Structural barriers to health care as risk factors for preterm and small-for-gestational-age birth among US-born Black and White mothers.

We develop county-level measures of structural and institutional barriers to care, and test associations between these barriers and birth outcomes for US-born Black and White mothers using national birth records for 2014-2017. Results indicate elevated odds of greater preterm birth severity for Black mothers in counties with higher uninsurance rates among Black adults, fewer Black physicians per Black residents, and fewer publicly-funded contraceptive services. Most structural barriers were not associated with small-for-gestational-age birth, and barriers defined for Black residents were not associated with birth outcomes for White mothers, with the exception of Black uninsurance rate. Structural determinants of care may influence preterm birth risk for Black Americans.

Polysubstance Use in Pregnancy: Surveillance, Interventions, and Next Steps.

Substance use during pregnancy increases risk for a wide range of adverse maternal and neonatal health outcomes. Polysubstance use is common among people who use substances during pregnancy; however, the risks of combined substance exposures during pregnancy are poorly understood. In this report, we provide an overview of the activities of the Centers for Disease Control and Prevention (CDC) and partners and identified gaps related to (1) surveillance, (2) routine screening, and (3) prevention of polysubstance use during pregnancy. Efforts by CDC and other partners to reduce polysubstance use during pregnancy can improve the health of pregnant people and their infants and children.

Evaluation in Life Cycle of Information Technology (ELICIT) framework: Supporting the innovation life cycle from business case assessment to summative evaluation.

OBJECTIVE: Our objective was to develop an evaluation framework for electronic health record (EHR)-integrated innovations to support evaluation activities at each of four information technology (IT) life cycle phases: planning, development, implementation, and operation. METHODS: The evaluation framework was developed based on a review of existing evaluation frameworks from health informatics and other domains (human factors engineering, software engineering, and social sciences); expert consensus; and real-world testing in multiple EHR-integrated innovation studies. RESULTS: The resulting Evaluation in Life Cycle of IT (ELICIT) framework covers four IT life cycle phases and three measure levels (society, user, and IT). The ELICIT framework recommends 12 evaluation steps: (1) business case assessment; (2) stakeholder requirements gathering; (3) technical requirements gathering; (4) technical acceptability assessment; (5) user acceptability assessment; (6) social acceptability assessment; (7) social implementation assessment; (8) initial user satisfaction assessment; (9) technical implementation assessment; (10) technical portability assessment; (11) long-term user satisfaction assessment; and (12) social outcomes assessment. DISCUSSION: Effective evaluation requires a shared understanding and collaboration across disciplines throughout the entire IT life cycle. In contrast with previous evaluation frameworks, the ELICIT framework focuses on all phases of the IT life cycle across the society, user, and IT levels. Institutions seeking to establish evaluation programs for EHR-integrated innovations could use our framework to create such shared understanding and justify the need to invest in evaluation. CONCLUSION: As health care undergoes a digital transformation, it will be critical for EHR-integrated innovations to be systematically evaluated. The ELICIT framework can facilitate these evaluations.

Hospital Outcomes of Infants with Neonatal Opioid Withdrawal Syndrome at a Tertiary Care Hospital with High Rates of Concurrent Nonopioid (Polysubstance) Exposure.

