Risk Factors, Etiologies, and Screening Tools for Sepsis in Pregnant Women: A Multicenter Case-Control Study.

BACKGROUND: Given the significant morbidity and mortality of maternal sepsis, early identification is key to improve outcomes. This study aims to evaluate the performance characteristics of the systemic inflammatory response syndrome (SIRS), quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA), and maternal early warning (MEW) criteria for identifying cases of impending sepsis in parturients. The secondary objective of this study is to identify etiologies and risk factors for maternal sepsis and to assess timing of antibiotics in patients diagnosed with sepsis. METHODS: Validated maternal sepsis cases during the delivery hospitalization from 1995 to 2012 were retrospectively identified at 7 academic medical centers in the United States and Israel. Control patients were matched by date of delivery in a 1:4 ratio. The sensitivity and specificity of SIRS, qSOFA, and MEW criteria for identifying sepsis were calculated. Data including potential risk factors, vital signs, laboratory values, and clinical management were collected for cases and controls. RESULTS: Eighty-two sepsis cases during the delivery hospitalization were identified and matched to 328 controls. The most common causes of sepsis were the following: chorioamnionitis 20 (24.4%), endometritis 19 (23.2%), and pneumonia 9 (11.0%). Escherichia coli 12 (14.6%), other Gram-negative rods 8 (9.8%), and group A Streptococcus 6 (7.3%) were the most commonly found pathogens. The sensitivities and specificities for meeting criteria for screening tools were as follows: (1) SIRS (0.93, 0.63); (2) qSOFA (0.50, 0.95); and (3) MEW criteria for identifying sepsis (0.82, 0.87). Of 82 women with sepsis, 10 (12.2%) died. The mortality rate for those who received antibiotics within 1 hour of diagnosis was 8.3%. The mortality rate was 20% for the patients who received antibiotics after >1 hour. CONCLUSIONS: Chorioamnionitis and endometritis were the most common causes of sepsis, together accounting for about half of cases. Notable differences were observed in the sensitivity and specificity of sepsis screening tools with the highest to lowest sensitivity being SIRS, MEW, and qSOFA criteria, and the highest to lowest specificity being qSOFA, MEW, and SIRS. Mortality was doubled in the cohort of patients who received antibiotics after >1 hour. Clinicians need to be vigilant to identify cases of peripartum sepsis early in its course and prioritize timely antibiotic therapy.

Promoting a Restrictive Intraoperative Transfusion Strategy: The Influence of a Transfusion Guideline and a Novel Software Tool.

BACKGROUND: The effect of neither transfusion guidelines nor decision support tools on intraoperative transfusion has been previously evaluated. The University of Michigan introduced a transfusion guideline in 2009, and in 2011, the Department of Anesthesiology developed a transfusion decision support tool. The primary aim of this study was to assess the associations of the transfusion guideline and the optional use of the software transfusion tool with intraoperative behaviors; pretransfusion hematocrit assessment (whether or not a hematocrit was checked before each red cell unit) and restrictive red cell use (withholding transfusion unless the hematocrit was ≤21%). METHODS: This was a before-after retrospective study without a concurrent control group of patients transfused 1-3 units of red cells intraoperatively. Three phases were studied to provide data both before and after the implementation of the transfusion guideline and the intraoperative software tool. Within each phase, trends of checking hematocrits before transfusion and restrictive transfusion were charted against time. F tests were used to measure differences of slopes. The difference between means of each phase was measured using Mann-Whitney U tests. Independent associations were measured using mixed-effects multivariable logistic regression. A secondary outcome analysis was conducted for 30-day mortality, myocardial infarction, renal injury, and their combination. RESULTS: The transfusion guideline was associated with increased pretransfusion hematocrit evaluation (67.4%, standard deviation [SD] 3.9 vs 76.5%, SD 2.7; P < .001) and restrictive transfusion practice (14.0%, SD 7.4 vs 33.3%, SD 4.4; P = .001). After adjustment for confounders, the guideline phase was independently associated with increased hematocrit checking (odds ratio, 1.72; 95% confidence interval, 1.46-2.03; P < .001) and restrictive red cell transfusion (odds ratio, 2.95; 95% confidence interval, 2.46-3.54; P < .001). The software tool was not associated with either transfusion behavior. There was no significant change in the rate of renal injury (16.06%), myocardial injury (4.93%), 30-day mortality (5.47%), or a composite (21.90%). CONCLUSIONS: The introduction of a transfusion guideline was independently associated with increased intraoperative pretransfusion hematocrit assessment and restrictive transfusion. The use of a software tool did not further influence either behavior.

