Factors Associated With Mortality and Hospice Use Among Medicare Beneficiaries With Heart Failure Who Received Home Health Services.

BACKGROUND: Although many Medicare beneficiaries with heart failure (HF) are discharged with home health services, little is known about mortality rates and hospice use in this group. OBJECTIVES: To identify risk factors for 6-month mortality and hospice use among patients hospitalized due to HF who receive home health care, which could inform efforts to improve palliative and hospice use for these patients. METHODS: A retrospective cohort analysis was conducted in a 100% national sample of Medicare fee-for-service beneficiaries with HF who were discharged to home health care between 2017 and 2018. Multivariable Cox regression models examined factors associated with 6-month mortality, and multivariable logistic regression models examined factors associated with hospice use at the time of death. RESULTS: A total of 285,359 Medicare beneficiaries were hospitalized with HF and discharged with home health care; 15.5% (44,174) died within 6 months. Variables most strongly associated with mortality included: age > 85 years (hazard ratio [HR] 1.66, 95% CI 1.61-1.71), urgent/emergency hospital admission (HR 1.68, 1.61-1.76), and "serious" condition compared to "stable" condition (HR 1.64, CI 1.52-1.78). Among 44,174 decedents, 48.2% (21,284) received hospice care at the time of death. Those with lower odds of hospice use at death included patients who were: < 65 years (odds ratio [OR] 0.65, CI 0.59-0.72); of Black (OR 0.64, CI 0.59-0.68) or Hispanic race/ethnicity (OR 0.79, CI 0.72-0.88); and Medicaid-eligible (OR 0.80, CI 0.76-0.85). CONCLUSIONS: Although many patients hospitalized for HF are at risk of 6-month mortality and may benefit from palliative and/or hospice services, our findings indicate under-use of hospice care and important disparities in hospice use by race/ethnicity and socioeconomic status.

Doppler Ultrasound and Resistive Indices in the Diagnosis of Ureteropelvic Junction Obstruction in the Pediatric Population.

OBJECTIVES: Mercapto acetyl tri-glycine renogram (MAG3) scan has been the gold standard assessment of pediatric ureteropelvic junction obstruction (UPJO) but requires intravenous access and radiation exposure. While Doppler ultrasound measurements of resistive indices (RI) of the arcuate arteries have been proposed as an alternative assessment of obstruction, they have not been widely adopted in the pediatric population. We hypothesized that RI of the main renal artery (RA) is more strongly correlated with MAG3 findings than arcuate RI. METHODS: Pediatric patients with unilateral Society for Fetal Urology grade 3-4 hydronephrosis undergoing concomitant RUS and MAG3 were recruited. Doppler ultrasound peak systolic velocity (PSV); RI of bilateral RA at the origin, middle, and hilum; and RI of the superior, middle, and lower pole arcuate arteries were obtained. MAG3 differential renal function (DRF) and T½ were recorded. Differences in RI measurements (DRI) between the affected and normal kidney were calculated and compared with DRF and T½. RESULTS: 31 patients (median 4.6-month-old) were enrolled. Only RA RI at the origin differed between affected and normal kidneys (p < .001). DRI RA at the origin showed weak evidence for an association with MAG3 DRF < 40% (p .07). DRI was not associated with T½ > 20 minutes. CONCLUSION: There was weak evidence for an association between RA DRI at the origin and DRF but not with T½. These findings suggest that RA DRI may provide additional data in the evaluation of patients with UPJO to tailor the use of MAG3 and associated risk of radiation exposure to those patients most at risk for concomitant renal function impairment.

Is tailored messaging more effective? An analysis of a digital health intervention to promote HPV vaccination intent among Latinx.

Latinx populations have unique barriers to HPV vaccination. In the current study, we assessed the effectiveness of an online intervention to increase HPV vaccination intentions among patients of clinics that principally serve a Latinx population (n = 85%) as part of a randomized control trial (RCT). Participants viewed on an iPad either an individually tailored educational website (CHiCOS) or untailored information derived from the Vaccine Information Sheet (VIS) for HPV. Vaccination intention and related covariates were assessed via survey items administered before (pre-test) and after (post-test) viewing the material. No statistically significant differences were seen in changes of intention to vaccinate between groups (N = 1294). However, 16% of all (tailored and untailored combined) participants increased in their intention to vaccinate, while 7% decreased in intention. Overall 72% of participants had high intentions to vaccinate, yet far fewer actually received a vaccine dose. The current study explores implications of the demonstrated intention-behavior gap. As such, it presents opportunities to improve future interventions-specifically those that employ tailored messaging.