OBJECTIVE: Neonatal opioid withdrawal syndrome (NOWS) describes infants' withdrawal signs and symptoms after birth due to an interruption of prenatal opioid exposure. Many infants with NOWS are also exposed to nonopioids, however. This study was to determine hospital outcomes of infants exposed to opioids alone or coexposed with nonopioid substances (polysubstance). STUDY DESIGN: We reviewed infants of ≥34 weeks of gestation with prenatal opioid exposure from April 2015 to May 2018. We compared the median lengths of stay (LOS) and treatment (LOT) and the percentages of infants requiring pharmacologic and adjunctive treatment in infants exposed to opioids alone or polysubstance. We used Wilcoxon's test for continuous outcomes or Chi-squared test for categorical outcomes to determine statistical significance. We used multivariable regression model to calculate each drug category's estimates of adjusted mean ratios for LOS and LOT plus estimates of adjusted odds ratios for pharmacologic/adjunctive treatments. RESULTS: Of the 175 infants, 33 (19%) infants had opioid exposure alone. Opioid exposure included short- and/or long-acting opioids. A total of 142 (81%) had polysubstance exposure with 47% of mothers using nicotine products. We saw similar hospital outcomes between infants exposed to opioids alone or polysubstance; however, a higher percentage of infants with both short- and long-acting opioid exposure required pharmacologic treatment compared with either opioid alone. Focusing on individual drug categories, we detected differential hospital outcomes in which short-acting opioids decreased LOT, whereas long-acting opioids increased LOS, LOT, and need for pharmacologic and adjunctive treatment. Coexposure of opioids with stimulants decreased LOT and reduced need for adjunctive treatment. Coexposures with antidepressants increased LOT, while with antiepilepetics increased LOS. CONCLUSION: Because infants with NOWS often have coexposures to other nonopioid substances, appreciating the associated risks of individual or combination of drugs in modulating hospital outcomes may help counsel families on their infants' expected hospital course. KEY POINTS: · Hospital outcomes were similar between infants exposed to opioids alone or polysubstance including opioids.. · Infants with short- and long-acting opioids required pharmacologic treatment more often than either opioid alone.. · Differential hospital outcomes exist for various co-exposures of opioids with nonopioids..

Respiratory Viral Infections and Infection Prevention Practices Among Women With Acute Respiratory Illness During Delivery Hospitalizations During the 2019-2020 Influenza Season.

BACKGROUND: We conducted a cross-sectional study of pregnant women with acute respiratory illness during delivery hospitalizations during influenza season to describe clinical testing for respiratory viruses and infection prevention practices. METHODS: Women had nasal swabs tested for influenza and other respiratory viruses. Among 91 enrolled women, 22 (24%) had clinical testing for influenza. RESULTS: Based on clinical and study testing combined, 41 of 91 (45%) women had samples positive for respiratory viruses. The most common virus was influenza (17 of 91, 19%); 53% (9 of 17) of influenza virus infections were identified through study testing alone. Only 16% of women were on droplet precautions. CONCLUSIONS: Peripartum respiratory infections may be underrecognized.

Establishing a multidisciplinary initiative for interoperable electronic health record innovations at an academic medical center.

OBJECTIVE: To establish an enterprise initiative for improving health and health care through interoperable electronic health record (EHR) innovations. MATERIALS AND METHODS: We developed a unifying mission and vision, established multidisciplinary governance, and formulated a strategic plan. Key elements of our strategy include establishing a world-class team; creating shared infrastructure to support individual innovations; developing and implementing innovations with high anticipated impact and a clear path to adoption; incorporating best practices such as the use of Fast Healthcare Interoperability Resources (FHIR) and related interoperability standards; and maximizing synergies across research and operations and with partner organizations. RESULTS: University of Utah Health launched the ReImagine EHR initiative in 2016. Supportive infrastructure developed by the initiative include various FHIR-related tooling and a systematic evaluation framework. More than 10 EHR-integrated digital innovations have been implemented to support preventive care, shared decision-making, chronic disease management, and acute clinical care. Initial evaluations of these innovations have demonstrated positive impact on user satisfaction, provider efficiency, and compliance with evidence-based guidelines. Return on investment has included improvements in care; over $35 million in external grant funding; commercial opportunities; and increased ability to adapt to a changing healthcare landscape. DISCUSSION: Key lessons learned include the value of investing in digital innovation initiatives leveraging FHIR; the importance of supportive infrastructure for accelerating innovation; and the critical role of user-centered design, implementation science, and evaluation. CONCLUSION: EHR-integrated digital innovation initiatives can be key assets for enhancing the EHR user experience, improving patient care, and reducing provider burnout.

Improvement Initiative: End-Tidal Carbon Monoxide Measurement in Newborns Receiving Phototherapy.

