Randomised controlled trial of treatment of unilateral visual impairment detected at preschool vision screening.
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Comment↗
Biomedical subjects
Alex R Kemper
Publications and source records attributed to Alex R Kemper.
Association between outpatient follow-up and pediatric emergency department asthma visits.
BACKGROUND: The National Heart, Lung, and Blood Institute (NHLBI) guidelines recommend that patients receive a follow-up outpatient asthma visit after being discharged from an emergency department (ED) for asthma. OBJECTIVE: To measure the frequency of follow-up outpatient asthma visits and its association with repeat ED asthma visit. DESIGN: We conducted a retrospective cohort study of children with asthma using claims data from a university-based managed care organization from January 1998 to October 2000. We performed a multivariate survival analysis using Cox proportional hazards model to determine the effect of follow-up outpatient asthma visits on the likelihood of a repeat ED asthma visit, after controlling for severity of illness, patient age, gender, insurance, and the specialty of the primary care provider. RESULTS: A total of 561 children had 780 ED asthma visits. Of these, 103 (17%) had a repeat ED asthma visit within 1 year. Almost two-thirds of children (66%) did not receive outpatient follow-up for asthma within 30 days of an ED asthma visit. Outpatient asthma visits within 30 days of an ED asthma visit are associated with an increased likelihood (relative risk = 1.80; 95% confidence interval 1.19, 2.72) for repeat ED asthma visits within 1 year. CONCLUSIONS: Most patients do not have outpatient follow-up after an ED asthma visit. However, those patients that present for outpatient follow-up have an increased likelihood for repeat ED asthma visits. For the primary care provider, these outpatient follow-up visits signal an increased risk that a patient will return to the ED for asthma and are a key opportunity to prevent future ED asthma visits.
Adolescent↗
Preschool vision screening in primary care after a legislative mandate for diagnostic eye examinations.
BACKGROUND: Kentucky legislation now requires that children entering public school receive a diagnostic eye examination. METHODS: Mail survey of randomly selected office-based primary care pediatricians (PDs, n = 221) and family physicians (FPs, n = 207) in Kentucky to assess the impact of the mandated eye examination. RESULTS: The response rate was 71% PDs and 51% FPs. Most offer preschool vision screening (PD 86%; FP 79%; P = 0.16), but many report they will be less likely to offer it in the future because of the mandated diagnostic eye examination (PD 61%; FP 50%; P = 0.09). Perceived barriers to the diagnostic eye examination include lack of parental knowledge about the requirement, belief by parents that they will need to pay, difficulty in getting an appointment, and lack of endorsement by primary care physicians. CONCLUSION: Most primary care physicians in Kentucky offer preschool vision screening, but many now are likely to reduce their screening effort. Until more data are available regarding the impact of the required eye examination, primary care providers should not change their screening practices.
Attitude of Health Personnel↗
Under scrutiny: smallpox vaccine recommendations.
The eradication of smallpox is widely considered to be one of the great achievements of public health. However, international terrorism in the US and elsewhere has led to increasing concern about vulnerability to a smallpox bioterror attack. Timely vaccination is highly protective against smallpox but carries risks of morbidity and mortality. Significant debate has therefore emerged regarding the optimal strategy for defence. In principle, there are three options: either mass or limited vaccination prior to an attack; quarantine and vaccination of all suspected cases of smallpox following an attack with isolation and vaccination of potential case contacts; and mass vaccination after the identification of a case of smallpox. This paper reviews smallpox disease, smallpox vaccination and the development of current smallpox vaccination policy in the US. Mathematical models of the spread of smallpox and control strategies are reviewed to explore specific smallpox vaccine policy considerations. Limitations of these models are considered and recommendations are made for future research.
Humans↗
Hospitalists and residency medical education: measured improvement.
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Hospitalists↗
Claims of equivalence in randomized controlled trials of the treatment of bacterial meningitis in children.
