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Collaboration among diverse stakeholders involved in the value transformation of health care requires consistent use of terminology. The objective of this study was to reach consensus definitions for the terms value-based care, value-based payment, and population health. A modified Delphi process was conducted from February 2017 to July 2017. An in-person panel meeting was followed by 3 rounds of surveys. Panelists anonymously rated individual components of definitions and full definitions on a 9-point Likert scale. Definitions were modified in an iterative process based on results of each survey round. Participants were a panel of 18 national leaders representing population health, health care delivery, academic medicine, payers, patient advocacy, and health care foundations. Main measures were survey ratings of definition components and definitions. At the conclusion of round 3, consensus was reached on the following definition for value-based payment, with 13 of 18 panelists (72.2%) assigning a high rating (7- 9) and 1 of 18 (5.6%) assigning a low rating (1-3): "Value-based payment aligns reimbursement with achievement of value-based care (health outcomes/cost) in a defined population with providers held accountable for achieving financial goals and health outcomes. Value-based payment encourages optimal care delivery, including coordination across healthcare disciplines and between the health care system and community resources, to improve health outcomes, for both individuals and populations." The iterative process elucidated specific areas of agreement and disagreement for value-based care and population health but did not reach consensus. Policy makers cannot assume uniform interpretation of other concepts underlying health care reform efforts.

This paper presents a feasibility study of audio computer-assisted self-interview (ACASI) technology used to elicit self-reported histories of child maltreatment among detained adolescent girls (N = 35). We focus on methodological, legal, ethical, and administrative challenges to the collection of sensitive information from minors who are wards of the state. We conclude that extensive collaboration with detention center staff was required to address and overcome these challenges. Pending the availability of additional evidence from demographically diverse samples, the extent to which the ACASI method improves the completeness and accuracy of child maltreatment histories reported by adolescent girls in juvenile detention remains unclear. Further research is needed to determine whether the advantages of the ACASI technology contribute to more valid and reliable reporting of maltreatment by detained girls in a setting where an empathetic interviewer, who may facilitate the disclosure process, is absent.

Objectives. We estimated the risk of HIV associated with sexually transmitted infection (STI) history during adolescence. Methods. We retrospectively studied a cohort of adolescents (n = 75 273, born in 1985–1993) who participated in the Philadelphia High School STD Screening Program between 2003 and 2010. We matched the cohort to STI and HIV surveillance data sets and death certificates and performed Poisson regression to estimate the association between adolescent STI exposures and subsequent HIV diagnosis. Results. Compared with individuals reporting no STIs during adolescence, adolescents with STIs had an increased risk for subsequent HIV infection (incidence rate ratio [IRR] for adolescent girls = 2.6; 95% confidence interval [CI] = 1.5, 4.7; IRR for adolescent boys = 2.3; 95% CI = 1.7, 3.1). Risk increased with number of STIs. The risk of subsequent HIV infection was more than 3 times as high among those with multiple gonococcal infections during adolescence as among those with none. Conclusions. Effective interventions that reduce adolescent STIs are needed to avert future STI and HIV acquisition. Focusing on adolescents with gonococcal infections or multiple STIs might have the greatest impact on future HIV risk.

The MOM Program is a randomized, controlled trial of an intervention to promote mothers’ care for the health and development of their children, including accessing early intervention (EI) services. Study aims were to determine whether, relative to controls, this intervention increased receipt of and referral to EI services. Mothers ( N = 302) living in high-poverty regions were recruited after having given birth to healthy infants and were randomized to the intervention ( n = 152) or control ( n = 150) group. Those in the intervention group received up to 11 home visits to promote well-child visits and referral to EI. Children in the intervention group were referred to and received EI services significantly more often than those in the control group. Maternal depression and age of the mother were significantly associated with referral to, and receipt of, EI.

BACKGROUND: Child maltreatment is a public health problem with lifelong health consequences for survivors. Each year, >29 000 adolescents leave foster care via emancipation without achieving family permanency. The previous 30 years of research has revealed the significant physical and mental health consequences of child maltreatment, yet health and well-being have not been a priority for the child welfare system. OBJECTIVES: To describe the health outcomes of maltreated children and those in foster care and barriers to transitioning these adolescents to adult systems of care. METHODS: We reviewed the literature about pediatric and adult health outcomes for maltreated children, barriers to transition, and recent efforts to improve health and well-being for this population. RESULTS: The health of child and adult survivors of child maltreatment is poor. Both physical and mental health problems are significant, and many maltreated children have special health care needs. Barriers to care include medical, child welfare, and social issues. Although children often have complex medical problems, they infrequently have a medical home, their complex health care needs are poorly understood by the child welfare system that is responsible for them, and they lack the family supports that most young adults require for success. Recent federal legislation requires states and local child welfare agencies to assess and improve health and well-being for foster children. CONCLUSIONS: Few successful transition data are available for maltreated children and those in foster care, but opportunities for improvement have been highlighted by recent federal legislation.

The reproductive consequences of cystic fibrosis (CF) have increased in relevance as individuals with CF now live well into their reproductive years. This article describes the first Internet-based study of sexual and reproductive health (SRH) knowledge, experiences, and preferences of adolescents and adults with CF participating in an online discussion board. Although broad SRH knowledge was demonstrated, CF-specific SRH knowledge was incomplete. Respondents reported wanting providers to initiate reproductive health discussions and offer more CF-specific SRH information. Respondents also reported experiencing a variety of disease-specific reproductive health issues (e.g., shortness of breath with sexual activity, vaginal dryness due to viscous mucous, etc.). Future research should explore how to enhance access to disease-specific SRH information.

