Commercial insurance delays direct-acting antiviral treatment for hepatitis C kidney transplantation into uninfected recipients.

INTRODUCTION: The advent of direct-acting antivirals (DAAs) has created an avenue for transplantation of hepatitis C virus (HCV)-infected donors into uninfected recipients (D+/R-). The donor transmission of HCV is then countered by DAA administration during the post-operative period. However, initiation of DAA treatment is ultimately dictated by insurance companies. METHODS: A retrospective chart review of 52 D+/R- kidney recipients who underwent DAA treatment post-transplant was performed. Patients were grouped according to their prescription coverage plans, managed by either commercial or government pharmacy benefit managers (PBMs). RESULTS: Thirty-nine patients had government PBMs and 13 had commercial PBMs. Demographics were similar between the two groups. All patients developed HCV viremia, but cleared the virus after treatment with DAA. Patients with government PBMs were treated earlier compared to those with commercial PBMs (11 days vs 26 days, P = .01). Longer time to DAA initiation resulted in higher peak viral loads (ß = 0.39, R2  = .15, P = .01) and longer time to HCV viral load clearance (ß = 0.41, R2  = .17, P = .01). CONCLUSIONS: D+/R- transplantation offers patients an alternative strategy to increase access. However, treatment can be profoundly delayed by a third-party payer authorization process that may be subjecting patients to unnecessary risks and worsened outcomes.

Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order Errors: A Randomized Clinical Trial.

Importance: Recommendations in the United States suggest limiting the number of patient records displayed in an electronic health record (EHR) to 1 at a time, although little evidence supports this recommendation. Objective: To assess the risk of wrong-patient orders in an EHR configuration limiting clinicians to 1 record vs allowing up to 4 records opened concurrently. Design, Setting, and Participants: This randomized clinical trial included 3356 clinicians at a large health system in New York and was conducted from October 2015 to April 2017 in emergency department, inpatient, and outpatient settings. Interventions: Clinicians were randomly assigned in a 1:1 ratio to an EHR configuration limiting to 1 patient record open at a time (restricted; n = 1669) or allowing up to 4 records open concurrently (unrestricted; n = 1687). Main Outcomes and Measures: The unit of analysis was the order session, a series of orders placed by a clinician for a single patient. The primary outcome was order sessions that included 1 or more wrong-patient orders identified by the Wrong-Patient Retract-and-Reorder measure (an electronic query that identifies orders placed for a patient, retracted, and then reordered shortly thereafter by the same clinician for a different patient). Results: Among the 3356 clinicians who were randomized (mean [SD] age, 43.1 [12.5] years; mean [SD] experience at study site, 6.5 [6.0] years; 1894 females [56.4%]), all provided order data and were included in the analysis. The study included 12 140 298 orders, in 4 486 631 order sessions, placed for 543 490 patients. There was no significant difference in wrong-patient order sessions per 100 000 in the restricted vs unrestricted group, respectively, overall (90.7 vs 88.0; odds ratio [OR], 1.03 [95% CI, 0.90-1.20]; P = .60) or in any setting (ED: 157.8 vs 161.3, OR, 1.00 [95% CI, 0.83-1.20], P = .96; inpatient: 185.6 vs 185.1, OR, 0.99 [95% CI, 0.89-1.11]; P = .86; or outpatient: 7.9 vs 8.2, OR, 0.94 [95% CI, 0.70-1.28], P = .71). The effect did not differ among settings (P for interaction = .99). In the unrestricted group overall, 66.2% of the order sessions were completed with 1 record open, including 34.5% of ED, 53.7% of inpatient, and 83.4% of outpatient order sessions. Conclusions and Relevance: A strategy that limited clinicians to 1 EHR patient record open compared with a strategy that allowed up to 4 records open concurrently did not reduce the proportion of wrong-patient order errors. However, clinicians in the unrestricted group placed most orders with a single record open, limiting the power of the study to determine whether reducing the number of records open when placing orders reduces the risk of wrong-patient order errors. Trial Registration: clinicaltrials.gov Identifier: NCT02876588.

Obesity and symptomatic cholelithiasis in childhood: epidemiologic and case-control evidence for a strong relation.

