Racial Disparities in Employment Status After Moderate/Severe Traumatic Brain Injuries in Southeast Michigan.

OBJECTIVE: To examine the progress made in recent decades by assessing the employment rates of Black and non-Hispanic White (NHW) patients after traumatic brain injury (TBI), controlling for pre-TBI employment status and education status. DESIGN: Retrospective analysis in a cohort of patients treated in Southeast Michigan at major trauma centers in more recent years (February 2010 to December 2019). SETTING: Southeastern Michigan Traumatic Brain Injury Model System (TBIMS): 1 of 16 TBIMSs across the United States. PARTICIPANTS: NHW (n=81) and Black (n=188) patients with moderate/severe TBI (N=269). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Employment status, which is separated into 2 categories: student plus competitive employment and noncompetitive employment. RESULTS: In 269 patients, NHW patients had more severe initial TBI, measured by percentage brain computed tomography with compression causing >5-mm midline shift (P<.001). Controlling for pre-TBI employment status, we found NHW participants who were students or had competitive employment prior to TBI had higher rates of competitive employment at 2-year (P=.03) follow-up. Controlling for pre-TBI education status, we found no difference in competitive and noncompetitive employment rates between NHW and Black participants at all follow-up years. CONCLUSIONS: Black patients who were students or had competitive employment before TBI experience worse employment outcomes than their NHW counterparts after TBI at 2 years post TBI. Further research is needed to understand better the factors driving these disparities and how social determinants of health affect these racial differences after TBI.

Shadow Coaching Improves Patient Experience With Care, But Gains Erode Later.

BACKGROUND: Health care organizations strive to improve patient care experiences. Some use one-on-one provider counseling (shadow coaching) to identify and target modifiable provider behaviors. OBJECTIVE: We examined whether shadow coaching improves patient experience across 44 primary care practices in a large urban Federally Qualified Health Center. RESEARCH DESIGN: Seventy-four providers with "medium" (ie, slightly below average) overall provider ratings received coaching and were compared with 246 uncoached providers. We fit mixed-effects regression models with random effects for provider (level of treatment assignment) and fixed effects for time (linear spline with a knot and "jump" at coaching date), patient characteristics and site indicators. By design, coached providers performed worse at selection; models account for the very small (0.2 point) regression-to-the-mean effects. We assessed differential effects by coach. SUBJECTS: A total of 46,452 patients (from 320 providers) who completed the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) Visit Survey 2.0. MEASURES: CAHPS overall provider rating and provider communication composite (scaled 0-100). RESULTS: Providers not chosen for coaching had a nonsignificant change in performance during the period when selected providers were coached. We observed a statistically significant 2-point (small-to-medium) jump among coached providers after coaching on the CAHPS overall provider rating and provider communication score. However, these gains disappeared after 2.5 years; effects differed by coach. CONCLUSIONS: Shadow coaching improved providers' overall performance and communication immediately after being coached. Regularly planned shadow coaching "booster" sessions might maintain or even increase the improvement gained in patient experience scores, but research examining additional coaching and optimal implementation is needed.

Family structure and childhood obesity: an analysis through 8th grade.

Research on the effect of family structure on childhood obesity is scarce. This study examines the effect of number of parents and number of siblings on US children's body mass index (BMI) and risk of obesity. We conducted a secondary data analysis of the Early Childhood Longitudinal Study-Kindergarten Cohort (ECLS-K), which consists of a nationally representative cohort of children who entered kindergarten in 1998-1999, to examine the effect of family structure on children's body mass index and risk of obesity from kindergarten through 8th grade. Study outcomes were BMI in kindergarten and 8th grade, obesity status in kindergarten and 8th grade, and change in BMI from kindergarten through 8th grade. Multivariate regressions were used to assess the association between family structure and study outcomes while adjusting for other covariates. In 8th grade, children with no siblings had higher BMI (23.7 vs. 22.6; P ≤ 0.01) and higher probability of being obese (25.8 vs. 19.7 %; P ≤ 0.05) than their counterparts with two or more siblings. They also had a larger increase in BMI from kindergarten through 8th grade than children living with two or more siblings (7.3 vs. 6.3; P = 0.02). Our analysis suggests that the association between family structure and obesity persists and even intensifies through 8th grade. These findings have important implications for targeting obesity support and counseling for families.

