Preventing abusive head trauma: can educating parents reduce the incidence?

Abusive head trauma (AHT) is the most lethal form of child abuse; preventing AHT should be a national priority, but research into this area is woefully underfunded. Prevention programs have primarily focused on universal parent education during the neonatal period, a time when parents are a captive audience of the health care establishment whose focus is on the needs of their newborn infant, and who will soon be exposed to the frustration and anger of infant crying. Research has suggested a strong causal link between infant crying and AHT, and parents - particularly fathers and father figures - have been identified as the most common perpetrators of AHT. A number of studies have suggested that educating parents during the postnatal period about the normalcy of inconsolable infant crying and its evolution over the first several months of postnatal life improves parental knowledge about infant crying and a number of positive parenting behaviors, and decreases emergency room visits for crying. In 1998, we began a pilot program in Upstate New York near Buffalo that led to a 47% reduction in AHT incidence. Similar studies have demonstrated 35-75% reductions in incidence, which has led to enthusiasm for this approach to preventing AHT. We, as well as another group, have enacted statewide programs in Pennsylvania and North Carolina; unfortunately, these two large statewide replication trials failed to demonstrate any impact of such an intervention on AHT rates. Serial messages for parents, provided repeatedly over the period of greatest risk for AHT, might be another avenue of research.

Association of a Postnatal Parent Education Program for Abusive Head Trauma With Subsequent Pediatric Abusive Head Trauma Hospitalization Rates.

Importance: Studies suggest that a postnatal parental intervention may reduce the incidence of abusive head trauma (AHT) of infants and young children. Objective: To assess the effect of statewide universal AHT education for parents on AHT hospitalization rates in Pennsylvania and on parents' self-reported knowledge gains and parenting behaviors. Design, Setting, and Participants: Changes in AHT hospitalization rates in Pennsylvania before and during the intervention were compared with those in 5 other states lacking universal parental AHT education during the same period. Data were collected from maternity units and birthing centers throughout Pennsylvania from the parents of 1 593 834 infants born on these units from January 1, 2003, to December 31, 2013. Parental behavior and knowledge were assessed through immediate (n = 16 111) and 7-month postintervention (n = 146) parent surveys in a per protocol analysis of evaluable parents. Interventions: Parents read a brochure, viewed an 8-minute video about infant crying and AHT, asked questions of the nurse, and signed a commitment statement affirming their participation. Educational posters were displayed on each unit. Main Outcomes and Measures: Changes in AHT hospitalization rates before and during the intervention in Pennsylvania and 5 other states. Secondary outcomes included self-reported knowledge gains and changes in parenting practices. Results: A total of 1 180 291 parents (74.1%) of children ranging in age from 0 to 23 months signed a commitment statement. Incidence rate ratios for hospitalization for AHT increased in Pennsylvania from 24.1 (95% CI, 22.1-26.3) to 26.6 (95% CI, 24.9-28.4) per 100 000 children aged 0 to 23 months during the intervention period; changes in Pennsylvania were not significantly different from aggregate changes in the 5 other states, from 22.4 (95% CI, 21.2-23.6) to 22.0 (95% CI, 21.2-22.8) per 100 000 children aged 0 to 23 months. A total of 16 111 parents (21.5% men, 78.5% women) completed the postnatal survey. Despite an overall 74.1% adherence with the intervention, only 20.6% of parents saw the brochure and video and only 5.7% were exposed to the entire intervention. Among the respondents answering individual questions on the postnatal surveys, 10 958 mothers (91.0%) and 2950 fathers (88.6%) reported learning a lot about understanding infant crying as normal; 11 023 mothers (92.2%) and 2923 fathers (88.9%), calming their infant, 11 396 mothers (94.6%) and 3035 fathers (91.9%), calming themselves; 10 060 mothers (85.1%) and 2688 fathers (83.4%), selecting other infant caregivers; and 11 435 mothers (94.8%) and 3201 fathers (95.8%), that the information would decrease the likelihood of shaking an infant. Among the 143 respondents completing the 7-month survey, 109 (76.2%) reported remembering the information while their child was crying. Conclusions and Relevance: This intervention was not associated with a reduction in pediatric AHT hospitalization rates but was associated with self-reported gains in parental knowledge that were retained for 7 months.

