Population-based Assessment of Cardiometabolic-related Diagnoses in Youth With Klinefelter Syndrome: A PEDSnet Study.

CONTEXT: Diabetes and cardiovascular diseases are common among men with Klinefelter syndrome (KS) and contribute to high morbidity and mortality. OBJECTIVE: To determine if cardiometabolic-related diagnoses are more prevalent among youth with KS than matched controls in a large population-based cohort. METHODS: Secondary data analysis of electronic health records from 6 pediatric institutions in the United States (PEDSnet). Patients included all youth with KS in the database (n = 1080) and 4497 youth without KS matched for sex, age (mean 13 years at last encounter), year of birth, race, ethnicity, insurance, site, and duration of care (mean 7 years). The main outcome measures were prevalence of 5 cardiometabolic-related outcomes: overweight/obesity, dyslipidemia, dysglycemia, hypertension, and liver dysfunction. RESULTS: The odds of overweight/obesity (OR 1.6; 95% CI 1.4-1.8), dyslipidemia (3.0; 2.2-3.9), and liver dysfunction (2.0; 1.6-2.5) were all higher in KS than in controls. Adjusting for covariates (obesity, testosterone treatment, and antipsychotic use) attenuated the effect of KS on these outcomes; however, boys with KS still had 45% greater odds of overweight/obesity (95% CI 1.2-1.7) and 70% greater odds of liver dysfunction (95% CI 1.3-2.2) than controls, and both dyslipidemia (1.6; 1.1-2.4) and dysglycemia (1.8; 1.1-3.2) were higher in KS but of borderline statistical significance when accounting for multiple comparisons. The odds of hypertension were not different between groups. CONCLUSION: This large, population-based cohort of youth with KS had a higher odds of most cardiometabolic-related diagnoses than matched controls.

Assessing and Augmenting Predictive Models for Hospital Readmissions With Novel Variables in an Urban Safety-net Population.

BACKGROUND: The performance of existing predictive models of readmissions, such as the LACE, LACE+, and Epic models, is not established in urban safety-net populations. We assessed previously validated predictive models of readmission performance in a socially complex, urban safety-net population, and if augmentation with additional variables such as the Area Deprivation Index, mental health diagnoses, and housing access improves prediction. Through the addition of new variables, we introduce the LACE-social determinants of health (SDH) model. METHODS: This retrospective cohort study included adult admissions from July 1, 2016, to June 30, 2018, at a single urban safety-net health system, assessing the performance of the LACE, LACE+, and Epic models in predicting 30-day, unplanned rehospitalization. The LACE-SDH development is presented through logistic regression. Predictive model performance was compared using C-statistics. RESULTS: A total of 16,540 patients met the inclusion criteria. Within the validation cohort (n=8314), the Epic model performed the best (C-statistic=0.71, P<0.05), compared with LACE-SDH (0.67), LACE (0.65), and LACE+ (0.61). The variables most associated with readmissions were (odds ratio, 95% confidence interval) against medical advice discharge (3.19, 2.28-4.45), mental health diagnosis (2.06, 1.72-2.47), and health care utilization (1.94, 1.47-2.55). CONCLUSIONS: The Epic model performed the best in our sample but requires the use of the Epic Electronic Health Record. The LACE-SDH performed significantly better than the LACE and LACE+ models when applied to a safety-net population, demonstrating the importance of accounting for socioeconomic stressors, mental health, and health care utilization in assessing readmission risk in urban safety-net patients.

Delays in Diagnosis and Treatment of Breast Cancer: A Safety-Net Population Profile.

Background: Timely detection and treatment of breast cancer is important in optimizing survival and minimizing recurrence. Given disparities in breast cancer outcomes based on socioeconomic status, we examined time to diagnosis and treatment in a safety-net hospital. Methods: We conducted a retrospective review of all patients with breast cancer diagnosed between July 1, 2010, and June 30, 2012 (N=120). We limited our analytic sample to patients with nonrecurrent, primary stage 0-III breast cancer (N=105) and determined intervals from presentation to diagnosis, diagnosis to first treatment, last surgery to chemotherapy initiation, and last surgery to start of radiation therapy (RT). Using logistic regression, we calculated unadjusted odds of receiving timely treatment (< median time) versus more delayed treatment (≥ median time) as a function of age, language, ethnicity, insurance, Charlson comorbidity index, disease stage, method of first presentation (screening mammography vs care provider), symptoms at presentation, and type of surgical treatment. Results: Patients aged 55 to 64 years accounted for most of the sample (n=37; 35.2%). Median time from presentation to diagnosis (23 days), time from diagnosis to first treatment, and time from surgery to chemotherapy initiation fell within intervals published in the literature; median time from last surgery to start of RT was greater than recommended intervals. Factors significantly associated with longer intervals than median time included stage, method of presentation, language, surgical treatment, insurance, and ethnicity. Conclusions: Patients in this safety-net setting experienced acceptable diagnosis and treatment intervals, except for time to RT. Focused interventions that help care providers access imaging quickly for their symptomatic patients could improve time to diagnosis. Concentrating additional efforts on non-English-speaking, Hispanic patients and those who need to receive RT could improve time to treatment.

Exploring Facilitators and Barriers to Initiation and Completion of the Human Papillomavirus (HPV) Vaccine Series among Parents of Girls in a Safety Net System.

