An ecological approach to evaluating a system of care program: dollars making sense.

System of care (SOC) models in North America were developed in response to the needs of children with a severe emotional disturbance. Such children experience problems across life spheres including issues at home that put them at risk of abuse and neglect, difficulties at school including special education classification and dropping-out, and involvement with the juvenile courts. SOC evaluations and research suggests that an overreliance of evaluative research efforts on standardized scales and preconceived measurable outcomes have resulted in a loss of other important data. This study's confirmatory and holistic approach to evaluation illuminates important information concerning commonly ignored variables when using traditional evaluation models. The evaluative research study described focuses on three often overlooked behavioral variables in one SOC initiative, KidsNet Georgia, of Rockdale County, GA. These variables are: (a) using cohort analysis over time; (b) costing out services utilized; and (c) focusing on behavioral indicators and chance over time. The evaluative strategy, data collection, data, and cost analysis are discussed along with implications for practice with severe emotional disturbance youth and their families.

Newborn hearing screening and follow-up: are children receiving recommended services?

OBJECTIVES: Newborn hearing screening programs have been implemented by all 50 states and most U.S. territories to detect hearing loss in infants and prevent delays in speech, language, and social and emotional development. To monitor progress toward national goals, the Centers for Disease Control and Prevention (CDC) collects data from state and territorial programs. This article summarizes findings from the CDC Early Hearing Detection and Intervention (EHDI) Hearing Screening and Follow-up Survey (HSFS) and provides a summary of recent efforts to identify infants with hearing loss in the U.S. METHODS: The HSFS was sent to representatives of U.S. EHDI programs to gather aggregate screening, diagnostic, intervention, and demographic data for 2005 and 2006. We analyzed these data to evaluate progress toward national goals. RESULTS: In 2005 and 2006, more than 90% of infants were screened for hearing loss. Of these infants, 2% in both years did not pass their final screening. Out of those not passing the final screening, approximately two-thirds were not documented as having a diagnostic finding. In both years, the reason reported for the majority of infants was loss to follow-up/loss to documentation (LFU/LTD). Although the majority of infants with permanent hearing loss were receiving intervention, more than 30% were classified as LFU/LTD and could not be documented as receiving intervention services. CONCLUSIONS: The HSFS enables the collection of more complete data that highlight the progress in screening infants for hearing loss. However, data indicate improvements are needed to reduce LFU/LTD and meet the national benchmarks.

Economic evaluation of a neural tube defect recurrence-prevention program.

BACKGROUND: Women with a pregnancy affected by a neural tube defect (NTD) are encouraged to take folic acid prior to a subsequent pregnancy, but it is unknown whether organized attempts to identify and counsel such women to prevent recurrent NTDs are cost effective. METHODS: Data from the South Carolina recurrence-prevention program for October 2001-September 2002 were analyzed between October 2002 and December 2003 to calculate costs. Cost-effectiveness modeling of the program during 1992-2006 was conducted during 2007. Results were calculated for three scenarios based on recurrence risk, supplement use, and the effectiveness of folic acid in preventing recurrences. For each scenario, quality-adjusted life years (QALYs) were calculated separately using prevented NTD-affected live births; prevented NTD-affected births (including fetal deaths); and all prevented NTD-affected pregnancies. RESULTS: The prevention program cost approximately $155,000 per year in 2003 dollars to protect 35 pregnancies and prevent approximately one NTD. The direct costs associated with an NTD depend on type and outcome, but are approximately $560,000 in 2003 dollars for a live birth with spina bifida. The base-case cost-effectiveness ratio was $39,600 per QALY gained from avoided NTD-affected live births and stillbirths, and $14,700 per QALY gained from the avoidance of all NTD-affected pregnancies. The baseline NTD recurrence risk and the use of folic acid supplements by women who are at high risk for an NTD-affected pregnancy were influential parameters. CONCLUSIONS: The South Carolina NTD recurrence-prevention program appears comparable in cost effectiveness to other preventive services. Other states might consider including NTD recurrence prevention in birth defect-prevention programs.

Measures of follow-up in early hearing detection and intervention programs: a need for standardization.

PURPOSE: To demonstrate the need for standardized data definitions and reporting for early hearing detection and intervention (EHDI) programs collecting information on newborn hearing screening and follow-up, and types of information best collected in a standardized manner. METHOD: A hypothetical birth cohort was used to show the potential effects of nonstandardized definitions and data classifications on rates of hearing screening, audiologic follow-up, and hearing loss. RESULTS: The true screening rate in this cohort was 92.4%. The calculated rate was between 90.0% and 96.5%, depending on the measure used. Among children documented as screened and referred for follow-up, 61.0% received this testing. Only 49.0% were documented to have been tested. Despite a true prevalence of 3.7 per 1,000 births, only 1.5 per 1,000 children were documented with a hearing loss. CONCLUSION: Ensuring that children receive recommended follow-up is challenging. Without complete reporting by audiologists to EHDI programs, accurate calculation of performance measures is impossible. Lack of documentation can lead to the overstatement of "loss to follow-up." Also, standardization of measures is essential for programs to evaluate how many children receive recommended services and assess progress toward national goals. A new survey has been implemented to collect more detailed and standardized information about recommended services.

