Developing a Sustainable Care Delivery Payment Model for Children With Medical Complexity.

Children with medical complexity (CMC) are a small but growing population representing <1% of all children while accounting for >30% of childhood health care expenditure. Complex care is a relatively new discipline that has emerged with goals of improving CMC care, optimizing CMC family function, and reducing health care costs. The provision of care coordination services is a major function of most complex care programs. Unfortunately, most complex care programs struggle to achieve financial sustainability in a predominately fee-for-service environment. The article describes how 2 programs in Wisconsin worked with their state Medicaid payer through a Centers for Medicare and Medicaid Services Health Care Innovation Award to develop a sustainable complex care payment model, and the value the payment model is currently bringing to stakeholders. Key elements of the process included: Developing a relationship between payer and clinicians that allowed for an understanding of each's viewpoint, use of an accepted clinical service model, and an effort to measure cost of care for the service provided supported by time-study methodology.

Prospective phenotyping of long-term survivors of generalized arterial calcification of infancy (GACI).

PURPOSE: Generalized arterial calcification of infancy (GACI), characterized by vascular calcifications that are often fatal shortly after birth, is usually caused by deficiency of ENPP1. A small fraction of GACI cases result from deficiency of ABCC6, a membrane transporter. The natural history of GACI survivors has not been established in a prospective fashion. METHODS: We performed deep phenotyping of 20 GACI survivors. RESULTS: Sixteen of 20 subjects presented with arterial calcifications, but only 5 had residual involvement at the time of evaluation. Individuals with ENPP1 deficiency either had hypophosphatemic rickets or were predicted to develop it by 14 years of age; 14/16 had elevated intact FGF23 levels (iFGF23). Blood phosphate levels correlated inversely with iFGF23. For ENPP1-deficient individuals, the lifetime risk of cervical spine fusion was 25%, that of hearing loss was 75%, and the main morbidity in adults was related to enthesis calcification. Four ENPP1-deficient individuals manifested classic skin or retinal findings of PXE. We estimated the minimal incidence of ENPP1 deficiency at ~1 in 200,000 pregnancies. CONCLUSION: GACI appears to be more common than previously thought, with an expanding spectrum of overlapping phenotypes. The relationships among decreased ENPP1, increased iFGF23, and rickets could inform future therapies.

Neonatal Abstinence Syndrome and Maternal Substance Use in Wisconsin, 2009-2014.

INTRODUCTION: Increasing rates of neonatal abstinence syndrome (NAS), most commonly linked to maternal opioid use, are a growing concern within clinical and public health domains. OBJECTIVES: The study aims to describe the statewide burden of NAS and maternal substance use, focusing on opioids in Wisconsin from 2009 to 2014. METHODS: Trends in NAS and maternal substance use diagnosis rates were calculated using Wisconsin's Hospital Discharge Data. Demographic and payer characteristics, health service utilization, and clinical outcomes were compared for newborns with and without NAS. Demographic and payer characteristics were compared between women with and without substance use identified at time of delivery. RESULTS: Rates of NAS and maternal substance use, most notably opioid use, increased significantly between 2009 and 2014. The majority of newborns diagnosed with NAS, and women identified with substance use, were non-Hispanic, white, and Medicaid-insured. Disproportionate rates of NAS and maternal opioid use were observed in American Indian/Alaska Native and Medicaid populations compared to white and privately insured groups, respectively. Women age 20-29 years had the highest rates of opioid use compared to the reference group (10-19 years). Odds of adverse clinical outcomes and levels of health service utilization were significantly higher for newborns with NAS. CONCLUSIONS: Similar to trends nationally, our findings show an increase in maternal opioid use and NAS rates in Wisconsin over time, with disproportionate effects in certain demographic groups. These findings support the need for targeted interventions in clinical and public health settings aimed at prevention and burden reduction of NAS and maternal substance use in Wisconsin.

Medical Student Views of the Affordable Care Act.

INTRODUCTION: With new insurance coverage under the Affordable Care Act (ACA) beginning in 2014 and the ever-changing practice of medicine, it is important to understand medical students' recent perspectives on health policy and reform. OBJECTIVE: This study describes the opinions, perceptions, and comprehension of the ACA and health care reform by a cross-section of medical students in Wisconsin. METHODS: A total of 578 students (35%) completed an original survey developed from previous surveys. RESULTS: Of those sampled, one-half identified as liberal or very liberal and 20% as conservative or very conservative. Respondents were split equally in their opinions of whether the United States or other nations had the highest quality care. One-half felt that faculty physicians and the media influenced their opinion of the ACA, while two-thirds felt that coursework and peers had no influence on their views. The vast majority sampled thought everyone is entitled to adequate medical care regardless of ability to pay and that physicians have a major responsibility to help reduce health care costs. A majority of liberal students and a minority of conservative students, supported the ACA. Personal and family experience as a patient influenced most liberals to support and most conservatives to oppose the ACA. One-half felt that medical school spent adequate time on health care policy education.

