Advanced imaging use and payment trends in a large pediatric accountable care organization.

BACKGROUND: Pediatric imaging use and payment trends in accountable care organizations (ACOs) are seldom studied but are important for health policy decisions and resource allocation. OBJECTIVE: To evaluate patterns of advanced imaging use and associated payments over a 7-year period at a large ACO in the USA serving a Medicaid population. MATERIALS AND METHODS: We reviewed paid claims data from 2011 through 2017 from an ACO, analyzing the MRI, CT and US use trends and payments from emergency department (ED) and outpatient encounters. We defined "utilization rate" as the number of advanced imaging procedures per 100 enrolled children per calendar year. Average yearly utilization and payments trends were analyzed using Pearson correlation. RESULTS: Across 7 years, 186,552 advanced imaging procedures were performed. The average overall utilization rate was 6.99 (95% confidence interval [CI]: 6.9-7.1). In the ED this was 2.7 (95% CI: 2.6-2.8) and in outpatients 4.3 (95% CI: 4.2-4.3). The overall utilization rate grew by 0.7% yearly (P=0.077), with US growing the most at 4.0% annually (P=0.0005), especially in the ED in the US, where it grew 10.8% annually (P=0.000019). The overall payments were stable from 2011 to 2017, with outpatient MRI seeing the largest payment decrease at 1.8% (P=0.24) and ED US showing the most growth at 3.3% (P=0.00016). Head CT and abdominal US were the two most common procedures. CONCLUSION: Over the study period, advanced imaging utilization at this large pediatric ACO serving the Medicaid population increased, especially with US use in the ED. Overall payments related to advanced imaging remained stable over this period.

Left behind again: Rural home health services in a Medicaid pediatric accountable care organization.

PURPOSE: To contrast trends in rural and urban pediatric home health care use among Medicaid enrollees. METHODS: Medicaid administrative claims data were used to assess differences in home health care use for child members in a large pediatric accountable care organization (ACO) in Ohio. Descriptive statistics assessed rural and urban differences in health care use over a 10-year period between 2010 and 2019. FINDINGS: Pediatric home health care use increased markedly in the low-income (CFC) and disabled (ABD) Medicaid categories. Over the past 10 years, CFC-enrolled children from urban communities have seen more home health visits, fewer emergency department (ED) visits, and more well child visits compared to rural CFC-enrolled children. Children enrolled due to disabilities in urban communities have also seen more home health visit use but fewer preventive care visits than their rural counterparts. CONCLUSIONS: Within a pediatric ACO, rural home health care use has remained relatively stagnant over a 10-year period, a stark contrast to increases in home health care use among comparable urban populations. There are likely multiple explanations for these differences, including overuse in urban communities, lack of access in rural communities, and changes to home health reimbursement. More can be done to improve rural home health access. Such improvement will likely necessitate large-scale changes to home health care delivery, workforce, and financing. Improvements should be evaluated for return-on-investment not only in terms of direct costs, that is, reduced inpatient or ED costs, but also in terms of patient and family quality-of-life or key indicators of child well-being such as educational attainment.

Trends in healthcare utilisation for firearm-related injuries among a cohort of publicly insured children in Ohio.

OBJECTIVE: To examine healthcare utilisation for all firearm-related injuries among publicly insured children. METHODS: A retrospective analysis of firearm injury medical claims among paediatric (<21 years) Medicaid beneficiaries in Ohio from 2010 to 2018. Factors associated with unintentional and intentional firearm injury were explored using multivariable logistic regression. Average annual patient healthcare costs were determined in 2019 US$. RESULTS: There were 1061 firearm injury-related claims (853 (80%) unintentional; 154 (15%) intentional; 54 (5%) unknown) occurring in 663 children over 2 736 517 available person-years. From 2010 to 2018, yearly total firearm claims rose from 19.7 to 31.3 per 100 000 persons (p=0.033). Urban children experienced a non-significant increase in firearm claims rate over time (26.1 vs 35.0/100 000; p=0.066) while the claims rate nearly tripled among those in rural areas (8.4 vs 24.0/100 000; p=0.012). Younger age, females and rural residence were associated with reduced odds of injury claims. The average annual costs for emergency department and inpatient visits, respectively, were $260 and $5735. CONCLUSION: Risk and type of firearm injury claims among low-income children in Ohio varies by age, sex and residence. Prevention programmes should be tailored based on these demographics.