Hearing screening and diagnostic evaluation of children with unilateral and mild bilateral hearing loss.

More than 90% of newborns in the United States are now being screened for hearing loss. A large fraction of cases of unilateral hearing loss and mild bilateral hearing loss are not currently identified through newborn hearing screening. This is of concern because a preponderance of research has demonstrated that unilateral hearing loss and mild bilateral hearing loss can lead to developmental delays and educational problems for some children. To help address this probable underidentification of unilateral hearing loss and mild bilateral hearing loss among infants and children, the Centers for Disease Control and Prevention Early Hearing Detection and Intervention program and the Marion Downs Hearing Center convened a workshop in Breckenridge, Colorado, in July 2005. During this workshop, several issues related to screening and diagnosing unilateral hearing loss and mild bilateral hearing loss were identified, as well as recommendations for future research in this area. Issues identified included the lack of standardized definitions for permanent unilateral hearing loss and mild bilateral hearing loss; the use of screening protocols that are primarily designed to identify bilateral and unilateral hearing losses of a moderate degree or greater (eg, above 40 dB); calibration of screening equipment; availability of facilities that can provide the full range of audiologic, diagnostic, and management services to this pediatric population; and an overall lack of awareness by many professionals and families about the potential effect of unilateral hearing loss and mild bilateral hearing loss. Suggestions for future research, such as identifying ways to improve the identification of cases of unilateral hearing loss and mild bilateral hearing loss, were also discussed.

Determining the effect of newborn hearing screening legislation: an analysis of state hearing screening rates.

OBJECTIVE: This study was conducted to determine the effect of state Universal Newborn Hearing Screening legislation on the percentage of infants having their hearing screened within one month of birth. METHODS: Hearing screening data for 2000-2003 were obtained from state hearing screening programs. States with Universal Newborn Hearing Screening legislation were categorized according to legislation type and implementation status, and hearing screening rates were compared between states with implemented legislation and states with no legislation. RESULTS: Hearing screening rates among states that implemented Universal Newborn Hearing Screening legislation were significantly higher than rates in no-legislation states throughout the study period, although the mean screening rate among no-legislation states increased substantially from 2000 through 2003. The percentage of states attaining a 95% national screening quality indicator in each year was substantially greater among states with implemented legislation. In 2003, 76% of states with implemented Universal Newborn Hearing Screening legislation reported screening at least 95% of infants, compared with 26% of states without legislation. Although there is a greater likelihood of meeting the national screening target with Universal Newborn Hearing Screening legislation than without, other factors such as collaborative relationships and federal funding can also influence this outcome. CONCLUSION: State legislation has had a positive effect on hearing screening rates and is one tool states can use to help ensure that infants are screened for hearing loss.

One-handed versus two-handed chest compressions in paediatric cardio-pulmonary resuscitation.

OBJECTIVES: To determine emergency department (ED) staff preference for one- or two-handed paediatric chest compressions and to determine if there was a difference in compression rates delivered and fatigability between the techniques. METHODS: This was a randomised, cross-over observational study of paediatric CPR performed on a standard paediatric manikin by ED staff. Consenting, eligible staff [ED doctors and nurses] performed CPR in pairs with chest compressions delivered using a one- and two-handed technique. The outcomes of interest were compression rates for one- and two-handed CPR, decrease in compression rate over time for each technique and staff preference for technique. Data was analysed using descriptive statistics, Chi Square test and Mann-Whitney U-test as appropriate. RESULTS: Sixty-two ED staff participated in the study. Compression rates with both techniques were similar and higher than guidelines recommend (133.6 min(-1) for one-handed and 135.7 min(-1) for two-handed respectively). The compression rate slowed by 6.9 compressions/min over 1 min in one-handed compressions compared with 2.6 compressions/min in two-handed compressions (p = 0.0264). 65.6% of participants reported that they preferred the two-handed compression technique. CONCLUSION: This study showed that CPR compression rate is similar with one- and two-handed compression techniques, but compression rate decreased more quickly with the one-handed technique. The majority of staff preferred the two-handed compression technique for reasons of ease, control and uniformity with other CPR techniques.

Meeting the challenge: using policy to improve children's health.

We reflect on the proceedings of a symposium at a conference of the Centers for Disease Control and Prevention National Center on Birth Defects and Developmental Disabilities. We present examples of bridging the gap between science and policy to achieve improvements in children's health through case studies in early hearing detection and intervention, folic acid fortification to prevent birth defects, sleep positioning recommendations to reduce infant mortality, and workplace lactation support programs. We discuss case studies that present different policy strategies (public health law and voluntary practices) for improving public health. These case studies demonstrate both the power of policy as a tool for improving children's health and the challenges of communicating public health research to policy decisionmakers.