The impact of behavioral risk assessments and tailored health information on pediatric injury.

BACKGROUND: Integrating age appropriate injury prevention messages during a well-child visit is challenging in the face of competing demands. PURPOSE: To describe a 7-month pilot using technology to facilitate injury prevention risk assessment and education integration. METHODS: We prospectively tracked responses to the computer-based injury prevention self-assessment tool, safety product distribution, and any subsequent contact with the local hospital system for related unintentional injuries. RESULTS: A total of 2091 eligible visits by 1368 unique patients were assessed. Eight hundred forty-three unique patients completed the Safe N' Sound assessment and 7 were subsequently injured, with an injury related to a Safe N' Sound target area. CONCLUSIONS: A kiosk-based tailored injury assessment tool can be successfully integrated into a busy pediatric practice. Unintentional injury outcomes can be linked to the tailored anticipatory guidance and can identify the effectiveness of this electronic integration of injury prevention messaging into well-child examinations.

Variability in the labeling of asthma among pediatricians.

OBJECTIVE: Few studies have examined variability among physicians in the perception and interpretation of asthma symptoms. We report the results of a pilot study to investigate the variability of symptom description and diagnostic labeling and nomenclature among a group of clinicians using standardized audiovisual presentations of asthma. METHODS: Practicing pediatricians in Wisconsin recruited from an electronic mailing list were shown the International Study of Asthma and Allergies in Childhood (ISAAC) video questionnaire online, and asked to describe the symptoms and signs they observed and suggest possible diagnostic labels for each presentation. RESULTS: A total of 113 pediatricians (mean age = 43 years; 56% female) responded to ≥1 of the 5 video scenes. The number of practitioners who described the principal symptom(s) of asthma depicted in the 5 sequences ranged from 5.5% for Scene 5 (featuring both dyspnea and wheeze), to 100% for Scene 4 (featuring cough). The number who suggested label of 'asthma' as a possible cause of the presentations ranged from 69.7% for Scene 3 (featuring nocturnal wheeze), to 92.7% for Scene 2 (featuring exercise induced wheeze). CONCLUSION: There is important unexplained variation in the perceptions and labeling of asthma symptoms among pediatricians. These differences may influence the likelihood of diagnosis and the apparent prevalence of asthma. Many participants suggested that the ISAAC video be used in the education and training of pediatricians.

Use of child death review to inform sudden unexplained infant deaths occurring in a large urban setting.

OBJECTIVE: To illustrate the benefits and utility of the child death review (CDR) reporting system when examining risk factors associated with infant death occurring within two subgroups of sudden unexpected infant deaths (SUID)-unintentional suffocation and sudden infant death syndrome (SIDS)-in a large urban county in Wisconsin. DESIGN: Retrospective CDR data were analysed, 2007-2008, for Milwaukee County, Wisconsin. PATIENTS OR SUBJECTS: Unintentional suffocation and SIDS infant deaths under 1 year of age in Milwaukee County, Wisconsin, 2007-2008, with a CDR record indicating a death in a sleep environment. Main outcome measure Study examined demographic characteristics, bed-sharing, incident sleep location, position of child when put to sleep, position of child when found, child's usual sleep place, crib in home, and other objects found in sleep environment. RESULTS: Unintentional suffocation (n=11) and SIDS (n=40) classified deaths with CDR data made up 18% (51/283) of all infant deaths in Milwaukee County from 2007 to 2008. The majority of infants who died of unintentional suffocation (n=9, 81.8%) or SIDS (n=26, 65.0%) were black and under the age of 3 months. Bed-sharing was involved in most of the unintentional suffocation deaths (n=10, 90.9%) and the SIDS deaths (n=28, 70.0%). All unintentional suffocation deaths (n=11, 100%) and the majority of SIDS deaths (n=31, 77.5%) took place in a non-crib sleeping environment. CONCLUSIONS: The study demonstrates how CDR provides enhanced documentation of risk factors to help steer prevention efforts regarding SUID deaths in a community and reaffirms infants in an unsafe sleep environment have an increased risk of death.

Motor vehicle crashes associated with alcohol: child passenger injury and restraint use.