Maternal leukocytosis after antenatal corticosteroid administration: a systematic review and meta-analysis.

Although it is known that corticosteroid administration causes leukocytosis, the magnitude and length of time this leukocytosis persists is unknown during pregnancy. This study aimed to establish the expected range of maternal leukocytosis in healthy pregnant women at risk for preterm delivery after antenatal corticosteroid administration. PubMed, Embase and ClinicalTrials.gov were searched to identify the studies in healthy women at risk for preterm delivery without signs of clinical infection that reported white blood cell values preceding and after antenatal corticosteroid administration. The inverse variance weighting technique was used to calculate the weighted means and the standard deviation from the mean for each time period. Six studies met inclusion criteria and included 524 patients and 1406 observations. Mean ± standard deviation maternal white blood cell count values prior to antenatal corticosteroid administration and up to 24, 48, 72 and 96 hours after corticosteroid administration were 10.4 ± 2.4, 13.6 ± 3.6, 12.1 ± 3.0, 11.5 ± 2.9 and 11.1 ± 2.5 × 109/L, respectively. Leukocytosis in healthy, non-infected women is expected to peak 24 hours after antenatal corticosteroid administration and the magnitude of increase is small. Impact statement What is already known on this subject: While it is well known that administration of antenatal corticosteroids causes leukocytosis, it is currently unknown the magnitude and length of time the leukocytosis persists. What the results of this study add: This study establishes the expected range and the temporal progression and regression with antenatal corticosteroid administration in healthy pregnant women at risk for preterm delivery without clinical signs of infection. What the implications are of these findings for clinical practice and/or further research: Clinicians may wish to consider further investigation into the clinical cause, whether infectious or non-infectious, for absolute values and changes outside this range.

Alarm Limits for Intraoperative Drug Infusions: A Report From the Multicenter Perioperative Outcomes Group.

BACKGROUND: Continuous medication infusions are commonly used during surgical procedures. Alarm settings for infusion pumps are considered important for patient safety, but limits are not created in a standardized manner from actual usage data. We estimated 90th and 95th percentile infusion rates from a national database for potential use as upper limit alarm settings. METHODS: We extracted infusion rate data from 17 major hospitals using intraoperative records provided by Multicenter Perioperative Outcomes Group for adult surgery between 2008 and 2014. Seven infusions were selected for study: propofol, remifentanil, dexmedetomidine, norepinephrine, phenylephrine, nitroglycerin, and esmolol. Each dosage entry for an infusion during a procedure was included. We estimated the 50th, 90th, and 95th percentile levels for each infusion across institutions, and performed quantile regression to examine factors that might affect the percentiles rates, such as use in general anesthesia versus sedation. RESULTS: The median 90th and 95th percentile infusion rates (with interquartile range) for propofol were 150 (140-150) and 170 (150-200) µg/kg/min. Quantile regression demonstrated higher 90th and 95th percentile rates during sedation for gastrointestinal endoscopy than for all surgical procedures performed under general anesthesia. For selected vasoactive medications, the corresponding median 90th and 95th percentile rates (with interquartile range) were norepinephrine 14.0 (9.8-18.1) and 18.3 (12.6-23.9) µg/min, and phenylephrine 60 (55-80) and 80 (75-100) µg/min. CONCLUSIONS: Alarm settings based on infusion rate percentile limits would be triggered at predictable rates; ie, the 95th percentile would be exceeded and an alarm sounded during 1 in 20 infusion rate entries. As a result, institutions could establish pump alarm settings consistent with desired alarm frequency using their own or externally validated usage data. Further study will be needed to determine the optimal percentile for infusion alarm settings.

Assessing anesthesiology residents' out-of-the-operating-room (OOOR) emergent airway management.

