RESUMEN
OBJECTIVE: Remote self-measured blood pressure (SMBP) programs improve racial health equity among postpartum people with hypertensive disorders of pregnancy (HDP) who receive recommended blood pressure ascertainment after hospital discharge.1-3 However, as prior studies have been conducted within racially diverse but ethnically homogeneous populations,1-3 the effect of SMBP programs on ethnicity-based inequities is less understood.4 We examined whether SMBP rates differed among Hispanic versus non-Hispanic participants in remote SMBP programs. STUDY DESIGN: This is a planned secondary analysis of a RCT conducted among postpartum patients with HDP who were enrolled into our remote SMBP program, in which they obtain SMBP and then manually enter the SMBP value into a patient portal for individual provider response. In the parent trial, consenting patients were randomized to continued manual blood pressure entry of SMBP or use of a Bluetooth-enabled blood pressure cuff synched to a smartphone application utilizing artificial intelligence to respond to each obtained blood pressure or symptom for six weeks and to flag abnormalities for providers. Both SMBP programs were available in Spanish and English. For this study, women who self-reported their ethnicity were stratified into two ethnic groups - Hispanic and non-Hispanic - regardless of randomization group. Those who did not self-report ethnicity but completed all study procedures in Spanish were also categorized as Hispanic. Outcomes were the same in the parent study and this secondary analysis. The primary outcome was ≥1 SMBP assessment within 10 days postpartum. Secondary outcomes included number of blood pressure assessments and healthcare utilization outcomes (remote antihypertensive medication initiation or dose-increase and presentation to the Emergency Department or readmission for hypertension within 30 days of discharge). Participants rated their experience with SMBP via a scale from 0 (worst possible) to 10 (best possible) and the Decision Regret Scale, which assessed their regret in SMBP program participation (0=no regret; 100=high regret)).5 Outcomes were compared between groups. Risk differences (RD) were calculated for categorical and regression coefficients for continuous outcomes. The parent RCT was IRB-approved and published on clinicaltrials.gov (NCT05595629) before enrollment. RESULTS: Among 119 women in the parent study, 83 (70%) self-reported ethnicity and the proportion of Hispanic people was similar in both treatment groups. This study compared 23 Hispanic (19% monolingual in Spanish) to 62 non-Hispanic women. Rates of SMBP assessment within 10 days postpartum was similar (Hispanic 64% vs non-Hispanic 79%; RD -0.1 (95% Confidence Interval (CI) -0.4, 0.1). There were no differences in mean number of remote SMBP assessments or rates of remote antihypertensive medication initiation or dose titration. The rates of hypertension-related presentations to the Emergency Department or hospital readmission were also similar between groups. Lastly, regardless of ethnicity, participants had low scores on the Decision Regret Scale and rated their experience with their remote SMBP program highly favorably. (See Table 1.) Conclusion: Hispanic and non-Hispanic postpartum patients with HDP had similar outcomes and favorable patient perceptions. The small sample size in this study may have produced inadequate power to detect a difference between study groups, thereby leading to Type II error. Thus, more research on Hispanic participants in remote SMBP programs is needed. However, the effect of remote SMBP programs on perinatal equity may not be limited to race-based disparities.
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Hispánicos o Latinos , Periodo Posparto , Adulto , Femenino , Humanos , Embarazo , Presión Sanguínea/fisiología , Determinación de la Presión Sanguínea , Hipertensión Inducida en el Embarazo/etnología , Proyectos Piloto , Telemedicina , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
OBJECTIVE: We aimed to evaluate uptake of the glucose tolerance test performed during delivery hospitalization as part of routine clinical care. STUDY DESIGN: This is a retrospective cohort study of people with GDM at a tertiary center. We collected 9 months of postimplementation data after the in-hospital ("early") glucose tolerance test was adopted as a routine screening option. Adherence was compared between those who elected early glucose tolerance testing versus those who deferred testing to the standard postpartum period. Bivariable statistics including demographics, care team, and postpartum testing/visit attendance were compared between those who received early testing and those who did not using chi-square, Fisher's exact, and t-tests. RESULTS: A total of 681 patients with GDM delivered during the study period. Of those who had an early glucose tolerance test ordered (n = 408), 340 (83.3%) completed the test. Among those who did not complete an early glucose tolerance test (ordered and not completed or never ordered), only 104/341 (30.5%) completed any postpartum glucose testing in the first 12 months of postpartum. There were significant differences in characteristics in terms of race/ethnicity, insurance, type of gestational diabetes (A1GDM vs. A2GDM), diabetes medications, obstetric care provider, and delivery mode. Among those who completed early testing, 43.7% of participants had impaired glucose metabolism and 6.5% had values concerning for overt diabetes mellitus. Among those who deferred testing to the standard 6- to 12-week period, 24.0% had impaired glucose metabolism and none had overt diabetes. Those who completed an early glucose tolerance test had a lower rate of postpartum visit attendance compared with those who deferred (75.6 vs. 91.5%, p < 0.01). CONCLUSION: In this cohort, when the early glucose tolerance test is offered in clinical practice, adherence rates are higher than when the test is deferred until the postpartum visit. KEY POINTS: · Adherence rates with the early glucose tolerance test (GTT) are higher than if the testing is deferred.. · Those who completed an early GTT had a lower rate of postpartum visit attendance compared with those who deferred.. · Offering an in-hospital postpartum GTT can help address low rates of glucose testing postpartum..