Objective: To assess, among parents of predominantly minority, low-income adolescent girls who had either not initiated (NI) or not completed (NC) the HPV vaccine series, attitudes and other factors important in promoting the series, and whether attitudes differed by language preference. Design/Methods: From August 2013-October 2013, we conducted a mail survey among parents of girls aged 12-15 years randomly selected from administrative data in a Denver safety net system; 400 parents from each group (NI and NC) were targeted. Surveys were in English or Spanish. RESULTS: The response rate was 37% (244/660; 140 moved or gone elsewhere; 66% English-speaking, 34% Spanish-speaking). Safety attitudes of NIs and NCs differed, with 40% NIs vs. 14% NC's reporting they thought HPV vaccine was unsafe (p < 0.0001) and 43% NIs vs. 21% NCs that it may cause long-term health problems (p < 0.001). Among NCs, 42% reported they did not know their daughter needed more shots (English-speaking, 20%, Spanish-speaking 52%) and 39% reported that "I wasn't worried about the safety of the HPV vaccine before, but now I am" (English-speaking, 23%, Spanish-speaking, 50%). Items rated as very important among NIs in the decision regarding vaccination included: more information about safety (74%), more information saying it prevents cancer (70%), and if they knew HPV was spread mainly by sexual contact (61%). Conclusions: Safety concerns, being unaware of the need for multiple doses, and low perceived risk of infection remain significant barriers to HPV vaccination for at-risk adolescents. Some parents' safety concerns do not appear until initial vaccination.

Infant, Maternal, and Hospital Factors' Role in Loss to Follow-up After Failed Newborn Hearing Screening.

OBJECTIVE: Completion of newborn hearing screening (NBHS) is recommended by 1 month old. Delays and loss to follow-up and documentation (LTF/LTD) after failed NBHS are common. Committees of experts have established hospital guidelines to reduce LTF/LTD. We aimed to identify maternal and infant factors associated with LTF/LTD and determine if adherence to hospital guidelines is associated with timely completion of follow-up screening. METHODS: We conducted a retrospective study of all infants born in Colorado hospitals who failed the newborn admission hearing screening from 2007 to 2012 and a cross-sectional survey of NBHS coordinators at Colorado birthing hospitals. Neonatal intensive care unit infants were excluded. Outcomes included documented completion of the follow-up NBHS and completion by 1 month. Data sources comprised the electronic birth record, infant hearing integrated data system, and NBHS coordinator survey. Data were analyzed by logistic regression. RESULTS: A total of 13,904 newborns did not pass the newborn admission hearing screening from 2007 to 2012, and 11,422 (82%) had documentation of a completed follow-up screening. A total of 10,558 (76%) completed follow-up screening by 1 month. All 53 NBHS coordinators completed the survey. Maternal age, education, smoking, and birth country; and payer, race, birth order, and population density were associated with completion of follow-up hearing screening. Maternal education, payer, population density, birth weight, and cleft lip were associated with completion by 1 month of age. Only birth in a facility that charges a rescreening fee was associated with completion of follow-up screening. CONCLUSIONS: Low-income, rural, and minority infants are at risk for LTF. Further studies are needed to determine if adherence to guidelines can overcome barriers to follow-up.

Use of rapid needs assessment as a tool to identify vaccination delays in Guatemala and Peru.

OBJECTIVE: To explore the use of rapid needs assessment (RNA) surveys to determine the prevalence and factors contributing to delays in vaccination of children in two low middle-income countries (LMIC). METHODS: Data from two RNA surveys performed as part of program improvement evaluations in Guatemala and Peru were used for this analysis. The primary endpoint was the timeliness of immunization with delay defined as administration of vaccines beyond 28 days from recommended age for DTwP-HepB-Hib (Penta) and measles-mumps-rubella (MMR) vaccines, as well as past age-restrictions for rotavirus vaccine. Independent risk factors analyzed included child's gender, birth year, number of children in household, maternal age, maternal education, and food insecurity. RESULTS: Vaccine information was available from 811 children from 838 households surveyed. High rate of immunization delays was observed, with 75.6% of children in Guatemala and 57.8% of children in Peru being delayed for the third dose of Penta primary series. Factors associated with delayed vaccination in Guatemala included advanced maternal age and increased number of children in household. In Peru, significant associations were birth year before 2009, lower maternal education level, and increased number of children in household. CONCLUSIONS: RNA is a fast and effective method to identify timely vaccine coverage and derive a hypothesis of factors possibly associated with vaccination delay.

Effectiveness and Cost of Bidirectional Text Messaging for Adolescent Vaccines and Well Care.

OBJECTIVE: To evaluate the effectiveness and cost of bidirectional short messaging service in increasing rates of vaccination and well child care (WCC) among adolescents. METHODS: We included all adolescents needing a recommended adolescent vaccine (n = 4587) whose parents had a cell-phone number in 5 private and 2 safety-net pediatric practices. Adolescents were randomized to intervention (n = 2228) or control (n = 2359). Parents in the intervention group received up to 3 personalized short messaging services with response options 1 (clinic will call to schedule), 2 (parent will call clinic), or STOP (no further short messaging service). Primary outcomes included completion of all needed services, WCC only, all needed vaccinations, any vaccination, and missed opportunity for vaccination. RESULTS: Intervention patients were more likely to complete all needed services (risk ratio [RR] 1.31, 95% confidence interval [CI] 1.12-1.53), all needed vaccinations (RR 1.29, 95% CI 1.12-1.50), and any vaccination (RR 1.36, 95% CI 1.20-1.54). Seventy-five percent of control patients had a missed opportunity versus 69% of intervention (P = .002). There was not a significant difference for WCC visits. Responding that the clinic should call to schedule ("1") was associated with the highest effect size for completion of all needed services (RR 1.89, 95% CI 1.41-2.54). Net cost ranged from $855 to $3394 per practice. CONCLUSIONS: Bidirectional short messaging service to parents was effective at improving rates for all adolescent vaccinations and for all needed services, especially among parents who responded they desired a call from the practice.