Ventilator-Associated Events in Neonates and Children--A New Paradigm.

OBJECTIVES: To identify a pediatric ventilator-associated condition definition for use in neonates and children by exploring whether potential ventilator-associated condition definitions identify patients with worse outcomes. DESIGN: Retrospective cohort study and a matched cohort analysis. SETTING: Pediatric, cardiac, and neonatal ICUs in five U.S. hospitals. PATIENTS: Children 18 years old or younger ventilated for at least 1 day. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We evaluated the evidence of worsening oxygenation via a range of thresholds for increases in daily minimum fraction of inspired oxygen (by 0.20, 0.25, and 0.30) and daily minimum mean airway pressure (by 4, 5, 6, and 7 cm H2O). We required worsening oxygenation be sustained for at least 2 days after at least 2 days of stability. We matched patients with a ventilator-associated condition to those without and used Cox proportional hazard models with frailties to examine associations with hospital mortality, hospital and ICU length of stay, and duration of ventilation. The cohort included 8,862 children with 10,209 hospitalizations and 77,751 ventilator days. For the fraction of inspired oxygen 0.25/mean airway pressure 4 definition (i.e., increase in minimum daily fraction of inspired oxygen by 0.25 or mean airway pressure by 4), rates ranged from 2.9 to 3.2 per 1,000 ventilator days depending on ICU type; the fraction of inspired oxygen 0.30/mean airway pressure 7 definition yielded ventilator-associated condition rates of 1.1-1.3 per 1,000 ventilator days. All definitions were significantly associated with greater risk of hospital death, with hazard ratios ranging from 1.6 (95% CI, 0.7-3.4) to 6.8 (2.9-16.0), depending on thresholds and ICU type. Each definition was associated with prolonged hospitalization, time in ICU, and duration of ventilation, among survivors. The advisory board of the study proposed using the fraction of inspired oxygen 0.25/mean airway pressure 4 thresholds to identify pediatric ventilator-associated conditions in ICUs. CONCLUSIONS: Pediatric patients with ventilator-associated conditions are at substantially higher risk for mortality and morbidity across ICUs, regardless of thresholds used. Next steps include identification of risk factors, etiologies, and preventative measures for pediatric ventilator-associated conditions.

Statin exposure is associated with decreased asthma-related emergency department visits and oral corticosteroid use.

RATIONALE: Statins, or HMG-CoA reductase inhibitors, may aid in the treatment of asthma through their pleiotropic antiinflammatory effects. OBJECTIVES: To examine the effect of statin therapy on asthma-related exacerbations using a large population-based cohort. METHODS: Statin users aged 31 years or greater with asthma were identified from the Population-Based Effectiveness in Asthma and Lung population, which includes data from five health plans. Statin exposure and asthma exacerbations were assessed over a 24-month observation period. Statin users with a statin medication possession ratio greater than or equal to 80% were matched to non-statin users by age, baseline asthma therapy, site of enrollment, season at baseline, and propensity score, which was calculated based on patient demographics and Deyo-Charlson conditions. Asthma exacerbations were defined as two or more oral corticosteroid dispensings, asthma-related emergency department visits, or asthma-related hospitalizations. The association between statin exposure and each of the three outcome measures was assessed using conditional logistic regression. MEASUREMENTS AND MAIN RESULTS: Of the 14,566 statin users, 8,349 statin users were matched to a nonuser. After adjusting for Deyo-Charlson conditions that remained unbalanced after matching, among statin users, statin exposure was associated with decreased odds of having asthma-related emergency department visits (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.53-0.77; P < 0.0001) and two or more oral corticosteroid dispensings (OR, 0.90; 95% CI, 0.81-0.99; P = 0.04). There were no differences in asthma-related hospitalizations (OR, 0.91; 95% CI, 0.66-1.24; P = 0.52). CONCLUSIONS: Among statin users with asthma, statin exposure was associated with decreased odds of asthma-related emergency department visits and oral corticosteroid dispensings.

