Improving Inpatient Asthma Management: The Implementation and Evaluation of a Pediatric Asthma Clinical Pathway.

INTRODUCTION: Asthma exacerbations are a leading cause of pediatric hospitalizations. Despite national guidelines, variability exists in the use and dosing of bronchodilators, oxygen management, and respiratory assessments of patients. We aimed to implement an inpatient Asthma Clinical Pathway (Pathway) to standardize care and reduce length of stay (LOS). METHODS: A respiratory therapy-driven Pathway was designed for inpatient asthma management. The Pathway included standardized respiratory therapy assessments, bronchodilator dosing, and protocols for progression and clinical worsening. We monitored key process measures. Patients admitted to the Pathway during pilot implementation (March to December 2011) were compared retrospectively with a "Usual Care" cohort admitted during the same period. We compared average LOS, average billed charges per hospitalization (charges), and 30-day readmissions between groups. Statistical process control charts were utilized to analyze LOS and charges for all asthma admissions following Pathway implementation (March 2011 to September 2016). Readmissions and Pathway removals were balancing measures. RESULTS: During pilot, Pathway patients (n = 153) compared with "Usual Care" patients (n = 166) had shorter LOS (0.95 versus 1.86 days; P < 0.001) and lower charges ($7,413 versus $11,078; P < 0.001). Readmission rates were not significantly different between groups. LOS for all asthma admissions (n = 3,429) decreased from 2.30 to 1.44 days (P < 0.001) following Pathway implementation. Charges remained stable. The readmission rate (per 100 discharges) for all asthma was 2.42 and not significantly different between Pathway and non-Pathway groups. CONCLUSIONS: Pathway implementation reduced LOS and stabilized charges while not increasing readmission rates. The Pathway facilitated sustainable widely adopted improvements in asthma care.

Exploring pre-school vision screening in primary care offices in Alabama.

PURPOSE: To investigate practices, barriers, and facilitators of universal pre-school vision screening (PVS) at pediatric primary care offices. METHODS: Focus group sessions (FGS) were moderated on-site at nine pediatric practices. A semi-structured topic guide was used to standardize and facilitate FGS. Discussions were audiotaped, and transcriptions were used to develop themes. All authors reviewed and agreed on the resultant themes. RESULTS: FGS included 13 physicians and 32 nurses/certified medical assistants (CMAs), of whom 82% personally conducted some facet of PVS. In all practices, nurses/CMAs tested visual acuity (most using a non-recommended test), and physicians completed vision screening with external observation, fix/follow, red reflex, and cover test. Facilitators included (1) accepting that PVS is a routine part of the well-child visit, and (2) using an electronic medical record with prompts to record acuity (eight of nine practices). Barriers were related to difficulty testing pre-schoolers, distractions in the office setting, time constraints, and limited reimbursement. CONCLUSIONS: Responsibility for PVS is shared by physicians and nurses/CMAs; thus, interventions to improve PVS should target both. Few practices are aware of new evidence-based PVS tests; thus, active translational efforts are needed to change current primary care practices.

Efficacy of a web-based intervention to improve and sustain knowledge and screening for amblyopia in primary care settings.

PURPOSE: To evaluate the efficacy of a physician-targeted website to improve knowledge and self-reported behavior relevant to strabismus and amblyopia ("vision") in primary care settings. METHODS: Eligible providers (filing Medicaid claims for at least eight well-child checks at ages 3 or 4 years, 1 year before study enrollment), randomly assigned to control (chlamydia and blood pressure) or vision groups, accessed four web-based educational modules, programmed to present interactive case vignettes with embedded questions and feedback. Each correct response, assigned a value of +1 to a maximum of +7, was used to calculate a summary score per provider. Responses from intervention providers (IPs) at baseline and two follow-up points were compared to responses to vision questions, taken at the end of the study, from control providers (CPs). RESULTS: Most IPs (57/65) responded at baseline and after the short delay (within 1 hour after baseline for 38 IPs). A subgroup (27 IPs and 42 CPs) completed all vision questions after a long delay averaging 1.8 years. Scores from IPs improved after the short delay (median score, 3 vs. 6; P = 0.0065). Compared to CPs, scores from IPs were similar at baseline (P = 0.6473) and higher after the short-term (P < 0.0001) and long-term (P < 0.05) delay. CONCLUSIONS: Significant improvements after the short delay demonstrate the efficacy of the website and the potential for accessible, standardized vision education. Although improvements subsided over time, the IPs' scores did not return to baseline levels and were significantly better compared to CPs tested 1 to 3 years later.

