Biomedical subjects

Kenneth D Mandl

Publications and source records attributed to Kenneth D Mandl.

At least 37 records · Page 2Linked to original sources

PubMed2005

Factors affecting automated syndromic surveillance.

OBJECTIVE: The increased threat of bioterroristic attacks and epidemic events requires the development of accurate and timely outbreak detection systems for early identification of anomalies in public health data. MATERIAL AND METHODS: We propose an automated outbreak detection system based on syndromic data. This system uses an autoregressive model with seasonal components to monitor, online, the daily counts of chief complaints for respiratory syndromes at the emergency department of two major metropolitan hospitals. We evaluate this system by estimating the false positive rate in real data under the assumption that there were no outbreaks of disease, and the true positive rate in real baseline data in which we injected stochastically simulated outbreaks of different shape and size. We then use directed graphical models to account for the effect of exogenous factors on the detection performance of the system. RESULTS: Our study shows that for a week-long outbreak, our model has an overall 84.8% true detection accuracy across all shapes of outbreaks, while the outbreak size influences the earliness to detection. The false and true positive rates are also associated with the exogenous factors and knowledge about these factors can help to improve the detection accuracy. CONCLUSION: This study suggests that the integration of multiple data sources can significantly improve the detection accuracy of syndromic surveillance systems.

Automation↗

PubMed2005

Reverse geocoding: concerns about patient confidentiality in the display of geospatial health data.

Widespread availability geographic information systems (GIS) software has facilitated the use health mapping in both academia and government. Maps that display patients as points are often exchanged in public forums (journals, meetings, web). However,even these low resolution maps may reveal confidential patient location information. In this report, we describe a method to test whether privacy is being breached. We reverse geocode from maps with cases and describe the accuracy with which patient addresses can be extracted.

Confidentiality↗

PubMed2005

Feasibility of leveraging electronic data from pediatric hospitals for national surveillance: a survey of chief information officers.

Public health informaticians are evaluating new data sources to optimize real-time surveillance for detecting disease outbreaks. Pediatric populations are often overlooked, but may provide important signals for many reportable and vaccine preventable diseases, as well as emerging infections. The ability of pediatric hospitals to contribute timely information to the identification of disease outbreaks has not been rigorously evaluated. We sought to determine the feasibility of leveraging data from pediatric hospitals to support national disease surveillance, by measuring: 1) the types of pediatric hospital records currently stored in electronic form and accessible to query; 2) the current automated reporting capabilities of pediatric hospitals; and 3) the attitudes of Chief Information Officers (CIOs) towards disease surveillance.

Child↗

PubMed2004

The PING personally controlled electronic medical record system: technical architecture.

Despite progress in creating standardized clinical data models and interapplication protocols, the goal of creating a lifelong health care record remains mired in the pragmatics of interinstitutional competition, concerns about privacy and unnecessary disclosure, and the lack of a nationwide system for authenticating and authorizing access to medical information. The authors describe the architecture of a personally controlled health care record system, PING, that is not institutionally bound, is a free and open source, and meets the policy requirements that the authors have previously identified for health care delivery and population-wide research.

Computer Security↗

PubMed2004

Measuring outbreak-detection performance by using controlled feature set simulations.

INTRODUCTION: The outbreak-detection performance of a syndromic surveillance system can be measured in terms of its ability to detect signal (i.e., disease outbreak) against background noise (i.e., normally varying baseline disease in the region). Such benchmarking requires training and the use of validation data sets. Because only a limited number of persons have been infected with agents of biologic terrorism, data are generally unavailable, and simulation is necessary. An approach for evaluation of outbreak-detection algorithms was developed that uses semisynthetic data sets to provide real background (which effectively becomes the noise in the signal-to-noise problem) with artificially injected signal. The injected signal is defined by a controlled feature set of variable parameters, including size, shape, and duration. OBJECTIVES: This report defines a flexible approach to evaluating public health surveillance systems for early detection of outbreaks and provides examples of its use. METHODS: The stages of outbreak detection are described, followed by the procedure for creating data sets for benchmarking performance. Approaches to setting parameters for simulated outbreaks by using controlled feature sets are detailed, and metrics for detection performance are proposed. Finally, a series of experiments using semisynthetic data sets with artificially introduced outbreaks defined with controlled feature sets is reviewed. RESULTS: These experiments indicate the flexibility of controlled feature set simulation for evaluating outbreak-detection sensitivity and specificity, optimizing attributes of detection algorithms (e.g., temporal windows), choosing approaches to syndrome groupings, and determining best strategies for integrating data from multiple sources. CONCLUSIONS: The use of semisynthetic data sets containing authentic baseline and simulated outbreaks defined by a controlled feature set provides a valuable means for benchmarking the detection performance of syndromic surveillance systems.

