Systematic data quality assessment of electronic health record data to evaluate study-specific fitness: Report from the PRESERVE research study.

Study-specific data quality testing is an essential part of minimizing analytic errors, particularly for studies making secondary use of clinical data. We applied a systematic and reproducible approach for study-specific data quality testing to the analysis plan for PRESERVE, a 15-site, EHR-based observational study of chronic kidney disease in children. This approach integrated widely adopted data quality concepts with healthcare-specific evaluation methods. We implemented two rounds of data quality assessment. The first produced high-level evaluation using aggregate results from a distributed query, focused on cohort identification and main analytic requirements. The second focused on extended testing of row-level data centralized for analysis. We systematized reporting and cataloguing of data quality issues, providing institutional teams with prioritized issues for resolution. We tracked improvements and documented anomalous data for consideration during analyses. The checks we developed identified 115 and 157 data quality issues in the two rounds, involving completeness, data model conformance, cross-variable concordance, consistency, and plausibility, extending traditional data quality approaches to address more complex stratification and temporal patterns. Resolution efforts focused on higher priority issues, given finite study resources. In many cases, institutional teams were able to correct data extraction errors or obtain additional data, avoiding exclusion of 2 institutions entirely and resolving 123 other gaps. Other results identified complexities in measures of kidney function, bearing on the study's outcome definition. Where limitations such as these are intrinsic to clinical data, the study team must account for them in conducting analyses. This study rigorously evaluated fitness of data for intended use. The framework is reusable and built on a strong theoretical underpinning. Significant data quality issues that would have otherwise delayed analyses or made data unusable were addressed. This study highlights the need for teams combining subject-matter and informatics expertise to address data quality when working with real world data.

Trends in Neonatal Opioid Withdrawal Syndrome and Opioid Exposure Diagnoses Among Infants With Private Health Insurance, 2016-2021: Introduction of the P04.14 ICD-10-CM Code.

OBJECTIVE: The opioid epidemic has led to a surge in diagnoses of neonatal opioid withdrawal syndrome (NOWS). Many states track the incidence of NOWS by using the P96.1 International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code for "neonatal withdrawal symptoms from maternal use of drugs of addiction." In October 2018, an ICD-10-CM code for neonatal opioid exposure (P04.14) was introduced. This code can be used when an infant is exposed to opioids in utero but does not have clinically significant withdrawal symptoms. We analyzed the effect of the P04.14 code on the incidence rate of NOWS (P96.1) and "other" neonatal drug exposure diagnoses (P04.49). METHODS: We used private health insurance data collected for infants in the United States from the first quarter of 2016 through the third quarter of 2021 to describe incidence rates for each code over time and examine absolute and percentage changes before and after the introduction of code P04.14. RESULTS: The exclusive use of code P96.1 declined from an incidence rate per 1000 births of 1.08 in 2016-2018 to 0.70 in 2019-2021, a -35.7% (95% CI, -47.6% to -23.8%) reduction. Use of code P04.49 only declined from an incidence rate of 2.34 in 2016-2018 to 1.64 in 2019-2021, a -30.0% (95% CI, -36.4% to -23.7%) reduction. Use of multiple codes during the course of treatment increased from an average incidence per 1000 births of 0.56 in 2016-2018 to 0.79 in 2019-2021, a 45.5% (95% CI, 24.8%-66.1%) increase. CONCLUSION: The introduction of ICD-10-CM code P04.14 altered the use of other neonatal opioid exposure codes. The use of multiple codes increased, indicating that some ambiguity may exist about which ICD-10-CM code is most appropriate for a given set of symptoms.

Evolving availability and standardization of patient attributes for matching.

Variation in availability, format, and standardization of patient attributes across health care organizations impacts patient-matching performance. We report on the changing nature of patient-matching features available from 2010-2020 across diverse care settings. We asked 38 health care provider organizations about their current patient attribute data-collection practices. All sites collected name, date of birth (DOB), address, and phone number. Name, DOB, current address, social security number (SSN), sex, and phone number were most commonly used for cross-provider patient matching. Electronic health record queries for a subset of 20 participating sites revealed that DOB, first name, last name, city, and postal codes were highly available (>90%) across health care organizations and time. SSN declined slightly in the last years of the study period. Birth sex, gender identity, language, country full name, country abbreviation, health insurance number, ethnicity, cell phone number, email address, and weight increased over 50% from 2010 to 2020. Understanding the wide variation in available patient attributes across care settings in the United States can guide selection and standardization efforts for improved patient matching in the United States.

