The implementation of an integrated information system for substance use screening in general medical settings.

UNLABELLED: The Massachusetts Screening, Brief Intervention and Referral to Treatment (MASBIRT) Program, a substance use screening program in general medical settings, created a web-based, point-of-care (POC), application--the MASBIRT Portal (the "Portal") to meet program goals. OBJECTIVES: We report on development and implementation of the Portal. METHODS: Five year program process outcomes recorded by an independent evaluator and an anonymous survey of Health Educator's (HEs) adoption, perceptions and Portal use with a modified version of the Technology Readiness Index are described. [8] Specific management team members, selected based on their roles in program leadership, development and implementation of the Portal and supervision of HEs, participated in semi-structured, qualitative interviews. RESULTS: At the conclusion of the program 73% (24/33) of the HEs completed a survey on their experience using the Portal. HEs reported that the Portal made recording screening information easy (96%); improved planning their workday (83%); facilitated POC data collection (84%); decreased time dedicated to data entry (100%); and improved job satisfaction (59%). The top two barriers to use were "no or limited wireless connectivity" (46%) and "the tablet was too heavy/bulky to carry" (29%). Qualitative management team interviews identified strategies for successful HIT implementation: importance of engaging HEs in outlining specifications and workflow needs, collaborative testing prior to implementation and clear agreement on data collection purpose, quality requirements and staff roles. DISCUSSION: Overall, HEs perceived the Portal favorably with regard to time saving ability and improved workflow. Lessons learned included identifying core requirements early during system development and need for managers to institute and enforce consistent behavioral work norms. CONCLUSION: Barriers and HEs' views of technology impacted the utilization of the MASBIRT Portal. Further research is needed to determine best approaches for HIT system implementation in general medical settings.

Randomized trial of a family-based, automated, conversational obesity treatment program for underserved populations.

OBJECTIVE: To evaluate the acceptability and feasibility of a scalable obesity treatment program integrated with pediatric primary care (PC) and delivered using interactive voice technology (IVR) to families from underserved populations. DESIGN AND METHODS: Fifty parent-child dyads (child 9-12 yrs, BMI > 95th percentile) were recruited from a pediatric PC clinic and randomized to either an IVR or a wait-list control (WLC) group. The majority were lower-income, African-American (72%) families. Dyads received IVR calls for 12 weeks. Call content was informed by two evidence-based interventions. Anthropometric and behavioral variables were assessed at baseline and 3-month follow-up. RESULTS: Forty-three dyads completed the study. IVR parents ate one cup more fruit than WLC (P < 0.05). No other group differences were found. Children classified as high users of the IVR decreased weight, BMI, and BMI z-score compared to low users ( P < 0.05). Mean number of calls for parents and children were 9.1 (5.2 SD) and 9.0 (5.7 SD), respectively. Of those who made calls, >75% agreed that the calls were useful, made for people like them, credible, and helped them eat healthy foods. CONCLUSION: An obesity treatment program delivered via IVR may be an acceptable and feasible resource for families from underserved populations.

Quality indicators and quality assessment in child health.

Quality indicators are systematically developed statements that can be used to assess the appropriateness of specific healthcare decisions, services and outcomes. In this review, the range and type of indicators that have been developed for children in the UK and USA by prominent governmental agencies and private organisations are highlighted. These indicators are classified in an effort to identify areas of child health that may lack quality measures. The current state of health information technology in both countries is reviewed, since these systems are vital to quality efforts. Finally, several recommendations are proposed to advance the quality indicator development agenda for children. The convergence of quality measurement and indicator development, a growing scientific evidence base and integrated information systems in healthcare may lead to substantial improvements for child health in the 21st century.

Immunization entry at the point of service improves quality, saves time, and is well-accepted.