BACKGROUND: At many academic institutions, anesthesiology residents are responsible for managing emergent intubations outside of the operating room (OOOR), with complications estimated to be as high as 39%. In order to create an OOOR training curriculum, we evaluated residents' familiarity with the content and correct adherence to the American Society of Anesthesiologists' Difficult Airway Algorithm (ASA DAA). METHODS: Residents completed a pre-simulation multiple-choice survey measuring their understanding and use of the DAA. Residents then managed an emergent, difficult OOOR intubation in the simulation center, where two trained reviewers assessed performance using checklists. Post-simulation, the residents completed a survey rating their behaviors during the simulation. The primary outcome was comprehension and adherence to the DAA as assessed by survey responses and behavior in the simulation. RESULTS: Sixty-three residents completed both surveys and the simulation. Post-survey responses indicated a shift toward decreased self-perceived familiarity with the DAA content compared to pre-survey responses. During the simulation, 22 (35%) residents were unsuccessful with intubation. Of these, 46% placed an LMA and 46% prepared for cricothyroidotomy. Nineteen residents did not attempt intubation. Of these, only 31% considered LMA placement, and 26% initiated cricothyroidotomy. CONCLUSIONS: Many anesthesiology residency training programs permit resident autonomy in managing emergent intubations OOOR. Residents self-reported familiarity with the content of and adherence to the DAA was higher than that observed during the simulation. Curriculum focused on comprehension of the DAA, as well as improving communication with higher-level physicians and specialists, may improve outcomes during OOORs.

Risk of Epidural Hematoma after Neuraxial Techniques in Thrombocytopenic Parturients: A Report from the Multicenter Perioperative Outcomes Group.

BACKGROUND: Thrombocytopenia has been considered a relative or even absolute contraindication to neuraxial techniques due to the risk of epidural hematoma. There is limited literature to estimate the risk of epidural hematoma in thrombocytopenic parturients. The authors reviewed a large perioperative database and performed a systematic review to further define the risk of epidural hematoma requiring surgical decompression in this population. METHODS: The authors performed a retrospective cohort study using the Multicenter Perioperative Outcomes Group database to identify thrombocytopenic parturients who received a neuraxial technique and to estimate the risk of epidural hematoma. Patients were stratified by platelet count, and those requiring surgical decompression were identified. A systematic review was performed, and risk estimates were combined with those from the existing literature. RESULTS: A total of 573 parturients with a platelet count less than 100,000 mm who received a neuraxial technique across 14 institutions were identified in the Multicenter Perioperative Outcomes Group database, and a total of 1,524 parturients were identified after combining the data from the systematic review. No cases of epidural hematoma requiring surgical decompression were observed. The upper bound of the 95% CI for the risk of epidural hematoma for a platelet count of 0 to 49,000 mm is 11%, for 50,000 to 69,000 mm is 3%, and for 70,000 to 100,000 mm is 0.2%. CONCLUSIONS: The number of thrombocytopenic parturients in the literature who received neuraxial techniques without complication has been significantly increased. The risk of epidural hematoma associated with neuraxial techniques in parturients at a platelet count less than 70,000 mm remains poorly defined due to limited observations.

Intraoperative medications associated with hemodynamically significant anaphylaxis.

STUDY OBJECTIVE: To facilitate the identification of drugs and patient factors associated with hemodynamically significant anaphylaxis. DESIGN: Using an existing database containing complete perioperative records, instances of hemodynamically significant anaphylaxis were identified using a physiologic and treatment-based screening algorithm. All cases were manually reviewed by 2 clinicians, with a third adjudicating disagreements, and confirmed cases were matched 3:1 with control cases. Intraoperative medications given in instances of hemodynamically significant anaphylaxis and patient risk factors were compared with control cases. SETTING: University of Michigan Hospital, a large, tertiary care hospital. PATIENTS: All adult patients undergoing surgery between January 1, 2004, and January 5, 2015. INTERVENTIONS: None. MEASUREMENTS: Incidence of hemodynamically significant anaphylaxis during anesthesia. Patient risk factors and intraoperative medications associated with hemodynamically significant anaphylaxis. MAIN RESULTS: Hemodynamically significant anaphylaxis occurred in 55 of 461 986 cases (1 in 8400). Hemodynamically significant anaphylaxis occurred in 52 patients, with 1 patient experiencing 3 instances and another patient 2 instances. Only 1 drug was associated with an increased risk of hemodynamically significant anaphylaxis: protamine (odds ratio, 11.78; 95% confidence interval, 1.40-99.26; P=.0233). No category of drugs was associated with increased risk. Of patient risk factors, only personal history of anaphylaxis was associated with an increased risk (odds ratio, 77.1; 95% confidence interval, 10.46-567.69; P=<.0001). Postoperative follow-up and evaluation of patients were low at our institution. A serum tryptase level was sent in only 49% of cases, and 41% of levels were positive, an overall positive rate of 20% of cases. Following instances of hemodynamically significant anaphylaxis, only 29% of patients were seen and evaluated by an allergist at our institution. CONCLUSIONS: Hemodynamically significant anaphylaxis is a rare complication of anesthesia, with an incidence consistent with the existing literature. Contrary to most existing literature, only protamine was associated with increased risk. A personal history of anaphylaxis appears to best predict risk of hemodynamically significant anaphylaxis.