OBJECTIVE: To evaluate claims of therapeutic equivalence in studies of the treatment of bacterial meningitis in children. METHODS: We performed a systematic review of randomized controlled trials of antimicrobial therapy for bacterial meningitis in children indexed in MEDLINE and published after 1980 and that claimed equivalency. The sample size of each trial was compared with the minimum sample size needed to rigorously claim equivalence. The primary endpoint was case fatality. RESULTS: Twenty-five studies were identified that met the inclusion criteria. Two of these were specifically designed to test equivalence, and the remaining based claims of equivalence on failed tests of superiority. The majority of these trials (24 of 25) that claimed equivalence had sufficient sample size to exclude a 20% difference in mortality between the tested therapies. Only 3 of the 25 trials could exclude a 10% difference in mortality. CONCLUSION: Few of the trials in this study had sufficient sample size to claim equivalence within 10% of the expected mortality. Proving equivalency is challenging because large sample sizes are often needed to ensure adequate statistical power to rule out clinically important differences between the standard of care and new therapies.
Anti-Bacterial Agents↗
Reevaluating the efficacy of naturopathic ear drops.
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Anesthetics, Local↗
Parents' trust in their child's physician: using an adapted Trust in Physician Scale.
OBJECTIVES: To assess the performance of the Pediatric Trust in Physician Scale (Pedi-TiPS) that refers to a child's physician and is a modified version of the Trust in Physician Scale (TiPS), and to explore the association of trust to demographic variables. METHODS: We performed a cross-sectional survey of parents in pediatric specialty and primary care sites. Parents completed an anonymous questionnaire that included the Pedi-TiPS. Our main outcome variable was total Pedi-TiPS score (higher scores = higher trust). Reliability was determined by Cronbach's alpha. Bivariate comparisons and linear regression modeling explored potential associations between demographic variables and total score. RESULTS: Five hundred twenty-six parents completed surveys (73% response rate). The mean total score was 45.4 (SD 6), with good internal consistency (alpha = .84). In bivariate analysis, lower scores were associated with being a father (P = 0.03), older parent age (P = 0.02), private insurance status (P < 0.01), parent education greater than high school (P = 0.04), and not having a child age <3 years (P = 0.03). In a regression model adjusted for other factors, parents who were either African American (P = 0.05), or "other" race (P < 0.01), parents with private insurance (P = 0.02), and parents who had no children <3 years of age (P = 0.04) had lower trust. CONCLUSIONS: The Pedi-TiPS has properties similar to the original instrument. We found associations between trust and demographic factors that should be confirmed with further studies.
Adult↗
Trends in diabetes mellitus among privately insured children, 1998-2002.
OBJECTIVE: To evaluate trends in health care administrative claims for childhood diabetes mellitus. METHODS: We conducted a serial cross-sectional study of a national sample of privately insured children < or = 18 years old. The number of subjects ranged from 306991 in 1998 to 974407 in 2002. We classified diabetes type by 2 schemes: one based on encounter claims only, and the other based on both encounter and pharmacy claims. The prevalence of diabetes was determined after adjusting for demographic changes in the study population, including age, proportion enrolled in managed care, and urban residence. RESULTS: The adjusted prevalence of diabetes overall increased from 183 (95% confidence interval [CI], 169-198) cases per 100,000 enrollees in 1998 to 218 (95% CI, 208-228) cases per 100,000 enrollees in 2002, primarily because of an increase in type 1 diabetes (based on both encounter and pharmacy claims, 135 [95% CI, 123-148] cases per 100000 enrollees in 1998 to 167 [95% CI, 158-176] cases per 100,000 enrollees in 2002). CONCLUSIONS: Our estimate of the overall prevalence of diabetes is consistent with national data. However, our finding that rising prevalence of type 1 diabetes appear to account for most of the increase in diabetes claims is surprising. Future research will be needed to validate these results.
Adolescent↗
Informing parents about newborn screening.
OBJECTIVE: To evaluate current rules and regulations for educating parents about newborn screening. DESIGN: Cross-sectional survey. SAMPLE: Newborn screening program coordinators in all 50 states and the District of Columbia. MEASUREMENTS: Answers to a standardized semi-structured telephone survey in January 2004. RESULTS: Fifty programs provide standardized information about screening, and 32 of these have information available in multiple languages. Most programs (n=36) believe that parents should be informed about newborn screening as a part of prenatal care; however, none has rules or regulations requiring this. Five require documented informed consent; only one provides the consent form in a language other than English. Hospitals and birthing centers are required by many programs to educate families, including providing information (n=12), obtaining informed consent (n=5), informing parents of the right to refuse screening (n=13), and documenting refusal on institutionally developed forms (n=9). We found considerable variation in policy language across the newborn screening programs. CONCLUSIONS: The complexity of current newborn screening programs and the likelihood of expansion in the number of conditions on newborn screening panels present a unique opportunity and challenge for public health nurses to ensure that these programs are effective and that care is integrated.
