications of conditions in administrative data similarly using ICD-9-CM/PCS and ICD-10-CM/PCS codes. This system may be applied to screen for cases with complications and in health services research., (© 2020 Health Research and Educational Trust.)

Objective: The objective of this study was to determine the incidence and recent trends in serious pediatric emergency conditions., Methods: We conducted a cross-sectional study of the Nationwide Emergency Department Sample from 2008 through 2014, and included patients with age below 18 years with a serious condition, defined as each diagnosis group in the diagnosis grouping system with a severity classification system score of 5. We calculated national incidences for each serious condition using annualized weighted condition counts divided by annual United States census child population counts. We determined the highest-incidence serious conditions over the study period and calculated percentage changes between 2008 and 2014 for each serious condition using a Poisson model., Results: The 2008 incidence of serious conditions across the national child population was 1721 visits per million person-years (95% confidence interval, 1485-1957). This incidence increased to 2020 visits per million person-years (95% confidence interval, 1661-2379) in 2014. The most common serious conditions were serious respiratory diseases, septicemia, and serious neurologic diseases. Anaphylaxis was the condition with the largest change, increasing by 147%, from 101 to 249 visits per million person-years., Conclusions: The most common serious condition in children presenting to United States emergency departments is serious respiratory disease. Anaphylaxis is the fastest increasing serious condition. Additional research attention to these diagnoses is warranted.

Background: Provision of high-quality care to acutely ill and injured children is a challenge to US hospitals because many have low pediatric volume. Delineating national trends in definitive pediatric acute care would inform improvements in care., Methods: We analyzed emergency department (ED) visits by children between 2008 and 2016 in the Nationwide Emergency Department Sample, a weighted sample of 20% of EDs nationally. For each hospital annually, we determined the Hospital Capability Index (HCI) to determine the frequency of definitive acute care, defined as hospitalization instead of ED transfer. Hospitals were classified annually according to 2008 HCI quartiles to understand shifts in pediatric capability., Results: The national median HCI was 0.06 (interquartile range: 0.01-0.17) in 2008 and 0.02 (interquartile range: 0.00-0.09) in 2016 ( P < .001). Definitive care became less common regardless of annual pediatric volume, urban or rural designation, or condition frequency. In 2016, 2171 EDs (49.0%) had HCIs <0.013, which represented the lowest 25% of ED HCIs in 2008. Pediatric visits to EDs categorized in the bottom 2008 capability quartile more than doubled from 2.5 million in 2008 to 5.3 million in 2016. Despite decreasing capability, centers with higher annual pediatric volume and urban centers provided more definitive inpatient care and had fewer inter-ED transfers than lower-volume and rural centers., Conclusions: Across the United States from 2008 to 2016, hospital provision of definitive acute pediatric care decreased, and ED visits to the hospitals least likely to provide definitive care increased. Systems improvements are needed to support hospital-based acute care of children., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Objectives: Differences in emergency care for children exist between general and pediatric emergency departments (EDs). Some pediatric quality measures are available but are not routinely employed nationwide. We sought to create a short list of applied measures that would provide a starting point for EDs to measure pediatric emergency care quality and to compare care between general and pediatric EDs for these measures., Methods: Previously reported lists comprising 465 pediatric emergency care quality measures were reconciled. Preset criteria were used to create a diverse list of quality measures measurable using a national database. We used the National Hospital Ambulatory Medical Care Survey from 2010 to 2015 to measure performance. Measures were excluded for total observation counts under a prespecified power threshold, being unmeasurable in the data set, or for missing clear definitions. Using survey-weighted statistics, we reported summary performance (mean, proportion, or count) with 95% confidence intervals for each analyzed quality measure and compared general and pediatric ED performance., Results: Among 465 quality measures, 28 (6%) were included in the analysis, including seven condition-specific measures and 21 general measures. We analyzed a sample of 36,430 visits corresponding to 179.0 million survey-weighted ED visits, of which 150.8 million (84.3%) were in general EDs. Performance was better in pediatric EDs for three of seven condition-specific measures, including antibiotics for viral infections (-6.2%), chest X-rays for asthma (-18.7%), and topical anesthesia for wound closures (+25.7%). Performance was similar for four of seven condition-specific measures: computed tomography for head trauma, steroids for asthma, steroids for croup, and oral rehydration for dehydration. Compared with pediatric EDs, general EDs discharged and transferred higher proportions of children, had shorter lengths of stay, and sent patients home with fewer prescriptions. General EDs obtained fewer pain scores for injured children. Pediatric EDs had a lower proportion of pediatric visits in which patients left against medical advice. General and pediatric EDs had similar rates of mortality, left without being seen, incomplete vital signs, labs in nonacute patients, and similar numbers of medications given per patient., Conclusions: Using a national sample of ED visits, we demonstrated the feasibility of using nationally representative data to assess quality measures for children cared for in the ED. Differences between pediatric and general ED care identify targets for quality improvement., (© 2018 by the Society for Academic Emergency Medicine.)

Objective: To determine the effect of state-level dependent coverage expansion (DCE) with and without other state health reforms on exit from dependent coverage for adolescents and young adults (AYA)., Data Sources: Administrative longitudinal data for 131,542 privately insured AYA in Massachusetts (DCE with other reforms) versus Maine and New Hampshire (DCE without other reforms) across three periods: prereform (1/00-12/06), poststate reform (1/07-9/10), and postfederal reform (10/10-12/12)., Study Design: A difference-in-differences estimator was used to determine the rate of exit from dependent coverage, age at exit from dependent coverage, and re-uptake of dependent coverage among AYA in states with comprehensive reforms versus DCE only., Principal Findings: Implementation of DCE with other reforms was significantly associated with a 23 percent reduction in exit from dependent coverage among AYA compared to the reduction observed for DCE alone. Additionally, comprehensive reforms were associated with over two additional years of dependent coverage for the average AYA and a 33 percent increase in the odds of regaining dependent coverage after a prior loss., Conclusions: Findings suggest that an individual mandate and other reforms may enhance the effect of DCE in preventing loss of coverage among AYA., (© Health Research and Educational Trust.)

