Pilot Evaluation of the Family Bridge Program: A Communication- and Culture-Focused Inpatient Patient Navigation Program.

OBJECTIVE: Children with low income and minority race and ethnicity have worse hospital outcomes due partly to systemic and interpersonal racism causing communication and system barriers. We tested the feasibility and acceptability of a novel inpatient communication-focused navigation program. METHODS: Multilingual design workshops with parents, providers, and staff created the Family Bridge Program. Delivered by a trained navigator, it included 1) hospital orientation; 2) social needs screening and response; 3) communication preference assessment; 4) communication coaching; 5) emotional support; and 6) a post-discharge phone call. We enrolled families of hospitalized children with public or no insurance, minority race or ethnicity, and preferred language of English, Spanish, or Somali in a single-arm trial. We surveyed parents at enrollment and 2 to 4 weeks post-discharge, and providers 2 to 3 days post-discharge. Survey measures were analyzed with paired t tests. RESULTS: Of 60 families enrolled, 57 (95%) completed the follow-up survey. Most parents were born outside the United States (60%) with a high school degree or less (60%). Also, 63% preferred English, 33% Spanish, and 3% Somali. The program was feasible: families received an average of 5.3 of 6 components; all received >2. Most caregivers (92%) and providers (81% [30/37]) were "very satisfied." Parent-reported system navigation improved from enrollment to follow-up (+8.2 [95% confidence interval 2.9, 13.6], P = .003; scale 0-100). Spanish-speaking parents reported decreased skills-related barriers (-18.4 [95% confidence interval -1.8, -34.9], P = .03; scale 0-100). CONCLUSIONS: The Family Bridge Program was feasible, acceptable, and may have potential for overcoming barriers for hospitalized children at risk for disparities.

Deficiencies in Provider-Reported Interpreter Use in a Clinical Trial Comparing Telephonic and Video Interpretation in a Pediatric Emergency Department.

BACKGROUND: Professional interpretation improves health care quality and outcomes for limited English proficient (LEP) patients, yet interpreter use remains low even when interpretation is available remotely. The researchers analyzed the effect of remote interpretation (telephone or video) on pediatric emergency provider attitudes and behaviors around professional interpretation. METHODS: A cross-sectional questionnaire of pediatric emergency providers was conducted as part of a randomized trial of telephone vs. video interpretation with Spanish speaking LEP families. Providers recalled lapses of professional interpretation for medical communication (use of an ad hoc or no interpreter), if they had delayed or deferred communication due to the need for professional interpretation, and were asked about their satisfaction with the interpretation modality. Bivariate and multivariate analysis of professional interpreter use and communication behaviors were analyzed by self-report of study group assignment. RESULTS: One third of providers reported lapses of professional interpretation and many reported less frequent (45.6%) and deferred (34.6%) communication due to the need for interpretation. There was no significant difference in these outcomes between telephone and video assignment. Interpreter skill and technical difficulties were similar between groups. Providers assigned to telephone, compared to video, were more likely to be dissatisfied (p < 0.001) and to report that interpretation was ineffective (p = 0.002). CONCLUSION: Despite access to interpretation, providers caring for patients enrolled in a study of professional interpreter modalities reported frequent lapses in professional interpretation and deferring or delaying communication because an interpreter was needed. Addressing barriers to remote interpreter use will improve quality of care and health equity for LEP patients.

Identifying Modifiable Health Care Barriers to Improve Health Equity for Hospitalized Children.