OBJECTIVES: The aims of this study were to correlate the temporal trends in obesity prevalence with hospitalization rates for symptomatic cholelithiasis and to estimate the strength of the association between obesity and symptomatic cholelithiasis in patients hospitalized at an urban children's hospital in New York serving a multiethnic population. METHODS: Using obesity prevalence data from the National Health and Nutrition Examination Survey and the rates of hospitalization for cholelithiasis derived from the Kids' Inpatient Database for 1997-2007, we estimated a correlation and a linear regression. We conducted a retrospective, case-control study in which each case ages 4 to 20 years with symptomatic cholelithiasis was individually matched to a control admitted with appendicitis based on age, sex, ethnicity, and race. RESULTS: The prevalence of obesity and the cholelithiasis hospitalization rate increased over time (R=0.87, P=0.0025). For every 1% increase in the obesity rate among children, the rate of hospitalization for gallstones increased by 0.65/100,000 children (R²=0.75, P=0.0025, 95% confidence interval [CI] 0.32-0.99). The odds ratio for obesity in cases versus controls was 5.78 (n=518, P<0.0001, 95% CI 3.50-9.53). We found a significant dose-response effect, which showed that for every 1 z score increase in body mass index, the risk of cholelithiasis was increased by 79% (P<0.0001, 95% CI 1.5-2.13). CONCLUSIONS: The national trend in the prevalence of obesity from 1997 to 2009 was significantly correlated with increasing rates of hospitalization for pediatric cholelithiasis. Our case-control study suggests that obesity is a significant risk factor for hospital admission because of cholelithiasis.

Parental and other factors associated with hydroxyurea use for pediatric sickle cell disease.

BACKGROUND: Hydroxyurea (HU) is highly effective treatment for sickle cell disease (SCD). While pediatric use of HU is accepted clinical practice, barriers to use may impede its potential benefit. PROCEDURE: A survey of parents of children ages 5-17 years with SCD was performed across five institutions to assess factors associated with HU use. RESULTS: Of the 173 parent responses, 65 (38%) had children currently taking HU. Among parents of children not taking HU, the most commonly cited reasons were that their hematology provider had not offered it, their child was not sufficiently symptomatic and concerns about potential side effects. Even parents of HU users reported widespread concern about effectiveness, long-term safety, and off-label use. In bivariate analyses, children's ages, parental demographics such as education level, or travel time to their hematology provider were not correlated with HU use. Bivariate analysis and multivariate logistic regression revealed three significant factors associated with current HU use: better parental knowledge about its major therapeutic effects (P < 0.001), sickle genotype (P = 0.005), and institution of clinical care (P = 0.04). CONCLUSIONS: Pervasive concerns about HU safety exist, even among parents of current users. Varying knowledge among parents appears to be independent of their demographics, and is associated with HU use. Inter-institutional variability in parental knowledge and drug uptake highlights potentially potent site-specific influences on likelihood of HU use. Overall, these survey data underscore the need for strategies to bolster parental understanding about benefits of HU and address concerns about its safety.

Hospital bed occupancy rate is an independent risk factor for COVID-19 inpatient mortality: a pandemic epicentre cohort study.

INTRODUCTION: COVID-19 first struck New York City in the spring of 2020, resulting in an unprecedented strain on our healthcare system and triggering multiple changes in public health policy governing hospital operations as well as therapeutic approaches to COVID-19. We examined inpatient mortality at our centre throughout the course of the pandemic. METHODS: This is a retrospective chart review of clinical characteristics, treatments and outcome data of all patients admitted with COVID-19 from 1 March 2020 to 28 February 2021. Patients were grouped into 3-month quartiles. Hospital strain was assessed as per cent of occupied beds based on a normal bed capacity of 1491. RESULTS: Inpatient mortality decreased from 25.0% in spring to 10.8% over the course of the year. During this time, use of remdesivir, steroids and anticoagulants increased; use of hydroxychloroquine and other antibiotics decreased. Daily bed occupancy ranged from 62% to 118%. In a multivariate model with all year's data controlling for demographics, comorbidities and acuity of illness, percentage of bed occupancy was associated with increased 30-day in-hospital mortality of patients with COVID-19 (0.7% mortality increase for each 1% increase in bed occupancy; HR 1.007, CI 1.001 to 1.013, p=0.004) CONCLUSION: Inpatient mortality from COVID-19 was associated with bed occupancy. Early reduction in epicentre hospital bed occupancy to accommodate acutely ill and resource-intensive patients should be a critical component in the strategic planning for future pandemics.

Scaling-up social needs screening in practice: a retrospective, cross-sectional analysis of data from electronic health records from Bronx county, New York, USA.