Superficial Temporal Artery-to-Middle Cerebral Artery Bypass in Ischemic Stroke With Blood Pressure-Dependent Symptoms.

The efficacy of extracranial-intracranial (EC-IC) bypass in preventing ischemic stroke progression and recurrence is controversial. As per the current hypothesis, EC-IC bypass is most beneficial for patients with persistent hemodynamic insufficiency. Hence, various approaches have been used to evaluate hemodynamic insufficiency, including repeated single photon emission CT (SPECT) imaging or continuous monitoring of cerebral flow with transcranial Doppler ultrasound (TCD). However, both modalities are time- and resource-intensive. In this report, we discuss how EC-IC bypass turned out to be beneficial for a patient presenting with blood pressure-dependent severe aphasia and right hemiparesis due to middle cerebral artery (MCA) occlusion that failed thrombectomy. CT perfusion (CTP) scan at admission demonstrated a persistent volume of delayed perfusion without core infarct. Following the superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass, the patient's National Institute of Health Stroke Scale (NIHSS) score improved from 12 to 1. Ischemic penumbra, as seen on CTP imaging, also improved after the STA-MCA bypass. Our case suggests that persistent volume of delayed perfusion and blood pressure-dependent neurological deficits can be used in tandem as selection criteria for EC-IC bypass.

Differences in CAHPS reports and ratings of health care provided to adults and children.

BACKGROUND: Consumer assessment of health care is an important metric for evaluating quality of care. These assessments can help purchasers, health plans, and providers deliver care that fits patients' needs. OBJECTIVE: To examine differences in reports and ratings of care delivered to adults and children and whether they vary by site. RESEARCH DESIGN: This observational study compares adult and child experiences with care at a large west coast medical center and affiliated clinics and a large mid-western health plan using Consumer Assessment of Healthcare Providers and Systems Clinician & Group 1.0 Survey data. RESULTS: Office staff helpfulness and courtesy was perceived more positively for adult than pediatric care in the west coast site. In contrast, more positive perceptions of pediatric care were observed in both sites for coordination of care, shared decision making, overall rating of the doctor, and willingness to recommend the doctor to family and friends. In addition, pediatric care was perceived more positively in the mid-west site for access to care, provider communication, and office staff helpfulness and courtesy. The differences between pediatric care and adult care were larger in the mid-western site than the west coast site. CONCLUSIONS: There are significant differences in the perception of care for children and adults with care provided to children tending to be perceived more positively. Further research is needed to identify the reasons for these differences and provide more definitive information at sites throughout the United States.

Cerebral infarction following bee stings: Case report and literature review.

Background: To date, only 25 cases of cerebral infarction following a bee or wasp sting have been reported. Due to its rarity, undefined pathogenesis, and unique clinical features, we report a case of a 62-year-old man with progressive cerebral infarction following bee stings, possibly related to vasospasm. Furthermore, we review relevant literature on stroke following bee or wasp stings. Case presentation: A 62-year-old retired male presented with progressive ischemic stroke after bee stings to the ear and face. Initial magnetic resonance imaging of the brain showed small punctate infarcts in the left medulla oblongata. Head and neck computed tomography angiography showed significant stenosis in the basilar artery and occlusion in the left V4 vertebral artery. The patient received intravenous alteplase (0.9 mg/kg) without symptomatic improvement. Digital subtraction angiography later demonstrated additional near occlusion in the left posterior cerebral artery (PCA). Thrombectomy was considered initially but was aborted due to hemodynamic instability. Repeated CT brain after 24 h showed acute infarcts in the left parieto-occipital region and left thalamus. The near occluded PCA was found to be patent again on magnetic resonance angiography (MRA) 25 days later. This reversibility suggests that vasospasm may have been the underlying mechanism. Unfortunately, the patient had persistent significant neurological deficits after rehabilitation one year later. Conclusion: Cerebral infarction following bee stings is rare. There are several proposed pathophysiological mechanisms. While the natural course of this phenomenon is not well characterized, early diagnosis and treatment are essential. Furthermore, it is important to establish standardized care procedures for this unique entity.

Family structure and childhood obesity, Early Childhood Longitudinal Study - Kindergarten Cohort.