BACKGROUND: Children from socially disadvantaged families experience worse hospital outcomes compared with other children. We sought to identify modifiable barriers to care to target for intervention. METHODS: We conducted a prospective cohort study of hospitalized children over 15 months. Caregivers completed a survey within 3 days of admission and 2 to 8 weeks after discharge to assess 10 reported barriers to care related to their interactions within the health care system (eg, not feeling like they have sufficient skills to navigate the system and experiencing marginalization). Associations between barriers and outcomes (30-day readmissions and length of stay) were assessed by using multivariable regression. Barriers associated with worse outcomes were then tested for associations with a cumulative social disadvantage score based on 5 family sociodemographic characteristics (eg, low income). RESULTS: Of eligible families, 61% (n = 3651) completed the admission survey; of those, 48% (n = 1734) completed follow-up. Nine of 10 barriers were associated with at least 1 worse hospital outcome. Of those, 4 were also positively associated with cumulative social disadvantage: perceiving the system as a barrier (adjusted ß = 1.66; 95% confidence interval [CI] 1.02 to 2.30), skill barriers (ß = 3.82; 95% CI 3.22 to 4.43), cultural distance (ß = 1.75; 95% CI 1.36 to 2.15), and marginalization (ß = .71; 95% CI 0.30 to 1.11). Low income had the most consistently strong association with reported barriers. CONCLUSIONS: System barriers, skill barriers, cultural distance, and marginalization were significantly associated with both worse hospital outcomes and social disadvantage, suggesting these are promising targets for intervention to decrease disparities for hospitalized children.

Medical Home-Head Start Partnership to Promote Early Learning for Low-Income Children.

OBJECTIVE: To improve Early Head Start/Head Start (EHS/HS) screening, referral, and enrollment for children from diverse, low-income communities. METHOD: Using existing resources, we built a pediatric clinic-Head Start partnership. Key steps included (1) screening protocol and tracking system, (2) a community partner as a single point of referral contact, (3) provider education, and (4) monthly outcome reporting. A pre- and post-cross-sectional study design was used to evaluate outcomes, with medical chart review conducted for all wellness visits among children aged 0 to 4 years pre- and postintervention. RESULTS: The preintervention group included 223 patients. The postintervention group included 235 patients. EHS/HS screening improved significantly after the intervention, rising from 8% in the preintervention period to 46% in the postintervention period (odds ratio [OR] 10.5, 95% confidence interval [CI] [5.9, 19.4]). EHS/HS documented referral rates increased from 1% in the preintervention period to 20% in the postintervention period (OR 18.3, 95% CI [5.7, 93.6]). Thirty-two of the 42 patients in the postintervention group referred to EHS/HS were reached to determine enrollment status. Six children (14%) had enrolled in EHS/HS. CONCLUSION: With use of existing resources, a medical home-Head Start partnership can build an integrated system that significantly improves screening and referral rates to early learning programs.

Audio-Recorded Discharge Instructions for Limited English Proficient Parents: A Pilot Study.

BACKGROUND: Parents with limited English proficiency (LEP) demonstrate lower comprehension of discharge instructions. A study was conducted to (1) determine the feasibility of providing a greeting card with language-specific, audio-recorded discharge instructions to LEP parents; (2) describe use of and satisfaction with the cards; and (3) evaluate card effect on instruction comfort with home care and comprehension. METHODS: LEP parents of children undergoing day surgery from April to September 2016 were eligible. Participants were randomized to usual discharge instructions, or usual instructions plus a three-minute card with language-specific audio instructions that could be replayed repeatedly. Parents were surveyed by telephone two to seven days postdischarge to assess card use and satisfaction, comfort with home care, and discharge instruction recall (medications, home care, follow-up, and return precautions). Parent-reported instructions were compared to instructions in the medical record; concordance was determined by two blinded reviewers. Due to difficulty achieving recruitment goals, analysis focused on feasibility and acceptability. RESULTS: Of 83 parents enrolled, 66 (79.5%) completed the follow-up survey. Most had not completed high school (61.0%) and spoke Spanish (89.2%). Parents reported high satisfaction with the card (4.5/5 for ease of use, helpfulness, and understandability). Ninety-four percent shared the card with others, and 45.2% reported listening > 5 times. Besides reviewing the care instructions generally, parents reported using the card to review medications and engage others in the child's care. CONCLUSION: Providing language-concordant, audio-recorded discharge instructions was feasible, and parents reported high satisfaction with and frequent use of the cards with multiple caregivers.