Background: Emergency department (ED) revisits are used as a measure of care quality. Many EDs measure only revisits to the same facility, underestimating true rates. We sought to determine the frequency, location, and predictors of ED revisits to the same or a different ED., Methods: We studied ED discharges for children <18 years old in Maryland and New York in the statewide ED and inpatient databases. Revisits were defined as ED visits within 7 days of an index visit. Our primary outcome was the proportion of revisits that were different-hospital revisits (DHRs). We measured the underestimation of total revisits when only same-hospital revisits were measured. We determined the risk of DHR by quartile of annual ED pediatric volume, adjusting for case mix, insurance, state, and urban location., Results: Revisits across 261 EDs occurred after 5.9% of 4.3 million discharges. A per-ED median 21.9% of revisits were DHRs (interquartile range 14.2%-34.6%). Measuring only same-hospital revisits underestimated total revisits by 17.4%. The proportions of revisits that were DHRs by increasing volume quartile were 28.1%, 25.5%, 22.6%, and 14.5%. The adjusted risk of DHR was lower for increasing quartiles of pediatric volume (adjusted odds ratio for highest versus lowest quartile 0.27; 95% confidence interval, 0.19-0.36)., Conclusions: Measuring ED revisits only at the index ED significantly underestimates total revisits. Lower pediatric volume is associated with higher DHRs as a proportion of revisits. When using revisits as a measure of emergency care quality, effort should be made to assess revisits to different EDs., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Background and Objectives: Pediatric out-of-hospital cardiac arrest (OHCA) has a low rate of survival to hospital discharge. Understanding whether pediatric emergency departments (EDs) have higher survival than general EDs may help identify ways to improve care for all patients with OHCA. We sought to determine if OHCA survival differs between pediatric and general EDs., Methods: We used the 2009-2014 Nationwide Emergency Department Sample to study children under 18 with cardiac arrest. We compared pediatric EDs (those with >75% pediatric visits) to general EDs on the outcome of survival to hospital discharge or transfer. We determined unadjusted and adjusted survival, accounting for age, region, and injury severity. Analyses were stratified by nontraumatic versus traumatic cause., Results: The incidences of nontraumatic and traumatic OHCA were 7.91 (95% confidence interval [CI]: 7.52-8.30) and 2.67 (95% CI: 2.49-2.85) per 100 000 person years. In nontraumatic OHCA, unadjusted survival was higher in pediatric EDs than general EDs (33.8% vs 18.9%, P < .001). The adjusted odds ratio of survival in pediatric versus general EDs was 2.2 (95% CI: 1.7-2.8). Children with traumatic OHCA had similar survival in pediatric and general EDs (31.7% vs 26.1%, P = .14; adjusted odds ratio = 1.3 [95% CI: 0.8-2.1])., Conclusions: In a nationally representative sample, survival from nontraumatic OHCA was higher in pediatric EDs than general EDs. Survival did not differ in traumatic OHCA. Identifying the features of pediatric ED OHCA care leading to higher survival could be translated into improved survival for children nationally., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Importance: The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotic use by 50% by 2020, but the extent of inappropriate outpatient antibiotic use is unknown., Objective: To estimate the rates of outpatient oral antibiotic prescribing by age and diagnosis, and the estimated portions of antibiotic use that may be inappropriate in adults and children in the United States., Design, Setting, and Participants: Using the 2010-2011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, annual numbers and population-adjusted rates with 95% confidence intervals of ambulatory visits with oral antibiotic prescriptions by age, region, and diagnosis in the United States were estimated., Exposures: Ambulatory care visits., Main Outcomes and Measures: Based on national guidelines and regional variation in prescribing, diagnosis-specific prevalence and rates of total and appropriate antibiotic prescriptions were determined. These rates were combined to calculate an estimate of the appropriate annual rate of antibiotic prescriptions per 1000 population., Results: Of the 184,032 sampled visits, 12.6% of visits (95% CI, 12.0%-13.3%) resulted in antibiotic prescriptions. Sinusitis was the single diagnosis associated with the most antibiotic prescriptions per 1000 population (56 antibiotic prescriptions [95% CI, 48-64]), followed by suppurative otitis media (47 antibiotic prescriptions [95% CI, 41-54]), and pharyngitis (43 antibiotic prescriptions [95% CI, 38-49]). Collectively, acute respiratory conditions per 1000 population led to 221 antibiotic prescriptions (95% CI, 198-245) annually, but only 111 antibiotic prescriptions were estimated to be appropriate for these conditions. Per 1000 population, among all conditions and ages combined in 2010-2011, an estimated 506 antibiotic prescriptions (95% CI, 458-554) were written annually, and, of these, 353 antibiotic prescriptions were estimated to be appropriate antibiotic prescriptions., Conclusions and Relevance: In the United States in 2010-2011, there was an estimated annual antibiotic prescription rate per 1000 population of 506, but only an estimated 353 antibiotic prescriptions were likely appropriate, supporting the need for establishing a goal for outpatient antibiotic stewardship.

Pragmatic research that compares interventions to improve the organization and delivery of health care may overlap, in both goals and methods, with quality improvement activities. When activities have attributes of both research and quality improvement, confusion often arises about what ethical oversight is, or should be, required. For routine quality improvement, in which the delivery of health care is modified in minor ways that create only minimal risks, oversight by local clinical or administrative leaders utilizing institutional policies may be sufficient. However, additional consideration should be given to activities that go beyond routine, local quality improvement to first determine whether such non-routine activities constitute research or quality improvement and, in either case, to ensure that independent oversight will occur. This should promote rigor, transparency, and protection of patients' and clinicians' rights, well-being, and privacy in all such activities. Specifically, we recommend that (1) health care organizations should have systematic policies and processes for designating activities as routine quality improvement, non-routine quality improvement, or quality improvement research and determining what oversight each will receive. (2) Health care organizations should have formal and explicit oversight processes for non-routine quality improvement activities that may include input from institutional quality improvement experts, health services researchers, administrators, clinicians, patient representatives, and those experienced in the ethics review of health care activities. (3) Quality improvement research requires review by an institutional review board; for such review to be effective, institutional review boards should develop particular expertise in assessing quality improvement research. (4) Stakeholders should be included in the review of non-routine quality improvement and quality improvement-related research proposals. Only by doing so will we optimally leverage both pragmatic research on health care delivery and local implementation through quality improvement as complementary activities for improving health., (© The Author(s) 2015.)

Each year in the United States, approximately two million persons become infected with antibiotic-resistant bacteria, at least 23,000 persons die as a direct result of these infections, and many more die from conditions complicated by a resistant infection. Antibiotic-resistant infections contribute to poor health outcomes, higher health care costs, and use of more toxic treatments. Although emerging resistance mechanisms are being identified and resistant infections are on the rise, new antibiotic development has slowed considerably.

Background: Differences in antibiotic knowledge and attitudes between parents of Medicaid-insured and commercially insured children have been previously reported. It is unknown whether understanding has improved and whether previously identified differences persist., Methods: A total of 1500 Massachusetts parents with a child <6 years old insured by a Medicaid managed care or commercial health plan were surveyed in spring 2013. We examined antibiotic-related knowledge and attitudes by using χ(2) tests. Multivariable modeling was used to assess current sociodemographic predictors of knowledge and evaluate changes in predictors from a similar survey in 2000., Results: Medicaid-insured parents in 2013 (n = 345) were younger, were less likely to be white, and had less education than those commercially insured (n = 353), P < .01. Fewer Medicaid-insured parents answered questions correctly except for one related to bronchitis, for which there was no difference (15% Medicaid vs 16% commercial, P < .66). More parents understood that green nasal discharge did not require antibiotics in 2013 compared with 2000, but this increase was smaller among Medicaid-insured (32% vs 22% P = .02) than commercially insured (49% vs 23%, P < .01) parents. Medicaid-insured parents were more likely to request unnecessary antibiotics in 2013 (P < .01). Multivariable models for predictors of knowledge or attitudes demonstrated complex relationships between insurance status and sociodemographic variables., Conclusions: Misconceptions about antibiotic use persist and continue to be more prevalent among parents of Medicaid-insured children. Improvement in understanding has been more pronounced in more advantaged populations. Tailored efforts for socioeconomically disadvantaged populations remain warranted to decrease parental drivers of unnecessary antibiotic prescribing., (Copyright © 2015 by the American Academy of Pediatrics.)

A learning health system (LHS) integrates research done in routine care settings, structured data capture during every encounter, and quality improvement processes to rapidly implement advances in new knowledge, all with active and meaningful patient participation. While disease-specific pediatric LHSs have shown tremendous impact on improved clinical outcomes, a national digital architecture to rapidly implement LHSs across multiple pediatric conditions does not exist. PEDSnet is a clinical data research network that provides the infrastructure to support a national pediatric LHS. A consortium consisting of PEDSnet, which includes eight academic medical centers, two existing disease-specific pediatric networks, and two national data partners form the initial partners in the National Pediatric Learning Health System (NPLHS). PEDSnet is implementing a flexible dual data architecture that incorporates two widely used data models and national terminology standards to support multi-institutional data integration, cohort discovery, and advanced analytics that enable rapid learning., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Infants have the highest wait-list mortality of all liver transplant candidates. Although previous studies have demonstrated that young children may be at increased risk when they receive partial grafts from adult and adolescent deceased donors (DDs), with few size-matched organs available, these grafts have increasingly been used to expand the pediatric donor pool. We aimed to determine the current adjusted risks of graft failure and mortality in young pediatric recipients of partial DD livers and to determine whether these risks have changed over time. We analyzed 2683 first-time recipients of DD livers alone under the age of 24 months in the United Network for Organ Sharing database (1995-2010), which included 1118 partial DD livers and 1565 whole DD organs. Transplant factors associated with graft loss in bivariate analyses (P < 0.1) were included in multivariate proportional hazards models of graft and patient survival. Interaction analysis was used to examine risks over time (1995-2000, 2001-2005, and 2006-2010). Although there were significant differences in crude graft survival by the graft type in 1995-2000 (P < 0.001), graft survival rates with partial and whole grafts were comparable in 2001-2005 (P = 0.43) and 2006-2010 (P = 0.36). Furthermore, although the adjusted hazards for partial graft failure and mortality were 1.40 [95% confidence interval (CI) = 1.05-1.89] and 1.41 (95% CI = 0.95-2.09), respectively, in 1995-2000, the adjusted risks of graft failure and mortality were comparable for partial and whole organs in 2006-2010 [hazard ratio (HR) for graft failure = 0.81, 95% CI = 0.56-1.18; HR for mortality = 1.02, 95% CI = 0.66-1.71]. In conclusion, partial DD liver transplantation has become less risky over time and now has outcomes comparable to those of whole liver transplantation for infants and young children. This study supports the use of partial DD liver grafts in young children in an attempt to significantly increase the pediatric organ pool., (© 2013 American Association for the Study of Liver Diseases.)