OBJECTIVES: To determine, as part of our Utah Newborn Nursery Bilirubin Management Program, whether end-tidal carbon monoxide concentration (ETCOc) measurements in all newborns in our nursery receiving phototherapy were associated with outcomes related to the management of hyperbilirubinemia, including time (hours after birth) when phototherapy was initiated, total duration of phototherapy during the nursery stay, repeat phototherapy treatments, and hospital readmission for phototherapy. STUDY DESIGN: We performed a planned interim analysis of a component of our program in which we measured ETCOc noninvasively using CoSense on each newborn in our nursery receiving phototherapy and recorded specific outcomes related to phototherapy management. RESULTS: Of 1856 newborns admitted to our nursery in a 6-month period in 2020, 170 (9.8%) were treated with phototherapy. An ETCOc reading was successfully obtained in 145 of 151 attempts (96%). Higher ETCOc values were associated with earlier institution of phototherapy and longer duration of phototherapy. For every 1-ppm increase in ETCOc, phototherapy was started 9 hours earlier (95% CI, 3.3-14.8; P = .002) and was administered for an additional 9.3 hours (95% CI, 4.1-14.6; P < .001). Three newborns were readmitted to the hospital for intensive phototherapy; while in the nursery, all 3 had an elevated ETCOc (2.2, 2.6, and 2.9 ppm). CONCLUSIONS: Our findings provide answers to questions raised in the 2004 American Academy of Pediatrics bilirubin guidelines. In our neonatal nursery, measuring ETCOc in all phototherapy recipients was feasible and safe, and the results were associated with multiple aspects of phototherapy management. Higher ETCOc values predicted earlier and longer phototherapy courses.

Respiratory Syncytial Virus Vaccination during Pregnancy and Effects in Infants.

BACKGROUND: Respiratory syncytial virus (RSV) is the dominant cause of severe lower respiratory tract infection in infants, with the most severe cases concentrated among younger infants. METHODS: Healthy pregnant women, at 28 weeks 0 days through 36 weeks 0 days of gestation, with an expected delivery date near the start of the RSV season, were randomly assigned in an overall ratio of approximately 2:1 to receive a single intramuscular dose of RSV fusion (F) protein nanoparticle vaccine or placebo. Infants were followed for 180 days to assess outcomes related to lower respiratory tract infection and for 364 days to assess safety. The primary end point was RSV-associated, medically significant lower respiratory tract infection up to 90 days of life, and the primary analysis of vaccine efficacy against the primary end point was performed in the per-protocol population of infants (prespecified criterion for success, lower bound of the 97.52% confidence interval [CI] of ≥30%). RESULTS: A total of 4636 women underwent randomization, and there were 4579 live births. During the first 90 days of life, the percentage of infants with RSV-associated, medically significant lower respiratory tract infection was 1.5% in the vaccine group and 2.4% in the placebo group (vaccine efficacy, 39.4%; 97.52% CI, -1.0 to 63.7; 95% CI, 5.3 to 61.2). The corresponding percentages for RSV-associated lower respiratory tract infection with severe hypoxemia were 0.5% and 1.0% (vaccine efficacy, 48.3%; 95% CI, -8.2 to 75.3), and the percentages for hospitalization for RSV-associated lower respiratory tract infection were 2.1% and 3.7% (vaccine efficacy, 44.4%; 95% CI, 19.6 to 61.5). Local injection-site reactions among the women were more common with vaccine than with placebo (40.7% vs. 9.9%), but the percentages of participants who had other adverse events were similar in the two groups. CONCLUSIONS: RSV F protein nanoparticle vaccination in pregnant women did not meet the prespecified success criterion for efficacy against RSV-associated, medically significant lower respiratory tract infection in infants up to 90 days of life. The suggestion of a possible benefit with respect to other end-point events involving RSV-associated respiratory disease in infants warrants further study. (Funded by Novavax and the Bill and Melinda Gates Foundation; ClinicalTrials.gov NCT02624947.).

Prenatal maternal hair cortisol concentrations are related to maternal prenatal emotion dysregulation but not neurodevelopmental or birth outcomes.