BACKGROUND: The role of alcohol in fatal motor vehicle crashes involving children has been well established. However, the nonfatal injury burden of alcohol on child passengers has not been comprehensively assessed. PURPOSE: This study sought to determine injury burden and restraint use in child passengers aged 1-15 years in alcohol-related motor vehicle crashes. METHODS: A retrospective cohort study including all people involved in all crashes with an injury or at least $1000 property damage occurring in Wisconsin in 2007 and involving at least one child passenger aged 1-15 years. RESULTS: A total of 22,464 child passengers were involved in motor vehicle crashes in Wisconsin in 2007; 2.5% (n=570) were in alcohol-related crashes. Child passengers in alcohol-related crashes experienced twice the risk of injury compared to non-alcohol-related crashes (risk ratio [RR]=2.42, 95% CI=2.08, 2.80). Two-vehicle crashes that were alcohol-related were more than two times more likely to result in child injury than those that were not (RR=2.78, 95% CI=2.30, 3.35). In alcohol-related crashes, the risk of injury in children was higher if they were passengers in the alcohol-related vehicle compared to the non-alcohol-related vehicle (RR=1.35, 95% CI=1.01, 1.79). Inappropriate restraint of child passengers was higher in alcohol-related vehicles (34.5% vs 17.1%, p<0.00005), particularly in the group aged 4-7 years (70.8% vs 44.9% inappropriately restrained). CONCLUSIONS: Motor vehicle crashes resulting from alcohol-related driving significantly increased child passenger injury and were associated with inappropriate child passenger restraint. Several evidence-based policies are recommended to address this public health problem.

Booster seat legislation: does it work for all children?

OBJECTIVE: To assess the impact of a booster seat law in Wisconsin on booster seat use in relation to race, ethnicity and socioeconomic status. METHODS: A longitudinal study in Milwaukee County, Wisconsin, involving repeated direct observational assessments of booster seat use rates by child passengers aged 4-7 years over five time periods, before and after legislation mandating booster seat use. RESULTS: Overall, booster seat use increased from 24% to 43%, whereas proper restraint use increased pre to post-legislation from 21% to 28%. Proper use increased after legislation in white, but not in black or Latino children. White individuals had a proper booster use increase from 48% to 68% over the time period of the study. Black children's proper use dropped from 18% to 7% over the study period and Latino children's proper use rates were stable at 10%. Driver-reported household income had a significant impact on overall use, but not on proper use. CONCLUSIONS: Racial/ethnic minority groups and those of lower socioeconomic status have significantly lower use and proper use of booster seats. Legislation may increase the total use of booster seats but not necessarily the correct use of the restraint, particularly in racial/ethnic minorities.

Graduated driver licensing policy in the Great Lakes states: current benefits and future potential.

BACKGROUND: Motor vehicle crashes are the leading cause of teenage deaths in the United States. Graduated Driver Licensing (GDL) policies effectively decrease teenage crash deaths. Emerging research is identifying the most effective components of GDL. This study examines GDL policies across 6 Great Lakes states, describing the beneficial impact, and investigating how evidence-based policy modifications could further reduce teenage driving deaths and injuries. METHODS: GDL policies were reviewed in 6 Great Lakes states (Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin). Incidence rate ratios for fatal and injury crashes for 16-year-old drivers were obtained from the Nationwide Review of GDL Study. Ratios were applied to the fatal and injury crashes reported from each state between 2002 and 2006 for 16-year-old drivers. The potential impact (crashes avoided) for each state was determined based on the state using a 3-phase GDL policy (a learner and intermediate stage prior to full licensure). In addition, the impact on crash reductions for each state if they had employed 5 of the recommended GDL components was determined. RESULTS: All 6 states had a 3-phase GDL policy, resulting in potential avoidance of 124 fatal and more than 21,000 injury crashes. The 6 states had 1 to 3 of the qualifying GDL components. If these states had adopted 5 of the qualifying components, an additional 309 fatal and more than 27,000 injury crashes could have been avoided. CONCLUSION: Three-phase GDL policy is effective at saving the lives of teenage drivers and vehicle occupants; evidence-based modification of GDL has the potential to further reduce teenage motor vehicle crash deaths and injuries.

Wisconsin firearm deer hunting season: injuries at a level I trauma center, 1999-2004.