Reliability of a patient survey assessing cost-related changes in health care use among high deductible health plan enrollees.

BACKGROUND: Recent increases in patient cost-sharing for health care have lent increasing importance to monitoring cost-related changes in health care use. Despite the widespread use of survey questions to measure changes in health care use and related behaviors, scant data exists on the reliability of such questions. METHODS: We administered a cross-sectional survey to a stratified random sample of families in a New England health plan's high deductible health plan (HDHP) with ≥ $500 in annualized out-of-pocket expenditures. Enrollees were asked about their knowledge of their plan, information seeking, behavior change associated with having a deductible, experience of delay in care due in part to cost, and hypothetical delay in care due in part to cost. Initial respondents were mailed a follow-up survey within two weeks of each family returning the original survey. We computed several agreement statistics to measure the test-retest reliability for select questions. We also conducted continuity adjusted chi-square, and McNemar tests in both the original and follow-up samples to measure the degree to which our results could be reproduced. Analyses were stratified by self-reported income. RESULTS: The test-retest reliability was moderate for the majority of questions (0.41 - 0.60) and the level of test-retest reliability did not differ substantially across each of the broader domains of questions. The observed proportions of respondents with delayed or foregone pediatric, adult, or any family care were similar when comparing the original and follow-up surveys. In the original survey, respondents in the lower-income group were more likely to delay or forego pediatric care, adult care, or any family care. All of the tests comparing income groups in the follow-up survey produced the same result as in the original survey. CONCLUSIONS: In this population of HDHP beneficiaries, we found that survey questions concerning plan knowledge, information seeking, and delayed or foregone care were moderately reliable. Our results offer reassurance for researchers using survey information to study the effects cost sharing on health care utilization.

Outcomes after periodic use of inhaled corticosteroids in children.

BACKGROUND: Many children with persistent asthma use inhaled corticosteroids on a periodic basis. Clinical trials in adults suggest that periodic use of inhaled corticosteroids may be effective for patients with mild persistent asthma. However, scant information exists on the clinical outcomes of children with asthma who are using inhaled corticosteroids on a periodic basis in real-world settings. OBJECTIVE: This prospective cohort study compared clinical outcomes during a 12-month follow-up period between children with persistent asthma whose parents believed that they were supposed to use inhaled steroids either (a) periodically or (b) daily year-round at the start of the period. The clinical outcomes studied were (1) asthma-related emergency department (ED) visits or hospitalizations, (2) uncontrolled asthma based on health care and medication use, and (3) outpatient visits for asthma. PATIENTS AND METHODS: The study population included children with persistent asthma from two health plans whose parents reported that they were using inhaled corticosteroids during a baseline telephone interview. The interviews collected information on whether the children's parents believed they were supposed to use inhaled corticosteroids on a periodic or daily basis, as well as baseline asthma symptom status, sociodemographic, and behavioral variables. We used computerized databases to identify clinical events for each child during the 12 months after their baseline interview. Uncontrolled asthma was defined as any asthma-related ED visit or hospitalization, two or more oral steroid prescription fills, or four or more beta-agonists canisters filled during the 12-month period. We compared these outcomes between the periodic versus daily users of inhaled corticosteroids using logistic regression analyses. We conducted both (1) a traditional logistic regression analysis in which we adjusted for selection bias by including covariates such as age, asthma physical status, sociodemographic and behavioral variables, and history of asthma-related health care use during the year before interview and (2) an analysis using propensity scores to more fully adjust for selection bias. RESULTS: Of a total of 476 children in the study, 55% of parents believed their children were supposed to be using inhaled corticosteroids on a periodic basis and 45% believed their children were supposed to be using them daily year-round based on the baseline parent interview. At baseline, periodic inhaled corticosteroid users had less severe asthma than daily users based on several measures including better asthma physical status scores on the Children's Health Survey for Asthma (mean 87 +/- 16.0 vs. 81 +/- 17.4, p = < 0.0001). During the year before the baseline interview, periodic users compared with daily users were less likely to have an ED visit or hospitalization (10% vs. 23%, p = 0.0001) and less likely to have had five or more albuterol prescription fills (13% vs. 31%, p < 0.0001). During the follow-up year, those who believed inhaled steroids were for periodic use were less likely than those who believed inhaled steroids were for daily use to have an ED visit or hospitalization for asthma (OR 0.36, 95% CI: 0.18-0.73), even after adjusting for baseline asthma status and other covariates. Similarly, those who believed inhaled steroids were for periodic use were less likely to have uncontrolled asthma, OR 0.38 (95% CI: 0.24-0.62). Analyses using propensity score adjustment yielded similar results to the logistic regression analyses. CONCLUSION: Children whose parents believed they were supposed to use inhaled corticosteroids on a periodic basis had less severe asthma at baseline than those whose parents believed they were supposed to be using them daily. Periodic users were less likely than daily users to have adverse asthma outcomes during 1-year follow-up. This suggests that clinicians may be applying appropriate selection criteria by choosing patients with less severe asthma for periodic inhaled corticosteroid regimens.