OBJECTIVE: To explore the attitudes of urban minority adolescent girls about an emergency department (ED)-based intervention to address emergency contraceptive pill (ECP) use. METHODS: We conducted an in-depth semistructured interview study of healthy 15- to 19-year-old African-American girls seeking care in a childrens hospital ED. Purposive sampling was used to recruit sexually and nonsexually active adolescents and those with or without a history of pregnancy. We collected demographic data and opinions about an ED-based intervention addressing ECP use. A modified grounded theory approach was used for analysis. RESULTS: Thirty interviews were completed. Mean participant age was 16.4 years; 53% reported sexual activity; and 17% reported a history of pregnancy. Most participants expressed that an intervention focused on ECP would be useful in the ED setting but this varied depending upon the type of ED visit. For example although most believed that patients with symptoms related to sexual activity should be offered an ECP intervention fewer stated that this type of intervention would be appropriate for patients presenting with headache or an injury. Participants stated that the information could be delivered by a health care professional or a peer counselor although no particular delivery modality was clearly favored. CONCLUSIONS: Urban minority adolescent girls are generally supportive of learning about ECP during an ED visit. Preferences about the appropriateness of the intervention related to the type of patient complaint. Because multiple sources and delivery modalities were acceptable future studies should determine whether tailoring the source and delivery modality to demographic characteristics enhances the uptake of the message.

To improve health and reduce inequities through health services research, investigators are increasingly actively involving individuals and institutions who would be affected by the research. In one such approach, community-based participatory research (CBPR), community members participate in every aspect of designing and implementing research with the expectation that this process will enhance the translation of research into practice in communities. Because few physician researchers have expertise in such community-based approaches to research, the Robert Wood Johnson Foundation leadership expanded the mission of the Robert Wood Johnson Clinical Scholars Program (RWJCSP), which historically focused on health services and clinical research, to include training and mentored experiences in CBPR.The authors discuss the three years of experience (2005-2008) implementing the new community research curricula at the four RWJCSP sites: University of California, Los Angeles; University of Pennsylvania in Philadelphia; University of Michigan in Ann Arbor; and Yale University in New Haven. Three common goals and objectives are identified across sites: teaching the principles of CBPR, providing opportunities for conducting CBPR, and making an impact on the health of the communities served. Each site's different approaches to teaching CBPR based on the nature of the existing community and academic environments are described. The authors use illustrative quotes to exemplify three key challenges that training programs face when integrating community-partnered approaches into traditional research training: relationship building, balancing goals of education/scholarship/relationships/product, and sustainability. Finally, the authors offer insights and implications for those who may wish to integrate CBPR training into their research training curricula.

Many adolescents with complex medical conditions regard their subspecialty providers as an important source of clinical information including sexual and reproductive health information related to their medical condition. Thus, training for pediatric subspecialty providers should include clinically relevant sexual and reproductive content. The purpose of this study is to understand what disease-relevant sexual and reproductive health information is currently included in content outlines for each of the available pediatric subspecialty certifying examinations. The American Board of Pediatrics (ABP) offers 17 subspecialty certifying examinations; 13 content outlines are available on the ABP website which defines the body of knowledge to be tested. Each available outline underwent content analysis for sexual and reproductive health information. A team of adolescent medicine physicians identified seven thematic areas including: 1) puberty; 2) sexual behavior and identity; 3) fertility; 4) contraceptio...

OBJECTIVE. The purpose of this work was to explore the knowledge, attitudes, and beliefs of urban, minority adolescent girls about intention to use emergency contraception pills and to identify barriers to emergency contraception pill use. PATIENTS AND METHODS. We conducted an in-depth, semistructured interview study of healthy, urban-dwelling, English-speaking 15- to 19-year-old black adolescents seeking care in a children's hospital emergency department. Purposive sampling was used to recruit sexually active and nonsexually active adolescents and those with and without a history of pregnancy. Enrollment continued until saturation of key themes was achieved. Participants returned after their emergency department visit for a 1-hour interview. The interview consisted of semistructured questions based on the theory of planned behavior constructs: attitudes (including knowledge), subjective norms, and perceived behavioral control, as well as demographic data collection. Interviews were recorded and transcribed. Transcripts were coded by 2 members of the study team by using a modified grounded-theory method. RESULTS. Thirty interviews were required for saturation. Mean participant age was 16.4 years; 53% reported being sexually active, and 17% reported a history of pregnancy. Specific knowledge gaps exist about emergency contraception pills, including misconceptions about the recommended time frame for taking the medication. Several major themes were noted for each of the constructs. Intention to use emergency contraception pills is affected by the conflicting attitudes that the emergency contraception pill works faster than birth control pills and that those who use emergency contraception pills are irresponsible; family and friends are important influences and have uninformed but generally supportive opinions; and adolescents have a perception of limited behavioral control because of their young age and concerns about confidentiality. CONCLUSIONS. Urban, minority adolescent girls have misconceptions about emergency contraception pills, are affected by the opinions of those close to them, and express concern about specific barriers. These findings can inform specific interventions aimed at addressing the barriers to emergency contraception pill use that are of most importance to this population of young women.

To describe the development and assess the validity and reliability of the Collaborative Care for Attention-Deficit Disorders Scale (CCADDS), a measure of collaborative care processes for children with attention-deficit/hyperactivity disorder who attend primary care practices.Collaborative care was conceptualized as a multidimensional construct. The 41-item CCADDS was developed from an existing instrument, review of the literature, focus groups, and an expert panel. The CCADDS was field tested in a national mail survey of 600 stratified and randomly selected practicing general pediatricians. Psychometric analysis included assessments of factor structure, construct validity, and internal consistency.The overall response rate was 51%. Most respondents were male (56%), 46 years old or older (59%), and white (69%). Common factor analysis identified 3 subscales: beliefs, collaborative activities, and connectedness. Internal consistency reliability (coefficient alpha) for the overall scale was .91, and subscale scores ranged from .80 to .89. The CCADDS correlated with a validated measure of provider psychosocial orientation (r = -.36, P.001) and with self-reported frequency of mental health referrals or consultations (r = -.24 to -.42, P.001). CCADDS scores were similar among physicians by race/ethnicity, gender, age group, and practice location.Scores on the CCADDS were reliable for measuring collaborative care processes in this sample of primary care clinicians who provide treatment for children with attention-deficit/hyperactivity disorder. Evidence for validity of scores was limited. Future research is needed to confirm its psychometric properties and factor structure and provide guidance on score interpretation.