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Diabetes Gestacional , Prueba de Tolerancia a la Glucosa , Periodo Posparto , Humanos , Femenino , Diabetes Gestacional/diagnóstico , Embarazo , Estudios Retrospectivos , Adulto , Hospitalización/estadística & datos numéricos , Tamizaje Masivo , Glucemia/análisisRESUMEN
BACKGROUND: The importance of prenatal care is undeniable, as pregnant persons who receive on-time, adequate prenatal care have better maternal and infant health outcomes compared with those receiving late, less than adequate prenatal care. Previous studies assessing the relationship between neighborhood factors and maternal health outcomes have typically looked at singular neighborhood variables and their relationship with maternal health outcomes. In order to examine a greater number of place-based risk factors simultaneously, our analysis used a unique neighborhood risk index to assess the association between cumulative risk and prenatal care utilization, which no other studies have done. METHODS: Data from Rhode Island Vital Statistics for births between 2005 and 2014 were used to assess the relationship between neighborhood risk and prenatal care utilization using two established indices. We assessed neighborhood risk with an index composed of eight socioeconomic block-group variables. A multivariate logistic regression model was used to examine the association between adequate use and neighborhood risk. RESULTS: Individuals living in a high-risk neighborhood were less likely to have adequate or better prenatal care utilization according to both the APNCU Index (adjusted odds ratio [aOR] 0.91, 95% confidence interval [CI] 0.87-0.95) and the R-GINDEX (aOR 0.88, 95% CI 0.85-0.91) compared with those in low-risk neighborhoods. CONCLUSION: Understanding the impact of neighborhood-level factors on prenatal care use is a critical first step in ensuring that underserved neighborhoods are prioritized in interventions aimed at making access to prenatal care more equitable.
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Aceptación de la Atención de Salud , Atención Prenatal , Características de la Residencia , Humanos , Femenino , Rhode Island/epidemiología , Embarazo , Atención Prenatal/estadística & datos numéricos , Adulto , Adulto Joven , Aceptación de la Atención de Salud/estadística & datos numéricos , Modelos Logísticos , Factores de Riesgo , Factores Socioeconómicos , Adolescente , Análisis Multivariante , Oportunidad RelativaRESUMEN
The objective of this study is to evaluate if proximity to food sources, rather than density, is associated with gestational diabetes mellitus (GDM) risk. Rhode Island birth certificate data from 2015-2016 were utilized. A proximity analysis was used to determine the distance from each pregnant person's home address to the closest food source (fast food restaurant, supermarket, and farmers market/community garden). Multivariable logistic regression was used to examine the association between distance to food source and the risk of GDM. Of the 20,129 births meeting inclusion criteria, 7.2% (1,447) had GDM. Distance to food sources differed by insurance type, educational background, and race/ethnicity. There was no statistically significant association between distance to any of the food sources and GDM in the adjusted model. Other factors need to be examined to improve interventions, influence policy, and impact neonatal and maternal outcomes.
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Diabetes Gestacional , Embarazo , Recién Nacido , Femenino , Humanos , Diabetes Gestacional/epidemiología , Etnicidad , Rhode Island/epidemiologíaRESUMEN
OBJECTIVES: To evaluate third-grade reading and math proficiency for children born to adolescent women compared with those born to non-adolescent women. METHODS: A statewide, retrospective cohort study was conducted in Rhode Island using third-grade year-end examination data from 2014 to 2017 as part of a statewide initiative to improve third grade reading levels. Children's third-grade reading and math proficiencies were compared between those born to nulliparous adolescent women (age 15-19 at the time of delivery), and nulliparous women 20 years or older at delivery. Bivariate analyses were conducted to compare maternal and child characteristics between adolescent and non-adolescent groups. Multivariable logistic regression was used to examine the association between having an adolescent mother and being proficient in reading and math after adjusting for lunch subsidy, core city residence, child race/ethnicity and sex. RESULTS: Of the 8,248 children meeting the inclusion criteria, 20% were born to adolescent women and the remaining 80% were born to non-adolescent women. After adjusting for potential confounders, children born to adolescent women were significantly less likely to be proficient in both reading (adjusted risk ratio (aRR) 0.77, 95% confidence interval (CI): 0.71-0.83) and math (aRR 0.78, 95% CI: 0.72-0.85). CONCLUSIONS FOR PRACTICE: Children born to adolescent women had significantly lower rates of reading and math proficiency when compared with children of non-adolescent women. These children may benefit from additional resources focused on early academic performance in order to address disparities in reading and math proficiency.
