Evaluation of a statewide medical home program on children and young adults with asthma.

OBJECTIVE: Asthma, the most common chronic condition among children, accounts for significant healthcare utilization and impact on quality of life. Care coordination in a medical home is considered standard practice, but has not been rigorously evaluated. METHODS: We initiated this pilot study of children/young adults with asthma (n = 967), ages: birth to 24 years, receiving care from a subset of pediatric practices (n = 20) participating in the Pennsylvania Medical Home Initiative, Educating Practices in Community-Integrated Care (92 practices statewide). We hypothesized children and youth with asthma receiving care coordination in the context of a formal medical home program would experience favorable associations with healthcare utilization and quality of life measures. RESULTS: A total of 9240 care coordination encounters for this cohort of children/youth occurred over 100 days. The average length of care coordination encounter was 20.7 minutes. The most common care coordination activity was referral management (21%) and the care coordinator in the practice most often contacted parent/family and specialists (75%). Children with more severe asthma had more hospitalizations and emergency department (ED) visits than children with less severe asthma. There was a significant decrease in school absences, ED visits and acute care visits for children/youth with asthma with increasing length of time in a medical home program (p < 0.05). CONCLUSION: Care coordination for children/youth with asthma is feasible and may yield improvements in healthcare utilization, expenditures and quality of life. Larger-scale implementation of care coordination and medical home models for children/youth with asthma and other diagnoses are warranted.

Industrial air pollution in rural Kenya: community awareness, risk perception and associations between risk variables.

BACKGROUND: Developing countries have limited air quality management systems due to inadequate legislation and lack of political will, among other challenges. Maintaining a balance between economic development and sustainable environment is a challenge, hence investments in pollution prevention technologies get sidelined in favor of short-term benefits from increased production and job creation. This lack of air quality management capability translates into lack of air pollution data, hence the false belief that there is no problem. The objectives of the study were to: assess the population's environmental awareness, explore their perception of pollution threat to their health; examine the association between specific health hazards. METHODS: A cross-sectional study was implemented by gathering quantitative information on demographic, health status, environmental perception and environmental knowledge of residents to understand their view of pollution in their neighborhood. Focus group discussions (FGDs) allowed for corroboration of the quantitative data. RESULTS: Over 80% of respondents perceived industrial pollution as posing a considerable risk to them despite the fact that the economy of the area largely depended on the factory. Respondents also argued that they had not been actively involved in identifying solutions to the environmental challenges. The study revealed a significant association between industrial pollution as a risk and, perception of risk from other familiar health hazards. The most important factors influencing the respondents' pollution risk perception were environmental awareness and family health status. CONCLUSION: This study avails information to policy makers and researchers concerning public awareness and attitudes towards environmental pollution pertinent to development and implementation of environmental policies for public health.

A Virtual Home Preparedness Intervention Centered on Children and Youth With Special Health Care Needs.

OBJECTIVE: Children and youth with special health care needs (CYSHCN) require additional considerations for staying safe in emergencies. Our team of clinicians and preparedness professionals developed and tested a virtual home preparedness intervention (VHPI) in families with CYSHCN receiving care in a statewide medical home network. METHODS: The VHPI comprised 1) a pre/post interview covering fire safety, emergency evacuation, sheltering in place, and informing emergency responders of the child/youth's care needs; 2) a resource packet containing emergency planning templates and information on local supports; and 3) individualized referrals coordinated through the medical home/community partners. Eligible CYSHCN had medical technology reliance, physical/mobility needs, communication/intellectual challenges, and/or vision/hearing loss. Preparedness was measured as pre/post affirmed rates of 19 items from the interview and as mean composite scores of these items; associations were evaluated using generalized estimating equations-based regression for repeated measures. RESULTS: The pre and post-VHPI interviews were completed by 170 and 148 participants, respectively. Significant individual-item gains included having a current Emergency Information Form for the child/youth (31% [pre] to 47% [post] affirmed) and assembling an evacuation kit (50% to 68%). The mean preparedness score was 13.33/19 items affirmed at baseline and increased to 14.96 post-VHPI (P < .01). In the adjusted regression model, the post-intervention preparedness score remained significantly higher than pre-VHPI, with mean increases of 1.22 preparedness steps affirmed for homeowners and 1.85 for renters. CONCLUSIONS: Preparedness scores improved post-VHPI in families with CYSHCN. Future work should address incorporating the VHPI into care visits in the medical home.