Design of a randomized clinical trial to improve rates of amblyopia detection in preschool aged children in primary care settings.

PURPOSE: To present the design of a cluster randomized controlled trial (cRCT) to evaluate the effectiveness of a web-based intervention for improving provider knowledge about strabismus and amblyopia (S/A) and preschool vision screening (PVS), increase PVS rates, and improve rates of S/A diagnoses made by eye specialists. This is the first cRCT targeting amblyopia prevention. METHODS: Participants were Medicaid providers in AL, SC, or IL who had Internet access and had filed at least 8 claims for well child visits (WCV) for children ages 3 or 4 years old during a 12-month period before enrollment. Randomization to the Intervention (vision) or Control (blood pressure) arm occurred at the cluster level, defined as the provider (or group of providers) and his/her patients seen for WCVs. RESULTS: 65 Intervention providers (IPs) with 3547 children aged 3 or 4 years, and 71 Control providers (CPs) with 5053 children enrolled. The study will report measures of knowledge and self-reported vision screening behaviors from web-based data. The primary outcomes will be rates of PVS among PCPs, and rates of diagnosis of S/A by eye specialists among the children belonging to Control and Intervention practices. CONCLUSIONS: We had the same difficulty recruiting PCPs as reported by others. Baseline rates of PVS were low (14.1%), as were rates that S/A were diagnosed by eye providers (1.4%). Our data show a need to improve both primary outcome measures.

Effect of revised IOM weight gain guidelines on perinatal outcomes.

OBJECTIVE: We sought to examine perinatal outcomes in women with a body mass index (BMI) of 25 kg/m(2) comparing those whose weight gain met 2009 IOM guidelines to women meeting 1990 IOM guidelines. METHODS: This is a retrospective cohort study utilizing birth records linked to hospital discharge data for all term, singleton infants born to overweight, Missouri residents (2000-2006) with a BMI of 25 kg/m(2). We excluded congenital anomalies, mothers with diabetes, hypertension, or previous cesarean delivery. RESULTS: Fourteen thousand nine hundred fifty-five women gained 25-35 lbs (1990 guidelines); 1.6% delivered low birth weight (LBW) infants and 1.1% delivered macrosomic infants. Eight thousand three hundred fifty women gained 15-25 lbs (2009 guidelines); 3.4% delivered LBW infants and 0.6% delivered macrosomic infants. Women who gained 15-25 lbs were 1.99 (95% CI 1.67, 2.38) times more likely to have a LBW infant and 0.59 (95% CI 0.40, 0.76) times less likely to deliver a macrosomic infant. CONCLUSION: Limiting weight gain in women with a BMI of 25 kg/m(2), per the 2009 guidelines, increases the risk of LBW deliveries and decreases the risk of macrosomia but does not reduce associated adverse perinatal outcomes. Further studies should explore the optimal weight gain to reduce these outcomes.

Use of ecological momentary assessment to guide curricular change in graduate medical education.

PURPOSE: To assess whether a novel evaluation tool could guide curricular change in an internal medicine residency program. METHOD: The authors developed an 8-item Ecological Momentary Assessment tool and collected daily evaluations from residents of the relative educational value of 3 differing ambulatory morning report formats (scale: 8  =  best, 0  =  worst). From the evaluations, they made a targeted curricular change and used the tool to assess its impact. RESULTS: Residents completed 1388 evaluation cards for 223 sessions over 32 months, with a response rate of 75.3%. At baseline, there was a decline in perceived educational value with advancing postgraduate (PGY) year for the overall mean score (PGY-1, 7.4; PGY-2, 7.2; PGY-3, 7.0; P < .01) and for percentage reporting greater than 2 new things learned (PGY-1, 77%; PGY-2, 66%; PGY-3, 50%; P < .001). The authors replaced the format of a lower scoring session with one of higher cognitive content to target upper-level residents. The new session's mean score improved (7.1 to 7.4; P  =  .03); the adjusted odds ratios before and after the change for percentage answering, "Yes, definitely" to "Area I need to improve" was 2.53 (95% confidence interval [CI], 1.45-4.42; P  =  .001) and to "Would recommend to others," it was 2.08 (95% CI, 1.12-3.89; P  =  .05). CONCLUSIONS: The Ecological Momentary Assessment tool successfully guided ambulatory morning report curricular changes and confirmed successful curricular impact. Ecological Momentary Assessment concepts of multiple, frequent, timely evaluations can be successfully applied in residency curriculum redesign.

