Staged Implementation of Awakening and Breathing, Coordination, Delirium Monitoring and Management, and Early Mobilization Bundle Improves Patient Outcomes and Reduces Hospital Costs.

OBJECTIVES: To measure the impact of staged implementation of full versus partial ABCDE bundle on mechanical ventilation duration, ICU and hospital lengths of stay, and cost. DESIGN: Prospective cohort study. SETTING: Two medical ICUs within Montefiore Healthcare Center (Bronx, NY). PATIENTS: One thousand eight hundred fifty-five mechanically ventilated patients admitted to ICUs between July 2011 and July 2014. INTERVENTIONS: At baseline, spontaneous (B)reathing trials (B) were ongoing in both ICUs; in period 1, (A)wakening and (D)elirium (AD) were implemented in both full and partial bundle ICUs; in period 2, (E)arly mobilization and structured bundle (C)oordination (EC) were implemented in the full bundle (B-AD-EC) but not the partial bundle ICU (B-AD). MEASUREMENTS AND MAIN RESULTS: In the full bundle ICU, 95% patient days were spent in bed before EC (period 1). After EC was implemented (period 2), 65% of patients stood, 54% walked at least once during their ICU stay, and ICU-acquired pressure ulcers and physical restraint use decreased (period 1 vs 2: 39% vs 23% of patients; 30% vs 26% patient days, respectively; p < 0.001 for both). After adjustment for patient-level covariates, implementation of the full (B-AD-EC) versus partial (B-AD) bundle was associated with reduced mechanical ventilation duration (-22.3%; 95% CI, -22.5% to -22.0%; p < 0.001), ICU length of stay (-10.3%; 95% CI, -15.6% to -4.7%; p = 0.028), and hospital length of stay (-7.8%; 95% CI, -8.7% to -6.9%; p = 0.006). Total ICU and hospital cost were also reduced by 24.2% (95% CI, -41.4% to -2.0%; p = 0.03) and 30.2% (95% CI, -46.1% to -9.5%; p = 0.007), respectively. CONCLUSIONS: In a clinical practice setting, the addition of (E)arly mobilization and structured (C)oordination of ABCDE bundle components to a spontaneous (B)reathing, (A)wakening, and (D) elirium management background led to substantial reductions in the duration of mechanical ventilation, length of stay, and cost.

Changes in abortions and births and the Texas parental notification law.

BACKGROUND: On January 1, 2000, Texas began enforcement of a law that requires physicians to notify a parent of a minor child seeking an abortion at least 48 hours before the procedure. METHODS: We assessed changes in the rates in Texas of abortions and births (events per 1000 age-specific population) before enforcement of the parental notification law (1998 to 1999) and after enforcement (2000 to 2002). We did this by comparing the rate changes among minors 15 to 17 years of age at the time of conception (i.e., those who were subject to the law) with those of teens 18 years of age at the time of conception (i.e., those who were not subject to the law). RESULTS: After enforcement of the law, abortion rates fell by 11 percent among 15-year-olds (rate ratio, 0.89; 95 percent confidence interval, 0.83 to 0.94), 20 percent among 16-year-olds (rate ratio, 0.80; 95 percent confidence interval, 0.76 to 0.85), and 16 percent among 17-year-olds (rate ratio 0.84; 95 percent confidence interval, 0.80 to 0.87), relative to the rates among 18-year-olds. Among the subgroup of minors 17.50 to 17.74 years of age at the time of conception (who would have been subject to the parental notification law in early pregnancy), birth rates rose by 4 percent relative to those of teens 18.00 to 18.24 years of age (rate ratio, 1.04; 95 percent confidence interval, 1.00 to 1.08). The adjusted odds ratio for having an abortion after 12 weeks' gestation among minors 17.50 to 17.74 years of age as compared with 18-year-olds was 1.34 (95 percent confidence interval, 1.10 to 1.62). CONCLUSIONS: The Texas parental notification law was associated with a decline in abortion rates among minors from 15 to 17 years of age. It was also associated with increased birth rates and rates of abortion during the second trimester among a subgroup of minors who were 17.50 to 17.74 years of age at the time of conception.

Misclassification bias and the estimated effect of parental involvement laws on adolescents' reproductive outcomes.

OBJECTIVES: We evaluated the presence of misclassification bias in the estimated effect of parental involvement laws on minors' reproductive outcomes when subjection to such laws was measured by age at the time of pregnancy resolution. METHODS: Using data from abortion and birth certificates, we evaluated the effect of Texas's parental notification law on the abortion, birth, and pregnancy rates of adolescents aged 17 years compared with those aged 18 years on the basis of age at the time of pregnancy resolution and age at conception. RESULTS: On the basis of age at the time of the abortion or birth, the law was associated with a fall of 26%, 7%, and 11% in the abortion, birth, and pregnancy rates, respectively, of 17- relative to 18-year-olds. Based on age at the time of conception, the abortion rate fell 15%, the birth rate rose 2%, and the pregnancy rate remained unchanged. CONCLUSIONS: Previous studies of parental involvement laws should be interpreted with caution because their methodological limitations have resulted in an overestimation of the fall in abortions and underestimation of the rise in births, possibly leading to the erroneous conclusion that pregnancies decline in response to such laws.

Comparing Two Models of Integrated Behavioral Health Programs in Pediatric Primary Care.