Disease Outbreaks↗

PubMed2004

Is it influenza or anthrax? A decision analytic approach to the treatment of patients with influenza-like illnesses.

STUDY OBJECTIVE: We analyze the risks and benefits of alternative treatment strategies for non-septic-appearing febrile patients with influenza-like illnesses and possible exposure to anthrax. METHODS: We used a decision analytic model to evaluate 6 testing and treatment strategies in an emergency department. Patients were non-septic-appearing and had influenza-like illnesses but low likelihood of exposure to anthrax. The following interventions were used: (1) no empiric antibiotics; (2) blood culture and treatment only if the result was positive; (3) rapid testing for influenza and, for those who tested negative, treatment with 60 days of ciprofloxacin; (4) a two-test strategy in which all patients were first tested for influenza; those who tested negative had a blood culture test and were treated empirically with ciprofloxacin for 3 days while waiting for blood culture results; (5) culture test for all patients and treatment with ciprofloxacin for up to 3 days while waiting for blood culture results; and (6) treatment of all patients with ciprofloxacin empirically for 60 days. Main outcome measures were deaths, complications from anthrax, adverse events from ciprofloxacin, and ciprofloxacin patient-days. RESULTS: For nonzero probabilities of anthrax, patient mortality was always lowest in the strategies in which all patients were treated empirically for anthrax either for 60 days or for 3 days pending blood culture results. These strategies, however, were associated with more morbidity (more ciprofloxacin patient-days and more antibiotic adverse events) than were strategies without empiric treatment. The numbers of adverse events and antibiotic patient-days were reduced substantially with the two-test strategy, in which patients with influenza were identified early and not treated. In general, for probabilities of anthrax equaling or exceeding 2%, treating all patients empirically for 60 days was best, but for probabilities between 0.1% and 2%, the sensitivity of blood culture for anthrax determined the optimal strategy: when the sensitivity exceeded 95%, a short course of empiric ciprofloxacin until blood culture results became available was best, but for sensitivities below 95%, more aggressive empiric antibiotics use was warranted. The proportion of patients with influenza in the community affected the choice of strategy, so that seasonal variation exists. CONCLUSION: During influenza season, our findings support rapid testing for influenza, followed by empiric treatment for anthrax pending blood culture results for those who test negative for influenza. Our results help to highlight the importance of developing rapid and sensitive tests for anthrax and of developing improved surveillance and methods to calculate the previous probability of attacks.

Anthrax↗

PubMed2004

Syndromic surveillance: the effects of syndrome grouping on model accuracy and outbreak detection.