Adolescent births have declined substantially in the past 15 years, especially with the increase in use of e fective contraception by young women. Longitudinal data have shown that previously identified disadvantages of early parenting for young women, particularly those from communities with high rates of poverty, may not be substantial. There are indications that higher order births carry a much greater burden than do first births to females younger than 20 years. For those interested in minimizing the burden for these young women, interventions to prevent second births are important. Studies have looked at how best to provide care to these women and infants and how to reduce rates of higher order births. These programs provide ideas on factors that can help identify those at greatest risk for second births and give models for working with young mothers to maximize career and life chances. Particular attention should be paid to contraception use, infant stimulation, school and work participation, postpartum depression, and breastfeeding when working with adolescent mothers.

Objectives To describe baseline perceptions of first-year pediatric residents of participating in community activities, to determine whether demographic factors are related to perceived benefits and constraints, and to identify factors associated with expected community involvement. Methods Pediatric residents beginning their training in the fall of 2000 to 2003 participated in a 12-item self-administered written survey as part of the national evaluation of the Dyson Community Pediatrics Training Initiative. Results Of the 612 first-year residents surveyed (90% response rate), most reported they receive personal satisfaction (92%) and gain valuable skills and knowledge (83%) from their involvement in community activities. Less than a quarter felt peer support and professional recognition were benefits. Almost two thirds reported logistics and lost personal time as constraints to community involvement. Compared with their colleagues, older residents (>29 years) and underrepresented minority residents reported fewer constraints. Most residents (72%) expect moderate to substantial involvement in community activities after graduating. Those expecting greater involvement were more likely to report personal satisfaction, gaining valuable skills and knowledge, peer support, and the opportunity to spend time with like-minded peers as benefits. Conclusions Pediatric residents beginning their postgraduate training perceive numerous benefits from their participation in community activities and most expect a moderate degree of future community involvement. Residency directors should: 1) consider their trainees' insights from prior community involvement and 2) integrate meaningful community experiences in ways that confront logistic barriers and time constraints.

Context Adolescents are frequent users of hormonal contraception (HC), yet their adherence to these methods is often poor. Concerns about side effects, especially those affecting the menstrual system, are often given as reasons for contraceptive nonadherence or discontinuation. We sought to identify teens' concerns and misperceptions about the menstrual-related side effects of HC. Methods Open focus groups were conducted with both sexually active and virgin adolescent women aged 12–18 years who were recruited from the Philadelphia area. The adolescents did not have to be contraceptive users in order to participate. The question put to each group was, “What are the things you have heard about the birth control pill, Depo-Provera and Norplant?” Groups were audio-recorded, transcribed and analyzed using qualitative software. Results We conducted 13 female-only groups. Participants raised frequent concerns about menstrual-related side effects, believing that these side effects were evidence of possible negative effects of HC on their reproductive health. Four themes related to hormonal contraceptive-induced menstrual irregularity emerged from the groups. Theme 1: Menstruation is natural and should not be altered in any way. Theme 2: The menstrual period is necessary for cleansing of the body. Theme 3: “Spotting,” intermenstrual bleeding and amenorrhea cause doubts about the method's effectiveness and worries about pregnancy. Theme 4: All menstrual irregularity, from intermenstrual bleeding to amenorrhea, causes worry about the effects on fertility and on physical health. Conclusions Teens have concerns about the menstrual irregularity caused by HC. Providers understand that these side effects are minor and of little medical consequence. Yet, adolescent patients may be ascribing great significance to these effects and may be declining these methods because of fear and misperceptions.

In one study of children in 27 families with maternal retardation, those children with higher IQ were more likely to have multiple behavior problems than those with lower IQ. If true, this result would affect clinical practice, but it has not been replicated. Since the setting of the initial observation is similar to the setting of childhood lead poisoning, we attempted a replication using data from the Treatment of Lead-exposed Children (TLC) study, in which 780 children aged 12–33 months with blood lead level 20–44 μg/dL were randomized to either succimer treatment or placebo and then followed up to 5 years. Of 656 mothers of TLC children with IQ measured, 113 demonstrated mental retardation (IQ < 70). Whether maternal IQ was less than 70 or over 70, children with IQ over 85 were rated more favorably on cognitive tests and behavioral questionnaires than children with IQ less than 85; these measures included Conners’ Parent Rating Scale-Revised at age 5, the Developmental Neuropsychological Assessment at ages 5 and 7, and the Behavioral Assessment System for Children at age 7. Among children of mothers with IQ

Objectives. To identify systematic problems in coordinating care for inner-city minority youths with attention-deficit/hyperactivity disorder. Methods. We recruited participants from inner-city minority communities in a single metropolitan area for a focus group study. We held separate meetings for pediatricians, mental health therapists, school staff, and parents (both black and Latino). We audiotaped and transcribed the meetings. We identified themes by consensus and used root cause analysis as a conceptual framework to guide our analysis. Results. We held 13 focus group meetings. Participants uniformly perceived insufficient communication and coordination of care. Five themes representing system and human factors that contributed to this fragmentation in care emerged: (1) a lack of consensus about who should oversee care; (2) changes in health care providers or teachers; (3) uncertainty in the diagnosis, insufficient training, and few resources; (4) distrust and blame that emerged when relationships among people who care for the child were absent or otherwise inadequate; and (5) lack of support from employers, friends, and family to engage in collaborative care. Conclusions. Using a root cause analysis framework, we identified system- and human-level factors that were perceived to impede communication and coordination of care for this population of children with attention-deficit/hyperactivity disorder. These results suggest that better organizational policies that define provider responsibilities and accountability, support the coordination of care, bridge relationships between agencies, and provide additional education and resources may improve collaboration. Additional study is needed to assess the generalizability of these finding to other settings.