Adult↗
Hospital readmission for bronchiolitis.
The objectives of this study were to determine the rate and risk factors for hospital readmission after inpatient treatment for bronchiolitis. We conducted a retrospective cohort study from 2000 to 2002. The readmission rate within 30 days was 3.7% (95% Confidence Interval: 2.1%-6.0%). Readmission was not associated with age, prematurity, respiratory syncytial virus status, receipt of intensive care, or the observation period off supplemental oxygen. Those who required supplemental oxygen had a lower risk of readmission. Identifying children at risk for readmission is challenging. Children who did not require supplemental oxygen may be at greater risk because they are progressing in their illness.
Bronchiolitis↗
Receipt of specialty eye care by children.
BACKGROUND: No nationally representative data are available regarding use of eye care services by children. OBJECTIVES: To determine the proportion of children who receive specialty eye care and to evaluate the association of such care with age and other factors associated with health care utilization. METHODS: We used the 2000 National Health Interview Survey to estimate the proportion of nonblind children who received eye care in the preceding 12 months. The association between eye care and the factors of interest among children aged 6-17 years was measured through adjusted bivariate comparisons and logistic regression modeling. RESULTS: Eye care was received in the preceding 12 months by an estimated 7.3% (95% confidence interval [CI] 6.0-8.6) of the 22.8 million children aged 0-5 years and 24.8% (95% CI 23.5-26.2) of the 48.5 million children aged 6-17 years. Among children aged 6-17 years, girls had 29% greater odds than boys to have received eye care (P=.001). Among children <200% of the federal poverty level, those with public health insurance had greater odds of receiving eye care than did uninsured children or those with private health insurance (P<.001). Among children >200% of the federal poverty level, uninsured children had lower odds than did children with public or private health insurance (P<.004) to receive eye care. Well-child care was associated with increased eye care utilization among children aged 12-14 years (P<.001). CONCLUSIONS: Receipt of specialty eye care is common and increases with age. However, there are marked variations among school-aged children. Future studies should address the causes and effects of these findings.
Adolescent↗
Willingness of eye care practices to evaluate children and accept Medicaid.
BACKGROUND: The willingness of eye care providers to evaluate children or to accept Medicaid may be a barrier to care for those with an abnormal screen. OBJECTIVES: To determine the proportion of eye care practices that would provide diagnostic evaluation for children and accept Medicaid payment and to evaluate the influence of child age and practice characteristics on provision of care or acceptance of Medicaid. METHODS: We conducted a telephone survey of 364 eye care practices in Michigan, which were randomly selected from telephone directories of 26 rural and urban cities as defined by metropolitan statistical areas. RESULTS: The response rate was 93%. Most eye care practices, but more optometry-listed practices than ophthalmology-listed ones, would evaluate preschool-aged children (88% vs 73%; P <.01) or school-aged children only (11% vs 7%; P <.01). The proportion of practices willing to evaluate preschool-aged children was lower in urban cities compared with rural cities for optometry-listed (83% vs 96%; P <.01) and ophthalmology-listed practices (67% vs 93%; P <.01). Medicaid acceptance among practices that would evaluate children was higher among ophthalmology-listed than optometry-listed practices (74% vs 59%; P =.01) and did not vary by urban or rural status. Practice size was not associated with willingness to provide care for children. However, among practices that would provide care for children, larger practice size was associated with increased odds of Medicaid acceptance in both optometry-listed and ophthalmology-listed practices. CONCLUSIONS: These findings contradict the perception that eye care for children is unavailable. More work is needed to understand the relationship of this availability with the accessibility of eye care.
Attitude of Health Personnel↗
Physician barriers to lead testing of Medicaid-enrolled children.
BACKGROUND: The rate of blood lead testing among Medicaid-enrolled children is low. OBJECTIVE: To determine barriers to lead testing perceived by pediatricians to develop future interventions to improve the rate of appropriate blood lead testing. METHODS: We developed a mail survey based on findings from 6 focus groups of primary-care providers in Michigan. We then surveyed a random sample of 520 primary-care pediatricians in Michigan. Pediatricians who did not accept Medicaid were excluded from the analysis. RESULTS: The overall response rate was 65% (257 of 396 potentially eligible respondents). Most (68%) reported that they routinely test 1-year-old Medicaid-enrolled children. Practices with onsite blood testing were more likely to report routine testing of 1-year-old children (79% vs 62%; P < .01). Most (76%) who do not routinely test were aware of the Medicaid requirements for testing. The most common reason (70%) for not testing Medicaid-enrolled children was physicians' belief that they practice in a low-risk area. However, 35% of those who do not test because they practice in a low-risk area actually have their main practice site in a high-risk area. CONCLUSIONS: To improve the rate of blood lead testing, the public health department should provide pediatricians with data regarding the local risk of lead poisoning. The public health department should also consider working with practices to facilitate onsite blood collection for lead testing.