Provider Language Proficiency and Decision-Making When Caring for Limited English Proficiency Children and Families.

OBJECTIVE: To examine associations between self-assessed language ability and provision of clinical care without professional interpretation. METHODS: We conducted an anonymous web-based survey of pediatric residents at a large pediatric training program. Respondents self-rated their language ability, and then reported on their willingness to deliver clinical care without professional interpretation in standardized clinical scenarios. RESULTS: All pediatric residents completed the survey (n=81; 100%). Many residents (58 of the total sample) indicated at least rudimentary skills in a second language, and seven (9%) indicated they were proficient in Spanish. Eight-five percent had sometimes relied upon friends or family to communicate with parents. Most (69%) reported occasional use of Spanish-language skills to take a history or provide medical advice without the use of a professional interpreter. In contrast, in clinical scenarios where a child was believed to have a complex medical history, few residents (2.5%) felt comfortable using their language skills in the clinical encounter. Residents were willing to have their language ability assessed. CONCLUSIONS: Residents still face circumstances in which care proceeds without an interpreter. Discomfort with providing care in a second language grows with the perceived complexity of care, and yet a complex condition may not be apparent when communication barriers exist. Overcoming barriers to the use of professional interpretation may improve care for LEP children.

The Relationship Between Objectively Measured Walking and Risk of Pedestrian-Motor Vehicle Collision.

Safe urban walking environments may improve health by encouraging physical activity, but the relationship between an individual's location and walking pattern and the risk of pedestrian-motor vehicle collision is unknown. We examined associations between individuals' walking bouts and walking risk, measured as mean exposure to the risk of pedestrian-vehicle collision. Walking bouts were ascertained through integrated accelerometry and global positioning system data and from individual travel-diary data obtained from adults in the Travel Assessment and Community Study (King County, Washington) in 2008-2009. Walking patterns were superimposed onto maps of the historical probabilities of pedestrian-vehicle collisions for intersections and midblock segments within Seattle, Washington. Mean risk of pedestrian-vehicle collision in specific walking locations was assessed according to walking exposure (duration, distance, and intensity) and participant demographic characteristics in linear mixed models. Participants typically walked in areas with low pedestrian collision risk when walking for recreation, walking at a faster pace, or taking longer-duration walks. Mean daily walking duration and distance were not associated with collision risk. Males walked in areas with higher collision risk compared with females, while vehicle owners, residents of single-family homes, and parents of young children walked in areas with lower collision risk. These findings may suggest that pedestrians moderate collision risk by using lower-risk routes.

"I wasn't texting; I was just reading an email ": a qualitative study of distracted driving enforcement in Washington State.

BACKGROUND: In response to the rise of distracted driving, many countries and most US states have adopted laws to restrict the use of handheld phones for drivers. Specific provisions of each law and the overall social mores of distracted driving influence enforceability and impact. OBJECTIVES: Identify multilevel interdependent factors that influence distracted driving enforcement through the perspective of police officers. DESIGN/METHODS: We conducted focus group discussions with active duty law enforcement officers from three large Washington State counties. Our thematic analysis used descriptive and pattern coding that placed our findings within a social ecological framework to facilitate targeted intervention development. RESULTS: Participants reported that the distracted driving law posed challenges for consistent and effective enforcement. They emphasised the need to change social norms around distracted driving, similar to the shifts seen around impaired driving. Many participants were themselves distracted drivers, and their individual knowledge, attitude and beliefs influenced enforcement. Participants suggested that law enforcement leaders and policymakers should develop and implement policies and strategies to prioritise and motivate increased distracted driving enforcement. CONCLUSIONS: Individual, interpersonal, organisational and societal factors influence enforcement of distracted driving laws. Targeted interventions should be developed to address distracted driving and sustain effective enforcement.

Availability of resources for emergency care at a second-level hospital in Ghana: A mixed methods assessment.