OBJECTIVES: There has been renewed focus on health systems integrating social care to improve health outcomes with relatively less related research focusing on 'real-world' practice. This study describes a health system's experience from 2018 to 2020, following the successful pilot in 2017, to scale social needs screening of patients within a large urban primary care ambulatory network. SETTING: Academic medical centre with an ambulatory network of 18 primary care practices located in an urban county in New York City (USA). PARTICIPANTS: This retrospective, cross-sectional study used electronic health records of 244 764 patients who had a clinical visit between 10 April 2018 and 8 December 2019 across any one of 18 primary care practices. METHODS: We organised measures using the RE-AIM framework domains of reach and adoption to ascertain the number of patients who were screened and the number of providers who adopted screening and associated documentation, respectively. We used descriptive statistics to summarise factors comparing patients screened versus those not screened, the prevalence of social needs screening and adoption across 18 practices. RESULTS: Between April 2018 and December 2019, 53 093 patients were screened for social needs, representing approximately 21.7% of the patients seen. Almost one-fifth (19.6%) of patients reported at least one unmet social need. The percentage of screened patients varied by both practice location (range 1.6%-81.6%) and specialty within practices. 51.8% of providers (n=1316) screened at least one patient. CONCLUSIONS: These findings demonstrate both the potential and challenges of integrating social care in practice. We observed significant variability in uptake across the health system. More research is needed to better understand factors driving adoption and may include harmonising workflows, establishing unified targets and using data to drive improvement.

Maternal smoking and the timing of WIC enrollment.

OBJECTIVE: To investigate the association between the timing of enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and smoking among prenatal WIC participants. METHODS: We use WIC data from eight states participating in the Pregnancy Nutrition Surveillance System (PNSS). We adjust the association between the timing of WIC participation and smoking behavior with a rich set of maternal characteristics. RESULTS: Women who enroll in WIC in the first trimester of pregnancy are 2.7% points more likely to be smoking at intake than women who enroll in the third trimester. Among participants who smoked before pregnancy and at prenatal WIC enrollment, those who enrolled in the first trimester are 4.5% points more likely to quit smoking 3 months before delivery and 3.4% points more likely to quit by postpartum registration, compared with women who do not enroll in WIC until the third trimester. However, among pregravid smokers who report quitting by the first prenatal WIC visit, first-trimester enrollment is associated with a 2% point increase in relapse by postpartum registration. These results differ by race/ethnicity; white women who enroll early are 3.6% points more likely to relapse, while black women are 2.5% points less likely to relapse. CONCLUSIONS: Early WIC enrollment is associated with higher quit rates, although changes are modest when compared to the results from smoking cessation interventions for pregnant women. Given the prevalence of prenatal smoking among WIC participants, efforts to intensify WIC's role in smoking cessation through more frequent, and more focused counseling should be encouraged.

Association of Race and Ethnicity With Comorbidities and Survival Among Patients With COVID-19 at an Urban Medical Center in New York.

