Widening our Focus: Characterizing Socioeconomic and Racial Disparities in Congenital Heart Disease.

BACKGROUND: Socioeconomic and racial (SER) disparities among patients with congenital heart disease (CHD) may limit access to high-quality care. We characterized the national SER landscape and its relationship to early outcomes and identified interactions among determinants mitigating adverse outcome. METHODS: The Pediatric Health Information System (PHIS) database was queried for patients (age <26 years) with CHD between 2016 and 2018. International Classification of Diseases, 10th Revision, codes were mapped to diagnostic categories for complexity adjustment. Correlational and hierarchical regression analyses identified risk factors and characterized interactions. RESULTS: We identified 166,599 unique admissions from 52 hospitals, with 58,395 having interventions. Median age was 0 years (interquartile range [IQR], 4 years). Race/ethnicity was predominantly White (59%), Hispanic (20%), and Black (16%). Median neighborhood household income (NHI) was $41,082 and varied among hospitals. Patient NHI had a parabolic relationship with mortality, with both higher and lower values having increased risk. Black patients had significantly higher death, and this relationship was potentiated by lower NHI and complexity. Hospital length of stay was longer among Black neonates (median, 51 days; IQR, 93 days) compared with neonates of other ethnic groups (median, 32 days; IQR, 71 days; P < .0001. Care pathways, including permanent feeding tubes, were also more prevalent among Black neonates (17.8%) compared with White neonates (15%; P = .02). CONCLUSIONS: Interactions among SER disparities modify CHD outcomes. Specific hospitals have more SER fragile patients but may have developed care pathways that prolong length of stay to mitigate risk among Black neonates. Adverse outcomes among SER-disadvantaged patients are magnified in complex CHD, suggesting tangible benefits to targeted resource allocation and population health initiatives.

Assessment of treatment burden and complexity in cystic fibrosis: A quality improvement project.

BACKGROUND: Treatment regimens for cystic fibrosis (CF) continue to evolve and grow in complexity. Treatment regimen burden, and associated sequelae, are incompletely understood. OBJECTIVE: Quality improvement (QI) methods were used to investigate treatment burden of CF care, family and care team partnerships, and potential interventions to reduce burden. METHODS: Patients 6-24 years with CF and caregivers of patients 6-13 years were surveyed. Portions of validated tools and existing surveys measured burden and family-care team partnership. An automated report calculated treatment complexity. Plan-do-study-act cycles tested survey administration during CF visits and run charts tracked progress. Interventions to reduce burden were tracked, and bidirectional assessments explored partnerships among patients, families and clinicians. RESULTS: Over 6 months, 110 patients and 62 caregivers completed assessments. Caregivers reported lower burden/higher quality of life (74.0, range 22.2-100) than patients (66.5, range 16.7-100). The mean treatment complexity score was 17.2 (range 6-34). Treatment complexity and burden increased with patient age (p < .05 and p < .01 respectively). Lower lung function correlated with higher patient-reported burden (p < .01) and higher treatment complexity (p < .0001). As burden increased, providers more often performed select interventions (discussed combining treatments, simplified regimens, or involved other team members (p < .05 for each)). Families reported high partnership (mean scores 4.7-4.8, 5 = high), and providers reported high utilization of partnership tools (tool used in 77% of encounters). CONCLUSION: We assessed, quantified, and responded to treatment burden and complexity in real-time during outpatient CF visits. Systematic and individualized assessments of treatment complexity and burden may enhance treatment adherence while preserving quality of life.

A Framework to Measure and Improve Well-Being in Primary Care.

Pediatricians aspire to optimize overall health and development, but there are no comprehensive measures of well-being to guide pediatric primary care redesign. The objective of this article is to describe the Cincinnati Kids Thrive at 5 outcome measure, along with a set of more proximal outcome and process measures, designed to drive system improvement over several years. In this article, we describe a composite measure of "thriving" at age 66 months, using primary care data from the electronic health record. Thriving is defined as immunizations up-to-date, healthy BMI, free of dental pain, normal or corrected vision, normal or corrected hearing, and on track for communication, literacy, and social-emotional milestones. We discuss key considerations and tradeoffs in developing the measure. We then summarize insights from applying this measure to 9544 patients over 3 years. Baseline rates of thriving were 13% when including all patients and 31% when including only patients with complete data available. Interpretation of results was complicated by missing data in 50% of patients and nonindependent success rates among bundle components. There was considerable enthusiasm among other practices and sectors to learn with us and to measure system performance using time-linked trajectories. We learned to present our data in ways that balanced aspirational long-term or multidisciplinary goal-setting with more easily attainable short-term aims. On the basis of our experience with the Thrive at 5 measure, we discuss future directions and place a broader call to action for pediatricians, researchers, policy makers, and communities.

Implementation of a Quality Improvement Initiative: Improved Congenital Muscular Torticollis Outcomes in a Large Hospital Setting.