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Etnicidad , Familia , Niño , Femenino , Humanos , Embarazo , Adolescente , Adulto Joven , Adulto , Estudios Retrospectivos , Escolaridad , Correlación de DatosRESUMEN
OBJECTIVE: To assess the predictive value of a pediatric screening tool by linking 2 independent databases: an educational database that includes data from standardized academic assessments administered during kindergarten and a pediatric database that includes screening results. METHODS: A database that includes results of the Survey of Well-being of Young Children (SWYC) completed during pediatric visits were linked to an educational database that includes STAR Early Literacy examinations in kindergarten. Linear multilevel regression modeling was used to examine if screening results on the developmental and behavioral sections of the most recently completed SWYC form predicted trends in the percentile rank on the STAR exam over the school year, adjusting for potential confounders. RESULTS: Linking the 2 databases resulted in a sample of 586 children who were administered at least one SWYC evaluation between 24 and 48 months and completed at least one STAR Early Literacy examination in kindergarten. The sample represents a diverse population with 55% Hispanic children, 25% Non-Hispanic black children, and 91% of children receiving a subsidized lunch. After adjusting for confounders, children with a positive developmental or behavioral screen had significantly lower percentile ranks on the STAR exam. CONCLUSIONS: Early developmental and behavioral screening results predicted performance on the STAR exam in kindergarten. Children with developmental and behavioral concerns may be less ready to enter kindergarten than peers without such concerns. These preliminary findings provide proof-of-principle of the potential utility of developmental screening tools in identifying children with reduced school readiness who may benefit from intervention prior to kindergarten.
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Conducta Infantil , Desarrollo Infantil , Alfabetización , Problema de Conducta , Humanos , Niño , Escolaridad , Tamizaje Masivo , Diagnóstico PrecozRESUMEN
BACKGROUND: Rates of vaginal birth after cesarean delivery have decreased and cesarean delivery rates have increased in the last 2 decades. Evidence on short-term neonatal outcomes is available, but data on long-term childhood outcomes following vaginal birth after cesarean delivery are insufficient. Long-term childhood outcome data are essential in decision-making regarding mode of delivery. OBJECTIVE: This study aimed to evaluate the association between delivery mode and long-term educational outcomes of the children of pregnant individuals with a previous cesarean delivery. STUDY DESIGN: This was a retrospective cohort study linking Rhode Island third-grade education data from 2014 to 2017 to birth certificate data. Data were obtained from a statewide database using Department of Education data, and were linked to Department of Health birth certificate data. Participants were children of multiparous women who were term, singleton births without congenital anomalies. Children delivered by primary cesarean delivery were excluded. The exposure was mode of delivery classified as vaginal birth after cesarean delivery, repeated cesarean delivery, or repeated vaginal birth. The primary outcome was children's third-grade reading and math proficiency. Bivariate analyses were conducted to assess differences in demographic variables. Bivariable and multivariable log-binomial regression was used to examine the association between subject proficiency and predictors including mode of delivery, maternal education, sex, child race or ethnicity, and lunch subsidy. RESULTS: Of the 10,923 children who met the inclusion criteria, 2.0% were delivered by vaginal birth after cesarean delivery, 22.0% by repeated cesarean delivery, and 76.0% by repeated vaginal delivery. After adjustment for confounders, there was no difference in reading proficiency (adjusted risk ratio, 0.98; 95% confidence interval, 0.84-1.15) or math proficiency (adjusted risk ratio, 0.99; 95% confidence interval, 0.84-1.15) between those born by vaginal birth after cesarean delivery and those born by repeated cesarean delivery. There was no difference found in either proficiency between children born by repeated vaginal birth and those born by repeated cesarean delivery (reading: adjusted risk ratio, 0.97; 95% confidence interval, 0.93-1.01; math: adjusted risk ratio, 0.97; 95% confidence interval, 0.92-1.02). CONCLUSION: In comparison with repeated cesarean delivery, both vaginal birth after cesarean delivery and repeated vaginal birth were not associated with differences in educational outcomes. This may aid in counseling about long-term safety outcomes regarding vaginal birth after cesarean delivery and may assist in shared decision-making when selecting between trial of labor after cesarean delivery and repeated cesarean delivery.