OBJECTIVE: Computer-based immunization tracking is a routine part of many pediatric practices; however, data quality is inconsistent and entry often relies on dedicated data entry personnel and is time-consuming, expensive, or difficult. The purpose of this study was to evaluate data quality, nursing satisfaction, and reduction in documentation burden after the introduction of a point-of-service immunization entry system in an inner-city pediatric primary care center. DESIGN: Prospective preintervention and postintervention study. METHODS: Visit records from all pediatric nonurgent care visits for patients <5 years old were collected during a 2-week period before (preintervention) and after (postintervention) the introduction of a computer-based immunization entry system. Nurses used software designed to allow rapid entry during immunization preparation followed by printing 2 adhesive labels for documentation. Satisfaction was evaluated using an 8-question survey administered 3 months after the intervention. RESULTS: One hundred forty-seven (63.6%) of 231 preintervention and 132 (51.4%) of 257 postintervention children received at least 1 immunization (immunized) during the study visit. Gender and mean age were similar for immunized children in the 2 groups. In the preintervention group, 56 (37.9%) of 147 immunized children had at least 1 dose missing (a total of 128 of 343 doses administered) from the immunization tracking database compared with none in the postintervention group. Medical record review showed that 92.6% of preintervention and 91.4% of postintervention children were on-schedule after the study visit. However, missing data lead to the misclassification of preintervention children-only 68.4% were reported by the database to be on-schedule. All 9 nurses reported using the program all the time to enter immunizations, 89% said that the program required somewhat or a lot less time, and 100% strongly recommended continued use of the program. All 9 nurses also reported that they would be somewhat or very unenthusiastic about the system if labels were not available. During the 12 months after introduction of the system, 8273 forms containing immunization information were printed, preventing nurses from having to write >101,000 dates. CONCLUSIONS: Immunization entry by nurses at the time of immunization preparation improves the quality of tracking data, reduces misclassification of immunization needs, saves time, and can be well-accepted. It is likely that poor data quality in some tracking systems has led to falsely low immunization coverage estimates. Systems such as the one in this study can improve quality and should be integrated into routine clinical practice.

Beliefs about diagnosing asthma in young children.

OBJECTIVES: To determine what factors primary care pediatricians believe are important in establishing the initial diagnosis of childhood asthma and to identify variations in physicians' beliefs concerning this clinical decision. STUDY DESIGN: Massachusetts American Academy of Pediatrics Fellows were surveyed about their beliefs concerning the importance of 20 clinical factors associated with establishing the initial diagnosis of asthma. RESULTS: Most clinicians considered recurrent wheeze (96%), symptomatic improvement with a bronchodilator (90%), recurrent cough (89%), exclusion of alternative diagnoses (87%), and suggestive peak flow findings (82%) as important in diagnosing asthma. However, there was substantial heterogeneity among clinicians as to which combinations of factors they each considered relevant; for example, only 60% identified all 5 of the above factors to be necessary or important. Further, <50% identified presence of any of the 20 factors as necessary. Although national guidelines cite objective assessment of pulmonary function as essential, spirometry and peak expiratory flow testing were identified as necessary by only 8% and 10%, respectively. Two factors believed to contribute to establishing the asthma diagnosis contradicted the National Asthma Education and Prevention Program guidelines and expert opinion (age >2 years and absence of fever during episodes) and these beliefs were more likely held by those clinicians in practice for >5 years. CONCLUSIONS: The majority of pediatricians believe several common clinical factors establish a diagnosis of childhood asthma, but disagree over what combinations of these factors are important. Some misconceptions persist despite wide dissemination of clinical practice guidelines. We believe that future asthma guidelines will need to organize diagnostic criteria in an easily understood format, like a decision tree, to facilitate early recognition of asthma in young children.

Efficacy of Haemophilus influenzae type b conjugate vaccines and persistence of disease in disadvantaged populations. The Haemophilus Influenzae Study Group.