Hair cortisol concentrations measured during pregnancy have emerged as a novel biomarker for prenatal stress exposure. However, associations between prenatal stress and distress, broadly defined, and hair cortisol concentrations during pregnancy are inconsistent. We examined relations among hair cortisol concentrations during the third trimester with (a) emotion dysregulation and (b) detailed measures of maternal prenatal stress. We also examined the predictive validity of maternal hair cortisol during pregnancy for adverse newborn health outcomes. Cortisol concentrations were derived from 6 cm of hair during the third trimester of pregnancy. Mothers reported on their emotion dysregulation and stress at this time. A standardized newborn neurobehavioral exam was conducted shortly after birth and newborn birth weight and gestational age were assessed from medical records. All hypotheses were preregistered on the Open Science Framework (osf.io/279ng). High levels of emotion dysregulation, but not stress, were predictive of high hair cortisol concentrations. Maternal prenatal BMI mediated the relation between maternal prenatal emotion dysregulation and hair cortisol concentrations. There was no association between hair cortisol and infant birth outcomes. This research supports the notion that transdiagnostic markers of psychopathology are important correlates of hair cortisol concentrations during pregnancy.

Improving the Bilirubin Management Program in the Newborn Nursery: Background, Aims, and Protocol.

BACKGROUND: Practices to detect and manage hyperbilirubinemia in newborn nurseries are highly variable. American Academy of Pediatrics guidelines in 1999, 2004, and 2009 have generated, perhaps unintentionally, divergent practices that might not all be of equivalent value. Evidence-based progress is needed to define less invasive, less expensive, uniform, and safe methods to reduce ER visits and hospital readmissions for jaundice treatment and bilirubin encephalopathy. OBJECTIVES: This research briefing is intended to inform readers of a new prospective quality improvement program aimed at testing the value of specific changes in newborn nursery hyperbilirubinemia detection and management. This new program includes predetermined means of assessing those specific changes, which relate to diagnosis, safety, outcomes, and cost. METHODS: In this briefing, we present the perceived problems in our present bilirubin management system, as voiced by stakeholders. We report our proposed means to test minimization of those problems utilizing already acquired data on approximately 400,000 well babies in the Intermountain Healthcare system of hospitals in the western USA. We then describe our methods of assessing specific outcomes in a pre- versus postpractice change analysis. RESULTS AND CONCLUSIONS: The University of Utah Newborn Nursery will implement a quality improvement project in bilirubin management during 2020 to test the feasibility and effectiveness of several changes to our current bilirubin management program. We maintain that the improved understanding generated by this project will be a step toward new evidence-based strategies for reducing ER visits and hospital readmissions for jaundice treatment and preventing bilirubin encephalopathy.

Association of an Electronic Health Record Add-on App for Neonatal Bilirubin Management With Physician Efficiency and Care Quality.

Importance: The usefulness of electronic health record (EHR) systems could be significantly enhanced by innovative, third-party EHR add-on apps. Objective: To evaluate whether an EHR add-on app for neonatal bilirubin management can save clinicians time and improve patient care. Design, Setting, and Participants: This quality improvement study was conducted at the University of Utah Health Well Baby nursery and outpatient clinics and consisted of 4 substudies: (1) time savings were estimated in an experimental task-timing study comparing the time required for physicians to manage newborns' bilirubin levels with and without the add-on app, (2) app use was estimated from app logs, (3) health care use measures and guideline compliance were compared retrospectively before and after the intervention, and (4) clinician-perceived usability was measured through System Usability Scale surveys. The study took place between April 1, 2016, and September 3, 2019. Data analyses were conducted from October 30, 2018, to September 23, 2019. Interventions: At baseline, clinicians used a manual approach to ensure compliance with an evidence-based clinical guideline for neonatal bilirubin management. To facilitate guideline compliance, an EHR add-on app that automatically retrieves, organizes, and visualizes relevant patient data was developed. The app provides patient-specific assessments and recommendations, including the risk of rebound hyperbilirubinemia following phototherapy based on a predictive model. The add-on app was integrated with the University of Utah Health EHR on April 12, 2017. Main Outcomes and Measures: Clinician time savings, app use, health care use measures, guideline-compliant phototherapy ordering, and perceived usability as measured by the System Usability Scale survey. The survey is composed of 10 statements with responses ranging from 1 (strongly disagree) to 5 (strongly agree). The survey results in a single score ranging from 0 to 100, with ratings described as worst imaginable (mean System Usability Scale score, 12.5), awful (20.3), poor (35.7), okay (50.9), good (71.4), excellent (85.5), and best imaginable (90.9). Results: In 2018, the application was used 20 516 times by clinicians for 91.84% of eligible newborns. Use of the app saved 66 seconds for bilirubin management tasks compared with a commonly used tool (95% CI, 53-79 seconds; P < .001). Following the intervention, health care use rates remained stable, while orders for clinically appropriate phototherapy during hospitalization increased for newborns with bilirubin levels above the guideline-recommended threshold (odds ratio, 1.84; 95% CI, 1.16-2.90; P = .009). Surveys indicated excellent usability (System Usability Scale score, 83.90; 95% CI, 81.49-86.31). Conclusions and Relevance: Well-designed EHR add-on apps may save clinicians time and improve patient care. If time-saving apps, such as the bilirubin app, were implemented widely across institutions and care domains, the potential association with improved patient care and clinician efficiency could be significant. The University of Utah Health bilirubin app is being prepared for release into EHR app stores as free-to-use software.