Use of electronic health record best practice alerts to improve adherence to American Urological Association vesicoureteral reflux guidelines.

PURPOSE: To evaluate the effect of a guidelines-based best practice alerts (BPA) in the electronic health record (EHR) on adherence to American Urological Association (AUA) vesicoureteral reflux (VUR) guidelines. METHODS: Retrospective cohort study of patients aged 0-17 years old with primary VUR with an initial urology clinic visit the year before or year after BPA implementation was done. Primary outcomes include obtaining vital signs, urinalysis, and ultrasound at initial and 1-year follow-up visit. RESULTS: We identified 123 patients with initial visits during the study period, 58 of whom returned for 1-year follow-up visits. Patients seen post-BPA were more likely to have height measured at initial visit than those seen pre-BPA (47.3% vs. 11.8%, p < 0.001). The majority of patients were screened with weight (98.3%) and ultrasound (87.9%) at 1-year follow-up both before and after BPA implementation. Neither blood pressure measurements (59.1% vs. 55.6%, p > 0.5) nor urinalysis orders (23.8% vs. 19.4%, p > 0.05) significantly increased post-BPA. CONCLUSION: The use of an EHR-based BPA increased the likelihood of obtaining height measurements by clinic intake staff but did not significantly affect provider adherence to other practice guideline recommendations. Our findings suggest that BPA implementation alone is not sufficient to impact provider uptake of VUR guideline recommendations.

Novel Claims-Based Outcome Phenotypes in Survivors of Pediatric Traumatic Brain Injury.

OBJECTIVE: For children hospitalized with acute traumatic brain injury (TBI), to use postdischarge insurance claims to identify: (1) healthcare utilization patterns representative of functional outcome phenotypes and (2) patient and hospitalization characteristics that predict outcome phenotype. SETTING: Two pediatric trauma centers and a state-level insurance claim aggregator. PATIENTS: A total of 289 children, who survived a hospitalization after TBI between 2009 and 2014, were in the hospital trauma registry, and had postdischarge insurance eligibility. DESIGN: Retrospective cohort study. MAIN MEASURES: Unsupervised machine learning to identify phenotypes based on postdischarge insurance claims. Regression analyses to identify predictors of phenotype. RESULTS: Median age 5 years (interquartile range 2-12), 29% (84/289) female. TBI severity: 30% severe, 14% moderate, and 60% mild. We identified 4 functional outcome phenotypes. Phenotypes 3 and 4 were the highest utilizers of resources. Morbidity burden was highest during the first 4 postdischarge months and subsequently decreased in all domains except respiratory. Severity and mechanism of injury, intracranial pressure monitor placement, seizures, and hospital and intensive care unit lengths of stay were phenotype predictors. CONCLUSIONS: Unsupervised machine learning identified postdischarge phenotypes at high risk for morbidities. Most phenotype predictors are available early in the hospitalization and can be used for prognostic enrichment of clinical trials targeting mitigation or treatment of domain-specific morbidities.

Development and Validation of a Predictive Model of the Risk of Pediatric Septic Shock Using Data Known at the Time of Hospital Arrival.

OBJECTIVE: To derive and validate a model of risk of septic shock among children with suspected sepsis, using data known in the electronic health record at hospital arrival. STUDY DESIGN: This observational cohort study at 6 pediatric emergency department and urgent care sites used a training dataset (5 sites, April 1, 2013, to December 31, 2016), a temporal test set (5 sites, January 1, 2017 to June 30, 2018), and a geographic test set (a sixth site, April 1, 2013, to December 31, 2018). Patients 60 days to 18 years of age in whom clinicians suspected sepsis were included; patients with septic shock on arrival were excluded. The outcome, septic shock, was systolic hypotension with vasoactive medication or ≥30 mL/kg of isotonic crystalloid within 24 hours of arrival. Elastic net regularization, a penalized regression technique, was used to develop a model in the training set. RESULTS: Of 2464 included visits, septic shock occurred in 282 (11.4%). The model had an area under the curve of 0.79 (0.76-0.83) in the training set, 0.75 (0.69-0.81) in the temporal test set, and 0.87 (0.73-1.00) in the geographic test set. With a threshold set to 90% sensitivity in the training set, the model yielded 82% (72%-90%) sensitivity and 48% (44%-52%) specificity in the temporal test set, and 90% (55%-100%) sensitivity and 32% (21%-46%) specificity in the geographic test set. CONCLUSIONS: This model estimated the risk of septic shock in children at hospital arrival earlier than existing models. It leveraged the predictive value of routine electronic health record data through a modern predictive algorithm and has the potential to enhance clinical risk stratification in the critical moments before deterioration.