OBJECTIVES: The purpose of this study was to evaluate the effectiveness of Haemophilus influenzae type b (Hib) conjugate vaccines among children aged 2 to 18 months and to determine risk factors for invasive Hib disease during a period of declining incidence (1991-1994). METHODS: A prospective population-based case-control study was conducted in a multistate US population of 15.5 million. A laboratory-based active surveillance system was used for case detection. RESULTS: In a multivariate analysis, having a single-parent mother (odds ratio [OR] = 4.3, 95% confidence interval [CI] = 1.2, 14.8) and household crowding (OR = 3.5, 95% CI = 1.03, 11.7) were risk factors for Hib disease independent of vaccination status. After adjustment for these risk factors, the protective efficacy of 2 or more Hib vaccine doses was 86% (95% CI = 16%, 98%). Among undervaccinated subjects, living with a smoker (P = .02) and several indicators of lower socioeconomic status were risk factors for Hib disease. CONCLUSIONS: Hib disease still occurs at low levels in the United States, predominantly in socioeconomically disadvantaged populations. Low immunization coverage may facilitate continuing transmission of Hib. Special efforts to achieve complete and timely immunization in disadvantaged populations are needed.

Anemia and elevated lead levels in underimmunized inner-city children.

OBJECTIVE: Underimmunized children are less frequently screened for anemia and elevated lead levels than those who are up-to-date (UTD). However, the association between underimmunization and actual disease (hemoglobin [Hgb] <11 g/dL or blood lead level [PbB] >/=10 microg/dL) has not been reported. The objective of this study was to evaluate the association between underimmunization, anemia, and elevated lead levels among children attending an inner-city clinic. STUDY DESIGN: Data from a computer-based immunization tracking system were integrated with primary care-based laboratory data. Cross-sectional data for immunization coverage, anemia, and elevated lead levels were evaluated for children who were 1, 2, 3, and 4 years of age. The first Hgb or PbB values obtained within 6 months of the child's birthday were used. SETTING: An inner-city hospital-affiliated pediatric primary care center. PATIENTS: A child was considered to be a pediatric primary care center patient if he/she had at least 3 immunizations in the immunization tracking system and at least 1 Hgb or PbB screening test during February 1993 through February 1996. RESULTS: A total of 4045 Hgb tests from 2672 children were available for analysis (1198, 1102, 945, and 800 at 1, 2, 3, and 4 years of age, respectively). Anemia was common during the first 4 years of life (21.2%, 15.8%, 11.0%, and 10.3% at 1, 2, 3, and 4 years of age, respectively). At 2 and 3 years of age, underimmunized children were significantly more likely to be anemic compared with UTD children (relative risk [RR] = 1.49, 95% confidence interval [CI] = 1.24-1.79 at 2 years of age; RR = 1.43, 95% CI = 1.12-1.83 at 3 years of age). Underimmunized children with anemia at 1 year of age were less likely than UTD children to resolve their anemia by 2 years of age (52.5% vs 20.8%, RR = 2.39; 95% CI = 1.47-3.87). Underimmunized children were also significantly more likely to have elevated lead levels at 2 years of age (RR = 1. 24; 95% CI = 1.03-1.5). CONCLUSION: Underimmunized children in the inner city are at especially high risk for anemia and elevated lead levels. These children need routine preventive health services, as well as immunization. Integrating laboratory screening data with immunization tracking systems would be an important step toward improving the health of inner-city children.

National trends in Haemophilus influenzae meningitis mortality and hospitalization among children, 1980 through 1991.