Whole-genome sequencing of 616 asymptomatically carried Streptococcus pneumoniae isolates was used to study the impact of the 7-valent pneumococcal conjugate vaccine. Comparison of closely related isolates showed the role of transformation in facilitating capsule switching to non-vaccine serotypes and the emergence of drug resistance. However, such recombination was found to occur at significantly different rates across the species, and the evolution of the population was primarily driven by changes in the frequency of distinct genotypes extant before the introduction of the vaccine. These alterations resulted in little overall effect on accessory genome composition at the population level, contrasting with the decrease in pneumococcal disease rates after the vaccine's introduction.

In 1910, in his recommendations for reforming medical education, Abraham Flexner responded to what he deemed to be the "public interest." Now, 100 years later, to respond to the current needs of society, the education of physicians must once again change. In addition to understanding the biological basis of health and disease, and mastering technical skills for treating individual patients, physicians will need to learn to navigate in and continually improve complex systems in order to improve the health of the patients and communities they serve. Physicians should not be mere participants in, much less victims of, such systems. Instead, they ought to be prepared to help lead those systems toward ever-higher-quality care for all. A number of innovative programs already exist for students and residents to help integrate improvement skills into professional preparation, and that goal is enjoying increasing support from major professional organizations and accrediting bodies. These experiences have shown that medical schools and residency programs will need to both teach the scientific foundations of system performance and provide opportunities for trainees to participate in team-based improvement of the real-world health systems in which they work. This significant curricular change, to meet the social need of the 21st century, will require educators and learners to embrace new core values, in addition to those held by the profession for generations. These include patient-centeredness, transparency, and stewardship of limited societal resources for health care.

Abraham Flexner's 1910 report is credited with promoting critical reforms in medical education. Because Flexner advocated scientific rigor and standardization in medical education, his report has been perceived to place little emphasis on the importance of public health in clinical education and training. However, a review of the report reveals that Flexner presciently identified at least three public-health-oriented principles that contributed to his arguments for medical education reform: (1) The training, quality, and quantity of physicians should meet the health needs of the public, (2) physicians have societal obligations to prevent disease and promote health, and medical training should include the breadth of knowledge necessary to meet these obligations, and (3) collaborations between the academic medicine and public health communities result in benefits to both parties. In this article, commemorating the Flexner Centenary, the authors review the progress of U.S. and Canadian medical schools in addressing these principles in the context of contemporary societal health needs, provide an update on recent efforts to address what has long been perceived as a deficit in medical education (inadequate grounding of medical students in public health), and provide new recommendations on how to create important linkages between medical education and public health. Contemporary health challenges that require a public health approach in addition to one-on-one clinical skills include containing epidemics of preventable chronic diseases, reforming the health care system to provide equitable high-quality care to populations, and responding to potential disasters in an increasingly interconnected world. The quantitative skills and contextual knowledge that will prepare physicians to address these and other population health problems constitute the basics of public health and should be included throughout the continuum of medical education.

Background & Aims: Data regarding the health care costs of inflammatory bowel disease (IBD) in the United States are limited. The objectives of this study were to estimate the direct costs of Crohn's disease (CD) and ulcerative colitis (UC) in the United States, describe the distribution of costs among inpatient, outpatient, and pharmaceutical services, and identify sociodemographic factors influencing these costs., Methods: We extracted medical and pharmacy claims from an administrative database containing insurance claims from 87 health plans in 33 states, occurring between 2003 and 2004. We identified cases of CD and UC using an administrative definition. For each case, we selected up to 3 non-IBD controls. Claims were classified as inpatient, outpatient, or pharmaceutical according to Current Procedural Terminology codes or National Drug Codes. Costs were based on the paid amount of each claim. IBD-attributable costs were estimated by subtracting costs for non-IBD patients from those for patients with IBD. Logistic regression was used to identify the sociodemographic factors affecting these costs., Results: We identified 9056 patients with CD and 10,364 patients with UC. Mean annual costs for CD and UC were $8265 and $5066, respectively. For CD, 31% of costs were attributable to hospitalization, 33% to outpatient care, and 35% to pharmaceutical claims. The corresponding distribution for UC was 38%, 35%, and 27%, respectively. Costs were significantly higher for children younger than 20 years compared with adults, but this did not vary substantially by sex or region., Conclusions: This study demonstrates a substantial economic burden of IBD and can be used to inform health policy.

Background: The use of physician profiles in "pay for performance" initiatives depend on their reliability and accuracy., Objectives: To evaluate whether health care delivery units (practices) can be reliably differentiated using the Health Employers Data Information System (HEDIS) performance measure., Research Design: Simulation was used to describe the relationship between practice size (number of children with persistent asthma) and precision of practice measures to estimate performance., Subjects: Children enrolled in 1 of the 39 practice groups from 1 of 3 managed care organizations participating in the Pediatric Asthma Care Patient Outcomes Research Team (PAC PORT)., Measures: The main outcome was reproducibility of 4 performance measures, the HEDIS measure and 3 additional measures available from automated claims data: the proportion of children with asthma related-hospitalization, emergency department visits and oral steroid dispensings for asthma., Results: The ability to reproducibly rank a practice is dependent on the performance measure, practice size, and the reproducibility threshold chosen. Of measures evaluated, none achieved a reproducibility >85% for practice size of 50 or less. At a practice size of 100 subjects, the HEDIS measure reproducibly ranked practices 89% of the time, compared with 85% for emergency department visits and 83% for hospitalizations. Only at a practice size of 100 children with persistent asthma, was reproducibility of ranking greater than 85% with all performance measures evaluated., Conclusions: The reliability of ranking medical practices depends on practice size. Only at the level of the health care organization can asthma measures, available within claims data, be used to rank performance reliably.

Purpose: In an environment of multiple campaigns promoting judicious antibiotic use in children, identification of effective strategies is important. We assessed physician responses to a community-level intervention with respect to antibiotic prescribing, related practices, and perceived effectiveness., Methods: This study was a mixed qualitative and quantitative evaluation of a randomized controlled community-wide educational intervention in 16 Massachusetts communities. Physicians in intervention communities received locally endorsed guidelines, group educational sessions, and biweekly newsletters. Parents simultaneously received materials in physicians' offices and by mail. After the intervention, we conducted a mailed physician survey and individual interviews to assess the impact of the intervention. We compared survey responses for intervention and control physicians, and we analyzed interview transcripts to provide in-depth information about selected topics., Results: Among survey respondents (n = 168), 91% of intervention and 4% of control physicians reported receiving intervention materials. Physicians received information from multiple other sources. More intervention than control physicians reported decreased antibiotic prescribing from 2000-2003 (75% vs 58%, P = .03), but there were no differences between groups in knowledge, attitudes, or behaviors favoring judicious antibiotic use. Both groups were concerned about antibiotic resistance and reported room to reduce their own prescribing. Interviewed physicians suggested frequent repetition of messages, brief written materials on specific topics for themselves and patients, and promotion in the mass media as the most effective strategies to reduce prescribing., Conclusions: In multiple communities an intervention in physician offices to promote judicious antibiotic prescribing reached its intended audience, but physicians' self-reported attitudes and practices were similar in intervention and control communities. Campaigns that repeat brief, consistent reminders to multiple stakeholder groups may be most effective at assuring judicious antibiotic use.