Screening patients with a family history of colorectal cancer.

OBJECTIVES: To compare screening practices and beliefs in patients with and without a clinically important family history. DESIGN: We mailed a brief questionnaire asking about family history and a second, longer survey asking about knowledge of and beliefs about colorectal cancer to all respondents with a family history and a random sample of respondents without a family history of colorectal cancer. We reviewed electronic medical records for screening examinations and recording of family history. PARTICIPANTS: One thousand eight hundred seventy of 6,807 randomly selected patients ages 35-55 years who had been continuously enrolled in a large multispecialty group practice for at least 5 years. MEASUREMENTS: Recognition of increased risk, screening practices, and beliefs-all according to strength of family history and patient's age. RESULTS: Nineteen percent of respondents reported a family history of colorectal cancer. In 11%, this history was strong enough to warrant screening before age 50 years. However, only 39% (95% CI 36, 42) of respondents under the age of 50 years said they had been asked about family history and only 45% of those with a strong family history of colorectal cancer had been screened appropriately. Forty-six percent of patients with a strong family history did not know that they should be screened at a younger age than average risk people. Medical records mentioned family history of colorectal cancer in 59% of patients reporting a family history. CONCLUSIONS: More efforts are needed to translate information about family history of colorectal cancer into the care of patients.

Economic analysis of a randomized trial of academic detailing interventions to improve use of antihypertensive medications.

The authors estimated the costs and cost savings of implementing a program of mailed practice guidelines and single-visit individual and group academic detailing interventions in a randomized controlled trial to improve the use of antihypertensive medications. Analyses took the perspective of the payer. The total costs of the mailed guideline, group detailing, and individual detailing interventions were estimated at 1000 dollars, 5500 dollars, and 7200 dollars, respectively, corresponding to changes in the average daily per person drug costs of -0.0558 dollars (95% confidence interval, -0.1365 dollars to 0.0250 dollars) in the individual detailing intervention and -0.0001 dollars (95% confidence interval, -0.0803 dollars to 0.0801 dollars) in the group detailing intervention, compared with the mailed intervention. For all patients with incident hypertension in the individual detailing arm, the annual total drug cost savings were estimated at 21,711 dollars (95% confidence interval, 53,131 dollars savings to 9709 dollars cost increase). Information on costs of academic detailing could assist with health plan decision making in developing interventions to improve prescribing.

Impact of routine intensive care unit surveillance cultures and resultant barrier precautions on hospital-wide methicillin-resistant Staphylococcus aureus bacteremia.