Importance: As of May 11, 2020, there have been more than 290 000 deaths worldwide from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19). Risk-adjusted differences in outcomes among patients of differing ethnicity and race categories are not well characterized. Objectives: To investigate whether presenting comorbidities in patients with COVID-19 in New York City differed by race/ethnicity and whether case fatality rates varied among different ethnic and racial groups, controlling for presenting comorbidities and other risk factors. Design, Setting, and Participants: This cohort study included 5902 patients who presented for care to the Montefiore Medical Center, a large urban academic medical center in the Bronx, New York, between March 14 and April 15, 2020, and tested positive for SARS-CoV-2 on reverse transcription quantitative polymerase chain reaction assay. Final data collection was April 27, 2020. Exposures: Patient characteristics, including self-identified ethnicity/race, age, sex, socioeconomic status, and medical comorbidities, were tabulated. Main Outcomes and Measures: Overall survival. Associations between patient demographic characteristics, comorbidities, and race/ethnicity were examined using χ2 tests, and the association with survival was assessed using univariable and multivariable Cox proportional hazards regression, based on time from positive COVID-19 test. Results: Of 9268 patients who were tested, 5902 ethnically diverse patients (63.7%) had SARS-CoV-2. Of these, 3129 patients (53.0%) were women, and the median (interquartile range) age was 58 (44-71) years. A total of 918 patients (15.5%) died within the study time frame. Overall, 1905 patients (32.3%) identified as Hispanic; 1935 (32.8%), non-Hispanic Black; 509 (8.6%), non-Hispanic White; and 171 (2.9%), Asian; the death rates were 16.2% (309), 17.2% (333), 20.0% (102), and 17.0% (29), respectively (P = .25). Hispanic and non-Hispanic Black patients had a higher proportion of more than 2 medical comorbidities with 654 (34.3%) and 764 (39.5%), respectively, compared with 147 (28.9%) among non-Hispanic White patients (P < .001). Hispanic and non-Hispanic Black patients were also more likely to test positive for COVID-19 than White patients, with 1905 of 2919 Hispanic patients (65.3%), 1935 of 2823 non-Hispanic Black patients (68.5%), and 509 of 960 non-Hispanic White patients (53.0%) having positive test results for SARS-CoV-2 (P < .001). While controlling for age, sex, socioeconomic status and comorbidities, patients identifying as Hispanic (hazard ratio, 0.77; 95% CI, 0.61-0.98; P = .03) or non-Hispanic Black (hazard ratio, 0.69; 95% CI, 0.55-0.87; P = .002) had slightly improved survival compared with non-Hispanic White patients. Conclusions and Relevance: In this cohort study of patients with COVID-19 who presented for care at the same urban medical center, non-Hispanic Black and Hispanic patients did not experience worse risk-adjusted outcomes compared with their White counterparts. This finding is important for understanding the observed population differences in mortality by race/ethnicity reported elsewhere.

Case Fatality Rate of Cancer Patients with COVID-19 in a New York Hospital System.

Patients with cancer are presumed to be at increased risk from COVID-19 infection-related fatality due to underlying malignancy, treatment-related immunosuppression, or increased comorbidities. A total of 218 COVID-19-positive patients from March 18, 2020, to April 8, 2020, with a malignant diagnosis were identified. A total of 61 (28%) patients with cancer died from COVID-19 with a case fatality rate (CFR) of 37% (20/54) for hematologic malignancies and 25% (41/164) for solid malignancies. Six of 11 (55%) patients with lung cancer died from COVID-19 disease. Increased mortality was significantly associated with older age, multiple comorbidities, need for ICU support, and elevated levels of D-dimer, lactate dehydrogenase, and lactate in multivariate analysis. Age-adjusted CFRs in patients with cancer compared with noncancer patients at our institution and New York City reported a significant increase in case fatality for patients with cancer. These data suggest the need for proactive strategies to reduce likelihood of infection and improve early identification in this vulnerable patient population. SIGNIFICANCE: COVID-19 in patients with cancer is associated with a significantly increased risk of case fatality, suggesting the need for proactive strategies to reduce likelihood of infection and improve early identification in this vulnerable patient population.This article is highlighted in the In This Issue feature, p. 890.

Underrepresentation of non-White children in trials of statins in children with heterozygous familial hypercholesterolemia.

BACKGROUND: The elimination of disparities in cardiovascular health is a major focus of the Healthy People 2010 national public health agenda. However, identifying and addressing such disparities within the realm of pediatrics in general, and preventive cardiology in particular, has not received recent attention. In published pediatric clinical trials of statins in heterozygous familial hypercholesterolemia that report race, minority children are underrepresented. OBJECTIVES: The purpose of this analysis was 3-fold: 1) to obtain and report on the racial composition of statin trials in children with heterozygous familial hypercholesterolemia; 2) to explore the hypothesis that founder effects among populations of White children may have facilitated or favored their inclusion in statin trials; and 3) to determine whether the selective lipid screening guidelines based on family history may inadvertently identify fewer minority children who would otherwise qualify for investigative trials. DESIGN: We conducted a Medline search to identify all pediatric familial hypercholesterolemia statin trials. We contacted the corresponding authors to obtain race/ethnicity data and to obtain information about the presence of founder effects in the populations studied. We conducted a second literature search for evidence that selective, family medical history-based screening of children for hypercholesterolemia, as proposed by the National Cholesterol Education Program, might fail to identify minority children who would otherwise qualify for inclusion in these studies. RESULTS: Ninety-two percent of the 885 children enrolled in statin trials were White. A predominance of White children was found even in studies from countries with a sizable population of nonWhite children and where founder effects have not been described. Strong but indirect evidence from both the adult literature and the pediatric literature suggests that the family history-based selective screening engenders healthcare disparities for minority and disadvantaged children. CONCLUSIONS: Non-White children are underrepresented in international clinical trials of statins. Both ethical and pharmacogenomic arguments exist to justify efforts to correct this. Our findings suggest that intensive efforts will be required to arrive at a fair representation of minority children in studies of pediatric heterozygous familial hypercholesterolemia.