Observational study on patterns of neuromuscular blockade reversal.

BACKGROUND: Using electronic health record data, we hypothesized that larger reversal doses are used for patients with deeper levels of neuromuscular blockade (NMB) as evidenced by the last recorded TOF measurement. We also examined if dosing regimens reflect current practice guidelines of using ideal body weight (IBW) for NMB agents and total body weight (TBW) for neostigmine. METHODS: This is a retrospective observational study of adult, ASA 1-4 patients who underwent general anaesthesia and received non-depolarizing NMB agents between 01/01/2004 and 12/31/2013. For the primary outcome, percentages of cases receiving neostigmine and median doses administered for each subjective train-of-four (TOF) category were calculated. Secondary analyses evaluated associations between NMB dosing and neostigmine administration based on Body Mass Index (BMI) categories. RESULTS: A total of 135,633 cases met inclusion criteria for the study. There was no clinically significant difference in median neostigmine dosing based on last TOF count prior to reversal administration: 37.5 mcg/kg for TOF of 4/4 vs. 37.9 mcg/kg for TOF of 0/4 for the total neostigmine dose. Significantly higher number of patients with lower TOF counts received additional neostigmine administration: 5.7 % for 0/4 vs. 1.5 % for 4/4 TOF counts. The median times to extubation following neostigmine administration were clinically similar across TOF count categories. The median doses for neostigmine based on TBW decreased with higher BMI categories and were significantly different between the lowest and highest categories: 42.8 mcg/kg vs 30.8 mcg/kg for total doses (p < .0001) respectively. The percentages of cases requiring reversal in addition to the initial dose increased with increasing BMI categories and were 2.1 % for BMI < 18 vs. 3.3 % for BMI ≥ 40. The total median dose of NMB agents in ED95 equivalents per IBW increased from 2.9 in the Underweight category to 4.2 in the Class III Obese category. The majority of patients in the pancuronium subgroup received very low ED95 equivalent dose of 0.1 and did not require reversal. Patients receiving cisatracurium were given significantly higher median ED95 equivalent dose of 5.6 vs 2.8-3.9 compared to other intermediate acting NMB agents, while receiving clinically similar doses of neostigmine. CONCLUSIONS: Neither neostigmine dosing nor times to extubation were affected by the depth of the neuromuscular blockade prior to reversal. The need for additional reversal, or rescue, correlated strongly with the depth of NMB. There was significant variability in neostigmine dosing across the BMI categories. Underweight patients received relatively lower NMB doses while simultaneously receiving relatively higher reversal doses, and the opposite was true for patients with BMI >40.

A Survey of Simulation Utilization in Anesthesiology Residency Programs in the United States.

Given the evolution of competency-based education and evidence supporting the benefits of incorporating simulation into anesthesiology residency training, simulation will likely play an important role in the training and assessment of anesthesiology residents. Currently, there are little data available regarding the current status of simulation-based curricula across US residency programs. In this study, we assessed simulation-based training and assessment in US anesthesiology programs using a survey designed to elicit information regarding the type, frequency, and content of the simulation courses offered at the 132 Accreditation Council of Graduate Medical Education-certified anesthesiology training programs. The response rate for the survey was 66%. Although most of the responding programs offered simulation-based courses for interns and residents and during CA-1 orientation, the curriculum varied greatly among programs. Approximately 40% of responding programs use simulation for resident assessment and remediation. The majority of responding programs favored standard simulation-based training as part of residency training (89%), and the most common perceived obstacles to doing so were time, money, and human resources. The results from this survey highlight that there are currently large variations in simulation-based training and assessment among training programs. It also confirms that many program directors feel that standardizing some components of simulation-based education and assessment would be beneficial. Given the positive impact simulation has on skill retention and operating room preparedness, it may be worthwhile to consider developing a standard curriculum.

