Improving transition from pediatric to adult cystic fibrosis care: lessons from a national survey of current practices.

OBJECTIVES: More than 500,000 adolescents with special health care needs age into adulthood each year in the United States, and there is growing recognition of the need for support of their transition to adult-oriented health care. Because of improved survival, cystic fibrosis has experienced this increasing transition need, and cystic fibrosis policy leaders responded by mandating the transition of adults with cystic fibrosis to adult-focused cystic fibrosis care programs by 2000. The primary objective of this study was to characterize in detail recent transition practices at US cystic fibrosis programs, to identify areas for improvement and to serve as a model for other diseases. A secondary objective of this study was to develop and validate a survey for formal assessment of transition practices. METHODS: A 105-question survey on key aspects of transition was administered to cystic fibrosis care team members from all 195 US Cystic Fibrosis Care programs. Rates of adherence to recommended components of transition care were measured. RESULTS: A total of 448 surveys were obtained from 170 (87%) of 195 cystic fibrosis programs. Although transfer of care occurs at a median age of 19 years, initial discussion of transition does not occur until a median age of 17 years, limiting time to foster self-care skills. Only half of programs consistently perform a transition readiness assessment, 28% of centers offer visits focused on transition, and <10% have a written list of desirable self-management skills. CONCLUSIONS: There is significant variability in transition support provided to young adults with cystic fibrosis, but there are simple steps that may lead to more consistent delivery of transition services. Methods of assessment and lessons learned from transitioning young adults at US cystic fibrosis programs may serve to improve transition for individuals with other childhood diseases.

Correlates of readiness to receive Chlamydia screening among 2 populations of youths.

OBJECTIVES: To assess young people's preferences for Chlamydia testing venues and methods, attitudes about testing, sex differences among these variables, and their predictive associations with young people's readiness for screening. DESIGN: Survey. SETTING: National Job Training site and Department of Youth Services site. PARTICIPANTS: One hundred fifty male and 150 female youths from the National Job Training site and 150 male youths from the Department of Youth Services site. MAIN OUTCOME MEASURE: Modifiable predictors of stage of readiness for Chlamydia screening. RESULTS: Modifiable variables associated with increasing readiness for Chlamydia screening included the following: (1) among males in the Department of Youth Services group, perceived likelihood of ever having a Chlamydia infection; (2) among males from the National Job Training site, lack of condom use as a risk factor for Chlamydia infection and perception of untreated Chlamydia infection as dangerous; and (3) among females from the National Job Training site, belief that a partner could have a Chlamydia infection and fewer perceived social consequences of Chlamydia testing. CONCLUSION: Interventions targeted at sex-specific modifiable variables may help reduce undiagnosed Chlamydia infection among sexually active youth.

Behavioral problems and the effects of early intervention on eight-year-old children with learning disabilities.

OBJECTIVES: 1) To investigate the comorbidity of verbal and nonverbal learning disability subtypes with several domains of behavior problems among 8-year-old children. 2) To determine whether receipt of an early intervention modified the association between childhood behavior problems and learning disabilities (LD). METHODS: This is a secondary data analysis of the Infant Health and Development Program (IHDP), a randomized clinical trial of an early intervention provided between ages 0 and 3 involving 985 children born low birthweight and premature. The findings are based on a prospective follow-up of these children at 8 years of age. RESULTS: Compared to children without verbal LD (VLD), those with VLD were twice as likely to exhibit clinical levels of total behavior problems and 89% more likely to exhibit externalizing behavior problems. Analysis of specific subscales of behavior revealed significant associations with anxious/depressed and withdrawn behaviors, as well as an increased likelihood of attention problems among children with VLD. No significant association was found between nonverbal LD (NVLD) and any type of behavior problem. Furthermore, there was a significant interaction between VLD and the intervention, in which the odds of internalizing behavior problems were greater among children with VLD. No interaction effect of the intervention occurred for any type of behavior problem among children with NVLD. CONCLUSIONS: These findings provide evidence that distinct differences exist for different learning disability subtypes with regards to behavioral outcomes and the effects of early intervention services among 8-year-old children.

Using propensity scores to estimate the cost-effectiveness of medical therapies.

