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Rationale: Racial disparities in pain management have been previously reported for children receiving emergency care. Objectives: To determine whether patient race or ethnicity is associated with the broader goal of pain management and sedation among pediatric patients mechanically ventilated for acute respiratory failure. Methods: Planned secondary analysis of RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure). RESTORE, a cluster-randomized clinical trial conducted in 31 U.S. pediatric intensive care units, compared protocolized sedation management (intervention arm) with usual care (control arm). Participants included 2,271 children identified as non-Hispanic white (white, n = 1,233), non-Hispanic Black (Black, n = 502), or Hispanic of any race (Hispanic, n = 536). Results: Within each treatment arm, neither opioid nor benzodiazepine selection, nor cumulative dosing, differed significantly among race and ethnicity groups. Black patients experienced fewer days with an episode of pain (compared with white patients in the control arm and with Hispanic patients in the intervention arm) and experienced less iatrogenic withdrawal syndrome (compared with white patients in either arm or with Hispanic patients in the intervention arm). The percentage of days awake and calm while intubated was not significantly different in pairwise comparisons by race and ethnicity groups in either the control arm (median: white, 75%; Black, 71%; Hispanic, 75%) or the intervention arm (white, 86%; Black, 88%; Hispanic, 85%). Conclusions: Across multiple measures, our study found scattered differences in sedation management among critically ill Black, Hispanic, and white children that did not consistently favor any group. However, racial disparities related to implicit bias cannot be completely ruled out. Clinical trial registered with clinicaltrials.gov (NCT 00814099).

Purpose Despite that human papillomavirus (HPV) vaccination could prevent ∼90% of HPV-associated cancers, only 65.5% of American adolescents initiate vaccination. African Americans have the highest prevalence of morbidity and mortality from HPV-associated cancers. Mounting evidence suggests that advice from social contacts is associated with vaccine acceptance. The present study examines the associations of social processes with HPV vaccine refusal among African American parents. Methods A cross-sectional survey was conducted among African American parents of children aged 10–12 years before a health-care visit at which HPV vaccine was offered by the health-care provider. Data from the 353 parents who named at least one social contact who advised them about vaccines were included in these analyses. Results Only 54.4% of the participants consented to HPV vaccination for their children. On average, parents had 2 to 3 social contacts who provided vaccine advice. Vaccine advice networks were generally dense, family-centric, and homophilous. Slightly over 80% of all parents trusted family members and friends for vaccine advice “some” or “a lot.” Controlling for sociodemographic characteristics and reason for the health-care visit, perceived high exposure to anti-HPV vaccine viewpoints and low exposure to pro-HPV vaccine viewpoints were both associated with HPV vaccine refusal (adjusted odds ratio = 1.5, 95% confidence interval = 1.01, 2.3, and adjusted odds ratio = 1.7, 95% confidence interval = 1.2, 2.6, respectively). Conclusions Social processes may be associated with HPV vaccine refusal among African American parents. Interventions designed to educate African American parents about HPV vaccine to increase uptake should consider leveraging vaccine advice networks for greater impact.

PURPOSE: Reducing acute care use is an important strategy for improving value in cancer care. However, little information is available to describe and compare population-level hospital use across cancer types. Our aim was to estimate unplanned hospitalization rates and to describe the reasons for hospitalization in a population-based cohort recently diagnosed with cancer. MATERIALS AND METHODS: California Cancer Registry data linked with administrative inpatient data were used to examine unplanned hospitalization among individuals diagnosed with cancer between 2009 and 2012 (n = 412,850). Hospitalizations for maintenance chemotherapy, radiotherapy, or planned surgery were excluded. Multistate models were used to estimate age-adjusted unplanned hospitalization rates, accounting for survival. RESULTS: Approximately 67% of hospitalizations in the year after diagnosis were unplanned, 35% of newly diagnosed individuals experienced an unplanned hospitalization, and 67% of unplanned hospitalizations originated in the emergency department (ED). Nonmalignancy principal diagnoses most frequently associated with unplanned hospitalization included infection (15.8%) and complications of a medical device or care (6.5%). Unplanned hospitalization rates were highest for individuals with hepatobiliary or pancreatic cancer (2.08 unplanned hospitalizations per person-year at risk), lung cancer (1.58 unplanned hospitalizations), and brain or CNS cancer (1.47 unplanned hospitalizations), and were lowest among individuals with prostate cancer (0.18 unplanned hospitalizations) and melanoma (0.25 unplanned hospitalizations). CONCLUSION: The population burden of unplanned hospitalization among individuals newly diagnosed with cancer is substantial. Many unplanned hospitalizations originate in the ED and are associated with potentially preventable admission diagnoses. Efforts to reduce unplanned hospitalization might target subgroups at higher risk and focus on the ED as a source of admission.

Background Improving the quality of cancer care and reducing preventable health system use are goals of increasing importance to health practitioners and policy makers. Emergency department (ED) visits are often cited as a source of preventable health system use, however, few studies have described the incidence of ED use by recently diagnosed cancer patients in population-based samples, and no study has addressed the full spectrum of cancer types. Objective To describe ED use by recently diagnosed cancer patients. Methods California Office of Statewide Health Planning and Development data and the California Cancer Registry were used to describe ED use in the year after a cancer diagnosis (2009-2010). The incidence of ED use was tabulated by cancer type. Logistic regression and recycled predictions were used to examine ED use adjusting for confounding factors. Results Most ED visits (68%) occurred within 180 days of diagnosis. The incidence of ED use for all cancer types examined was 17% within 30 days, 35% within 180 days and 44% within 365 days of diagnosis. ED use varied by cancer type (5%-39% within 30 days of diagnosis; 14% -62% within 180 days; and 22%-69% within 365 days). Patterns of ED use by cancer type remained similar after accounting for demographic and socioeconomic factors. Limitations Those common to administrative and registry datasets. Specifically, we were unable to account for ED visits in relation to cancer treatment dates and comorbid conditions. Conclusions Cancer patients use EDs at higher rates than previously reported, with considerable variability by cancer type. Future research should examine reasons for ED visits by cancer type and identify predictors of ED use, including treatment and comorbid conditions.

Author(s): Koebner, Ian J; Fishman, Scott M; Paterniti, Debora; Sommer, Doris; Witt, Claudia M; Ward, Deborah; Joseph, Jill G | Abstract: ObjectiveThis mixed-methods study examines the feasibility of art museum tours (Art Rx) as an intervention for individuals with chronic pain.MethodsArt Rx provided 1-hour docent-led tours in an art museum to individuals with chronic pain. Survey data were collected pre-tour, immediately post-tour, and at three weeks post-tour. Pain intensity and unpleasantness were measured with a 0-10 numerical rating scale. Social disconnection was measured with a 12-item social disconnection scale. Participants also reported percent pain relief during the tour and program satisfaction in the post-tour survey. Change in pain and social disconnection was analyzed with paired t tests, bias-corrected and accelerated bootstrap confidence intervals (BCa CIs), and Cohen's d. Thematic analysis of semistructured interviews with participants explored the feasibility and perceived impact of the program.ResultsFifty-four individuals participated in this study (mean age [SD] = 59 [14.5] years, 64.8% female), and 14 were interviewed. Fifty-seven percent of participants reported pain relief during the tour, with an average pain relief (SD) of 47% (34.61%). Participants reported decreased social disconnection and pain unpleasantness pre- to post-tour (3.65, BCa 95% CI = 1.70-5.73, P l 0.001, d = 0.37; and 0.49, BCa 95% CI = 0.06-0.90, P = 0.016, d = 0.20, respectively). Participants indicated high satisfaction with the program. Interviewees remarked on the isolating impact of chronic pain and how negative experiences with the health care system often compounded this sense of isolation. Participants experienced Art Rx as a positive and inclusive experience, with potential lasting benefit.ConclusionsArt museum tours for individuals with chronic pain are feasible, and participants reported positive effects on perceived social disconnection and pain.

