Tertiary paediatric hospital admissions in children and young people with cerebral palsy.

BACKGROUND: Many previous studies that have investigated hospital admissions in children and young people with cerebral palsy lack information on cerebral palsy severity and complexity. Consequently, little is known about factors associated with the frequency and type of hospital admissions in this population. This study used hospital admission data available for all children and young people known to a population-based cerebral palsy register to describe the patterns of use of tertiary paediatric hospital services over a 5-year period. METHODS: This was a retrospective cohort analysis of routinely collected admission data from the two tertiary paediatric hospitals in the Australian state of Victoria. Data on admissions of individuals born between 1993 and 2008 registered on the Victorian Cerebral Palsy Register were analysed (n = 2183). RESULTS: Between 2008 and 2012, 53% of the cohort (n = 1160) had at least one same-day admission, and 46% (n = 996) had one or more multi-day admissions. Those with a moderate to severe motor impairment and those with a co-diagnosis of epilepsy had more admissions, and for multi-day admissions, longer lengths of stay, P < 0.05. Across all severity levels, respiratory and musculoskeletal diseases were the most frequently reported reasons for medical and surgical admissions, respectively. All-cause readmission rates for urgent multi-day stays within 7, 30 and 365 days of an index admission were 10%, 23% and 63%, respectively. CONCLUSIONS: The reasons for hospital admissions reported here reflect the range of comorbidities experienced by children and young people with cerebral palsy. This study highlights priority areas for prevention, early diagnosis and medical management in this group. Improved primary and secondary prevention measures may decrease non-elective hospital admissions and readmissions in this group and reduce paediatric inpatient resource use and healthcare expenditure attributable to cerebral palsy.

Getting heavier, younger: trajectories of obesity over the life course.

CONTEXT: Although recent trends in obesity have been well documented, generational patterns of obesity from early childhood through adulthood across birth cohorts, which account for the recent epidemic of childhood obesity, have not been well described. Such trends may have implications for the prevalence of obesity-associated conditions among population subgroups, including type 2 diabetes. OBJECTIVE: Our objective was to evaluate trajectories of obesity over the life course for the US population, overall and by gender and race. DESIGN, SETTING AND PARTICIPANTS: We conducted an age, period and birth cohort analysis of obesity for US individuals who participated in the National Health and Nutrition Examination Surveys (NHANES) (1971-2006). MAIN OUTCOME MEASURES: Obesity was defined as a body mass index >or=95th percentile for individuals aged 2-16 years or >or=30 kg m(-2) among individuals older than 16 years. Age was represented by the age of the individual at each NHANES, period was defined by the year midpoint of each survey, and cohort was calculated by subtracting age from period. RESULTS: Recent birth cohorts are becoming obese in greater proportions for a given age, and are experiencing a greater duration of obesity over their lifetime. For example, although the 1966-1975 and 1976-1985 birth cohorts had reached an estimated obesity prevalence of at least 20% by 20-29 years of age, this level was only reached by 30-39 years for the 1946-1955 and 1956-1965 birth cohorts, by 40-49 years for the 1936-1945 birth cohort and by 50-59 years of age for the 1926-1935 birth cohort. Trends are particularly pronounced for female compared with male, and black compared with white cohorts. CONCLUSIONS: The increasing cumulative exposure to excess weight over the lifetime of recent birth cohorts will likely have profound implications for future rates of type 2 diabetes, and mortality within the US population.

Parental perceptions regarding mandatory mouthguard use in competitive youth soccer.