Cost and reimbursement of providing routine vaccines in outpatient obstetrician/gynecologist settings.

OBJECTIVE: To determine the costs and reimbursement associated with running a vaccine program in 5 obstetrics/gynecology practices in Colorado that had participated in a 3-year randomized, controlled trial focused on increasing vaccination in this setting. MATERIALS AND METHODS: This was a secondary analysis on costs from 5 clinics participating in a cluster-randomized controlled trial that assessed the effectiveness of a multimodal intervention to improve vaccination rates in outpatient obstetrics/gynecology clinics in central Colorado. The intervention included designation of an immunization champion within the practice, purchasing recommended vaccines for the practice, guidance on storage and management, implementing practices for routine identification of eligible patients for vaccination using the medical record, implementation of standing orders for vaccination, and vaccine administration to patients. Data on costs were gathered from office invoices, claims data, surveys and in-person observations during the course of the trial. These data incorporated supply and personnel costs for administering vaccines to individual patients that were derived from a combination of time-motion studies of staff and provider clinical activity, and practice reports, as well as costs related to maintaining the vaccination program at the practice level, which were derived from practice reports and invoices. Cost data for personnel time during visits in which vaccination was assessed and/or discussed, but no vaccine was given to the patient were also included in the main analysis. Data on practice revenue were derived from practice reimbursement records. All costs were described in 2014 dollars. The primary analysis was the proportion of costs for the program that were reimbursed, aggregated over all years of the study and combining all vaccines and practices, separated by obstetrics vs gynecology patients. RESULTS: Collectively the 5 clinics served >40,000 patient during the study period and served a population that was 16% Medicaid. Over the 3-year observation period, there were 6573 vaccination claims made collectively by the practices (4657 for obstetric patients, 1916 for gynecology patients). The most expensive component of the program was the material costs of the vaccines themselves, which ranged from a low of $9.67 for influenza vaccines, to a high of $141.40 for human papillomavirus vaccine. Staff costs for assessing and delivering vaccines during patient visits were minimal ($0.09-$1.24 per patient visit depending on the practice and whether an obstetrics or gynecology visit was being assessed) compared with staff costs for maintaining the program at a practice level (ie, assessing inventory, ordering and stocking vaccines; $0.89-$105.89 per vaccine dose given). When assessing all costs compared with all reimbursement, we found that vaccines for obstetrics patients were reimbursed at 159% of the costs over the study period, and for gynecology patients at 97% of the costs. Overall, the vaccination program was financially favorable across the practices, averaging 125% reimbursement of costs across the three study years. CONCLUSION: Providing routine vaccines to patients in the ambulatory obstetrics/gynecology setting is generally not financially prohibitive for practices, and may even be financially beneficial, though there is variability between practices that can affect the overall reimbursement margin.

A Values-Tailored Web-Based Intervention for New Mothers to Increase Infant Vaccine Uptake: Development and Qualitative Study.