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.

Objectives. The aims of this study were to describe the characteristics surrounding female-to-female nonpartner violence and to identify independent factors associated with risk of female-to-female intentional injuries. Methods. A case–control investigation was conducted among women who resided in an urban, low-income community and presented for emergency department care for injuries inflicted by female nonpartners. Results. Women were typically victimized by women they knew (88%), in outdoor locations (60%), and in the presence of others (91%). Those found to be at risk for injury typically were young and socially active, used marijuana, and had experienced other kinds of violence. Conclusions. The present results showed that women injured by female nonpartners had limited resources, experienced disorder in their lives, and were the victims of violence within multiple relationships. (Am J Public Health. 2003;93:1098–1103)

Suicide is a major public health problem in the United States. Suicide and attempted suicide are important causes of morbidity and mortality in adolescents. Epidemiologic trends in adolescent suicide point to increasing rates of suicide and increasing access to lethal attempts, particularly firearms. It is important for clinicians to recognize risk factors for suicide, but it is even more important to screen all adolescents for suicidal thoughts and feelings. This article highlights important publications from the past year (April 2000 to April 2001) regarding adolescent suicidal behavior, with particular focus on risk factors, recognition, and management.

Objective.Many urban children rely on emergency departments (ED) for ambulatory care. The objective of this study was to determine whether enrollment in Medicaid managed care (MMC) alters ED or other ambulatory care compared with fee-for-service Medicaid (FFSM).Methods.A prospective cohort study of infants born between May 1994 and April 1995 with a 6-month follow-up period was conducted in an urban, teaching hospital and surrounding ambulatory settings. A consecutive sample of 644 infants enrolled in MMC or FFSM was studied; 92% of eligible patients were enrolled, and 94% completed follow-up. The main outcome measures were 1) proportion of patients in each group visiting an ED, primary care practitioner (PCP), or specialist; 2) mean number of visits per group; and 3) ED reliance (EDR) defined as the proportion of all ambulatory visits occurring in an ED.Results.Fifty-six percent of MMC and 54% of FFSM patients visited an ED (relative risk: 1.03; 95% confidence interval [CI]: 0.83, 1.27). More MMC patients had a sick visit to their PCP (relative risk: 1.34; 95% CI: 1.03, 1.74); no difference in proportion with well-child or specialty visits was found. Although the mean number of total ambulatory, ED, and specialty visits was the same, MMC patients had fewer well-child and more sick visits to the PCP than FFSM patients (P = .01). EDR was 21% for both groups (P = .95). After adjustment for other factors in multivariate analysis, insurance status remained unassociated with EDR (adjusted odds ratio [OR]: 0.91; 95% CI: 0.56, 1.69). Factors associated with EDR included United States-born mother (OR: 5.34; 95% CI: 1.61, 17.68) and use of a hospital-based primary care physician (OR: 2.00; 95% CI: 1.34, 2.98). Variables that characterized infants who were less likely to be ED reliant included adequate maternal prenatal care (OR: 0.52; 95% CI: 0.34, 0.78) and having a mother who completed high school (OR: 0.67; 95% CI: 0.45, 0.99).Conclusions.Enrollment in MMC did not alter ED usage patterns when compared with FFSM. Some variation in use of other ambulatory services was detected.

Background.Underimmunization is distributed unevenly across populations, concentrated among the impoverished. Managed care has stimulated the development of quality indicators such as immunization rates to assess health status of populations.Objective.To determine if enrollment in Medicaid managed care (MMC) improves quality of health care as reflected by immunization rates when compared with fee-for-service Medicaid (FFSM).Design.Prospective cohort study of infants born between May 1994 and April 1995 with a 24-month follow-up period.Setting.Urban teaching hospital and surrounding ambulatory settings.Participants.Consecutive sample of infants (n = 644) enrolled in MMC or FFSM. Ninety-two percent of eligible patients were enrolled, and 87% completed follow-up.Main Outcome Measure.Up-to-date immunization status.Results.Seventy-three percent of the MMC and 72.4% of the FFSM patients were up-to-date on their immunizations: relative risk 1.01, (95% confidence interval [CI] 0.87, 1.17). No differences were found in age at immunization between the MMC and FFSM groups. After adjusting for other factors in multivariate analysis, insurance status remained unassociated with immunization status: adjusted odds ratio (OR) 1.04, (95% CI: 0.90, 1.10). Factors associated with up-to-date immunization included firstborn child, OR 2.28 (95% CI: 1.45, 3.60) and adequate maternal prenatal care, OR 2.24 (95% CI: 1.44, 3.48). Variables characterizing children less likely to be adequately immunized included father living in home with child, OR 0.53 (95% CI: 0.33, 0.85) and using private office-based primary care, OR 0.39 (95% CI: 0.23, 0.63).Conclusions.Enrollment in MMC did not improve rates of immunizations when compared with FFSM.

Background Although the rate of death from injuries due to violent acts is much higher among black women than among white women in the United States, little is known about the nature and correlates of violent injuries among black women living in urban areas. Methods In this case–control study conducted at three emergency departments in one inner-city community (in west Philadelphia), we studied 405 adolescent girls and women who had been intentionally injured and 520 adolescent girls and women (control subjects) who had health problems not related to violent injury. Data were collected by conducting standardized interviews with use of questionnaires and by screening urine for illicit drugs. Individual logistic-regression models were constructed to identify factors associated with violent injuries inflicted by partners and those inflicted by persons other than the partners of the victims. Results The male partners of the injured women were much more likely than the male partners of control subjects to use ...