INTRODUCTION: Emergency care is an essential component of health systems, particularly in low- and middle-income countries. We sought to assess the availability of resources to provide emergency care at a second-level hospital in Ghana. By doing so, deficits that could guide development of targeted intervention strategies to improve emergency care could be identified. METHODS: A qualitative and quantitative assessment of capacity for care of emergency patients was performed at the Emergency Centre of the Police Hospital, a second-level hospital in Accra, Ghana. Direct inspection and job-specific survey of clinical, orderly, administrative and ambulance staff was performed. Responses to quantitative questions were described. Qualitative responses were examined by content analysis. RESULTS: Assessment revealed marked deficiencies in many essential items and services. However, several successes were identified, such as laboratory capacity. Among the unavailable essential items, some were of low-cost, such as basic airway supplies, chest tubes and several emergency medications. Themes from staff responses when asked how to improve emergency care included: provide periodic training, increase bed numbers in the emergency unit, ensure availability of essential items and make personal protective equipment available for all staff caring for patients. CONCLUSION: This study identified opportunities to improve the care of patients with emergency conditions at the Police Hospital in Ghana. Low-cost improvements in training, organization and planning could improve item and service availability, such as: developing a continuing education curriculum for staff in all areas of the emergency centre; holding in-service training on existing protocols for triage and emergency care; adding checklists to guide appropriate triage and safe transfer of patients; and perform a root cause analysis of item non-availability to develop targeted interventions.

INTRODUCTION: Les soins d'urgence sont une composante essentielle des systèmes de santé, notamment dans les pays à faible et moyen revenus. Nous avons cherché à évaluer la disponibilité des ressources allouées aux soins d'urgence dans un hôpital de deuxième niveau au Ghana. Il serait ainsi possible d'identifier les lacunes et ainsi guider le développement de stratégies d'intervention ciblées afin d'améliorer les soins d'urgence. MÉTHODES: Une évaluation qualitative et quantitative de la capacité de prise en charge des urgences a été réalisée au sein de l'Unité accidents et urgences de l'hôpital de la Police, un hôpital de second niveau situé à Accra, au Ghana. Un examen direct et propre à la profession a été réalisé à propos du personnel soignant, administratif et ambulancier. Les réponses aux questions quantitatives ont été décrites. Les réponses qualitatives ont été examinées par une analyse de leur contenu. RÉSULTATS: L'évaluation a révélé des déficiences prononcées dans nombre d'articles et services essentiels. Cependant, plusieurs succès ont été enregistrés, tels que la capacité des laboratoires. Parmi le matériel essentiel faisant défaut, il s'agissait pour certains de matériel peu coûteux, comme les dispositifs d'alimentation des voies aériennes de base, les drains thoraciques et plusieurs traitements d'urgence. Les réponses fournies par le personnel à la question de savoir comment améliorer les soins d'urgence incluaient les thèmes suivants: l'accès à une formation périodique, l'augmentation du nombre de lits au sein des urgences, la garantie de la disponibilité du matériel essentiel, et la mise à disposition de tous les employés s'occupant des urgences d'un équipement de protection individuelle. CONCLUSION: Cette étude a identifié des opportunités d'amélioration de la prise en charge des urgences au sein de l'hôpital de la Police au Ghana. Des améliorations peu coûteuses en termes de formation, d'organisation et de planification pourraient améliorer la disponibilité du matériel et du service, telles que l'élaboration d'un programme d'enseignement médical continu dans tous les domaines du centre des urgences, la tenue d'une formation interne sur les protocoles de triage et de soins d'urgence existants, l'ajout de listes de vérification afin de permettre un triage approprié et le bon transfert des patients, et la conduite d'une analyse des causes premières de la non-disponibilité de matériel afin d'élaborer des interventions ciblées.

Availability of Outpatient Rehabilitation Services for Children After Traumatic Brain Injury: Differences by Language and Insurance Status.