This study examined how to design, staff, and evaluate the feasibility of 2 different models of integrated behavioral health programs in pediatric primary care across primary care sites in the Bronx, NY. Results suggest that the Behavioral Health Integration Program model of pediatric integrated care is feasible and that hiring behavioral health staff with specific training in pediatric, evidence-informed behavioral health treatments may be a critical variable in increasing outcomes such as referral rates, self-reported competency, and satisfaction.

Programs to reduce teen pregnancy, sexually transmitted infections, and associated sexual risk behaviors: a systematic review.

PURPOSE: This systematic review provides a comprehensive, updated assessment of programs with evidence of effectiveness in reducing teen pregnancy, sexually transmitted infections (STIs), or associated sexual risk behaviors. METHODS: The review was conducted in four steps. First, multiple literature search strategies were used to identify relevant studies released from 1989 through January 2011. Second, identified studies were screened against prespecified eligibility criteria. Third, studies were assessed by teams of two trained reviewers for the quality and execution of their research designs. Fourth, for studies that passed the quality assessment, the review team extracted and analyzed information on the research design, study sample, evaluation setting, and program impacts. RESULTS: A total of 88 studies met the review criteria for study quality and were included in the data extraction and analysis. The studies examined a range of programs delivered in diverse settings. Most studies had mixed-gender and predominately African-American research samples (70% and 51%, respectively). Randomized controlled trials accounted for the large majority (87%) of included studies. Most studies (76%) included multiple follow-ups, with sample sizes ranging from 62 to 5,244. Analysis of the study impact findings identified 31 programs with evidence of effectiveness. CONCLUSIONS: Research conducted since the late 1980s has identified more than two dozen teen pregnancy and STI prevention programs with evidence of effectiveness. Key strengths of this research are the large number of randomized controlled trials, the common use of multiple follow-up periods, and attention to a broad range of programs delivered in diverse settings. Two main gaps are a lack of replication studies and the need for more research on Latino youth and other high-risk populations. In addressing these gaps, researchers must overcome common limitations in study design, analysis, and reporting that have negatively affected prior research.

Do parental involvement laws deter risky teen sex?

Parental involvement (PI) laws require that physicians notify or obtain consent from a parent(s) of a minor seeking an abortion before performing the procedure. Several studies suggest that PI laws curb risky sexual behavior because teens realize that they would be compelled to discuss a subsequent pregnancy with a parent. We show that prior evidence based on gonorrhea rates overlooked the frequent under-reporting of gonorrhea by race and ethnicity, and present new evidence on the effects of PI laws using more current data on the prevalence of gonorrhea and data that are novel to this literature (i.e., chlamydia rates and data disaggregated by year of age). We improve the credibility of our estimates over those in the existing literature using an event-study design in addition to standard difference-in-difference-in-differences (DDD) models. Our findings consistently suggest no association between PI laws and rates of sexually transmitted infections or measures of sexual behavior.

Minors' behavioral responses to parental involvement laws: delaying abortion until age 18.

CONTEXT: Prior research on the effect of laws mandating parental involvement in minors' abortions has failed to examine an important behavioral response to such laws: Older teenagers may delay an abortion until age 18; for some, this may mean terminating a pregnancy after the first trimester. METHODS: Statewide data were obtained on abortions in Texas in 1997-2003. Analysis of relative rate ratios with narrowly defined comparison groups was used to evaluate the association between Texas's parental notification law and the occurrence of second-trimester abortions among minors who have responded to the law by delaying abortion until age 18. RESULTS: In the four years after the law went into effect, the proportion of abortions obtained at age 18 increased by six percentage points among minors who conceived at age 17 years and eight months, and by 13 points among those who did so at 17 years and nine months. As a result, the second-trimester abortion rate of these groups combined increased by 21%; by contrast, there was no evidence of an increase in this rate among younger minors, for whom delaying the abortion until age 18 was not feasible. CONCLUSIONS: Some minors postpone abortion until the second or even third trimester of pregnancy to circumvent parental notification requirements. Given the greater costs of and medical risks associated with late-term abortions, policymakers should not ignore this behavior.

The changing association between prenatal participation in WIC and birth outcomes in New York City.

We analyze the relationship between prenatal WIC participation and birth outcomes in New York City from 1988-2001. The analysis is unique for several reasons. First, we have over 800,000 births to women on Medicaid, the largest sample ever used to analyze prenatal participation in WIC. Second, we focus on measures of fetal growth distinct from preterm birth, since there is little clinical support for a link between nutritional supplementation and premature delivery. Third, we restrict the primary analysis to women on Medicaid who have no previous live births and who initiate prenatal care within the first four months of pregnancy. Our goal is to lessen heterogeneity between WIC and non-WIC participants by limiting the sample to highly motivated women who have no experience with WIC from a previous pregnancy. Fourth, we analyze a large sub-sample of twin deliveries. Multifetal pregnancies increase the risk of anemia and fetal growth retardation and thus may benefit more than singletons from nutritional supplementation. We find no relationship between prenatal WIC participation and measures of fetal growth among singletons. We find a modest pattern of association between WIC and fetal growth among U.S.-born Black twins. Our findings suggest that prenatal participation in WIC has had a minimal effect on adverse birth outcomes in New York City.