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The purpose of this literature review was to identify interventions designed to improve healthcare team communication in the United States. We conducted a review of peer-reviewed, English-language articles describing interventions aimed at improving healthcare team communication. We analyzed articles that met pre-specified inclusion and exclusion criteria and characterized who is testing communication interventions, the rationale for testing, and ways of measuring effectiveness. We descriptively categorized the strength and types of study findings. Thirty articles were retained in our analysis. Most assessments were conducted by academic medical centers, the Veterans Health Administration, and teaching hospitals. Interventions sought to improve teamwork, patient safety, clinical outcomes, costs of care, and enhance provider job satisfaction and well-being. Intervention strategies included didactic lectures, simulation, Crew Resource Management, quality improvement, or a combination of these approaches. The vast majority employed a pre-post survey design and measured outcomes using participant feedback. Many assessments failed to utilize a social science theory or communication-specific measures. Interventions with the best training content were conducted at academic medical centers, used a pre-post design, and utilized statistical analysis to analyze results. While interventions for improving healthcare team communication are diverse and have uneven effectiveness, early markers of success merit continued development and assessment.

Asthma and obesity are the two most common childhood illnesses and are physiologically interrelated. Few studies have assessed parental perceptions and beliefs about this relationship to better target education and therapy. This study aimed to determine caregiver beliefs and perceptions regarding weight, health status, and asthma diagnoses. Data from a survey of caregivers to children aged 4–11 years are merged with corresponding anthropometric and medical data from the electronic medical record. Caregivers of children with asthma completed a supplemental questionnaire. Univariable and multivariable logistic regressions were used to evaluate associations between perception of health problem, asthma, and weight status. Increased weight status was ≥ 85th body mass index percentile per Centers for Disease Control classifications. Compared to caregivers of healthy children and those of children with healthy weight and asthma, caregivers of dual diagnosis children were more likely to identify weight as a health problem (OR = 3.89, 95% confidence interval [1.48, 10.21]). Nevertheless, only 31% of caregivers of children with dual diagnosis believed weight contributed to the severity of their child’s asthma. Less than one third of caregivers of dual diagnosis children believed that these diagnoses are interrelated. Addressing this gap in understanding is a critical next step to developing family-centered interventions.

This observational analysis explores how the COVID-19 pandemic contributed to a decrease in infant vaccinations.

Attrition from clinical interventions targeting underserved populations is a substantive challenge to achieving optimal health outcomes. Our nationally recognised enriched medical home intervention (EMHI) utilised community health worker home visitation to improve health outcomes of children by engaging the entire family and removing barriers to care-seeking. Families were enrolled into the program between 2013 and 2016, and, as part of the evaluation of the program's success, we identified predictors of program completion by conducting a secondary analysis of 304 families participating in the EMHI evaluation research. Program completers finished participation in the EMHI with mutual agreement that the family can independently follow recommended care. Program non-completers were either lost to follow-up or dropped out before reaching this milestone. Data were collected using electronic medical records and validated self-report surveys to assess constructs such as social support, mental health difficulties and neighbourhood characteristics. The EMHI participants were primarily families with infants

BackgroundLarge scale implementation of new strategies and healthcare delivery standards in academic medical centers (AMCs) requires training of healthcare workforce at different stages of their medical career. The patient-centered medical home (PCMH) model for healthcare delivery involves adoption by all members of the healthcare workforce, including seasoned professionals and trainees. Though widely known, the PCMH model has been implemented sporadically at large AMCs and methods to implement the model across healthcare workforce have not been well-documented.MethodsTo meet all PCMH standards and achieve sustainable level 3 recognition, the authors implemented in 2014–2015 a multi-pronged approach that capitalized on existing educational infrastructure among faculty, residents, and medical students. Within 18 months, the authors applied new interdisciplinary practices and policies, redesigned residency training in continuity practices and extensively modified medical school curricula.ResultsThese innovative transformational education efforts addressed the six PCMH standards for faculty, residents, and undergraduate medical students. Faculty played a major role as system change agents and facilitators of learning. Residents learned to better understand patients’ cultural needs, identify ‘at-risk’ patients, ensure continuity of care, and assess and improve quality of care. Medical students were exposed to PCMH core standards throughout their training via simulations, training in the community and with patients, and evaluation tasks. By implementing these changes across the healthcare workforce, the AMC achieved PCMH status in a short time, changed practice culture and improved care for patients and the community. Since then, the AMC has been able to maintain PCMH recognition annually with minimal effort.ConclusionsSuccessful strategies that capitalize on existing strengths in infrastructure complemented by innovative educational offerings and inter-professional partnerships can be adapted by other organizations pursuing similar transformation efforts. This widespread transformation across the healthcare workforce facilitate a deep-rooted change that enabled our academic medical center to sustain PCMH recognition.

Healthcare providers are in a unique position to identify barriers to healthcare for socioeconomically disadvantaged families, provide patient navigation for reducing disparities, and implement system changes for alleviating these barriers. Significant barriers to obtaining pediatric dental care exist for families with young children. This curricular resource describes an interprofessional education program that was conducted with small teams of health science students (nursing, pediatric medicine, dental medicine) at a suburban university. Five objectives were identified to assist students in realizing the barriers faced by socioeconomically disadvantaged families when seeking dental care for their young children. Students were assigned simulated child-patients, along with relevant health, demographic and insurance information and asked to use their cellular smartphones to identify timely and logistically compatible dental care for these simulated patients. Debriefing revealed that students had difficulty identifying appropriate pediatric dental care providers within a wide urban and suburban region. Post-workshop student surveys identified increased awareness of income, care access, and health literacy as factors contributing to health disparities.