Medicaid Coverage and Continuity for Juvenile Justice-Involved Youth.

This study examined Medicaid coverage and continuity for youth with varying levels of justice system involvement and the impact of a policy change allowing Medicaid suspension, rather than termination. Data for this study were collected using a retrospective cohort design using arrest records and Medicaid enrollment tables for 20,688 youth. Age, gender, race/ethnicity, and deepest level of justice system involvement all were associated with time to de-enrollment from Medicaid. Suspension was associated with a small improvement in Medicaid continuity for justice-involved youth. In addition, youth with deeper levels of justice system involvement had faster time to de-enrollment. This study highlights the importance of maximizing opportunities to keep youth enrolled, as gaps in coverage will likely affect juveniles' access to physical, mental, and behavioral health care.

Electronic Health Record (EHR)-Based Community Health Measures: An Exploratory Assessment of Perceived Usefulness by Local Health Departments.

BACKGROUND: Given the widespread adoption of electronic health record (EHR) systems in health care organizations, public health agencies are interested in accessing EHR data to improve health assessment and surveillance. Yet there exist few examples in the U.S. of governmental health agencies using EHR data routinely to examine disease prevalence and other measures of community health. The objective of this study was to explore local health department (LHD) professionals' perceptions of the usefulness of EHR-based community health measures, and to examine these perceptions in the context of LHDs' current access and use of sub-county data, data aggregated at geographic levels smaller than county. METHODS: To explore perceived usefulness, we conducted an online survey of LHD professionals in Indiana. One hundred and thirty-three (133) individuals from thirty-one (31) LHDs participated. The survey asked about usefulness of specific community health measures as well as current access to and uses of sub-county population health data. Descriptive statistics were calculated to examine respondents' perceptions, access, and use. A one-way ANOVA (with pairwise comparisons) test was used to compare average scores by LHD size. RESULTS: Respondents overall indicated moderate agreement on which community health measures might be useful. Perceived usefulness of specific EHR-based community health measures varied by size of respondent's LHD [F(3, 88) = 3.56, p = 0.017]. Over 70% of survey respondents reported using community health data, but of those < 30% indicated they had access to sub-county level data. CONCLUSION: Respondents generally preferred familiar community health measures versus novel, EHR-based measures that are not in widespread use within health departments. Access to sub-county data is limited but strongly desired. Future research and development is needed as LHD staff gain access to EHR data and apply these data to support the core function of health assessment.

Preventive Care Use Among Justice-Involved and Non-Justice-Involved Youth.

BACKGROUND AND OBJECTIVES: Youth involved in the juvenile justice system (ie, arrested youth) are at risk for health problems. Although increasing preventive care use by justice-involved youth (JIY) is 1 approach to improving their well-being, little is known about their access to and use of care. The objective of this study was to determine how rates of well-child (WC) and emergency department visits, as well as public insurance enrollment continuity, differed between youth involved in the justice system and youth who have never been in the system. We hypothesized that JIY would exhibit less frequent WC and more frequent emergency service use than non-justice-involved youth (NJIY). METHODS: This was a retrospective cohort study of administrative medical and criminal records of all youth (ages 12-18) enrolled in Medicaid in Marion County, Indiana, between January 1, 2004, and December 31, 2011. RESULTS: The sample included 88 647 youth; 20 668 (23%) were involved in the justice system. JIY had lower use rates of WC visits and higher use rates of emergency services in comparison with NJIY. JIY had more and longer gaps in Medicaid coverage compared with NJIY. For all youth sampled, both preventive and emergency services use varied significantly by Medicaid enrollment continuity. CONCLUSIONS: JIY experience more and longer gaps in Medicaid coverage, and rely more on emergency services than NJIY. Medicaid enrollment continuity was associated with differences in WC and emergency service use among JIY, with policy implications for improving preventive care for these vulnerable youth.

Lessons Learned When Introducing Pharmacogenomic Panel Testing into Clinical Practice.