STUDY OBJECTIVE: Data used by syndromic surveillance systems must be grouped into syndromes or prodromes. Previous studies have examined the accuracy of different methods of syndromic grouping. We seek to study the effects of different syndrome grouping methods on model accuracy, a key factor in the outbreak-detection performance of syndromic surveillance systems. METHODS: Daily emergency department visit rates were analyzed from 2 urban academic tertiary care hospitals for 1,680 consecutive days. During this period, each hospital census totaled approximately 230,000 patient visits. Three methods were used to group the visits into a respiratory-related syndrome category: 1 relying on chief complaint, 1 on diagnostic codes, and 1 on a combination of the two. The different groupings of the syndromic data resulting from these methods were used to build different historical models that were then tested for forecasting accuracy and for sensitivity to detecting simulated outbreaks. RESULTS: For both hospitals, the data grouped according to chief complaints alone yielded the lowest model accuracy and the lowest detection sensitivity. Using diagnostic codes to group the data yielded better results in accuracy and sensitivity. Combining the 2 grouping methods yielded the best results in accuracy and sensitivity. Temporal smoothing of the data was shown to improve sensitivity in all cases, although to various degrees in the different models. CONCLUSION: The methods used to group input data into syndromic categories can have substantial effects on the overall performance of syndromic surveillance systems. The results suggest that incorporating diagnostic data into these systems can improve the modeling accuracy and its detection sensitivity. Furthermore, the best results may be achieved by using a combination of methods to group visits into syndromic categories.

Bioterrorism↗

PubMed2004

Use of emergency department chief complaint and diagnostic codes for identifying respiratory illness in a pediatric population.

OBJECTIVES: (1) To determine the value of emergency department chief complaint (CC) and International Classification of Disease diagnostic codes for identifying respiratory illness in a pediatric population and (2) to modify standard respiratory CC and diagnostic code sets to better identify respiratory illness in children. METHODS: We determined the sensitivity and specificity of CC and diagnostic codes by comparing code groups with a criterion standard. CC and diagnostic codes for 500 pediatric emergency department patients were retrospectively classified as respiratory or nonrespiratory. Respiratory diagnostic codes were further classified as upper or lower respiratory. The criterion standard was a blinded, reviewer-assigned illness category based on history, physical examination, test results, and treatment. We also modified our respiratory code sets to better identify respiratory illness in this population. RESULTS: Four hundred ninety-six charts met inclusion criteria. By the criterion standard, 87 (18%) patients had upper and 47 (10%) had lower respiratory illness. The specificity of CC and diagnostic codes groups was >0.97 [95% confidence interval (CI) 0.95-0.98]. The code group sensitivities were as follows: CC was 0.47 (95% CI 0.38-0.55), upper respiratory diagnostic was 0.56 (95% CI 0.45-0.67), lower respiratory diagnostic was 0.87 (95% CI 0.74-0.95), and combined CC and/or diagnostic was 0.72 (95% CI 0.63-0.79). Modifying the respiratory code sets to better identify respiratory illness increased sensitivity but decreased specificity. CONCLUSIONS: Diagnostic and CC codes have substantial value for emergency department syndromic surveillance. Adapting our respiratory code sets to a pediatric population forced a tradeoff between sensitivity and specificity.

Child↗

PubMed2004

Selective imaging strategies for the diagnosis of appendicitis in children.

BACKGROUND: We previously reported an appendiceal imaging protocol in which children with equivocal clinical presentations for acute appendicitis undergo ultrasonography (US) followed by computed tomography (CT). However, risk groups of children who would benefit most from imaging studies have not been established. OBJECTIVE: To define and test selective imaging guidelines to increase diagnostic accuracy and reduce unnecessary testing for children with suspected appendicitis. METHODS: We modeled outcomes under 3 different management guidelines. Patients were risk-stratified by a recursive partitioning analysis of a retrospective cohort. Subjects included children with equivocal presentations of acute appendicitis evaluated between January 1996 and December 1999. By using recursive partitioning, 3 risk groups were identified: low, medium, and high risk for acute appendicitis. Three imaging guidelines were defined. Under the first guideline, representing standard clinical practice at Children's Hospital Boston at the time of the study, all children with equivocal signs and symptoms for acute appendicitis undergo US first. If the US is positive, the child proceeds to appendectomy. If the US is negative, the child undergoes CT. Under guideline 2, low-risk children undergo US and, if negative, are discharged from the hospital. High-risk children undergo CT, and medium-risk children undergo US followed by CT. Under the third guideline, low-risk children undergo no imaging and are admitted for observation. High-risk children proceed directly to appendectomy without imaging studies. Medium-risk children undergo US followed by CT. Clinical outcomes and the number of imaging studies performed were modeled under current practice and under each guideline. RESULTS: Identified were 1401 cases of equivocal appendicitis; 958 (68.4%) with complete data. The mean age was 11 +/- 4.3 years. Of 958 children, 588 (61.4%) had acute appendicitis. One hundred forty-three patients were in the low-risk group, defined as neutrophils 67%, white blood cell count >10,000/mm(3), guarding, and abdominal pain >13 hours. Of these, 202 (90%) had appendicitis. Under guideline 1, there were 22 negative appendectomies, 35 missed or delayed diagnoses, and 958 USs and 673 CT scans performed. Under guideline 2, there would have been 23 negative appendectomies, 36 missed or delayed diagnoses, and 733 USs and 637 CT scans performed. Under guideline 3, there would have been 36 negative appendectomies, 37 missed or delayed diagnoses, and 590 USs and 412 CT scans performed. CONCLUSIONS: Selective imaging guidelines can reduce the number of radiographic studies performed with minimal diminution in accuracy of diagnosis of pediatric appendicitis.