The cost-effectiveness ratio is a popular statistic that is used by policy makers to decide which programs are cost-effective in the public health sector. Recently, the net monetary benefit has been proposed as an alternative statistical summary measure to overcome the limitations associated with the cost-effectiveness ratio. Research on using the net monetary benefit to assess the cost-effectiveness of therapies in non-randomized studies has yet to be done. Propensity scores are useful in estimating adjusted effectiveness of programs that have non-randomized or quasi-experimental designs. This article introduces the use of propensity score adjustment in cost-effectiveness analyses to estimate net monetary benefits for non-randomized studies. The uncertainty associated with the net monetary benefit estimate is evaluated using cost-effectiveness acceptability curves. Our method is illustrated by applying it to SEER-Medicare data for muscle invasive bladder cancer to determine the most cost-effective treatment protocol.

A propensity score approach to estimating the cost-effectiveness of medical therapies from observational data.

Health summary measures are commonly used by policy makers to help make decisions on the allocation of societal resources for competing medical treatments. The net monetary benefit is a health summary measure that overcomes the statistical limitations of a popular measure namely, the cost-effectiveness ratio. We introduce a linear model framework to estimate propensity score adjusted net monetary benefit. This method provides less biased estimates in the presence of significant differences in baseline measures and demographic characteristics between treatment groups in quasi-randomized or observational studies. Simulation studies were conducted to better understand the utility of propensity score adjusted estimates of net monetary benefits when important covariates are unobserved. The results indicated that the propensity score adjusted net monetary benefit provides a robust measure of cost-effectiveness in the presence of hidden bias. The methods are illustrated using data from SEER-Medicare for the treatment of bladder cancer.

Changes in pathology instruction and student performance on the United States Medical Licensing Examination Step 1, 1995-2000: a nationwide 6-year longitudinal study.

A multi-institutional collaborative longitudinal study was conducted to assess the effect of curricular change (overall curricular format and detailed pathology instruction) and school policy regarding the Step 1 requirement on the United States Medical Licensure Examination (USMLE) Step 1 Total and Step 1 Pathology scores over a period of 6 years (1995 to 2000). Detailed descriptions of instruction (overall curricular format and the format and number of hours of instruction in various areas of pathology) and the school policy of USMLE Step 1 requirement for classes entering in 1993 to 1998 were matched with Step 1 Total scores and Step 1 Pathology scores for 48,166 students from 73 schools who took the corresponding June 1995 to 2000 examination. Hierarchical linear modeling was used for analysis while controlling for students' MCAT-bpv (Medical College Admission Test, composite of biological and physical sciences and verbal reasoning) scores and undergraduate grade point average (GPA). Results indicated that the GPA and MCAT-bpv scores of students significantly impacted their Step 1 Total score and Step 1 Pathology score for each year. The mean MCAT-bpv scores of entering classes showed a steady increase from 1993 to 1998. About this same time, Step 1 Total scores were on the rise (especially for classes entering 1994 to 1996, after which they stabilized). During the same time period (1993 to 1998), there was a substantial move toward integrated instruction of Pathology. The mean Step 1 scores of schools with integrated instruction were slightly higher than those of schools with nonintegrated instruction, but the difference was not significant. Analyses of variance were run to examine the effect of change of curriculum on Step 1 Total and Step 1 Pathology scores. Our analysis does not appear to show a cause-and-effect relationship between changes in curriculum toward integrated instruction and the increasing Step 1 scores during the study period. The MCAT-bpv scores showed an upward pattern during the study period, and given that they are strong predictors of Step 1 scores, it appears that the rising MCAT-bpv scores are a major contributory factor to the upward trend in the scores during the study period. The only clearly significant result at the school level is that a requirement to pass Step 1 before moving on to clinical rotations is positively related to Step 1 Total and Step 1 Pathology scores.

Prevalence, stability, and predictors of clinically significant behavior problems in low birth weight children at 3, 5, and 8 years of age.

