Pricing the priceless childcare: Early childhood education for babies and toddlers.

This article connects Viviana Zelizer's theory of the social meaning of money to family studies, using the case of American parents' spending on children. We investigate how money spent on the youngest children-babies and toddlers-reflects the growing expert emphasis on the importance of parental investment in the critical early period for child development. First, we review literature on expert knowledge to trace the shift in increasing emphasis on the importance of building children's cognitive skills through formal education beginning in infancy, offered in center-based care, moving from spaces of "childcare" to "early childhood education" centers. Second, we use quantitative data from the Consumer Expenditure Survey (1995-2017) to show that parents have increasingly spent money, and an increasing share of their income, on center-based care for babies and toddlers but not on other child items. Additionally, lower income families have been spending a greater share of their income on center-based care for their infants than other families. We interpret our findings using Zelizer's theory about the cultural influences on the meaning of money, showing how these can be expert-led and persist even when families are faced with structural economic constraints.

Cet article relie la théorie de Viviana Zelizer sur la signification sociale de l'argent aux études sur la famille, en utilisant le cas des dépenses des parents américains pour leurs enfants. Nous étudions comment l'argent dépensé pour les plus jeunes enfants­ les bébés et les tout­petits­reflète l'importance croissante que les experts accordent à l'investissement parental dans la période critique du développement de l'enfant. Tout d'abord, nous passons en revue la littérature sur les connaissances des experts afin de retracer l'évolution de l'accent mis sur l'importance de développer les compétences cognitives des enfants par le biais d'une éducation formelle dès la petite enfance, proposée dans des centres d'accueil, qui sont moins des espaces de « garde d'enfants ¼ et davantage des centres d'« éducation de la petite enfance ¼. Deuxièmement, nous utilisons les données quantitatives du Consumer Expenditure Survey (1995­2017) pour montrer que les parents dépensent de plus en plus d'argent, et une part de plus en plus importante de leurs revenus, pour la garde des bébés et des jeunes enfants dans des centres d'accueil, mais pas pour d'autres articles liés à l'enfance. De plus, les familles à faibles revenus consacrent une part plus importante de leurs revenus à la garde de leurs enfants en bas âge dans des centres que les autres familles. Nous interprétons nos résultats en utilisant la théorie de Zelizer concernant les influences culturelles sur la signification de l'argent, en montrant comment celles­ci peuvent être dirigées par des experts et persister même lorsque les familles sont confrontées à des contraintes économiques structurelles.

Pricing the priceless child 2.0: children as human capital investment.

This article takes Viviana Zelizer's (1985) Pricing the Priceless Child to the new millennium. Zelizer documented the transformation between the 19th and 20th century from an "economically useful" to an "emotionally priceless" child. She observed that by the 1930s, American children were practically economically worthless but invested with significant emotional value. What has happened to this emotionally priceless child at the dawn of the new millennium? Has there been a new transformation in the social value of children, and, if so, what might have such a transformation entailed? To address these questions, we examine overtime trends that point to increasing devotion of resources and time to children's education, a key input in the exceedingly influential human capital theory, which connects investment into children's human capital with their future market value. Therefore, we argue that the priceless child 2.0 is a useful-to-be human capital investment child. We use four empirical examples of overtime growth in children's human capital investment: (a) enrollments in early childhood education, (b) federal spending on early education, (c) federal spending on K-12 programs, and (d) parental spending on child care, education and extracurricular activities. In the conclusion, we discuss some potential consequences and concerns about raising children as human capital investment.

Clinician attitudes and concordance with self-assessed and actual intravenous fluid prescribing patterns: A single-institution evaluation of survey and electronic prescribing data.

BACKGROUND: Recent studies suggest that balanced fluids improve inpatient outcomes compared to normal saline. The objective of this study was to obtain insights into clinicians' knowledge, attitudes and perceived prescribing practices concerning IV isotonic fluids and to analyze perceived prescribing in the context of actual prescribing. METHODS: This study, conducted at a single center (Medical University of South Carolina), included 1) a cross-sectional survey of physicians and advanced practice providers (APPs) (7/2019-8/2019) and 2) review electronic health record (EHR) claims data (2/2018-1/2019) to quantify the prescribing patterns of isotonic fluids. RESULTS: Clinicians perceived ordering equivalent amounts of normal saline and balanced fluids although normal saline ordering predominated (59.7%). There was significant variation in perceived and actual ordering across specialties, with internal medicine/subspecialty and emergency medicine clinicians reporting preferential use of normal saline and surgical/subspecialty and anesthesia clinicians reporting preferential use of balanced fluids (p < 0.0001). Clinicians who self-reported providing care in an intensive care unit (ICU) reported more frequent use of balanced fluids than non-ICU clinicians (p = 0.03). Actual prescribing data mirrored these differences. Clinicians' self-reported use of continuous infusions (p = 0.0006) and beliefs regarding the volume of fluid required to cause harm (p = 0.003) were also associated with self-reported differences in fluid prescribing. Clinician experience, most clinical considerations (e.g., indications, contraindications, barriers to using a specific fluid), and fluid cost were not associated with differential prescribing. CONCLUSIONS: Persistent normal saline utilization is associated with certain specialties, care locations, and the rate and volume of fluid administered, but not with other clinical considerations or cost. These findings can guide interventions to improve evidence-based fluid prescribing.