Family Experience of Caregiver Burden and Health Care Usage in a Statewide Medical Home Program.

OBJECTIVE: To evaluate family-reported caregiver experiences and health care utilization of patients enrolled in the Pennsylvania Medical Home Program (PA-MHP) statewide practice network and compare results to PA-MHP practices' Medical Home Index (MHI) scores. We hypothesized families enrolled in higher-scoring patient-and-family-centered medical homes (PCMH) on completed MHIs would report decreased caregiver burden and improved health care utilization. METHODS: We analyzed surveys completed by families receiving care coordination services in PA-MHP's network and each practice's mean MHI score. A total of 3221 caregivers completed surveys evaluating hours spent coordinating care/week, missed school/workdays, sick visits, and emergency department (ED) visits. A total of 222 providers from 54 participating PA-MHP practices completed the nationally recognized MHI. Family/practice demographics were collected. We developed multivariate logistic regression models assessing independent associations among family survey outcomes and corresponding practices' MHI scores. RESULTS: Families enrolled in high-scoring PCMHs had decreased odds of spending >1 h/wk coordinating care (odds ratio [OR] 0.82, adjusted OR [aOR]: 0.70, 95% confidence interval [CI] 0.55-0.90), missing workdays in the past 6 months (OR 0.82, aOR: 0.72, 95% CI 0.69-0.97), and ED visits in the past 12 months (OR 0.83, aOR: 0.81, 95% CI 0.65-0.99) in comparison to families enrolled in lower-scoring PCMHs. Families enrolled in higher-scoring PCMHs did not report fewer sick visits despite fewer ED visits, indicating more appropriate health care utilization. High-scoring PCMHs had lower percentages of publicly insured and low-income children. CONCLUSIONS: Higher-scoring PCMHs are associated with decreased caregiver burden and improved health care utilization across diverse PA practices. Future studies should evaluate interventions uniformly improving PCMH quality and equity.

A mixed methods evaluation of the effect of the protect and respect intervention on the condom use and disclosure practices of women living with HIV/AIDS.

This mixed methods study evaluated the efficacy of an intervention to increase HIV status disclosure and condom use among 184 women living with HIV/AIDS (WLH/A). Participants were recruited from an HIV clinic and randomly assigned to: (1) a comparison group, who received brief messages from their health care providers (HCPs), or; (2) an intervention group, who received messages from HCPs, a group-level intervention, and peer-led support groups. Participants completed risk surveys at baseline, 6-, 12-, and 18-months. Quantitative analyses using hierarchical generalized linear models within a repeated measures framework indicated that intervention participants had significantly higher odds of reporting condom use with sexual partners in months 6 and 18. Grounded Theory-based qualitative analyses suggested that the opportunity to discuss the social context of their lives in addition to HIV/AIDS, including continued stigma and fear related to disclosure, are also essential components of a prevention strategy for WLH/A.

Children With Special Needs: Social Determinants of Health and Care Coordination.

Care coordination (CC) facilitates access to resources/services for children/youth with special health care needs (CYSHCN). We conducted a cross-sectional analysis of the 2009-2010 National Survey of CSHCN to examine socioeconomic factors related to report of receiving adequate CC services for CYSHCN. Descriptive statistics were used to describe sociodemographic characteristics of respondents and examine socioeconomic factors. Receiving adequate CC varied by socioeconomic variables including income (100% to 199% federal poverty line [FPL]; aOR [adjusted odds ratio] = 0.848; 95% CI [confidence interval] = 0.722-0.997; P < .05), insurance (uninsured; aOR = 0.446; 95% CI = 0.326-0.609; P < .0001), and marital status (never married; aOR = 0.79; 95% CI = 0.64-0.97; P < .05). More families reporting adequate CC had private insurance, non-Hispanic white ethnicity, income >400% federal poverty level, and 2-parent households. Findings suggest unmet needs in terms of adequate access or knowledge leading to insufficient provision of CC for families with the greatest needs. Further analysis identifying specific deficits and implementing strategies to address these disparities is warranted.