All-terrain vehicle injuries in Texas, mapping the path to intervention with a geographic information system.

The state of Texas was ranked 10th for all-terrain vehicle-related deaths among all states from 2007-2009. Health Service Region 4/5N of eastern Texas has a statistically significant higher rate of all-terrain vehicle-related injuries in children under the age of 18 than Texas as a whole (p < 0.001.) It is unknown why east Texas has a higher all-terrain vehicle-related injury rate. A retrospective analysis of the registry of the Texas Trauma Service Area G, which serves the east Texas area, from the years 2004-2010 was performed. Variations within the region were assessed using a geographic information system and the analysis demonstrated that the highest rates of all-terrain vehicle-related injuries in east Texas are found in two neighboring rural eastern counties. Recording mechanism of injury was an important adjunct to identifying all-terrain vehicle-related injuries. Using E-codes alone underestimated the actual injuries. Other findings demonstrated that children under age 16 had a high rate of injury, one third of those injured sustained a head injury, and helmet use was very low. This analysis can be used by the Texas Department of State Health Services in conjunction with key regional partners to direct further investigation in these areas into the role of the rural environment, other factors associated with the high injury rates, and to plan and conduct preventive intervention at the community level.

Physicians' experiences using commercial e-prescribing systems.

Public and private efforts are under way to promote electronic prescribing to improve health care safety, quality, and efficiency. Findings from this qualitative study of physician practices suggest that substantial gaps may exist between advocates' vision of e-prescribing and how physicians use commercial e-prescribing systems today. While physicians were positive about the most basic e-prescribing features, they reported major barriers to maintaining complete patient medication lists, using clinical decision support, obtaining formulary data, and electronically transmitting prescriptions to pharmacies. Three factors help explain the gaps: product limitations, external implementation challenges, and physicians' preferences about using specific product features.

Clinical information technology gaps persist among physicians.

Physicians in smaller practices continue to lag well behind physicians in larger practices in reporting the availability of clinical information technology (IT) in their offices, according to a new national study from the Center for Studying Health System Change (HSC). The proportion of physicians reporting access to IT for each of five clinical activities increased across all practice settings between 2000-01 and 2004-05. Adoption gaps between small and large practices persisted, however, for two of the clinical activities--obtaining treatment guidelines and exchanging clinical data with other physicians--and widened for the other three--accessing patient notes, generating preventive care reminders and writing prescriptions. In contrast, clinical IT was generally as likely or more likely to be available to physicians in practices treating larger proportions of vulnerable and underserved patients as other physicians, a pattern that did not change between the two periods

Most Medicare outpatient visits are to physicians with limited clinical information technology.

This Data Bulletin uses linked data from two sources: the Centers for Medicare and Medicaid Services (CMS) 2001 5 Percent Carrier File, which contains complete claims for a representative sample of 5 percent of Medicare fee-for-service beneficiaries, and the 2001 Center for Studying Health System Change (HSC) Community Tracking Study (CTS) Physician Survey, a nationally representative survey of nearly 12,400 physicians. The linked sample includes claims for more than 506,000 Medicare outpatient visits to 8,641 CTS physicians. Estimates are weighted to be nationally representative of all Medicare fee-for-service physician outpatient visits in 2001. Use of the Medicare data is permitted under a data use agreement between Peter B. Bach, M.D., of Memorial Sloan-Kettering Cancer Center and CMS.

An update on Americans' access to prescription drugs.