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Trabajo de Parto , Parto Vaginal Después de Cesárea , Preescolar , Embarazo , Recién Nacido , Humanos , Niño , Femenino , Parto Vaginal Después de Cesárea/efectos adversos , Estudios Retrospectivos , Cesárea/efectos adversos , Parto ObstétricoRESUMEN
OBJECTIVE: Both small for gestational age (SGA) birthweight and pregnancies complicated by maternal hypertension (HTN) are independently associated with poorer childhood learning outcomes, however the relative contribution of each remains unknown. STUDY DESIGN: A retrospective cohort was created in which 2014-2017 third grade Rhode Island Department of Education data were linked to Rhode Island Department of Health birth certificate data. The study population was composed of non-anomalous, singleton births between 22- and 42-weeks' gestation. Reading and math proficiency were compared among four groups: 1) appropriate for gestational age (AGA) and no maternal HTN (referent), 2) AGA with HTN, 3) SGA without HTN and 4) SGA with HTN. MAIN OUTCOME MEASURES: Bivariable and multivariable log-binomial regression were used to examine the association between subject proficiency and pregnancy complication, adjusting for potential confounders. RESULTS: Of the 23,097 who met inclusion criteria, 1004 (4%) were AGA with HTN, 1575 (7%) were SGA without HTN and 176 (1%) were SGA with HTN. Overall, when adjusted for maternal age, gestational age, sex and socioeconomic factors, only children born SGA without HTN had reduced reading proficiency (relative risk (RR) 0.86 95% confidence interval (CI) 0.78, 0.92) and math proficiency (RR 0.88 95% CI 0.82, 0.94) compared to children born AGA without HTN. CONCLUSION: In a diverse, statewide cohort, only SGA without HTN was associated with lower reading and math proficiency compared to uncomplicated pregnancies. This suggests that only decreased fetal growth from causes other than HTN is associated with risk of poorer school-age outcomes, and has implications for early resource allocation.
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Recién Nacido Pequeño para la Edad Gestacional , Trastornos del Neurodesarrollo/epidemiología , Preeclampsia , Diagnóstico Prenatal , Adulto , Niño , Estudios de Cohortes , Femenino , Desarrollo Fetal , Humanos , Recién Nacido , Trastornos del Neurodesarrollo/economía , Trastornos del Neurodesarrollo/etiología , Embarazo , Resultado del Embarazo , Estudios Retrospectivos , Rhode Island/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Burn injury continues to cause significant morbidity and mortality in the US pediatric population. Many studies using inpatient samples have found a relationship between low socioeconomic status (SES) and burn injury. The purpose of our study was to evaluate the association between SES and the likelihood of admission for Emergency Department (ED) visits for pediatric burn injury. STUDY DESIGN: A retrospective database review of pediatric ED visits for burn injury from a statewide hospital system, from January 1, 2005 to December 31, 2014. SES was assigned using an eight factor Neighborhood Risk Index (NRI) created from census block group data, with a higher score indicative of lower SES. The outcome measure was ED visits admitted to inpatient care. RESULTS: We analyzed a sample of 1845 pediatric ED visits for burn injuries. Most visits were discharged from the ED (88.4%) while 10.5% were admitted to inpatient care and 1.0% were transferred to another hospital. In a multivariable logistic regression model, patients from high risk areas (>75th percentile NRI) had 1.58 higher odds of inpatient admission compared to patients from low risk areas (<75th percentile NRI; 95% CI: 1.08-2.30), after adjusting for age, gender, ethnicity, distance to the hospital, and previous ED visit for burn injury in the past 30 days. In addition, for every 1-mile increase in distance, a child's likelihood of admission increased by 6% (95% CI: 4-9%). CONCLUSIONS: Children with a burn injury from the highest risk socioeconomic areas in Rhode Island had a higher likelihood of inpatient admission. Further research is needed to determine what factors associated with socioeconomic status impact this finding.
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Quemaduras , Hospitalización , Clase Social , Quemaduras/epidemiología , Quemaduras/terapia , Niño , Servicio de Urgencia en Hospital , Hospitales , Humanos , Estudios RetrospectivosRESUMEN
OBJECTIVES: Frequent use of the emergency department (ED) is often targeted as a quality improvement metric. The objective of this study was to assess ED visit frequency by the demographic and health characteristics of children who visit the ED to better understand risk factors for high ED utilization. METHODS: The majority of pediatric ED services in Rhode Island are provided by a hospital network that includes the state's only children's hospital. Using 10 years of data (2005-2014) from this statewide hospital network, we examined ED use in this network for all children aged 0 to 17 years. Patients' home addresses were geocoded to assess their neighborhood characteristics. RESULTS: Between 2005 and 2014, 17,844 children visited 1 or more of the network EDs at least once. In their year of maximum use, 67.8% had only 1 ED visit, 20.1% had 2 visits, 6.9% had 3 visits, and 5.2% had 4 or more visits. In the adjusted multinomial logistic regression model, age, race/ethnicity, language, insurance coverage, medical complexity, neighborhood risk, and distance to the ED were found to be significantly associated with increased visit frequency. CONCLUSIONS: Risk factors for frequent ED use by children include age, race/ethnicity, language, insurance coverage, medical complexity, neighborhood risk, and distance to the hospital. To decrease frequent pediatric ED use, improved medical management of complex medical problems is needed, but it is also essential to address modifiable social determinants of health care utilization in this population.