Urban college student self-report of hookah use with health care providers.

OBJECTIVE: This study's purpose was to describe urban college students' communication about hookah with health care providers. PARTICIPANTS: Participants included a random sample of undergraduate urban college students and health care providers. METHODS: Students surveyed determined the epidemiology of hookah use in this population, how many health care providers asked about hookah, and how many students admitted hookah use to a physician. RESULTS: Of 375 students surveyed, 78 (20.8%) had never tried it, 284 (75.7%) had smoked hookah at least once, and 64 students (22.6%) were classified as frequent hookah smokers. Only 15 (4.7%) reported a health care provider asking about hookah during visits, whereas 36 (12.7%) admitted their hookah use to a health care provider. CONCLUSION: Hookah use was found to be highly prevalent among students in one urban university. This study supports the hypothesis that few health care providers broach the topic with patients. Additional research on health consequences of hookah use, education, and improved screening is warranted.

Care Coordination for Children and Youth With Special Health Care Needs: National Survey Results.

We analyzed findings from the 2009-2010 National Survey of Children with Special Health Care Needs to identify associations between families with children and youth with special health care needs (CYSHCN) reporting adequate care coordination (CC) with family-provider relations, shared decision making (SDM), and child outcomes. Eligible subjects were the 98% of families asked about CC, service use, and communication. Bivariate analysis using χ2 tests were performed on binary outcome variables to determine the strength of the associations between CC and independent and dependent variables. Weighted, multivariate logistic regression models were constructed to assess independent associations of adequate CC with child outcomes and associations of SDM on adequate CC. Among families of CYSHCN asked about CC, 72% reported receiving help with CC. Of these, 55% reported receiving adequate CC. Family report of adequate CC was favorably associated with family-provider relations, child outcomes, and report of provider participation in SDM.

A Youth Compendium of Physical Activities: Activity Codes and Metabolic Intensities.

PURPOSE: A Youth Compendium of Physical Activities (Youth Compendium) was developed to estimate the energy costs of physical activities using data on youth only. METHODS: On the basis of a literature search and pooled data of energy expenditure measurements in youth, the energy costs of 196 activities were compiled in 16 activity categories to form a Youth Compendium of Physical Activities. To estimate the intensity of each activity, measured oxygen consumption (V˙O2) was divided by basal metabolic rate (Schofield age-, sex-, and mass-specific equations) to produce a youth MET (METy). A mixed linear model was developed for each activity category to impute missing values for age ranges with no observations for a specific activity. RESULTS: This Youth Compendium consists of METy values for 196 specific activities classified into 16 major categories for four age-groups, 6-9, 10-12, 13-15, and 16-18 yr. METy values in this Youth Compendium were measured (51%) or imputed (49%) from youth data. CONCLUSION: This Youth Compendium of Physical Activities uses pediatric data exclusively, addresses the age dependency of METy, and imputes missing METy values and thus represents advancement in physical activity research and practice. This Youth Compendium will be a valuable resource for stakeholders interested in evaluating interventions, programs, and policies designed to assess and encourage physical activity in youth.

Racial variation in end-of-life intensive care use: a race or hospital effect?