A novel, sustainable digital badge-awarding online course was developed to prepare learners with familiarity of patient navigation. Learners offered favorable endorsement of essentially all elements of the program, especially the utility of the Blackboard learning management software program. Quality Matters standards provided a rigorous framework for the challenges of designing, implementing, and evaluating online curricula. Online education is an effective method for meeting the professional development needs of those seeking careers in care coordination/patient navigation.

While CHW interventions improve health outcomes, evidence identifying specific domains of CHW-delivered support resulting in positive outcomes is limited. Our goals were to identify domains of CHW-delivered support that assist families with adhering to recommended pediatric care; and, to identify predictors of successful completion of an enriched medical home intervention (EMHI) using trained CHWs making home visits to provide health education and support positive health behaviors. We performed a prospective descriptive study of 88 families participating in a protocol-based EMHI. Completers (N = 46) finished the program with mutual agreement that the family can independently adhere to recommended clinical care. Non-completers (N = 42) were lost to follow-up or dropped out of the program before reaching this milestone. Using Grounded Theory, two trained coders evaluated CHW tasks recorded in an electronic database and classified these tasks across 17 domains. We assessed predictors of EMHI completion using logistic regression. The 88 EMHI participants were primarily

The transition from a fee-for-service payment system to value-based payment system gained momentum in the US in 2010 with the passage of the Affordable Care Act and continues to progress rapidly. Market research estimates that value-based payment models will surpass fee-for-service by 2020. This change offers both great opportunity and great risk to the medical care of the heterogeneous populations of children with chronic respiratory disease. The fee-for-service model has driven the emergence of a healthcare delivery infrastructure markedly misaligned with the medical needs of children with chronic respiratory disease. A change to value-based payment models offers the opportunity to create systems better aligned with the complex and varied care needs of these children. However, rapid change without input from the relevant stakeholders could yield an infrastructure even more misaligned with the needs of children with chronic respiratory disease than the current one and threaten access to high quality medical care for these populations. Through the lens offered by three fictional case studies, this review: (1) illustrates current and evolving payment models; (2) describes limitations of these payment models; and (3) suggests a novel way to envision and evaluate value-based payment models for children with chronic respiratory disease.

SummaryBackground A consequence of childhood obesity may be poor developmental outcomes. Objectives This study aimed to examine the relationship between weight and developmental delays in young children. Methods We conducted a secondary analysis of the Early Childhood Longitudinal Study Birth Cohort data. Logistic regression models quantified the association between different weight statuses (normal weight

Objective Though stable insurance is important to support optimal child health, the reproducibility of metrics to assess child health insurance retention at the state and county level has not been examined. We sought to determine reproducibility of public insurance retention rates for children using 3 different metrics at the state and county level. Methods Public health insurance retention for children was assessed using 3 different metrics calculated from 2006–2009 Medicaid Analytic Extract data from 12 selected states. The metrics were: 1) Duration: a prospective metric that quantifies the number of newly enrolled children continuously enrolled in public insurance 6, 12, and 18 months after initial enrollment during a selected period; (2) Infant Duration: assesses Duration only among infants born during a selected period; (3) Coverage: a prospective metric that quantifies the average percentage of time a selected population is enrolled over an 18-month interval. Reproducibility of the metrics was assessed using a range of sample sizes with resampling and determining changes in relative rankings of states/counties by retention rate. Results All 3 metrics demonstrated reproducible estimates at the state level with sample sizes of 2000, 5000, and 10,000. Reproducibility of relative rankings for child health insurance retention of counties within states were sensitive to county child population size and the amount of variability in retention rates within the county and at the state level. Conclusions As health care reform unfolds, the complete set of these 3 reproducible metrics can be used to evaluate multipronged and multilevel strategies to retain eligible children in public health insurance.

BACKGROUND An essential component of any effective adolescent weight management program is physical activity (PA). PA levels drop dramatically in adolescence, contributing to the rising prevalence of adolescent obesity. Therefore, finding innovative interventions to address this decline in PA may help adolescents struggling with weight issues. The growing field of health technology provides potential solutions for addressing chronic health issues and lifestyle change, such as adolescent obesity. Activity trackers, used in conjunction with smartphone apps, can engage, motivate, and foster support among users while simultaneously providing feedback on their PA progress. OBJECTIVE The objective of our study was to evaluate the effect of a 10-week pilot study using smartphone-enabled activity tracker data to tailor motivation and goal setting on PA for overweight and obese adolescents and their parents. METHODS We queried enrolled adolescents, aged 14 to 16 years, with a body mass index at or above the 85th percentile, and 1 of their parents as to behaviors, barriers to change, and perceptions about exercise and health before and after the intervention. We captured daily step count and active minutes via activity trackers. Staff made phone calls to dyads at weeks 1, 2, 4, and 8 after enrollment to set daily personalized step-count and minutes goals based on their prior data and age-specific US national guidelines. We evaluated dyad correlations using nonparametric Spearman rank order correlations. RESULTS We enrolled 9 parent-adolescent dyads. Mean adolescent age was 15 (SD 0.9) years (range 14-16 years; 4 female and 5 male participants); mean parent age was 47 (SD 8.0) years (range 36-66 years). On average, adolescents met their personalized daily step-count goals on 35% (range 11%-62%) of the days they wore their trackers; parents did so on 39% (range 3%-68%) of the days they wore their trackers. Adolescents met their active-minutes goals on 55% (range 27%-85%) of the days they wore their trackers; parents did so on 83% (range 52%-97%) of the days. Parent and adolescent success was strongly correlated (step count: r=.36, P=.001; active minutes: r=.30, P=.007). Parental age was inversely correlated with step-count success (r=–.78, P=.01). CONCLUSIONS Our findings illustrate that parent-adolescent dyads have highly correlated PA success rates. This supports further investigation of family-centered weight management interventions for adolescents, particularly those that involve the parent and the adolescent working together.