OBJECTIVE: The objective of this study was to explore associations between English proficiency, insurance status, outpatient rehabilitation service availability, and travel time for children with traumatic brain injury. DESIGN: The authors used an ecologic cross-sectional design. Data were analyzed from a cohort of 82 children with moderate to severe traumatic brain injury and rehabilitation providers in Washington State. Main measures included availability and travel time to services. RESULTS: Less than 20% of providers accepted children with Medicaid and provided language interpretation. Mental health services were most limited. Adjusted for median household income, multilingual service availability was lowest in counties with greater language diversity; for every 10% increase in persons older than 5 yrs speaking a language other than English at home, there was a 34% decrease in availability of multilingual services (prevalence ratio, 0.66; 95% confidence interval, 0.48-0.90). Adjusted for education and Medicaid status, children from Spanish-speaking families had significantly longer travel times to services (mean, 16 additional minutes to mental health; 9 to other therapies). CONCLUSIONS: Children in households with limited English proficiency and Medicaid faced significant barriers in availability and proximity of outpatient rehabilitation services. Innovative service strategies are needed to equitably improve availability of rehabilitation for children with traumatic brain injury. Similar studies in other regions will inform one's understanding of the scope of these disparities.

Prevalence of preventable household risk factors for childhood burn injury in semi-urban Ghana: A population-based survey.

OBJECTIVE: Childhood burns are a leading cause of injury in low- and middle-income countries; most of which are preventable. We aimed to describe the prevalence of household risk factors for childhood burn injury (CBI) in semi-urban Ghana to inform prevention strategies for this growing population. METHODS: We conducted a population-based survey of 200 households in a semi-urban community in Ghana. Households were randomly selected from a list of 6520 households with children aged <18 years. Caregivers were interviewed about CBI within the past 6 months and potentially modifiable household risk factors. RESULTS: Of 6520 households, 3856 used charcoal for cooking (59%) and 3267 cooked indoors (50%). In 4544 households (70%), the stove/cooking surface was within reach of children under-five (i.e., <1m). Higher household wealth quintiles (OR 0.95; 95%CI 0.61-1.49) and increasing age (OR 0.82; 95%CI 0.68-0.99) were associated with lower odds of CBI. Living in uncompleted accommodation (OR 11.29; 95%CI 1.48-86.18 vs rented room) and cooking outside the house (OR 1.13; 95%CI 0.60-2.14 vs cooking indoors) were also predictive of CBI. CONCLUSIONS: This study identified a high prevalence of CBI risk factors in semi-urban households that may benefit from targeted community-based prevention initiatives.

Functional independence after inpatient rehabilitation for traumatic brain injury among minority children and adolescents.

OBJECTIVE: To compare motor and cognitive functional independence scores between Hispanic, non-Hispanic black (NHB), and non-Hispanic white (NHW) children with traumatic brain injury (TBI) after discharge from inpatient rehabilitation. DESIGN: Retrospective cohort study using the Uniform Data System for Medical Rehabilitation national dataset from the years 2002 to 2012. SETTING: Inpatient rehabilitation units. PARTICIPANTS: Children (N=10,141) aged 6 months to 18 years who received inpatient rehabilitation for TBI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Motor and cognitive functional independence after discharge from inpatient rehabilitation, adjusting for age, sex, admission function, length of stay, insurance, and region. RESULTS: Inpatient rehabilitation therapy improved functional independence for all children. Younger age, lower admission functional independence scores, and Medicaid insurance were associated with lower functional independence at discharge. Hispanic and NHB children had lower discharge cognitive scores compared with NHW children; however, differences were small and were partially explained by insurance status and region. Children who received rehabilitation therapy at pediatric facilities had greater cognitive improvement. CONCLUSIONS: While racial/ethnic disparities are small, minority children are more likely to be younger, to have Medicaid, and to be cared for at nonpediatric facilities, factors that increase their risk for lower functional outcomes.

Evaluation of a quality improvement intervention to increase use of telephonic interpretation.