BACKGROUND: Vaccine hesitancy among parents leads to childhood undervaccination and outbreaks of vaccine-preventable disease. As the reasons for vaccine hesitancy are diverse, there is often not enough time during regular clinical visits for medical providers to adequately address all the concerns that parents have. Providing individually tailored vaccine information via the internet before a clinical visit may be a good mechanism for effectively allaying parents' vaccination concerns while also being time efficient. Including tailoring based on values is a promising, but untested, approach to message creation. OBJECTIVE: This study aimed to describe the process by which we developed a Web-based intervention that is being used in an ongoing randomized controlled trial aimed at improving the timeliness of infant vaccination by reducing parental vaccine hesitancy. METHODS: Development of the intervention incorporated evidence-based health behavior theories. A series of interviews, surveys, and feedback sessions were used to iteratively develop the intervention in collaboration with vaccination experts and potential end users. RESULTS: In all, 41 specific content areas were identified to be included in the intervention. User feedback elucidated preferences for specific design elements to be incorporated throughout the website. The tile-based architecture chosen for the website was perceived as easy to use. Creating messages that were two-sided was generally preferred over other message formats. Quantitative surveys identified associations between specific vaccine values and vaccination beliefs, suggesting that values tailoring should vary, depending on the specific belief being endorsed. CONCLUSIONS: Using health behavior theories, qualitative and quantitative data, and significant expert and end user input, we created a novel, Web-based intervention to improve infant vaccination timeliness. The intervention is based on tailoring messages according to each individual's values and beliefs. This intervention is currently being tested in a controlled randomized clinical trial.

The role of preoperative instructions in parents' understanding of preoperative fasting for outpatient pediatric urology procedures.

PURPOSE: To assess the impact of modifications in preoperative instructions on parental understanding of preoperative fasting guidelines. METHODS: A prospective postoperative parental survey was conducted to assess parental understanding of preoperative fasting requirements in patients undergoing surgery before and after institution of instructions that included visual aids. Data regarding demographics, procedure type, and time to surgery from preoperative visit were also captured. Survey data were compared between pre- and post-intervention groups using Chi-squared tests for categorical variables and Wilcoxon rank sum test for continuous variables. RESULTS: 173 parents in the pre-intervention group and 162 parents in the post-intervention group were included in the analysis. Parent identification of aspiration risk as the reason for fasting almost doubled after intervention (72.2% vs. 38.2%). There was some evidence of demographic differences between groups; however, in an adjusted model, there was strong evidence (p < 0.001) that parents in the post-intervention group were more likely to identify aspiration as the reason for preoperative fasting (OR 4.73; 95% CI 2.93-7.63). CONCLUSIONS: Addition of visual aids in preoperative instructions was associated with improvement in parents' understanding of the rationale behind preoperative fasting instructions. Further studies are needed to determine whether improved understanding is associated with improved adherence.

Timing of Information-Seeking about Infant Vaccines.

OBJECTIVES: To assess among pregnant and recently delivered women the timing of thinking about and seeking information about childhood vaccines and the preferred modes of vaccine education. STUDY DESIGN: An e-mail survey among women in 9 urban and rural obstetrics practices in Colorado was conducted from February to April 2014, timed so that approximately one-half had delivered and one-half were still pregnant, designed to assess the frequency of thinking about and seeking information about vaccines in relation to estimated or actual delivery date. A shortened version of the Parental Attitudes About Childhood Vaccines scale was used to assess vaccine hesitancy. RESULTS: The response rate was 54% (230 of 425); 56% were pregnant, 44% had delivered, and 18% were vaccine-hesitant. Compared with pregnant women, women who had delivered more often reported thinking about vaccines for their infant (pregnant: 19% often, 42% sometimes; delivered: 29% often, 51% sometimes; P < .05) and looking for information about vaccines (pregnant: 6% often, 22% sometimes; delivered: 16% often, 34% sometimes; P < .01). Women most frequently reported seeking information about vaccines 2-4 weeks after delivery, followed by 4-6 weeks after delivery. The most preferred method for vaccine education was their child's doctor (95% acceptable; 92% likely to use) followed by their obstetrician (79% acceptable; 64% likely to use). CONCLUSIONS: Within 6 weeks postdelivery appears to be when the most women seek vaccine information. A child's doctor remains the most acceptable source of vaccine education.

Effectiveness on Early Childhood Caries of an Oral Health Promotion Program for Medical Providers.

OBJECTIVES: To assess an oral health promotion (OHP) intervention for medical providers' impact on early childhood caries (ECC). METHODS: We implemented a quasiexperimental OHP intervention in 8 federally qualified health centers that trained medical providers on ECC risk assessment, oral examination and instruction, dental referral, and fluoride varnish applications (FVAs). We measured OHP delivery by FVA count at medical visits. We measured the intervention's impact on ECC in 3 unique cohorts of children aged 3 to 4 years in 2009 (preintervention; n = 202), 2011 (midintervention; n = 420), and 2015 (≥ 4 FVAs; n = 153). We compared numbers of decayed, missing, and filled tooth surfaces using adjusted zero-inflated negative binomial models. RESULTS: Across 3 unique cohorts, the FVA mean (range) count was 0.0 (0), 1.1 (0-7), and 4.5 (4-7) in 2009, 2011, and 2015, respectively. In adjusted zero-inflated negative binomial models analyses, children in the 2015 cohort had significantly fewer decayed, missing, and filled tooth surfaces than did children in previous cohorts. CONCLUSIONS: An OHP intervention targeting medical providers reduced ECC when children received 4 or more FVAs at a medical visit by age 3 years.