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Servicio de Urgencia en Hospital , Características del Vecindario , Niño , Humanos , Cobertura del Seguro , Modelos Logísticos , Aceptación de la Atención de SaludRESUMEN
BACKGROUND: Operative vaginal delivery rates continue to drop nationally with many citing neonatal safety concerns as a primary driver of this decrease. Previous evidence on short-term neonatal outcomes does not support this concern. OBJECTIVE: This study aimed to better understand the impact of delivery mode on childhood educational outcomes. STUDY DESIGN: A statewide retrospective cohort was created in which third grade Rhode Island Department of Education data for 2014 to 2017 were linked to Rhode Island Department of Health birth certificate data. Children's third grade reading and math proficiencies were compared by the mode of delivery listed in their birth certificates. The study population was limited to children who were term, singleton births without congenital anomalies. The mode of delivery was classified as operative vaginal (forceps or vacuum), primary cesarean, or spontaneous vaginal delivery. Children born via repeat cesarean delivery were excluded. Bivariate analyses were conducted to assess differences in demographic variables between mothers and children by mode of delivery and between reading and math proficiencies and mode of delivery. Bivariable and multivariable log-binomial regression was used to examine the association between subject proficiency and predictors including mode of delivery, gestational age, sex, race/ethnicity, and lunch subsidy. RESULTS: Of the 18,247 children who met the inclusion criteria, 6% were delivered by operative vaginal delivery, 19% by primary cesarean delivery, and the remaining 75% by spontaneous vaginal delivery. After adjustment for confounders including gestational age at delivery, child's race/ethnicity, sex, and socioeconomic factors, there was no difference in reading proficiency (adjusted risk ratio, 1.03; 95% confidence interval, 0.96-1.10) or math proficiency (adjusted risk ratio, 1.01; 95% confidence interval, 0.95-1.08) in those born by operative vaginal delivery compared with primary cesarean delivery, and no difference was found in either proficiency when spontaneous vaginal delivery was compared with primary cesarean delivery (reading, adjusted risk ratio, 0.97; 95% confidence interval, 0.93-1.01; math, adjusted risk ratio, 0.98; 95% confidence interval, 0.94-1.01). CONCLUSION: Operative vaginal delivery was not associated with differences in later childhood educational outcomes after adjusting for baseline differences. This should assuage previous concerns about long-term safety outcomes after operative vaginal delivery and may assist in shared decision making when operative vaginal or primary cesarean delivery is being considered.
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Cesárea , Parto Obstétrico , Niño , Femenino , Edad Gestacional , Humanos , Recién Nacido , Embarazo , Estudios Retrospectivos , Rhode IslandRESUMEN
BACKGROUND: Women with congenital heart defects (CHDs) experiencing pregnancies require specialized delivery care and extensive monitoring that may not be available at all birthing hospitals. In this study, we examined proximity to, and delivery at, a hospital with an appropriate level of perinatal care for pregnant women with CHDs and evaluated predictors of high travel distance to appropriate care. Appropriate care was defined as Level 3 perinatal hospitals and Regional Perinatal Centers (RPCs). METHODS: Inpatient delivery records for women with CHD in New York State (NYS) between 2008 and 2013 were obtained. Driving time and transit time were calculated between the pregnant woman's residence and the actual delivery hospital as well as the closest Level 3 or RPC hospital using Geographic Information Systems (GIS). Linear and logistic regression models evaluated predictors of high distance to, and utilization of, appropriate delivery care respectively. RESULTS: From 2008 to 2013, there were 909 deliveries in a NYS hospital by women with CHDs. Approximately 75% of women delivered at a Level 3 or RPC hospital. Younger women, those who reside in rural and smaller urban areas, and those who are non-Hispanic White had a greater drive time to an appropriate care facility. After adjustment for geographic differences, racial/ethnic minorities and poor women were less likely to deliver at an appropriate delivery care center. CONCLUSIONS: Although most women with CHDs in NYS receive appropriate delivery care, there are some geographic and socio-demographic differences that require attention to ensure equitable access.