BACKGROUND: Serial interventions are often used to reduce the risk of health care-associated methicillin-resistant Staphylococcus aureus (MRSA) infections. To our knowledge, the relative impact of these interventions has not previously been ascertained. METHODS: We conducted a retrospective study of 4 major infection control interventions using an interrupted time series design to evaluate their impact on MRSA bacteremia in an 800-bed hospital with 8 intensive care units (ICUs). Interventions were introduced 1 at a time during a 9-year period and involved the promotion of compliance with maximal sterile barrier precautions during central venous catheter placement, the institution of alcohol-based hand rubs for hand disinfection, the introduction of a hand hygiene campaign, and the institution of routine nares surveillance cultures for MRSA in all ICUs for patients on ICU admission and weekly thereafter while in the ICU. Positive cultures resulted in the initiation of contact isolation precautions. Using segmented regression analyses, we evaluated changes in monthly incidence and prevalence of MRSA bacteremia from their predicted values. Methicillin-susceptible Staphylococcus aureus bacteremia was monitored as a control. RESULTS: Routine surveillance cultures and subsequent contact isolation precautions resulted in substantial reductions in MRSA bacteremia in both ICUs and non-ICUs. In 16 months, the incidence density of MRSA bacteremia decreased by 75% in ICUs (P=.007) and by 40% in non-ICUs (P=.008), leading to a 67% hospital-wide reduction in the incidence density of MRSA bacteremia (P=.002). Methicillin-susceptible S. aureus bacteremia rates remained stable during this time. The other interventions were not associated with a statistically significant change in MRSA bacteremia. CONCLUSIONS: Routine surveillance for MRSA in ICUs allowed earlier initiation of contact isolation precautions and was associated with large and statistically significant reductions in the incidence of MRSA bacteremia in the ICUs and hospital wide. In contrast, no similar decrease was attributable to the other infection control interventions.

Clinical and nonclinical correlates of adherence to prescribing guidelines for hypertension in a large managed care organization.

To examine correlates of guideline adherence in a population with access to health care and prescription drug benefits, the authors conducted a cross-sectional analysis among 5789 patients undergoing hypertension treatment with a single medication in a large New England managed care organization. Logistic regression was used to determine correlates of adherence, defined as use of diuretics or beta blocker as antihypertensive monotherapy during the 1-year study period. Women were more likely than men to receive guideline-adherent therapy (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.45-1.85). Compared with patients covered by health maintenance organization plans, Medicare coverage was positively associated with guideline adherence (OR, 1.38; 95% CI, 1.13-1.69), but fee-for-service coverage was negatively associated (OR, 0.66; 95% CI, 0.48-0.91). Patient age was not a significant correlate of adherence to guidelines (OR, 1.01; 95% CI, 0.94-1.09). Understanding these observations may lead to strategies to improve guideline adherence and reduce health care disparities.

Mismatching Among Guidelines, Providers, and Parents on Controller Medication Use in Children with Asthma.

BACKGROUND: Underuse of controller medicines among children with asthma remains widespread despite national guidelines. OBJECTIVES: To (1) assess provider prescribing patterns for asthma controller medications; (2) assess how frequently parents' reports of their child's asthma controller medicine use were mismatched with their provider's recommendations; and (3) evaluate parent attitudes and demographic characteristics associated with these mismatches. METHODS: In this cross-sectional study, we conducted linked surveys of parents and providers of children with probable persistent asthma in a Medicaid program and 4 commercial health plans in 2011. Probable persistent asthma was defined as a diagnosis of asthma and 1 or more controller medication dispensing. RESULTS: This study included 740 children (mean age, 8.6 years). Providers for 50% of the children reported prescribing controller medications for daily year-round use, 41% for daily use during active asthma months, and 9% for intermittent use for relief. Among parents, 72% knew which class of controller medication the provider prescribed and 49% knew the administration frequency and the medication class. Parents were less likely to report the same controller medication type as the provider, irrespective of dose and frequency, if they were Latino (odds ratio [OR], 0.23; CI, 0.057-0.90), had a household smoker (OR, 2.87; CI, 0.42-19.6), or believed the controller medicine was not helping (OR, 0.15; CI, 0.048-0.45). CONCLUSIONS: Mismatches between parent reports and providers intentions regarding how the child was supposed to use inhaled steroids occurred for half of the children. Efforts should focus on ways to reduce mismatches between parent and provider intentions regarding controller medication use.