Contribution of Social Determinant of Health Factors to Rural-Urban Preventive Care Differences Among Medicaid Enrollees.

OBJECTIVE: 1) Assess whether rural-urban disparities are present in pediatric preventive health care utilization; and 2) use regression decomposition to measure the contribution of social determinants of health (SDH) to those disparities. METHODS: With an Ohio Medicaid population served by a pediatric Accountable Care Organization, Partners For Kids, between 2017 and 2019, we used regression decomposition (a nonlinear multivariate regression decomposition model) to analyze the contribution of patient, provider, and SDH factors to the rural-urban well-child visit gap among children in Ohio. RESULTS: Among the 453,519 eligible Medicaid enrollees, 61.2% of urban children received a well-child visit. Well-child visit receipt among children from large rural cities/towns and small/isolated towns was 58.2% and 55.5%, respectively. Comparing large rural towns to urban centers, 55.8% of the 3.0 percentage-point difference was explained by patient, provider, and community-level SDH factors. In comparing small/isolated town to urban centers, 89.8% of the 5.7 percentage-point difference was explained by these characteristics. Of provider characteristics, pediatrician providers were associated with increased well visit receipt. Of the SDH factors, unemployment and education contributed the most to the explained difference in large rural towns while unemployment, education, and food deserts contributed significantly to the small/isolated town difference. CONCLUSIONS: The receipt of pediatric preventive care is slightly lower in rural communities. While modest, the largest part of the rural-urban preventive care gap can be explained by differences in provider type, poverty, unemployment, and education levels. More could be done to improve pediatric preventive care in all communities.

Providers' Behaviors and Beliefs on Prescribing Antipsychotic Medication to Children: A Qualitative Study.

Fragmentation in behavioral and mental health care to children has resulted in suboptimal care and high rates of psychotropic medication use, especially antipsychotic medications (APM). A qualitative study, based on the Theory of Planned Behavior (TPB), aimed to better understand prescribing practices, barriers to optimal treatment, and potential interventions to safeguard the use of APM for children in Kentucky. The most common barrier to optimal care was access to mental health specialists. Social norms and pressure from families contribute to increased medication use. We identify promising interventions to safeguard the use of APM through the lens of the TPB.

Zinc deficiency exacerbates while zinc supplement attenuates cardiac hypertrophy in high-fat diet-induced obese mice through modulating p38 MAPK-dependent signaling.

Childhood obesity often leads to cardiovascular diseases, such as obesity-related cardiac hypertrophy (ORCH), in adulthood, due to chronic cardiac inflammation. Zinc is structurally and functionally essential for many transcription factors; however, its role in ORCH and underlying mechanism(s) remain unclear and were explored here in mice with obesity induced with high-fat diet (HFD). Four week old mice were fed on either HFD (60%kcal fat) or normal diet (ND, 10% kcal fat) for 3 or 6 months, respectively. Either diet contained one of three different zinc quantities: deficiency (ZD, 10mg zinc per 4057kcal), normal (ZN, 30mg zinc per 4057kcal) or supplement (ZS, 90mg zinc per 4057kcal). HFD induced a time-dependent obesity and ORCH, which was accompanied by increased cardiac inflammation and p38 MAPK activation. These effects were worsened by ZD in HFD/ZD mice and attenuated by ZS in HFD/ZS group, respectively. Also, administration of a p38 MAPK specific inhibitor in HFD mice for 3 months did not affect HFD-induced obesity, but completely abolished HFD-induced, and zinc deficiency-worsened, ORCH and cardiac inflammation. In vitro exposure of adult cardiomyocytes to palmitate induced cell hypertrophy accompanied by increased p38 MAPK activation, which was heightened by zinc depletion with its chelator TPEN. Inhibition of p38 MAPK with its specific siRNA also prevented the effects of palmitate on cardiomyocytes. These findings demonstrate that ZS alleviates but ZD heightens cardiac hypertrophy in HFD-induced obese mice through suppressing p38 MAPK-dependent cardiac inflammatory and hypertrophic pathways.

Up-regulation of Nrf2 is involved in FGF21-mediated fenofibrate protection against type 1 diabetic nephropathy.