Early-Onset Sepsis Risk Calculator Integration Into an Electronic Health Record in the Nursery.

BACKGROUND AND OBJECTIVES: An early-onset sepsis (EOS) risk calculator tool to guide evaluation and treatment of infants at risk for sepsis has reduced antibiotic use without increased adverse outcomes. We performed an electronic health record (EHR)-driven quality improvement intervention to increase calculator use for infants admitted to a newborn nursery and reduce antibiotic treatment of infants at low risk for sepsis. METHODS: This 2-phase intervention included programming (1) an EHR form containing calculator fields that were external to the infant's admission note, with nonautomatic access to the calculator, education for end-users, and reviewing risk scores in structured bedside rounds and (2) discrete data entry elements into the EHR admission form with a hyperlink to the calculator Web site. We used statistical process control to assess weekly entry of risk scores and antibiotic orders and interrupted time series to assess trend of antibiotic orders. RESULTS: During phase 1 (duration, 14 months), a mean 59% of infants had EOS calculator scores entered. There was wide variability around the mean, with frequent crossing of weekly means beyond the 3σ control lines, indicating special-cause variation. During phase 2 (duration, 2 years), mean frequency of EOS calculator use increased to 85% of infants, and variability around the mean was within the 3σ control lines. The frequency of antibiotic orders decreased from preintervention (7%) to the final 6 months of phase 2 (1%, P < .001). CONCLUSIONS: An EHR-driven quality improvement intervention increased EOS calculator use and reduced antibiotic orders, with no increase in adverse events.

Intergenerational transmission of emotion dysregulation: Part II. Developmental origins of newborn neurobehavior.

We investigated whether neurobehavioral markers of risk for emotion dysregulation were evident among newborns, as well as whether the identified markers were associated with prenatal exposure to maternal emotion dysregulation. Pregnant women (N = 162) reported on their emotion dysregulation prior to a laboratory assessment. The women were then invited to the laboratory to assess baseline respiratory sinus arrhythmia (RSA) and RSA in response to an infant cry. Newborns were assessed after birth via the NICU Network Neurobehavioral Scale. We identified two newborn neurobehavioral factors-arousal and attention-via exploratory factor analysis. Low arousal was characterized by less irritability, excitability, and motor agitation, while low attention was related to a lower threshold for auditory and visual stimulation, less sustained attention, and poorer visual tracking abilities. Pregnant women who reported higher levels of emotion dysregulation had newborns with low arousal levels and less attention. Larger decreases in maternal RSA in response to cry were also related to lower newborn arousal. We provide the first evidence that a woman's emotion dysregulation while pregnant is associated with risks for dysregulation in her newborn. Implications for intergenerational transmission of emotion dysregulation are discussed.

Influenza in Infants Born to Women Vaccinated During Pregnancy.