OBJECTIVE: Haemophilus influenzae type b (Hib) conjugate vaccines were licensed for routine use in the United States in December 1987. We compared national trends in deaths and hospitalization from H influenzae meningitis among children < 5 years old before and after Hib conjugate vaccine licensure. METHODS: H influenzae meningitis mortality rates were calculated using data from the 1980 through 1991 computerized national mortality files. Hospitalization rates from H influenzae meningitis were calculated using data from the 1980 through 1991 National Hospital Discharge Surveys. Trends in H influenzae mortality and hospitalization from 1980 through 1887 were compared with trends from 1988 through 1991. Trends for Streptococcus pneumoniae and Neisseria meningitidis meningitis were also examined. RESULTS: From 1980 through 1987, mortality from H influenzae meningitis decreased an average of 8.5% each year, compared with a 48% annual decrease from 1988 through 1991 (P < .001 for difference in trends). H influenzae meningitis hospitalization rates increased 1% each year from 1980 through 1987, and decreased an average of 34% each year from 1988 through 1991. There was no significant difference in mortality or hospitalization trends for S pneumoniae or N meningitidis meningitis during the two periods. Among infants, H influenzae meningitis mortality decreased an average of 8% per year from 1980 through 1987 and 43% per year from 1988 through 1991. One- to four-year-old children had similar average annual declines, 8% and 58% for the two periods. Although there were regional differences in the absolute mortality rates, all regions of the country had similar trends in meningitis mortality. CONCLUSIONS: Among US children < 5 years old, we found substantial decreases in deaths and hospitalization from H influenzae meningitis, but not S pneumoniae or N meningitidis meningitis, in the years after Hib conjugate vaccine licensure. These results suggest that the declines in H influenzae meningitis were due primarily to the use of Hib conjugate vaccines.

Outbreak of early onset group B streptococcal sepsis.

During January and August, 1990, 23 cases of early onset Group B Streptococcus (GBS) disease occurred in a Kansas City, MO, hospital with an attack rate of 14/1000 live births, compared with an annual rate of 1.2 cases/1000 live births for 1988 through 1989. Case infants were compared with controls matched by birth weight, race, maternal age and day of delivery and to a second group of infants of mothers colonized with GBS to identify risk factors and consider intervention strategies during the outbreak. The presence of multiple serotypes among the invasive strains suggested that the outbreak was not caused by a common source. Case mothers were more likely than control mothers to have chorioamnionitis, intrapartum fever or rupture of membranes > 12 hours, and premature case infants were more likely to have a history of rupture of membranes before onset of labor. Multiparous mothers of case infants were more likely to have a history of spontaneous abortion (odds ratio, 6.7; 95% confidence interval, 1.0 to 45.9). No single factor could explain the increase in GBS disease. If intrapartum antibiotic prophylaxis had been used for selected GBS carriers based on presence of either rupture of membranes > 12 hours, intrapartum maternal fever or preterm labor, 7.4% of all deliveries would have received antibiotics and 73% of cases could potentially have been prevented. We conclude that identification of colonized mothers with perinatal risk factors and use of intrapartum antibiotics could be expected to prevent substantial disease during an outbreak of early onset GBS disease.

Decline of childhood Haemophilus influenzae type b (Hib) disease in the Hib vaccine era.

OBJECTIVE: Effective Haemophilus influenzae type b (Hib) conjugate vaccines were first licensed for use in US children at least 18 months old in December 1987 and for infants at least 2 months old in October 1990. We evaluated trends in Hib disease associated with licensure of Hib conjugate vaccines. DESIGN: Data from two sources, an intensive laboratory-based active surveillance system and the National Bacterial Meningitis Reporting System (NBMRS), were used separately to evaluate disease incidence. Data from vaccine manufacturers on Hib vaccine doses distributed in the United States were compared with trends in Hib disease incidence. RESULTS: The age-specific incidence of Hib disease among children less than 5 years old decreased by 71% from 37 per 100,000 persons in 1989 to 11 per 100,000 persons in 1991 (active surveillance data). Haemophilus influenzae meningitis incidence decreased by 82% between 1985 and 1991 (NBMRS data). Increases in doses of Hib vaccine distributed in the United States coincided with steep declines in Hib disease. Both surveillance systems showed decreased rates of Hib disease in infants less than 1 year old before vaccine was licensed for use in this age group. Haemophilus influenzae type b disease incidence in persons at least 12 years old and pneumococcal meningitis incidence in children less than 5 years old did not change substantially during the same period; therefore, decreased Hib disease in children less than 5 years old is not likely to be explained solely by changes in surveillance sensitivity or decreases in bacterial disease due to changes in medical practice. CONCLUSION: Our data suggest that conjugate vaccines have already had a marked impact on the incidence of Hib disease in the United States, preventing an estimated 10,000 to 16,000 cases of Hib disease in 1991. The decline of disease in infants less than 1 year old before licensure for this age group warrants further investigation.

