The role of pediatric networks in managing social health needs.

Pediatric-specific networks have emerged over the past decade as Medicaid payment models have shifted away from fee-for-service, which rewards volume of service delivery, towards more value-based payments that incentivize improved health outcomes. More recently, growing recognition that health care alone is insufficient to produce health has resulted in the Centers for Medicare and Medicaid Services advancing value-based payment models that allow greater flexibility for networks to address the "social determinants of health" - those social and economic conditions which significantly influence health outcomes. Although pediatricians have long advocated for understanding and addressing social health needs, pediatric networks must now determine their role in managing or mitigating the impact of these complex factors on the health of their attributed populations. Pediatric networks can implement basic screening and referral processes to address social health needs, invest network resources in direct service provision, and/or leverage the network's expertise in child health to influence upstream changes in health policy. This article presents some questions that pediatric networks can use to explore their potential role in managing social health needs.

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.

Promoting correct car seat use in parents of young children: challenges, recommendations, and implications for health communication.

Injuries involving motor vehicles continue to be the biggest threat to the safety of children. Although child safety seats (CSS) have been established as a central countermeasure in decreasing injury risk, the majority of parents do not use the correct car seat correctly. There are many challenges in promoting correct car seat use, which itself is a complex behavior. To advance this critical protective behavior, the public health community would benefit from clarifying CSS messaging, communicating clearly, and addressing the conflicting recommendations of product use. In this article, we present current challenges in promoting CSS use and draw on health communication and other fields to offer recommendations for future work in this area.

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.

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.

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.

Reliability and validity of child passenger safety restraint observations by community observers.

OBJECTIVE: To compare the accuracy of trained community observers for direct observation of child passenger restraint use to certified child passenger safety technicians who are either professional observers or community-based technicians, and to compare these three groups with a gold standard. METHODS: This is a cross-sectional study of interobserver agreement and accuracy in which 75 photos of children depicted in different child passenger restraint systems were rated by 9 observers total, with 3 representing professional observers, 3 representing certified child passenger safety technicians, and 3 representing trained community observers. For each photo, observers indicated type of restraint; the appropriateness of the harness, if applicable; and overall appropriateness of the restraint. A gold standard was established by consensus agreement of 2 certified car seat technician instructors. RESULTS: The sensitivity and specificity for trained community observers in identifying broad groupings of restraint types was good (78-100% sensitivity; 93-99% specificity), but they had low agreement with the gold standard for overall appropriateness of the child passenger restraints (kappa = 0.28). The community observer group was 42 percent less likely to code the photo depiction of appropriate restraint use as appropriate. CONCLUSION: Community trained observers do show good sensitivity and specificity for identifying the type of restraint but have a trend toward poorer judgment when determining harness appropriateness and overall appropriateness. They may be a cost-effective option for limited restraint identification.

Validation of two child passenger safety questionnaires.

OBJECTIVE: To measure the validity of a booster seat questionnaire and a car seat questionnaire so that they can be reliably used in future trials. DESIGN: The two child passenger safety questionnaires were created. Each underwent expert review to ensure face and content validity. Two reliability studies were conducted independently of each other. Care givers for children who were cared for in a paediatric emergency department were enrolled. Criterion validity was tested by direct observation, and inter-rater reliability was measured. Test-retest reliability and internal consistency were also measured on the booster seat questionnaire. RESULTS: Booster seat questionnaire: test-retest agreement was good, with 16 of the 18 questions having agreement of at least 80%. Agreement was acceptable (>70%) in all other questions in which agreement was expected when the answers of two different care givers were compared. All care givers were able to report booster seat use as it was found on direct observation, yielding a κ value of 1. Car seat questionnaire: the respondents showed 95% agreement between their reported type of child safety restraint and what was found on direct observation. Inter-rater agreement for the type of safety restraint was 77% or a κ value of 0.7. CONCLUSION: Both the booster seat questionnaire and the car seat questionnaire are valid and can be reliably used in future studies. The findings of this study need to be verified with larger studies and different populations.

Legislating child restraint usage -Its effect on self-reported child restraint use rates in a central city.