Background & Aims: Previous US studies of inflammatory bowel disease (IBD) prevalence have sampled small, geographically restricted populations and may not be generalizable to the entire nation. This study sought to determine the prevalence of Crohn's disease (CD) and ulcerative colitis (UC) in a large national sample and to compare the prevalence across geographic regions and other sociodemographic characteristics., Methods: We analyzed the health insurance claims for 9 million Americans, pooled from 87 health plans in 33 states, and identified cases of CD and UC using diagnosis codes. Prevalence was determined by dividing the number of cases by the number of persons enrolled for 2 years. Logistic regression was used to compare prevalence estimates by geographic region, age, sex, and insurance type (Medicaid vs commercial)., Results: The prevalence of CD and UC in children younger than 20 years was 43 (95% confidence interval [CI], 40-45) and 28 (95% CI, 26-30) per 100,000, respectively. In adults, the prevalence of CD and UC was 201 (95% CI, 197-204) and 238 (95% CI, 234-241), respectively. The prevalence of both conditions was lower in the South, compared with the Northeast, Midwest, and West. IBD appears to be more common in commercially insured individuals, compared with those insured by Medicaid., Conclusions: This estimation of the prevalence of IBD in the US should help quantify the overall burden of disease and inform the planning of appropriate clinical services.

Background: Variation in care is a ubiquitous feature of medical practice and may lead to significant differences in health care costs, quality, and outcomes. We undertook this study to determine the extent of intercenter variation in the initial management of children newly diagnosed with Crohn's disease., Methods: We analyzed the utilization of 5 classes of medication (immunomodulators, prednisone, antibiotics, 5-aminosalicylates, and infliximab) among 311 children with newly diagnosed Crohn's disease followed at 10 North American pediatric gastroenterology centers. Multivariate logistic regression was used to compare the utilization rate of each class of medication at each of the 10 centers, adjusting for potential confounders including patient age, sex, race, disease severity, and anatomic location of disease., Results: Median utilization of each class of medication was: immunomodulators, 56% (range 29%-97%); prednisone, 78% (range 32%-88%); antibiotics, 29% (range 11%-68%); 5-aminosalicylates, 63.5% (range 18%-92%); and infliximab, 7.5% (range 3%-21%). Each of these treatments showed statistically significant intercenter variation in utilization (P < 0.001 for immunomodulators, prednisone, antibiotics, and 5-ASA; P = 0.02 for infliximab). After adjusting for the demographic and clinical factors listed above, intercenter variation remained significant; however, the low utilization of infliximab precluded multivariate analysis., Conclusions: Widespread intercenter variation in the medical management of newly diagnosed children with Crohn's disease was observed, even after adjusting for possible differences in case mix between institutions. This variation may lead to unintended differences in health care costs and outcomes.

Purpose: To estimate the prevalence of use of prescription drugs with a potential for fetal harm among pregnant women in the United States., Methods: A retrospective study was conducted using the automated databases of eight health maintenance organizations involved in the HMO Research Network Center for Education and Research on Therapeutics (CERT). Women who delivered an infant from January 1996 to December 2000 were identified. The frequency of use of prescription drugs with a potential for fetal harm was based upon the expert review of a clinical teratologist and the U.S. Food and Drug Administration (FDA) risk classification system, assuming a gestational duration of 270 days., Results: Among the 114 165 women with no documentation of a diagnosis suggesting potential pre-term birth or dispensing of ovulation stimulants in the 270 days before delivery, 1305 (1.1%) received a teratogenic drug during the 270 days before delivery, based upon the expert review of a clinical teratologist. A larger proportion of women received U.S. FDA category D or X drugs (5.8%; N = 6600). However, the general patterns of use were similar, with higher use in early pregnancy compared to later trimesters. The proportion of women dispensed a teratogen during pregnancy was substantially higher among women who received a teratogen in the 90 days before pregnancy compared to women who did not (adjusted RR = 38.9, 95%CI, 33.5, 45.3)., Conclusions: Our results suggest that further efforts directed at physicians to counsel women or at the women themselves about the potential risks of particular medications appear warranted., (Copyright 2006 John Wiley & Sons, Ltd.)

Context: Of children with sore throat, 15% to 36% have pharyngitis caused by group A beta-hemolytic streptococci (GABHS). Performance of a GABHS test prior to antibiotic prescribing is recommended for children with sore throat. Penicillin, amoxicillin, erythromycin, and first-generation cephalosporins are the recommended antibiotics for treatment of sore throat due to GABHS., Objectives: To measure rates of antibiotic prescribing and GABHS testing and to evaluate the association between testing and antibiotic treatment for children with sore throat., Design, Setting, and Participants: Analysis of visits by children aged 3 to 17 years with sore throat to office-based physicians, hospital outpatient departments, and emergency departments in the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 1995 to 2003 (N = 4158) and of a subset of visits with GABHS testing data (n = 2797)., Main Outcome Measures: National rates of antibiotic prescribing, prescribing of antibiotics recommended and not recommended for GABHS, and GABHS testing., Results: Physicians prescribed antibiotics in 53% (95% confidence interval [CI], 49%-56%) of an estimated 7.3 million annual visits for sore throat and nonrecommended antibiotics to 27% (95% CI, 24%-31%) of children who received an antibiotic. Antibiotic prescribing decreased from 66% of visits in 1995 to 54% of visits in 2003 (P = .01 for trend). This decrease was attributable to a decrease in the prescribing of recommended antibiotics (49% to 38%; P = .002). Physicians performed a GABHS test in 53% (95% CI, 48%-57%) of visits and in 51% (95% CI, 45%-57%) of visits at which an antibiotic was prescribed. GABHS testing was not associated with a lower antibiotic prescribing rate overall (48% tested vs 51% not tested; P = .40), but testing was associated with a lower antibiotic prescribing rate for children with diagnosis codes for pharyngitis, tonsillitis, and streptococcal sore throat (57% tested vs 73% not tested; P<.001)., Conclusions: Physicians prescribed antibiotics to 53% of children with sore throat, in excess of the maximum expected prevalence of GABHS. Although there was a decrease in the proportion of children receiving antibiotics between 1995 and 2003, this was due to decreased prescribing of agents recommended for GABHS. Although GABHS testing was associated with a lower rate of antibiotic prescribing for children with diagnosis codes of pharyngitis, tonsillitis, and streptococcal sore throat, GABHS testing was underused.

Background: A decision to implement innovative disease management interventions in health plans often requires evidence of clinical benefit and financial impact. The Pediatric Asthma Care Patient Outcomes Research Team II trial evaluated 2 asthma care strategies: a peer leader-based physician behavior change intervention (PLE) and a practice-based redesign called the planned asthma care intervention (PACI)., Objective: To estimate the cost-effectiveness of the interventions., Methods: This was a 3-arm, cluster randomized trial conducted in 42 primary care practices. A total of 638 children (age range, 3-17 years) with mild to moderate persistent asthma were followed up for 2 years. Practices were randomized to PLE (n = 226), PACI (n = 213), or usual care (n = 199). The primary outcome was symptom-free days (SFDs). Costs included asthma-related health care utilization and intervention costs., Results: Annual costs per patient were as follows: PACI, USD 1292; PLE, USD 504; and usual care, USD 385. The difference in annual SFDs was 6.5 days (95% confidence interval [CI], -3.6 to 16.9 days) for PLE vs usual care and 13.3 days (95% CI, 2.1-24.7 days) for PACI vs usual care. Compared with usual care, the incremental cost-effectiveness ratio was USD 18 per SFD gained for PLE (95% CI, USD 5.21-dominated) and USD 68 per SFD gained for PACI (95% CI, USD 37.36-361.16)., Conclusions: Results of this study show that it is possible to increase SFDs in children and move organizations toward guideline recommendations on asthma control in settings where most children are receiving controller medications at baseline. However, the improvements were realized with an increase in the costs associated with asthma care.