Administrative data are often used to estimate state Medicaid/Children's Health Insurance Program duration of enrollment and insurance continuity, but they are generally not used to estimate participation (the fraction of eligible children enrolled) because administrative data do not include reasons for disenrollment and cannot observe eligible never-enrolled children, causing estimates of eligible unenrolled to be inaccurate. Analysts are therefore forced to either utilize survey information that is not generally linkable to administrative claims or rely on duration and continuity measures derived from administrative data and forgo estimating claims-based participation. We introduce appendectomy-based participation (ABP) to estimate statewide participation rates using claims by taking advantage of a natural experiment around statewide appendicitis admissions to improve the accuracy of participation rate estimates.We used Medicaid Analytic eXtract (MAX) for 2008-2010; and the American Community Survey for 2008-2010 from 43 states to calculate ABP, continuity ratio, duration, and participation based on the American Community Survey (ACS).In the validation study, median participation rate using ABP was 86% versus 87% for ACS-based participation estimates using logical edits and 84% without logical edits. Correlations between ABP and ACS with or without logical edits was 0.86 (P .0001). Using regression analysis, ABP alone was a significant predictor of ACS (P .0001) with or without logical edits, and adding duration and/or the continuity ratio did not significantly improve the model.Using the ABP rate derived from administrative claims (MAX) is a valid method to estimate statewide public insurance participation rates in children.

To identify parent, child, community, and health care provider characteristics associated with early intervention (EI) referral and multidisciplinary evaluation (MDE) by EI.We conducted a mixed methods secondary analysis of data from a randomized controlled trial of a developmental screening program in 4 urban primary care practices. Children30 months of age not currently enrolled in EI and their parents were included. Using logistic regression, we tested whether parent, child, community, and health care provider characteristics were associated with EI referral and MDE completion. We also conducted qualitative interviews with 9 pediatricians. Interviews were recorded, transcribed, and coded. We identified themes using modified grounded theory.Of 2083 participating children, 434 (21%) were identified with a developmental concern. A total of 253 children (58%) with a developmental concern were referred to EI. A total of 129 children (30%) received an MDE. Failure in 2 or more domains on developmental assessments was associated with EI referral (adjusted odds ratio [AOR] 3.15, 95% confidence interval [CI] 1.89-5.24) and completed MDE (AOR 2.16, 95% CI 1.19-3.93). Faxed referral to EI, as opposed to just giving families a phone number to call was associated with MDE completion (AOR 2.94, 95% CI 1.48-5.84). Pediatricians reported that office processes, family preference, and whether they thought parents understood the developmental screening tool influenced the EI referral process.In an urban setting, one third of children with a developmental concern were not referred to EI, and two thirds of children with a developmental concern were not evaluated by EI. Our results suggest that practice-based strategies that more closely connect the medical home with EI such as electronic transmission of referrals (e.g., faxing referrals) may improve completion rates of EI evaluation.

Publicly financed insurance programs are tasked with maintaining coverage for eligible children, but published measures to assess coverage have not been evaluated. Therefore, we sought to identify and categorize measures of health insurance continuity for children and adolescents. We conducted a systematic review of Medline and HealthStar databases, review of reference lists of eligible articles, and contact with experts. We categorized measures into 8 domains based on a conceptual framework. We identified 147 measures from 84 eligible articles. Most measures evaluated the following domains: always insured (41%), repeatedly uninsured (36%), and transition out of coverage (29%), while fewer assessed single gap in coverage, always uninsured, transition into coverage, change in coverage, and eligibility. Only 18% of measures assessed associations between continuity of coverage and child and adolescent health outcomes. These results suggest that a number of measures of continuity of coverage exist, but few measures have assessed impact on outcomes.

BACKGROUND AND OBJECTIVES: Community health workers (CHWs) have great potential to extend medical home services and reduce emergent health care use, but evidence in pediatrics is scarce. We evaluated the impact of an existing enriched medical home intervention (EMHI) that directly integrates CHWs into emergency department (ED) visits and hospitalizations for pediatric ambulatory care–sensitive conditions (ACSCs). METHODS: The EMHI group in this prospective cohort study received home visits from trained CHWs to support adherence to recommended care; the comparison group received usual care (UC). Sociodemographic characteristics were compiled from the EMHI database, and ED and hospitalization information was extracted for study participants from a statewide database. The Wilcoxon signed rank test was used to compare ED data and the Wald test was used to compare hospitalization use for ACSCs between the intervention and UC groups after adjusting for different characteristics between groups by using propensity score matching method. RESULTS: The study sample included 922 children (225 intervention, 697 UC). After propensity score matching, the analytic sample included 450 children (225 intervention, 225 UC). After propensity score matching, the intervention group was significantly less likely than the UC group to visit the ED for an ACSC (18.2% vs 35.1%; P = .004). We found no differences in ACSC hospitalizations between the 2 groups. CONCLUSIONS: Our findings suggest that EMHIs using trained CHWs may be a cost-effective model to reduce preventable ED utilization, especially among vulnerable children.