OBJECTIVES: To examine the prevalence, stability, and predictors of clinically significant behavior problems in 869 preterm low birth weight (LBW) infants at 3, 5, and 8 years of age. METHODS: A prospective cohort study was conducted. Clinically significant behavior problems were assessed using dichotomized total problem Child Behavior Checklist scores in LBW children at ages 3, 5, and 8 years. Baseline sociodemographic and obstetric data were collected. Maternal General Health Questionnaire performed at 40 weeks' gestation was dichotomized at a score of 12 to give a measure of maternal psychological distress. Prevalence and stability of behavior problems at ages 3, 5, and 8 were determined and potential predictors of behavior problems at age 3, 5, and 8 were examined using multiple logistic regression. RESULTS: Prevalence of behavior problems remained at approximately 20% at 3, 5, and 8 years. Stability of behavior problems between different ages was approximately 50%. Significant behavior problems at ages 3, 5, and 8 were predicted by maternal psychological distress at 40 weeks (odds ratio [OR]: 1.59; 95% confidence interval [CI]: 1.21-2.09), maternal cigarette smoking during pregnancy (OR: 1.57; 95% CI: 1.20-2.04), Hispanic ethnicity (OR: 2.00; 95% CI: 1.24-3.24), and maternal age (OR: 0.97; 95% CI: 0.94-0.99). CONCLUSIONS: This sample had double the prevalence of behavior problems expected in the general child population. These problems showed stability over time. Cigarette smoking in pregnancy, maternal psychological distress at 40 weeks' gestation, maternal age, and Hispanic ethnicity all were significant predictors of the development of behavior problems from ages 3 to 8. These findings have implications for health policies on smoking and postnatal depression.

Relationship between pathology curricular approaches and performance in the United States medical licensing examination (USMLE), step 1: a national cross-sectional study.

A collaborative multi-institutional study was conducted to study the relationship between characteristics of pathology instruction and student performance in the United States Medical Licensing Examination (USMLE), Step 1. Detailed descriptions of pathology instruction, such as curriculum format, style of instruction, and design of instruction of various areas of pathology for the 1996-1997 academic year were matched with Step 1 total scores and pathology subscores for 10,159 students from 88 schools who took the June 1997 examination. Hierarchical linear modeling was used for analysis while controlling for students' MCAT-bpv scores (Medical College Admission Test scores, average of biological and physical sciences and verbal reasoning). The Step 1 total scores correlate with Step 1 pathology subscores, and both correlate with students' MCAT-bpv scores. The MCAT-bpv scores account for most of the variation in Step 1 scores. Of all of the curricular variables analyzed, 2 possible factors that significantly influence the impact of MCAT-bpv scores on Step 1 scores are (1) multidisciplinary format of instruction and (2) discipline-based general pathology instruction in year 2. Overall, the multidisciplinary format reduced the impact of MCAT-bpv scores on both the Step 1 total score and the pathology subscore by 1 point per MCAT-bpv. Overall, the general pathology instruction in year-2 increased that impact on Step 1 total score by 1 point per MCAT-bpv. The slope became less steep with multidisciplinary format and more steep with year-2 general pathology instruction. As a result, students with higher MCAT-bpv scores tend to benefit from year-2 general pathology instruction, whereas those with lower MCAT-bpv scores appear to benefit from a multidisciplinary format. These differences become more apparent as the MCAT-bpv scores move away from the mean in either direction, indicating that scores of most students are not affected by curricular variables. Overall, there is no significant difference in the school means of Step 1 total scores and pathology subscores of schools with different curricular approaches. This is most likely due to the finding that the students' MCAT-bpv scores, and not curricular variables, are the major predictors of Step 1 scores, and all schools have a mix of students with various MCAT-bpv scores.

Childhood growth and exposure to dichlorodiphenyl dichloroethene and polychlorinated biphenyls.

OBJECTIVES: Dichlorodiphenyl dichloroethene (DDE) and polychlorinated biphenyls (PCB), toxic contaminants known to be persistent in the environment, may affect growth. We investigated whether growth from birth to 10 years of age is associated with blood concentrations of DDE and PCB taken at 8 years of age. STUDY DESIGN: We ambispectively followed up a cohort of 343 German children. DDE and PCB blood concentrations were determined in 1995. Height measurements were conducted prospectively between 1994 and 1997 and obtained retrospectively from each Child's Health Card. Linear regression models for repeated measurements, controlling for confounding factors, were applied. RESULTS: Growth was significantly reduced by an average of 1.8 cm (P <.0275) for girls in the highest DDE concentration quartile (>.44 microg/L in whole blood) compared with girls in the lowest quartile (0.08-0.2 microg/L). There was no observed growth effect of DDE in boys. PCB blood concentrations were not related to growth reduction in either girls or boys. CONCLUSIONS: Background level concentrations to DDE, but not PCB, during childhood are associated with a small reduction in growth for girls evident through the age of 8 years. The observed differences narrow at the year 9 examination and disappear at the year 10 examination. No effects on boys' heights were observed.