Intraoperative Lung-Protective Ventilation Trends and Practice Patterns: A Report from the Multicenter Perioperative Outcomes Group.

BACKGROUND: The use of an intraoperative lung-protective ventilation strategy through tidal volume (TV) size reduction and positive end-expiratory pressure (PEEP) has been increasingly investigated. In this article, we describe the current intraoperative lung-protective ventilation practice patterns and trends. METHODS: By using the Multicenter Perioperative Outcomes Group database, we identified all general endotracheal anesthetics from January 2008 through December 2013 at 10 institutions. The following data were calculated: (1) percentage of patients receiving TV > 10 mL/kg predicted body weight (PBW); (2) median initial and overall TV in mL/kg PBW and; (3) percentage of patients receiving PEEP ≥ 5 cm H2O. The data were analyzed at 3-month intervals. Interinstitutional variability was assessed. RESULTS: A total of 330,823 patients met our inclusion criteria for this study. During the study period, the percentage of patients receiving TV > 10 mL/kg PBW was reduced for all patients (26% to 14%) and in the subpopulations of obese (41% to 25%), short stature (52% to 36%), and females (39% to 24%; all P values <0.001). There was a significant reduction in TV size (8.90-8.20 mL/kg PBW, P < 0.001). There was also a statistically significant but clinically irrelevant difference between initial and overall TV size (8.65 vs 8.63 mL/kg PBW, P < 0.001). Use of PEEP ≥ 5 cm H2O increased during the study period (25%-45%, P < 0.001). TV usage showed significant interinstitutional variability (P < 0.001). CONCLUSIONS: Although decreasing, a significant percentage of patients are ventilated with TV > 10 mL/kg PBW, especially if they are female, obese, or of short stature. The use of PEEP ≥ 5 cm H2O has increased significantly. Creating awareness of contemporary practice patterns and demonstrating the efficacy of lung-protective ventilation are still needed to optimize intraoperative ventilation.

Influence of Ventilation Strategies and Anesthetic Techniques on Regional Cerebral Oximetry in the Beach Chair Position: A Prospective Interventional Study with a Randomized Comparison of Two Anesthetics.

BACKGROUND: Beach chair positioning during general anesthesia is associated with cerebral oxygen desaturation. Changes in cerebral oxygenation resulting from the interaction of inspired oxygen fraction (FIO2), end-tidal carbon dioxide (PETCO2), and anesthetic choice have not been fully evaluated in anesthetized patients in the beach chair position. METHODS: This is a prospective interventional within-group study of patients undergoing shoulder surgery in the beach chair position that incorporated a randomized comparison between two anesthetics. Fifty-six patients were randomized to receive desflurane or total intravenous anesthesia with propofol. Following induction of anesthesia and positioning, FIO2 and minute ventilation were sequentially adjusted for all patients. Regional cerebral oxygenation (rSO2) was the primary outcome and was recorded at each of five set points. RESULTS: While maintaining FIO2 at 0.3 and PETCO2 at 30 mmHg, there was a decrease in rSO2 from 68% (SD, 12) to 61% (SD, 12) (P < 0.001) following beach chair positioning. The combined interventions of increasing FIO2 to 1.0 and increasing PETCO2 to 45 mmHg resulted in a 14% point improvement in rSO2 to 75% (SD, 12) (P <0.001) for patients anesthetized in the beach chair position. There was no significant interaction effect of the anesthetic at the study intervention points. CONCLUSIONS: Increasing FIO2 and PETCO2 resulted in a significant increase in rSO2 that overcomes desaturation in patients anesthetized in the beach chair position and that appears independent of anesthetic choice.

Incidence and prevalence of systemic lupus erythematosus among Arab and Chaldean Americans in southeastern Michigan: the Michigan Lupus Epidemiology and Surveillance Program.