INTRODUCTION: Little is known about the effect of family structure on childhood obesity among US children. This study examines the effect of number of parents and number of siblings on children's body mass index and risk of obesity. METHODS: We conducted a secondary data analysis of the Early Childhood Longitudinal Study - Kindergarten Cohort (ECLS-K), which consists of a nationally representative cohort of children who entered kindergarten during 1998-1999. Our analyses included 2 cross-sectional outcomes and 1 longitudinal outcome: body mass index (BMI) calculated from measured height and weight, obesity defined as BMI in the 95th percentile or higher for age and sex, and change in BMI from kindergarten through fifth grade. RESULTS: Other things being equal, children living with single mothers were more likely to be obese by fifth grade than were children living with 2 parents (26% vs 22%, P = .05). Children with siblings had lower BMI and were less likely to be obese than children without siblings. We also found that living with a single mother or no siblings was associated with larger increases in BMI from kindergarten through fifth grade. CONCLUSION: Children from single-mother families and, especially, children with no siblings are at higher risk for obesity than children living with 2 parents and children with siblings. These findings highlight the influential role that families play in childhood obesity. Additionally, they suggest that health care providers should consider the structure of children's families in discussions with families regarding childhood obesity.

Impact of palivizumab on RSV hospitalizations for children with hemodynamically significant congenital heart disease.

The objective of this study was to evaluate the impact of palivizumab prophylaxis on respiratory syncytial virus (RSV) hospitalizations among children with hemodynamically significant congenital heart disease (CHD). In 2003, the American Academy of Pediatrics (AAP) revised the bronchiolitis policy statement and recommended the use of palivizumab in children <24 months old with hemodynamically significant CHD (HS-CHD). California statewide hospital discharge data from years 2000-2002 (pre-AAP policy revision) were compared to those from years 2004-2006 (post-AAP policy revision). Hospitalizations due to RSV bronchiolitis for children <2 years of age were identified by IDC-9 CM codes 4661.1, 480.1, and 079.6 as the Principal Diagnosis. Children with CHD and children with HS-CHD were identified by the codiagnoses. The overall RSV hospitalization rate was 71 per 10,000 children <2 years of age. Of all RSV hospitalizations, 3.0% were among children with CHD, and 0.50% among children with HS-CHD. HS-CHD patients accounted for 0.56% of RSV hospitalizations in 2000-2002, compared to 0.46% RSV hospitalizations in 2004-2006. That represents a 19% reduction in RSV hospitalizations among HS-CHD patients after 2003. The 19% decrease in RSV hospitalizations equates to seven fewer hospitalizations (76 hospital days) per year among HS-CHD patients. We conclude that, since the recommendation of palivizumab for children with HS-CHD in 2003, the impact on RSV hospitalizations in California among HS-CHD patients has been limited. Considering the high cost of palivizumab administration, the cost-benefit of RSV prophylaxis with palivizumab warrants further investigation.

Prior treatment of fracture patients in a tertiary pediatric emergency department: informal referrals from other emergency departments.

BACKGROUND: The purposes of this study were to determine the following: (1) the percentage of fracture patients at a tertiary pediatric emergency department (ED) who previously sought treatment for the injury elsewhere and (2) how often such patients were sent from another ED. METHODS: A prospective survey was conducted in the ED of a tertiary pediatric medical center in a large metropolitan area. Patients who presented with suspected extremity fractures and previously sought treatment elsewhere were asked where they had sought treatment and whether staff at another ED had told them to come to the tertiary ED. Demographic, clinical, insurance, and transfer information were also collected. RESULTS: Ninety-two patients who had sought previous care for the injury elsewhere participated in the survey, with 82 (89%) ultimately being diagnosed with fractures. This represents 33% (82/246) of the patients with extremity fractures treated by the participating ED physicians during the study. Seventy-nine percent (73/92) of the subjects had previously sought treatment at another ED. For those who did not also visit a regular physician, 69% (37/54) were told to come to the tertiary ED by staff at the initial ED. No differences were observed based on race or insurance status because the study subjects were predominantly minority (91%, including 80% Hispanic) and lacking private insurance (84%). CONCLUSIONS: Seeking follow-up care in a tertiary ED, often on the advice of staff from another ED, is a common practice for this largely minority and poorly insured population. Because patients did not present to our ED until an average of 3 days after injury and many had been discharged to a primary care physician, it is likely that many of the patients did not require emergency care. This practice inefficiently uses limited emergency care resources. LEVEL OF EVIDENCE: Level II prospective survey.

Sudden infant death syndrome: changing epidemiologic patterns in California 1989-2004.