BACKGROUND: Language barriers are associated with poor health care outcomes, and barriers exist for timely in-person interpretation. Although available on-demand, telephonic interpretation remains underutilized. This study evaluates whether a quality improvement (QI) intervention was associated with rates of interpretation and parent-reported language service use at a children's hospital. METHODS: The QI intervention was developed by a multidisciplinary team and included provider education, electronic alerts, standardized dual-handset telephones, and 1-touch dialing in all hospital rooms. Interpreter use was tracked for 12 months before, 5 months during, and 12 months after the intervention. Weekly rates of interpretation per limited English proficient (LEP) patient-day were evaluated by using segmented linear regression. LEP parents were surveyed about professional interpretation and delays in care. Responses before, during, and after the intervention were compared by using the χ(2) test for trend. RESULTS: Telephonic interpretation rates increased by 53% after the intervention (baseline 0.38 per patient-day, increased 0.20 [0.13-0.28]). Overall (telephonic and in-person) interpretation increased by 54% (baseline 0.96, increased by 0.51 [0.38-0.64]). Parent-reported interpreter use improved, including more frequent use of professional interpreters (53.3% before, 71.8% during, 69.3% after, P trend = .001), less frequent use of ad hoc interpreters (52.4% before, 38.1% during, 41.4% after, P trend = .03), and fewer interpretation-related delays in care (13.3% before, 7.9% during, 6.0% after, P trend = .01). CONCLUSIONS: This QI intervention was associated with increased telephonic interpreter use and improved parent-reported use of professional language services. This is a promising approach to deliver safe, timely, and equitable care for the growing population of LEP children and families.

Identifying families with limited English proficiency using a capture-recapture approach.

BACKGROUND AND OBJECTIVE: Health providers need reliable estimates of the number of families with limited English proficiency (LEP) to assess language need and language service provision. Hospitals often lack reliable language screening tools and fail to provide interpretation for LEP families. The objective of this study was to develop a simple audit tool to more accurately identify LEP patients and families. METHODS: We conducted a cross-sectional analysis of a retrospective cohort of patients admitted to a large pediatric hospital between July 1 and December 31, 2009. We used a "capture-recapture" approach to develop a simple audit tool to measure language screening, determine the rate of language interpretation, and estimate the number of LEP families. The captures were based on 2 independent sources: (1) language need identified at registration and (2) request for interpretation during hospital admission. Assuming a closed population, we estimated the number of LEP families missed by both captures. RESULTS: During the study period, 6887 patients were admitted for care. There were 948 LEP families identified at registration and 847 families received interpretation at least once during hospital admission. We determined that the "ascertainment corrected" number of LEP families was 1031 (95% confidence interval: 1022-1040). The number of patients who had been "missed" by both methods was 15 (95% confidence interval: 7-24). Only 76% of LEP patients were identified in both data sources. CONCLUSIONS: A simple language audit tool can be used to determine language need, rates of interpretation, and unmet demand for language services, even when both sources of data are incomplete.

Postoperative pain management in children, parental English proficiency, and access to interpretation.

BACKGROUND AND OBJECTIVE: Patients with limited English proficiency (LEP) are at risk for undertreated pain. The goal of this study was to examine the association between parental language proficiency, interpreted care, and postsurgical pediatric pain management. METHODS: This was a retrospective matched cohort study among children <18 years of age. Children of LEP and English-proficient (EP) parents were matched according to age group, surgical procedure, and admission date. Mean number of daily pain assessments and mean daily pain scores were compared between language groups. We also compared the association between pain scores and type of medication given (opioid versus nonopioid). Within the LEP group, similar analyses compared pain assessment and treatment of children whose families received ≥ 2 professional interpretations per day versus those who received lower rates of interpretation. RESULTS: A total of 474 children (237 LEP and 237 EP) were included in the study. Children of LEP parents had fewer pain assessments (mean: 7 [95% confidence interval: 2-13] vs 9 [95% confidence interval: 4-15]; P = .012), and higher levels of pain recorded before receiving opioid analgesics, compared with children of EP parents (P = .003). Within the LEP group, children with ≥ 2 interpretations per day had lower pain scores after medication administration (P < .05) and were more likely to receive opioids at pain levels similar to those of EP families. CONCLUSIONS: Children of LEP parents received fewer pain assessments and were less likely to receive opioid analgesics for similar levels of pain compared with children of EP parents. More frequent use of professional interpreters when assessing pain may aid in reducing the gap in pain management between LEP and EP pediatric patients.