Background: Widespread use of broad-spectrum antibiotics contributes to increasing rates of bacterial resistance to antibiotics. Second-generation macrolides have become popular for use among children because of their broad spectrum and favorable dosing and side-effect profiles, although experts do not generally recommend them for use as initial treatment of infections among younger children., Objective: To assess trends in second-generation macrolide use from 1996 to 2000 among children treated as outpatients in 9 US health plans, including associated diagnoses and use as initial treatment., Methods: We sampled claims data for 25000 children, 3 months to <18 years of age, who were enrolled between September 1, 1995, and August 31, 2000, in each of 9 US health plans. Medications dispensed were linked with ambulatory visit claims to assign diagnoses. Dispensings without another antibiotic dispensing recorded in the previous 42 days were analyzed as initial treatment of a new illness episode. We analyzed trends in prescribing overall, for initial therapy, and, within specific diagnoses, for differences among health plans., Results: From 1995-1996 to 1999-2000, although overall antibiotic use decreased from 1.15 to 0.91 dispensings per person-year, second-generation macrolide use increased from 0.022 to 0.063 dispensings per person-year. Use as a proportion of all antibiotic dispensings increased from 1.9% to 6.9%, and use as initial therapy increased from 1.4% to 6%. For children <6 years of age, second-generation macrolide use as initial therapy increased from 0.9% to 5.0% for otitis media and from 5.2% to 24.0% for pneumonia. There was a wide range of prescribing rates among health plans during the last year of the study, from 0.006 to 0.135 dispensings per person-year., Conclusions: Despite recent trends toward decreased antibiotic use among children, the use of second-generation macrolides among children has increased dramatically, even among younger children, for whom use for initial treatment of illness is not recommended. Large differences in prescribing rates exist among health plans. Continued efforts to promote the use of narrower-spectrum agents when appropriate are needed.

Background: Traditional primary care practice change approaches have not led to full implementation of national asthma guidelines., Objective: To evaluate the effectiveness of 2 asthma care improvement strategies in primary care., Design: Two-year randomized controlled clinical trial., Setting: Forty-two primary care pediatric practices affiliated with 4 managed care organizations., Participants: Children aged 3 to 17 years with mild to moderate persistent asthma enrolled in primary care practices affiliated with managed care organizations., Interventions: Peer leader education consisted of training 1 physician per practice in asthma guidelines and peer teaching methods. Planned care combined the peer leader program with nurse-mediated organizational change through planned visits with assessments, care planning, and self-management support, in collaboration with physicians. Analyses compared each intervention with usual care., Main Outcome Measures: Annualized asthma symptom days, asthma-specific functional health status (Children's Health Survey for Asthma), and frequency of brief oral steroid courses (bursts)., Results: Six hundred thirty-eight children completed baseline evaluations, representing 64% of those screened and eligible. Mean +/- SD age was 9.4 +/- 3.5 years; 60% were boys. Three hundred fifty (55%) were taking controller medication. Mean +/- SD annualized asthma symptom days was 107.4 +/- 122 days. Children in the peer leader arm had 6.5 fewer symptom days per year (95% confidence interval [CI], - 16.9 to 3.6), a nonsignificant difference, but had a 36% (95% CI, 11% to 54%) lower oral steroid burst rate per year compared with children receiving usual care. Children in the planned care arm had 13.3 (95% CI, - 24.7 to -2.1) fewer symptom days annually (-12% from baseline; P =.02) and a 39% (95% CI, 11% to 58%) lower oral steroid burst rate per year relative to usual care. Both interventions showed small, statistically significant effects for 2 of 5 Children's Health Survey for Asthma scales. Planned care subjects had greater controller adherence (parent report) compared with usual care subjects (rate ratio, 1.05 [95% CI, 1.00 to 1.09])., Conclusions: Planned care (nurse-mediated organizational change plus peer leader education) is an effective model for improving asthma care in the primary care setting. Peer leader education on its own may also serve as a useful model for improving asthma care, although it is less comprehensive and the treatment effect less pronounced.

Objective: The purpose of this study was to provide information on the prevalence of the use of prescription drugs among pregnant women in the United States., Study Design: A retrospective study was conducted with the use of the automated databases of 8 health maintenance organizations that are involved in the Health Maintenance Research Network Center for Education and Research on Therapeutics. Women who delivered of an infant in a hospital from January 1, 1996, through December 31, 2000, were identified. Prescription drug use according to therapeutic class and the United States Food and Drug Administration risk classification system was evaluated, with the assumption of a gestational duration of 270 days, with three 90-day trimesters of pregnancy, and with a 90-day period before pregnancy. Nonprescription drug use was not assessed., Results: During the period 1996 through 2000, 152,531 deliveries were identified that met the criteria for study. For 98,182 deliveries (64%), a drug other than a vitamin or mineral supplement was prescribed in the 270 days before delivery: 3595 women (2.4%) received a drug from category A; 76,292 women (50.0%) received a drug from category B; 57,604 women (37.8%) received a drug from category C; 7333 women (4.8%) received a drug from category D, and 6976 women (4.6%) received a drug from category X of the United States Food and Drug Administration risk classification system. Overall, 5157 women (3.4%) received a category D drug, and 1653 women (1.1%) received a category X drug after the initial prenatal care visit., Conclusion: Our finding that almost one half of all pregnant women received prescription drugs from categories C, D, or X of the United States Food and Drug Administration risk classification system highlights the importance of the need to understand the effects of these medications on the developing fetus and on the pregnant woman.

Background: Little is known about whether pneumococcal conjugate vaccine (PCV) has altered pediatricians' practices regarding well-child and acute care., Objectives: To (1) describe whether PCV caused pediatricians to move other routine infant vaccines and/or add routine visits; (2) characterize adherence to national immunization recommendations; and (3) determine whether PCV altered pediatricians' planned clinical approach to well-appearing febrile infants., Design and Methods: One year after PCV was added to the pediatric immunization schedule, we mailed a 23-item survey to 691 randomly selected pediatricians in Massachusetts. The adjusted response rate was 77%., Results: After PCV introduction, 39% of pediatricians moved other routine infant vaccines to different visits and 15% added routine visits to the infant schedule. The self-reported immunization schedules of 36% were nonadherent to national immunization guidelines for at least 1 vaccine. Nonadherence rates were significantly higher among pediatricians who had been in practice longer, moved another vaccine because of PCV introduction, and/or offered to give shots later when multiple injections were due. For a hypothetical febrile 8-month-old girl who had received 3 doses of PCV, pediatricians reported they were significantly less likely to (1) perform both blood and urine testing and (2) prescribe antibiotics than in the pre-PCV era., Conclusions: The introduction of PCV may have had unintended effects on pediatric primary care, including decreased adherence to national recommendations for the timing of immunizations and decreased urine testing for well-appearing febrile infants. Special efforts may be warranted to ensure that pediatricians remain current with changing recommendations.