Objective Healthcare providers (HCPs) are advised to give all parents a strong recommendation for HPV vaccination. However, it is possible that strong recommendations could be less effective at promoting vaccination among African Americans who on average have greater mistrust in the healthcare system. This study examines the associations of parental trust in HCPs and strength of HCP vaccination recommendation on HPV vaccine acceptance among African American parents. Methods Participants were recruited from an urban, academic medical center between July 2012 and July 2014. We surveyed 400 African American parents of children ages 10–12 years who were offered HPV vaccine by their HCPs to assess sociodemographic factors, vaccine beliefs, trust in HCPs, and the HPV vaccine recommendation received. Medical records were reviewed to determine vaccination receipt. Results In multivariable analysis, children whose parents were “very strongly” recommended the HPV vaccine had over four times higher odds of vaccine receipt compared with those whose parents were “not very strongly” recommended the vaccine. Having a parent with “a lot of” versus “none” or only “some” trust in HCPs was associated with over twice the odds of receiving HPV vaccine. Very strong HCP recommendations were associated with higher odds of vaccination among all subgroups, including those with more negative baseline attitudes toward HPV vaccine and those with lower levels of trust. Adding the variables strength of HCP recommendation and parental trust in HCPs to a multivariable model already adjusted for sociodemographic factors and parental vaccine beliefs improved the pseudo R2 from 0.52 to 0.55. Conclusions Among participants, receiving a strong vaccine recommendation and having a higher level of trust in HCPs were associated with higher odds of HPV vaccination, but did not add much to the predictive value of a model that already adjusted for baseline personal beliefs and sociodemographic factors.

Background Agricultural work can expose workers to increased risk of heat strain and volume depletion due to repeated exposures to high ambient temperatures, arduous physical exertion and limited rehydration. These risk factors may result in acute kidney injury (AKI). Methods We estimated AKI cumulative incidence in a convenience sample of 283 agricultural workers based on elevations of serum creatinine between preshift and postshift blood samples. Heat strain was assessed based on changes in core body temperature and heart rate. Volume depletion was assessed using changes in body mass over the work shift. Logistic regression models were used to estimate the associations of AKI with traditional risk factors (age, diabetes, hypertension and history of kidney disease) as well as with occupational risk factors (years in farm work, method of payment and farm task). Results 35 participants were characterised with incident AKI over the course of a work shift (12.3%). Workers who experienced heat strain had increased adjusted odds of AKI (1.34, 95% CI 1.04 to 1.74). Piece rate work was associated with 4.24 odds of AKI (95% CI 1.56 to 11.52). Females paid by the piece had 102.81 adjusted odds of AKI (95% CI 7.32 to 1443.20). Discussion Heat strain and piece rate work are associated with incident AKI after a single shift of agricultural work, though gender differences exist. Modifications to payment structures may help prevent AKI.

BACKGROUND Cancer care coordination addresses the fragmented and inefficient care of individuals with complex care needs. The complexity of care coordination can be aided by innovative technology. Few examples of information technology-enabled care coordination exist beyond the conventional telephone follow-up. For this study, we implemented a custom-designed app, the Personal Health Network (PHN)—a Health Insurance Portability and Accountability Act-compliant social network built around a patient to enable patient-centered health and health care activities in collaboration with clinicians, care team members, caregivers, and others designated by the patient. The app facilitates a care coordination intervention for patients undergoing chemotherapy. OBJECTIVE This study aimed to understand patient experiences with PHN technology and assess their perspectives on the usability and usefulness of PHNs with care coordination during chemotherapy. METHODS A two-arm randomized clinical trial was conducted to compare the PHN and care coordination with care coordination alone over a 6-month period beginning with the initiation of chemotherapy. A semistructured interview guide was constructed based on a theoretical framework of technology acceptance addressing usefulness, usability, and the context of use of the technology within the participant’s life and health care setting. All participants in the intervention arm were interviewed on completion of the study. Interviews were recorded and transcribed verbatim. A summative thematic analysis was completed for the transcribed interviews. Features of the app were also evaluated. RESULTS A total of 27 interviews were completed. The resulting themes included the care coordinator as a partner in care, learning while sick, comparison of other technology to make sense of the PHN, communication, learning, usability, and usefulness. Users expressed that the nurse care coordinators were beneficial to them because they helped them stay connected to the care team and answered their questions. They shared that the mobile app gave them access to the health information they were seeking. Users expressed that the mobile app would be more useful if it was fully integrated with the electronic health record. CONCLUSIONS The findings highlight the value of care coordination from the perspectives of cancer patients undergoing chemotherapy and the important role of technology, such as the PHN, in enhancing this process by facilitating better communication and access to information regarding their illness.

Background Cancer care coordination addresses the fragmented and inefficient care of individuals with complex care needs. The complexity of care coordination can be aided by innovative technology. Few examples of information technology-enabled care coordination exist beyond the conventional telephone follow-up. For this study, we implemented a custom-designed app, the Personal Health Network (PHN)—a Health Insurance Portability and Accountability Act-compliant social network built around a patient to enable patient-centered health and health care activities in collaboration with clinicians, care team members, caregivers, and others designated by the patient. The app facilitates a care coordination intervention for patients undergoing chemotherapy. Objective This study aimed to understand patient experiences with PHN technology and assess their perspectives on the usability and usefulness of PHNs with care coordination during chemotherapy. Methods A two-arm randomized clinical trial was conducted to compare the PHN and care coordination with care coordination alone over a 6-month period beginning with the initiation of chemotherapy. A semistructured interview guide was constructed based on a theoretical framework of technology acceptance addressing usefulness, usability, and the context of use of the technology within the participant’s life and health care setting. All participants in the intervention arm were interviewed on completion of the study. Interviews were recorded and transcribed verbatim. A summative thematic analysis was completed for the transcribed interviews. Features of the app were also evaluated. Results A total of 27 interviews were completed. The resulting themes included the care coordinator as a partner in care, learning while sick, comparison of other technology to make sense of the PHN, communication, learning, usability, and usefulness. Users expressed that the nurse care coordinators were beneficial to them because they helped them stay connected to the care team and answered their questions. They shared that the mobile app gave them access to the health information they were seeking. Users expressed that the mobile app would be more useful if it was fully integrated with the electronic health record. Conclusions The findings highlight the value of care coordination from the perspectives of cancer patients undergoing chemotherapy and the important role of technology, such as the PHN, in enhancing this process by facilitating better communication and access to information regarding their illness.

BACKGROUND Cancer is a top concern in the United States and globally. Cancer care suffers from lack of coordination, silos of information, and high cost. Interest is emerging in developing formalized coordination mechanisms to address these challenges. Person-centered technology can improve coordination, thereby improving the lives and health of individuals with cancer. However, few examples of patient engagement in technology-enabled care coordination exist and we lack tools to measure engagement or adoption. OBJECTIVE The “personal health network” (PHN) developed by the authors fills this gap: a personalized social network built around a patient for collaboration with clinicians, care team members, carers, and others designated by a patient, to enable patient-centered health and health care activities across a relevant community. The PHN is a mobile, social application that integrates person-generated data related to clinical concerns, symptom assessment, a shared care plan, secure messaging, and educational materials for individuals undergoing chemotherapy. The purpose of this study is to understand patients’ acceptance and use of the PHN. METHODS The PHN was implemented in a two arm (n=60), randomized, pragmatic trial of a 6-month-long care coordination intervention at a cancer center. The intervention arm received nurse care coordination plus the PHN on a tablet and a data plan. Technology acceptance was measured with a new Health Technology Acceptance and Use (HTAU) tool validated in an oncology population by one of the authors (KK). HTAU include 8 constructs (33 items): performance expectancy (8 items), effort expectancy (4), social influence (5), facilitating conditions (4), hedonic motivation (3), price-value (3), habit (3), and behavioral intention (3). Each construct score is the mean of the items within it, all rated from 0=not at all to 6=a great deal. HTAU was collected at 3 months and 6 months. We report on 3-month results. RESULTS HTAU at 3 months (n=33 intervention group, 94% response) shows high reliability, and Cronbach alpha is 0.96. The mean total score is 123.72 out of 198 (SD 40.60). The highest scored constructs are facilitating conditions (mean 4.48, SD 0.12), price-value (mean 4.40, SD 0.12), and effort expectancy (mean 3.86, SD 0.11) The lowest scored is habit (mean 2.37, SD 0.08) Other scores are moderate: performance expectancy (mean 3.10, SD 0.40), social influence (mean 3.13, SD 0.10), hedonic motivation (mean 3.30, SD 0.30), and behavioral intention (mean 3.41, SD 0.23). CONCLUSIONS Person-generated data and access to clinical data for patients has potential for improving cancer care coordination. Technologies to support this purpose must be accepted by patients. An in-depth understanding of technology adoption requires rigorous evaluation of the usability and usefulness constructs that underly it. Using HTAU we found that PHN usability was high, usefulness was moderate, and habit formation was low. Further evaluation of final results and interviews will help elucidate which constructs were meaningful, how they relate to outcomes, and suggest where future effort should be focused to improve adoption. This study contributes to person-centered design of technology-enabled care coordination interventions.