OBJECTIVE: To understand factors that influence parental perceptions regarding mandatory mouthguard use in competitive youth soccer. SETTING AND SUBJECTS: A web based survey of parents whose 8-14 year old children participated in outdoor competitive youth soccer during the fall of 2002. Questions focused on: previous injury, education provided, dentist/physician recommendations, and parental perceptions of mouthguard use. MAIN OUTCOME MEASURE: The outcome variable was parental agreement with the statement "mouthguards should be mandatory for competitive youth soccer". Logistic regression and chi(2) were performed using STATA 8.0. RESULTS: Altogether 120 parents participated. The children had a mean (SD) age of 11.8 (1.5) years and 48% were female; 14% wore mouthguards and 11% suffered orofacial injuries. Nineteen percent of parents reported receiving educational material from the youth soccer organization. Although 92% of parents believed that mouthguards were effective in reducing orofacial injuries, only one half agreed that mouthguards should be mandatory. Thirty percent of respondents reported that their dentist/physician recommended mouthguards for competitive youth soccer. Logistic regression showed that dentist/physician recommendation and parental female gender were independently associated with parental agreement for mandatory mouthguard use (odds ratio 2.9, 95% confidence interval (CI) 1.2 to 7.3; odds ratio 3.0, 95% CI 1.1 to 6.5). CONCLUSIONS: Few athletes wear mouthguards during competitive youth soccer. Health care professionals in this study did not capitalize on the apparent influence they have on parental beliefs regarding mouthguard use. Efforts are needed by both health professionals and soccer organizations to educate parents about orofacial injuries and mouthguard use in competitive youth soccer.

Hepatitis B vaccination practices in hospital newborn nurseries before and after changes in vaccination recommendations.

BACKGROUND: Routine use of hepatitis B vaccine for low-risk newborns was suspended on July 7, 1999, because of concern about the potential risk of thimerosal, a mercury-containing vaccine preservative. Reinstatement of the birth dose was recommended when a thimerosal-free vaccine became available. OBJECTIVE: To explore changes in hepatitis B vaccination practices for newborns related to the revised recommendations for low-risk infants (in this study, the terms newborn and infant are used interchangeably). DESIGN: A telephone survey of a random sample of 1000 US hospitals. PARTICIPANTS: Nurse managers, nursery directors, and staff nurses of the newborn nurseries. MAIN OUTCOME MEASURES: Nursery vaccination practices before and after July 7, 1999, and the availability and use of thimerosal-free vaccine. RESULTS: Interviews were conducted with 773 (87%) of 886 eligible hospitals. Before July 7, 1999, 78% of the hospitals reported vaccination practices that were consistent with recommendations at that time, although only 47% vaccinated all low-risk infants at birth. After July 7, 1999, almost all hospitals discontinued vaccination of low-risk infants, in accordance with the recommendation change; however, there was a 6-fold increase in the number of hospitals that were not vaccinating all high-risk infants. After the introduction of thimerosal-free vaccine, only 39% of the hospitals reported vaccinating all low-risk infants. CONCLUSIONS: Most hospital nurseries altered their newborn hepatitis B vaccination practices consistent with changes in national recommendations. However, unintended consequences included the failure of some hospitals to continue vaccinating all high-risk infants and the delay in reintroducing vaccination for low-risk newborns after the introduction of a thimerosal-free vaccine. Assessments of the appropriateness of this country's response to the threat of thimerosal in vaccines should consider these findings.

A new paradigm in academic health centers: productivity-based physician compensation.

This article describes the challenge of designing an incentive-based compensation program for a large group of academic pediatricians in the Division of General Pediatrics at the University of Michigan Health System. The program is based on an incentive system that measures performance in clinical care, education and research. Faculty members' salaries arise from five components: base, clinical incentive, academic supplement, administrative differential and teaching credit.

Physicians' early challenges related to the pneumococcal conjugate vaccine.

OBJECTIVE: To characterize the obstacles faced by physicians regarding administration of a 7-valent pneumococcal conjugate vaccine (Prevnar) to all children younger than 2 years and to high-risk children from 2--5 years of age during the months immediately following national recommendations. DESIGN: Semistructured telephone interviews. PARTICIPANTS: Convenience sample (n = 24) of pediatricians and family physicians. RESULTS: Eighteen physicians were recommending pneumococcal vaccine and 6 were not. Those who were recommending pneumococcal vaccine had encountered resistance from parents and variations in private and public insurance coverage. Physicians who were not recommending pneumococcal vaccine expressed concern about the cost of the vaccine and general caution in adopting new vaccine recommendations. Respondents offered several suggestions for improving the vaccine recommendation process. CONCLUSIONS: This analysis of physicians' early decision making regarding pneumococcal vaccine reflects obstacles to vaccine implementation that may arise with the introduction of other childhood vaccines.