BACKGROUND: The American Physical Therapy Association (APTA) published a guideline for congenital muscular torticollis (CMT) in 2013. Our division adopted the guideline as the institutional practice standard and engaged in a quality improvement (QI) initiative to increase the percentage of patients who achieved resolution of CMT within 6 months of evaluation. OBJECTIVE: The aims of this report are to describe the QI activities conducted to improve patient outcomes and discuss the results and implications for other institutions and patient populations. DESIGN: This was a quality improvement study. METHODS: In alignment with the Chronic Care Model and Model of Improvement, an aim and operationally defined key outcome and process measures were established. Interventions were tested using Plan-Do-Study-Act cycles. A CMT registry was established to store and manage data extracted from the electronic record over the course of testing. Statistical process control charts were used to monitor progress over time. RESULTS: The QI initiative resulted in an increase in the percentage of patients who achieved full resolution of CMT within a 6-month episode of care from 42% to 61% over an 18-month period. Themes that emerged as key drivers of improvement included: (1) timely, optimal access to care, (2) effective audit and clinician feedback, and (3) accurate, timely documentation. LIMITATIONS: The initiative took place at a single institution with a supportive culture and strong QI resources, which may limit direct translation of interventions and findings to other institutions and patient populations. CONCLUSIONS: Improvement science methodologies provided the tools and structure to improve division-wide workflow and increase consistency in the implementation of the APTA CMT guideline. In doing so, significant CMT population outcome improvements were achieved.

Factors associated with the interfacility transfer of the pediatric trauma patient: implications for prehospital triage.

OBJECTIVE: The goal of this study was to identify prehospital factors associated with increased likelihood of interfacility transfer of pediatric trauma patients. Such factors might serve as a basis for improvements in future field pediatric trauma triage guidelines. METHODS: This was a retrospective cohort study of children aged 12 years or younger with blunt, penetrating, or thermal injuries who were transported by ground emergency medical services from the scene to the emergency department of a Level I, II, or III trauma center within the Denver metropolitan area from January 1, 2000, to December 31, 2008. Characteristics predicting subsequent interfacility transfer to a pediatric trauma center (PTC) were assessed. RESULTS: A total of 1673 patients were included in the analysis. Variables hypothesized to be most commonly associated with interfacility transfer were age, sex, mechanism of injury, body region of injury, and Glasgow Coma Scale score. The cohort included 1079 males and 593 females. Logistic regression analysis yielded the following as significant predictors of transfer: younger age (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.15-1.25), lower Glasgow Coma Scale score (OR, 1.08; 95% CI, 1.01-1.16), the presence of burns (OR, 37.52; 95% CI, 7.3-191.7), non-accidental trauma (OR, 6.09; 95% CI, 2.44-15.25), falls (OR, 1.62; 95% CI, 1.06-2.48), other motor vehicle-related incidents (OR, 2.37; 95% CI, 1.08-5.19), abdominal injury (OR, 5.39; 95% CI, 2.31-12.55), head/neck injury (OR, 7.89; 95% CI, 4.21-14.77), limb injury (OR, 5.31; 95% CI, 2.78-10.16), and multiple injuries (OR, 13.01; 95% CI, 5.0-33.8). CONCLUSIONS: Factors highly associated with transfer of an injured child from a non-PTC to a PTC included younger age, burns, non-accidental trauma, head/neck injury, and multiple injuries in younger children. Further investigation is warranted to determine whether these factors may have applicability in future improvements in field pediatric trauma patient triage guidelines.

Gender ratios for reading difficulties.

The prevalence of reading difficulties is typically higher in males than females in both referred and research-identified samples, and the ratio of males to females is greater in more affected samples. To explore possible gender differences in reading performance, we analysed data from 1133 twin pairs in which at least one member of each pair had a school history of reading problems and from 684 twin pairs from a comparison sample with no reading difficulties. Although the difference between the average scores of males and females in these two samples was very small, the variance of reading performance was significantly greater for males in both groups. We suggest that a greater variance of reading performance measures in males may account at least in part for their higher prevalence of reading difficulties as well as for the higher gender ratios that are observed in more severely impaired samples.

DeFries-Fulker and Pearson-Aitken model-fitting analyses of reading performance data from selected and unselected twin pairs.

Although a comparison of concordance rates for deviant scores in identical and fraternal twin pairs can provide prima facie evidence for a genetic etiology, information is not fully utilized when continuous measures are analyzed in a dichotomous manner. Thus, DeFries and Fulker (Behav Genet 15:467-473, 1985; Acta Genet Med Gemellol, 37:205-216, 1988) developed a regression-based methodology (DF analysis) to assess genetic etiology in both selected and unselected twin samples. While the DF analysis is a very versatile and relatively powerful statistical approach, it is not easily extended to the multivariate case. In contrast, structural equation models may be readily extended to analyze multivariate data sets (Neale and Cardon, Methodology for genetic studies of twins and families, 1992). However, such methodologies may yield biased estimates of additive genetic, shared environmental, and non-shared environmental influences when multivariate models are fitted to selected twin data. Therefore, the Pearson-Aitken (PA) selection formula (Aitken, Proc Edinburgh Math Soc B, 4:106-110, 1934) was used to analyze reading performance data from twins with reading difficulties (selected sample) and a population of normally-achieving twin pairs (control sample). As a comparison, DF models were also fitted to these same data sets. In general, resulting estimates of additive genetic, shared environmental, and non-shared environmental influences were similar when the DF and PA models were fitted to the data. However, the PA selection formula may be more readily generalized to the multivariate case.