The lipid lowering medication, fenofibrate (FF), is a peroxisome proliferator-activated receptor-alpha (PPARα) agonist, possessing beneficial effects for type 2 diabetic nephropathy (DN). We investigated whether FF can prevent the development of type 1 DN, and the underlying mechanisms. Diabetes was induced by a single intraperitoneal injection of streptozotocin in C57BL/6J mice. Mice were treated with oral gavage of FF at 100mg/kg every other day for 3 and 6 months. Diabetes-induced renal oxidative stress, inflammation, apoptosis, lipid and collagen accumulation, and renal dysfunction were accompanied by significant decrease in PI3K, Akt, and GSK-3ß phosphorylation as well as an increase in the nuclear accumulation of Fyn [a negative regulator of nuclear factor (erythroid-derived 2)-like 2 (Nrf2)]. All these adverse effects were significantly attenuated by FF treatment. FF also significantly increased fibroblast growth factor 21 (FGF21) expression and enhanced Nrf2 function in diabetic and non-diabetic kidneys. Moreover, FF-induced amelioration of diabetic renal damage, including the stimulation of PI3K/Akt/GSK-3ß/Fyn pathway and the enhancement of Nrf2 function were abolished in FGF21-null mice, confirming the critical role of FGF21 in FF-induced renal protection. These results suggest for the first time that FF prevents the development of DN via up-regulating FGF21 and stimulating PI3K/Akt/GSK-3ß/Fyn-mediated activation of the Nrf2 pathway.

The obesity epidemic in children: Latino children are disproportionately affected at younger ages.

BACKGROUND AND OBJECTIVES: National surveillance clearly illustrates that U.S. children are becoming increasingly overweight. However, the timing of the onset of childhood overweight has not been well-described. PATIENTS AND METHODS: An accelerated failure time (AFT) model was used to describe the emergence of overweight based on a 12-year collection of height and weight data of over 40,000 children. Race, sex, insurance status and their interactions were specifically examined as predictors of earlier onset of overweight. The outcome of interest was an estimate of the age at which the model predicted that a subgroup would attain a 20% prevalence of overweight. RESULTS: The three-way interaction of race, sex, and insurance status was a significant predictor of onset of overweight. The model estimated that the publicly insured Latino male subgroup had the earliest onset of overweight, attaining a prevalence of 20% overweight by 4.3 years of age. The emergence of overweight in Latino subjects was significantly earlier than that for black or white subjects, irrespective of sex or insurance status. CONCLUSION: Regardless of sex or insurance status, overweight emerges at significantly younger ages in Latino children when compared to black and white children. Substantial numbers of Latino male children are predicted to develop overweight at preschool ages. Obesity prevention may need to be directed toward parents or children well before children enter grade-school.

Creating a safe place for pediatric care: A no hit zone.

OBJECTIVES: Our goal was to create and implement a program, Kosair Children's Hospital's No Hit Zone, which trains health care workers in de-escalation techniques to address parental disruptive behaviors and physical discipline of children commonly encountered in the hospital environment. METHODS: The Child Abuse Task Force, a multidisciplinary group, along with key hospital administrators developed specific content for the policy, as well as marketing and educational materials. The No Hit Zone policy designates Kosair Children's Hospital as "an environment in which no adult shall hit a child, no adult shall hit another adult, no child shall hit an adult, and no child shall hit another child. When hitting is observed, it is everyone's responsibility to interrupt the behavior as well as communicate system policy to those present." RESULTS: Via a multidisciplinary, collaborative approach, the No Hit Zone was successfully implemented at Kosair Children's Hospital in 2012. Cost was nominal, and the support of key hospital administrators was critical to the program's success. Education of health professionals on de-escalation techniques and intervention with families at the early signs of parental stress occurred via live sessions and online training via case-based scenarios. CONCLUSIONS: The No Hit Zone is an important program used to provide a safe and caring environment for all families and staff of Kosair Children's Hospital. Demand for the program continues, demonstrated by the establishment of No Hit Zones at other local hospitals and multiple outpatient clinics. This article offers information for other organizations planning to conduct similar initiatives.

When Informationists Get Involved: the CHICA-GIS Project.