Objective: More than half of Medicaid enrollees are now in managed care. Scant information exists about which policies of practice sites improve quality of care in managed Medicaid. Children with asthma are a sentinel group for Medicaid quality monitoring because they are at elevated risk for adverse outcomes. The objective of this study was to identify practice-site policies and features associated with quality of care for Medicaid-insured children with asthma., Methods: A prospective cohort study with 1-year follow-up was conducted in 5 health plans in California, Washington, and Massachusetts. Data were collected via telephone interviews with parents at baseline and 1 year, surveys of practice sites and clinicians, and computerized databases. The practice site survey asked about policies to promote cultural competence, the use of several types of reports to clinicians, support for self-management of asthma, case management and care coordination, and access to and continuity of care. Quality of care was evaluated on the basis of 5 measures: 1) preventive medication underuse based on parent report; 2) the parent's rating of asthma care; 3) the 1-year change in the child's asthma physical status based on a standardized measure; 4) preventive medication underprescribing based on computerized data; and 5) the occurrence of a hospital-based episode., Results: Of the 1663 children in the study population, 67% had persistent asthma at baseline based on parent report of symptoms and medications. At 1-year follow-up, 65% of the children with persistent asthma were underusing preventive medication based on parent report. In multivariate analyses, patients of practice sites with the highest cultural competence scores were less likely to be underusing preventive asthma medications based on parent report at follow-up (odds ratio [OR]: 0.15; 95% confidence interval [CI]: 0.06-0.41 for the highest vs lowest categories) and had better parent ratings of care. The use of asthma reports to clinicians was predictive of less preventive medication underprescribing based on computerized data (OR: 0.33; 95% CI: 0.16-0.69), better parent ratings of care, and better asthma physical status at follow-up. Patients of practice sites with policies to promote access and continuity had less underuse of preventive medications (OR: 0.56; 95% CI: 0.34-0.93). Among the 83 practice sites, the practice site's size, organizational type, percentage of patients insured by Medicaid, mechanism of payment for specialty care, and other primary care features were not consistently associated with quality measures., Conclusions: Practice-site policies to promote cultural competence, the use of reports to clinicians, and access and continuity predicted higher quality of care for children with asthma in managed Medicaid.

Background: Regular use of inhaled anti-inflammatory (AI) medication improves outcomes for children with persistent asthma., Objective: To relate 3 measures of asthma medication dispensing to physical health and hospital-based events among children with asthma who were enrolled in 1 of 5 managed care health plans., Methods: Parents of Medicaid-insured children with asthma were interviewed at baseline and 1-year follow-up. Utilization data were collected from the health plans in which the children were enrolled. Subjects were stratified into 3 subgroups according to asthma severity: intermittent asthma; persistent asthma for which beta-agonist (BA) medication was dispensed infrequently (< or = 3 times per year); and persistent asthma for which BA medication was dispensed frequently (> or = 4 times per year)., Results: Baseline interviews were completed by 1,663 parents (63% response rate), 1,504 of whom were enrolled in their health plan for at least 11 months during the baseline year. Follow-up interviews were completed by 1,287 (86%) of the 1,504 parents. Among the subgroup of children with persistent asthma for whom BA was dispensed frequently, those who had 1 to 3 AI dispensings had a greater risk for hospital-based events than those with 6 or more AI dispensings. Baseline-year AI medication utilization patterns were not associated with follow-up-year outcomes. No clinically meaningful association was found in subgroups with less severe asthma; however, few AI medications were dispensed to these children., Conclusions: Policymakers and clinicians who wish to use medication-based measures to evaluate quality of asthma care should consider counting the number of times AI medication is dispensed among children with more severe asthma.

Background: Although appendicitis is a common pediatric surgical condition, it is often misdiagnosed. Because higher hospital volume has been associated with improved outcome for many surgical procedures, the current study investigates whether hospital volume of pediatric appendectomies is associated with misdiagnosis of appendicitis in children., Methods: The Kids' Inpatient Database is a national sample of pediatric discharges from 2521 hospitals in 22 states in 1997. In this study, misdiagnosis was defined as a patient with a principal International Classification of Diseases, Ninth Revision procedure code for nonincidental appendectomy without a corresponding diagnosis code for appendicitis. Hospitals were stratified into 5 groups based on the number of nonincidental appendectomies performed on children in 1997: lowest (<1 per month), low (>or=1 per month but <1 per week), medium (1-2 per week), high (2-3 per week), and highest (>or=3 per week). Using generalized estimating equations to control for clustering within hospitals, we developed a logistic regression model of the effect of hospital volume on misdiagnosis while adjusting for patient age, gender, race, and insurance status., Results: In the database, 37,109 nonincidental appendectomies were performed on children 1 to 18 years old in 1997. Of those, 3103 (8.4%) were misdiagnosed. Of all appendectomies, 24,655 (66.4%) were performed at lowest- or low-volume hospitals. After adjusting for patient characteristics, lowest- (odds ratio [OR]: 1.5; 95% confidence interval [CI]: 1.0-2.2) and low- (OR: 1.6; 95% CI: 1.1-2.3) volume hospitals had a significantly increased likelihood of misdiagnosis compared with highest-volume hospitals. Misdiagnosis at medium- (OR: 1.5; 95% CI: 1.0-2.2) and high- (OR: 1.4; 95% CI: 0.9-2.2) volume hospitals was similar to misdiagnosis at lower-volume hospitals, although not statistically different from highest-volume hospitals., Conclusions: Almost two thirds of pediatric appendectomies are performed at hospitals performing <1 pediatric appendectomy per week. Lower hospital volume of pediatric appendectomies is associated with a significantly increased likelihood of misdiagnosis of appendicitis in children.

Objective: To characterize and describe variability in processes of asthma care and services tailored for low-income populations in practice sites participating in Medicaid managed care (MMC)., Study Setting: Eighty-five practice sites affiliated with five not-for-profit organizations participating in managed Medicaid (three group-model health maintenance organizations [HMOs] and two Medicaid managed care organizations [MCOs])., Study Design/data Collection: We conducted a mail survey of managed care practice site informants using a conceptual model that included chronic illness care and services targeting low-income populations. The survey asked how frequently a number of processes related to asthma care occurred at the practice sites (on a scale from "never" to "always"). We report mean and standard deviations of item scores and rankings relative to other items. We used within-MCO intraclass correlations to assess how consistent responses were among practice sites in the same MCO., Principal Findings: Processes of care related to asthma varied gready in how often practice sites reported doing them, with information systems and self-management support services ranking lowest. There was also significant variation in the availability of services targeting low-income populations, specifically relating to cultural diversity, communication, and enrollee empowerment. Very little of the site-to-site variation was attributable to the MCO., Conclusions: Our conceptual framework provides a means of assessing the provision of chronic illness care for vulnerable populations. There is room for improvement in provision of chronic asthma care for children in managed Medicaid, particularly in the areas of self-management support and information systems. The lack of consistency within MCOs on many processes of care suggests that care may be driven more at the practice site level than the MCO level, which has implications for quality improvement efforts.

Background: High rates of antibiotic prescribing to children contribute to antibiotic resistance in the community. The Centers for Disease Control and Prevention, in collaboration with other national and state level organizations, have actively promoted more judicious prescribing for children., Objective: We sought to assess changes in the rate of antibiotic prescribing from 1996-2000 in 9 US health plans, patterns of diagnosis and treatment responsible for these trends, and changes in the use of first-line antimicrobial agents., Design/methods: We analyzed claims data for dispensed medications and physician visits from 9 health plans. Each provided data on 25,000 children aged 3 months to <18 years enrolled between September 1, 1995, and August 31, 2000. Antibiotic dispensings were linked with an ambulatory visit claim to assign diagnosis. Antibiotic dispensings per person-year (antibiotics/p-y) were calculated for the age groups 3 months to <3 years, 3 years to <6 years, and 6 years to <18 years. The contribution of each diagnosis to changes in the overall rate of antibiotic use was determined. Generalized linear mixed models were used to test for trend and assess differences in rates by site., Results: From 1996-2000, antibiotic rates for children 3 months to <3 years decreased from 2.46 to 1.89 antibiotics/p-y (24%); for children 3 years to <6 years from 1.47 to 1.09 antibiotics/p-y (25%); and for children 6 to <18 years from 0.85 to 0.69 antibiotics/p-y (16%). The reduction varied among health plans from 6% to 39% for children 3 months to <3 years. A decrease in prescriptions for otitis media accounted for 59% of the total decrease, and was primarily accounted for by a decrease in the rate of diagnosis of this condition. The proportion of first-line penicillins increased from 49% to 53%, with health plans with the lowest initial rates increasing most., Conclusions: Antibiotic prescribing decreased significantly between 1996 and 2000, concurrent with decreased frequency of diagnosis of potential bacterial infections, especially otitis media. Attention by public health and professional organizations and the news media to antibiotic resistance may have contributed to changes in diagnostic thresholds, resulting in more judicious prescribing.