Care transitions for individuals with disabling conditions, such as stroke, are often ineffective and inefficient, resulting in unmet patient and caregiver (CG) needs, increased safety risks, high rates of preventable readmissions, and increased health care costs. This is particularly problematic for stroke patients transitioning from an inpatient rehabilitation facility (IRF) to home. There is no assessment instrument specifically designed to evaluate a family member’s commitment and capacity to assume the caregiving role following a stroke survivor (SS) discharge from an IRF or sub-acute facility. This is critically needed to facilitate the development of tailored care plans and interventions to mitigate risks associated with the crisis of stroke and the associated health effects on the CG and SS. The purpose of this study is determine the psychometric properties of the Preparedness Assessment for the Transition Home after Stroke (PATH-s) instrument. The PATH-s instrument is a 25-item, 4-point scale based on the foundational work of B. Lutz (Co-Investigator). A prospective cohort study was conducted to establish the psychometric properties of the PATH-s instrument using a convenience sample of 184 SSs and their family caregivers during IRF admission. Data collection from SSs and CGs at IRF admission was conducted to determine the quality of the items, internal consistency, reliability, construct validity, and criterion-related validity. We will describe the characteristics of CG responses on the PATH-s instrument during IRF in addition to correlation with other measures (general health, perceived stress, depression). This novel instrument can support a primary prevention strategy to identify gaps in preparedness for stroke survivor-caregiver dyads following the complex transition from IRF to home, with the long-range goal to mitigate the effects of suboptimal preparation and the associated adverse effects associated with this transition on the health of CGs and SSs. Once gaps are identified, care plans can be tailored to address gaps and better prepare caregivers for the transition home.

New models of healthcare delivery such as accountable care organizations and patient-centered medical homes seek to improve quality, access, and cost. They rely on a robust, secure technology infrastructure provided by health information exchanges (HIEs) and distributed research networks and the willingness of patients to share their data. There are few large, in-depth studies of US consumers’ views on privacy, security, and consent in electronic data sharing for healthcare and research together. Objective This paper addresses this gap, reporting on a survey which asks about California consumers’ views of data sharing for healthcare and research together. Materials and Methods The survey conducted was a representative, random-digit dial telephone survey of 800 Californians, performed in Spanish and English. Results There is a great deal of concern that HIEs will worsen privacy (40.3%) and security (42.5%). Consumers are in favor of electronic data sharing but elements of transparency are important: individual control, who has access, and the purpose for use of data. Respondents were more likely to agree to share deidentified information for research than to share identified information for healthcare (76.2% vs 57.3%, p < .001). Discussion While consumers show willingness to share health information electronically, they value individual control and privacy. Responsiveness to these needs, rather than mere reliance on Health Insurance Portability and Accountability Act (HIPAA), may improve support of data networks. Conclusion Responsiveness to the public’s concerns regarding their health information is a pre-requisite for patient-centeredness. This is one of the first in-depth studies of attitudes about electronic data sharing that compares attitudes of the same individual towards healthcare and research.

Author(s): Nutor, Jerry John; Bell, Janice F; Slaughter-Acey, Jaime C; Joseph, Jill G; Apesoa-Varano, Ester Carolina; de Leon Siantz, Mary Lou | Abstract: IntroductionAlthough the association between child mortality and socioeconomic status is well established, the role of household assets as predictors of child mortality, over and above other measures of socioeconomic status, is not well studied in developing nations. This study investigated the contribution of several household resources to child mortality, beyond the influence of maternal education as a measure of socioeconomic status.MethodsThis secondary analysis used data from the 2007 Ghana Maternal Health Survey to explore the relationship of child mortality to household resources. The analysis of 7183 parous women aged 15-45 years examined household resources for their association with maternal reports of any child's death for children aged less than 5 years using a survey-weighted logistic regression model while controlling for sociodemographic and health covariates.ResultsThe overall household resources index was significantly associated with the death of one or more child in the entire sample (adjusted odd ratios (OR)=0.95; 95% confidence interval (CI): 0.92, 0.98]. In stratified analysis, this finding held for women living in rural but not in urban areas. Having a refrigerator at the time of interview was associated with lower odds of reporting child mortality (OR=0.63; 95%CI: 0.48, 0.83). Having a kerosene lantern (OR=1.40; 95%CI: 1.06, 1.85) or flush toilet (OR=1.84; 95%CI: 1.23, 2.75) was associated with higher odds of reporting child mortality. Adjusted regression models showed only possession of a refrigerator retained significance.ConclusionsPossession of a refrigerator may play a role in child mortality. This finding may reflect unmeasured socioeconomic status or the importance of access to refrigeration in preventing diarrheal disease or other proximal causes of child mortality in sub-Saharan Africa.

Author(s): Lash, Rebecca S; Bell, Janice F; Reed, Sarah C; Poghosyan, Hermine; Rodgers, James; Kim, Katherine K; Bold, Richard J; Joseph, Jill G | Abstract: BackgroundRecent reports call for reductions in costly and potentially avoidable services such as emergency department (ED) visits. Providing high-quality and safe care for oncology patients remains challenging for ED providers given the diversity of patients seeking care and the unpredictable clinical environment. While ED use by oncology patients is appropriate for acute health concerns, some ED visits may be preventable with well-coordinated care and adequate symptom management.ObjectiveThe aim of this study was to summarize available evidence regarding the incidence, predictors of, and reasons for ED visits among oncology patients.MethodsKeyword/MeSH term searches were conducted using 4 online databases. Inclusion criteria were publication date between April 1, 2003, and December 5, 2014; sample size of 50 or more; and report of the incidence or predictors of ED use among oncology patients.ResultsThe 15 studies that met criteria varied in study aim, design, and time frames for calculating ED utilization rates. The incidence of ED visits among oncology patients ranged from 1% to 83%. The 30-day standardized visit rate incidence ranged from 1% to 12%. Collectively, the studies lack population-based estimates for all cancers combined.ConclusionsThe studies included in this review suggest that rates of ED use among cancer patients exceed those of the general population. However, the extent of ED use by oncology patients and the reasons for ED visits remain understudied.Implications for practiceNurses are involved in the treatment of cancer, patient education, and symptom management. Nurses are well positioned to develop patient-centered treatment and care coordination plans to improve quality of care and reduce ED visits.

The Human papillomavirus (HPV) vaccine has been available for protection against HPV-associated cervical cancer and genital warts since 2006. Nonetheless, uptake has varied among countries and populations within countries. Studies have found that individuals' knowledge and attitudes toward the vaccine are associated with immunization uptake. The purpose of the current review is to summarize and evaluate the evidence for educational interventions to increase HPV vaccination acceptance.We searched the databases of PubMed and Web of Science for English-language articles describing educational interventions designed to improve HPV vaccination uptake, intention or attitude.We identified 33 studies of HPV vaccination educational interventions: 7 tested the effectiveness of interventions with parents, 8 with adolescents or young adults, and 18 compared the effectiveness of different message frames in an educational intervention among adolescents, young adults or their parents. Most studies involved populations with higher educational attainment and most interventions required participants to be literate. The minority of studies used the outcome of HPV vaccine uptake. Well-designed studies adequately powered to detect change in vaccine uptake were rare and generally did not demonstrate effectiveness of the tested intervention.There is not strong evidence to recommend any specific educational intervention for wide-spread implementation. Future studies are required to determine the effectiveness of culturally-competent interventions reaching diverse populations.