Child Health Improvement through Computer Automation (CHICA) is a computer decision support system (CDSS) that interfaces with existing electronic medical record systems (EMRS) and delivers "just-in-time" patient-relevant guidelines to physicians during the clinical encounter and accurately captures structured data from all who interact with the system. "Delivering Geospatial Intelligence to Health Care Professionals (CHICA-GIS)" (1R01LM010923-01) expands the medical application of Geographic Information Systems (GIS) by integrating a geographic information system with CHICA. To provide knowledge management support for CHICA-GIS, three informationists at the Indiana University School of Medicine were awarded a supplement from the National Library Medicine. The informationists will enhance CHICA-GIS by: improving the accuracy and accessibility of information, managing and mapping the knowledge which undergirds the CHICA-GIS decision support tool, supporting community engagement and consumer health information outreach, and facilitating the dissemination of new CHICA-GIS research results and services.

The role of perceived parent monitoring and support on urban child and adolescent problem behavior.

Parental practices on problem behavior based on gender and age effects with urban youth were studied. Participants were 8-17 years old (N = 3,658; 66% African-American) and logistic regression models were conducted. For pre-teen females, decreased friend monitoring was related to high problem behavior; for teen females, lower maternal support and decreased home monitoring were significant. None of the models were significant for pre-teen males and lack of home monitoring was significant for teen males. Strategies for preventing problem behavior within urban communities will be more effective if they are tailored to gender and developmental factors.

Gender differences in the association between perceived discrimination and adolescent smoking.

OBJECTIVES: We examined associations between perceived racial/ethnic discrimination, gender, and cigarette smoking among adolescents. METHODS: We examined data on Black and Latino adolescents aged 12 to 19 years who participated in the Moving to Opportunity study (N = 2561). Perceived discrimination was assessed using survey items asking about unfair treatment because of race/ethnicity in the prior 6 months. We used logistic regression to investigate associations between discrimination and smoking, stratified by gender and controlling for covariates. RESULTS: One fourth of adolescents reported that discrimination had occurred in at least 1 location. Discrimination was associated with increased odds of smoking among boys (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.2, 3.0) and decreased odds among girls (OR = 0.6; 95% CI = 0.3, 1.1). Discrimination at school or work contributed to associations for girls (OR = 0.3; 95% CI = 0.1, 0.9), and discrimination at shops (OR = 2.0; 95% CI = 1.1, 3.8) and by police (OR = 2.0; 95% CI = 1.2, 3.4) contributed to associations for boys. CONCLUSIONS: Associations between discrimination and smoking differ by gender. Girls' decreased smoking in higher-discrimination settings may be a result of protective factors associated with where they spend time. Boys' increased smoking in higher-discrimination settings may reflect increased stress from gender-specific targeting by police and businesses.

Neighborhood greenness and 2-year changes in body mass index of children and youth.

BACKGROUND: Available studies of the built environment and the BMI of children and youth suggest a contemporaneous association with neighborhood greenness in neighborhoods with high population density. The current study tests whether greenness and residential density are independently associated with 2-year changes in the BMI of children and youth. METHODS: The sample included children and youth aged 3-16 years who lived at the same address for 24 consecutive months and received well-child care from a Marion County IN clinic network within the years 1996-2002 (n=3831). Multiple linear regression was used to examine associations among age- and gender-specific BMI z-scores in Year 2, residential density, and a satellite-derived measure of greenness, controlling for baseline BMI z-scores and other covariates. Logistic regression was used to model associations between an indicator of BMI z-score increase from baseline to Time 2 and the above-mentioned predictors. RESULTS: Higher greenness was significantly associated with lower BMI z-scores at Time 2 regardless of residential density characteristics. Higher residential density was not associated with Time 2 BMI z-scores in models regardless of greenness. Higher greenness was also associated with lower odds of children's and youth's increasing their BMI z-scores over 2 years (OR=0.87; 95% CI=0.79, 0.97). CONCLUSIONS: Greenness may present a target for environmental approaches to preventing child obesity. Children and youth living in greener neighborhoods had lower BMI z-scores at Time 2, presumably due to increased physical activity or time spent outdoors. Conceptualizations of walkability from adult studies, based solely on residential density, may not be relevant to children and youth in urban environments.

Using GPS-enabled cell phones to track the travel patterns of adolescents.