OBJECTIVE:To determine the effectiveness of developmental screening on the identification of developmental delays, early intervention (EI) referrals, and EI eligibility.METHODS:This randomized controlled, parallel-group trial was conducted from December 2008 to June 2010 in 4 urban pediatric practices. Children were eligible if they were RESULTS:A total of 2103 children were enrolled. Most were African-American with family incomes less than $30 000. Children in either screening arm were more likely to be identified with delays (23.0% and 26.8% vs 13.0%; P < .001), referred to EI (19.9% and 17.5% vs 10.2%; P < .001), and eligible for EI services (7.0% and 5.3% vs 3.0%; P < .001) than children in the surveillance arm. Children in the screening arms incurred a shorter time to identification, EI referral, and EI evaluation than children in the surveillance arm.CONCLUSIONS:Children who participated in a developmental screening program were more likely to be identified with developmental delays, referred to EI, and eligible for EI services in a timelier fashion than children who received surveillance alone. These results support policies endorsing developmental screening.

Objective To examine compliance of Medicaid-renewal applications to established state guidelines for reading level of Medicaid-related materials. Methods We assessed the reading level of the 2008 Medicaid renewal applications by using 3 readability tests: Flesch-Kincaid Grade Level Index, New Fog Count, and FORCAST. Results In 2008, 45 states and the District of Columbia had reading level guidelines for Medicaid-related materials. Of these, 24 (52.2%) states' Medicaid renewal applications failed to meet their guidelines on all 3 readability tests; in particular, 41 states (89.1%) failed the Flesch-Kincaid Grade Level Index. Only one state's application had a Flesch-Kincaid score below a 5th-grade reading level. Conclusions As health care reform unfolds, complying with established reading level guidelines for Medicaid-related materials is one simplification strategy that should be implemented to improve access for Medicaid-eligible families and prevent eligible children from losing coverage unnecessarily.

To advance the conceptualization and measurement of mother-reported instrumental support, the degree to which an individual receives assistance in the completion of daily life tasks. The psychometric properties of a 9-item instrumental support scale were evaluated using classical (descriptive statistics, factor analyses, evaluation of construct validity) and modern (Rasch modeling, differential item functioning) methods. Differences in perceived instrumental support were evaluated as a function of mothers' socio-demographic characteristics. Factor analytic and differential item functioning analyses provided support for two components of instrumental support, household and childcare assistance. Instrumental support is distinct from structural support and the quality of mothers' social relationships. Socio-demographic characteristics (e.g., marital status, education level, income) are associated with access to instrumental support. Differentiating appropriately between support subtypes may reveal important differences in mother's qualitative instrumental support experiences and facilitate effective targeting of social support interventions.

Objectives: Hospital crowding adversely affects access to emergent and elective care, quality and safety, patient and staff satisfaction, and trainee education. Reliable and valid measurements are crucial to operational planning and improvement, but traditional measures of hospital utilization may not accurately describe dynamic demand at hospitals. The goal of this study was to determine how effectively traditional measures express demand for hospital services and to describe the dynamic nature of patient flow in children’s hospitals compared with alternative measures. Methods: This was a retrospective administrative data review conducted at an urban, tertiary care children’s hospital. A total of 28 045 inpatients (22 310 from fiscal year 2008 and 5735 from 2 months in the fall of 2009 during the H1N1 influenza surge [October 16, 2009–November 18, 2009]) were reviewed. Admission-discharge-transfer data were abstracted from a total of 14 months (1 fiscal year and a separate 2 months including an influenza surge). Hourly hospital census and occupancy were determined. Measures of mean and median length of stay (LOS) were compared. Turnover was calculated by summing admissions, discharges, and interunit transfers. Coefficient of variation (SD/mean) was used to describe variation. Results: Midnight occupancy was generally closer to minimum occupancy than peak. Peak was usually between 10 AM and 12 PM and was a mean of 4% points higher than midnight (but as large as 13% points). Median LOS was 58% shorter than average LOS. There was a high level of turnover, and patient-days did not express the wide variation in how demand was generated by day of week. Conclusions: Traditional metrics for hospital utilization do not accurately express the true extent and dynamic nature of patient flow and inpatient demand at a children’s hospital. Hospitals and government regulatory agencies should consider additional means of measuring utilization to accurately determine demand, including its variation, and thus assist in budgeting, staffing, and capacity planning.

To quantify the difference in weekday versus weekend occupancy, and the opportunity to smooth inpatient occupancy to reduce crowding at children's hospitals.Daily inpatient census data for 39 freestanding, tertiary-care children's hospitals were used to calculate occupancy and to model the impact of reducing variation in occupancy and the change in the number of patients, patient-days, and hospitals exposed to high occupancy pre- and post-smoothing. We also calculated the proportion of weekly admissions that would require different scheduling to achieve within-week smoothing.Overall, hospitals' mean occupancy ranged from 70.9% to 108.1% on weekdays, and 65.7% to 94.9% on weekends. Weekday occupancy exceeded weekend occupancy with a median difference of 8.2% points. The mean post-smoothing reduction in weekly maximum occupancy across all hospitals was 6.6% points. Through smoothing, 39,607 patients from the 39 hospitals were removed from exposure to occupancy levels95%. To achieve within-week smoothing, a median 2.6% of admissions would have to be scheduled on a different day of the week; this equates to a median of 7.4 patients per week (range: 2.3-14.4).Hospitals do have substantial unused capacity, and smoothing occupancy over the course of a week could be a useful strategy that hospitals can use to reduce crowding and protect patients from crowded conditions.