Objectives. To delineate the mechanism of serious bicycle handlebar-related injuries in children and make recommendations for preventive strategies. Methods. Prospective cross-sectional surveillance system of seriously injured child bicyclists supplemented by in-depth, on-site crash investigation to delineate specific injury mechanisms. Interdisciplinary analyses involved engineers, clinicians, epidemiologists, and biostatisticians. Setting. The emergency department and in-patient trauma service of an urban level one pediatric trauma center between October 1995 and September 1997. Participants. Patients under 18 years of age who were treated for serious bicycle-related injuries (Abbreviated Injury Scale scores of 2 or greater). Results. The surveillance system identified two distinct circumstances for serious child bicyclist injury: 1) handlebar-related injuries associated with minor incidents (falls from bicycles) and 2) nonhandlebar-related injuries associated with severe incidents (bicycle-motor vehicle crashes). Crash investigations explored the minor incidents that resulted in serious handlebar-associated injuries. In the typical mechanism, as the child lost control of the bicycle and began to fall, the front wheel rotated into a plane perpendicular to the child's body. The child then landed on the end of the handlebar resulting in serious truncal injuries. Conclusions. A discordancy exists between the apparently minor circumstances and serious injuries sustained by child bicyclists who impact bicycle handlebars. Recognition of the mechanism of handlebar-related injuries might aid the practitioner in early diagnosis of serious abdominal injuries in child bicyclists. This injury mechanism may be avoided through bicycle redesign that would involve both limiting rotation of the front wheel and modifying the ends of handlebars. An integrated approach involving a surveillance system to identify an injury hazard supplemented by in-depth, on-site crash investigations effectively provided the detailed mechanism of injury needed to develop interventions.

OBJECTIVE: Home visiting programs aim to improve child health, reduce developmental risks, and enhance use of community resources. How these programs can work in collaboration with pediatric practice has been understudied. The MOM Program was a randomized controlled trial of an innovative home visiting program to serve urban, low-income children. Program aims included promoting child health through regular pediatric visits and enhancing school readiness through developmental screenings and referrals to early intervention. The objective of this report was to describe the partnership with the pediatric community and selected program results. METHODS: A total of 302 mothers were enrolled in the program at the time of children’s birth. Eligible infants were full-term, without identified neurologic/genetic disorder or ICU intervention, and from high-poverty zip codes. A total of 152 were randomized to the home visiting program, with 9 visits over 3 years, scheduled before well-child visits; 150 were randomized to the control condition with no home visits. Medical records and case notes provided information on pediatric appointments kept and program outcomes. RESULTS: Eighty-nine percent of both groups were retained throughout the 3-year program; 86% of the home-visited group received at least 7 of the 9 planned home visits. Home-visited mothers were >10 times as likely to keep pediatric appointments, compared with those not visited. Barriers to service access were varied, and theory-driven approaches were taken to address these. CONCLUSIONS: Home visiting programs can provide important partnerships with pediatric health care providers. Integrating home visiting services with pediatric care can enhance child health, and this subject warrants expansion.

BACKGROUND In the United States, more than 600 municipalities have smoke-free parks, and more than 100 have smoke-free beaches. Nevertheless, adoption of outdoor smoke-free policies has been slow in certain regions. Critical to widespread adoption is the sharing of knowledge about the policy development and implementation process. In this article, we describe our experience in making City of Philadelphia recreation centers and playgrounds smoke-free. COMMUNITY CONTEXT Of the 10 largest US cities, Philadelphia has among the highest rates of adult and youth smoking. Our objectives for an outdoor smoke-free policy included protecting against secondhand smoke, supporting a normative message that smoking is harmful, motivating smokers to quit, and mitigating tobacco-related sanitation costs. METHODS The Philadelphia Department of Public Health and the Department of Parks and Recreation engaged civic leaders, agency staff, and community stakeholders in the following steps: 1) making the policy case, 2) vetting policy options and engaging stakeholders, and 3) implementing policy. Near-term policy impacts were assessed through available data sources. OUTCOME More than 220 recreation centers, playgrounds, and outdoor pools became smoke-free through a combined mayoral executive order and agency regulation. Support for the policy was high. Estimates suggest a policy reach of 3.6 million annual visitors and almost 850 acres of new smoke-free municipal property. INTERPRETATION Localities can successfully implement outdoor smoke-free policies with careful planning and execution. Such policies hold great potential for reducing exposure to secondhand smoke, promoting nonsmoking norms, and providing additional motivation for residents to quit smoking.

Objective. The purpose of this study was to determine the prevalence of exposure to violence in preadolescent children in communities that vary by family income and to determine patterns of physical symptomatology and communication after exposure to a traumatic event. Methods. Two hundred twenty-eight sixth-grade students from a suburban middle school (school A) and 209 sixth-grade students from an urban middle school (school B) in the Philadelphia metropolitan area were surveyed by a group-administered anonymous questionnaire. Results. Two hundred two students (89%) from school A and 200 students (96%) from school B reported knowing someone who had been robbed, beaten, stabbed, shot, or murdered. One hundred twenty-nine students (57%) and 183 students (88%), respectively, witnessed a robbing, beating, stabbing, shooting, or murder. Ninety-one students (40%) and 141 students (67%) had been personally robbed, beaten up, stabbed, shot, or caught in gun cross fire. One hundred thirty-four (59%) and 152 (73%) reported hearing gunfire in their neighborhood. One hundred eighty-eight (82%) and 202 (97%) had at least one positive response in all three categories: knowing a victim, witnessing an event, and being a victim of violence. The proportion of positive responses from school B was significantly greater than the proportion from school A for all of these results. Many students reported symptoms associated with somatization syndromes, depression, and posttraumatic stress disorder; the school B group had significantly more symptoms than the school A group. Both student groups had discussed episodes of witnessing an event or victimization with others, mostly family members and friends, and expressed feelings of fear, anger, sadness, and frustration about these episodes. A very low percentage of the students (from 1% to 8% in the different analyses) consulted a medical or mental health professional. Conclusions. These data support a substantial prevalence of exposure to violence for suburban and, even more dramatically, for urban middle school-aged children. The higher-prevalence group reported a higher incidence of symptoms sometimes seen after traumatic stress. Many students in both groups expressed multiple feelings about their exposure to violence, and most talked to someone about their exposure; rarely was this person a health professional.