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Parto Obstétrico , Accesibilidad a los Servicios de Salud , Cardiopatías Congénitas , Maternidades , Parto , Aceptación de la Atención de Salud , Atención Perinatal , Adolescente , Adulto , Población Negra , Femenino , Disparidades en Atención de Salud/etnología , Hispánicos o Latinos , Humanos , Recién Nacido , New York , Aceptación de la Atención de Salud/etnología , Embarazo , Población Rural , Viaje , Población Blanca , Adulto JovenRESUMEN
Importance: Although labor induction at 39 weeks of gestation has been shown to reduce the number of cesarean deliveries, compared with expectant management, without increasing neonatal morbidity in nulliparous, low-risk women, the association between induction at 39 weeks and longer-term childhood cognitive outcomes is not certain. Objective: To evaluate educational outcomes of children born by induction at 39 or 40 weeks compared with those whose mothers were expectantly managed beyond those weeks. Design, Setting, and Participants: This statewide cohort study was conducted in Rhode Island. The participants included children of nulliparous women who were born at 39 weeks of gestation or later and then completed third-grade math and reading tests during the 2014 to 2017 academic year. Data analysis was performed from July 2019 to October 2019. Exposures: Induction of labor compared with expectant management. Main Outcomes and Measures: Third-grade math and reading test scores and proficiency (based on achievement level) among children born after induction in the 39th or 40th week were compared with scores for those who remained in utero beyond that same gestational week. The hypothesis was that induction in the 39th or 40th week would not be associated with differences in math or reading scores or proficiency compared with expectant management past the 39th or 40th week of gestation. Results: Of the 6393 children meeting the inclusion criteria (mean [SD] age, 8.00 [0.22] years; 3208 boys [50.2%]; 376 [5.8%] black; 1280 [22.0%] Hispanic), 455 were delivered by induction in the 39th week and 610 were delivered by induction in the 40th week. There were no differences in mean math or reading test scores or in the frequency of math or reading proficiency between children delivered by induction at 39 or 40 weeks compared with those whose mothers were expectantly managed (overall mean [SD] math score, 744 [33]; overall mean [SD] reading score, 743 [38]; 2945 children [46%] achieved proficiency in math and 2833 [44%] achieved proficiency in reading). After adjusting for plausible confounders (race/ethnicity, maternal education, hypertension, diabetes, and socioeconomic status), induction continued to be associated with similar proficiency in math and reading compared with expectant management. For children born by induction at 39 weeks, the adjusted relative risks were 1.07 (95% CI, 0.97-1.18) for math proficiency and 0.98 (95% CI, 0.88-1.08) for reading proficiency. For children born by induction at 40 weeks, the adjusted relative risks were 0.97 (95% CI, 0.88-1.08) for math proficiency and 0.98 (95% CI, 0.89-1.08) for reading proficiency. Conclusions and Relevance: These findings suggest that the offspring of nulliparous women for whom labor is induced at 39 or 40 weeks have similar third-grade educational outcomes compared with the offspring of mothers who underwent expectant management past those gestational ages.
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Rendimiento Académico/estadística & datos numéricos , Trabajo de Parto Inducido/estadística & datos numéricos , Espera Vigilante/estadística & datos numéricos , Niño , Estudios de Cohortes , Femenino , Humanos , Masculino , Embarazo , Rhode IslandRESUMEN
BACKGROUND AND OBJECTIVES: Pediatric surveillance of young children depends on providers' assessment of developmental milestones, yet normative data are sparse. Our objectives were to develop new norms for common milestones to aid in clinical interpretation of milestone attainment. METHODS: We analyzed responses to the developmental screening form of the Survey of Well-being of Young Children from 41 465 screens across 3 states. Associations between developmental status and a range of child characteristics were analyzed, and norms for individual questions were compared to guidelines regarding attainment of critical milestones from the Centers for Disease Control and Prevention (CDC). RESULTS: A contemporary resource of normative data for developmental milestone attainment was established. Lower developmental status was associated with child age in the presence of positive behavioral screening scores (P < .01), social determinants of health (P < .01), Medicaid (P < .01), male sex (P < .01), and child race (P < .01). Comparisons between Survey of Well-being of Young Children developmental questions and CDC guidelines reveal that a high percentage of children are reported to pass milestones by the age at which the CDC states that "most children pass" and that an even higher percentage of children are reported to pass milestones by the age at which the CDC states that parents should "act early." An interactive data visualization tool that can assist clinicians in real-time developmental screening and surveillance interpretation is also provided. CONCLUSIONS: Detailed normative data on individual developmental milestones can help clinicians guide caregivers' expectations for milestone attainment, thereby offering greater specificity to CDC guidelines.
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Desarrollo Infantil/fisiología , Pediatría/normas , Rol del Médico , Guías de Práctica Clínica como Asunto/normas , Niño , Preescolar , Femenino , Humanos , Masculino , Pediatría/tendencias , Encuestas y Cuestionarios/normas , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: We aimed to explore the leading causes and risk factors for infant mortality in a statewide study of infant deaths from 2005 to 2016. METHODS: Rhode Island Vital Statistics was linked with KIDSNET, a statewide-integrated child health information system. Descriptive analyses examined infant mortality rates as well as risk factors of infant, neonatal, and postneonatal death. A multivariable logistic regression model of the risk of infant mortality adjusting for risk factors was computed. RESULTS: The majority (74%) of infant deaths occurred during the neonatal period. The top cause of infant mortality was prematurity (20.4%). After adjustment, infants born <28 weeks had 38.1 higher odds of mortality compared to term infants (p<0.01). Low 5-minute Apgar score, birth defects, less than 10 prenatal visits, and low maternal weight gain were associated with higher odds of infant mortality (p<0.01). DISCUSSION: Substantial reductions in the infant mortality rate will require improving strategies to prevent preterm births as well as using factors identifiable at birth to focus prevention efforts on those at higher risk.