OBJECTIVE: To determine if gender is associated with diagnostic evaluation by primary care pediatricians caring for children with growth-faltering. PATIENTS AND METHODS: This was a retrospective study of children who were attending 4 urban pediatric primary care practices affiliated with a tertiary pediatric hospital. Growth-faltering was defined as height at the RESULTS: Of 33 476 children, 3007 had growth-faltering (mean height: −1.5 ± 1.0 vs 0.3 ± 0.9 SDs in those without growth-faltering). Boys comprised 53% of the growth-faltering group (vs 51% of the nonfaltering group; P < .01). Among children with growth-faltering, 2.8% had endocrinology appointments (vs 0.8% of others; P < .0001) and 6% had gastroenterology appointments (vs 1.5% of others; P < .0001). Subspecialty care was not associated with gender. Pediatricians ordered diagnostic tests for a significantly greater proportion of children with growth-faltering than others. In multivariate analysis of height z score among children with growth-faltering, tests for chromosomes (1.4% of short girls vs 0.4% of short boys; P < .005) and growth hormone/insulin-like growth factor axis (0.9% of short girls vs 1.8% of short boys; P < .05) were associated with gender. Thirty-five percent of the girls for whom chromosome testing was performed were 12 years old or older. CONCLUSIONS: Patterns in diagnostic testing of children with growth-faltering by their pediatricians may lead to underdiagnosis of Turner syndrome and growth hormone deficiency among girls.

We examined the influence of maternal health literacy on child participation in social welfare programs. In this cohort, 20% of the mothers had inadequate or marginal health literacy. Initially, more than 50% of the families participated in Temporary Assistance for Needy Families (TANF), the Food Stamp Program, and Special Supplemental Nutrition Program for Women, Infants, and Children, whereas fewer than 15% received child care subsidies or public housing. In multivariate regression, TANF participation was more than twice as common among children whose mothers had adequate health literacy compared with children whose mothers had inadequate health literacy.

Background: An essential component of any effective adolescent weight management program is physical activity (PA). PA levels drop dramatically in adolescence, contributing to the rising prevalence of adolescent obesity. Therefore, finding innovative interventions to address this decline in PA may help adolescents struggling with weight issues. The growing field of health technology provides potential solutions for addressing chronic health issues and lifestyle change, such as adolescent obesity. Activity trackers, used in conjunction with smartphone apps, can engage, motivate, and foster support among users while simultaneously providing feedback on their PA progress. Objective: The objective of our study was to evaluate the effect of a 10-week pilot study using smartphone-enabled activity tracker data to tailor motivation and goal setting on PA for overweight and obese adolescents and their parents. Methods: We queried enrolled adolescents, aged 14 to 16 years, with a body mass index at or above the 85th percentile, and 1 of their parents as to behaviors, barriers to change, and perceptions about exercise and health before and after the intervention. We captured daily step count and active minutes via activity trackers. Staff made phone calls to dyads at weeks 1, 2, 4, and 8 after enrollment to set daily personalized step-count and minutes goals based on their prior data and age-specific US national guidelines. We evaluated dyad correlations using nonparametric Spearman rank order correlations. Results: We enrolled 9 parent-adolescent dyads. Mean adolescent age was 15 (SD 0.9) years (range 14-16 years; 4 female and 5 male participants); mean parent age was 47 (SD 8.0) years (range 36-66 years). On average, adolescents met their personalized daily step-count goals on 35% (range 11%-62%) of the days they wore their trackers; parents did so on 39% (range 3%-68%) of the days they wore their trackers. Adolescents met their active-minutes goals on 55% (range 27%-85%) of the days they wore their trackers; parents did so on 83% (range 52%-97%) of the days. Parent and adolescent success was strongly correlated (step count: r=.36, P=.001; active minutes: r=.30, P=.007). Parental age was inversely correlated with step-count success (r=–.78, P=.01). Conclusions: Our findings illustrate that parent-adolescent dyads have highly correlated PA success rates. This supports further investigation of family-centered weight management interventions for adolescents, particularly those that involve the parent and the adolescent working together.

OBJECTIVE: To determine if maternal health literacy influences early infant immunization status. METHODS: Longitudinal prospective cohort study of 506 Medicaid-eligible mother-infant dyads. Immunization status at age 3 and 7 months was assessed in relation to maternal health literacy measured at birth using the Test of Functional Health Literacy in Adults (short version). Multivariable logistic regression quantified the effect of maternal health literacy on immunization status adjusting for the relevant covariates. RESULTS: The cohort consists of primarily African-American (87%), single (87%) mothers (mean age 23.4 yrs). Health literacy was inadequate or marginal among 24% of mothers. Immunizations were up-to-date among 73% of infants at age 3 months and 43% at 7 months. Maternal health literacy was not significantly associated with immunization status at either 3 or 7 months. In multivariable analysis, compared to infants who had delayed immunizations at 3 months, infants with up-to-date immunizations at 3 months were 11.3 times (95%CI 6.0–21.3) more likely to be up-to-date at 7 months. The only strong predictors of up-to-date immunization status at 3 months were maternal education (high school graduate or beyond) and attending a hospital-affiliated clinic. CONCLUSIONS: Though maternal health literacy is not associated with immunization status in this cohort, later immunization status is most strongly predicted by immunization status at 3 months. These results further support the importance of intervening from an early age to ensure that infants are fully protected against vaccine preventable diseases.

Asthma is the most common chronic illness of childhood and leading cause of pediatric hospitalization. Patient/parent adherence rates to medications and home-management recommendations are low. The provision of incentives for adherence to parents has had limited consideration. The objective of this study was to assess physician views regarding appropriateness and effectiveness of incentives for adherence in the management of childhood asthma. We performed a cross-sectional, web-based anonymous survey of Pennsylvania pediatricians and specialists caring for children with asthma. Three hundred and twenty-nine physicians responded, reflecting demographic characteristics of the state’s physicians. Overall, 61% agreed incentives for adherence would be appropriate, 77% agreed they would be effective, and 50% agreed they would be both appropriate and effective. Among 287 respondents supporting incentives as appropriate and/or effective, 4 activities were endorsed by a majority for linkage to incentives: schedule...