BACKGROUND: Infants <6 months old with influenza are at risk for adverse outcomes. Our objective was to compare influenza outcomes in infants <6 months old born to women who did and did not report influenza vaccine during pregnancy. METHODS: The study included all women who delivered from 12/2005 to 3/2014 at Intermountain facilities and their infants. Influenza outcomes included infant influenza-like illness (ILI), laboratory-confirmed influenza, and influenza hospitalizations. RESULTS: The cohort included 245 386 women and 249 387 infants. Overall, 23 383 (10%) pregnant women reported influenza immunization. This number increased from 2.2% before the H1N1 pandemic to 21% postpandemic (P < .001). A total of 866 infants <6 months old had ≥1 ILI encounter: 32 (1.34/1000) infants born to women reporting immunization and 834 (3.70/1000) born to women who did not report immunization (relative risk [RR] 0.36; 95% confidence interval [CI], 0.26-0.52; P < .001). A total of 658 infants had laboratory-confirmed influenza: 20 (0.84/1000) born to women reporting immunization and 638 (2.83/1000) born to unimmunized women (RR 0.30; 95% CI, 0.19-0.46; P < .001). A total of 151 infants with laboratory-confirmed influenza were hospitalized: 3 (0.13/1000) born to women reporting immunization and 148 (0.66/1000) born to unimmunized women (RR 0.19; 95% CI, 0.06-0.60; P = .005). CONCLUSIONS: Self-reported influenza immunization during pregnancy was low but increased after the H1N1 pandemic. Infants born to women reporting influenza immunization during pregnancy had risk reductions of 64% for ILI, 70% for laboratory-confirmed influenza, and 81% for influenza hospitalizations in their first 6 months. Maternal influenza immunization during pregnancy is a public health priority.

Tetanus, diphtheria, acellular pertussis vaccine during pregnancy: pregnancy and infant health outcomes.

OBJECTIVE: To assess pregnancy and birth outcomes in infants born to women who did or did not receive tetanus, diphtheria, acellular pertussis (Tdap) vaccine during pregnancy. STUDY DESIGN: Retrospective cohort. Pregnant women 12-45 years of age who received Tdap at Intermountain Healthcare facilities and their infants were identified and compared with mother-infant pairs without documented Tdap from May 2005 through August 2009. Primary measures included pregnancy outcomes and infant health outcomes at birth through 12 months. RESULTS: From 162,448 pregnancies we identified 138 women (0.08%) with documented Tdap administration during pregnancy (cases); 552 pregnant women without documented Tdap were randomly selected as controls. Of 138 immunized women, 63% received Tdap in the first trimester and 37% after. Tdap was given most commonly as wound prophylaxis. The incidence of spontaneous or elective abortion was no greater in Tdap cases than in controls. There were no significant differences in preterm delivery, gestational age, or birth weight between groups. One or more congenital anomaly was identified in 3.7% (95% CI 1.2%-8.5%) of case infants and 4.4% (95% CI 2.7%-6.5%) of control infants (P = .749). In infants born to women receiving Tdap during pregnancy, 3.6% (0.8%-10.2%) had International Classification of Diseases, Ninth Revision, Clinical Modification diagnoses consistent with complex chronic conditions within 12 months compared with 10.4% (95% CI 7.2%-14.4%) of infants of controls (P = .054). CONCLUSIONS: Documented Tdap administration during pregnancy was uncommon and occurred most often in the first trimester as prophylaxis following trauma. No increase in adverse outcomes was identified in infants born to women receiving Tdap compared with infants of controls.

Public health communication with frontline clinicians during the first wave of the 2009 influenza pandemic.

