Search

ObjectivesReducing unnecessary antibiotic use, particularly among children, continues to be a public health priority. Previous intervention studies have been limited by size or design and have shown mixed results. The objective of this study was to determine the impact of a multifaceted, community-wide intervention on overall antibiotic use for young children and on use of broad-spectrum agents. In addition, we sought to compare the intervention's impact on commercially and Medicaid-insured children.MethodsWe conducted a controlled, community-level, cluster-randomized trial in 16 nonoverlapping Massachusetts communities, studied from 1998 to 2003. During 3 years, we implemented a physician behavior-change strategy that included guideline dissemination, small-group education, frequent updates and educational materials, and prescribing feedback. Parents received educational materials by mail and in primary care practices, pharmacies, and child care settings. Using health-plan data, we measured changes in antibiotics dispensed per person-year of observation among children who were aged 3 to

Objective. The purpose of this study was to evaluate the effects of an early postpartum discharge program and a subsequent legislative mandate for 48 hours of hospital coverage on incidence of newborn jaundice and feeding problems. We tested the hypothesis that heightened postdischarge ascertainment (rather than short stays) is responsible for apparent increases in these outcomes. Methods. Interrupted time series analysis was conducted on retrospective data from the automated medical records of a large Massachusetts health maintenance organization (HMO). A population of 20 366 mother-infant pairs with normal vaginal deliveries between October 1990 and March 1998 was identified. The interventions included a new HMO protocol in 1994 of 1 hospital overnight after delivery, plus a nurse home visit, then the Massachusetts' 1996 minimum coverage law. Postpartum length of stay, clinical evaluation on day 3 or 4 of life, health center visits up to day 21, health center diagnoses of jaundice or feeding problems, bilirubin testing and test severity, rehospitalizations, and emergency department visits were measured. Results. Postpartum stays Conclusions. Sudden increases in jaundice-related measures and identification of infant feeding problems were not associated with changes in length of stay in this setting. Instead, these increases seem to be the result of more frequent evaluation of newborns during the critical day 3 to 4 period and may also have been elevated by a new climate of concern about neonatal vulnerability. "Ascertainment bias" may have confounded findings in previous reports that raised concerns about the safety of early discharge. Pediatrics 2004;113:42-49; newborn infant, length of stay, health policy, neonatal jaundice, research design., The clinical and political controversies over reductions in postpartum lengths of stay (LOSs) in the early to mid-1990s have been well documented. (1-3) The design limitations and contradictory findings that [...]

Objective. The purpose of this study was to evaluate the effects on breastfeeding rates of a private-sector early discharge program and a subsequent government mandate guaranteeing 48 hours of hospital coverage. Methods. Interrupted time-series analyses were conducted on retrospective data from the automated medical records of a large health maintenance organization in eastern Massachusetts. A population of 20 366 mother--infant pairs with normal vaginal deliveries between October 1990 and March 1998 was identified. This study period spanned the 2 interventions of interest: 1) the introduction of a new health maintenance organization protocol of 1 postpartum overnight hospitalization followed by a nurse home visit for normal vaginal deliveries, then 2) Massachusetts state minimum coverage legislation. Breastfeeding initiation and breastfeeding continuation among initiators (exclusive or with supplements) into the third month of life were determined through a text search of the first 90 days of infants' automated medical records. Results. Both policies had dramatic impacts on length of stay (LOS); postpartum LOS Conclusions. Early postpartum discharge with outpatient breastfeeding support and a home visitor program has no adverse effects on initiation or continuation of breastfeeding. Pediatrics 2003;111:519-524; breastfeeding, length of stay, maternity health services, health policy, research design., ABBREVIATIONS. SES, socioeconomic status; LOS, length of stay; HMO, health maintenance organization; HVMA, Harvard Vanguard Medical Associates; HPHC, Harvard Pilgrim Health Care; ROLOS, Reduced Obstetrical Length of Stay program; AMRS, [...]

Objective. Hospitalist systems decrease length of stay (LOS) and cost for hospitalized adults. Whether hospitalist systems decrease LOS and cost for hospitalized children has not been conclusively established. We wanted to determine whether a health maintenance organization's (HMO's) implementation of a pediatric hospitalist system affected LOS, costs, mortality, readmission rate, follow-up rate, and parents' ratings of care. Design. Interrupted time-series study of general pediatric patients admitted to a freestanding pediatric teaching hospital from 1993 to 1998. The intervention group consisted of all patients admitted to a staff model not-for-profit HMO that began using hospitalists in October 1996. Patients in other HMOs and traditional insurance groups were studied for comparison. The main outcomes were mean LOS and inflation-adjusted costs. Other outcomes included parents' ratings of care and mortality, readmission, and follow-up rates. Results. Immediately after the introduction of the hospitalist system, mean LOS for staff model not-for-profit HMO fell 12% (0.3 days), and mean cost of hospitalization decreased 16% ($217) compared with prehospitalist levels. Parental ratings of care, initially somewhat low, improved substantially. Seven-day follow-up rates, mortality, and readmission rates did not change. Comparison groups experienced no concurrent improvements in LOS, cost, parental ratings, mortality, or readmission rates. Conclusions. A pediatric hospitalist system within a staff-model HMO significantly improved LOS, cost, and parental ratings of care without affecting rates of post-hospitalization follow-up. Additional studies are needed both to measure broader aspects of quality and to assess the impact of such a program on patients being cared for through other types of delivery and insurance systems. Pediatrics 2002;110:720-728; hospitalists, pediatrics, time-series analysis, health services research., ABBREVIATIONS. LOS, length of stay; SMHMO, staff-model health maintenance organization; HMO, health maintenance organization; FTE, full-time equivalencies; APDRG, All Patient Diagnosis-Related Groups. Since 1996, systems of care employing hospitalists have [...]

The prescribing of drugs to infants and children has not been examined as extensively as drug prescribing in the elderly population. One study showed that a child receives an average of 8.5 courses of medications during the first five years of life. Like elderly patients, children also suffer consequences from prescription of drugs in inappropriate doses, or for vague diagnoses or trivial illnesses. Problems of drug prescribing in pediatrics and the effectiveness of various plans to improve prescribing practices are discussed. Specific problems associated with the use of antibiotics and psychoactive drugs are described. Approaches to improving the quality of prescribing should focus on educational methods that provide physicians with the information and skills to prescribe drugs in the most effective ways. The literature on improving the prescribing of drugs in primary care settings was reviewed, and several conclusions were reached. Although the distribution of educational materials had no effect on prescribing practices, it established a foundation for more personalized educational efforts. Mere distribution of patient-specific medication profiles without specific recommendations does not reduce drug costs or the use of ineffective drug combinations. Reminder systems prevent the omission of essential care, but are only effective if reminders are continuously produced. Repeated feedback to physicians consisting of specific suggestions for alternative drugs has increased the use of generic drugs in academic practice. Small group tutorials conducted by senior physicians have been shown to improve the use of antibiotics and drugs that control high blood pressure. In addition, brief, face-to-face educational outreach visits conducted by clinical pharmacists, physician counselors, or opinion leaders are effective in improving prescribing of drugs in pediatrics and the primary care setting. (Consumer Summary produced by Reliance Medical Information, Inc.)