© 2015, Springer Science+Business Media New York. Purpose: The aim of this study is to examine predictors of cancer-related financial difficulties and work modifications in a national sample of cancer survivors. Methods: Using the 2011 Medical Expenditure Panel Survey and Experiences with Cancer Survivorship Supplement, the prevalence of financial difficulties and work modifications was examined. Logistic regression and survey weights were used to model these outcomes as functions of sociodemographic and health covariates separately among survivors in active treatment and survivors under age 65 years. Results: Among all survivors, 33.2 % reported any financial concern, with 17.9 % reporting financial difficulties such as debt or bankruptcy. Among working survivors, 44.0 % made any work modification and 15.3 % made long-term work modifications (e.g., delayed or early retirement). Among those in active treatment, predictors of financial difficulty included: race/ethnicity other than white, non-Hispanic [OR = 8.0; 95 % CI 2.2–28.4]; income

Objective: To reduce direct parental referral of low acuity ill pediatric patients to the outpatient facilities of a nation’s only pediatric referral hospital. Patients and Methods: Longitudinal monitoring of outpatient visits at Orotta Children’s Hospital (OCH) and primary health facilities (PHFs) following implementation of an intervention designed in response to information provided by parents and health-care providers. Parental surveys were undertaken before and after exposure to the intervention to assess effects on knowledge, attitudes, and behavioral intentions. Results: We analyzed 5,639 visits between baseline and follow-up, documenting a decline in parental referral among OCH outpatients from 95% to approximately 80%. Educational intervention increased the proportion of parents intending to use PHF for future outpatient care from 28% to 82%. Staff of the PHFs responded enthusiastically to this intervention program and requested further activities. Conclusions: Self-referral to tertiary care hospital was reduced following a modest program of parental education designed and implemented by residents in training.

Adolescent mothers and their children are particularly susceptible to witnessing or directly experiencing violence. Such violence exposure predicts maternal distress, parenting, and child behavior problems. The current study examined how mothers’ depressive symptoms, aggression, harsh disciplinary practices, and home environment independently explain the association between mothers’ violence exposure and children’s externalizing and internalizing behavior, controlling for their children’s violence exposure. Data were collected from 230 African American mothers living in Washington, DC who gave birth as adolescents and whose children were 3 to 5 years old. Path analysis revealed that the effect of mothers’ experienced violence on children’s externalizing and internalizing behavior was mediated by mothers’ depressive symptoms and aggression. However, neither harsh discipline nor stimulation in the home environment acted as significant mediators, and there were no direct or indirect effects of mothers’ witnessed violence on child behavior. This study builds on previous work by identifying an association between maternal violence exposure and children’s behavior, independent of children’s own violence exposure that is explained by mothers’ increased distress but not their parenting. These findings suggest that a potential means of preventing behavior problems in minority children born to adolescent mothers is to identify mothers who have been directly exposed to violence and treat their depressive symptoms and aggressive behaviors.

Urban, minority, adolescent mothers are particularly vulnerable to violence exposure, which may increase their children's developmental risk through maternal depression and negative parenting. The current study tests a conceptual model of the effects of community and contextual violence exposure on the mental health and parenting of young, African-American mothers living in Washington, DC. A path analysis revealed significant direct effects of witnessed and experienced violence on mothers' depressive symptoms and general aggression. Experiences of discrimination were also associated with increased depressive symptoms. Moreover, there were significant indirect effects of mothers' violence exposure on disciplinary practices through depression and aggression. These findings highlight the range of violence young African-American mothers are exposed to and how these experiences affect their mental health, particularly depressive symptoms, and thus disciplinary practices.

The prevalence of children's violence exposure, particularly among ethnic minorities living in urban areas, is troubling. Gender differences in the rates and effects of violence exposure on behavior have been found for older children, and the current study extends this research to preschool-age children. We draw on data collected from a sample of 3- to 5-year-olds born to 230 adolescent African American mothers living in Washington, DC. Girls and boys were exposed to comparable levels of witnessed and directly experienced violence. In contrast to findings from studies of older children, preschool-age boys' and girls' externalizing and internalizing behavior were comparably associated with directly experienced and witnessed violence. These findings highlight the importance of further developmental research to differentiate the effects of violence exposure as children grow older.

Environmental tobacco smoke (ETS) exposure during pregnancy contributes to adverse infant health outcomes. Limited previous research has focused on identifying correlates of ETS avoidance. This study sought to identify proximal and more distal correlates of ETS avoidance early in pregnancy among African-American women.From a sample of low-income, black women (n=1044) recruited in six urban, prenatal care clinics (July 2001-October 2003), cotinine-confirmed nonsmokers with partners, household/family members, or friends who smoked (n=450) were identified and divided into two groups: any past-7-day ETS exposure and cotinine-confirmed ETS avoidance. Bivariate and multivariate logistic regression analyses identified factors associated with ETS avoidance. Data were initially analyzed in 2004. Final models were reviewed and revised in 2007 and 2008.Twenty-seven percent of pregnant nonsmokers were confirmed as ETS avoiders. In multivariate logistic regression analysis, the odds of ETS avoidance were increased among women who reported household smoking bans (OR=2.96; 95% CI=1.83, 4.77; p0.0001), that the father wanted the baby (OR=2.70; CI=1.26, 5.76; p=0.01), and that no/few family members/friends smoked (OR=3.15; 95% CI=1.58, 6.29; p0.001). The odds were decreased among women who had a current partner (OR=0.42; 95% CI=0.23, 0.76; p0.01), reported any intimate partner violence during pregnancy (OR=0.43; 95% CI=0.19, 0.95; p0.05), and reported little social support to prevent ETS exposure (OR=0.50; 95% CI=0.30, 0.85; p=0.01). Parity, emotional coping strategies, substance use during pregnancy, partner/household member smoking status, and self-confidence in avoiding ETS were significant in bivariate, but not multivariate analyses.Social contextual factors were the strongest determinants of ETS avoidance during pregnancy. Results highlight the importance of prenatal screening to identify pregnant nonsmokers at risk, encouraging household smoking bans, gaining support from significant others, and fully understanding the interpersonal context of a woman's pregnancy before providing behavioral counseling and advice to prevent ETS exposure.

OBJECTIVE: To evaluate the efficacy of an integrated multiple risk intervention, delivered mainly during pregnancy, in reducing such risks (cigarette smoking, environmental tobacco smoke exposure, depression, and intimate partner violence) postpartum. METHODS: Data from this randomized controlled trial were collected prenatally and on average 10 weeks postpartum in six prenatal care sites in the District of Columbia. African Americans were screened, recruited, and randomly assigned to the behavioral intervention or usual care. Clinic-based, individually tailored counseling was delivered to intervention women. The outcome measures were number of risks reported postpartum and reduction of these risks between baseline and postpartum. RESULTS: The intervention was effective in significantly reducing the number of risks reported in the postpartum period. In bivariate analyses, the intervention group was more successful in resolving all risks (47% compared with 35%, P=.007, number needed to treat=9, 95% confidence interval [CI] 5-31) and in resolving some risks (63% compared with 54%, P=.009, number needed to treat=11, 95% CI 7-43) as compared with the usual care group. In logistic regression analyses, women in the intervention group were more likely to resolve all risks (odds ratio 1.86, 95% CI 1.25-2.75, number needed to treat=7, 95% CI 4-19) and resolve at least one risk (odds ratio 1.60, 95% CI 1.15-2.22, number needed to treat=9, 95% CI 6-29). CONCLUSION: An integrated multiple risk factor intervention addressing psychosocial and behavioral risks delivered mainly during pregnancy can have beneficial effects in risk reduction postpartum. Language: en