OBJECTIVES: We assessed the burden of systemic lupus erythematosus (SLE) among Arab and Chaldean Americans residing in southeast Michigan. METHODS: For those meeting SLE criteria from the Michigan Lupus Epidemiology and Surveillance Registry, we determined Arab or Chaldean ethnicity by links with demographic data from birth certificates and with a database of Arab and Chaldean names. We compared prevalence and incidence of SLE for Arab and Chaldean Americans with estimates for non-Arab and non-Chaldean American Whites and Blacks. RESULTS: We classified 54 individuals with SLE as Arab and Chaldean Americans. The age-adjusted incidence and prevalence estimates for Arab and Chaldean Americans were 7.6 and 62.6 per 100 000, respectively. Arab and Chaldean Americans had a 2.1-fold excess SLE incidence compared with non-Arab and non-Chaldean American Whites. Arab and Chaldean American women had both significantly higher incidence rates (5.0-fold increase) and prevalence estimates (7.4-fold increase) than did Arab and Chaldean American men. CONCLUSIONS: Recognizing that Arab and Chaldean Americans experience different disease burdens from Whites is a first step toward earlier diagnosis and designing targeted interventions. Better methods of assigning ethnicity would improve research in this population.

Vaccination with tetanus, diphtheria, and acellular pertussis vaccine of pregnant women enrolled in Medicaid--Michigan, 2011-2013.

In October 2011, the Advisory Committee on Immunization Practices (ACIP) first recommended the routine administration of a tetanus, diphtheria, and acellular pertussis vaccine (Tdap) during pregnancy as a strategy to protect infants from pertussis (also known as whooping cough). This recommendation applied to women previously unvaccinated with Tdap and specified the optimal vaccination time as late second or third trimester (after 20 weeks' gestation). By vaccinating pregnant women, infants, who are at highest risk for mortality and morbidity from pertussis, gain passive immunity from maternal antibodies transferred to them in utero. Since this recommendation was made, little has been published on the percentage of women receiving Tdap during pregnancy. In Michigan, Medicaid pays for costs of pregnancy for approximately 40% of births. Infants enrolled in Medicaid are a particularly vulnerable population; in Michigan, their all-cause mortality is higher than that of privately insured infants. To assess vaccination coverage among pregnant women enrolled in a publicly funded insurance program in Michigan, Medicaid administrative claims data and statewide immunization information system data for mothers of infants born during November 2011-February 2013 were analyzed. This report describes the results of that analysis, which indicated that only 14.3% of these women received Tdap during pregnancy, with rates highest (17.6%) among non-Hispanic, non-Arab whites and lowest (6.8%) among Arab women. Vaccination was related to maternal age and gestational age at birth, but not to adequacy of prenatal care. In 2013, recognizing the importance of Tdap for every pregnancy, ACIP revised its guidelines to include a Tdap dose during every pregnancy. Ensuring that all infants receive the protection against pertussis afforded by maternal vaccination will require enhanced efforts to vaccinate pregnant women.

Identifying sickle cell disease cases using administrative claims.

OBJECTIVE: To develop and test the accuracy of administrative claims method for identifying children with sickle cell disease (SCD) to enable quality of care assessments among children enrolled in Medicaid. METHODS: All administrative claims with an SCD diagnosis were obtained from Michigan Medicaid from 2008 to 2011 for children ≤18 years, representing 1828 individuals. All Medicaid claims were obtained for these children and classified into categories on the basis of SCD care; these classifications were used to develop 37 alternative case definitions for identifying children with SCD. Children with ≥1 SCD claim in 2010 or 2011 were identified as confirmed SCD or not SCD using the gold standard of Michigan newborn screening administrative records. Measures of performance were calculated for each case definition for eligible children in 2010. Further validation of the case definitions was performed among eligible children in 2011. RESULTS: In 2010, a total of 938 children met eligibility criteria and were linked to newborn screening records; 605 (59%) were confirmed SCD, and 333 (32%) were not SCD. Measures of performance varied among the 37 case definitions, and the 4 best case definitions on the basis of the sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve were validated among 924 children meeting eligibility criteria in 2011. The case definition of at least 3 SCD claims in any position identified children with SCD with the most accuracy, with an area under the ROC curve of 0.91 (95% confidence interval 0.89, 0.93). CONCLUSIONS: This definition can be used to facilitate a more accurate identification of children with SCD in future studies. Further investigation is necessary to determine whether this method translates to other populations besides Michigan Medicaid-insured children.