Background We sought to determine whether maternal Medicaid retention influences child Medicaid retention because caregivers play a critical role in assuring children’s health access. Methods We conducted a longitudinal prospective cohort study of a convenience sample of 604 Medicaid-eligible mother-child dyads followed from the infant’s birth through 24 months of age with parent surveys. Individual enrollment status was abstracted from administrative Medicaid eligibility files. Generalized estimating equations quantified the effect of maternal Medicaid enrollment status on child Medicaid retention, adjusting for relevant covariates. Because varying lengths of gaps may have different effects on child health outcomes, Medicaid enrollment status was further categorized by length of gap: any gap, > 14-days, and > 60-days. Results This cohort consists primarily of African-American (94%), unmarried mothers (88%), with a mean age of 23.2 years. In multivariable analysis, children whose mothers experienced any gaps in coverage had 12.6 times greater odds of experiencing gaps when compared to children whose mothers were continuously enrolled. Use of varying thresholds to define coverage gaps resulted in similar odds ratios (> 14-day gap = 11.8, > 60-day gap = 16.8). Cash assistance receipt and maternal knowledge of differences between Temporary Assistance to Needy Families and Medicaid eligibility criteria demonstrated strong protective effects against child Medicaid disenrollment. Conclusions Medicaid disenrollment remains a significant policy problem and maternal Medicaid retention patterns show strong effects on child Medicaid retention. Policymakers need to invest in effective outreach strategies, including family-friendly application processes, to reduce enrollment barriers so that all eligible families can take advantage of these coverage opportunities.

Growth hormone (GH) treatment of idiopathic short stature (ISS), defined as height

Creating a stable insurance coverage system for American children has been one of the most persistent and intractable challenges in health policy. Previous studies have documented that uninsured children are less likely to use medical services, less likely to use preventive services, and less likely to have a usual source of care.1–6 Cross-sectional studies of uninsured children likely capture some children who experience short-term gaps in coverage as well as those who are ineligible for any coverage within the current system. Unlike ineligible children, it is likely that children with short-term gaps in coverage are eligible for insurance but not enrolled, and there may be opportunities to simplify the current system of enrollment and renewal to prevent these lapses in coverage. Because gaps in coverage can disrupt patient–provider relationships and affect appropriate utilization for children during critical periods of growth and development,7,8 maintaining stable coverage is an important priority. Many childhood and adolescent problems, such as developmental delays, risk-taking behaviors, and nutritional concerns, require regular supervision for early identification and optimal treatment.9–11 For children with chronic conditions, such as asthma or diabetes, continuous coverage is critical to ensure compliance with care regimens.12,13 Despite recent efforts to expand and simplify insurance enrollment procedures, ~8.2 million children, or 12% of all children, were without health insurance coverage at some point in 2003.14 For children in low-income families, the separation of eligibility and enrollment in Medicaid from public cash assistance (known as Temporary Assistance to Needy Families [TANF]) in 1996 was followed by declines in Medicaid enrollment likely as a result of confusion about eligibility and enrollment.15–18 Subsequent outreach and education efforts have led to modest increases in Medicaid enrollment,19,20 yet retention remains a persistent problem. Data from the early 1990s showed that one third to one quarter of children were disenrolled from the program in any given year, and most of these children were uninsured for 4 to 6 months.7,21–23 It is not known whether the separation of TANF eligibility from Medicaid eligibility and the enactment of the State Child Health Insurance Program has affected the number of children who experience gaps in health care coverage in recent years. Although there is clear evidence that children from racial/ethnic minorities and those who live in poverty are more likely to be uninsured than their peers,1,2,24 it is not known whether they are also more likely to experience gaps in insurance coverage. It is also not known whether children from other vulnerable subgroups, such as those with chronic illness, experience considerable gaps in coverage. In this study, we analyzed data from the 1999–2001 Medical Expenditure Panel Survey (MEPS) linked to the National Health Interview Survey to quantify the number of children with gaps in coverage at the national level and to determine whether vulnerable subgroups of children experience noteworthy lapses in insurance coverage. Given the recent policy changes related to TANF and Medicaid eligibility and previous studies showing that TANF recipients are less likely to be uninsured, we also explored the association between TANF status and the likelihood of experiencing gaps in coverage.

Prior research identified foster care children using Medicaid eligibility codes specific to foster care, but it is unknown whether these codes capture all foster care children.To describe the sampling bias in relying on Medicaid eligibility codes to identify foster care children.Using foster care administrative files linked to Medicaid data, we describe the proportion of children whose Medicaid eligibility was correctly encoded as foster child during a 1-year follow-up period following a new episode of foster care. Sampling bias is described by comparing claims in mental health, emergency department (ED), and other ambulatory settings among correctly and incorrectly classified foster care children.Twenty-eight percent of the 5683 sampled children were incorrectly classified in Medicaid eligibility files. In a multivariate logistic regression model, correct classification was associated with duration of foster care (9 vs2 months, odds ratio [OR] 7.67, 95% confidence interval [CI] 7.17-7.97), number of placements (3 vs 1 placement, OR 4.20, 95% CI 3.14-5.64), and placement in a group home among adjudicated dependent children (OR 1.87, 95% CI 1.33-2.63). Compared with incorrectly classified children, correctly classified foster care children were 3 times more likely to use any services, 2 times more likely to visit the ED, 3 times more likely to make ambulatory visits, and 4 times more likely to use mental health care services (P.001 for all comparisons).Identifying children in foster care using Medicaid eligibility files is prone to sampling bias that over-represents children in foster care who use more services.