Appendicitis↗

PubMed2004

Length-of-stay policies and ascertainment of postdischarge problems in newborns.

OBJECTIVE: The purpose of this study was to evaluate the effects of an early postpartum discharge program and a subsequent legislative mandate for 48 hours of hospital coverage on incidence of newborn jaundice and feeding problems. We tested the hypothesis that heightened postdischarge ascertainment (rather than short stays) is responsible for apparent increases in these outcomes. METHODS: Interrupted time series analysis was conducted on retrospective data from the automated medical records of a large Massachusetts health maintenance organization (HMO). A population of 20,366 mother-infant pairs with normal vaginal deliveries between October 1990 and March 1998 was identified. The interventions included a new HMO protocol in 1994 of 1 hospital overnight after delivery, plus a nurse home visit, then the Massachusetts' 1996 minimum coverage law. Postpartum length of stay, clinical evaluation on day 3 or 4 of life, health center visits up to day 21, health center diagnoses of jaundice or feeding problems, bilirubin testing and test severity, rehospitalizations, and emergency department visits were measured. RESULTS: Postpartum stays <2 nights rose from 28% of newborns before implementation of the program to 70% immediately after implementation. Later, this rate fell from 66% before the mandate to 21% just after the law went into effect. Day 3 or 4 evaluation rose from 24.5% to 64% after the program, then dropped somewhat to 53% after the mandate. Controlling for longer-term trends in health center visits, implementation of the early discharge program was associated with approximately 1 extra visit for every 4 newborns within the first 21 days of life. The state mandate did not affect health center visit rates. Jaundice diagnoses were flat at 8% of newborns during the baseline, then rose to a constant 11% throughout the program and postmandate periods. Bilirubin testing of newborns also rose by 3.4 percentage points at the time of program implementation, and the proportion of tested newborns with results calling for at least consideration of phototherapy rose by 6 percentage points. Phototherapy use rose from a flat 1.8% to 2.4% of newborns after program implementation. Feeding problem diagnoses more than doubled at the time of program implementation and remained elevated after the mandate. Rehospitalizations overall and specifically for jaundice were constant over time, whereas more rare emergency department visits for jaundice dropped from 0.3% of newborns to 0 on program implementation. CONCLUSIONS: Sudden increases in jaundice-related measures and identification of infant feeding problems were not associated with changes in length of stay in this setting. Instead, these increases seem to be the result of more frequent evaluation of newborns during the critical day 3 to 4 period and may also have been elevated by a new climate of concern about neonatal vulnerability. "Ascertainment bias" may have confounded findings in previous reports that raised concerns about the safety of early discharge.

Breast Feeding↗

PubMed2004

Efficacy of an educational Web site for educating physicians about bioterrorism.