Attitude of Health Personnel↗
Services provided for preschool-aged children with suspected amblyopia.
BACKGROUND: Little is known about the pattern and variation of care offered to preschool-aged children who have had an abnormal vision screening test. PURPOSE: To evaluate the variations in pediatric eye care services and availability of optometrists and ophthalmologists for preschool-aged patients, referral patterns, and barriers to providing care as perceived by eye care specialists. METHODS: A survey was mailed to 542 ophthalmologists and a random sample of 501 optometrists actively practicing in Michigan. RESULTS: The response rate was 65% (optometrists, 75%; ophthalmologists, 57%). More optometrists than ophthalmologists evaluated preschool-aged children (97% vs 79%; P < .001). Of these, most managed amblyopia (80% vs 77%; P = .372) and strabismus (89% vs 80%; P = .002) themselves. Fewer optometrists than ophthalmologists dilated eyes routinely during the first evaluation of a preschool-aged child (39% vs 93%; P < .001). The leading barrier to care for preschool-aged children reported by both optometrists and ophthalmologists was difficulty of the examination (25% vs 23%; P = .501). Optometrists reported that most of their patients were referred from community-based screening programs or by parent self-referral. Ophthalmologists reported that most of their preschool-aged patients were referred from primary care providers. CONCLUSIONS: There are different sources of referrals for optometrists and ophthalmologists. Although most eye care specialists treat amblyopia, the types of care offered by optometrists and ophthalmologists differ. Future studies should address the impact that these patterns have on outcomes and cost. The results of these studies should be shared with those responsible for screening.
Amblyopia↗
Expected adverse events in a mass smallpox vaccination campaign.
CONTEXT: Recent anthrax attacks in the United States have raised concern about the nation's vulnerability to a smallpox attack. Many strategies have been suggested to minimize the impact of such an attack, ranging from quarantine and vaccination of case contacts to resumption of routine vaccination. Before the latter strategy is adopted, an understanding of the likely consequences of mass vaccination is essential. COUNT: Number of adverse events resulting from two vaccination campaigns: vaccinating persons 1 to 29 years of age and vaccinating those 1 to 65 years of age. CALCULATION: Number of adverse events = incidence rate of adverse events x number vaccinated. We assumed 75% vaccine uptake in the target group (i.e., we estimated that about 25% of potential vaccine recipients would be excluded because they are, or have close contact with, individuals who have eczema or are immunocompromised). DATA SOURCE: Historical data on the incidence of adverse events from smallpox vaccination were identified by a literature search. Number vaccinated was drawn from the January 2000 U.S. Census estimate. RESULTS: Fever (<1 case per 5 vaccine recipients) and rash (<1 case per 100 vaccine recipients) would be the most common adverse events. Serious adverse events, including encephalitis (<3 cases per million) and death (<2 cases per million), although rare, would be more common than with other currently recommended vaccines. After excluding high-risk individuals and their contacts, we estimate that a vaccination strategy directed at people aged 1 to 29 years would result in approximately 1600 serious adverse events and 190 deaths. Vaccinating people aged 1 to 65 years would result in approximately 4600 serious adverse events and 285 deaths. LIMITATIONS: While advances in health care over the past three decades could mitigate vaccine complications, the increased number of unimmunized high-risk individuals (e.g., those with eczema or immune suppression) could increase complication rates. CONCLUSIONS: The decision to resume smallpox vaccination depends on weighing the likelihood of a smallpox attack and its anticipated mortality against expected harm from a mass immunization program. Smallpox vaccine has a higher complication rate than any other vaccine currently being used. Careful prevaccination exclusion of high-risk individuals and their close contacts would be essential to minimize complications of a mass vaccination campaign, although such exclusions necessarily mean that some proportion of the population will remain susceptible to smallpox.
Adolescent↗