Objectives. We assessed the ability of managed care gatekeeping strategies (i.e., requiring a designated primary care provider to authorize referrals) to control health care costs in the mid-1990s. Methods. We analyzed expenditure data from 8195 privately insured adults sampled in the nationally representative 1996 Medical Expenditure Panel Survey. Managed care gatekeeping plan enrollees included those in health maintenance organizations and other plans requiring a primary care gatekeeper. All others were considered indemnity plan enrollees. Results. In 1996, total per capita annual health expenditures for adult gatekeeping enrollees were about $50 less than those of indemnity enrollees, primarily owing to lower out-of-pocket expenditures. After multivariate adjustment, mean per capita expenditures were approximately 6% lower for gatekeeping enrollees than for indemnity enrollees. Conclusions. In the private sector, gatekeeping strategies resulted in modest cost savings over indemnity plans.

The balance between spending on children and spending on the elderly is important in evaluating the allocation of public welfare spending. We examine trends in public spending on social welfare programs for children and the elderly during 1980–2000. For both groups, social welfare spending as a percentage of gross domestic product changed little, even during the economic expansions of the 1990s. In constant dollars, the gap in per capita social welfare spending between children and the elderly grew 20 percent. Unlike spending for programs for the elderly, spending for children’s programs suffered during recessions. Public discussion about the current imbalance in public spending is needed.

Objective. Gatekeeping requirements were widely adopted by health insurers in an attempt to control costs in the mid-1990s, but empirical evidence demonstrating decreased health expenditures for children enrolled in such plans is lacking.Methods. We analyzed data from 3254 children with private health insurance sampled in the 1996 Medical Expenditure Panel Survey (MEPS) to compare total per capita health expenditures among gatekeeping versus indemnity plan enrollees. This sample represents 40.4 million privately insured American children. Total expenditures were defined as payments from all sources, including third-party and out-of-pocket payments, but excluding administrative costs. MEPS data are based on information provided by patients, health care providers, and hospitals. Gatekeeping plans included all children enrolled in health maintenance organizations or other plans requiring a primary care gatekeeper. All others were considered indemnity plan enrollees.Results. Mean total per capita annual expenditures for children in gatekeeping versus indemnity plans differed by Conclusion. In 1996, total per capita annual health expenditures for children in gatekeeping plans were approximately $8 less than for those in indemnity plans. These data indicate that gatekeeping is not an effective cost-containment method for children.

Background. Health technology provides a wealth of strategies to address chronic health issues, such as childhood obesity. Few studies have assessed parental preferences regarding use of health technology to support weight management for adolescents. Objective. This study determined caregiver beliefs, attitudes, and practices towards using traditional methods and technology-based health applications to address weight management among overweight adolescents. Methods. Self-administered surveys were distributed to caregivers of children ages 11–18 years in Stony Brook Children’s Hospital outpatient offices with a BMI ≥ 85th percentile for age, gender. The data were entered into StudyTrax research platform and analyzed using SAS. Results. N=114. Mean BMI z-score = 1.95 ± 0.50. Two-thirds (65.8%) of caregivers preferred a weight management program that includes both traditional and technology components. Most parents rated involvement in program development (68.1%), access to content (72.4%) as very important. Those who believed their child’s weight was a problem (p=0.01) were more likely than other parents to prefer a program that combined both traditional and technology components. Conclusions. Parents’ perceptions of their child’s weight drove preferences about incorporating technology elements into a weight management program. Future weight management programs should incorporate parental content preferences and be tailored to different age groups.

BackgroundResearch is needed to identify challenges to developmental screening and strategies for screening in an urban pediatric setting.MethodsParents of young children and clinicians at four urban pediatric practices participated in focus groups prior to implementation of screening. Participants were queried regarding attitudes, social norms, and barriers to developmental screening. Using information from the focus groups, workflow strategies were developed for implementing screening. Referral rates and satisfaction with screening were gathered at the conclusion.ResultsSix focus groups of parents and clinicians were conducted. Major themes identified included 1) parents desired greater input on child development and increased time with physicians, 2) physicians did not fully trust parental input, 3) physicians preferred clinical acumen over screening tools, and 4) physicians lacked time and training to conduct screening. For the intervention, developmental screening was implemented at the 9-, 18-, 24-, and 30-month well visits using the Ages & Stages Questionnaire-II and the Modified Checklist for Toddlers. 1397 (98% of eligible) children under 36 months old were enrolled, and 1184 (84%) were screened at least once. 1002 parents (85%) completed a survey at the conclusion of the screening trial. Most parents reported no difficulty completing the screens (99%), felt the screens covered important areas of child development (98%), and felt they learned about their child’s strengths and limitations (88%).ConclusionsDevelopmental screening in urban low-income practices is feasible and acceptable, but requires strategies to capture parental input, provide training, facilitate referrals, and develop workflow procedures and electronic decision support.

Traditional performance expectations and career advancement paths for academic physicians persist despite dramatic transformations in the academic workflow, workload, and workforce over the past twenty years. While the academic physician’s triple role as clinician, researcher, and educator has been lauded as the ideal by academic medical centers, current standards of excellence for promotion and tenure are based on outdated models. These models fail to reward collaboration and center around rigid career advancement plans that do little to accommodate the changing needs of individuals and organizations. Here, the authors describe an innovative, comprehensive, multi-pronged initiative at the Perelman School of Medicine at the University of Pennsylvania to initiate change in the culture of academic medicine and improve academic productivity, job satisfaction, and overall quality of life for junior faculty. As a key part of this intervention, task forces from each of the 13 participating departments/divisions met 5 times between September 2010 and January 2011 to produce recommendations for institutional change. The authors discuss how this initiative, using principles adopted from business transformation, generated themes and techniques that can potentially guide workforce environment innovation in academic health centers across the United States. Recommendations include embracing a promotion/tenure/evaluation system that supports and rewards tailored individual academic career plans; ensuring leadership, decision-making roles and recognition for junior faculty; deepening administrative and team supports for junior faculty; and solidifying and rewarding mentorship for junior faculty. By doing so, academic health centers can ensure the retention and commitment of faculty throughout all stages of their careers.