Violence affects children and adolescents widely. Pediatricians see many of these effects and need to be prepared to address them. A key role for providers in addressing violence, however, lies in working to prevent it. In this endeavor, the provider must be knowledgeable about the risk factors and vigilant for discerning these risks during office visits. Family factors, peer group issues, other risky behaviors, and weapons availability and use all are within the range of topics that a provider might choose to address. At the same time, pediatricians have a key role to play as advocates for children in working with community partners to increase supports for children and families, to institute new programs to prevent violence, and to help remove firearms from the hands of children and youth.

Injury control studies, from inception and design to dissemination of results, tend to remain within individual discipline. This is largely because each of the disciplines has a unique language and approach to research. Collaborative research is often performed serially with one discipline presenting the results of that discipline's studies to another discipline. Epidemiologists and clinicians tell engineers to design a safety technology to prevent a specific injury. Engineers tell lawyers what is feasible to include in standards. As a result, epidemiological studies lack mechanical data needed by the engineers and engineering studies lack generalizability. The procedure for incorporating the best of multiple disciplines throughout the performance of injury control studies has not existed until recently and is presented conceptually in this manuscript. This new approach, Biomechanical Epidemiology, is an exciting enhancement to current injury control research.

Background: In 2010, Philadelphia enacted a menu-labeling law requiring full-service restaurant chains to list values for calories, sodium, fat, and carbohydrates for each item on all printed menus. Purpose: The goal of the study was to determine whether purchase decisions at full-service restaurants varied depending on the presence of labeling. Methods: In August 2011, this cross-sectional study collected 648 customer surveys and transaction receipts at seven restaurant outlets of one large full-service restaurant chain. Two outlets had menu labeling (case sites); five outlets did not (control sites). Outcomes included differences in calories and nutrients purchased and customers’ reported use of nutrition information when ordering. Data were analyzed in 2012. Results: Mean age was 37 years; 60% were female; 50% were black/African-American and reported incomes Z$60,000. Customers purchased food with approximately 1600 kcal (food plus beverage, 1800 kcal); 3200 mg sodium; and 35 g saturated fat. After adjustment for confounders, customers at labeled restaurants purchased food with 151 fewer kilocalories (95% CI¼� 270, � 33); 224 mg less sodium (95% CI¼� 457, þ8); and 3.7 g less saturated fat (95% CI¼� 7.4, � 0.1) compared to customers at unlabeled restaurants (or 155 less kilocalories from food plus beverage, 95% CI¼� 284, � 27). Those reporting that nutrition information affected their order purchased 400 fewer food calories, 370 mg less sodium, and 10 g less saturated fat. Conclusions: Mandatory menu labeling was associated with better food choices among a segment of the public dining at full-service restaurants. Consumer education on the availability and use of nutrition information may extend the impact of menu labeling. (Am J Prev Med 2013;45(6):710–719) & 2013 American Journal of Preventive Medicine

Background: Atopic dermatitis is an important cause of morbidity in children of all ages. Despite its high prevalence, there has been no examination of ways in which care for atopic dermatitis is delivered. Objective: This study reviewed the costs for care of childhood atopic dermatitis in an urban setting and estimated the national cost for treatment of the disease. Methods: We used data from one children's hospital to study the use of the emergency room for atopic dermatitis and used national data sets to estimate the cost of care in the United States. Results: A large proportion of visits occur in the emergency department, during daytime office hours, and mostly by patients who have public insurance. The total national cost for treatment of childhood atopic dermatitis is $364 million annually, which is a conservative estimate. Conclusion: Given its high prevalence, associated morbidity, and cost, resources must be better allocated to improve the organization of care for patients with atopic dermatitis.

OBJECTIVES. Injury is a major US public health problem, particularly in urban minority communities. This paper evaluates the impact of the Safe Block Project, a comprehensive injury prevention trial, on home hazards and injury prevention knowledge in a poor urban African-American community. METHODS. Nine census tracts in the community were allocated to either the intervention area or the control area. The intervention, carried out by trained community outreach workers, consisted of (1) home modification for simple prevention measures, (2) home inspection accompanied by information about home hazards, and (3) education about selected injury prevention practices. Approximately 12 months after the intervention, random samples of control and intervention homes were assessed for home hazards and injury prevention knowledge. RESULTS. A significantly larger proportion of intervention homes than control homes had functioning smoke detectors, syrup of ipecac, safely stored medications, and reduced electrical and tripping hazards. No consistent differences were observed between control and intervention homes on home hazards requiring major effort to correct. CONCLUSIONS. There was a distinct difference between control and intervention homes with respect to safety knowledge and home hazards requiring minimal to moderate effort to correct. The Safe Block Project could serve as a model for future urban injury prevention efforts.

OBJECTIVES: This study analyzed short-term trends in pediatric injury hospitalizations. METHODS: We used a population-based retrospective cohort design to study all children 15 years or younger who were admitted to all acute care hospitals in Pennsylvania with traumatic injuries between 1991 and 1995. RESULTS: Injuries accounted for 9% of all acute hospitalizations for children. Between 1991 and 1995, admissions of children with minor injuries decreased by 29% (P < .001). However, admissions for children with moderate (P = .69) or serious (P = .41) injuries did not change. CONCLUSIONS: Significant declines in pediatric admissions for minor injuries were noted and may reflect both real reductions in injury incidence and changes in admission practices over the period of the study.