Contextual Factors Associated With Quality Improvement Success in a Multisite Ambulatory Setting.

The Model for Understanding Success in Quality (MUSIQ) is a framework of contextual factors for quality improvement (QI) projects. We sought to determine which MUSIQ contextual factors were associated with successful QI initiatives. In a cross-sectional survey study, at a 21-site, ambulatory, urban primary care network, a modified MUSIQ survey tool questionnaire was administered to QI team members. The primary analysis associated objective measures of QI success with MUSIQ contextual factors. Objective QI success was defined as reaching goal percentages of adult patients with diabetes achieving glycated hemoglobin less than 8% and/or pediatric patients who had received combination toddler vaccines. Objective outcomes were compared with a subjective, self-reported outcome measure of QI success because previous literature found subjective outcomes were associated with specific MUSIQ factors. In the 143 survey responses collected, across 21 sites, no contextual factors from the MUSIQ survey were associated with either the adult or pediatric objective measure of QI project success. In a post hoc analysis, objective and subjective measures of success were often not associated and/or negatively correlated. In conclusion, contextual factors were not associated with objective measures of QI outcomes, in contrast to previous studies finding associations with subjective QI outcome measures.

Screening and Referral for Low-Income Families' Social Determinants of Health by US Pediatricians.

OBJECTIVE: To measure the frequency US pediatricians report screening and referring for social needs and identify pediatrician and practice-level predictors for screening and referral. METHODS: Data were from the American Academy of Pediatrics Periodic Survey for October 2014 to March 2015 with a response rate of 46.6% (732/1570). Respondents reported on: 1) routine screening of low-income families for social needs, 2) attitudes toward screening, and 3) referral of low-income families for community resources. Results were analyzed by pediatrician and practice characteristics. RESULTS: Although most pediatricians (61.6%) thought that screening is important, fewer (39.9%) reported that screening is feasible or felt prepared addressing families' social needs (20.2%). The topics that pediatricians reported routinely asking low-income families about at visits (defined as ≥50% visits) were need for childcare (41.5%) and transportation barriers (28.4%). Pediatricians were less likely to report asking about housing (18.7%), food (18.6%), and utilities/heating (14.0%) insecurity. In multivariable analyses, pediatricians were more likely to report both that they screen and refer when they reported having more patients in financial hardship and having someone in the practice with the responsibility to connect low-income families to community services. Pediatricians who endorsed the importance of screening and who reported being prepared were also more likely to screen/refer. CONCLUSIONS: A minority of pediatricians report routinely screening for social needs. Pediatricians were more likely to report that they screen and refer if they had positive attitudes toward the importance of screening, felt prepared, and had support staff to assist families in need.

Effect of Mental Health Screening and Integrated Mental Health on Adolescent Depression-Coded Visits.

Adolescent depression causes morbidity and is underdiagnosed. It is unclear how mental health screening and integrated mental health practitioners change adolescent depression identification. We conducted a retrospective primary care network natural cohort study where 10 out of 19 practices implemented mental health screening, followed by the remaining 9 practices implementing mental health screening with less coaching and support. Afterward, a different subset of 8 practices implemented integrated mental health practitioners. Percentages of depression-coded adolescent visits were compared between practices (1) with and without mental health screening and (2) with and without integrated mental health practitioners, using difference-in-differences analyses. The incidence of depression-coded visits increased more in practices that performed mental health screening (ratio of odds ratios = 1.22; 95% confidence interval =1.00-1.49) and more in practices with integrated mental health practitioners (ratio of odds ratios = 1.58; 95% confidence interval = 1.30-1.93). Adolescent mental health screening and integrated mental health practitioners increase depression-coded visits in primary care.

Risk of Wrong-Patient Orders Among Multiple vs Singleton Births in the Neonatal Intensive Care Units of 2 Integrated Health Care Systems.