OBJECTIVES: Implementing new programs to support precision medicine in clinical settings is a complex endeavor. We describe challenges and potential solutions based on the Indiana GENomics Implementation: an Opportunity for the Underserved (INGenious) program at Eskenazi Health-one of six sites supported by the Implementing GeNomics In pracTicE network grant of the National Institutes of Health/National Human Genome Research Institute. INGenious is an implementation of a panel of genomic tests. METHODS: We conducted a descriptive case study of the implementation of this pharmacogenomics program, which has a wide scope (14 genes, 27 medications) and a diverse population (patients who often have multiple chronic illnesses, in a large urban safety-net hospital and its outpatient clinics). CHALLENGES: We placed the clinical pharmacogenomics implementation challenges into six categories: patient education and engagement in care decision making; clinician education and changes in standards of care; integration of technology into electronic health record systems; translational and implementation sciences in real-world clinical environments; regulatory and reimbursement considerations, and challenges in measuring outcomes. A cross-cutting theme was the need for careful attention to workflow. Our clinical setting, a safety-net health care system, presented some distinctive challenges. Patients often had multiple chronic illnesses and sometimes were taking more than one pharmacogenomics-relevant medication. Reaching patients for recruitment or follow-up was another challenge. CONCLUSIONS: New, large-scale endeavors in health care are challenging. A description of the challenges that we encountered and the approaches that we adopted to address them may provide insights for those who implement and study innovations in other health care systems.

Trends in Use and Cost of Second-Generation Antipsychotics Among Children and Teens in Indiana Medicaid, 2004-2012.

OBJECTIVE: To replicate and extend a study by the Agency for Healthcare Research and Quality (AHRQ) and Rutgers on antipsychotic use among youths in Medicaid, the authors analyzed Indiana Medicaid claims from 2004 to 2012, extending the earlier study by focusing on second-generation antipsychotics, including both fee-for-service (FFS) and non-FFS patients, and analyzing cost trends. METHODS: The authors evaluated the impact of several Indiana Medicaid policy changes on medication utilization and cost among children enrolled for at least one month during 2004-2012 (N=683,716-793,637), using an exhaustive antipsychotic list to search the database. RESULTS: Annual utilization rates for antipsychotics were 2%-3% but were much higher among foster children (10%-15%). Policies implemented in 2007 or later were associated with a significant plateauing of utilization in 2008-2012. CONCLUSIONS: Growth of second-generation antipsychotic utilization and costs was similar to trends described in the AHRQ-Rutgers study. Several containment strategies appeared effective in addressing these trends.

Mortality of Youth Offenders Along a Continuum of Justice System Involvement.

INTRODUCTION: Black male youth are at high risk of homicide and criminal justice involvement. This study aimed to determine how early mortality among youth offenders varies based on race; gender; and the continuum of justice system involvement: arrest, detention, incarceration, and transfer to adult courts. METHODS: Criminal and death records of 49,479 youth offenders (ages 10-18 years at first arrest) in Marion County, Indiana, from January 1, 1999, to December 31, 2011, were examined. Statistical analyses were completed in November 2014. RESULTS: From 1999 to 2011 (aggregate exposure, 386,709 person-years), 518 youth offender deaths occurred. The most common cause of death was homicide (48.2%). The mortality rate of youth offenders was nearly 1.5 times greater than that among community youth (standardized mortality ratio, 1.48). The youth offender mortality rate varied depending on the severity of justice system involvement. Arrested youth had the lowest rate of mortality (90/100,000), followed by detained youth (165/100,000); incarcerated youth (216/100,000); and youth transferred to adult court (313/100,000). A proportional hazards model demonstrated that older age, male gender, and more severe justice system involvement 5 years post-arrest predicted shorter time to mortality. CONCLUSIONS: Youth offenders face greater risk for early death than community youth. Among these, black male youth face higher risk of early mortality than their white male counterparts. However, regardless of race/ethnicity, mortality rates for youth offenders increase as youth involvement in the justice system becomes more protracted and severe. Thus, justice system involvement is a significant factor to target for intervention.

A Comparison of Data Driven-based Measures of Adherence to Oral Hypoglycemic Agents in Medicaid Patients.

We evaluated and compared different methods for measuring adherence to Oral Antihyperglycemic Agents (OHA), based on the correlation between these measures and glycated hemoglobin A1C (HbA1c) levels in Medicaid patients with Type 2 diabetes. An observational sample of 831 Medicaid patients with Type 2 diabetes who had HbA1c test results recorded between January 1, 2001 and December 31, 2005 was identified in the Indiana Network of Patient Care (INPC). OHA adherence was measured by medication possession ratio (MPR), proportion of days covered (PDC), and the number of gaps (GAP) for 3, 6, and 12-month intervals prior to the HbA1c test date. All three OHA adherence measurements showed consistent and significant correlation with HbA1c level. The 6-month PDC showed the strongest association with HbA1c levels in both unadjusted (-1.07, P<0.0001) and adjusted (-1.12, P<0.0001) models.