Building a virtual cancer research organization.

BACKGROUND: The Cancer Research Network (CRN) comprises the National Cancer Institute and 11 nonprofit research centers affiliated with integrated health care delivery systems. The CRN, a public/private partnership, fosters multisite collaborative research on cancer prevention, screening, treatment, survival, and palliation in diverse populations. METHODS: The CRN's success hinges on producing innovative cancer research that likely would not have been developed by scientists working individually, and then translating those findings into clinical practice within multiple population laboratories. The CRN is a collaborative virtual research organization characterized by user-defined sharing among scientists and health care providers of data files as well as direct access to researchers, computers, software, data, research participants, and other resources. The CRN's research management Web site fosters a high-functioning virtual scientific community by publishing standardized data definitions, file specifications, and computer programs to support merging and analyzing data from multiple health care systems. RESULTS: Seven major types of standardized data files developed to date include demographics, health plan eligibility, tumor registry, inpatient and ambulatory utilization, medication dispensing, laboratory tests, and imaging procedures; more will follow. Data standardization avoids rework, increases multisite data integrity, increases data security, generates shorter times from initial proposal concept to submission, and stimulates more frequent collaborations among scientists across multiple institutions. CONCLUSIONS: The CRN research management Web site and associated standardized data files and procedures represent a quasi-public resource, and the CRN stands ready to collaborate with researchers from outside institutions in developing and conducting innovative public domain research.

Group versus individual academic detailing to improve the use of antihypertensive medications in primary care: a cluster-randomized controlled trial.

PURPOSE: To compare group versus individual academic detailing to increase diuretic or beta-blocker use in hypertension. METHODS: We conducted a cluster-randomized controlled trial in a large health maintenance organization. Subjects (N=9820) were patients with newly treated hypertension in the year preceding the intervention (N=3692), the 9 months following the intervention (N=3556), and the second year following intervention (N=2572). We randomly allocated 3 practice sites to group detailing (N=227 prescribers), 3 to individual detailing (N=235 prescribers), and 3 to usual care (N=319 prescribers). Individual detailing entailed a physician-educator meeting individually with clinicians to address barriers to prescribing guideline-recommended medications. The group detailing intervention incorporated the same social marketing principles in small groups of clinicians. RESULTS: In the first year following the intervention, the rates of diuretic or beta-blocker use increased by 13.2% in the group detailing practices, 12.5% in the individual detailing practices, and 6.2% in the usual care practices. As compared with usual care practices, diuretic or beta-blocker use was more likely in group detailing practices (adjusted odds ratio (OR), 1.40; 95% confidence interval (CI), 1.11 - 1.76) and individual detailing practices (adjusted OR, 1.30; 95% CI, 0.95 - 1.79). Neither intervention affected blood pressure control. Two years following this single-visit intervention, there was still a trend suggesting a persistent effect of individual (OR, 1.22; 95% CI, 0.92 - 1.62), but not group, detailing (OR, 1.06; 95% CI, 0.80 - 1.39), as compared with usual care. CONCLUSION: Both group and individual academic detailing improved antihypertensive prescribing over and above usual care but may require reinforcement to sustain improvements.

Primary adherence to controller medications for asthma is poor.