Outbreak of leptospirosis associated with swimming.

Between July 7 and 18, 1991, five boys from a small town in rural Illinois experienced the onset of an acute febrile illness subsequently confirmed as leptospirosis by serologic tests. A cohort study found that swimming in a small swimming hole, Steel Tunnel Pond, was associated with disease (P < 0.01), the attack rate being 28%. Leptospira interrogans serovar grippotyphosa was isolated from urine cultures from two of the case patients and from a culture of Steel Tunnel Pond water. A high seroprevalence for grippotyphosa was found in animals near the pond. Drought conditions had been present in the month before the outbreak, creating an environment in the pond which probably facilitated transmission of the organism from area animals to humans. Although leptospirosis is infrequently reported in humans in the United States, it is endemic in animals and the potential for outbreaks exists, especially when environmental conditions are favorable.

Extreme pyrexia during bretylium administration.

Body temperatures exceeding 41.1 degrees C (106 degrees F) occur with relatively few conditions. In the unusual case reported here, the patient's temperature reached 42.3 degrees C (108.2 degrees F) during intravenous administration of bretylium for refractory ventricular fibrillation. The temperature started to drop as soon as the infusion was stopped and was close to normal within four hours. This appears to be the first report of extreme pyrexia resulting from use of this agent.

Chromosomal analyses in vinyl chloride exposed workers. Results from analysis 18 and 42 months after an initial sampling.

In a previous study (Purchase et al., Mutation Res., 57 (1978) 325-334) it was reported that 57 workers occupationally exposed to vinyl chloride had an increase in the incidence of chromosomal abnormalities in their lymphocytes by comparison with 24 control workers. Since that time (July 1974) threshold limit values for vinyl chloride and plant exposure levels have been reduced. In the present study, 2 further samples from the same population of workers have been analysed for chromosomal aberrations 18 and 42 months after the initial sampling. At 18 months, 21 VC workers and 6 on-site controls were investigated as were 23 workers and 8 on-site controls at 42 months. In the second sampling there was a tendency to an increase in chromosomal abnormalities of VC-exposed workers except in those people who had changed occupation. By the third sampling, however, there was a decrease by comparison with previous samplings and the levels of abnormalities had returned to values similar to those of the controls. Thus, reduction in exposure to vinyl chloride is accompanied by a reduction in the chromosomal abnormalities to levels indistinguishabe from those of controls.

Epidemiological study of respiratory disease in workers exposed to polyvinylchloride dust.

The respiratory health of workers exposed to polyvinylchloride (PVC) dust has been investigated in 818 men sampled from the work force of a factory manufacturing PVC. In a cross-sectional survey, the lung function and prevalences of respiratory symptoms and chest radiographic abnormalities were compared with estimates of individual PVC dust exposures based on detailed occupational histories and current measurements of respirable PVC dust. Complaints of slight exertional dyspnoea were associated with PVC dust exposure, though age and smoking effects were much stronger. The forced expired volume in one second (FEV1) and forced vital capacity (FVC) were inversely related to dust exposure after age, height, and smoking effects had been taken into account. This effect was seen principally in cigarette smokers, and there was suggestive evidence that PVC dust exposure and cigarette smoking interacted in the reduction of FEV1 and FVC. Gas transfer factor was not related to dust exposure. The chest radiographs were read according to the ILO U/C classification by three experienced readers. One reader recorded a low prevalence of small rounded opacities, and these were not related to age or dust exposure. Another reader recorded a higher prevalence of small rounded opacities category 0/1 or more, and these were related to age but not to dust exposure. The third reader recorded the highest prevalence of small rounded opacities (though none greater than category 1/1), and these were independently related both to age and to PVC dust exposure, indicating an effect of PVC dust on the appearance of the chest radiography. These appearances were so slight that only the higher sensitivity of this reader in the interpretation of profusion of small rounded opacities on the ILO U/C scale enabled detection of this effect of PVC dust. In conclusion, exposure to PVC dust is associated with some deterioration of lung function, slight abnormalities of the chest radiograph, and complaints of slight dyspnoea. The mean decline in FEV1 associated with the average dust exposure experienced in the study was small, though some of the men with higher dust exposures may have suffered clinically important loss of lung function as a result of their occupation.