State-level perspectives on immunization policies, practices, and program financing in the 1990s.

This article reports on a series of structured interviews with immunization program officials in all 50 states regarding the effects of changes in federal policies and funding in the 1990s on the goals, priorities, and activities of state immunization programs. The purchase of vaccines is a major component of all state immunization programs. The Vaccines for Children (VFC) program, implemented in 1994, has become the primary source of vaccine purchase support in almost all states. A concern of many state immunization programs is their ability to ensure that vaccines are available to children who are not VFC eligible.State immunization programs also are involved in a myriad of activities necessary to ensure that children are adequately and appropriately immunized (e.g. , vaccine administration, outreach to parents). Federal funding to support these activities increased significantly during the mid-1990s, but was substantially reduced beginning in 1997. Because of these funding decreases, most states had to reduce the scale and scope of their immunization activities.State-level funding support for immunization programs varies, with state governments more likely to support vaccine purchase than immunization activities. Immunization will never be completed. Along with each new birth cohort, changes to the primary immunization schedule (i.e., addition of new vaccines and expansion of existing recommendations to encompass broader target groups) create ongoing needs for vaccine purchase and other immunization activities. Long-term immunization planning must reflect these continually expanding needs.

Measuring immunization coverage.

OBJECTIVE: Information about immunization coverage comes from five major sources: the National Immunization Survey, the National Health Interview Survey, retrospective school-entry surveys, the Health Plan Employer Data and Information Set (HEDIS) measures reported by managed care plans, and assessments performed on clinics and private practices. In this article, we describe the methodology of the major surveys, discuss technical and policy issues in measuring immunization coverage, and identify issues that must be addressed to harmonize immunization rates calculated from different sources. METHODS AND TOPICS: We describe the (1) design and methodology of the five major sources of immunization coverage assessments, (2) issues and controversies in measuring immunization coverage, and (3) preliminary efforts to harmonize calculation of immunization coverage. Technical and policy issues involve dose and interval requirements, which vaccines are included in the series-completion calculations, and who is excluded from each method of calculation. CONCLUSIONS: The purpose of measuring up-to-date immunization coverage determines the way that it is measured. The tension between measuring immunization coverage to monitor population protection against disease and measuring immunization coverage to determine how well the health care delivery system is working leads to different ways of selecting a sample and reporting coverage. These differences create confusion for the public policymakers who try to identify problems and to set priorities for immunization efforts. Although some unavoidable differences may occur because of differences in purpose of the measurement, greater harmonization is possible.

Pediatrician and family physician prescription of selective serotonin reuptake inhibitors.