CONTEXT: During public health emergencies, office-based frontline clinicians are critical partners in the detection, treatment, and control of disease. Communication between public health authorities and frontline clinicians is critical, yet public health agencies, medical societies, and healthcare delivery organizations have all called for improvements. OBJECTIVES: Describe communication processes between public health and frontline clinicians during the first wave of the 2009 novel influenza A(H1N1) pandemic; assess clinicians' use of and knowledge about public health guidance; and assess clinicians' perceptions and preferences about communication during a public health emergency. DESIGN AND METHODS: During the first wave of the pandemic, we performed a process analysis and surveyed 509 office-based primary care providers in Utah. SETTING AND PARTICIPANTS: Public health and healthcare leaders from major agencies involved in emergency response in Utah and office-based primary care providers located throughout Utah. MAIN OUTCOME MEASURE(S): Communication process and information flow, distribution of e-mails, proportion of clinicians who accessed key Web sites at least weekly, clinicians' knowledge about recent guidance and perception about e-mail load, primary information sources, and qualitative findings from clinician feedback. RESULTS: The process analysis revealed redundant activities and messaging. The 141 survey respondents (28%) received information from a variety of sources: 68% received information from state public health; almost 100% received information from health care organizations. Only one-third visited a state public health or institutional Web site frequently enough (at least weekly) to obtain updated guidance. Clinicians were knowledgeable about guidance that did not change during the first wave; however, correct knowledge was lower after guidance changed. Clinicians felt overwhelmed by e-mail volume, preferred a single institutional e-mail for clinical guidance, and suggested that new information be concise and clearly identified. CONCLUSION: : Communication between public health, health care organizations and clinicians was redundant and overwhelming and can be enhanced considering clinician preferences and institutional communication channels.

Urgent care providers' knowledge and attitude about public health reporting and pertussis control measures: implications for informatics.

OBJECTIVES: We assessed urgent care providers' knowledge about public health reporting, guidelines, and actions for the prevention and control of pertussis; attitudes about public health reporting and population-based data; and perception of reporting practices in their clinic. METHODS: We identified the 106 providers (95% are physicians) employed in 28 urgent care clinics owned by Intermountain Healthcare located throughout Utah and Southern Idaho. We performed a descriptive, cross-sectional survey and assessed providers' knowledge, attitudes, beliefs, and behaviors associated with population-based data and public health mandates and recommendations. The online survey was completed between November 1, 2007, and February 29, 2008. RESULTS: Among 63 practicing urgent care providers (60% response rate), 19 percent knew that clinically diagnosed pertussis was reportable, and only half (52%) the providers correctly responded about current pertussis vaccination recommendations. Most (35%-78%) providers did not know the prevention and control measures performed by public health practitioners after reporting occurs, including contact tracing, testing, treatment, and prophylaxis. Half (48%) the providers did not know that health department personnel can prescribe antibiotics for contacts of a reported case, and only 22 percent knew that health department personnel may perform diagnostic testing on contacts. Attitudes about reporting are variable, and reporting responsibility is diffused. CONCLUSION: To improve our ability to meet public health goals, systems need to be designed that engage urgent care providers in the public health process, improve their knowledge and attitude about reporting, and facilitate the flow of information between urgent care and public health settings.

Should the pertussis case definition for public health reporting be refined?

BACKGROUND: The surveillance case definition for confirmed pertussis requires that an individual with a positive polymerase chain reaction (PCR) result for Bordetella pertussis have 2 weeks or more of cough and at least one of the following: paroxysmal coughing, inspiratory "whoop," or posttussive vomiting. OBJECTIVES: Determine (1) proportion of individuals with a positive PCR result who met additional criteria for surveillance confirmed pertussis, (2) whether the likelihood of PCR-positive individuals meeting additional elements of surveillance case definition varied by age or vaccination status, and (3) whether elements of the current case definition influence the likelihood of pertussis confirmation in PCR-positive individuals. METHODS: Pertussis PCR results were compared with case investigation data. RESULTS: Eighty-eight percent (165/188) of PCR-positive individuals met requirements for confirmed pertussis. Sixty-one percent (14/23) of PCR-positive individuals who had less than 2 weeks but more than 1 week of cough had at least one other reported sign or symptom. Fourteen (100%) reported paroxysmal coughing, 7 (50%) "whoop," and 7 (50%) posttussive vomiting. Infants who met case definition were more likely to have reported apnea than were older individuals (15/17 vs 45/86, OR = 6.8, 95% CI = 1.4-64.2). CONCLUSIONS: Decreasing cough duration from 2 weeks or more to more than 1 week would result in 95 percent of those with positive PCR results meeting confirmation criteria for pertussis. Apnea should be considered an additional sign for pertussis confirmation in infants.