OBJECTIVES: To determine whether a Web-based educational intervention improves emergency physicians' knowledge about bioterrorism and to survey physicians' knowledge and sources of information on bioterrorism. METHODS: Prospective randomized controlled trial using pre- and postintervention testing in hospitals. Participants were general and pediatric emergency medicine attending physicians, fellows, and fourth-year emergency medicine residents. All participants completed a pretest and attended a lecture on bioterrorism. Participants were then randomized to the Web intervention group that received continuous access to a bioterrorism educational Web site with weekly exposure to case scenarios of diseases due to biological agents, or the control group. Participants were retested after one and six months and surveyed to identify their sources of information and assess their knowledge. RESULTS: Sixty-three physicians completed the pretest. There was no difference in mean +/- standard deviation (SD) pretest scores between Web intervention (45% +/- 10%) and control (44% +/- 10%) groups (mean difference: 1.9%; 95% confidence interval [CI] = -6.7% to 2.9%). There was no significant difference between pre- and posttest scores among groups at one month (Web intervention 48% +/- 10% vs. control 45% +/- 10%; mean difference: 3.3%; 95% CI = -8.5% to 2.0%) and six months (Web intervention 51% +/- 8% vs. control 47% +/- 9%; mean difference: 3.8%; 95% CI = -8.8% to 1.2%). More than 60% of physicians cited media reports as their primary source of information on bioterrorism and believed that their knowledge of bioterrorism was limited after one month. CONCLUSIONS: Providing physicians information on bioterrorism through simulated cases and continuous access to an educational Web site does not increase knowledge of bioterrorism. Physicians are more likely to use media reports for their primary source of information.

Attitude of Health Personnel↗

PubMed2003

Implementing syndromic surveillance: a practical guide informed by the early experience.

Syndromic surveillance refers to methods relying on detection of individual and population health indicators that are discernible before confirmed diagnoses are made. In particular, prior to the laboratory confirmation of an infectious disease, ill persons may exhibit behavioral patterns, symptoms, signs, or laboratory findings that can be tracked through a variety of data sources. Syndromic surveillance systems are being developed locally, regionally, and nationally. The efforts have been largely directed at facilitating the early detection of a covert bioterrorist attack, but the technology may also be useful for general public health, clinical medicine, quality improvement, patient safety, and research. This report, authored by developers and methodologists involved in the design and deployment of the first wave of syndromic surveillance systems, is intended to serve as a guide for informaticians, public health managers, and practitioners who are currently planning deployment of such systems in their regions.

Bioterrorism↗

PubMed2003

Using temporal context to improve biosurveillance.

Current efforts to detect covert bioterrorist attacks from increases in hospital visit rates are plagued by the unpredictable nature of these rates. Although many current systems evaluate hospital visit data 1 day at a time, we investigate evaluating multiple days at once to lessen the effects of this unpredictability and to improve both the timeliness and sensitivity of detection. To test this approach, we introduce simulated disease outbreaks of varying shapes, magnitudes, and durations into 10 years of historical daily visit data from a major tertiary-care metropolitan teaching hospital. We then investigate the effectiveness of using multiday temporal filters for detecting these simulated outbreaks within the noisy environment of the historical visit data. Our results show that compared with the standard 1-day approach, the multiday detection approach significantly increases detection sensitivity and decreases latency while maintaining a high specificity. We conclude that current biosurveillance systems should incorporate a wider temporal context to improve their effectiveness. Furthermore, for increased robustness and performance, hybrid systems should be developed to capitalize on the complementary strengths of different types of temporal filters.

Bioterrorism↗

PubMed2003

Time series modeling for syndromic surveillance.