Factors associated with nonurgent use of pediatric emergency care among Latino families.

OBJECTIVE: This study investigates Latino parents' decision to seek pediatric emergency care for nonurgent health conditions. METHODS: Three focus groups were conducted with Spanish-speaking parents. Eligible families had a pediatric primary care provider, and their child received emergency treatment for a nonurgent health condition in the previous year. Transcripts were transcribed, translated, and thematically coded. RESULTS: Parents shared a heightened concern about symptoms such as fever or diminished energy. Many related experiences where delay resulted in serious illness or death. Other factors included low utilization of telephone triage and long clinic wait times. Nearly every family had managed the child's illness at home prior to seeking care, employing medical and natural remedies. CONCLUSIONS: The study findings suggest that strengthening the connection with a child's medical home, eliminating barriers to receiving primary care in urgent situations and educating parents about management of common illnesses may improve care for Latino children.

The state of US health, 1990-2010: burden of diseases, injuries, and risk factors.

IMPORTANCE: Understanding the major health problems in the United States and how they are changing over time is critical for informing national health policy. OBJECTIVES: To measure the burden of diseases, injuries, and leading risk factors in the United States from 1990 to 2010 and to compare these measurements with those of the 34 countries in the Organisation for Economic Co-operation and Development (OECD) countries. DESIGN: We used the systematic analysis of descriptive epidemiology of 291 diseases and injuries, 1160 sequelae of these diseases and injuries, and 67 risk factors or clusters of risk factors from 1990 to 2010 for 187 countries developed for the Global Burden of Disease 2010 Study to describe the health status of the United States and to compare US health outcomes with those of 34 OECD countries. Years of life lost due to premature mortality (YLLs) were computed by multiplying the number of deaths at each age by a reference life expectancy at that age. Years lived with disability (YLDs) were calculated by multiplying prevalence (based on systematic reviews) by the disability weight (based on population-based surveys) for each sequela; disability in this study refers to any short- or long-term loss of health. Disability-adjusted life-years (DALYs) were estimated as the sum of YLDs and YLLs. Deaths and DALYs related to risk factors were based on systematic reviews and meta-analyses of exposure data and relative risks for risk-outcome pairs. Healthy life expectancy (HALE) was used to summarize overall population health, accounting for both length of life and levels of ill health experienced at different ages. RESULTS: US life expectancy for both sexes combined increased from 75.2 years in 1990 to 78.2 years in 2010; during the same period, HALE increased from 65.8 years to 68.1 years. The diseases and injuries with the largest number of YLLs in 2010 were ischemic heart disease, lung cancer, stroke, chronic obstructive pulmonary disease, and road injury. Age-standardized YLL rates increased for Alzheimer disease, drug use disorders, chronic kidney disease, kidney cancer, and falls. The diseases with the largest number of YLDs in 2010 were low back pain, major depressive disorder, other musculoskeletal disorders, neck pain, and anxiety disorders. As the US population has aged, YLDs have comprised a larger share of DALYs than have YLLs. The leading risk factors related to DALYs were dietary risks, tobacco smoking, high body mass index, high blood pressure, high fasting plasma glucose, physical inactivity, and alcohol use. Among 34 OECD countries between 1990 and 2010, the US rank for the age-standardized death rate changed from 18th to 27th, for the age-standardized YLL rate from 23rd to 28th, for the age-standardized YLD rate from 5th to 6th, for life expectancy at birth from 20th to 27th, and for HALE from 14th to 26th. CONCLUSIONS AND RELEVANCE: From 1990 to 2010, the United States made substantial progress in improving health. Life expectancy at birth and HALE increased, all-cause death rates at all ages decreased, and age-specific rates of years lived with disability remained stable. However, morbidity and chronic disability now account for nearly half of the US health burden, and improvements in population health in the United States have not kept pace with advances in population health in other wealthy nations.