Knowledge, attitudes, and environment: what primary care providers say about pre-school vision screening.

PURPOSE: To evaluate knowledge, attitudes, and environment of primary care providers, and to develop a conceptual framework showing their impact on self-reported pre-school vision screening (PVS) behaviors. METHODS: Eligible primary care providers were individuals who filed claims with Medicaid agencies in Alabama, South Carolina, or Illinois, for at least eight well child checks for children aged 3 or 4 years during 1 year. Responses were obtained on-line from providers who enrolled in the intervention arm of a randomized trial to improve PVS. We calculated a summary score per provider per facet: (1) for behavior and knowledge, each correct answer was assigned a value of +1; and (2) for attitudes and environment, responses indicating support for PVS were assigned a value of +1, and other responses were assigned -1. RESULTS: Responses were available from 53 participants (43 of 49 enrolled pediatricians, 8 of 14 enrolled family physicians, one general physician, and one nurse practitioner). Recognizing that amblyopia often presents without outward signs was positively related to good PVS: [odds ratio (OR) = 3.9; p = 0.06]. Reporting that "preschool VS interrupts patient flow" posed a significant barrier (OR = 0.2; p = 0.05). Providers with high summed scores on attitudes (OR = 6.0; p = 0.03), or knowledge and attitudes (OR = 11.4; p < 0.001) were significantly more likely to report good PVS behavior. There was a significant trend between the number of "good" scores on knowledge, attitudes or environment, and "good" PVS behavior (p = 0.04). CONCLUSIONS: PVS is influenced by positive attitudes, especially when combined with knowledge about amblyopia. Interventions to improve PVS should target multiple facets, emphasizing (1) asymptomatic children are at risk for amblyopia, (2) specific evidence-based tests have high testability and sensitivity for amblyopia in pre-school children, and (3) new tests minimize interruptions to patient flow.

Can residents accurately abstract their own charts?

PURPOSE: To assess the accuracy of residents' record review, using trained abstractors as a gold standard comparison. METHOD: In 2005, the authors asked 74 residents to review their own charts (n = 392) after they received brief instruction on both how to locate data on the medical record and how to use a data abstraction form. Trained abstractors then re-reviewed these charts to assess performance of preventive health care measures in medicine (smoking screening, smoking cessation advice, mammography, colon cancer screening, lipid screening, and pneumonia vaccination) and pediatrics (parent smoking screening, parent smoking cessation advice, car seat safety, car restraint use, eye alignment, and immunizations up to date). The authors then quantified agreement between the two record reviews and assessed the sensitivity and specificity of the residents versus the trained abstractors. RESULTS: Overall resident-measured performance was similar (within 5%) to that of the trained abstractor for five of six measures in medicine and four of six in pediatrics. For the various measures, sensitivity of resident-measured performance ranged from 100% to 15% and specificity from 100% to 33% compared with the trained abstractors. Relative to the trained abstractor record review, residents did not overestimate their performance. Most residents' (81%) relative performance rankings did not change when the basis for the ranking was resident measured versus trained abstractor measured. CONCLUSIONS: Residents' self-abstraction can be an alternative to costly trained abstractors. Appropriate use of these data should be carefully considered, acknowledging the limitations.

Validity of pure-tone hearing screening at well-child visits.