CONTEXT: Hunting continues to be a passion and common pastime for many US citizens, especially in rural areas. Unfortunately, with the large volume of hunters entering the woods each season, hunting injuries continue to be common. OBJECTIVE: Review the experience of a level I trauma center during each of Wisconsin's 9-day deer firearm hunting seasons over a 6-year period and identify potential prevention elements based on the findings. DESIGN: We retrospectively reviewed all hunting-related injury patient data entered into the University of Wisconsin Hospital and Clinic's (UWHC) level I trauma registry from 1999 to 2004, for each 9-day Wisconsin deer hunting firearm season. We compared injury occurrence with Wisconsin DNR statewide hunting-related firearm injury incidence data over the same time frame. The study was conducted at a level I university tertiary referral trauma center. The study included any patient admitted to the UWHC during the study period with a hunting-related injury entered into the trauma registry. OUTCOMES MEASURED: Primary outcomes recorded included patient demographics, mechanism of injury, types of injuries, comorbidities, injury severity scores, and mortality. RESULTS: Twenty-four patients were treated for hunting-related injuries during the study period. The majority of hunters were male (95%), with an average age of 44.5 years. Treestand injuries accounted for 16 of the 24 injuries treated; the rest of the injuries were firearm-related. Most of the injuries (18) occurred during the first 3 days of the hunting season, with the remaining 6 injuries taking place around the Thanksgiving holiday period. Injury severity scores (ISS) ranged from 1 to 50. Orthopedic concerns accounted for 79% of the injuries, while general surgical was 50%, and neurosurgical was 12.5%. Two fatalities occurred due to complications from injuries caused by falling from a treestand. CONCLUSION: Falls from a tree-stand and firearm shootings represent 2 mechanisms for severe hunting-related injuries during the 9-day deer firearm hunting season in Wisconsin. Formal treestand safety instruction should be emphasized during hunting education classes and all hunters need to heed safe hunting recommendations pertaining to firearms and treestands, and be particularly cautious during the first few days of the hunting season.

The perils of snowmobiling.

Snowmobiling is a popular winter sport in Wisconsin, but it can result in serious injury and death. From 1998-2002, 1090 people in Wisconsin were hospitalized due to injuries related to snowmobiling. From 2002 to 2004, 51 snowmobile-related fatalities were reported to the Wisconsin Department of Natural Resources. Multiple risk factors exist for snowmobile injury and death, with alcohol consumption and male gender being the 2 largest associated risks. Many of the risk factors are modifiable, and health care professionals can facilitate snowmobiling-related injury prevention.

The role of the health care professional in bicycle safety.

Learning to ride a bicycle and enjoying the pleasures of cycling are synonymous with childhood; unfortunately, cycling does not come without risk of serious injury. Children under 15 years old account for the majority of cycling time in the United States, and on average, 1 child dies every day from a bicycle-related injury. Health care professionals can play an important role in making cycling a safe activity by encouraging and advocating for safe bicycling practices. Specific areas for physicians and health care professionals to emphasize involve the cyclist, environmental factors, and equipment factors. Helmet use by cyclists, avoidance of risk-taking, safe cycling road behavior, and proper cycling equipment fit and usage are all areas in which health care professionals can instruct families during office visits. The physician and the health care community can also be advocates for mandatory helmet legislation in order to achieve higher helmet usage rates and decreased cycling injuries. The health care professional's role in bicycle safety is an important component in building a foundation for safe cycling.

Promoting childhood water safety: the physician's role.

Injuries and deaths secondary to drowning are a significant issue for children. The risks associated with drowning change with a child's age and developmental abilities. Nationally, children under the age of 4 years and male adolescents represent the pediatric groups with the highest rates of drowning. In Wisconsin, 1998-2002, preteen children were involved in drowning or near-drowning events more often than teens, with boys being involved more than 2 times as often as girls for all childhood ages assessed. The drowning gender disparity is even greater among adults. Physicians are in a position to promote water safety for their patients and the community by educating families on age-appropriate drowning-prevention methods, supporting community safety campaigns, and advocating for "best practice" drowning-prevention legislation. Although injury prevention anticipatory guidance is important for all family members, directing the message to males is particularly important. Physicians can help children enjoy the benefits of water recreation while decreasing the risk for water-associated injury.

Development of an advocacy curriculum in a pediatric residency program.

BACKGROUND: The Accreditation Council for Graduate Medical Education now requires pediatric residency programs to include advocacy training, but few guidelines for development exist. PURPOSE: To determine faculty and resident attitudes regarding advocacy training, and to develop consensus on the best method to teach and learn advocacy. METHODS: Pediatric residents (n = 28) and faculty (n = 51) participated in a survey about experience and training in advocacy, identified issues important to address in an advocacy curriculum, and rated a variety of learning methods. RESULTS: Nearly 90% of residents felt advocacy training was needed, and 82% felt advocacy activities would continue following residency. Faculty and residents agreed that participation in short-term or longitudinal projects was the best way to teach and learn advocacy skills. Respondents identified and ranked 45 issues to address through advocacy efforts and training, and these results were used to develop and implement an advocacy curriculum. CONCLUSIONS: Residents and faculty were interested in incorporating an advocacy curriculum, and survey results were used to guide curriculum development.