OBJECTIVES: Selective serotonin reuptake inhibitor (SSRI) prescriptions for children and adolescents have increased greatly in recent years despite a paucity of demonstrated safety and efficacy data and a lack of clear guidelines for use. Our study sought to describe family physician and pediatrician SSRI prescribing patterns for children and adolescents, identify influences on SSRI prescription variations, and describe the use of SSRI within the overall management of depression and other mental disorders in primary care. DESIGN: A survey was mailed to all 596 active North Carolina general pediatricians and a random sample of 557 family physicians in primary care practice. Family physicians who did not see children in their practice were excluded. The survey instrument consisted of a 4-page questionnaire. Survey items included physician demographics, practice characteristics, general management, volume of pediatric patients with depressive symptoms, prescription of SSRIs for depression and other diagnoses, and potential influences on SSRI prescribing practices. The main outcomes were self-reported physician prescription of SSRIs for children and adolescents. Results were analyzed using chi(2) comparisons and logistic regression. RESULTS: The overall response rate was 66% (55% family physicians and 76% pediatricians). Of the physicians, 72% had prescribed an SSRI for a child or adolescent. Depression was the most common reason for prescribing an SSRI; over two thirds of respondents had prescribed an SSRI for depression in a child 18 years of age or younger. Over half of the physicians reported they had prescribed an SSRI for a diagnosis other than depression in a child 18 years of age or younger. Attention-deficit/hyperactivity disorder was the most frequent use cited other than depression, followed by obsessive-compulsive disorder, aggression, eating disorders, and enuresis. Primary care physicians prescribed SSRIs for adolescents more commonly than for younger children. Only 6% of the respondents had ever prescribed an SSRI for a child younger than 6 years of age. In terms of SSRI prescriptions written for depression in the last 6 months, 32% of the physicians had recently prescribed SSRIs for adolescent patients and 6% for patients younger than 12 years of age. Family physicians were more likely than pediatricians to have recently prescribed SSRIs for adolescent patients (41% vs 26%), but there was no difference in recent SSRI prescriptions for children <12 years of age by physician specialty (4% vs 6%). Prescription of SSRIs was not associated with decreased use of counseling for treatment of depression, but prescription of SSRIs was associated with decreased use of referrals (63% vs 74%). There was no difference in the use of counseling between family physicians and pediatricians (61% vs 59%). However, pediatricians were more likely to use referrals in their usual approach to depression (77% vs 48%) compared with family physicians. More family physicians had prescribed SSRIs for pediatric patients compared with pediatricians (91% vs 58%), and more family physicians had prescribed SSRIs in combination with other psychotropic medications (54% vs 31%). For the majority of respondents, SSRI prescriptions constituted most of the medications used to treat childhood depression (75% of family physicians vs 61% of pediatricians). Family physicians were more likely to report a belief in the safety (63% vs 48%) and effectiveness (40% vs 32%) of SSRIs. Only 8% of physicians reported adequate training in the treatment of childhood depression and just 16% were comfortable with the treatment of depression. There were no specialty differences in training for the treatment of childhood depression; however, more family physicians than pediatricians agreed that they were comfortable with the management of childhood depression (22% vs 11%). (ABSTRACT TRUNCATED)

Primary care role in the management of childhood depression: a comparison of pediatricians and family physicians.

OBJECTIVE: To provide a self-described assessment of pediatricians' and family physicians' management of childhood depression. DESIGN: Mail survey of 595 general pediatricians and 557 family physicians in North Carolina. RESULTS: The response rate was 66%. Most primary care physicians used referral (65%) and counseling (61%) for management of childhood depression. Family physicians used medications more commonly (18% vs 9%), and pediatricians referred patients more commonly (77% vs 48%). In logistic regression analysis, physicians comfortable with management of depression (odds ratio [OR], 4.8: 2.7-8.4), physicians who believed that antidepressants are more effective than counseling (OR, 2.6: 1.4-4.8), and family physicians (OR, 2.2: 1.9-4.1) were more likely to have used medications for childhood depression. CONCLUSIONS: Most primary care physicians refer pediatric patients with depression; however, practice patterns vary by specialty and other factors. Future studies must consider the role of primary care and evaluate how interspecialty variations affect costs and outcomes of childhood depression.

Parental knowledge, attitudes, and demand regarding a vaccine to prevent varicella.

BACKGROUND: Maintenance of high immunization rates is challenged by frequent changes to the recommended immunization schedule. This study assessed parent-reported knowledge of, attitudes about, and demand for a new vaccine against varicella. METHODS: Six months following licensure of the varicella vaccine, a cross-sectional study was conducted by mailed survey among a sample of parents of 23- to 35-month-old children. Effective response rate was 65%. RESULTS: Three quarters of parents had heard about the vaccine to prevent varicella. The lay media was the most frequently mentioned source of information. Thirteen percent of parents had already obtained the vaccine for their child, another quarter planned to get it, and one half were undecided. The most frequently cited factor influencing parents who had obtained or intended to obtain the vaccine was their doctor's recommendation. For those undecided or not inclined to get the vaccine, insufficient information about the vaccine was the most frequently listed factor. CONCLUSION: Publicizing a new vaccine through the media may be effective in raising public awareness, but detailed information about the vaccine and the recommendation of providers is still important in a parent's decision about the vaccine for their child.

Impact of North Carolina's universal vaccine purchase program by children's insurance status.