BACKGROUND: Few tools exist to directly measure the microsocial and physical environments of adolescents in circumstances where participatory observation is not practical or ethical. Yet measuring these environments is important as they are significantly associated with adolescent health-risk. For example, health-related behaviors such as cigarette smoking often occur in specific places where smoking may be relatively surreptitious. RESULTS: We assessed the feasibility of using GPS-enabled cell phones to track adolescent travel patterns and gather daily diary data. We enrolled 15 adolescent women from a clinic-based setting and asked them to carry the phones for 1 week. We found that these phones can accurately and reliably track participant locations, as well as record diary information on adolescent behaviors. Participants had variable paths extending beyond their immediate neighborhoods, and denied that GPS-tracking influenced their activity. CONCLUSION: GPS-enabled cell phones offer a feasible and, in many ways, ideal modality of monitoring the location and travel patterns of adolescents. In addition, cell phones allow space- and time-specific interaction, probing, and intervention which significantly extends both research and health promotion beyond a clinical setting. Future studies can employ GPS-enabled cell phones to better understand adolescent environments, how they are associated with health-risk behaviors, and perhaps intervene to change health behavior.

Adolescent travel patterns: pilot data indicating distance from home varies by time of day and day of week.

We conducted a pilot study using new technology to track adolescent "place." Using Global Positioning System (GPS)-enabled cell phones, we recruited and tracked 15 female adolescents for a 1-week period. Distance away from home was greatest in the evenings on weekends or holidays. The greatest percentage of time spent more than 1 kilometer away from home was also during these times. Such GPS technology holds promise for future adolescent health research in allowing more specific and dynamic measurement of where adolescents spend time.

Use of unstructured parent narratives to evaluate medical student competencies in communication and professionalism.

OBJECTIVE: Medical education programs across the country are now required to conduct meaningful assessments of trainees' competencies, although uniform standards for conducting these evaluations have yet to be established. In 1999, the Indiana University School of Medicine introduced a comprehensive competency-based undergraduate curriculum. The overall goal of the curriculum is to make medical students' day-to-day experiences of training a source of learning about professionalism, communication, and aspects of medicine beyond factual knowledge. We sought to examine free-text comments by parents of pediatric inpatients as substrate for competency evaluation and feedback for third-year students on their pediatrics rotation. METHODS: The study was conducted from June 2001 to February 2004. Parents of hospitalized children completed a short medical student evaluation form that included 2 questions inviting free-text response. We used narrative analysis, a qualitative research technique, to describe both the content and meaning of the parents' responses. RESULTS: We collected 573 evaluations with narrative comments about 412 students. The most common aspect of medical student performance commented on by parents related to communication (53.8%). The next most common narrative comment was some form of affirmation of the student as a health care professional (26.0%). Other themes included establishing context for the comment, perceptions of the health care system, criticizing medical student performance, perceptions of the role of medical students, physical approach to the patient, expression of humility by the student, holistic approach to the patient, physical appearance of the student, superlative description of student, and advocating for the patient. Multiple themes were identified in 232 narrative comments (40.4%). Examples of each theme are provided. CONCLUSIONS: Family members of pediatric inpatients are a valuable source of information about medical student performance in at least 2 of the Accreditation Council for Graduate Medical Education competency areas (Communication and Professionalism). Themes identified in this study could be used to inform the design of a comprehensive 360-degree student evaluation strategy.

Green neighborhoods, food retail and childhood overweight: differences by population density.

PURPOSE: This study examines relationships between overweight in children and two environmentalfactors--amount of vegetation surrounding a child's place of residence and proximity of the child's residence to various types of food retail locations. We hypothesize that living in greener neighborhoods, farther from fast food restaurants, and closer to supermarkets would be associated with lower risk of overweight. DESIGN: Cross-sectional study. SETTING: Network of primary care pediatric clinics in Marion County, Indiana. SUBJECTS: We acquired data for 7334 subjects, ages 3 to 18 years, presenting for routine well-child care. MEASURES: Neighborhood vegetation and proximity to food retail were calculated using geographic information systems for each subject using circular and network buffers. Child weight status was defined using body mass index percentiles. Analysis. We used cumulative logit models to examine associations between an index of overweight, neighborhood vegetation, and food retail environment. RESULTS: After controlling for individual socio-demographics and neighborhood socioeconomic status, measures of vegetation and food retail significantly predicted overweight in children. Increased neighborhood vegetation was associated with decreased risk for overweight, but only for subjects residing in higher population density regions. Increased distance between a subject's residence and the nearest large brand name supermarkets was associated with increased risk of overweight, but only for subjects residing in lower population density regions. CONCLUSIONS: This research suggests that aspects of the built environment are determinants of child weight status, ostensibly by influencing physical activity and dietary behaviors.