There have been an increasing number of descriptive analyses of pediatric medical errors as the release of the Institute of Medicine reports over 5 years ago (IOM 2000, IOM 2001, IOM 2004). These include single and multi-institution studies, studies of medication errors, and several broad characterizations of medical errors in hospitalized children. The incidence of medical errors in hospitalized children is estimated to range from 0.8 to 1.3 percent and is highly dependent upon the definitions and classifications used (Brennan et al. 1991; Localio et al. 1991; Smith, Langlois, and Buechner 1991; Rosen et al. 1992; Silber et al. 1992; Roos et al. 1995; Duke, Butt, and South 1997; Gawande et al. 1999; McCormick et al. 2000; Miller et al. 2001; Connors et al. 2001; Kaushal et al. 2001; Davis et al. 2002; Miller, Elixhauser, and Zhan 2003; Proctor et al. 2003; Slonim et al. 2003; Kanter, Turenne, and Slonim 2004; Miller and Zhan 2004; Sedman et al. 2005). The study of pediatric medical errors has been limited by the relatively small numbers of children hospitalized at individual institutions and the need for detailed prospective and retrospective reviews. One method of overcoming the methodological challenges of small sample sizes and the potential idiosyncrasies of data from a single institution is to use administrative datasets that contain large volumes of discharges from multiple institutions (McCormick et al. 2000; Miller et al. 2001; Miller, Elixhauser, and Zhan 2003; Proctor et al. 2003; Slonim et al. 2003; Kanter, Turenne, and Slonim 2004; Miller and Zhan 2004; Sedman et al. 2005). Miller and colleagues developed an effective method for screening the large number of discharges in these datasets to identify potential medical errors (Miller et al. 2001; Miller, Elixhauser, and Zhan 2003; Miller and Zhan 2004). This method uses events known as patient safety indicators (PSIs). For pediatric patients, analyses of PSIs have included both community hospitals and Children's hospitals (Miller et al. 2001; Miller, Elixhauser, and Zhan 2003; Miller and Zhan 2004). However, when synthesized, the prior literature on medical errors in children during hospitalization is subject to two important caveats, both of which are informed by this study. First, inpatient error estimates generated using the PSI method are likely to be higher in freestanding, academic Children's Hospitals where children with complex conditions receive their care, because children with more complex health care needs may be more prone to medical errors (Miller, Elixhauser, and Zhan 2003; Slonim et al. 2003). Therefore, a description of the types and frequencies of PSIs in a unique dataset of these institutions may help to prioritize efforts aimed at reducing their occurrence in specific subgroups of patients (Slonim et al. 2003). These associations and the incidence rates, however, may be misrepresented if the analytic approach inadequately considers the statistical methods used in the analysis. The second caveat addresses the analytic approach and the methodological challenge that occurs when modeling a multi-institutional dataset (Normand, Glickman, and Gastoonis 1997; y,Snijders and Bosker 1999; McCulloch and Searle 2000; Williams 2000; Leyland and Goldstein 2001; Palta 2003; Loehlin 2004; Luke 2004; Skrondal and Hesketh 2004; Zaslavasky, Zaborski, and Cleary 2004). Patients being treated in the same hospital may be more similar to each other than those treated in other hospitals. Independence, one of the key assumptions for regression, is violated under these circumstances. Therefore, unmeasured hospital characteristics that introduce variability into the results require additional effort to appropriately control. Several techniques can account for the “clustering” which exists in the dataset. Clustering represents the correlations associated with data that are organized at specific sites or levels. The techniques used to adjust for hospital clustering, which allow for measuring both patient and hospital level characteristics are, as a group, referred to as hierarchical or mixed models (Goldstein 1987, Goldstein, 1995; Gatsonis et al. 1995; Daniels and Gastonis 1999; Landrum and Normand 1999; Landrum et al. 1999; Burgess and Lourdes 2000; Bryck and Raudnebush 2002; Hox 2002). The justifications for performing these models arise from empirical, statistical, and theoretical foundations, but their usefulness in practice remains questionable. The empirical justification arises from the possibility that the rates of PSIs differ at the individual hospital level (Goldstein 1987; Snijders 1999; Williams 2000; Bryck and Raudenbush 2002; Palta 2003; Loehlin 2004; Luke 2004; Skrondal 2004). Second, a statistical justification arises from the fact that the cases are not independent, but are clustered by hospital and may have correlated errors. Third, a theoretical justification would suggest that a multilevel model will more accurately estimate the extent to which both the patient-level and hospital-level characteristics influence PSI rates. Consequently, we studied the incidence rates of PSIs in children hospitalized at a sample of academic Children's Hospitals and accounted for the effects of hospital “clustering” using three different statistical modeling techniques. We compared these models to a “base-state” that excluded institutional variables to determine the effect that each of these techniques may have on the characteristics associated with PSIs.

O RIGINAL C ONTRIBUTION Relationship of Physician-identified Patient Race and Ethnicity to Use of Computed Tomography in Pediatric Blunt Torso Trauma JoAnne E. Natale, MD, PhD, Jill G. Joseph, MD, PhD, Alexander J. Rogers, MD, Michael Tunik, MD, David Monroe, MD, Benjamin Kerrey, MD, MS, Bema K. Bonsu, MD, Lawrence J. Cook, MStat, PhD, Kent Page, MStat, Kathleen Adelgais, MD, MPH, Kimberly Quayle, MD, Nathan Kuppermann, MD, MPH, and James F. Holmes, MD, MPH Abstract Objectives: The objective was to determine whether a child’s race or ethnicity as determined by the treating physician is independently associated with receiving abdominal computed tomography (CT) after blunt torso trauma. Methods: We performed a planned secondary analysis of a prospective observational cohort of children < 18 years old presenting within 24 hours of blunt torso trauma to 20 North American emergency departments (EDs) participating in a pediatric research network, 2007–2010. Treating physicians documented race/ethnicity as white non-Hispanic, black non-Hispanic, or Hispanic. Using a previously derived clinical prediction rule, we classified each child’s risk for having an intra-abdominal injury undergoing acute intervention to define injury severity. We performed multivariable analyses using generalized estimating equations to control for confounding and for clustering of children within hospitals. Results: Among 12,044 enrolled patients, treating physicians documented race/ethnicity as white non- Hispanic (n = 5,847, 54.0%), black non-Hispanic (n = 3,687, 34.1%), or Hispanic of any race (n = 1,291, 11.9%). Overall, 51.8% of white non-Hispanic, 32.7% of black non-Hispanic, and 44.2% of Hispanic children underwent abdominal CT imaging. After age, sex, abdominal ultrasound use, risk for intra- abdominal injury undergoing acute intervention, and hospital clustering were adjusted for, the likelihood of receiving an abdominal CT was lower (odds ratio [OR] = 0.8, 95% confidence interval [CI] = 0.7 to 0.9) for black non-Hispanic than for white non-Hispanic children. For Hispanic children, the likelihood of receiving an abdominal CT did not differ from that observed in white non-Hispanic children (OR = 0.9, 95% CI = 0.8 to 1.1). Conclusions: After blunt torso trauma, pediatric patients identified by the treating physicians as black non-Hispanic were less likely to receive abdominal CT imaging than those identified as white non- Hispanic. This suggests that nonclinical factors influence clinician decision-making regarding use of From the Department of Pediatrics (JEN, NK), the Betty Irene Moore School of Nursing (JGJ), and the Department of Emergency Medicine (NK, JFH), University of California at Davis, Sacramento, CA; the Departments of Emergency Medicine and Pediatrics, University of Michigan Medical Center and University of Michigan School of Medicine (AJR), Ann Arbor, MI; the Departments of Pediatrics and Emergency Medicine, New York University School of Medicine (MT), New York City, NY; Howard County General Hospital, Columbia (DM), MD; the Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati (BK), OH; the Department of Pediatrics, Nationwide Children’s Hospital (BKB), Columbus, OH; the Department of Pediatrics, University of California at San Diego (BKB), San Diego, CA; the University of Utah (LJC, KP), Salt Lake City, UT; the Department of Pediatrics and Emergency Medicine, University of Colorado (KA), Denver, CO; and the St. Louis Children’s Hospital, Washington University (KQ), St. Louis, MO. Participating centers and site investigators for the Pediatric Emergency Care Applied Research Network (PECARN) are listed in Appendix A. Received September 7, 2015; revision received December 2, 2015; accepted December 14, 2015. This work was presented in part at the Society for Academic Emergency Medicine Annual Meeting, Dallas, TX, May 2014. This work was supported by a grant from the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 1 R49CE00100201. The Pediatric Emergency Care Applied Research Network (PECARN) is supported by cooperative agreements U03MC00001, U03MC00003, U03MC00006, U03MC00007, U03MC00008, U03MC22684, and U03MC22685 from the EMSC program of the MCHB/HRSA. Supervising Editor: Jennifer D. H. Walthall, MD. Address for correspondence and reprints: JoAnne E. Natale, MD, PhD, FAAP; e-mail: jenatale@ucdavis.edu. ISSN 1069-6563 PII ISSN 1069-6563583 © 2016 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12943