BACKGROUND: Emergency department (ED) based syndromic surveillance systems identify abnormally high visit rates that may be an early signal of a bioterrorist attack. For example, an anthrax outbreak might first be detectable as an unusual increase in the number of patients reporting to the ED with respiratory symptoms. Reliably identifying these abnormal visit patterns requires a good understanding of the normal patterns of healthcare usage. Unfortunately, systematic methods for determining the expected number of (ED) visits on a particular day have not yet been well established. We present here a generalized methodology for developing models of expected ED visit rates. METHODS: Using time-series methods, we developed robust models of ED utilization for the purpose of defining expected visit rates. The models were based on nearly a decade of historical data at a major metropolitan academic, tertiary care pediatric emergency department. The historical data were fit using trimmed-mean seasonal models, and additional models were fit with autoregressive integrated moving average (ARIMA) residuals to account for recent trends in the data. The detection capabilities of the model were tested with simulated outbreaks. RESULTS: Models were built both for overall visits and for respiratory-related visits, classified according to the chief complaint recorded at the beginning of each visit. The mean absolute percentage error of the ARIMA models was 9.37% for overall visits and 27.54% for respiratory visits. A simple detection system based on the ARIMA model of overall visits was able to detect 7-day-long simulated outbreaks of 30 visits per day with 100% sensitivity and 97% specificity. Sensitivity decreased with outbreak size, dropping to 94% for outbreaks of 20 visits per day, and 57% for 10 visits per day, all while maintaining a 97% benchmark specificity. CONCLUSIONS: Time series methods applied to historical ED utilization data are an important tool for syndromic surveillance. Accurate forecasting of emergency department total utilization as well as the rates of particular syndromes is possible. The multiple models in the system account for both long-term and recent trends, and an integrated alarms strategy combining these two perspectives may provide a more complete picture to public health authorities. The systematic methodology described here can be generalized to other healthcare settings to develop automated surveillance systems capable of detecting anomalies in disease patterns and healthcare utilization.

Bioterrorism↗

PubMed2003

The value of parental report for diagnosis and management of dehydration in the emergency department.

STUDY OBJECTIVES: We define the predictive value of parents' computer-based report for history and physical signs of dehydration for a primary outcome of percentage of dehydration (fluid deficit) and 2 secondary outcomes: clinically important acidosis and hospital admission. We also sought to compare the reports of physical signs related to dehydration made by parents and nurses. METHODS: We performed a prospective observational trial in an urban pediatric emergency department. A convenience sample of parents completed a computer-based interview covering historical details and physical signs (ill appearance, sunken fontanelle, sunken eyes, decreased tears, dry mouth, cool extremities, and weak cry) related to dehydration. Nurses independently completed an assessment of physical signs for enrolled children. The primary outcome was the degree of dehydration (fluid deficit), which was defined as the percentage difference between initial ED weight and stable final weight after the illness. Secondary outcomes included clinically important acidosis (defined as a serum CO(2) value of </=15 mEq/L) and hospital admission. RESULTS: One hundred thirty-two parent-child dyads comprised the final sample. Parent-reported data manifested higher sensitivity (range 73% to 100%) than specificity (range 0% to 49%) for the prediction of dehydration of 5% or greater. Likelihood ratios (LRs) near zero (<0.1) suggest that a normal history of fluid intake and urine output reduced the likelihood of significant dehydration. Parental report of a normal tearing state reduced the likelihood of significant dehydration and clinically important acidosis (negative LRs of 0.4 and 0.1, respectively). Two physical signs reported by parents, sunken fontanelle and decreased tears, were associated with hospital admission (positive LR of 3.4 and 4.0, respectively). CONCLUSION: Parents' report of history and observations for children captured through computer-based interview demonstrates predictive value for relevant outcomes in dehydration.

Adult↗

PubMed2003

Prolonged partial thromboplastin times in children with fever and petechiae without bacteremia or sepsis.

OBJECTIVES: In a prior uncontrolled study, 23% of children with fever and petechiae without bacteremia or sepsis had a prolonged partial thromboplastin time (PTT). We attempted to validate this finding by comparing the PTTs of children with fever and petechiae who were neither septic nor bacteremic with those of children without fever and petechiae. METHODS: Design. Secondary analysis of a prospective cohort with a newly identified retrospective control cohort. Setting. Emergency department of an urban pediatric teaching hospital from December 1993 to June 1995. Study group. All patients 1 month to 18 years old from a previously identified cohort with (1) fever (temperature >or=38.0); (2) petechiae; (3) prothrombin time and partial thromboplastin time performed in the emergency department (n = 273). Control group. Age-matched patients 1 month to 18 years old who presented to the emergency department during the same time period as the study patients with (1) an injury or other potentially surgical diagnosis; (2) neither fever nor petechiae; (3) prothrombin time and partial thromboplastin time performed in the emergency department. Main outcome measures. partial thromboplastin time and prothrombin time. RESULTS: 117 control patients were identified. Partial thromboplastin time was prolonged in 23% of study patients, but in only 6% of control patients (P < 0.001). Prothrombin time was prolonged in 9% of patients with fever and petechiae compared with only 4% of control patients (P = 0.09). CONCLUSION: Children with fever and petechiae without bacteremia or sepsis are more likely than controls to have prolonged partial thromboplastin time.