Shortcomings in infant iron deficiency screening methods.

BACKGROUND: Screening for iron deficiency anemia is a well-established practice in pediatrics, but numerous challenges surrounding current recommendations raise questions about the effectiveness of this strategy. OBJECTIVE: To evaluate iron deficiency anemia screening approaches, by assessing rates of follow-up testing and resolution among patients meeting screening criteria in a primary care setting. METHODS: A retrospective cohort study was performed. We extracted electronic medical record data on complete blood counts for infants who received primary care in our clinics in the past 10 years. We calculated rates of positive screening results with 9 different measurement criteria and determined rates of follow-up testing and of documented correction of iron deficiency among those who screened positive. RESULTS: Our cohort consisted of 4984 children who were screened at 9 to 15 months of age, between 1994 and 2004. There was a wide distribution of positive detection rates (range: 1.5-14.5%) among the 9 screening criteria. Follow-up testing rates were low. No more than 25% of infants who screened positive by any criterion underwent a repeat complete blood count within 6 months. Moreover, no more than 11.6% (range: 4.4-11.6%) had documented correction of their laboratory abnormalities. CONCLUSIONS: Significant shortcomings exist in current iron deficiency anemia screening practices. A widely agreed-on, specific, and inexpensive screening criterion, with increased emphasis on systems-based approaches to iron deficiency screening, is needed.

Training young pediatricians as leaders for the 21st century.

OBJECTIVE: To conduct a needs assessment with young pediatricians who participate in a leadership training program and to evaluate the effectiveness of that program. METHODS: In concert with the Johnson & Johnson Pediatric Institute, LLC, the American Academy of Pediatrics developed a 1-year strategy to train pediatricians who are <40 years old or <5 years in practice in leadership skills. Participants were nominated by American Academy of Pediatrics chapters and/or sections and were required to complete a detailed needs assessment, attend a 3-day training program, and commit to 1 leadership-related behavior change to be implemented within 6 months. A preanalytic/postanalytic design strategy was used. RESULTS: A total of 56 applicants representing 33 US states participated; 44.6% were male, and more than half (51.8%) were employed at a medical school/hospital. The needs assessment indicated that participants were confident in many of their leadership qualities but desired increased training, particularly in areas of time and priority management and leading "from the middle." Postsurvey instruments (n = 54, 96% response rate) determined that participants positively evaluated the training program and improved in self-reported basic competencies; 87% also reported fully or partially achieving a leadership-related goal identified in a behavior change contract. CONCLUSIONS: Results demonstrate that young physicians are eager for leadership training and that continuing medical education in this area can be provided with positive results. Core competencies, curriculum, and evaluative tools need to be developed further and training opportunities need to be expanded to other subpopulations of pediatricians and pediatric health care providers.

Race, urban community stressors, and behavioral and emotional problems of children with special health care needs.

OBJECTIVES: This study examined the relationship of community-level stressors to behavioral and emotional problems among African-American and white children with special health care needs. METHODS: The authors interviewed 257 low-income caregivers of children with special health care needs in an urban Midwestern city who brought their child for a primary health care visit to a community health center between September 2001 and May 2002. Sociodemographic characteristics as well as information about the children's behavioral and emotional problems, the health status of the children, perceptions of urban community stress, access to health care, and satisfaction with health care were collected to determine racial differences in the impact of urban stress on behavioral and emotional problems. RESULTS: Urban community stressors, race, and child's health status were significantly associated with behavioral and emotional problems among children with special health care needs. The association between urban stress and total behavioral problems did not differ by race. CONCLUSIONS: When caring for children with special health care needs, especially those with emotional or behavioral problems, primary care providers may be better able to identify important aggravating factors if they also assess urban stress. Systems of care are needed that can assist in addressing urban community-level stressors.