RATIONALE: Few previous studies have evaluated primary adherence (whether a new prescription is filled within 30 d) to controller medications in individuals with persistent asthma. OBJECTIVE: To compare adherence to the major controller medication regimens for asthma. METHODS: This was a retrospective cohort study of enrollees from five large health plans. We used electronic medical data on patients of all ages with asthma who had experienced an asthma-related exacerbation in the prior 12 months. We studied adherence measures including proportion of days covered and primary adherence (first prescription filled within 30 d). MEASUREMENTS AND MAIN RESULTS: Our population included 69,652 subjects who had probable persistent asthma and were prescribed inhaled corticosteroids (ICSs), leukotriene antagonists (LTRAs), or ICS/long-acting ß-agonists (ICS/LABAs). The mean age was 37 years and 58% were female. We found that 14-20% of subjects who were prescribed controller medicines for the first time did not fill their prescriptions. The mean proportion of days covered was 19% for ICS, 30% for LTRA, and 25% for ICS/LABA over 12 months. Using multivariate logistic regression, subjects prescribed LTRA were less likely to be primary adherent than subjects prescribed ICS (odds ratio, 0.82; 95% confidence interval, 0.74-0.92) or ICS/LABA (odds ratio, 0.88; 95% confidence interval, 0.80-0.97). Black and Latino patients were less likely to fill the prescription compared with white patients. CONCLUSIONS: Adherence to controller medications for asthma is poor. In this insured population, primary adherence to ICSs was better than to LTRAs and ICS/LABAs. Adherence as measured by proportion of days covered was better for LTRAs and ICS/LABAs than for ICSs.

Underuse of controller medications among Medicaid-insured children with asthma.

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

Pediatricians' self-reported clinical practices and adherence to national immunization guidelines after the introduction of pneumococcal conjugate vaccine.

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

Immunization status among children newly enrolled in a health plan: a new frontier for quality measurement?

BACKGROUND: The National Scientific Panel on Immunization Measurement Standards recently recommended that the assessment population for the childhood immunization measure of the Health Plan Employer Data and Information Set include 24-month-olds with > or = 6 months of continuous enrollment in a health plan. The current inclusion criterion is > or = 12 months of continuous enrollment. The new recommendation would expand the assessment population to include children with more recent enrollment. OBJECTIVES: To compare the immunization status of children enrolled in a large health plan between ages 12 and 17 months vs earlier in life and to describe the proportion of children enrolled between ages 12 and 17 months that could be fully immunized by 24 months. METHODS: All children enrolled in a group-model HMO who turned 24 months old during a 12-month study were identified for a retrospective cohort study. A computerized immunization database was used to identify all vaccines administered to each child, and summary measures were created to describe immunization status at selected times. The full-text medical records of children who seemed to have no immunizations in the computerized database were reviewed. RESULTS: Of the 3448 children in the study population, 3130 (91%) enrolled between birth and 11 months of age and 161 (5%) enrolled between 12 and 17 months of age. Whereas 87% of children who enrolled between birth and 11 months of age were fully immunized at age 24 months, only 57% of those enrolled between 12 and 17 months of age were fully immunized at 24 months of age (risk difference, 30%; 95% confidence interval, 24%-36%; P < .001). Of the 161 children enrolled between 12 and 17 months of age, 68% had received all of the immunizations in the primary series. Only 6% of these 161 children would have been impossible or difficult to fully immunize by age 24 months using accelerated catch-up vaccination schedules. CONCLUSIONS: Children who enrolled in an HMO between 12 and 17 months of age were less likely than those who enrolled earlier in life to be fully immunized by age 24 months, but it would be feasible to bring almost all of them up to date by that age. Including such children in immunization measures, either together with earlier-enrolled children or as a separate stratum, would expand the scope of the quality of care under evaluation.

Pediatricians' views on financial barriers and values for pneumococcal vaccine for children.