Lower provider volume is associated with higher failure rates for endoscopic retrograde cholangiopancreatography.

BACKGROUND: Among physicians who perform endoscopic retrograde cholangiopancreatography (ERCP), the relationship between procedure volume and outcome is unknown. OBJECTIVE: Quantify the ERCP volume-outcome relationship by measuring provider-specific failure rates, hospitalization rates, and other quality measures. RESEARCH DESIGN: Retrospective cohort. SUBJECTS: A total of 16,968 ERCPs performed by 130 physicians between 2001 and 2011, identified in the Indiana Network for Patient Care. MEASURES: Physicians were classified by their average annual Indiana Network for Patient Care volume and stratified into low (<25/y) and high (≥25/y). Outcomes included failed procedures, defined as repeat ERCP, percutaneous transhepatic cholangiography or surgical exploration of the bile duct≤7 days after the index procedure, hospitalization rates, and 30-day mortality. RESULTS: Among 15,514 index ERCPs, there were 1163 (7.5%) failures; the failure rate was higher among low (9.5%) compared with high volume (5.7%) providers (P<0.001). A second ERCP within 7 days (a subgroup of failure rate) occurred more frequently when the original ERCP was performed by a low-volume (4.1%) versus a high-volume physician (2.3%, P=0.013). Patients were more frequently hospitalized within 24 hours when the ERCP was performed by a low-volume (28.3%) versus high-volume physician (14.8%, P=0.002). Mortality within 30 days was similar (low=1.9%, high=1.9%). Among low-volume physicians and after adjusting, the odds of having a failed procedure decreased 3.3% (95% confidence interval, 1.6%-5.0%, P<0.001) with each additional ERCP performed per year. CONCLUSIONS: Lower provider volume is associated with higher failure rate for ERCP, and greater need for postprocedure hospitalization.

A vision for the systematic monitoring and improvement of the quality of electronic health data.

In parallel with the implementation of information and communications systems, health care organizations are beginning to amass large-scale repositories of clinical and administrative data. Many nations seek to leverage so-called Big Data repositories to support improvements in health outcomes, drug safety, health surveillance, and care delivery processes. An unsupported assumption is that electronic health care data are of sufficient quality to enable the varied use cases envisioned by health ministries. The reality is that many electronic health data sources are of suboptimal quality and unfit for particular uses. To more systematically define, characterize and improve electronic health data quality, we propose a novel framework for health data stewardship. The framework is adapted from prior data quality research outside of health, but it has been reshaped to apply a systems approach to data quality with an emphasis on health outcomes. The proposed framework is a beginning, not an end. We invite the biomedical informatics community to use and adapt the framework to improve health data quality and outcomes for populations in nations around the world.

Impact of dementia on payments for long-term and acute care in an elderly cohort.

BACKGROUND: Older people with dementia have increased risk of nursing home (NH) use and higher Medicaid payments. Dementia's impact on acute care use and Medicare payments is less well understood. OBJECTIVES: Identify trajectories of incident dementia and NH use, and compare Medicare and Medicaid payments for persons having different trajectories. RESEARCH DESIGN: Retrospective cohort of older patients who were screened for dementia in 2000-2004 and were tracked for 5 years. Trajectories were identified with latent class growth analysis. SUBJECTS: A total of 3673 low-income persons aged 65 or older without dementia at baseline. MEASURES: Incident dementia diagnosis, comorbid conditions, dual eligibility, acute and long-term care use and payments based on Medicare and Medicaid claims, medical record systems, and administrative data. RESULTS: Three trajectories were identified based on dementia incidence and short-term and long-term NH use: (1) high incidence of dementia with heavy NH use (5% of the cohort) averaging $56,111/year ($36,361 Medicare, $19,749 Medicaid); (2) high incidence of dementia with little or no NH use (16% of the cohort) averaging $16,206/year ($14,644 Medicare, $1562 Medicaid); and (3) low incidence of dementia and little or no NH use (79% of the cohort) averaging $8475/year ($7558 Medicare, $917 Medicaid). CONCLUSIONS: Dementia and its interaction with NH utilization are major drivers of publicly financed acute and long-term care payments. Medical providers in Accountable Care Organizations and other health care reform efforts must effectively manage dementia care across the care continuum if they are to be financially viable.