Postpartum depression and timing of spousal military deployment relative to pregnancy and delivery.

OBJECTIVE: This study aimed to determine the relationship between spousal deployment and postpartum depression diagnosis among U.S. military wives, accounting for the timing of deployment with respect to pregnancy and delivery. METHODS: A retrospective cohort study was conducted to evaluate the association between spousal deployment and postpartum depression among pregnant wives of active-duty service members. Electronic medical records for 161,454 births occurring between 2004 and 2009 were used to define postpartum depression. Three non-mutually exclusive exposure variables were created to categorize deployments as occurring before, during, or after the infant's delivery. A multivariable logistic regression model mutually adjusted for these exposure variables was fitted, producing an odds ratio for each of the three timing categories. RESULTS: A modest significant association was detected only in those whose husbands deployed in pregnancy and returned after delivery (i.e., deployed during delivery) [odds ratio (OR) 1.10, 95 % confidence interval (CI) 1.04-1.15]. An interactive effect between preexisting depression or anxiety and deployment during delivery was also detected in the data (OR 1.13, 95 % CI 1.07-1.20 for those without a preexisting diagnosis; OR 0.87, 95 % CI 0.80-0.95 for those with a preexisting diagnosis). CONCLUSION: Health care providers should continue to be aware of spousal deployment as a military-unique stressor in this population and rigorously screen for potential symptoms of postpartum depression, especially among those whose husbands are absent at delivery.

Caregiver decisional regret following reconstructive bladder surgery in children with neurogenic bladder.

BACKGROUND: Surgical management for neurogenic bladder requires complex decision-making by physicians, patients, and caregivers. Assessing decisional regret (DR) as a patient-reported outcome among caregivers could inform future counseling and shared decision-making. OBJECTIVE: To assess DR among caregivers of children with neurogenic bladder following reconstructive bladder surgery. STUDY DESIGN: A questionnaire including a validated DR survey was distributed to English-speaking caregivers of children with neurogenic bladder who had undergone reconstructive bladder surgery at Children's Hospital Colorado. DR scores range from zero to 100, with higher numbers indicating higher regret. Wilcoxon rank sum test and Spearman correlation were performed to assess differences in DR scores by patient demographic factors or disease factors. RESULTS: Forty-five of 210 English-speaking caregivers completed the DR survey. The median DR score was 5, with 40% of subjects reporting with a DR score of zero and 24% of subjects with a DR score of 30 or higher. Patient sex and Mitrofanoff leakage were found to be associated with DR, with caregivers of male patients reporting significantly higher DR. Surgical procedure did not have a statistically significant impact on DR scores. DISCUSSION: Sparse existing data exploring DR among patients with neurogenic bladder suggest DR following reconstructive bladder surgery is low, with few identifiable predictors of regret. While the majority of caregivers in our study report little or no DR, one quarter of caregivers report moderate to high DR. The limitations of this study include small cohort size, low response rate, exclusion of non-English speaking patients, and the potential for recall bias due to the survey design of the study. CONCLUSION: Caregiver DR following bladder reconstruction in children with neurogenic bladder is generally low, however a subset of caregivers reports significant DR. This study suggests that caregivers of male children may have higher DR, a finding that merits further investigation.

Health Differs by Foster Care Eligibility: A Nine-Year Retrospective Observational Study Among Medicaid-Enrolled Children.