Adolescent↗

PubMed2003

Notifying emergency department patients of negative test results: pitfalls of passive communication.

OBJECTIVE: Many emergency departments that perform a high volume of group A Streptococcus throat cultures inform patients or parents that unless they are notified of a positive result they can assume that their throat culture result is negative. Thus, positive throat culture results are communicated actively and negative results are communicated passively. We sought to determine the effectiveness and safety of such a system. METHODS: Prospective cohort study of 301 consecutive patients who had group A Streptococcus throat cultures obtained between March 28, 2000, and May 10, 2000, in the emergency department of an urban, academic, tertiary-care children's hospital. Outcomes were determined by telephone surveys of patients or their parents or guardians. The primary outcome was whether respondents had accurate knowledge of the throat culture result. Secondary outcomes included receipt of appropriate treatment instructions, need for another telephone call to the emergency department or primary-care provider to clarify the result or treatment instructions, satisfaction with the communication process, and preference to receive both positive and negative results or just positive results. RESULTS: Fifty-three percent of respondents did not have accurate knowledge of the throat culture result, 5% received inappropriate treatment instructions, 13% sought further clarification, 29% were dissatisfied with the communication process, and 85% preferred to receive both positive and negative results. Parents of patients with positive results were more likely to have accurate knowledge of the result (odds ratio 6.9, 95% confidence interval 1.4-65.7) and to be satisfied with the communication process. CONCLUSIONS: Passive communication of negative throat culture results to patients seen in the emergency department can be unreliable. Active communication of both positive and negative results may improve patient knowledge and satisfaction and ensure appropriate therapy, but in the absence of automated notification systems, would be resource intensive.

Adolescent↗

PubMed2003

Effects on breastfeeding of changes in maternity length-of-stay policy in a large health maintenance organization.

OBJECTIVE: The purpose of this study was to evaluate the effects on breastfeeding rates of a private-sector early discharge program and a subsequent government mandate guaranteeing 48 hours of hospital coverage. METHODS: Interrupted time-series analyses were conducted on retrospective data from the automated medical records of a large health maintenance organization in eastern Massachusetts. A population of 20 366 mother-infant pairs with normal vaginal deliveries between October 1990 and March 1998 was identified. This study period spanned the 2 interventions of interest: 1) the introduction of a new health maintenance organization protocol of 1 postpartum overnight hospitalization followed by a nurse home visit for normal vaginal deliveries, then 2) Massachusetts state minimum coverage legislation. Breastfeeding initiation and breastfeeding continuation among initiators (exclusive or with supplements) into the third month of life were determined through a text search of the first 90 days of infants' automated medical records. RESULTS: Both policies had dramatic impacts on length of stay (LOS); postpartum LOS <2 nights rose from 29% of pairs to 65% when the early discharge program was implemented, then fell to 15% after the state mandate. Breastfeeding initiation, however, rose gradually from 71% in the fourth quarter of 1990 to 82% in the first quarter of 1998, with no changes after the interventions. Continuation of breastfeeding among those who initiated remained constant at 73%. Younger maternal age, primiparity, low socioeconomic status, and nonwhite race all were found to be risk factors for lower rates of breastfeeding (either initiation or continuation), but there was no evidence of a decline in breastfeeding associated with shorter LOS among these vulnerable groups. CONCLUSIONS: Early postpartum discharge with outpatient breastfeeding support and a home visitor program has no adverse effects on initiation or continuation of breastfeeding.

Breast Feeding↗