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Mortalidad Infantil/tendencias , Nacimiento Prematuro/mortalidad , Atención Prenatal/estadística & datos numéricos , Adolescente , Adulto , Puntaje de Apgar , Causas de Muerte , Femenino , Edad Gestacional , Humanos , Lactante , Recién Nacido de Bajo Peso , Recién Nacido , Modelos Logísticos , Masculino , Edad Materna , Persona de Mediana Edad , Análisis Multivariante , Embarazo , Características de la Residencia , Estudios Retrospectivos , Rhode Island/epidemiología , Factores de Riesgo , Adulto JovenRESUMEN
Flame injuries are the primary cause of burns in young adults. Although drug and alcohol intoxication has been associated with other types of trauma, its role in burn injury has not been well described in this population. The purpose of this study was to investigate the association of intoxication and flame burn injuries in young adults in the United States. The 2014 Nationwide Emergency Department Sample was queried for burn injury visits of young adult patients, 13-25 years old. This data is weighted to allow for national estimates. Burn mechanism and intoxication status were determined by International Classification of Diseases, Ninth Revision codes. Multivariable logistic regression analysis was used to assess the association of intoxication and emergency department (ED) visits due to flame burns, adjusting for patient age, gender, zip code median income, zip code rural-urban designation, timing of visit, and hospital region. Further analyses assessed the odds of admission or transfer, as a possible proxy of injury severity, in patients with flame or other burns, with and without intoxication adjusting for patient age, gender, primary insurance, and hospital trauma designation. There were 20,787 visits for patients 13-25 years old with burn injuries and 12.9% (n = 2678) had a codiagnosis of intoxication. There was an increasing proportion of intoxication by age (5.8% 13-17 years old, 25% 18-20 years old, 69% 21-25 years old, P < .001). ED visits for burns with a codiagnosis of intoxication had 1.34 times ([95% confidence interval (CI): 1.18, 1.52], P < .01) higher odds of having flame burns compared to other burn mechanisms. Those with flame burns and intoxication were most likely to be admitted or transferred when compared to nonflame, nonintoxication visits in the adjusted model (odds ratio [OR] 5.49, [95% CI: 4.29, 7.02], P < .01). Furthermore, the odds of admission or transfer in visits with the combined exposure of intoxication and flame mechanism were significantly higher than visits due to nonflame burns and intoxication (OR 2.75, [2.25, 3.36], P < .01) or flame burns without intoxication (OR 3.00, [95% CI: 2.61, 3.42], P < .01). This study identified a significant association between flame-burn-related ED visits and intoxication in the young adult population in the United States. In addition, the combination of flame mechanism and intoxication appears to result in more substantial injury compared with either exposure alone. The relationship seen between intoxication and flame burn injury underscores a major target for burn prevention efforts in the young adult population.
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Intoxicación Alcohólica/epidemiología , Quemaduras/epidemiología , Servicio de Urgencia en Hospital/estadística & datos numéricos , Puntaje de Gravedad del Traumatismo , Adolescente , Adulto , Femenino , Humanos , Masculino , Factores de Riesgo , Lesión por Inhalación de Humo/epidemiología , Estados Unidos , Adulto JovenRESUMEN
BACKGROUND: Pregnant women with congenital heart defects (CHDs) may be at increased risk for adverse events during delivery. OBJECTIVES: This study sought to compare comorbidities and adverse cardiovascular, obstetric, and fetal events during delivery between pregnant women with and without CHDs in the United States. METHODS: Comorbidities and adverse delivery events in women with and without CHDs were compared in 22,881,691 deliveries identified in the 2008 to 2013 National Inpatient Sample using multivariable logistic regression. Among those with CHDs, associations by CHD severity and presence of pulmonary hypertension (PH) were examined. RESULTS: There were 17,729 deliveries to women with CHDs (77.5 of 100,000 deliveries). These women had longer lengths of stay and higher total charges than women without CHDs. They had greater odds of comorbidities, including PH (adjusted odds ratio [aOR]: 193.8; 95% confidence interval [CI]: 157.7 to 238.0), congestive heart failure (aOR: 49.1; 95% CI: 37.4 to 64.3), and coronary artery disease (aOR: 31.7; 95% CI: 21.4 to 47.0). Greater odds of adverse events were observed, including heart failure (aOR: 22.6; 95% CI: 20.5 to 37.3), arrhythmias (aOR: 12.4; 95% CI: 11.0 to 14.0), thromboembolic events (aOR: 2.4; 95% CI: 2.0 to 2.9), pre-eclampsia (aOR: 1.5; 95% CI: 1.3 to 1.7), and placenta previa (aOR: 1.5; 95% CI: 1.2 to 1.8). Cesarean section, induction, and operative vaginal delivery were more common, whereas fetal distress was less common. Among adverse events in women with CHDs, PH was associated with heart failure, hypertension in pregnancy, pre-eclampsia, and pre-term delivery; there were no differences in most adverse events by CHD severity. CONCLUSIONS: Pregnant women with CHDs were more likely to have comorbidities and experience adverse events during delivery. These women require additional monitoring and care.