Background: In 1998, the economic burden of asthma in the United States was estimated to be 12.7 billion dollars. Yet few studies have examined the relationship between the total costs of asthma-related care and measures of asthma morbidity. Understanding the relationship between total costs of asthma-related care and morbidity can assist in designing the most cost-effective asthma care strategies to improve patient outcomes and minimize total costs., Objective: To investigate correlates of asthma costs for children with mild-to-moderate persistent asthma and, specifically, to characterize how closely the percentage of predicted forced expiratory volume in 1 second (FEV1) and symptom days were correlated with costs of illness., Methods: A total of 638 parents and children with mild-to-moderate persistent asthma in 4 managed care delivery systems in 3 different US geographic regions were enrolled. Symptom burden and annual resource utilization were determined from reports of physician visits, hospitalizations, emergency department visits, medication use, and parental missed workdays. Spirometry was conducted on children who were 5 years and older. To characterize the relationship between symptom days and the percentage of predicted FEV1 with costs, we specified a multivariate regression model., Results: The median total annual asthma-related cost for the group was 564 dollars (interquartile range [IQR], 131 dollars-1602 dollars). Indirect costs represented 54.6% of total costs. Medicines accounted for 52.6% of direct costs. The mean percentage of predicted FEV1 was 101.6% (range, 39.3%-183.5%; IQR, 91.6%-111.3%), with 91.4% of patients with a percentage of predicted FEV1 of more than 80%. Based on multivariate modeling, increasing asthma severity, use of peak expiratory flow rate meters, younger age, low-income status and nonwhite race, and longer duration of asthma were significantly associated with increasing cost. Symptom days (P < 0.001) predicted annual costs better than percentage of predicted FEV1 (P < 0.16) in this group of children., Conclusions: For the large number of children with mild-to-moderate persistent asthma and normal or near-normal lung function, symptom days are predictive of health care costs. For these insured children receiving care from 3 large managed care providers, low-income status and nonwhite race were the strongest correlates for increased asthma-related costs.

A liberation psychology is needed to bridge the gap between psychology's focus on individual distress and broad social forces that foster such distress. We offer a model for bridging this gap by focusing on a specific area of psychology (psychological research on girls) and a specific social movement (feminist activism). Psychological research on girls and feminist activism share the common goal of improving the lives of girls and women. However, both have fallen short of this goal. This is due, in part, to the weaknesses associated with each endeavor and to the fact that the complementary strengths of each have remained isolated from the other. In this paper, we propose a common language and shared framework to integrate psychological research with feminist activism. First, we review the basic strengths and weaknesses associated with psychological research and feminist activism, with a particular focus on how they are distinct from one another. Second, we provide a taxonomic framework for integrating these two areas on the basis of the stress paradigm, with specific examples provided from our recent reviews of the literature and our own empirical work with adolescent girls. Finally, we conclude with recommendations for future work needed to integrate psychological research on girls with feminist activism toward the goal of building a liberation psychology in the United States.

Objective: Nonadherence to regular inhaled anti-inflammatory medication use is a frequent contributor to poor control of persistent asthma and may result from misunderstanding of the preventive role of such medications. This study's aims are to 1) test the hypothesis that misunderstanding is associated with decreased adherence to its daily use and 2) identify factors associated with increased risk of misunderstanding., Study Design: A sample of parents of children with asthma insured by Medicaid and enrolled in managed care programs in Northern California, Washington, and Massachusetts were interviewed by telephone. This analysis focused on the subset that reported having an inhaled anti-inflammatory medication and whose medication use and symptom frequency in the 2 weeks before the interview suggested persistent asthma. Misunderstanding of the role of inhaled anti-inflammatory medication was defined as identifying it as being for treatment of symptoms after they begin and not for prevention of symptoms before they start., Results: A total of 1663 parents of children with asthma (63% response rate) were interviewed. Of those, 571 subjects (34%) reported use of an inhaled anti-inflammatory medication and met our criteria for persistent asthma. Among those with persistent asthma, 23% (131 parents) misunderstood the role of their child's inhaled anti-inflammatory. Misunderstanding of inhaled anti-inflammatory medication was associated with decreased adherence to its daily use (odds ratio [OR] 0.18, 95% confidence interval [CI], 0.11-0.29). The risk for misunderstanding was lower if the patient had seen a specialist (OR 0.42, 95% CI, 0.24-0.75) or had graduated high school (OR=0.54, 95% CI, 0.34-0.84)., Conclusion: Misunderstanding of the role of inhaled anti-inflammatory medication is associated with reduced adherence to its daily use.

Background: Children with persistent asthma underuse controller medications and overuse relievers. A better understanding of the appropriateness of regimens, medication adherence, and adequacy of asthma control is needed., Objectives: To describe use of asthma medications and disease burden in children with persistent asthma, to determine whether use of controllers and relievers is consistent with national guidelines, and to estimate adequacy of asthma control., Design: Cross-sectional cohort study., Setting: Forty-two primary care practices participating in 3 regions of the United States., Participants: Parents of 638 children aged 3 to 15 years with asthma., Main Outcomes Measures: Asthma symptom-days, use of reliever and controller medications, and adequacy of asthma control, ascertained by face-to-face questionnaire., Results: The mean age was 9.4 years, and 59.9% were boys. In the preceding 2 weeks, two thirds (67.5%) of subjects had 0 to 4 symptom-days, 15.8% had 5 to 9 symptom-days, and 16.6% had 10 to 14 symptom-days (percentages do not total 100 because of rounding). One third (32.6%) of children using relievers had high levels of use. One third (34.3%) of children using controllers used them 4 or fewer days per week. Among children with some evidence of persistent disease (use of controllers, excess symptoms, or excess reliever use), almost two thirds (64.3%) were inadequately controlled. This group consisted both of children reportedly using controllers less than recommended and those reporting not receiving controller medication at all., Conclusions: In this insured population, inappropriate reliance on relievers and nonadherence to controllers were common. Inadequate asthma control was common regardless of whether controllers were prescribed.

Objective: To determine the effect of a pediatric hospitalist system on housestaff education and experience., Setting: Free-standing academic children's hospital. Hospitalists were introduced in June 24, 1998, to supervise teaching and care on the general pediatric wards., Methods: On 2 surveys, housestaff rated their skills, knowledge, and experiences on the wards (experiences survey), and the quality of teaching and supervision by attending physicians (attending survey). Responses before and after the introduction of the hospitalist system were compared using Wilcoxon nonparametric tests., Results: Seventy-six (70%) of the 109 interns and 54 (62%) of the 87 senior residents responded to the experiences survey. Following introduction of the hospitalist system, the interns' mean overall rating of the general pediatrics wards rose from 4.1 to 4.7 on a 5-point Likert scale (P =.01). Their ratings of comparison rotations did not change significantly. Interns' satisfaction with the educational experience (3.2 to 3.5 of a 4-point Likert scale, P<.05), supervision, and quality of life on the pediatrics wards also improved significantly, as did their self-assessments of skills and knowledge related to general pediatrics training. Senior residents' ratings were generally unchanged. Three hundred seventy-one (63%) of the 593 attending physicians' surveys were completed. Compared with nonhospitalist attendings, hospitalists were rated more effective role models (4.7 vs 4.5 points, P<.05) and teachers (4.7 vs 4.4 points, P<.01). They were rated more knowledgeable (4.8 vs 4.5 of 5, P<.001) and accessible (4.7 vs 4.5 points, P<.05), involved housestaff more in the learning process (4.7 vs 4.4 points, P<.05), and gave better feedback (4.5 vs 4.2 points, P<.01). Hospitalists' bedside teaching, however, was rated lower (3.7 vs 4.2 points, P<.001)., Conclusions: Overall, hospitalists were rated significantly higher as educators than were traditional attending physicians. Introduction of a hospitalist system was associated with improved intern experience and quality of life on general pediatrics wards, and with improved self-reported skills and knowledge in general pediatrics.