OBJECTIVE: To estimate the sensitivity and specificity of pure-tone audiometry hearing screening in the primary care setting. DESIGN: Prospective cohort study. SETTING: Eight academic and private pediatric practices. PARTICIPANTS: A subset of children from a convenience sample of 1061 children between 3 and 19 years of age were screened for hearing loss using pure-tone audiometry. Intervention Formal audiologic evaluations (gold standard) for those children referred by their primary care physician (28 children) and for a random sample of children not referred (102 children). Main Exposure Pure-tone audiometry screening. MAIN OUTCOME MEASURES: Audiologic evaluations. RESULTS: A total of 28 children were referred to an audiologist for formal hearing testing after pure-tone audiometry screening during a well-child visit, at which 25 children did not pass the initial screening and 3 could not complete the screening. Of the 25 children, only 7 were evaluated by an audiologist, for a follow-up rate of 25%. One child was diagnosed as having hearing loss. Formal audiologic assessment was also performed on a random sample of 102 children who were not referred to the audiologist. For the random sample, hearing loss was identified in 2 of 76 (3%) children who passed and 1 of 16 (6%) children who did not pass pure tone audiometry screening. The sensitivity and specificity of pure-tone audiometry were 50% and 78%, respectively. CONCLUSION: In light of the increasing burden on physicians to provide preventive care, this study calls into question the value of hearing screening using pure-tone audiometry during well-child visits given the lack of follow-up after referral and the poor sensitivity.

Quantitative pediatric vision screening in primary care settings in Alabama.

PURPOSE: Alabama Medicaid reimburses "objective" vision screening (VS), i.e., by acuity or similar quantitative method, and well child checks (WCCs) separately. We analyzed the frequency of each service obtained. METHODS: Claims for WCC and VS provided between October 1, 2002 and September 30, 2003 for children aged 3 to 18 years, and summary data for all enrolled children, were obtained from Alabama Medicaid. We used univariate analysis followed by logistic regression to explore the potential influence of factors (patient age, provider type, and provider's volume of WCCs) on the receipt of VS at pre-school ages. RESULTS: Children receiving WCCs were 55% black, 40% white, and 5% other. Percentages of children with WCC claims were highest at 4 years (57%) and thereafter declined to 30% at 6 to 14 years and to <10% at 18 years. Nearly all VS (>98% at each age) occurred the same day as the WCC. Pediatricians provided 68% of all WCCs. Multivariate analysis, after adjusting for nesting of pre-school patients within provider, showed the odds ratios (ORs) of VS were increased by patient age (5 years vs. 3 years, OR = 3.57, p < 0.0001), nonphysician provider type (nonphysician vs. pediatrician, OR = 1.80, p = 0.0004) and high WCC volume (at or above vs. below the median number (n = 8) of WCC per provider per year (OR = 7.11, p < 0.0001)). Because VS rates were high when attendance to WCC visits was low, few enrolled children received VS at any age (6% at the age of 3, 13% at the age of 4, and a maximum of 20% at the age of 5). CONCLUSIONS: National efforts to reduce preventable vision loss from amblyopia are hampered because children are not available for screening and because providers miss many opportunities to screen vision at pre-school age. Efforts to improve VS should target pediatrician-led practices, because these serve greater numbers of children.

Hearing screening practices among a national sample of primary care pediatricians.

The objective of this study was to describe variations in hearing screening using a survey mailed to a national sample of primary care pediatricians prior to the 2003 American Academy of Pediatrics (AAP) hearing screening guidelines. Of the 390 primary care respondents, only 303 (78%) performed audiometry, routinely beginning at age 3 (32%), 4 (44%), or 5 (17%); 81% defined abnormal audiometry primarily as failure to hear at a specified decibel level: 15 dB hearing level (HL) (<1%), 16 to 20 dB HL (10%), 21 to 25 dB HL (23%), 26 to 30 dB HL (44%), 31 to 40 dB HL (16%), and more than 40 dB HL (6%). This study serves as a baseline for comparison with postguideline practices.

Measuring resident physicians' performance of preventive care. Comparing chart review with patient survey.