Asunto(s)
Parto Obstétrico/efectos adversos , Cardiopatías Congénitas/epidemiología , Mortalidad Hospitalaria , Mortalidad Materna , Complicaciones del Embarazo/epidemiología , Embarazo de Alto Riesgo , Adolescente , Adulto , Cesárea/mortalidad , Cesárea/estadística & datos numéricos , Estudios de Cohortes , Comorbilidad , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/epidemiología , Parto Obstétrico/métodos , Femenino , Cardiopatías Congénitas/diagnóstico por imagen , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/epidemiología , Humanos , Tiempo de Internación , Modelos Logísticos , Salud Materna , Análisis Multivariante , Placenta Previa/diagnóstico , Placenta Previa/epidemiología , Preeclampsia/diagnóstico , Preeclampsia/epidemiología , Embarazo , Complicaciones del Embarazo/diagnóstico , Resultado del Embarazo , Estudios Retrospectivos , Análisis de Supervivencia , Adulto JovenRESUMEN
OBJECTIVE: To examine national trends of emergency department (ED) visits owing to traumatic brain injury (TBI) among infants (age <12 months), specifically in the context of intentional and unintentional mechanisms. STUDY DESIGN: National Electronic Injury Surveillance System-All Injury Program data documenting nonfatal ED visits from 2003 to 2012 were analyzed. TBI was defined as ED visits resulting in a diagnosis of concussion, or fracture, or internal injury of the head. Intentional and unintentional injury mechanisms were compared using multivariable models. Joinpoint regression was used to identify significant time trends. RESULTS: TBI-related ED visits (estimated n = 713 124) accounted for 28% of all injury-related ED visits by infants in the US, yielding an average annual rate of 1722 TBI-related ED visits per 100 000 infants. Trend analysis showed an annual increase of 9.48% in the rate of TBI-related ED visits over 10 years (P < .05). For these visits, an estimated 701 757 (98.4%) were attributed to unintentional mechanisms and 11 367 (1.6%) to intentional mechanisms. Unintentional TBI-related ED visit rates increased by 9.52% annually (P < .05) and the rates of intentional TBI were relatively stable from 2003 to 2012. Infants with intentional TBI were more likely to be admitted (aOR, 11.44; 95% CI, 3.02-21.75) compared with those with unintentional TBI. CONCLUSIONS: The rate of TBI-related ED visits in infants increased primarily owing to unintentional mechanisms and intentional TBI-related ED visits remained stable over the decade. Improved strategies to reduce both intentional and unintentional injuries in infants are required.
Asunto(s)
Lesiones Traumáticas del Encéfalo/diagnóstico , Lesiones Traumáticas del Encéfalo/terapia , Servicio de Urgencia en Hospital/estadística & datos numéricos , Abuso Físico/estadística & datos numéricos , Distribución por Edad , Lesiones Traumáticas del Encéfalo/epidemiología , Lesiones Traumáticas del Encéfalo/etiología , Intervalos de Confianza , Estudios Transversales , Femenino , Humanos , Lactante , Recién Nacido , Puntaje de Gravedad del Traumatismo , Masculino , Oportunidad Relativa , Prevalencia , Medición de Riesgo , Distribución por Sexo , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVES: For many children, the emergency department (ED) serves as the main destination for health care, whether it be for emergent or nonurgent reasons. Through examination of repeat utilization and ED reliance (EDR), in addition to overall ED utilization, we can identify subpopulations dependent on the ED as their primary source of health care. METHODS: Nationally representative data from the 2010 to 2014 Medical Expenditure Panel Survey were used to examine the annual ED utilization of children age 0 to 17 years by insurance coverage. Overall utilization, repeat utilization (two or more ED visits), and EDR (percentage of all health care visits that occur in the ED) were examined using multivariate models, accounting for weighting and the complex survey design. High EDR was defined as having > 33% of outpatient visits in a year being ED visits. RESULTS: A total of 47,926 children were included in the study. Approximately 12% of children visited an ED within a 1-year period. A greater number of children with public insurance (15.2%) visited an ED at least once, compared to privately insured (10.1%) and uninsured (6.4%) children. Controlling for covariates, children with public insurance were more likely to visit the ED (adjusted odds ratio [aOR] = 1.55, 95% confidence interval [CI] = 1.40-1.73) than children with private insurance, whereas uninsured children were less likely (aOR = 0.64, 95% CI = 0.51-0.81). Children age 3 and under were significantly more likely to visit the ED than children age 15 to 17, whereas female children and Hispanic and non-Hispanic other race children were significantly less likely to visit the ED than male children and non-Hispanic white children. Among children with ED visits, 21% had two or more visits to the ED in a 1-year period. Children with public insurance were more likely to have two or more visits to the ED (aOR = 1.53, 95% CI = 1.19-1.98) than children with private insurance whereas there was no significant difference in repeat ED utilization for uninsured children. Publicly insured (aOR = 1.70, 95% CI = 1.47-1.97) and uninsured children (aOR = 1.90, 95% CI = 1.49-2.42) were more likely to be reliant on the ED than children with private insurance. CONCLUSIONS: Health insurance coverage was associated with overall ED utilization, repeat ED utilization, and EDR. Demographic characteristics, including sex, age, income, and race/ethnicity were important predictors of ED utilization and reliance.