More Americans--especially those with chronic conditions such as diabetes, asthma and depression--are going without prescription drugs because of cost concerns, according to a new national study by the Center for Studying Health System Change (HSC). In 2003, more than 14 million American adults with chronic conditions--over half of whom were low income--could not afford all of their prescriptions. Between 2001 and 2003, the proportion of privately insured, working-age people with chronic conditions who reported not filling at least one prescription because of cost concerns increased from 12.7 percent to 15.2 percent. Likewise, the proportion of elderly, chronically ill Medicare beneficiaries without supplemental private insurance with problems affording prescription drugs rose from 12.4 percent to 16.4 percent between 2001 and 2003. At the same time, significant disparities in prescription drug access persisted between black and white Americans with chronic conditions, with blacks about twice as likely to report problems affording prescriptions.

Limited information technology for patient care in physician offices.

Evidence of physicians' use of information technology (IT) to support patient care has been sketchy and anecdotal to date. However, new findings from the Center for Studying Health System Change (HSC) show wide variation in information technology adoption across physician practices, particularly by physician practice size. In 2001, nearly 60 percent of physicians in traditional practice settings--primarily solo or relatively small group practices where the vast majority of Americans receive care--reported that their practice used information technology in no more than one of the five following clinical functions: obtaining treatment guidelines, exchanging clinical data with other physicians, accessing patient notes, generating treatment reminders for the physician's use and writing prescriptions. Highest levels of IT support for patient care were found in staff- and group-model health maintenance organization (HMO) practices, followed by medical school faculty practices and large group practices. Overall rates of information technology adoption may have increased since 2001, but the variation in IT adoption by practice setting is unlikely to have changed

Benefits of and barriers to large medical group practice in the United States.

BACKGROUND: For decades, reformers argued that medical groups can efficiently provide high-quality care and a collegial professional environment. The growth of managed care and the movement to improve quality provide additional reasons for physicians to practice in groups, especially large groups. However, information is lacking on recent trends in group size and the benefits of and barriers to group practice. OBJECTIVES: To identify benefits of and barriers to large medical group practice, and to describe recent trends in group size. DESIGN, SETTING, AND PARTICIPANTS: Information on benefits and barriers was obtained from 195 interviews conducted during round 3 (2000-2001) of the Community Tracking Study with leaders of the largest groups, hospitals, and health insurance plans in 12 randomly selected metropolitan areas. Information on recent trends in group size was obtained from more than 6000 physicians in private practice in 48 randomly selected metropolitan areas via Community Tracking Study telephone surveys in 1997-1998, 1998-1999, and 2000-2001. MAIN OUTCOME MEASURES: Benefits of and barriers to large group practice, as perceived by interviewees, and changes in percentages of physicians in groups of varying sizes. RESULTS: Gaining negotiating leverage with health insurance plans was the most frequently cited benefit; it was cited 8 times more often than improving quality. Lack of physician cooperation, investment, and leadership were the most frequently cited barriers. Survey data indicate that 47% of private physicians work in practices of 1 or 2 physicians and 82% in practices of 9 or fewer, and that the percentage of physicians in groups of 20 or more did not increase between 1996 and 2001. CONCLUSIONS: Current payment methods reward gaining size to obtain negotiating leverage more than they reward quality. However, barriers to creating large medical groups are substantial, and most private physicians continue to practice in small groups, although the size of these groups is slowly increasing.

Behind the times: physician income, 1995-99.

This Data Bulletin is based on physicians' reports of net income from the practice of medicine from the HSC Community Tracking Study Physician Survey in 1996-97, 1998-99 and 2000-01. Net income equals income from the practice of medicine after expenses and before taxes. Reported income is lagged--for example, in the 2000-01 survey, physicians provide 1999 net income. Adjustments for inflation use the Bureau of Labor Statistics (BLS) online inflation calculator.

Physicians and care management: more acceptance than you think.

Physicians' acceptance of care management tools--practice guidelines, patient satisfaction surveys and practice profiling--is an important indication of whether these efforts to improve quality and control health costs will succeed. According to a new study by the Center for Studying Health System Change (HSC), a majority of physicians affected by these tools believe the overall effect of each on the quality and efficiency of care they provide has been positive. Physicians affected by related financial incentives are more likely to view care management techniques positively if they are risk adjusted to reflect the greater need for services by people with health problems.