Disparities in disability after traumatic brain injury among Hispanic children and adolescents.

OBJECTIVE: To compare the extent of disability in multiple areas of functioning after mild, moderate, and severe traumatic brain injury (TBI) between Hispanic and non-Hispanic white (NHW) children. METHODS: This was a prospective cohort study of children aged <18 years treated for a TBI between March 1, 2007, and September 30, 2008. Hispanic (n = 74) and NHW (n = 457) children were included in the study. Outcome measures were disability in health-related quality of life, adaptive skills, and participation in activities 3, 12, 24, and 36 months after injury compared with preinjury functioning. We compared change in outcome scores between Hispanic and NHW children at each follow-up time. All analyses were adjusted for age, gender, severity and intent of injury, insurance, family function at baseline, parental education, and income. RESULTS: The health-related quality of life for all children was lower at all follow-up times compared with baseline. Although NHW children showed some improvement during the first 3 years after injury, Hispanic children remained significantly impaired. Significant differences were also observed in the domains of communication and self-care abilities after TBI. Differences between groups in scores for participation in activities were also present but were only significant 3 months after injury. CONCLUSIONS: Hispanic children with TBI report larger and long-term reductions in their quality of life, participation in activities, communication, and self-care abilities compared with NHW children. The reasons for these differences need to be better understood and interventions implemented to improve the outcomes of these children.

Trends and correlates of child passenger restraint use in 6 Northwest tribes: the Native Children Always Ride Safe (Native CARS) project.

OBJECTIVES: We compared proportions of children properly restrained in vehicles in 6 Northwest American Indian tribes in 2003 and 2009, and evaluated risks for improper restraint. METHODS: During spring 2009 we conducted a vehicle observation survey in Oregon, Washington, and Idaho tribal communities. We estimated the proportions of children riding properly restrained and evaluated correlates of improper restraint via log-binomial regression models for clustered data. RESULTS: We observed 1853 children aged 12 years and younger in 1207 vehicles; 49% rode properly restrained. More children aged 8 years and younger rode properly restrained in 2009 than 2003 (51% vs 29%; P < .001). Older booster seat-eligible children were least likely to ride properly restrained in 2009 (25%). American Indian children were more likely to ride improperly restrained than nonnative children in the same communities. Other risk factors included riding with an unrestrained or nonparent driver, riding where child passenger restraint laws were weaker than national guidelines, and taking a short trip. CONCLUSIONS: Although proper restraint has increased, it remains low. Tribe-initiated interventions to improve child passenger restraint use are under way.

A comparison of self-report and direct observation of booster seat use in Latino families.

OBJECTIVE: To develop a reliable self-report tool for measuring child booster seat use among Latino families. DESIGN: Cross-sectional and observational survey of a convenience sample. SETTING: Five retail stores in King County, Washington. PARTICIPANTS: 50 parents of children 4-8 years old that self-identified as Latino or Hispanic. MAIN EXPOSURES: Parent-reported measures of how often the child uses a booster seat, if the child used a booster seat on the last trip, how often the child complains about using a booster seat, how often the child asks to not use a booster seat, and how often other families they know use a booster seat. OUTCOME MEASURE: Observed booster seat use by child. RESULTS: 26 children (52%) were observed using a booster seat. Parent-reported booster seat use was a poor predictor of observed booster seat use. Although 34 parents reported that their child 'always' uses a booster seat, 8 (24%) of these children were not using a booster seat. A logistic model to predict booster seat use had a sensitivity of 81% and a specificity of 71%, and misclassified 24% of the participants' observed use. CONCLUSIONS: Reliance on parent-reported booster seat use significantly overstated observed booster seat use in the study. Among this study population, accurate determination of booster seat use required direct observation.