Psychiatric medication refill practices of juvenile detainees.

To examine the psychiatric medication fill rates of adolescents after release from juvenile detention. The team reviewed 177 charts. A fill was defined as a psychiatric medication charge to Medicaid 30- or 90-days after release. Differences in demographic characteristics were compared among individuals with fills at 30- or 90-days and those with no medication fills. Forty-five percent of patients were on at least one psychiatric medication. Among detainees on a psychiatric medication, 62 % had a fill by 30 days after release, and 78 % by 90 days. At least 50 % of the adolescents on a psychiatric medication were on an atypical antipsychotic. There was no significant relationship between medication fill and race, age, or sex. Despite the known associations between mental health diagnosis and treatment-seeking with age, sex, and race, it appears that psychiatric medication fill patterns after release from detention are not associated with these factors.

Spatial relationships between lead sources and children's blood lead levels in the urban center of Indianapolis (USA).

Urban children remain disproportionately at risk of having higher blood lead levels than their suburban counterparts. The Westside Cooperative Organization (WESCO), located in Marion County, Indianapolis, Indiana, has a history of children with high blood lead levels as well as high soil lead (Pb) values. This study aims at determining the spatial relationship between soil Pb sources and children's blood lead levels. Soils have been identified as a source of chronic Pb exposure to children, but the spatial scale of the source-recipient relationship is not well characterized. Neighborhood-wide analysis of soil Pb distribution along with a furnace filter technique for sampling interior Pb accumulation for selected homes (n = 7) in the WESCO community was performed. Blood lead levels for children aged 0-5 years during the period 1999-2008 were collected. The study population's mean blood lead levels were higher than national averages across all ages, race, and gender. Non-Hispanic blacks and those individuals in the Wishard advantage program had the highest proportion of elevated blood lead levels. The results show that while there is not a direct relationship between soil Pb and children's blood lead levels at a spatial scale of ~100 m, resuspension of locally sourced soil is occurring based on the interior Pb accumulation. County-wide, the largest predictor of elevated blood lead levels is the location within the urban core. Variation in soil Pb and blood lead levels on the community level is high and not predicted by housing stock age or income. Race is a strong predictor for blood lead levels in the WESCO community.

Insurance status of urban detained adolescents.

The primary goal was to describe the health care coverage of detained youth. An exploratory second goal was to describe the possible relationship between redetention and coverage. Health care coverage status was abstracted from electronic detention center records for 1,614 adolescents in an urban detention center (October 2006 to December 2007). The majority of detained youth reported having Medicaid coverage (66%); 18% had private insurance and 17% had no insurance. Lack of insurance was more prevalent among older, male, and Hispanic youth. A substantial minority of detained youth were uninsured or had inconsistent coverage over time. While having insurance does not guarantee appropriate health care, lack of insurance is a barrier that should be addressed to facilitate coordination of medical and mental health care once the youth is released into the community.

Effect of an annual benefit limit on adult dental expenditure and utilization: a cross-sectional analysis.

OBJECTIVES: Despite widespread use of dental benefit limits in terms of the types of services provided, an annual maximum on claims, or both, there is a dearth of literature examining their impact on either cost to the insurer or health outcomes. This study uses a natural experiment to examine dental care utilization and expenditure changes following Indiana Medicaid's introduction of a $600 individual annual limit on adult dental expenditure in 2003. METHODS: In a before and after comparison, we use two separate cross-sections of paid claims for 96+ percent of the Medicaid adult population. Paid claims were available as a per-member-per-year (PMPY) figure. RESULTS: Between 2002 and 2007, the eligible population decreased 3 percent (from 323,209 to 313,623), yet the number of people receiving any dental services increased 60 percent and total Medicaid dental claims increased 18 percent (from $34.1 million to $40.1 million). In both years, those Dually (Medicare/Medicaid) Eligible had the largest percentage of members receiving services, about 75 percent, and the Disabled Adult group had the lowest percentage (5-8 percent), yet both populations are likely to have high dental need due to effects of chronic conditions and medications. CONCLUSIONS: The increase in the number and percentage of people receiving Diagnostic and Restorative care suggests that the expenditure limit's introduction did not impose a barrier to accessing basic dental services. However, among those receiving any service, PMPY claims fell by 37 percent and 31 percent among the Dually Eligible and Disabled Adults categories, respectively, suggesting that the benefit limit affected these generally high need populations most.