Impact of psychosocial risk factors on prenatal care delivery: a national provider survey.

To evaluate providers' perspectives regarding the delivery of prenatal care to women with psychosocial risk factors. A random, national sample of 2,095 prenatal care providers (853 obstetricians and gynecologists (Ob/Gyns), 270 family medicine (FM) physicians and 972 midwives) completed a mailed survey. We measured respondents' practice and referral patterns regarding six psychosocial risk factors: adolescence (age ≤19), unstable housing, lack of paternal involvement and social support, late prenatal care (>13 weeks gestation), domestic violence and drug or alcohol use. Chi square and logistic regression analyses assessed the association between prenatal care provider characteristics and prenatal care utilization patterns. Approximately 60 % of Ob/Gyns, 48.4 % of midwives and 32.2 % of FM physicians referred patients with psychosocial risk factors to clinicians outside of their practice. In all three specialties, providers were more likely to increase prenatal care visits with alternative clinicians (social workers, nurses, psychologists/psychiatrists) compared to themselves for all six psychosocial risk factors. Drug or alcohol use and intimate partner violence were the risk factors that most often prompted an increase in utilization. In multivariate analyses, Ob/Gyns who recently completed clinical training were significantly more likely to increase prenatal care utilization with either themselves (OR 2.15; 95 % CI 1.14-4.05) or an alternative clinician (2.27; 1.00-4.67) for women with high psychosocial risk pregnancies. Prenatal care providers frequently involve alternative clinicians such as social workers, nurses and psychologists or psychiatrists in the delivery of prenatal care to women with psychosocial risk factors.

Relative Contributions of Pre-Kindergarten and Kindergarten to Children's Literacy and Mathematics Skills.

A difficulty for developmental researchers is disambiguating children's general maturation from the influence of schooling. In this study, we use a natural experiment to examine the influence of pre-kindergarten and kindergarten schooling experiences on the development of literacy and mathematics. Children (n = 60) whose birthdates fell within two months of the state-determined cut-off date for pre-kindergarten and kindergarten entry were administered four subtests of the Woodcock-Johnson Tests of Achievement III in the fall and spring of the school year. Using hierarchical linear modeling coupled with propensity score matching, children who were starting kindergarten, and who had prior experience in pre-kindergarten, had higher scores on measures of phonological awareness, early reading, and mathematics skills than did children who had not attended pre-kindergarten previously, even though they were essentially the same age. Fall vocabulary scores did not differ in relation to whether children had pre-kindergarten experience. In addition, although children who attended kindergarten as well as those who attended pre-kindergarten exhibited growth on all measures during the school year, children who attended kindergarten demonstrated greater gains in early reading and vocabulary during the school year. These findings highlight the potential of early schooling processes to facilitate children's intellectual growth.

The factors associated with high-quality communication for critically ill children.

OBJECTIVE: Timely, high quality communication with families is essential to family-centered decision-making. Quality communication is represented by widespread documentation of prognostic, goals-of-care conversations (PGOCC) in the pediatric intensive care unit (PICU) and should occur without variation by patient characteristics. METHODS: Cohort included 645 PICU admissions in the top decile of risk of mortality on admission over six years. Electronic medical records were used to determine PGOCC, diagnosis on admission and complex chronic condition (CCC) status. Multivariate logistic regression and time-to-event analyses were used. RESULTS: Overall, 31% had a documented PGOCC. 51% had CCC status. 11% had an oncologic, 13% had a cardiovascular diagnosis on admission. 94% of patients who died in the PICU had PGOCC documented, but among the 200 patients with documented PGOCC, 78% did not die in the PICU. Oncologic diagnosis on admission was associated with a higher likelihood of PGOCC compared to non-CCC patients (ARR=1.86; SE=0.26) whereas no other diagnosis category reached the level of statistical significance. Median time from admission to PGOCC was 2 days. Age, gender and CCC status were not associated with whether a PGOCC was documented or with time from admission to PGOCC documentation. 45% of PGOCC in the cohort and 50% of conversations in patients with CCC were documented by PICU physicians. CONCLUSIONS: This study reveals the opportunity for improvement in documentation of PGOCC for critically ill children. It raises the questions of why there is variation of PGOCC across disease categories and whether PGOCC should be considered a quality measure for family-centered care.