OBJECTIVE: This study sought to determine the prevalence and rates of physical, behavioral, and chronic health conditions among Medicaid-enrolled Colorado children by foster care eligibility codes over 9 years. METHODS: This retrospective, population-based study used Colorado's Medicaid administrative data for all enrolled children, aged <19 years old, from July 2011 to August 2020 to determine the period prevalence and rates of physical, behavioral, and chronic health conditions. We identified children in foster care by Medicaid eligibility codes and used the Pediatric Medical Complexity Algorithm version 3.0 to describe health condition outcomes. We report frequencies and percentages by foster care eligibility status, birth year cohort, and sex. RESULTS: Among 1,084,026 children, we identified 34,971 children in the foster cohort. Rates of physical (1105.0 per 100,000 person-months (PMs)) and behavioral health conditions (583.6 per 100,000 PMs) were two to threefold higher among the foster cohort than peers (physical 685.1 per 100,000 PMs; behavioral 212.2 per 100,000 PMs). By birth cohort, rates of behavioral health conditions among children in foster care were up to 8 times greater than peers. The foster cohort had greater prevalence of chronic conditions with (55.2%) and without (38.6%) behavioral health inclusion. CONCLUSIONS: This study provides a broader health assessment among Medicaid-enrolled children and finds condition disparities concentrated among youth in foster care. A more complete understanding of health problems among children in foster care is critical for health, child welfare, and Medicaid systems to improve health outcomes through coordinated and evidence-based interventions, programs, and policies.

Comparison of the effectiveness of trivalent inactivated influenza vaccine and live, attenuated influenza vaccine in preventing influenza-like illness among US military service members, 2006-2009.

BACKGROUND: Influenza is a significant cause of morbidity, and vaccination is the preferred preventive strategy. Data regarding the preferred influenza vaccine type among adults are limited. METHODS: The effectiveness of 2 currently available influenza vaccines LAIV and TIV in preventing influenza-like illness (ILI) was compared among US military members (aged 18-49 years) during 3 consecutive influenza seasons (2006-2009). ILI, influenza, and pneumonia events post-vaccination were compared between vaccine types using Cox proportional hazard models adjusted for sociodemographic factors, occupation, and geographic area. RESULTS: A total of 41 670 vaccination events were evaluated, including 28 929 during 2 "well-matched" seasons (2006-2007 and 2008-2009: LAIV n = 22 734, TIV n = 6195) and 12 741 during a suboptimally matched season due to mild antigenic drift (2007-2008: LAIV n = 9447, TIV n = 3294). ILI crude incidence rates for LAIV and TIV were 139 and 127 cases per 1000 person-seasons for the well-matched seasons, respectively, and 150 and 165 cases per 1000 person-seasons for the suboptimally matched season, respectively. In the multivariable models, there were no differences in ILI events by vaccine type (well-matched seasons: hazard ratio [HR], 0.97; 95% confidence interval [CI], .90-1.06; suboptimally matched season: HR, 1.00; 95% CI, .90-1.11). There were also no differences in influenza and/or pneumonia events by vaccine group. CONCLUSIONS: Between 2006 and 2009, TIV and LAIV had similar effectiveness in preventing ILI and influenza/pneumonia events among healthy adults.

Birth defects in infants born in 1998-2004 to men and women serving in the U.S. military during the 1990-1991 Gulf War era.

BACKGROUND: Concerns about reproductive health persist among U.S. military members who served in the 1990-1991 Gulf War. This study explores the long-term impact of 1990-1991 Gulf War deployment on the prevalence of birth defects among infants of Gulf War veterans. METHODS: Health care data from the Department of Defense Birth and Infant Health Registry and demographic and deployment information from the Defense Manpower Data Center were used to identify infants born between 1998 and 2004 to both male and female 1990-1991 Gulf War veterans. Multivariable logistic regression models estimated the adjusted odds of any birth defect and eight specific birth defects among infants of deployers versus non-deployers. In addition, birth defects were evaluated among infants born to 1990-1991 Gulf War veterans with deployment-specific exposures. RESULTS: Among 178,766 infants identified for these analyses, 3.4% were diagnosed with a birth defect in the first year of life. Compared to infants of non-deployers, infants of deployers were not at increased odds of being diagnosed with a birth defect, or any of eight specific birth defects, in the first year of life. A slightly increased prevalence of birth defects was observed among infants born to men who deployed to the 1990-1991 Gulf War for 153 to 200 days compared to those who deployed for 1 to 92 days. No other deployment-specific exposures were associated with birth defects in these infants. CONCLUSIONS: The 1990-1991 Gulf War deployers, including those with specific exposures of concern, were not found to be at increased risk for having infants with birth defects 7 to 14 years after deployment.