Incremental dementia-related expenditures in a medicaid population.

OBJECTIVES: With the growing number of older adults, understanding expenditures associated with treating medical conditions that are more prevalent among older adults is increasingly important. The objectives of this research were to estimate incremental medical encounters and incremental Medicaid expenditures associated with dementia among Indiana Medicaid recipients 40 years or older in 2004. METHODS: A retrospective cohort design analyzing Indiana Medicaid administrative claims files was used. Individuals at least 40 years of age with Indiana Medicaid eligibility during 2004 were included. Patients with dementia were identified via diagnosis codes in claims files between July 2001 and December 2004. Adjusted annual incremental medical encounters and expenditures associated with dementia in 2004 were estimated using negative binomial regression and zero-inflated negative binomial regression models. RESULTS: A total of 18,950 individuals (13%) with dementia were identified from 145,684 who were 40 years or older. The unadjusted mean total annualized Medicaid expenditures for the cohort with dementia ($28,758) were significantly higher than the mean expenditures for the cohort without dementia ($14,609). After adjusting for covariates, Indiana Medicaid incurred annualized incremental expenditures of $9,829 per recipient with dementia. Much of the annual incremental expenditure associated with dementia was driven by the higher number of days in nursing homes and resulting nursing-home expenditures. Drug expenditures accounted for the second largest component of the incremental expenditures. On the basis of disease prevalence and per recipient annualized incremental expenditures, projected incremental annualized Indiana Medicaid spending associated with dementia for persons 40 or more years of age was $186 million. CONCLUSIONS: Dementia is associated with significant expenditures among Medicaid recipients. Disease management initiatives designed to reduce nursing-home use among recipients with dementia may have much potential to decrease Medicaid expenditures associated with dementia.

Volume of home- and community-based services and time to nursing-home placement.

OBJECTIVE: The purpose of this study was to determine whether the volume of Home- and Community-Based Services (HCBS) that target Activities of Daily Living disabilities, such as attendant care, homemaking services, and home-delivered meals, increases recipients' risk of transitioning from long-term care provided through HCBS to long-term care provided in a nursing home. DATA SOURCES: Data are from the Indiana Medicaid enrollment, claims, and Insite databases. Insite is the software system that was developed for collecting and reporting data for In-Home Service Programs. STUDY DESIGN: Enrollees in Indiana Medicaid's Aged and Disabled Waiver program were followed forward from time of enrollment to assess the association between the volume of attendant care, homemaking services, home-delivered meals, and related covariates, and the risk for nursing-home placement. An extension of the Cox proportional hazard model was computed to determine the cumulative hazard of nursing-home placement in the presence of death as a competing risk. PRINCIPAL FINDINGS: Of the 1354 Medicaid HCBS recipients followed in this study, 17% did not receive any attendant care, homemaking services, or home-delivered meals. Among recipients who survived through 24 months after enrollment, one in five transitioned from HCBS to a nursing-home. Risk for nursing-home placement was significantly lower for each five-hour increment in personal care (HR=0.95, 95% CI=0.92-0.98) and homemaking services (HR=0.87, 95% CI=0.77-0.99). CONCLUSIONS: Future policies and practices that are focused on optimizing long-term care outcomes should consider that a greater volume of HCBS for an individual is associated with reduced risk of nursing-home placement.

Breastfeeding experiences among physicians.

BACKGROUND: During medical school and residency training, physicians are taught that breastfeeding is the preferred feeding for all infants, with rare exceptions. But evidence is accumulating that while physician mothers have a high rate of breastfeeding initiation, they face significant obstacles to sustained breastfeeding. METHODS: In our academic medical center, we conducted a brief survey of physicians who have young children, to explore their own experiences with breastfeeding. The survey explored the physician-as-parent's own experiences with breastfeeding -- prenatal intentions, postnatal difficulties, ability to meet goals, emotions if goals were not met, resources for support pre- and postnatally, and ideas about what would have helped her breastfeed longer. RESULTS: Two-thirds of the physicians who initiated breastfeeding had difficulties. Among those with difficulties, about three-fourths were able to resolve them. CONCLUSIONS: Even mothers who are medical professionals experience, and often cannot overcome, difficulties with breastfeeding. Women in medicine need enhanced breastfeeding support and services/resources. Advocacy is needed, in our work environments, for better breastfeeding support not only for our physician colleagues, but also for all lactating employees within our institutions.