Financial incentives and physicians' perceptions of conflict of interest and ability to arrange medically necessary services.

Many believe that physician payment mechanisms that include incentives to restrain utilization create conflicts of interest for physicians and result in the withholding of needed services. Pooled data from two rounds of the Community Tracking Study physician survey, a nationally representative telephone survey of physicians, are the basis of this analysis. We examine the association between explicit financial incentives linked to physician profiling and perceived conflict of interest, and the reported ability to obtain specific, medically necessary secondary services (referrals, hospitalizations and diagnostic imaging). Logistic regression models were employed to control for potentially confounding influences. After controlling for other factors, physicians subject to profiling linked with financial incentives were much less likely than physicians not affected by profiling to strongly agree that they can make clinical decisions in the best interests of their patients without the possibility of reducing their income. They were also less likely to report that they could always obtain selected medically necessary secondary services for their patients. Physicians subject to explicit financial incentives based on profiling are more likely than other physicians to perceive a conflict of interest. Physicians with financial incentives tied to profiling also experience greater difficulty obtaining medically necessary secondary services for their patients.

Prescription drug access disparities among working-age Americans.

Working-age African Americans and Latinos are much more likely than white Americans to report they cannot afford all of their prescription drugs, according to a new study by the Center for Studying Health System Change (HSC). In 2001, nearly one in five blacks and one in six Latinos 18 to 64 years old did not purchase all of their prescriptions because of cost, compared with slightly more than one in 10 whites. Cost-related prescription drug access problems are considerably higher for people with chronic conditions, particularly African Americans. Regardless of race or ethnicity, uninsured working-age people with chronic conditions are at particular risk for not being able to afford all of their prescriptions, with about half reporting cost-related prescription access problems. Increased patient cost sharing for prescription drugs will likely increase prescription drug access disparities for insured African Americans and Latinos, especially those with chronic conditions.

Triple jeopardy: low income, chronically ill and uninsured in America.

At least 7.4 million working-age Americans with chronic conditions--such as diabetes, heart disease and depression--lacked health insurance in 1999, according to new research findings from the Center for Studying Health System Change(HSC). Uninsured people with chronic conditions report worse health and more functional limitations and are three times more likely not to get needed medical care compared to those who are privately insured. The vast majority of uninsured people with chronic conditions delayed or did not get needed care because of cost. About 63 percent of the uninsured with chronic conditions--roughly 4.7 million Americans--have family incomes below 200 percent of poverty, or about $35,000 a year for a family of four in 2001. Faced with the triple threat of low income, ongoing health problems and no health insurance, this group confronts great difficulty getting and paying for needed care.

Options for expanding health insurance for people with chronic conditions.

As policy makers explore options such as tax credits and expansion of public programs to cover uninsured Americans, working-age adults with chronic conditions merit special attention. Because their medical needs are likely to be greater than healthy people's, coverage expansion proposals that don't factor in the greater need of people with chronic conditions are likely to fall short of reaching this vulnerable group. Often perceived primarily as a problem of the elderly, chronic conditions are widespread among working-age adults, according to a new study by the Center for Studying Health System Change (HSC). This Issue Brief examines existing coverage sources for insured working-age people with chronic conditions and assesses how various coverage proposals might affect uninsured people with chronic conditions.

Who do you trust? Americans' perspectives on health care, 1997-2001.

A turbulent backlash against managed care in the mid-1990s pitted consumers and health care providers against health plans in a struggle for control over medical decision making. New findings from the Center for Studying Health System Change (HSC) Community Tracking Study Household Survey indicate consumer confidence in the system and trust in physicians increased slightly between 1997 and 2001, perhaps as a result of changes in laws and loosening of health plan restrictions. Nevertheless, there is strong evidence of continued public concern about the influence of health plans on medical decision making. For example, the level of trust in their physicians among people in fair or poor health has not increased, and more than 40 percent of privately insured Americans continue to believe their doctor is strongly influenced by health plan rules when deciding about their care.