Objective To determine the initial effectiveness of a novel, pediatric office-based intervention in motivating mothers to seek further assessment of positive depression screens. Methods In this pilot randomized controlled trial, English-speaking mothers (n = 104) with positive 2-question depression screens and presenting with children 0 to 12 years old for well-child care to a general pediatric training clinic received interventions from a trained research assistant. The Motivating Our Mothers (MOM) intervention included office-based written and verbal targeted depression education and motivational messages encouraging further depression assessment and a semistructured telephone booster delivered 2 days later. The control intervention included nontargeted written and verbal messages and 2 days later, an attention control telephone survey. Both groups received a list of depression care resources. The primary outcome was the proportion of mothers in each group who reported trying to contact any of 6 types of resources to discuss the positive screen at 2 weeks after intervention (ClinicalTrials.gov NCT01453790). Results Despite 6 contact attempts, 10 MOM and 9 control mothers were lost to follow-up. More mothers in the MOM intervention tried to contact a resource compared to control (73.8% vs 53.5%, difference 20.3%, 95% confidence interval for difference −0.1 to 38.5, P = .052). Conclusions Mothers receiving the MOM intervention made more attempts to contact a resource for follow-up of positive depression screens. If found effective in larger studies, MOM may prove a promising approach for motivating depression screen–positive mothers identified in general pediatric settings within and beyond the postpartum period to seek further depression assessment and support.

Online information can influence attitudes toward vaccination. The aim of the present study was to provide a systematic evaluation of the search engine ranking, quality, and content of Web pages that are critical versus noncritical of human papillomavirus (HPV) vaccination.We identified HPV vaccine-related Web pages with the Google search engine by entering 20 terms. We then assessed each Web page for critical versus noncritical bias and for the following quality indicators: authorship disclosure, source disclosure, attribution of at least one reference, currency, exclusion of testimonial accounts, and readability level less than ninth grade. We also determined Web page comprehensiveness in terms of mention of 14 HPV vaccine-relevant topics.Twenty searches yielded 116 unique Web pages. HPV vaccine-critical Web pages comprised roughly a third of the top, top 5- and top 10-ranking Web pages. The prevalence of HPV vaccine-critical Web pages was higher for queries that included term modifiers in addition to root terms. Compared with noncritical Web pages, Web pages critical of HPV vaccine overall had a lower quality score than those with a noncritical bias (p.01) and covered fewer important HPV-related topics (p.001). Critical Web pages required viewers to have higher reading skills, were less likely to include an author byline, and were more likely to include testimonial accounts. They also were more likely to raise unsubstantiated concerns about vaccination.Web pages critical of HPV vaccine may be frequently returned and highly ranked by search engine queries despite being of lower quality and less comprehensive than noncritical Web pages.

Academic health centers, health systems, and, to a lesser degree, medical schools and residency programs have merged, consolidated, or formed strategic alliances. There are few published reports of residency program mergers, and only one involving a merger between a historically black college and university (HBCU) and a predominantly white institution.This case study describes a merger between two dissimilar urban pediatric residency programs. The Howard University Hospital (HUH) pediatric residency program is affiliated with a HBCU, and the Children's National Medical Center (CNMC) pediatric residency program, is affiliated with a leading children's hospital which had relatively few underrepresented minority physicians or residents. The pediatric residency program merger between HUH and CNMC occurred in 2003 and presented organizational, cultural, and programmatic challenges and opportunities for both institutions. However, there was a sharp contrast between the opinions of the HUH and CNMC residents with respect to the perceived effect of the merger on residency training, patient care, and the individual institutions. Increasing the size and diversity of CNMC's resident pool and the granting of accreditation for the community health track were positive outcomes, but the magnitude of the institutional change process and the disruption to residents' routines and schedules were significant challenges. The merger served as an impetus to embed cultural competency guiding principles and expectations into the organizational fabric of the combined residency program.

Objective.The American Academy of Pediatrics (AAP) recommends that parents not use harsh disciplinary practices. Previous studies have characterized the disciplinary practices of African American parents as harsh, with reliance on more aggressive techniques not currently recommended by the AAP. However, recent research has indicated more disciplinary practice diversity among African Americans. This study describes factors associated with the use of AAP-recommended disciplinary practices among lower-income African American caregivers of children in Head Start.Methods.Subjects were caregivers of children at three Head Start sites. Participants were eligible for inclusion if the biological mother, biological father, or target child was identified as African American. Using consensus methods, responses to the Parental Discipline Methods Interview (PDMI) were described as consistent or inconsistent with AAP guidelines regarding use of negative disciplinary practices (e.g., spanking, yelling). Caregivers avoiding any of these inconsistent methods were referred to as “adherent.”Results.“Adherent” caregivers were older (32.5 years vs. 30.4 years) and had more education (86.0% vs. 75.4% high school graduates). They were also less likely to report that their child had behavioral problems (12.9% vs. 25.2%) or deficient social skills (1.7% vs. 8.0%).Conclusions.Lower-income African American caregivers were more likely to use disciplinary practices consistent with AAP guidelines if they had higher levels of education and were living in an urban setting. Caregivers describing their child as having fewer behavior problems, better social skills, or themselves as less stressed were also more likely to be “adherent.”

Objectives: To determine if there are racial/ethnic differences in the rates of appendiceal rupture among the children of two large states. Because rupture is primarily due to delayed diagnosis, differences would suggest disparities in timely access to quality emergency care. Methods: This was an observational, cross-sectional analysis of full-year samples of acute appendicitis cases from California and New York children 4 to 18 years old. Racial/ethnic groups were compared for risk of appendiceal rupture adjusted for biological factors both before and after adjustment for the following socioeconomic, hospital, and admission characteristics: income, insurance, hospital type, and admission source. Results were interpreted in light of census data on the proportion of immigrants in each racial/ethnic group. Results: Compared with white children with acute appendicitis, Hispanic and Asian children have higher odds of rupture in California, whereas Asian and black/African American children have higher odds in New York. These differences roughly parallel the within-state proportion of immigrant children in these groups. Adjustments for family, socioeconomic, and hospital characteristics attenuate but do not eliminate disparities. Conclusions: The authors found evidence of significant racial/ethnic disparities in rate of appendiceal rupture, an important and preventable outcome, in two large but dissimilar states. Immigrant groups may be most at risk for delayed emergency care. Future research should focus on immigration and acculturation as risk factors for appendicitis rupture in children.