OBJECTIVES: To 1) describe barriers to pneumococcal conjugate vaccine adoption and 2) estimate the value of the vaccine based on pediatricians' responses to willingness-to-pay questions. METHODS: In June 2000, we mailed a random sample of pediatricians in Massachusetts a questionnaire about barriers to adoption of the vaccine and willingness to pay for the vaccine and associated outcomes. Respondents were assigned at random to 1 of 2 survey versions: the Personal Perspective version, for which they imagined spending their own money for their own child, or the Public Perspective version, for which they imagined spending the government's money for the average child. RESULTS: Of the 546 pediatricians who responded (estimated completion rate, 80%), only 9% were using the vaccine routinely at the time of the survey. Most said that if the state did not provide the vaccine, financial barriers including inadequate insurance reimbursement would limit their use of the vaccine either a great deal (61%) or a moderate amount (25%). Pediatricians who were asked how much they would pay for the vaccine for their own child (personal perspective) gave a mean of $56 per dose, whereas those who were asked how much the government should pay on behalf of an average child (public perspective) gave a mean of $36 per dose. Alternatively, when we used a decision analysis model and incorporated pediatricians' values for preventing pneumococcal infections to estimate the vaccine's value, the value per dose was $38 from the personal perspective and $34 from the public perspective. CONCLUSIONS: Pediatricians in Massachusetts identified significant financial barriers to the adoption of pneumococcal conjugate vaccine related to insurance arrangements. Based on willingness-to-pay questions, the value of the vaccine is lower than the current list price. The methods used to estimate the value of a vaccine, including the perspective used to frame questions, may substantially influence the results.

Use of leukotriene receptor antagonists are associated with a similar risk of asthma exacerbations as inhaled corticosteroids.

BACKGROUND: Based on results of clinical trials, inhaled corticosteroids (ICS) are the most-effective controller medications for preventing asthma-related exacerbations, yet few studies in real-life populations have evaluated the comparative effectiveness of ICS. OBJECTIVE: To determine the likelihood of asthma exacerbations among children with asthma after initiation of controller medications: ICS, leukotriene antagonists (LTRA), and ICS-long-acting ß-agonist (LABA) combination therapy. METHODS: This was a retrospective cohort study of subjects who were part of the Population-Based Effectiveness in Asthma and Lung Diseases Network. We conducted Cox regression analyses by adjusting for baseline covariates, adherence by using proportion of days covered, and high-dimensional propensity scores. The main outcome measurements were emergency department visits, hospitalizations, or oral corticosteroid use. RESULTS: Our population included 15,567 health plan subjects and 10,624 TennCare Medicaid subjects with uncontrolled asthma. Overall adherence to controller medications was low, with no more than 50% of the subjects refilling the medication after the initial fill. For subjects with allergic rhinitis, the subjects in TennCare Medicaid treated with LTRAs were less likely to experience ED visits (hazard ratio 0.44 [95% CI, 0.21-0.93]) compared with the subjects treated with ICS. For all other groups, the subjects treated with LTRA or ICS-LABA were just as likely to experience ED visits or hospitalizations, or need oral corticosteroids as the subjects treated with ICS. CONCLUSION: Risks of asthma-related exacerbations did not differ between children who initiated LTRA and ICS. These findings may be explainable by LTRA, which has similar effectiveness as ICS in real-life usage by residual confounding by indication or other unmeasured factors.

Methicillin-resistant Staphylococcus aureus infection and hospitalization in high-risk patients in the year following detection.

BACKGROUND: Many studies have evaluated methicillin-resistant Staphylococcus aureus (MRSA) infections during single hospitalizations and subsequent readmissions to the same institution. None have assessed the comprehensive burden of MRSA infection in the period after hospital discharge while accounting for healthcare utilization across institutions. METHODOLOGY/PRINCIPAL FINDINGS: We conducted a retrospective cohort study of adult patients insured by Harvard Pilgrim Health Care who were newly-detected to harbor MRSA between January 1991 and December 2003 at a tertiary care medical center. We evaluated all MRSA-attributable infections associated with hospitalization in the year following new detection, regardless of hospital location. Data were collected on comorbidities, healthcare utilization, mortality and MRSA outcomes. Of 591 newly-detected MRSA carriers, 23% were colonized and 77% were infected upon detection. In the year following detection, 196 (33%) patients developed 317 discrete and unrelated MRSA infections. The most common infections were pneumonia (34%), soft tissue (27%), and primary bloodstream (18%) infections. Infections occurred a median of 56 days post-detection. Of all infections, 26% involved bacteremia, and 17% caused MRSA-attributable death. During the admission where MRSA was newly-detected, 14% (82/576) developed subsequent infection. Of those surviving to discharge, 24% (114/482) developed post-discharge infections in the year following detection. Half (99/185, 54%) of post-discharge infections caused readmission, and most (104/185, 55%) occurred over 90 days post-discharge. CONCLUSIONS/SIGNIFICANCE: In high-risk tertiary care patients, newly-detected MRSA carriage confers large risks of infection and substantial attributable mortality in the year following acquisition. Most infections occur post-discharge, and 18% of infections associated with readmission occurred in hospitals other than the one where MRSA was newly-detected. Despite gains in reducing MRSA infections during hospitalization, the risk of MRSA infection among critically and chronically ill carriers persists after discharge and warrants targeted prevention strategies.