Chromosomal analyses in vinyl chloride-exposed workers.

Chromosomal morphology from cultured peripheral lymphocytes was studied in 81 men; 57 of the men were employed on plants manufacturing vinyl chloride or polyvinylchloride, 19 were on-site controls and 5 were off-site controls. There was a significant increase in chromosomal abnormalities in the exposed workers when compared with the controls. The greatest statistically significant increase in total B and total C cells occurred in autoclave operators, with smaller increases in other job categories. The increase in chromosomal aberrations was correlated with the length of exposure and with a history during the year prior to sampling (1973--1974) of exposure to excursion levels of vinyl chloride. Information on smoking habits was obtained 18 months after blood sampling and a positive correlation between these and total C cell abnormalities was found. There was no positive correlation with various other parameters (bilirubin, platelets, gamma-glutamyltranspeptidase, alkaline phosphatase, alanine transaminase and aspartate transaminase). It was not possible to estimate which of the three parameters (smoking history, length of employment or exposure to excursion levels) was the most important.

Screening for liver disease in vinyl chloride workers.

Following the occurrence of hepatic fibrosis and angiosarcoma in polyvinyl chloride autoclave workers, a screening programme was set up for workers at risk in a large production plant. There was no significant difference in liver function tests between workers and a control group of men in the same factory, not exposed to vinyl chloride. Four exposed workers out of 422 were found to have enlarged spleens compared with none out of 202 controls. Liver biopsies from selected cases showed no significant pathological changes, although there was minimal increase in portal tract and sinusoidal fibrosis in exposed workers.

Long-term effects on the health of men engaged in the manufacture of tolylene di-isocyanate.

A prospective study of workers engaged in the manufacture of tolylene di-isocyanate (TDI) was carried out over nine years. The study was in two parts: (1) assessment of the symptoms and ventilatory function of men working on the plants who did not complain of respiratory symptoms; (2) assessment of the long-term effects in men who were removed from the plants because of respiratory symptoms. Use of the MRC Questionnaire on Respiratory Symptoms in a group of 76 TDI workers showed no significant differences in symptoms compared with 76 control subjects. Annual lung function tests were carried out on 180 asymptomatic men with possible exposure to TDI. The relationship of the forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) to the height, age, and duration of exposure was examined by linear regression analysis. The equations formulated did not differ significantly from those calculated for non-TDI exposed subjects. Thus exposure to very small concentrations of TDI does not necessarily cause symptoms or a drop in ventilatory capacity. Forty-six TDI workers who had developed symptoms reported more long-term symptoms than a comparable number of controls. The difference was significant at the 1% level. Ventilation test records of 61 TDI workers who had developed symptoms were available since it was possible to use the records of men who had left the company. The lung function of this group was matched against predicted figures obtained from a control group of 608 subjects living in the same area as the exposed group but not exposed to TDI. It was found that the FEV1 of the affected men was on average 267 ml lower than predicted, and the FVC 269 ml lower. These findings are confirmed by examination of the indivdual records of a futher 20 men.