© 2013 by the American College of Medical Quality. This study assessed the impact of participation in a virtual quality improvement (QI) learning network on adherence to clinical guidelines for childhood obesity prevention in rural clinics. A total of 7 primary care clinics in rural California included in the Healthy Eating Active Living TeleHealth Community of Practice and 288 children seen in these clinics for well-child care participated in this prospective observational pre-post study. Clinics participated in a virtual QI learning network over 9 months to implement best practices and to exchange strategies for improvement. Following the intervention, documentation of weight assessment and counseling increased significantly. Children who received care from clinicians who led the implementation of the intervention at their clinic showed significant improvements in nutrition and physical activity. Virtual QI learning networks in geographically dispersed clinics can significantly increase clinicians’ adherence to guidelines for childhood obesity and improve access to recommended care for rural and underserved children.

Objective Patients' trust in their primary care providers has important implications in terms of health outcomes and, among minority patients, mitigating racial health disparities. This study aims to identify family, provider, and health care setting characteristics that predict African American parents' trust in their child's primary care provider and whether provider partnership-building communication style explains this association. Methods Data were collected via retrospective telephone interviews completed 2 weeks after a child's health care visit to 1 of 7 pediatric primary care clinics in Washington, DC (3 community health centers, 3 private practices, and 1 hospital-based clinic). Four hundred twenty-five self-identified African American parents of children 0 to 5 years of age participated. Parents completed several standard survey instruments about trust and provider communication style as well as demographic questionnaires about their family and their child's provider. Results A step-wise linear regression revealed significant independent effects of having a previous relationship with the provider and seeing a provider in a community health center (CHC) on higher trust. There was also evidence of mediation by provider communication style, suggesting that parents who take their child to a CHC report greater trust in their child's provider because they have higher perceptions of provider partnership building. Conclusions African American parents' trust in their child's provider may be enhanced by continuity of care and greater use of a partnership-building communication style by providers.

In 1984, over 1000 gay and bisexual men volunteered to participate in both the Chicago Multicenter AIDS Cohort Study (MACS) and a companion psychosocial study, the Coping and Change Study (CCS). Participants in the semiannual Chicago MACS/CCS evaluations comprise the largest cohort of high-risk men under continuous medical, behavioral, and psychosocial observation. Chicago MACS/CCS researchers prospectively chart the sexual behavior change patterns of the cohort and relate those behavioral changes to psychosocial correlates and actual HIV infection risk. This report summarizes the behavioral natural history of the Chicago MACS/CCS cohort from 1984 to 1990, focusing on receptive anal sex practices and use patterns for alcohol and the most frequently used recreational drugs. As these are prospective observational and not controlled intervention studies, psychosocial correlates of sexual behavior change by members of the cohort are suggestive of factors influencing behavior change rather than indicative of causal relationships. However, the voluntary availability to participants in the Chicago MACS/CCS of HIV-1 antibody test results beginning in late 1985 provided the opportunity to examine whether demographic, psychosocial, or behavioral factors were indicators of sexual behavior change following disclosure and counseling about HIV-1 serostatus. Recommendations for promotion and maintenance of safer sexual behavior for the long run, and limitations in the generalizability of these findings to the much more diverse populations of men who have sex with other men conclude this article.

While biomedical risks contribute to poor pregnancy and neonatal outcomes in African American (AA) populations, behavioral and psychosocial risks (BPSR) may also play a part. Among low income AA women with psychosocial risks, this report addresses the impacts on pregnancy and neonatal outcomes of an integrated education and counseling intervention to reduce BPSR, as well as the contributions of other psychosocial and biomedical risks. Subjects were low income AA women ≥18 years living in the Washington, DC, metropolitan area and seeking prenatal care. Subjects (n = 1,044) were screened for active smoking, environmental tobacco smoke exposure (ETSE), depression, or intimate partner violence (IPV) and then randomized to intervention (IG) or usual care (UCG) groups. Data were collected prenatally, at delivery, and postpartum by maternal report and medical record abstraction. Multiple imputation methodology was used to estimate missing variables. Rates of pregnancy outcomes (miscarriage, live birth, perinatal death), preterm labor, Caesarean section, sexually transmitted infection (STI) during pregnancy, preterm birth (37 weeks), low birth weight (2,500 g), very low birth weight (1,500 g), small for gestational age, neonatal intensive care unit (NICU) admission, and2 days of hospitalization were compared between IG and UCG. Logistic regression models were created to predict outcomes based on biomedical risk factors and the four psychosocial risks (smoking, ETSE, depression, and IPV) targeted by the intervention. Rates of adverse pregnancy and neonatal outcomes were high and did not differ significantly between IG and UCG. In adjusted analysis, STI during the current pregnancy was associated with IPV (OR = 1.41, 95% CI 1.04-1.91). Outcomes such as preterm labor, caesarian section in pregnancy and preterm birth, low birth weight, small for gestational age, NICU admissions and2 day hospitalization of the infants were associated with biomedical risk factors including preexisting hypertension and diabetes, previous preterm birth (PTB), and late initiation of prenatal care, but they were not significantly associated with active smoking, ETSE, depression, or IPV. Neither the intervention to reduce BPSR nor the psychosocial factors significantly contributed to the pregnancy and neonatal outcomes. This study confirms that biomedical factors significantly contribute to adverse outcomes in low income AA women. Biomedical factors outweighed psychosocial factors in contributing to adverse pregnancy and neonatal outcomes in this high-risk population. Early identification and management of hypertension, diabetes and previous PTB in low income AA women may reduce health disparities in birth outcomes. Level of evidence I.

Objective To identify family, provider, and healthcare setting characteristics associated with African-American parents’ perceptions of partnership with their child’s primary care provider. Study design Data were collected via a telephone survey of 425 African-American parents of 0- to 5-year-old children who had presented for a health visit 1 to 2 weeks earlier at participating pediatric primary care practices in Washington, DC. Parents’ perceptions of the level of partnership building by their child’s provider were assessed using the Street Provider Communication Style instrument. Results Multivariate logistic regression models indicated that, after adjusting for other family and provider/setting characteristics, parents seen in community health centers were more likely to report high partnership building compared with parents seen at private or hospital-based practices. Parents with at least a college education and those who described their child’s provider’s race as “other” were most likely to report moderate partnership building. Conclusions Future studies should examine elements of care delivery at community health centers that may lead to better partnerships between parents and providers in private and hospital- based practice settings.

Since initial reports emerged of an association between recreational drug use and high-risk sexual behaviors in gay men, there has been interest in studying this relationship for its relevance to behavioral interventions. Reported here are the longitudinal patterns of alcohol and recreational drug use in the Chicago Multicenter AIDS Cohort Study (MACS)/Coping and Change Study (CCS) of gay men. A pattern of decreasing drug use over 6 years was observed that paralleled a decline in high-risk sexual behavior (i.e., unprotected anal intercourse). In contrast, alcohol consumption tended to be more stable over time, and to show no relationship to sexual behavior change. Men who combined volatile nitrite (popper) use with other recreational drugs were at highest risk both behaviorally and in terms of human immunodeficiency virus-1 (HIV) seroconversion throughout the study. Popper use also was associated independently with lapse from safer sexual behaviors (failure to use a condom during receptive anal sex). Use of other recreational substances showed no relationship to sexual behavior change patterns, and stopping popper use was unrelated to improvement in safer sexual behavior. When popper use and lapse from safer sex were reanalyzed, controlling for primary relationship status, popper use was associated with failure to use condoms during receptive anal sex among nonmonogamous men only. These findings suggest an association between popper use and high-risk sexual behavior among members of the Chicago MACS/CCS cohort that has relevance to HIV prevention intervention efforts.

Objectives. We evaluated the efficacy of a primary care intervention targeting pregnant African American women and focusing on psychosocial and behavioral risk factors for poor reproductive outcomes (cigarette smoking, secondhand smoke exposure, depression, and intimate partner violence). Methods. Pregnant African American women (N = 1044) were randomized to an intervention or usual care group. Clinic-based, individually tailored counseling sessions were adapted from evidence-based interventions. Follow-up data were obtained for 850 women. Multiple imputation methodology was used to estimate missing data. Outcome measures were number of risks at baseline, first follow-up, and second follow-up and within-person changes in risk from baseline to the second follow-up. Results. Number of risks did not differ between the intervention and usual care groups at baseline, the second trimester, or the third trimester. Women in the intervention group more frequently resolved some or all of their risks than did women in the usual care group (odds ratio = 1.61; 95% confidence interval = 1.08, 2.39; P = .021). Conclusions. In comparison with usual care, a clinic-based behavioral intervention significantly reduced psychosocial and behavioral pregnancy risk factors among high-risk African American women receiving prenatal care.