OBJECTIVE: To determine if racial and ethnic variations exist in intensive care (ICU) use during terminal hospitalizations, and, if variations do exist, to determine whether they can be explained by systematic differences in hospital utilization by race/ethnicity. DATA SOURCE: 1999 hospital discharge data from all nonfederal hospitals in Florida, Massachusetts, New Jersey, New York, and Virginia. DESIGN: We identified all terminal admissions (N = 192,705) among adults. We calculated crude rates of ICU use among non-Hispanic whites, blacks, Hispanics, and those with "other" race/ethnicity. We performed multivariable logistic regression on ICU use, with and without adjustment for clustering of patients within hospitals, to calculate adjusted differences in ICU use and by race/ethnicity. We explored both a random-effects (RE) and fixed-effect (FE) specification to adjust for hospital-level clustering. DATA COLLECTION: The data were collected by each state. PRINCIPAL FINDINGS: ICU use during the terminal hospitalization was highest among nonwhites, varying from 64.4 percent among Hispanics to 57.5 percent among whites. Compared to white women, the risk-adjusted odds of ICU use was higher for white men and for nonwhites of both sexes (odds ratios [ORs] and 95 percent confidence intervals: white men = 1.16 (1.14-1.19), black men = 1.35 (1.17-1.56), Hispanic men = 1.52 (1.27-1.82), black women = 1.31 (1.25-1.37), Hispanic women =1.53 (1.43-1.63)). Additional adjustment for within-hospital clustering of patients using the RE model did not change the estimate for white men, but markedly attenuated observed differences for blacks (OR for men =1.12 (0.96-1.31), women = 1.10 (1.03-1.17)) and Hispanics (OR for men =1.19 (1.00-1.42), women = 1.18 (1.09-1.27)). Results from the FE model were similar to the RE model (OR for black men = 1.10 (0.95-1.28), black women = 1.07 (1.02-1.13) Hispanic men = 1.17 (0.96-1.42), and Hispanic women = 1.14 (1.06-1.24)) CONCLUSIONS: The majority of observed differences in terminal ICU use among blacks and Hispanics were attributable to their use of hospitals with higher ICU use rather than to racial differences in ICU use within the same hospital.

No benefit when placing drains after kidney transplant: a complex statistical analysis.

OBJECTIVES: This paper sought to determine if there were an association between drain placement and the incidence of wound complications. MATERIALS AND METHODS: A single-center institutional review board-approved retrospective study between 2001 to 2008, comparing 680 kidney transplant patients who either had a drain placed or were left undrained. Linear regression modeling was used to adjust the risk factors between the groups. Patients received calcineurin inhibitors, steroids, and a mycophenolate formulation. The incidence of early major and minor wound complications were captured. Minor wound complications were defined as seroma, lymphocele, and perigraft fluid collection, and major wound complications were defined as wound dehiscence, hematomas, evisceration, infections, wound necrosis, and hernias. Patients with incomplete data or those taking sirolimus were excluded. RESULTS: Six hundred eighty kidney transplant cases were reviewed. Four hundred seventy-nine received drains; 201 did not. Demographic analyses revealed that the drain group had a higher average value in age and body mass index. The drain group had a lower albumin and a lower mean platelet count after surgery. The number of patients without diabetes in the drain group numbered nearly twice as many as did those without drains. An attempt was made to statistically account for demographic differences. Seventy-eight of 479 drained patients (16.28%) and 24 of 201 no-drain patients (11.94%) had a wound complication. Minor wound complications were observed in 9 patients (1.88%) in the drain group and 6 in no-drain group (2.99%) (P = .3702). Major wound complications were observed in 58 patients in the drain group (12.18%) and 17 in the no-drain group (8.46%) (P = .1655). Drain placement had no effect on major or minor wound complications. CONCLUSIONS: Drain placement is not associated with major or minor wound complications in kidney transplants.

Factors influencing physical activity in children and youth with special health care needs: a pilot study.

Background. Evidence suggests that children and youth with special health care needs (CYSHCN) have decreased physical activity compared to peers. This study describes weight status and physical activity in CYSHCN and identifies factors associated with physical activity and community resources to promote physical activity. Methods. Parents (n = 21) and CYSHCN (n = 23) were recruited from a pediatric clinic. The most prevalent diagnoses were autism (n = 7, 30%) and cerebral palsy (n = 3, 13%). Interviews were conducted with parents for information on physical activity and community resources. Children's height and weight were measured to calculate body mass index (BMI). Results. The majority of CYSHCN (n = 13, 59%) were obese. CYSHCN did not meet recommended levels of 60 minutes of daily physical activity and engaged in more screen time than recommended. More children with cognitive/behavioral/emotional diagnoses were obese compared to children with physical/medical diagnoses. A majority of parents (n = 16, 73%) indicated their CYSHCN need more supervision to participate in physical activity in community programs. Conclusion. The majority of CYSHCN in this study were obese and sedentary. Resources to promote physical activity are needed for this population.