BACKGROUND: The Accreditation Council for Graduate Medical Education has suggested various methods for evaluation of practice-based learning and improvement competency, but data on implementation of these methods are limited. OBJECTIVE: To compare medical record review and patient surveys on evaluating physician performance in preventive services in an outpatient resident clinic. DESIGN: Within an ongoing quality improvement project, we collected baseline performance data on preventive services provided for patients at the University of Alabama at Birmingham (UAB) Internal Medicine Residents' ambulatory clinic. PARTICIPANTS: Seventy internal medicine and medicine-pediatrics residents from the UAB Internal Medicine Residency program. MEASUREMENTS: Resident- and clinic-level comparisons of aggregated patient survey and chart documentation rates of (1) screening for smoking status, (2) advising smokers to quit, (3) cholesterol screening, (4) mammography screening, and (5) pneumonia vaccination. RESULTS: Six hundred and fifty-nine patient surveys and 761 charts were abstracted. At the clinic level, rates for screening of smoking status, recommending mammogram, and for cholesterol screening were similar (difference <5%) between the 2 methods. Higher rates for pneumonia vaccination (76% vs 67%) and advice to quit smoking (66% vs 52%) were seen on medical record review versus patient surveys. However, within-resident (N=70) comparison of 2 methods of estimating screening rates contained significant variability. The cost of medical record review was substantially higher ($107 vs $17/physician). CONCLUSIONS: Medical record review and patient surveys provided similar rates for selected preventive health measures at the clinic level, with the exception of pneumonia vaccination and advising to quit smoking. A large variation among individual resident providers was noted.

Hearing screening at well-child visits.

OBJECTIVES: To determine hearing screening failure rates in primary care settings and to examine the referral practices in response to an abnormal screening test. METHODS: We enrolled a convenience sample of children between 3 and 19 years of age who were undergoing hearing screening during a well-child visit. A failure was defined as missing any frequency (1000, 2000, or 4000 Hz) in either ear at 20-dB hearing level. The pediatrician made the decision of whether to refer the patient for further evaluation. RESULTS: Three academic and 5 private practices enrolled 1061 children. Sixty-seven children (7%) were unable to complete the screening. Of the 948 children who completed the screen, a total of 852 children (90%) passed the screening and 96 children (10%) failed. After multivariable logistic regression analysis, the only statistically significant factor predictive of a failed screen was developmental delay (P = .02). Of the 96 children who failed the hearing screening, 57 (59%) had no further evaluation, 12 (13%) were rechecked, and 27 (28%) were referred. Similar percentages were seen with children who could not be screened. CONCLUSIONS: Although 10% of the children failed hearing screening, pediatricians neither rechecked nor referred more than half of these children. Screening that does not result in action for those failing the screening wastes resources and fails to properly identify hearing impairment in children.

Improving physician performance through Internet-based interventions: who will participate?

BACKGROUND: The availability of Internet-based continuing medical education is rapidly increasing, but little is known about recruitment of physicians to these interventions. OBJECTIVE: The purpose of this study was to examine predictors of physician participation in an Internet intervention designed to increase screening of young women at risk for chlamydiosis. METHODS: Eligibility was based on administrative claims data, and eligible physicians received recruitment letters via fax and/or courier. Recruited offices had at least one physician who agreed to participate in the study by providing an email address. After one physician from an office was recruited, intensive recruitment of that office ceased. Email messages reminded individual physicians to participate by logging on to the Internet site. RESULTS: Of the eligible offices, 325 (33.2%) were recruited, from which 207 physicians (52.8%) participated. Recruited versus nonrecruited offices had more eligible patients (mean number of eligible patients per office: 44.1 vs 33.6; P < .001), more eligible physicians (mean number of eligible physicians per office: 6.2 vs 4.1; P < .001), and fewer doctors of osteopathy (mean percent of eligible physicians per office who were doctors of osteopathy: 20.5% vs 26.4%; P = .02). Multivariable analysis revealed that the odds of recruiting at least one physician from an office were greater if the office had more eligible patients and more eligible physicians. More participating versus nonparticipating physicians were female (mean percent of female recruited physicians: 39.1% vs 27.0%; P = .01); fewer participating physicians were doctors of osteopathy (mean percent of recruited physicians who were doctors of osteopathy: 15.5% vs 23.9%; P = .04) or international medical graduates (mean percent of recruited physicians who were international graduates: 12.3% vs 23.8%; P = .003). Multivariable analysis revealed that the odds of a physician participating were greater if the physician was older than 55 years (OR = 2.31; 95% CI = 1.09-4.93) and was from an office with a higher Chlamydia screening rate in the upper tertile (OR = 2.26; 95% CI = 1.23-4.16). CONCLUSIONS: Physician participation in an Internet continuing medical education intervention varied significantly by physician and office characteristics.