No-Show Rates for Telemedicine Versus In-Person Appointments During the COVID-19 Pandemic: Implications for Medicaid Populations.

The objective of this study was to assess no-show rates among in-person and telemedicine visits during the COVID-19 pandemic among Medicaid members. We analyzed data from an urban safety net hospital in Denver, Colorado. Using multivariable binomial regression models, we estimated differences in probability of no shows by patient characteristics and assessed for effect modification by telemedicine use. Overall, the no-show rate was 20.5% with increased probability of no show among Hispanic (2.3%) and non-Hispanic, Black (7.4%) patients compared with their non-Hispanic, White counterparts. Modification by telemedicine was observed, decreasing no-show rates among both groups (P < .0001). Similar patterns were observed among medically complex patients. Audio-only telemedicine significantly impacted no-show rates within certain populations.

Exploring mechanisms of a web-based values-tailored childhood vaccine promotion intervention trial: Effects on parental vaccination values, attitudes, and intentions.

A recent childhood vaccine promotion intervention trial showed no effects on vaccination outcomes relative to usual care. The purpose of this paper was to test assumptions and theory-based relationships underlying hypothesised mechanisms for two vaccine promotion educational websites (one tailored to parental values, beliefs, and intentions; one untailored) compared with usual care. This is a secondary analysis of a three-arm randomized controlled trial. Parental vaccine values, hesitancy, attitudes, and intention to vaccinate surveys were administered at baseline (≤2 months) and at 4-6 and 10-12 months of age. Vaccination was assessed using electronic health records. Analyses included random coefficient models and risk differences with exact confidence limits. Parental vaccine values were mostly stable over time. Vaccine attitudes were generally positive, with no differences among study arms. Both tailored and untailored website arms showed similar increases in intention to vaccinate more than usual care. Positive changes in intentions were associated with lower rates of late vaccination. Although attitudes and intentions predicted vaccination behavior and the intervention increased intention to vaccinate all on time, the web-based education and values-tailored messaging approaches were not effective at increasing vaccination rates. Intentions are necessary but insufficient targets for vaccine promotion interventions.

Feasibility of establishing a multi-center research database using the electronic health record: The PURSUIT network.

BACKGROUND: Although multi-center research is needed in pediatric urology, collaboration is impeded by differences in physician documentation and research resources. Electronic health record (EHR) tools offer a promising avenue to overcome these barriers. OBJECTIVE: To assess the accuracy, completeness, and utilization of structured data elements across multiple practices. STUDY DESIGN: A standardized template was developed and implemented at five academic pediatric urology practices to document clinic visits for patients with congenital hydronephrosis and/or vesicoureteral reflux. Data from standardized elements in the template and from pre-existing EHR fields were extracted into a secure database. A 20% random sample of infants with data from structured elements from 1/1/2020 and 4/30/2021 were identified and compared to manual chart review at sites with >100 charts; all other sites reviewed at least 20 charts. Manual chart review was standardized across sites and included: clinic and operative notes, orders linked to the clinic encounter, radiology results, and active medications. Accuracy of data extraction was evaluated by computing the kappa statistic and percentage agreement. For sites that had adopted the templates prior to 6/1/2019 (early adopters), a list of eligible patients with an initial clinic visit from 1/1/2020-7/27/2020 was generated using standardized reporting techniques and confirmed by manual chart review. Physician utilization of the template was then calculated by comparing patients with data obtained from the note template to the generated list of eligible patients. RESULTS: 230 patient records met study criteria. Agreement between manual chart review and data extracted from the EHR was high (>85%). Race, ethnicity and insurance data were misclassified in about 10-15% of cases; this was due to site-specific differences in how these fields were coded. Renal ultrasound was misclassified 12% of the time; this was primarily due to outside images documented in radiology results but not included in the clinical note. All other data elements had >90% agreement (Figure). Template utilization for early adopters was >75% (75.5-87.5%). DISCUSSION: This is the first study in urology to demonstrate that use of structured data elements can support multi-center research. Limitations include: inclusion of only academic sites with the Epic EHR and lack of data on utilization and sustainability at sites without a prior history of structured template use. CONCLUSIONS: Multi-center research collaboration using EHR-based data collection tools is feasible with generally high accuracy compared to manual chart review. Additionally, sites with a long history of template adoption have high levels of provider utilization.