OBJECTIVE: To examine the impact of a new universal purchase vaccine program on immunization rates of children with different types of insurance. DESIGN: Ecologic study using parent telephone interviews, medical chart abstraction in sites of outpatient care, and insurance verification with Medicaid and private insurers. SETTING: State of North Carolina. PARTICIPANTS: Of a random birth certificate sample of 4385 children born in North Carolina during 1994 and 1995, 507 were excluded. A total of 2767 children had completed parent interviews; 95% of those had medical chart abstraction and insurance data. MAIN OUTCOME MEASURES: Immunization rates at each month during the first 2 years of age, site of delivery for immunizations and well-child visits, and insurance status. RESULTS: In month-by-month comparisons, children born in 1995 had immunization rates 4% to 10% higher than their 1994 counterparts. By 24 months of age, 84% of the 1995 cohort had completed the primary immunization series, compared with 79% of the 1994 cohort (P<.001). In all insurance subgroups, 1995 immunization rates were higher than 1994 rates. The largest increases occurred among privately insured children with no well-child coverage, children who had periods of being uninsured, and children enrolled in Medicaid exclusively or with private insurance. More children in the 1995 cohort received immunizations in the private sector. CONCLUSIONS: Implementation of North Carolina's universal purchase program was associated with improved immunization rates, especially for children with inadequate insurance for well-child care. However, insurance status still influences the ability of children to receive immunizations on schedule.

Influences on the receipt of well-child visits in the first two years of life.

OBJECTIVE: To determine demographic and health care system factors associated with children receiving an adequate number of well-child visits (WCVs). METHODS: Information on 4385 children and their families was obtained via birth certificates, parent interviews, chart review of outpatient sites of care, and insurance records. RESULTS: Only 77% of children received at least five WCVs by age 2. In regression analysis, the factors most strongly associated with children's total number of WCVs were delay in the initiation of prenatal care (odds ratio = 0.6) and receipt of all outpatient care in private physician offices (odds ratio = 4.2 to 5.6). Having an adequate number of WCVs was associated with being up to date for immunizations. CONCLUSIONS: Children of mothers who delay prenatal care are at high risk for not receiving adequate numbers of WCVs. Recognition of this marker can allow for targeted interventions that aim to ensure that children receive appropriate preventive care.

[Hepatitis B vaccination: knowledge and acceptance by Swiss physicians]. / Hepatitis-B-Impfung: Kenntnisse und Akzeptanz bei Schweizer Arzten.

Difficulties with the acceptance of immunization recommendations by physicians have been documented. A recommendation for universal hepatitis B vaccination was published in 1998 for Switzerland. We conducted a qualitative study of pediatricians and family physicians in the fall of 1996 with eight focus groups stratified by region of the country and medical specialty. Sixty-two physicians participated. Most participants felt that universal hepatitis B immunization would be useful. Pediatricians in the French-speaking part of the country were more willing to implement such a recommendation, while family physicians in the German-speaking regions were least willing. Before supporting universal hepatitis B immunization, physicians stated that they need more information about the epidemiology of the infection, the effectiveness and safety of the vaccine, and the perceived high cost of an immunization program. Participants felt that two injections per visit was the maximum tolerable for infants and young children. Many preferred to immunize older children or adolescents against hepatitis B, both because fewer injections are currently recommended at that age and because adolescence is a developmentally appropriate age to address sexuality and drug abuse. Physicians expected the population to be reluctant to accept universal hepatitis B vaccination, partly because of a lack of understanding of the disease and partly because of a feeling that children already receive more than enough immunizations. While the general sentiment for a universal hepatitis B immunization recommendation in Switzerland seems to be positive among physicians, concerns regarding its implementation linger. It remains to be seen how hepatitis B will be perceived in the population, and how willing parents and adolescents will be to get their children and themselves vaccinated. Helping physicians to understand the importance of this measure, in addition to convincing them to immunize their patients, will be an important first step towards achieving sufficient hepatitis B immunization coverage.

Use of public immunization services after initiation of a universal vaccine purchase program.