Differences in preventive health quality by residency year. Is seniority better?

BACKGROUND: It is assumed that the performance of more senior residents is superior to that of interns, but this has not been assessed objectively. OBJECTIVE: To determine whether adherence to national guidelines for outpatient preventive health services differs by year of residency training. DESIGN: Cross-sectional study. PARTICIPANTS: One hundred twenty Internal Medicine residents, postgraduate year (PGY)- 1 and PGY -2, attending a University Internal Medicine teaching clinic between June 2000 and May 2003. MEASUREMENTS: We studied 6 preventive health care services offered or received by patients by abstracting data from 1,017 patient records. We examined the differences in performance between PGY-1 and PGY-2 residents. RESULTS: Postgraduate year-2 residents did not statistically outperform PGY-1 residents on any measure. The overall proportion of patients receiving appropriate preventive health services for pneumococcal vaccination, advising tobacco cessation, breast and colon cancer screening, and lipid screening was similar across levels of training. PGY-1s outperformed PGY-2s for tobacco use screening (58%, 51%, P = .03). These results were consistent after accounting for clustering of patients within provider and adjusting for patient age, gender, race and insurance, resident gender, and number of visits during the measurement year. CONCLUSIONS: Overall, patients cared for by PGY-2 residents did not receive more outpatient preventive health services than those cared for by PGY-1 residents. Efforts should be made to ensure quality patient care in the outpatient setting for all levels of training.

Designing tailored Web-based instruction to improve practicing physicians' preventive practices.

BACKGROUND: The World Wide Web has led to the rapid growth of medical information and continuing medical educational offerings. Ease of access and availability at any time are advantages of the World Wide Web. Existing physician-education sites have often been designed and developed without systematic application of evidence and cognitive-educational theories; little rigorous evaluation has been conducted to determine which design factors are most effective in facilitating improvements in physician performance and patient-health outcomes that might occur as a result of physician participation in Web-based education. Theory and evidence-based Web design principles include the use of: needs assessment, multimodal strategies, interactivity, clinical cases, tailoring, credible evidence-based content, audit and feedback, and patient-education materials. Ease of use and design to support the lowest common technology denominator are also important. OBJECTIVE: Using these principles, design and develop a Web site including multimodal strategies for improving chlamydial-screening rates among primary care physicians. METHODS: We used office-practice data in needs assessment and as an audit/feedback tool. In the intervention introduced in 4 phases over 11 months, we provided a series of interactive, tailored, case vignettes with feedback on peer answers. We included a quality-improvement toolbox including clinical practice guidelines and printable patient education materials. RESULTS: In the formative evaluation of the first 2 chlamydia modules, data regarding the recruitment, enrollment, participation, and reminders have been examined. Preliminary evaluation data from a randomized, controlled trial has tested the effectiveness of this intervention in improving chlamydia screening rates with a significant increase in intervention physicians' chlamydia knowledge, attitude, and skills compared to those of a control group. CONCLUSIONS: The application of theory in the development and evaluation of a Web-based continuing medical education intervention offers valuable insight into World Wide Web technology's influence on physician performance and the quality of medical care.

Identifying physician-recognized depression from administrative data: consequences for quality measurement.

BACKGROUND: Multiple factors limit identification of patients with depression from administrative data. However, administrative data drives many quality measurement systems, including the Health Plan Employer Data and Information Set (HEDIS). METHODS: We investigated two algorithms for identification of physician-recognized depression. The study sample was drawn from primary care physician member panels of a large managed care organization. All members were continuously enrolled between January 1 and December 31, 1997. Algorithm 1 required at least two criteria in any combination: (1) an outpatient diagnosis of depression or (2) a pharmacy claim for an antidepressant Algorithm 2 included the same criteria as algorithm 1, but required a diagnosis of depression for all patients. With algorithm 1, we identified the medical records of a stratified, random subset of patients with and without depression (n = 465). We also identified patients of primary care physicians with a minimum of 10 depressed members by algorithm 1 (n = 32,819) and algorithm 2 (n = 6,837). RESULTS: The sensitivity, specificity, and positive predictive values were: Algorithm 1: 95 percent, 65 percent, 49 percent; Algorithm 2: 52 percent, 88 percent, 60 percent. Compared to algorithm 1, profiles from algorithm 2 revealed higher rates of follow-up visits (43 percent, 55 percent) and appropriate antidepressant dosage acutely (82 percent, 90 percent) and chronically (83 percent, 91 percent) (p < 0.05 for all). CONCLUSIONS: Both algorithms had high false positive rates. Denominator construction (algorithm 1 versus 2) contributed significantly to variability in measured quality. Our findings raise concern about interpreting depression quality reports based upon administrative data.