OBJECTIVE: To evaluate the changes of sudden infant death syndrome (SIDS) epidemiology in California. STUDY DESIGN: We used 1989 to 2004 California statewide death registry data. SIDS cases were selected by "age of decedent" <1 year and "cause of death" listed as SIDS. RESULTS: We identified 6303 cases (61% males) of SIDS. SIDS incidence rate decreased by 77%, from 1.38 per 1000 births in 1989 to 0.31 per 1000 births in 2004. No further decrease in SIDS incidence was noted from 2002 to 2004. The incidence rate was highest among blacks (2.02 per 1000 births) and lowest in Asian/Pacific Islanders (0.46 per 1000 births). The overall median age at death was 82 days, with no significant change over time. However, the peak age at death shifted from 2 months of age in 1989 to 2001 to 3 months of age in 2002 to 2004. Seasonal variation in the incidence of SIDS was attenuated. The difference in incidence rates between weekdays and weekends increased over the study period. CONCLUSIONS: The incidence rate of SIDS declined in California from 1989 to 2001, with no further decline after 2002. Several epidemiologic changes were noted: The peak age of SIDS death shifted from 2 months to 3 months of age; seasonal variation diminished; and weekday to weekend difference became more pronounced.

Multiple sclerosis: Frequency, cost, and economic burden in the United States.

Multiple sclerosis (MS) is one of the most common neurological diseases, affecting young and middle-aged adults. The full economic cost of managing chronic MS is substantial. To investigate the recent trend of medical cost and economic burden of MS management in the United States (U.S.), we inquired for available data from the National Inpatient Sample database (NIS; from 1994 to 2013). The annual rates of changes were determined by linear regression analysis. We found an estimated half million increase in MS admissions, annually, which was projected to exceed 43.5 million by the end of year 2017. We also found the charge and the costs associated with MS care increased at rates of US$ 40 million a year and US$ 8 million a year, respectively. We revealed a 1.6 fold increase in the inflation of medical bill in the past decade, and the inflation of medical bills was inversely correlated to the cost-to-charge ratios. In sum, we outline the national trends of medical care use and the expenditure of caring for patients with MS. Periodic reviews and characterizations of expenditure trends are critical for formulating future policy.

Implementation of Practice Transformation: Patient Experience According to Practice Leaders.

OBJECTIVE: Examine practice leaders' perceptions and experiences of how patient-centered medical home (PCMH) transformation improves patient experience. SUBJECTS: Thirty-six interviews with lead physicians (n = 13), site clinic administrators (n = 13), and nurse supervisors (n = 10). METHODS: Semi-structured interviews at 14 primary care practices within a large urban Federally Qualified Health Center (FQHC) delivery system to identify critical patient experience domains and mechanisms of change. Identified patient experience domains were compared with Consumer Assessment of Healthcare Providers and Systems (CAHPS) items. RESULTS: We identified 28 patient experience domains improved by PCMH transformation, of which 22 are measured by CAHPS, and identified 24 mechanisms of change commonly reported by practice leaders during PCMH transformation. CONCLUSIONS: PCMH practice transformation can improve patient experience. Most patient experience domains reported as improved during PCMH efforts are measured by CAHPS items. Practices would benefit from collecting specific information on staff behaviors related to teamwork, team-based communication, scheduling, emergency and inpatient follow-up, and referrals. All 3 types of practice leaders reported 4 main mechanisms of PCMH change that improved patient experience. Our findings provide guidance for practice leaders on which strategies of PCMH practice transformation lead to specific improvements in patient experience measures. Further research is needed on the relationship between PCMH changes and changes in CAHPS patient experience scores.

Implementation and Sequencing of Practice Transformation in Urban Practices with Underserved Patients.

BACKGROUND: Patient-centered medical home (PCMH) has gained momentum as a model for primary-care health services reform. METHODS: We conducted interviews at 14 primary care practices undergoing PCMH transformation in a large urban federally qualified health center in California and used grounded theory to identify common themes and patterns. RESULTS: We found clinics pursued a common sequence of changes in PCMH transformation: Clinics began with National Committee for Quality Assurance (NCQA) level 3 recognition, adding care coordination staff, reorganizing data flow among teams, and integrating with a centralized quality improvement and accountability infrastructure. Next, they realigned to support continuity of care. Then, clinics improved access by adding urgent care, patient portals, or extending hours. Most then improved planning and management of patient visits. Only a handful worked explicitly on improving access with same day slots, scheduling processes, and test result communication. The clinics' changes align with specific NCQA PCMH standards but also include adding physicians and services, culture changes, and improved communication with patients. CONCLUSIONS: NCQA PCMH level 3 recognition is only the beginning of a continuous improvement process to become patient centered. Full PCMH transformation took time and effort and relied on a sequential approach, with an early focus on foundational changes that included use of a robust quality improvement strategy before changes to delivery of and access to care.