IMPORTANCE: Multiple-birth infants in neonatal intensive care units (NICUs) have nearly identical patient identifiers and may be at greater risk of wrong-patient order errors compared with singleton-birth infants. OBJECTIVES: To assess the risk of wrong-patient orders among multiple-birth infants and singletons receiving care in the NICU and to examine the proportion of wrong-patient orders between multiple-birth infants and siblings (intrafamilial errors) and between multiple-birth infants and nonsiblings (extrafamilial errors). DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was conducted in 6 NICUs of 2 large, integrated health care systems in New York City that used distinct temporary names for newborns per the requirements of The Joint Commission. Data were collected from 4 NICUs at New York-Presbyterian Hospital from January 1, 2012, to December 31, 2015, and 2 NICUs at Montefiore Health System from July 1, 2013, to June 30, 2015. Data were analyzed from May 1, 2017, to December 31, 2017. All infants in the 6 NICUs for whom electronic orders were placed during the study periods were included. MAIN OUTCOMES AND MEASURES: Wrong-patient electronic orders were identified using the Wrong-Patient Retract-and-Reorder (RAR) Measure. This measure was used to detect RAR events, which are defined as 1 or more orders placed for a patient that are retracted (ie, canceled) by the same clinician within 10 minutes, then reordered by the same clinician for a different patient within the next 10 minutes. RESULTS: A total of 10 819 infants were included: 85.5% were singleton-birth infants and 14.5% were multiple-birth infants (male, 55.8%; female, 44.2%). The overall wrong-patient order rate was significantly higher among multiple-birth infants than among singleton-birth infants (66.0 vs 41.7 RAR events per 100 000 orders, respectively; adjusted odds ratio, 1.75; 95% CI, 1.39-2.20; P < .001). The rate of extrafamilial RAR events among multiple-birth infants (36.1 per 100 000 orders) was similar to that of singleton-birth infants (41.7 per 100 000 orders). The excess risk among multiple-birth infants (29.9 per 100 000 orders) appears to be owing to intrafamilial RAR events. The risk increased as the number of siblings receiving care in the NICU increased; a wrong-patient order error occurred in 1 in 7 sets of twin births and in 1 in 3 sets of higher-order multiple births. CONCLUSIONS AND RELEVANCE: This study suggests that multiple-birth status in the NICU is associated with significantly increased risk of wrong-patient orders compared with singleton-birth status. This excess risk appears to be owing to misidentification between siblings. These results suggest that a distinct naming convention as required by The Joint Commission may provide insufficient protection against identification errors among multiple-birth infants. Strategies to reduce this risk include using given names at birth, changing from temporary to given names when available, and encouraging parents to select names for multiple births before they are born when acceptable to families.

Increased Medicaid Payment and Participation by Office-Based Primary Care Pediatricians.

BACKGROUND AND OBJECTIVES: Whether the Medicaid primary care payment increase of 2013 to 2014 changed physician participation remains unanswered amid conflicting evidence. In this study, we assess national and state-level changes in Medicaid participation by office-based primary care pediatricians before and after the payment increase. METHODS: Using bivariate statistical analysis, we compared survey data collected from 2011 to 2012 and 2015 to 2016 by the American Academy of Pediatrics from state-stratified random samples of pediatrician members. RESULTS: By 4 of 5 indicators, Medicaid participation increased nationally from 2011 and 2012 to 2015 and 2016 (n = 10 395). Those accepting at least some new patients insured by Medicaid increased 3.0 percentage points (ppts) to 77.4%. Those accepting all new patients insured by Medicaid increased 5.9 ppts to 43.3%, and those accepting these patients at least as often as new privately insured patients increased 5.7 ppts to 55.6%. The average percent of patients insured by Medicaid per provider panel increased 6.0 ppts to 31.3%. Nonparticipants dropped 2.1 ppts to 14.6%. Of the 27 studied states, 16 gained in participation by 1 or more indicators, 11 gained by 2 or more, and 3 gained by all 5. CONCLUSIONS: Office-based primary care pediatricians increased their Medicaid participation after the payment increase, in large part by expanding their Medicaid panel percentage. Continued monitoring of physician participation in Medicaid at the national and state levels is vital for guiding policy to optimize timely access to appropriate health care for >37 million children insured by Medicaid.

United States Pediatricians' Attitudes Regarding Public Policies for Low-Income Children and Their Profession's Advocacy Priorities.