Lack of physical activity has contributed to the nation’s childhood obesity crisis, but the impact of physical activity on self-efficacy as a mediator of behavior change has not been examined. This systematic review (SR) describes the published evidence related to the impact of physical activity intervention programs on self-efficacy among youths. From January 2000 to June 2011, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards were used to identify publications from PubMed, PsychInfo, Web of Knowledge, and the Cochran Database of Systematic Reviews. The Cochrane Population, Intervention, Control, Outcome, Study Design (PICOS) approach guided this SR articles selection and evaluation process. Of the 102 publications screened, 10 original studies matched the SR inclusion criteria. The types of physical activity interventions and self-efficacy assessments for these 10 studies were diverse. Of the 10 included articles, 6 articles identified an improvement in post-self-efficacy assessments compared to baseline and 4 showed no effect. In conclusion, physical activity intervention programs may improve self-efficacy in youths. A standardized approach to classify and measure self-efficacy is required. Further research is needed to quantify the association of self-efficacy ratings after completing physical activity interventions with objective health improvements, such as weight loss.

The objective of this study is to develop new methods to better identify psychosocial risk such that children with the greatest risk of poor future outcomes receive more intensive preventive health services. Based on structured literature review and secondary data analysis, a 52-item psychosocial risk questionnaire was administered to 2,083 families of children (36 months). To quantify the questionnaire's construct validity, developmental concern was assessed with the Ages and Stages Questionnaire version II (ASQ) [n = 1,163]. An iterative model selection process was used to produce the most parsimonious predictive model. Model fit was examined using c-statistics, the Hosmer-Lemeshow test, and a heuristic measure of model overfit based on the fitted log-likelihood values and associated number of degrees of freedom. We found 13 items easily obtained from parental report produced a regression model with a c-statistic of 0.70. Using an integer scoring system derived from the regression model, we calculated stratum specific likelihood ratios to revise a given prior probability of ASQ failure. The posterior probability of ASQ failure was 44.9 % for a child in the highest risk group (score25) on the questionnaire, more than double our observed average failure rate of 19.5 %, while it was less than 7 % for a child with the lowest possible score on the questionnaire. Thirteen parent-reported items can be compiled into a summary psychosocial risk questionnaire that predicts failure on developmental screening among preschool children. With further validation, this questionnaire could conceivably be used by clinicians to tailor pediatric preventive care to children at varying levels of risk.

We sought to assess the association between parental depressive symptoms and school attendance and emergency department (ED) use among children with and without chronic health conditions. Secondary analysis of the 1997-2004 National Health Interview Survey, a nationally representative survey. Parental depressive symptoms were measured by three questions assessing sadness, hopelessness, or worthlessness in the past month. Children with and without asthma or attention-deficit/hyperactivity disorder (ADHD) were identified, and their school attendance and ED visits were reported by adult household respondents. Children with information on parental depressive symptoms, health conditions, and services use were eligible. We incorporated weights available in the survey for each eligible child to reflect the complex sampling design. 104,930 eligible children were identified. The point prevalence of parental depressive symptoms was low (1.8 %, 95 % CI 1.7-2.0), but greater among children with asthma (2.7 %, 95 % CI 2.4-3.0) and ADHD (3.8 %, 95 % CI 3.2-4.4) than among other children (1.6 %, 95 % CI 1.5-1.7). After adjustment for potential confounders, children whose parents reported depressive symptoms most or all of the time were more likely to report an ED visit (adjusted incident rate ratio [IRR] 1.18, 95 % CI 1.06-1.32) or school absence (adjusted IRR 1.36, 95 % CI 1.14-1.63) than children whose parents did not. The effect of parental depressive symptoms was not modified by child health conditions. Parental depressive symptoms were adversely associated with school attendance and ED use in children. These results suggest the importance of measuring depressive symptoms among adult caregivers of children.

Background Changes in well child care (WCC) adherence over time have not previously been examined. Our objective is to describe adherence rates to WCC over time in a low-income urban population of infants 0-24 months of age, and to identify predictors of WCC adherence in this population. Methods This is a secondary analysis of a cohort of Medicaid-eligible children followed from birth to 2 years between 2005 and 2008 with structured telephone surveys to assess maternal well-being, social support, and household and demographic information. For the 260 children attending 4 urban pediatric practices, WCC adherence was assessed based on visit data abstracted from electronic medical records. A random-intercept mixed effects logit model clustered on subject was used. Results 92% of the mothers were African-American, 27% had not finished high school, 87% were single, and 43% earned < $500/month; mean age was 23. WCC adherence decreased from 88% at 6 months to 47% (12 mo), 44% (18 mo), and 67% (24 mo). The difference across time periods was statistically significant (p < 0.001). Married (OR 1.71, p = 0.02) and primiparous (OR 1.89, p < 0.001) mothers had significantly greater odds of adherence, along with women who reported having been adherent to prenatal care visits (OR 1.49, p = 0.03) and those with the lowest household income (OR 1.40, p = 0.03). Conclusions Maternal education efforts should emphasize the importance of establishing WCC, especially for mothers of more than one child. Further studies using larger, more broadly defined populations are needed to confirm our findings that efforts to increase WCC adherence should be intensified after 6 months of age, particularly for children at higher risk.