Background: National guidelines recommend daily use of controller medications for children with persistent asthma. Although studies suggest low rates of controller use, little is known about predictors of underuse among low-income children in whom asthma morbidity is greatest., Objectives: To determine the frequency of underuse of controller medications among Medicaid-insured children in a variety of managed care arrangements, and to examine demographic factors and processes of asthma care associated with underuse., Design: Cross-sectional telephone survey of parents of children and adolescents aged 2 to 16 years with asthma, insured by Medicaid, and enrolled in 1 of 5 managed care plans. The main outcome was parent-reported underuse of controllers among children with persistent asthma. Survey items included demographic factors and reports of specific processes of care. Current symptom level was determined by recall of the number of days with symptoms in the previous 14 and by the Physical Function Score of the American Academy of Pediatrics (AAP) Child Health Status Assessment for Asthma. Logistic regression was used to identify factors independently associated with underuse., Results: The response rate was 66%, with 1648 children included in the analysis; 1083 were classified as having persistent asthma. Of these, 73% were underusers of controller therapy, with 49% reporting no controller use and 24% reporting less than daily use. A multivariate model that adjusted for age, managed health care organization, and AAP Physical Function Score found that black (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.2-2.4) or Latino (OR, 2.2; 95% CI, 1.3-3.8) race were associated with underuse and that parental education beyond high school was protective (OR, 0.6; 95% CI, 0.4-0.8). Having a primary care physician (OR, 0.4; 95% CI, 0.2-0.8), written action plan (OR, 0.5; 95% CI, 0.4-0.7), or a follow-up visit (OR, 0.5; 95% CI, 0.4-0.8) and having seen an asthma specialist (OR, 0.5; 95% CI, 0.4-0.7) were associated with lower rates of underuse., Conclusions: Underuse of controller medications among Medicaid-insured children is widespread. Racial minorities and children whose parents are less educated are at higher risk for underuse. Patients who have received action plans or had follow-up visits or specialty consultations are less likely to be symptomatic underusers of controller medications.

Background: Many factors affect use of inhaled therapy in asthma. Relatively little is known about current patterns of use of anti-inflammatory medication in children with asthma and whether variations occur with age and use of bronchodilator medication., Objective: To study the factors associated with dispensing of anti-inflammatory (controller) asthma medication to children in 3 managed care organizations (MCOs)., Methods: Using automated databases, a 1-year cross-sectional study of children with asthma aged 3 to 15 years cared for in 3 MCOs was used to evaluate the association of age and other factors with controller medication use., Results: A total of 13 352 children were studied. Significantly fewer children aged 3 to 5 years were dispensed any (> or =1) controller medication than older children (P<.001). Among children dispensed 6 or more beta-agonists, only 39% also received 5 or more controller dispensings, with adolescents significantly less likely than younger children to receive 5 or more controllers (33%; P<.001). Significant differences were seen among MCOs in proportions of patients dispensed controller medication. In a multiple logistic regression model, controlling for frequency of beta-agonist dispensing and MCO, significantly lower dispensing of any controller medication was seen for those aged 3 to 5 years (odds ratio [OR], 0.8; 95% confidence interval [CI], 0.7-0.9) and for girls (OR, 0.9; 95% CI, 0.8-0.96). In contrast, for repeated (> or =5) controller dispensing there were significantly fewer dispensings to adolescents (OR, 0.7; 95% CI, 0.6-0.9) and girls (OR, 0.8; 95% CI, 0.7-0.9)., Conclusions: There may be differences in the use of preventive asthma medication in children that are affected by age, sex, and health care organization. Few children with frequent symptoms are using controllers regularly, as is recommended by national guidelines.

Purpose: Little is known about how enrollees in health maintenance organizations (HMOs) perceive the benefits and risks of participating in the education of medical students. This case study elicited the views of enrollees of one academically affiliated HMO about the education of medical students., Method: Data from focus groups were used to design two questionnaires that were mailed to 488 adult patients and 298 parents or guardians of pediatric patients. A sample of non-respondents was followed up by telephone. Descriptive analyses were performed on the responses to the questionnaires., Results: Response rates were 46% (adult) and 43% (parent or guardian). More than 75% of the respondents thought the HMO should be involved in teaching, most because teaching contributes to the training of better doctors and increases the skills of teacher-clinicians. Of those who responded, 28% of adults were concerned about risks to confidentiality and 18% were concerned about increased costs for enrollees. Nearly 50% of adults would be uncomfortable with students participating in visits involving "internal" examinations or emotional problems. Of those who responded, 56% of adults and 33% of parents or guardians were uncomfortable about a student's conducting an unsupervised history and physical examination. A total of 52% of adults preferred that the preceptor and student discuss their case in their presence. Respondents who had seen students previously were more comfortable with student activities associated with their care., Conclusions: The respondents thought the HMO should be involved in teaching, but they had specific concerns about the effects of student participation. Educators in other settings may wish to explore these concerns among their patient populations and develop policies to maximize the "enrollee-friendliness" of medical education in HMOs. While the study provides a first look at how enrollees at one HMO viewed participation in medical students' education, further research is needed at HMOs elsewhere to determine the representativeness of the study's findings.

Managed care is becoming the dominant form of health care delivery and financing in the United States, necessitating changes in pediatric education. This transition is redefining the questions of what needs to be taught, who should be teaching it, where it should be taught, and how to pay for this education. We performed a literature review and examined reports from policy and professional groups to seek answers to these questions. We have identified curricular, administrative, and financial challenges to pediatric education in managed care. Although road maps for innovation have been described, there is a deficiency of research and information in key areas of pediatric education in the managed care environment.

Objective: To determine whether patient race or source of payment is associated with differences in the quality of inpatient and outpatient treatment for young children with asthma., Design: Structured medical record review., Setting: Tertiary care pediatric hospital., Patients: We studied 354 patients aged 1 to 6 years discharged with asthma between October 1, 1989 and September 30, 1990., Measures: We developed indicators of the quality of asthma care provided before and during hospitalization and planned after discharge. Outpatient indicators were the use of inhaled beta-agonists and the use of preventive anti-inflammatory medications (inhaled steroids or cromolyn sodium) before admission. In-hospital indicators were the intensity of inhaled beta-agonist therapy in the emergency department and length of stay. Planning for post-hospital care was assessed by the prescription of a nebulizer for home use. We examined associations between these indicators and patient race and source of payment, and explored the influence of primary-care practice type on these associations., Results: After adjustment for potential confounders, we found that Hispanic patients were less likely than white patients to have taken inhaled beta-agonists before admission. Both black and Hispanic patients were less likely than white patients to have taken anti-inflammatory medications. When we adjusted for the patients' primary-care practice type, the effect of patient race did not persist for these indicators of outpatient care. We found no differences by patient race in emergency department care or length of hospital stay. However, black and Hispanic patients were much less likely to be prescribed a nebulizer for home use upon discharge. After adjustment for confounders, there were no differences in the quality of asthma care by source of payment., Conclusions: We found that young children of racial minorities admitted for an asthma exacerbation were less likely to have received maximally effective preventive therapy. We also identified marked differences in the quality of care planned after hospital discharge for black and Hispanic patients, compared with white patients. Particularly in an era of health reform, attention should focus on barriers to high-quality care for underserved children, who are already at high risk for asthma-related morbidity.