OBJECTIVE: To explore the reasons why North Carolina families continue to use public immunization services 2 years after implementation of a universal vaccine purchase program, a state program intended to eliminate financial barriers to immunization in private physicians' offices. METHODS: In-person interviews were conducted in 11 local public health departments in North Carolina. PARTICIPANTS: Consecutive sample of 64 adults accompanying children aged 2 years or younger presenting for immunization services. MAIN OUTCOME MEASURES: (1) Reasons for seeking immunization at the health department and (2) history of immunization from private physicians. RESULTS: Two thirds of children obtained immunizations at the health department because of cost, including two thirds of children enrolled in Medicaid. Only 33% of children received well-child care from a private physician; for more than half of this group, the parents cited cost as the reason for using the health department, even though their physician was participating in the state universal purchase program. Of the 8 parents who told their child's private physician that they could not afford immunizations, none was told that the vaccine administration fee would be waived. CONCLUSIONS: Even though North Carolina's universal vaccine purchase program had been in effect for more than 2 years, a substantial number of children still received care from a private physician but used the health department for immunizations because of cost. These results indicate a need to explore additional strategies to preserve children's "medical homes."

Enforcement of age-appropriate immunization laws.

BACKGROUND: The state of North Carolina has statutes that require age-appropriate immunization as recommended by the U.S. Public Health Service. Provisions of this statute allow for criminal misdemeanor charges and injunctions to be brought against parents who do not have their children immunized on time. The decision to invoke the age-appropriate immunization statute rests with the health director of each county. This study was performed to determine if the county health directors were aware of this statute and whether they had ever utilized it to enforce age-appropriate immunization. METHODS: All health department directors in the state of North Carolina (N = 86) received letters inviting them to complete a 20-minute structured phone interview at a time of their convenience. Specific questions addressed their knowledge of the statutes and the specific penalties available. Additional questions addressed their attitudes and beliefs about the law and what they believed the state government could do to assist in enforcing the law. RESULTS: Interviews were completed for 75 of the 86 (87%) county health departments or districts. All respondents reported they were aware, prior to receiving the materials informing them of the study, that the state required children to be immunized on time. Over 95% reported they knew the law required age-appropriate immunization and 100% were aware of school/licensed day-care requirements. The vast majority (83%) of county health directors believe that criminal misdemeanor charges and injunctions should be brought against parents for failing to have their child age-appropriately immunized. However, only 5% (n = 4) of health directors reported that their county had ever brought criminal misdemeanor charges, and none had filed an injunction against a parent whose child was not immunized on time. CONCLUSIONS: Despite the presence of legal statutes, there have been only rare efforts to compel age-appropriate immunization through enactment and enforcement of criminal penalties on parents. Much of the hesitancy for such efforts likely comes from the fear of the confusing, hard-to-understand legal procedures and from the potential negative impact on public opinion that these tactics may create. Although such actions should be taken only as a last resort, they may be necessary on some occasions.

Vaccine-associated liability risk and provider immunization practices.

OBJECTIVE: To explore the effect of concern about vaccine-associated malpractice litigation on provider immunization practices and attitudes. DESIGN: A cross-sectional mail survey. PARTICIPANTS: One thousand one hundred sixty-five pediatricians and 1849 family physicians. MAIN OUTCOME MEASURES: Physicians' perceptions of the legal and financial risks of providing immunizations and of the liability protection afforded by state programs and their current immunization practices. RESULTS: The response rate was 72% for pediatricians and 63% for family physicians. Overall, less than 30% of the respondents believed that federal and state programs protect them against vaccine-related lawsuits, with pediatricians more likely to believe so (32% vs 21%, P < .0001). Pediatricians were also more likely than family physicians to believe that the diphtheria, tetanus, and pertussis vaccine could be administered safely to children with a family history of seizures, a minor respiratory tract illness, or a previous local reaction to the vaccine. Liability issues were not significantly associated with any of the outcome variables, except that those physicians who believed that the whole-cell diphtheria, tetanus, and pertussis vaccine increased their risk for lawsuits were less likely to indicate that the diphtheria, tetanus, and pertussis vaccine was safe for children with a family history of seizures (P < .001). CONCLUSIONS: Liability-related variables were not independently associated with most immunization behaviors examined. This raises the question as to whether physicians cite liability as a reason for not immunizing children with acute and chronic illnesses, when their concerns are actually otherwise. These data suggest that educational efforts focused on liability issues alone will have little effect on inappropriate delaying of immunization for these children. Rather, education is needed regarding inappropriate contraindications themselves.