Five-Year Secular Trends and Predictors of Nonconsent to Receive Donor Milk in the Neonatal Intensive Care Unit.

OBJECTIVE: To identify independent maternal and infant factors associated with donor milk nonconsent and to examine secular trends in nonconsent rates. MATERIALS AND METHODS: Mothers of infants eligible to receive donor milk (≤32 weeks of gestation or ≤1,800 g) born between August 2010 and 2015 were included. Multivariable logistic regression modeled odds of nonconsent. RESULTS: Of the 486 mother/infant dyads from the first 5 years of the donor milk program, nonwhite race (adjusted odds ratio [aOR] 1.69; 95% confidence interval [CI] 1.04-2.76) and increasing gestational age (aOR 1.11; 95% CI 1.03-1.21) independently predicted nonconsent. Each year the program existed, there was a 48% reduction in odds of nonconsent (aOR 0.52; 95% CI 0.43-0.62). The most common reason given for nonconsent was "it's someone else's milk." CONCLUSION: Program duration was associated with reduced nonconsent rates and may reflect increased exposure to information and acceptance of donor milk use among neonatal intensive care unit staff and parents. Despite overall improvements in consent rates, race-specific disparities in rates of nonconsent for donor milk persisted after 5 years of this donor milk program. Further research is warranted to clarify the basis for race-based disparities in donor milk nonconsent rates, with the goal of designing interventions to reduce donor milk refusal among minority mothers.

Implementation of referral guidelines at the interface between pediatric primary and subspecialty care.

BACKGROUND: In pediatric medicine, inadequate access to subspecialty care is widespread. Referral Guidelines are structured tools that describe criteria for subspecialty referral and may decrease medically unnecessary referrals and thereby improve access. PROBLEM: Variation in referral rates and suboptimal communication around pediatric subspecialty referrals leads to inappropriate and ineffective use of scarce clinical resources. GOALS: Connecticut Children׳s Medical Center prioritized the development of collaborative care tools at the interface between primary and subspecialty care, including Referral Guidelines. STRATEGY: A comprehensive set of Referral Guidelines was developed and consisted of background information on a given condition, strategies for initial evaluation and management, instructions for how and when to refer, and what the patient and family could expect at the visit with the subspecialist. A key component of the initiative was the integral role of the PCP during development. RESULTS: Twenty-eight Referral Guidelines have been developed among 15 subspecialty areas. A novel process for active dissemination of Referral Guidelines was piloted in one medical subspecialty area and led to a reduction in overall referrals and an increase in the proportion of referrals meeting the necessary criteria.

Impact of Co-management at the Primary-Subspecialty Care Interface on Follow-up and Referral Patterns for Patients With Concussion.

BACKGROUND: Co-management is a collaborative care model that consists of structured tools to define and document care delivered by 2 or more providers. We evaluated the impact of implementing co-management at the interface between pediatric primary care providers (PCPs) and subspecialists. METHODS: Participating PCPs (n = 9) were trained on management of concussion using the co-management tools. Co-managed patients with concussion were prospectively enrolled (n = 148) and compared to a retrospective audit of non-co-managed patients (n = 50). RESULTS: PCPs using co-management demonstrated adherence to the tools. PCPs were significantly more likely to provide follow-up care to patients when using the co-management tools. All participating PCPs reported that co-management enhanced their expertise in caring for patients with concussion. CONCLUSIONS: Co-management can enhance PCPs' capacity to independently manage the care of patients with concussion. Co-management led to an observed change in practice that merits further exploration in terms of cost, quality, and clinical outcomes.