Patient Experiences with Care Differ with Chronic Care Management in a Federally Qualified Community Health Center.

This study compares patient experience among practices that vary in adoption of the chronic care management (CCM) dimension of the patient-centered medical home (PCMH) model that focuses on care coordination and management of chronic diseases. Study participants were 2903 adult patients (ages 18 years or older) at 14 primary care centers in California. Seven of the sites were classified as high (more CCM) and the other 7 low on a CCM index. Hypotheses were tested using ordinary least squares regression models. After adjusting for the number of providers at the sites, high CCM scores were associated with significantly better overall ratings of providers, provider communication, follow-up on test results, and willingness to recommend the provider (differences of 5.82, 6.85, 9.81, and 4.56, respectively on the 0-100 scale scores). The results of this study provide support for the value of the PCMH for patient experiences with care.

Development and Testing of the Pediatric Respiratory Illness Measurement System (PRIMES) Quality Indicators.

OBJECTIVES: To develop and test quality indicators for assessing care in pediatric hospital settings for common respiratory illnesses. PATIENTS: A sample of 2796 children discharged from the emergency department or inpatient setting at 1 of the 3 participating hospitals with a primary diagnosis of asthma, bronchiolitis, croup, or community-acquired pneumonia (CAP) between January 1, 2010, and December 31, 2011. SETTING: Three tertiary care children's hospitals in the United States. METHODS: We developed evidence-based quality indicators for asthma, bronchiolitis, croup, and CAP. Expert panel-endorsed indicators were included in the Pediatric Respiratory Illness Measurement System (PRIMES). This new set of pediatric quality measures was tested to assess feasibility of implementation and sensitivity to variations in care. Medical records data were extracted by trained abstractors. Quality measure scores (0-100 scale) were calculated by dividing the number of times indicated care was received by the number of eligible cases. Score differences within and between hospitals were determined by using the Student's t-test or analysis of variance. RESULTS: CAP and croup condition-level PRIMES scores demonstrated significant between-hospital variations (P < .001). Asthma and bronchiolitis condition-level PRIMES scores demonstrated significant within-hospital variation with emergency department scores (means [SD] 82.2(6.1)-100.0 (14.4)] exceeding inpatient scores (means [SD] 71.1 (2.0)-90.8 (1.3); P < .001). CONCLUSIONS: PRIMES is a new set of measures available for assessing the quality of hospital-based care for common pediatric respiratory illnesses.

Effects of family structure on children's use of ambulatory visits and prescription medications.

OBJECTIVE: To examine the effects of family structure, including number of parents, number of other children, and number and type of other adults, on office visits, emergency room visits, and use of prescription medications by children. DATA SOURCE: The Household Component of the 1996-2001 Medical Expenditure Panel Survey (MEPS). STUDY DESIGN: The study consisted of a nationally representative sample of children 0-17 years of age living in single-mother or two-parent families. We used negative binomial regression to model office visits and emergency room visits and logistic regression to model the likelihood of prescription medication use. Our analyses adjusted for demographic and socioeconomic characteristics as well as measures of children's health and parental education and child-rearing experience. DATA COLLECTION/EXTRACTION METHOD: We combined 1996-2001 MEPS Full Year Consolidated Files and Medical Conditions Files. PRINCIPAL FINDINGS: Descriptive data showed that children in single-mother families had fewer office visits than children in two-parent families; however, the effect of number of parents in the family on children's office visits or use of prescription medications was completely explained by other explanatory variables. By contrast, children living in families with many other children had fewer total and physician office visits and a lower likelihood of using a prescription medication than children living in families with no other children even after adjusting for other explanatory variables. Children who lived with other adults in addition to their parents also had fewer office visits and a lower likelihood of using a prescription medication than children who lived only with their parents. CONCLUSIONS: Children living in families with many other children or with other adults use less ambulatory care and prescription medications than their peers. Additional research is needed to determine whether these differences in utilization affect children's health.