To explore the attitudes of urban, minority adolescent girls about an emergency department (ED)-based intervention to address emergency contraceptive pill (ECP) use.We conducted an in-depth, semistructured interview study of healthy, 15- to 19-year-old African-American girls seeking care in a children's hospital ED. Purposive sampling was used to recruit sexually and nonsexually active adolescents and those with or without a history of pregnancy. We collected demographic data and opinions about an ED-based intervention addressing ECP use. A modified grounded theory approach was used for analysis.Thirty interviews were completed. Mean participant age was 16.4 years; 53% reported sexual activity; and 17% reported a history of pregnancy. Most participants expressed that an intervention focused on ECP would be useful in the ED setting, but this varied depending upon the type of ED visit. For example, although most believed that patients with symptoms related to sexual activity should be offered an ECP intervention, fewer stated that this type of intervention would be appropriate for patients presenting with headache or an injury. Participants stated that the information could be delivered by a health care professional or a peer counselor, although no particular delivery modality was clearly favored.Urban, minority adolescent girls are generally supportive of learning about ECP during an ED visit. Preferences about the appropriateness of the intervention related to the type of patient complaint. Because multiple sources and delivery modalities were acceptable, future studies should determine whether tailoring the source and delivery modality to demographic characteristics enhances the uptake of the message.

OBJECTIVE. The goal was to understand the concerns of adult health care providers regarding transition for young adult patients with childhood-onset conditions.METHODS. Internists from the 2000 American Board of Medical Specialties directory were selected randomly. A 2-stage mail survey was conducted from August 2001 to November 2004. In stage 1, providers stated their concerns regarding accepting care of transitioning young adult patients. In stage 2, providers ranked their concerns.RESULTS. A total of 241 internal medicine providers were selected for participation. In stage 1, 134 of 241 physicians were eligible to participate, and 67 (50%) of 134 completed stage 1 surveys. In stage 2, 112 physicians were eligible, and 65 (58%) of 112 responded. Concerns elicited in stage 1 were clustered into 6 categories: patient maturity, patient psychosocial needs, family involvement, providers' medical competency, transition coordination, and health system issues. In stage 2, concerns rated highest were lack of training in congenital and childhood-onset conditions, lack of family involvement, difficulty meeting patients' psychosocial needs, needing a superspecialist, lack of adolescent training, facing disability/end-of-life issues during youth and early in the relationship, financial pressures limiting visit time, and families' high expectations.CONCLUSIONS. Internists clearly stated the need for better training in congenital and childhood-onset conditions, training of more adult subspecialists, and continued family involvement. They also identified concerns about patients' psychosocial issues and maturity, as well as financial support to care for patients with complex conditions.

Objective—To improve understanding of processes leading to injury and assess more specifically the degree of intentionality. Methods—A new paradigm was developed that characterizes the act of inflicting injury (self, other, not inflicted) and the motive. Motives are determined for the act of injury and for the outcome. To test this, 986 cases of adolescent injuries in seven hospitals were reviewed. Three investigators independently classified all cases using the new paradigm and three used standard definitions of intent. Inter-rater reliability was measured. Results—Of injuries inflicted by others, 61% were intentional using the standard classification. In the new paradigm 67% were intended acts and 59% involved intentional motive for outcome. Altogether 87% of sports injuries were coded as unintentional acts compared with 96% using standard methods. Using standard classification there was 93% agreement between paired raters, with an average κ of 0.86. In the new paradigm questions on intentionality of act, outcome, and infliction of act, the agreement was 89%, 91%, 88%, with a κ of 0.79, 0.80, 0.76, respectively. Conclusions—This paradigm defines a spectrum of injury intent, enhances understanding of the causal sequence of injury, and has important implications for research and prevention.

Objective To determine availability of and test whether on-site mental health providers (MHP) is associated with greater odds of reported mental health consultation and referral among primary care pediatricians. Methods Pediatricians were identified from the American Medical Association's 2004 physician directory and stratified by region. Six hundred were randomly selected to receive a mail survey. The main independent variable was on-site MHP. The dependent variable was reported frequency (4-point rating) of mental health consultation and referral. Estimates were weighted to account for survey design and nonresponse. Results Overall response rate was 51%. The majority of respondents were male (56%), age ≥46 years old (59%), white (68%), and practicing in suburban locations (52%). Approximately half reported consultation with (44%) or referral to (51%) MHP always or often, but a few (17%) reported on-site MHP. After adjustment for demographic and practice characteristics, pediatricians with on-site MHP were more likely to consult (odds ratio [OR] 6.58, 95% confidence interval [95% CI] 3.55- 12.18) or refer (OR 4.25, 95% CI 2.19–8.22) than those without on-site MHP. Among those without on-site MHP, pediatricians with greater practice burden were less likely to consult (OR 0.69, 95% CI 0.48–0.99) or refer (OR 0.75, 95% CI 0.54–1.04) than those with lesser burden. Conclusions Most pediatricians in the United States experienced practice-related burdens that limit mental health collaboration, but those with co-located services reported a greater likelihood of consultation and referral. Policy changes that encourage co-location of mental health services and limit practice burden may facilitate mental health consultation and referral.