Objective Children of adolescent mothers are at increased risk of violence exposure and behavior problems, which have been linked to mothers' disciplinary practices. This study examines how the effect of young African American mothers' discipline on their preschool-age children's externalizing and internalizing behavior varies by mother and child violence exposure. Methods A sample of 230 African American mothers who gave birth as adolescents and their 3- to 6-year-old children were recruited from community-based day care and primary health care sites in the Washington, DC, metropolitan region. In-person interviews were conducted by trained research assistants who administered standard survey instruments. Results Hierarchical regression models revealed an interaction effect such that adolescent mothers' harsh disciplinary practices, specifically physical discipline strategies, were positively associated with young children's internalizing and externalizing behavior in the context of high or moderate, but not low, maternal violence exposure. Conclusions Compared with less violence-exposed mothers, the harsh disciplinary practices of young African American mothers who have been exposed to high levels of violence are more strongly associated with their children's problem behavior. Practitioners should screen mothers for violence exposure in order to address potential issues of discipline and behavior problems.

BACKGROUND: Blood product transfusions are a valuable health-care resource. Guidelines for transfusion exist, but variability in their application, particularly in children, remains. The risk factors that threaten transfusion safety are well established, but because their occurrence in children is rare, single-institution studies have limited utility in determining the rates of occurrence. An epidemiologic approach that investigates blood transfusions in hospitalized children may help improve our understanding of transfused blood products in this vulnerable population. STUDY DESIGN AND METHODS: This was a nonconcurrent cohort study of pediatric patients not more than 18 years of age hospitalized from 2001 to 2003 at 35 academic children's hospitals that are members of the Pediatric Health Information System (PHIS). RESULTS: A total of 51,720 (4.8%) pediatric patients received blood product transfusions during the study period. Red blood cells (n = 44,632) and platelets (n = 14,274) were the two most frequently transfused products. The rate of transfusions was highest among children with neutropenia, agranulocytosis, and sickle cell crisis. Asian and American Indian patients had important differences in the rate of blood transfusions and their complications. Resource use in terms of length of stay and costs were higher in patients who received transfusion. Of those patients who received transfusions, 492 (0.95%) experienced a complication from the administered blood product. This accounted for a rate of complications of 10.7 per 1,000 units transfused. CONCLUSIONS: The administration of blood products to children is a common practice in academic children's hospitals. Complications associated with these transfused products are rare.

This study examined the prevalence of psychosocial difficulties and use of mental health services among 290 parents of children in the Head Start program. Data on demographic characteristics, child behavior problems, parents' difficulties, home environment, child behavior, and use of health services were collected. A total of 161 parents (56 percent) had identifiable psychosocial difficulties, and 41 (14 percent) reported use of mental health services in the previous 12 months. Child behavior problems, unmet need for mental and physical health services, and less optimal home environments were associated with parents' psychosocial difficulties. Parents who had an unmet need for mental health services were more likely to report behavior problems among their children.

To determine if there are racial/ethnic differences in the rates of appendiceal rupture among the children of two large states. Because rupture is primarily due to delayed diagnosis, differences would suggest disparities in timely access to quality emergency care.This was an observational, cross-sectional analysis of full-year samples of acute appendicitis cases from California and New York children 4 to 18 years old. Racial/ethnic groups were compared for risk of appendiceal rupture adjusted for biological factors both before and after adjustment for the following socioeconomic, hospital, and admission characteristics: income, insurance, hospital type, and admission source. Results were interpreted in light of census data on the proportion of immigrants in each racial/ethnic group.Compared with white children with acute appendicitis, Hispanic and Asian children have higher odds of rupture in California, whereas Asian and black/African American children have higher odds in New York. These differences roughly parallel the within-state proportion of immigrant children in these groups. Adjustments for family, socioeconomic, and hospital characteristics attenuate but do not eliminate disparities.The authors found evidence of significant racial/ethnic disparities in rate of appendiceal rupture, an important and preventable outcome, in two large but dissimilar states. Immigrant groups may be most at risk for delayed emergency care. Future research should focus on immigration and acculturation as risk factors for appendicitis rupture in children.

Background Evaluating access to and delivery of mental health services for young children was a primary objective of the national research demonstration program Starting Early Starting Smart (SESS). Objective To present preliminary findings on family mental health and use of services in a community Head Start population at time of entry into a longitudinal study as part of the SESS program. Subjects Children enrolled for Head Start entry in 1998 and 1999 (N = 290; mean age, 4.3 years). Of these children, 52% were boys. Methods Data on demographic factors, child and parent mental health, and service use were collected from the sample at baseline. Information was gathered from primary caregivers and teachers using standardized questionnaires and structured interviews. Results There was low concordance between parent and teacher ratings of child behavior. Factors predicting behavior problems in young children varied according to whether the parent or teacher rated the child as having behavior problems. Sex (male) and home environment were associated with teachers rating the child as having a behavior problem. Parent mental health problems and problems in the parent-child relationship were associated with parent ratings. Only home environment was associated with child-focused service utilization (services that help parents manage children's behavior). Conclusions Demographic risk factors were not associated with child behavior problems or use of mental health services in this group of Head Start children. Findings suggest that children with behavioral problems have unmet mental health service needs. Interventions designed to address both parent mental health needs and sensitivity to the developmental needs of children may increase child-focused mental health service utilization.

Objective To describe physicians' experiences in attempting to provide optimal care for families of children who suffer from sudden, acute life-threatening conditions (SALTC). Design To generate descriptive data in this exploratory study, we used qualitative methods including focus groups and in-depth interviews. Transcripts of focus groups and interviews were analyzed for content using standard phenomenologic analysis methods, which resulted in a participant-generated conceptual model of optimal care for families of children with SALTC. Setting The intensive care unit of an urban pediatric teaching hospital. Participants Twenty-two pediatric intensive care unit physicians, including residents, fellows, and attendings. Intervention None. Main Outcome Measures Each participating physician provided qualitative descriptions of experiences caring for families of children with SALTC. Results Physicians identified 4 components of optimal care for families: (1) providing timely, accurate information about their child; (2) maintaining privacy for confidential discussions and personal grieving; (3) giving adequate emotional support; and (4) granting family members the right to hold and comfort their dying child. Physicians also described barriers to, and facilitators of this optimal care. Conclusions Descriptive information provided in this exploratory study offers a complex model of optimal family care. Issues that affect the quality of care to families include those related to the context of providing care in a large teaching hospital, as well as subtleties of communication between parents and staff. Physicians' beliefs about optimal care of families in the pediatric intensive care unit revealed implications for both practice and training in pediatrics.

This cross-sectional survey determined the prevalence of motherhood among severely mentally ill women hospitalized in an inner-city facility and examined the demographic characteristics and perceived needs of the 32 mothers who were identified. Slightly less than one-quarter of these mothers had seen their children within the last week, and only about 20 percent maintained full custody of their children. However, none of the respondents reported feeling that it was unimportant whether they continued mothering their children. Approximately half described needing help in dealing with their sadness about their children. The pilot data presented in this paper suggest that motherhood is common among severely mentally ill and hospitalized women and that issues relevant to mothering remain important to them.

Survey data collected in 1984-85 from a community sample of 637 gay and bisexual men were used to determine the features of social relationships that were most conductive to changes in both psychological health and AIDS-related sexual risk behavior. Multiple regression analyses showed that both the perceived availability of social support and the absence of conflicts in the social network were related to improve psychological health. At the same time, the subjective experience of integration into social networks was associated with increased psychological distress, and validation (the experience of being accepted by others) was related to a higher level of risk activity. These findings are discussed in terms of the social relationships among community members that share a common stressor--in this case the shared problem of being at risk for AIDS.