Health care use and decision making among lower-income families in high-deductible health plans.

BACKGROUND: Lower-income families may face unique challenges in high-deductible health plans (HDHPs). METHODS: We administered a cross-sectional survey to a stratified random sample of families in a New England health plan's HDHP with at least $500 in annualized out-of-pocket expenditures. Lower-income families were defined as having incomes that were less than 300% of the federal poverty level. Primary outcomes were cost-related delayed or foregone care, difficulty understanding plans, unexpected costs, information-seeking, and likelihood of families asking their physician about hypothetical recommended services subject to the plan deductible. Multivariate logistic regression was used to control for potential confounders of associations between income group and primary outcomes. RESULTS: Lower-income families (n = 141) were more likely than higher-income families (n = 273) to report cost-related delayed or foregone care (57% vs 42%; adjusted odds ratio [AOR], 1.81; 95% confidence interval [CI], 1.15-2.83]). There were no differences in plan understanding, unexpected costs, or information-seeking by income. Lower-income families were more likely than others to say they would ask their physician about a $100 blood test (79% vs 63%; AOR, 1.97; 95% CI, 1.18-3.28) or a $1000 screening colonoscopy (89% vs 80%; AOR, 2.04; 95% CI, 1.06-3.93) subject to the plan deductible. CONCLUSIONS: Lower-income families with out-of-pocket expenditures in an HDHP were more likely than higher-income families to report cost-related delayed or foregone care but did not report more difficulty understanding or using their plans, and might be more likely to question services requiring out-of-pocket expenditures. Policymakers and physicians should consider focused monitoring and benefit design modifications to support lower-income families in HDHPs.

Asthma care quality for children with minority-serving providers.

OBJECTIVE: To compare asthma care quality for children with and without minority-serving providers. DESIGN: Cross-sectional telephone survey of parents, linked with a mailed survey of their children's providers. SETTING: A Medicaid-predominant health plan and multispecialty provider group in Massachusetts. PARTICIPANTS: A total of 563 children with persistent asthma, identified by claims and encounter data. Main Exposure Whether the child's provider was minority serving (>25% of patients black or Latino). Outcomes Parent report of whether the child had (1) ever received inhaled steroids, (2) received influenza vaccination during the past season, and (3) received an asthma action plan in the past year. RESULTS: In unadjusted analyses, Latino children and those with minority-serving providers were more likely to have never received inhaled steroids. In adjusted models, the odds of never receiving inhaled steroids were not statistically significantly different for children with minority-serving providers (odds ratio [OR], 1.29; 95% confidence interval [CI], 0.63-2.64), or for Latino vs white children (OR, 1.76; 95% CI, 0.74-4.18); odds were increased for children receiving care in community health centers (OR, 4.88; 95% CI, 1.70-14.02) or hospital clinics (OR, 4.53; 95% CI, 1.09-18.92) vs multispecialty practices. Such differences were not seen for influenza vaccinations or action plans. CONCLUSIONS: Children with persistent asthma are less likely to receive inhaled steroids if they receive care in community health centers or hospital clinics. Practice setting mediated initially observed disparities in inhaled steroid use by Latino children and those with minority-serving providers. No differences by race/ethnicity or minority-serving provider were observed for influenza vaccinations or asthma action plans.