OBJECTIVE: To assess the effect of the newly enacted child passenger safety law, Wisconsin Act 106, on self-report of proper restraint usage of children in Milwaukee's central city population. METHOD: A prospective, non-randomized study design was used. The settings used were (a) a pediatric urban health center, and (b) two Women, Infants and Children offices in Milwaukee, Wisconsin. Participants included 11,566 surveys collected over 18 months that spanned the pre-legislation and post-legislation time periods from February 2006 through August 2008. RESULTS: The study set out to assess appropriate child passenger restraint. The results showed that the changes in adjusted proper restraint usage rates for infants between the pre-law, grace period, and post-fine periods were 94%, 94%, and 94% respectively. For children 1-3years old, the adjusted proper usage rates were 65%, 63%, and 59%, respectively. And for children 4-7years old, the rates were 43%, 44% and 42%, respectively. There was a significant increase in premature booster seat use in children who should have been restrained in a rear- or forward-facing car seat (10% pre-law, 12% grace period, 20% post-fine; p<0.0005). There was no statistically significant change over time in unrestrained children (2.1%, 1.7%, 1.7%, p=0.7, respectively). CONCLUSIONS: The passage of a strengthened child passenger safety law with fines did not significantly improve appropriate restraint use for 0-7year olds, and appropriate use in 1-7year olds remained suboptimal with a majority of urban children inappropriately restrained. Although the number of unrestrained children decreased, we identified an unintended consequence of the legislation - a significant increase in the rate of premature belt-positioning booster seat use among poor, urban children. IMPACT ON INDUSTRY: The design of child restraint systems maximizes protection of the child. Increasing reports of misuse is a call to those who manufacture these child passenger restraints to improve advertising and marketing to the correct age group, ease of installation, and mechanisms to prevent incorrect safety strap and harness placement. To ensure accurate and consistent use on every trip, car seat manufacturers must ensure that best practice recommendations for use as well as age, weight, and height be clearly specified on each child restraint. The authors support the United States Department of Transportation's new consumer program that will assist caregivers in identifying the child seat that will fit in their vehicle. In addition, due to the increase in premature graduation of children into belt-positioning booster seats noted as a result of legislation, promoting and marketing booster seat use for children less than 40 pounds should not be accepted. Child passenger safety technicians must continue to promote best practice recommendations for child passenger restraint use and encourage other community leaders to do the same.

Free child passenger restraints for patients in an urban pediatric medical home: effects on caregiver behavior.

CONTEXT: Motor vehicle crashes are a leading cause of death in children despite the availability of effective child passenger restraints that reduce morbidity and mortality. Inappropriate restraint is more common in minority and low-income populations. Removing barriers by distributing child passenger restraint systems (CPRS) and providing education has been 1 approach to improve child safety. The objective of this study was to evaluate the efficacy of providing no-cost CPRS in combination with targeted education to improve restraint use for low-income, minority, and urban children in a medical home. DESIGN: This prospective, non-randomized, community-based cohort study used a certified car seat technician to provide CPRS and training to the caregivers of 101 children when those caregivers reported not owning the appropriate type of restraint system during the index clinic visit. RESULTS: In the first 3 months of follow-up, caregivers were 2.4 times more likely to report appropriate use of CPRS: relative risk 2.4 (95% confidence interval [CI] 1.7 to 3.5). Reported improvement declined slightly between months 4 and 9. CONCLUSIONS: Appropriate restraint significantly improved, yet rates remained suboptimal. Multifactoral approaches are needed to understand why the set of patients studied and other at-risk populations may not use child restraints properly even when given access and information.

Knowledge and behaviors of physicians and caregivers about appropriate child passenger restraint use.

The object of this research was to ascertain caregivers' and physicians' knowledge, behaviors, and comfort levels regarding child passenger safety restraint transitions with belt positioning booster seats (BPB). A targeted survey of physicians caring for 4-8 year olds plus convenience sampling surveys of caregivers across an urban community was conducted. Data revealed 42% of physicians and 47% of caregivers did not know that motor vehicle crashes are the leading cause of death in children in this age group. Only 34% of caregivers consistently placed children in booster seats; 48% reported receiving physician information about proper restraint; 67% reported wanting to learn about proper restraint; and 36% wanted such information from physicians. Caregivers who recalled physician questions about restraints were three times more likely than others to use booster seats correctly. 70% of physicians reported asking about child restraint in vehicles in this age group. However, only 48% were very comfortable with knowing when to recommend booster seats, 43% reported having received no training in child passenger safety, and only 37% knew where to refer caregivers for more information. Physicians need more information about appropriate child passenger safety restraints as children grow and ways to deliver and reinforce the message so that it is retained to improve community health. Caregivers indicate willingness to learn, but providers miss many opportunities to teach.

Booster seat use in an inner-city day care center population.

OBJECTIVE: To determine use and knowledge of belt positioning booster seats by drivers transporting children from day care centers in the central city of Milwaukee, Wisconsin. METHODS: A prospective, direct observational, community-based, exploratory study was undertaken in May 2005. Eighteen day care centers in urban Milwaukee that met the predetermined criteria, including > 10 children ages 4-8 enrolled, were invited to participate. Volunteer observers, including Spanish-speaking members, from community organizations were trained in proper placement by certified car seat technicians. Teams visited sites, completed a standardized survey form with drivers who agreed to participate, and observed the type and placement of restraint in which each child was placed. RESULTS: Of 841 children observed, 283 were determined to be booster-seat eligible. Only 21% were in the appropriate restraint. Latino, African American, and older children were significantly less likely than white and younger children to be appropriately restrained. Appropriate restraint use was more frequent among those living in the proper ZIP codes with higher median incomes. CONCLUSIONS: This is the first observational study of booster seat use in this Milwaukee population with appropriate restraint use varying widely from reported state and national data. The low rates of appropriate booster seat use, particularly by Latino and African American caregivers and those living in low-income neighborhoods, in this large metropolitan center supports the need for further study and targeted interventions.