Genetic influences on reading difficulties in boys and girls: the Colorado twin study.

To test the hypothesis that the genetic etiology for reading disability may differ in males and females, data from identical and fraternal twin pairs were analysed using both concordance and multiple regression methods. The sample included 264 identical (129 male, 135 female) and 214 same-sex fraternal (121 male, 93 female) twin pairs in which at least one member of each pair had reading difficulties. The difference between the identical and fraternal twin pair concordance rates was slightly larger for females than for males, suggesting a possible sex difference in etiology; however, a loglinear analysis of the three-way interaction of sex, zygosity, and concordance was not significant (p> or = 0.17). The estimate of group heritability (h2g), a standardized measure of the extent to which reading difficulties are due to genetic influences, was somewhat greater for females than males (0.65 vs 0.54), but this difference was also not significant (p > or = 0.35). Gender differences in h2g were larger for younger children (less than 11.5 years of age) than for older children. However, the three-way interaction of sex, zygosity, and age was not significant when age was treated either categorically (p > or = 0.86) or continuously (p > or = 0.71). Thus, results of this study provide little or no evidence for a differential genetic etiology of reading difficulties in males and females.

Effects of a program of human interaction and alterations in diet composition on activity of the hypothalamic-pituitary-adrenal axis in dogs housed in a public animal shelter.

OBJECTIVE: To determine whether a program of human interaction or alterations in diet composition would alter activity of the hypothalamic-pituitary-adrenal (HPA) axis in dogs housed in an animal shelter. DESIGN: Prospective study. ANIMALS: 40 dogs. PROCEDURE: Dogs were (n = 20) or were not (20) enrolled in a program of regular supplemental human interaction (20 min/d, 5 d/wk, for 8 weeks) involving stroking, massaging, and behavioral training. In addition, half the dogs in each group were fed a typical maintenance-type diet, and the other half were fed a premium diet. Plasma cortisol and ACTH concentrations were measured during weeks 0, 2, 4, and 8 and before and after exposure to a battery of novel situations during weeks 0 and 8. RESULTS: Plasma cortisol concentration was significantly decreased by week 2, but plasma ACTH concentration was not significantly decreased until week 8 and then only in dogs fed the premium diet. Following exposure to novel situations, plasma cortisol and ACTH concentrations were significantly increased. However, during week 8, dogs enrolled in the program of human interaction had significantly lower increases in cortisol concentration than did dogs not enrolled in the program. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that both a program of human interaction and alterations in diet composition have moderating effects on activity of the HPA axis in dogs housed in an animal shelter and that activity of the HPA axis may be increased for a longer period during shelter housing than measurement of plasma cortisol concentration alone would suggest.

Social influences on cortisol and behavioral responses of preweaning, periadolescent, and adult guinea pigs.

In various species, the presence of an attachment figure can reduce hypothalamic-pituitary-adrenal (HPA) responses. In the guinea pig, the mother reduces HPA elevations of her young both prior to and following weaning. Recently, an unfamiliar female was also found to reduce the HPA responses of postweaning guinea pigs. The present study evaluated the specificity and ontogenetic course of the effect of the unfamiliar female. Experiment 1 found that an unfamiliar adult male did not reduce the cortisol response of periadolescent subjects during novelty exposure. Experiment 2 showed that the effect of the unfamiliar female was present as early as the second week of life. Experiment 3 found that neither an unfamiliar adult female nor male affected the cortisol response in adult guinea pigs. In all experiments, the mother reduced the cortisol elevations of her offspring. The ability to buffer the cortisol response could not be explained by the amount of agonistic behavior subjects received from the stimulus animals. Results indicate that the mother guinea pig has a persisting ability to buffer HPA responses in her developing offspring; that during at least a large portion of the time that the mother can moderate the cortisol response of her young, so too can an unfamiliar adult female, but not an unfamiliar adult male; and that the ability of social partners to moderate HPA activity is not readily predictable from behavioral interactions.

Exploring human interaction and diet effects on the behavior of dogs in a public animal shelter.

This study examined the effects of 2 manipulations--a brief, regular period of human contact and diet--on the behavior of dogs confined in a public animal shelter. A behavioral battery designed to assess reactions to novel situations, and a test of responsiveness to an unfamiliar human were administered both prior to (pretest) and immediately following (posttest) the 8-week intervention period. Overall, the regular periods of increased human contact together with a diet that contained augmented levels of digestible protein, fat, calories, and animal-derived ingredients reduced signs of behavioral reactivity from pretest to posttest. In some cases, the comparison diet appeared more effective, but only for dogs receiving minimal human interaction. The results indicate that a combination of human interaction and high quality diet may positively affect the behavior of dogs in animal shelters.