Does early discharge with nurse home visits affect adequacy of newborn metabolic screening?

OBJECTIVE: To examine the impact of early discharge on newborn metabolic screening. STUDY DESIGN: Metabolic screening results were obtained from the Alabama State Lab for all infants born at our hospital between 8/1/97, and 1/31/99, and were matched with an existing database of early discharge infants. An early newborn discharge was defined as a discharge between 24 and 47 hours of age. Metabolic screening tests included phenylketonuria (PKU), hypothyroidism, and congenital adrenal hyperplasia (CAH). Early discharge and traditional stay infants were compared to determine the percentage of newborns screened and the timing of the first adequate specimen. RESULTS: The state laboratory received specimens from 3860 infants; 1324 were on early discharge newborns and 2536 infants in the traditional stay group. At least one filter paper test (PKU, hypothyroidism, and CAH) was collected on 99.2% of early discharge infants and 96.0% of traditional stay infants (P<.0001). Early discharge infants had a higher rate of initial filter paper specimens being inadequate (22.9%) compared with traditional stay infants (14.3%, P<.0001) but had a higher rate of repeat specimens when the initial specimen was inadequate (85.0% early discharge vs 75.3% traditional stay, P=.002). The early discharge group was more likely to have an adequate specimen within the first 9 days of life (1001, 98.8% early discharge vs 2016, 96.7% traditional stay, P=.0005). CONCLUSIONS: In this well established early discharge program with nurse home visits, newborn metabolic screening is not compromised by early discharge.

Compliance with vision-screening guidelines among a national sample of pediatricians.

OBJECTIVE: The American Academy of Pediatrics (AAP) recommends vision screening from birth through adolescence, with visual acuity testing and binocular screening to begin at age 3 years. The 1996 AAP guidelines advised referral for visual acuity worse than 20/40 for children aged 3 to 5 years and worse than 20/30 for children aged 6 years and older. Our objective was to describe vision-screening and referral practices in a national sample of primary care pediatricians. METHODS: We mailed a survey to a random sample of US pediatricians. Initial nonresponders were mailed up to 3 additional surveys. All mailings occurred between May and October 1998. Analyses focused on primary care pediatricians and consisted of descriptive statistics and regression analyses. The main outcome measure was compliance with 1996 AAP recommendations for vision screening. RESULTS: Of the 1491 surveys mailed, 888 (60%) were returned, including 576 (65%) from primary care pediatricians. Vision-screening methods included visual acuity testing (92%), cover test (64%), red reflex test (95%), fundoscopic examinations (65%), and stereopsis testing (32%). Respondents routinely performed visual acuity testing at 3 years (37%), 4 years (79%), 5 years (91%), 6 years (80%), 7-12 years (82%), and 13-18 years (80%). Visual acuity thresholds for referring 3- and 4-year-olds were 20/40 (47%, 51%), 20/50 (36%, 32%), or worse than 20/50 (14%, 12%). The majority of pediatricians referred children aged 5 years and older at 20/40, although thresholds worse than 20/40 were reported commonly (18%-33%). Logistic regressions were done to identify factors associated with higher likelihood of performing specific screening tests. Although no factor was consistently associated with use of all screening tests, size of the practice was significant in several regression models. CONCLUSIONS: Many pediatricians do not follow AAP guidelines for vision screening and referral, especially in younger children. Two thirds of pediatricians do not begin visual acuity testing at age 3 years as recommended, and about one fifth do not test until age 5 years. In addition, one fourth do not perform cover tests or stereopsis testing at any age.