Improved dietary variety and adequacy but lower dietary moderation with acculturation in Chinese women in the United States.

Acculturation is associated with increased chronic disease risk among Asian Americans, but its association with different aspects of diet quality remains unclear. Associations of acculturation with diet quality were examined in a convenience sample of 243 Chinese participants in a study of diet and mammographic density in the Philadelphia region between January 2002 to May 2003. An acculturation index was created based on self-reported English proficiency and within- and cross-ethnicity social interactions. Diet Quality Index-International (DQI-I) scores were based on responses to an 88-item food frequency questionnaire. Odds ratios (ORs) for falling into a higher vs lower quartile for DQI-I and its components (ie, variety, adequacy, moderation, balance) were estimated with logistic regression analysis for polytomous outcomes. In the sample, mean age was 53.2 (standard deviation=10.5) years, body mass index (calculated as kg/m2) was 24.1 (standard deviation=3.5), and acculturation was significantly associated with improved dietary variety (OR: 2.4; 95% confidence interval [CI]: 1.5 to 3.8) and adequacy (OR: 1.6; 95% CI: 1.0 to 2.6) and lower dietary moderation (OR: 0.6; 95% CI 0.4 to 0.9), but these associations were evident only among women with less than a high school education. Acculturation and education were not associated with overall diet quality or balance. Although an association of less dietary moderation with acculturation suggests the likely importance of acculturation-related dietary change to chronic disease risk, these findings highlight the need for flexible dietary interventions among immigrant populations to discourage the adoption of some new dietary habits, while encouraging the retention of other, traditional ones.

Urban fitness centers: removing barriers to promote exercise in underserved communities.

African Americans, women, the elderly, obese people, and those in underserved communities are less likely than others to participate in leisure-time physical activity. Mercy Catholic Medical Center opened two fitness centers in low-income, predominately minority Philadelphia neighborhoods. Obese/overweight women from ethnic minorities living in low-income neighborhoods participated most frequently.

Care coordination for CSHCN: associations with family-provider relations and family/child outcomes.

OBJECTIVE: To examine the association between receiving adequate care coordination (CC) with family-provider relations and family/child outcomes. METHODS: We analyzed data from the 2005-2006 National Survey of Children With Special Health Care Needs. Eligible subjects were the 88% of families asked about experience with CC, service use, and communication. Respondents also reported on demographic characteristics, health status, family-provider relations, and family/child outcomes. Weighted, multivariate logistic regression models were constructed to assess independent associations of adequate CC with outcomes. RESULTS: Among families with children with special health care needs asked about CC, 68.2% reported receiving some type of CC help. Of these, 59.2% reported receiving adequate CC help, and 40.8% reported inadequate CC. Families that reported adequate compared with inadequate CC had increased odds of receiving family-centered care, experiencing partnerships with professionals, and satisfaction with services. They had decreased odds of having problems with referrals for specialty care, missing >6 school days because of illness (previous year), and visiting the emergency department more than twice in the previous 12 months (P < .001). Those who reported adequate compared with inadequate CC had decreased odds of the following: more than $500/y of out-of-pocket expenses, family financial burden, spending more than 4 hours/week coordinating care, and stopping/reducing work hours. CONCLUSIONS: Parental report of adequate CC was associated with favorable family-provider relations and family/child outcomes. Additional efforts are needed to discern which aspects of CC are most beneficial and for which subgroups of children with special health care needs.

Survival models with time-varying coefficients: a flexible approach to the analysis of psychiatric survival data.

's model for the modeling of time-varying effects of covariates.