OBJECTIVE: To examine pediatricians' attitudes toward public policies for low-income children and the advocacy efforts for the American Academy of Pediatrics (AAP). METHODS: Data from the AAP Periodic Survey in October 2014 to March 2015 were used. Respondents ranked 1) attitudes toward government programs, and 2) attitudes toward AAP policies on: income support, housing, education, job training, food, and health care. Results were analyzed according to age, gender, practice location, practice region, type of practice setting, and percent of patients with economic hardship. RESULTS: Response rate was 47% (n = 650). Most respondents reported that for children, the government should guarantee health insurance (88.9%), and food and shelter (90.0%). Most also reported that the government should guarantee health insurance (68.9%) and food and shelter (63.9%) for every citizen and to take care of people who cannot take care of themselves. There was variation among the level of support on the basis of practice setting. In multivariable analyses related to supporting the role of government for children and citizens, not being from the Northeast was associated with lower odds of support of children as well as citizens; primary care practices in rural areas were less supportive of government involvement related to all citizens but similar for children; and those younger than 40 and 50 to 59 years of age were more supportive of government guaranteeing enough to eat and a place to sleep for children. More than 55% supported the AAP advocating for income support, housing, education, and access to health care. CONCLUSIONS: Pediatricians strongly support government policies that affect child poverty and the provision of basic needs to families. This support should be used to inform professional organizations, advocates, and policy-makers focused on children and families.

A Learning Collaborative Approach to Improve Primary Care STI Screening.

The Bronx Ongoing Pediatric Screening (BOPS) project sought to improve screening for sexual activity and sexually transmitted infections (gonorrhea and chlamydia [GCC] and HIV) in a primary care network, employing a modified learning collaborative, real-time clinical data feedback to practices, improvement coaching, and a pay-for-quality monetary incentive. Outcomes are compared for 11 BOPS-participating sites and 10 non-participating sites. The quarterly median rate for documenting sexual activity status increased from 55% to 88% (BOPS sites) and from 13% to 74% (non-BOPS sites). GCC screening of sexually active youth increased at BOPS and non-BOPS sites. Screening at non-health care maintenance visits improved more at BOPS than non-BOPS sites. Data from nonparticipating sites suggests that introduction of an adolescent EMR template or other factors improved screening rates regardless of BOPS participation; BOPS activities appear to promote additional improvement of screening during non-health maintenance visits.

Maternal education, child immunizations, and public policy: evidence from the US National Immunization Survey.

This article measures the independent association of maternal education level and childhood immunization rates in the USA and compares the associations in states that provide free vaccines to all residents (Universal) and those that do not (non-Universal). To do this, the US-based National Immunization Survey data from 1995 to 2003 for children 19-35 months of age were analyzed. Unadjusted estimates of up-to-date status for the 4:3:1:3:3 series and the pneumococcal conjugate vaccine were estimated by the level of maternal education. Linear probability regressions produced adjusted estimates of maternal education effects controlling for covariates. Adjusting for race/ethnicity, income, and other covariates, children of mothers with less than high school education were found to be 7.8% (p<0.05) less likely than children of mothers with college education to be up-to-date for the 4:3:1:3:3 vaccine series. For the newer pneumococcal conjugate vaccine, these children were 4.5% (p<0.05) less likely to be up-to-date. Residence in a Universal state was found to significantly attenuate these effects. As such, higher maternal education, independent of income and race/ethnicity is associated with improved child immunization rates, but subsidizing immunization choices diminishes the disadvantage associated with lower maternal educational achievement.

Preventive pediatric mental health care: A co-location model.

Current practice recommendations in both the fields of infant mental health and pediatrics support the co-location of mental health professionals into the pediatric setting. Multiple policy reports and statements of the past 5 years have repeatedly argued the need for coordination and integration between mental health care and pediatrics (Halfon, Regalado, McLearn, Kuo, & Wright, 2003; Osofsky, 2004). The pediatric office is recognized as a universally accessed, nonstigmatized setting, ideal for the assessment and treatment of early childhood mental health problems. However, barriers to this type of care are rampant, including time limitations on the part of pediatricians, inadequate reimbursement structures, inadequate training of pediatricians, and insufficient connections between medical and mental health providers. An innovative response to these barriers is the co-location of a mental health professional in the pediatric practice to provide pediatrician education and appropriate screening, assessment, referral, and treatment of young patients. This article describes a successful program of this type situated in the Bronx, NY, where a psychologist with expertise in infant mental health spends 25 hours per week in a large pediatric practice to address the developmental and mental health needs of children aged 0-3 years old. Preliminary descriptive data regarding the patient population, screening scores, and disposition are presented.