Development and implementation of a clinical decision support-based initiative to drive intravenous fluid prescribing.

OBJECTIVE: Studies suggest superior outcomes with use of intravenous (IV) balanced fluids compared to normal saline (NS). However, significant fluid prescribing variability persists, highlighting the knowledge-to-practice gap. We sought to identify contributors to prescribing variation and utilize a clinical decision support system (CDSS) to increase institutional balanced fluid prescribing. MATERIALS AND METHODS: This single-center informatics-enabled quality improvement initiative for patients hospitalized or treated in the emergency department included stepwise interventions of 1) identification of design factors within the computerized provider order entry (CPOE) of our electronic health record (EHR) that contribute to preferential NS ordering, 2) clinician education, 3) fluid stocking modifications, 4) re-design and implementation of a CDSS-integrated IV fluid ordering panel, and 5) comparison of fluid prescribing before and after the intervention. EHR-derived prescribing data was analyzed via single interrupted time series. RESULTS: Pre-intervention (3/2019-9/2019), balanced fluids comprised 33% of isotonic fluid orders, with gradual uptake (1.4%/month) of balanced fluid prescribing. Clinician education (10/2019-2/2020) yielded a modest (4.4%/month, 95% CI 1.6-7.2, p = 0.01) proportional increase in balanced fluid prescribing, while CPOE redesign (3/2020) yielded an immediate (20.7%, 95% CI 17.7-23.6, p < 0.0001) and sustained increase (72% of fluid orders in 12/2020). The intervention proved most effective among those with lower baseline balanced fluids utilization, including emergency medicine (57% increase, 95% CI 0.7-1.8, p < 0.0001) and internal medicine/subspecialties (18% increase, 95% CI 14.4-21.3, p < 0.0001) clinicians and substantially reduced institutional prescribing variation. CONCLUSION: Integration of CDSS into an EHR yielded a robust and sustained increase in balanced fluid prescribing. This impact far exceeded that of clinician education highlighting the importance of CDSS.

Behavioral Economics and Parent Participation in an Evidence-Based Parenting Program at Scale.

Evidence-based and culturally relevant parenting programs strengthen adults' capacity to support children's health and development. Optimizing parent participation in programs implemented at scale is a prevailing challenge. Our collaborative team of program developers, implementers, and researchers applied insights from the field of behavioral economics (BE) to support parent participation in ParentCorps-a family-centered program delivered as an enhancement to pre-kindergarten-as it scaled in a large urban school district. We designed a bundle of BE-infused parent outreach materials and successfully showed their feasibility in site-level randomized pilot implementation. The site-level study did not show a statistically significant impact on family attendance. A sub-study with a family-level randomization design showed that varying the delivery time of BE-infused digital outreach significantly increased the likelihood of families attending the parenting program. Lessons on the potential value of a BE-infused approach to support outreach and engagement in parenting programs are discussed in the context of scaling up efforts.

Pride-Based Self-Affirmations and Parenting Programs.

We newly apply the concept of self-affirmation typically used in the domain of health and education to the domain of parenting. Recruiting parents of children age 13 or younger (n = 1,044), we test how eliciting positive self-concept affects interest in receiving parenting materials and participating in a parenting program. We find that an adapted, pride-based written self-affirmation exercise increased parents' positive self-concept and their interest in parenting programs and resources, particularly among parents with a high baseline fear of judgment associated with seeking help. Implications for applying insights from psychology as a strategy to mitigate fear of judgment to optimize participation in an evidence-based parenting program at scale are discussed.

Characteristics of Pulmonary Critical Care Medicine and Pulmonary Medicine Applicants and Fellowships.

Background: Little is known about historical and recent application trends for pulmonary critical care medicine (PCCM) or pulmonary medicine (PM) fellowship programs. Describing trends in and characteristics of PCCM and PM applications, applicants, and fellowship programs can help program directors and medical educators understand trainees' interest in and application patterns for these fellowship programs. Objective: The objective of this study was to use National Residency Match Program data to assess recent trends in PCCM and PM fellowship applications and compare characteristics of applicants and fellowship programs. Methods: In 2019, we used National Residency Match Program data to evaluate applicant ranking and matching in PCCM and PM fellowship programs and to compare applicant and fellowship program characteristics. Results: From 2008 through 2019, the majority of applicants (59.1%) matched into PCCM were graduates of U.S. allopathic or osteopathic medical schools, whereas 87% of PM fellows were non-U.S. graduates. PCCM was the preferred specialty for 90.8% of matched applicants versus only 31.6% of matched PM applicants (P < 0.001). The match rate for PCCM applicants was 67.2% versus 23.8% for PM applicants (P < 0.001). Of PCCM applicants, 36.6% matched into their top choice versus 10.8% of PM applicants (P < 0.001). There are far fewer PM fellowship positions (n = 23) and programs (n = 12) than PCCM positions (n = 450) and programs (n = 131). The mean fill rates from the 2004 through 2016 appointment years are 94.1% in PCCM and 97.4% in PM (P = 0.009). Conclusion: PCCM is a prevailing specialty choice over PM among residency graduates, with matched applicants more likely to list PCCM than PM as their preferred specialty. Further exploration into applicants' interest in critical care compared with PM may prove beneficial in guiding applicants to programs that will best meet their career goals.