Even though injuries are a leading cause of morbidity and mortality among the elderly in the United States, no comprehensive population-based study of nonfatal and fatal injuries has been carried out in an elderly minority inner-city population. To study injuries in this population, we developed an active surveillance system as part of a large injury prevention program in a poor urban black community. We report 577 cases of nonfatal and fatal injuries in a community of 12,139 persons 65 years of age and older that resulted in emergency room treatment or death between March 1, 1987, and February 29, 1988. Nearly 5% of the elderly population was treated at an emergency room for, or died as a result of, an injury during the study period; the overall injury rate was 48 injuries per 1,000 persons. Injury rates for older women exceeded those for older men and increased with advancing age in both sexes. Fall injuries accounted for 312 (54%) of all injuries and 75% of all hospitalizations for injury. Motor vehicle incidents and violence were the second and third most common injuries, accounting for 13% and 7% of injuries, respectively. Given the predominance of falls relative to other injuries, prevention of falls should receive major emphasis in injury prevention efforts in inner-city minority populations. Language: en

Objective To identify correlates of behavioral management strategies and to test whether children with more severe behavioral problems have care transferred to mental health specialists. Methods Secondary analysis of the Child Behavior Study. Children aged 4 to 15 years were identified with new behavioral problems at nonurgent visits to primary care clinicians. Treatment strategies were categorized into mutually exclusive groups: primary care (psychotropic prescription and/or office-based counseling), mental health care (referral for or ongoing specialist mental health care), joint care (primary care and mental health care), or observation. Child-, family-, clinician-, and practice-level characteristics were assessed for association with management strategies by use of multivariate methods. Results A total of 1377 children from 201 practices in 44 states and Puerto Rico were newly identified with behavioral problems. Behavioral/conduct (41%), attentional/hyperactivity (37%), adjustment (32%), and emotional (22%) problems were most commonly identified. Children with comorbid behavioral problems were more likely to be managed with joint care than other treatment strategies. In addition, clinicians who were male or who had greater mental health orientation were more likely to provide joint care than mental health care only. Conclusions Clinicians were more likely to manage new behavioral problems jointly with mental health providers than use other strategies if children had coexisting mental health problems or if providers had stronger beliefs about psychosocial aspects of care. These results do not support the hypothesis that children with more severe behavioral problems are transferred to specialists but suggest that primary care and mental health care clinicians may benefit from collaborating on treatment plans.

OBJECTIVES: To describe the causes and circumstances of conflict leading to assault injury among urban youth seeking care in the emergency department. METHODS: The authors conducted in-person and telephone interviews with a convenience sample of 143 youth aged 12-19 years presenting to two urban emergency departments with an interpersonal assault injury. Patients were interviewed about the nature and circumstances of their injury. Descriptive analysis was performed, including stratified analysis by gender, age (12-15 vs. 16-19 years), and weapon use. RESULTS: Seventy percent of patients knew or knew of the person(s) who injured them; most were friends, classmates, or acquaintances. More than half of the injuries (56%) were related to a past disagreement. Among assaults related to a past disagreement, 33% of patients had previous arguments with their assailant, 16% had previous fights, and 14% had previous weapons threats. Twenty-nine percent had been previously threatened, and 11% had previously threatened their assailant. Twenty-eight percent of patients believed they helped to cause the injury by provoking a fight or letting down their guard. Nearly two thirds (64%) believed there were things they could change to prevent future injury, including staying away from dangerous situations and bad influences or controlling their tempers. CONCLUSIONS: Most assault injuries among adolescents involved past disagreements with people they knew. Many injured youth were mutually involved in conflict before their injury. Over time, many victims and perpetrators may be interchangeable. These data may help inform emergency department-based interventions to prevent assault injury. Language: en

Many patients use emergency departments (EDs) for primary care. Previous studies have found that patient characteristics affect ED utilization. However, such studies have led to few policy changes.We sought to determine whether Medicaid patients' ED use is associated with characteristics of their primary care practices.This was a cohort study.A total of 57,850 patients, assigned to 353 primary care practices affiliated with a Medicaid HMO, were included.Predictor variables were characteristics of primary care practices, which were measured by visiting each practice. The outcome variable was ED use adjusted for patient characteristics.On average, patients made 0.80 ED visits/person/yr. Patients from practices with more than 12 evening hours/wk used the ED 20% less than patients from practices without evening hours. A higher ratio of the number of active patients per clinician-hour of practice time was associated with more ED use. When more Medicaid patients were in a practice, these patients used the ED more frequently. Other factors associated with ED use included equipment for the care of asthma and presence of nurse practitioners and physician assistants.Modifiable characteristics of primary care practices were associated with ED use. Because the observational design of this study does not allow definitive conclusions about causality, future studies should include intervention trials to determine whether changing practice characteristics can reduce ED use.Improving primary care access and scope of services may reduce ED use. Focusing on systems issues rather than patient characteristics may be a more productive strategy to improve appropriate use of emergency medical care.

Children residing in Philadelphia, Pennsylvania, who were enrolled in a clinical trial of oral chelation therapy (n=73) were studied to determine the effects of a follow-up professional lead dust cleaning of their homes 18 mo after an initial cleaning and commencement of therapy. Home dust lead levels were determined from dust-wipe specimens collected from the kitchen and playroom floors, and from a playroom windowsill, prior to, immediately following, and 3 and 6 mo after the second cleaning. Children's blood lead levels were assessed at 3-mo intervals before and after the follow-up cleaning. Professional cleaning produced immediate decreases in dust lead levels; however, dust lead re-accumulated to precleaning levels within 3-6 mo. Frequent, repeated cleanings may be required if blood lead or dust lead levels are to be reduced and sustained at low levels in urban homes.

Social welfare programs support the income, education, nutrition, and medical care needs of many of this country's elders and children. Over the past twenty years, however, three times as many children as elders have lived in poverty, and poverty rates for children have consistently exceeded those for the elderly. Given the continued disparity in poverty rates, it is important to track levels of public spending for each group and the generational balance in allocating limited public funds. This Issue Brief evaluates trends in social welfare spending for children and the elderly from 1980 to 2000, and the relationship of national economic trends to public spending patterns.