The goal was to understand the concerns of adult health care providers regarding transition for young adult patients with childhood-onset conditions.
Internists from the 2000 American Board of ...Medical Specialties directory were selected randomly. A 2-stage mail survey was conducted from August 2001 to November 2004. In stage 1, providers stated their concerns regarding accepting care of transitioning young adult patients. In stage 2, providers ranked their concerns.
A total of 241 internal medicine providers were selected for participation. In stage 1, 134 of 241 physicians were eligible to participate, and 67 (50%) of 134 completed stage 1 surveys. In stage 2, 112 physicians were eligible, and 65 (58%) of 112 responded. Concerns elicited in stage 1 were clustered into 6 categories: patient maturity, patient psychosocial needs, family involvement, providers' medical competency, transition coordination, and health system issues. In stage 2, concerns rated highest were lack of training in congenital and childhood-onset conditions, lack of family involvement, difficulty meeting patients' psychosocial needs, needing a superspecialist, lack of adolescent training, facing disability/end-of-life issues during youth and early in the relationship, financial pressures limiting visit time, and families' high expectations.
Internists clearly stated the need for better training in congenital and childhood-onset conditions, training of more adult subspecialists, and continued family involvement. They also identified concerns about patients' psychosocial issues and maturity, as well as financial support to care for patients with complex conditions.
Background In 2010, Philadelphia enacted a menu-labeling law requiring full-service restaurant chains to list values for calories, sodium, fat, and carbohydrates for each item on all printed menus. ...Purpose The goal of the study was to determine whether purchase decisions at full-service restaurants varied depending on the presence of labeling. Methods In August 2011, this cross-sectional study collected 648 customer surveys and transaction receipts at seven restaurant outlets of one large full-service restaurant chain. Two outlets had menu labeling (case sites); five outlets did not (control sites). Outcomes included differences in calories and nutrients purchased and customers’ reported use of nutrition information when ordering. Data were analyzed in 2012. Results Mean age was 37 years; 60% were female; 50% were black/African-American and reported incomes ≥$60,000. Customers purchased food with approximately 1600 kcal (food plus beverage, 1800 kcal); 3200 mg sodium; and 35 g saturated fat. After adjustment for confounders, customers at labeled restaurants purchased food with 151 fewer kilocalories (95% CI=−270, −33); 224 mg less sodium (95% CI=−457, +8); and 3.7 g less saturated fat (95% CI=−7.4, −0.1) compared to customers at unlabeled restaurants (or 155 less kilocalories from food plus beverage, 95% CI=−284, −27). Those reporting that nutrition information affected their order purchased 400 fewer food calories, 370 mg less sodium, and 10 g less saturated fat. Conclusions Mandatory menu labeling was associated with better food choices among a segment of the public dining at full-service restaurants. Consumer education on the availability and use of nutrition information may extend the impact of menu labeling.
Epidemic increases in obesity negatively affect the health of US children, individually and at the population level. Although surveillance of childhood obesity at the local level is challenging, ...height and weight data routinely collected by school districts are valuable and often underused public health resources.
We analyzed data from the School District of Philadelphia for 4 school years (2006-2007 through 2009-2010) to assess the prevalence of and trends in obesity and severe obesity among public school children.
The prevalence of obesity decreased from 21.5% in 2006-2007 to 20.5% in 2009-2010, and the prevalence of severe obesity decreased from 8.5% to 7.9%. Both obesity and severe obesity were more common among students in grades 6 through 8 than among children in lower grades or among high school students. Hispanic boys and African American girls had the highest prevalence of obesity and severe obesity; Asian girls had much lower rates of obesity and severe obesity than any other group. Although obesity and severe obesity declined during the 4-year period in almost all demographic groups, the decreases were generally smaller in the groups with the highest prevalence, including high school students, Hispanic males, and African American females.
Although these data suggest that the epidemic of childhood obesity may have begun to recede in Philadelphia, unacceptably high rates of obesity and severe obesity continue to threaten the health and futures of many school children.
Child maltreatment is a public health problem with lifelong health consequences for survivors. Each year, >29 000 adolescents leave foster care via emancipation without achieving family permanency. ...The previous 30 years of research has revealed the significant physical and mental health consequences of child maltreatment, yet health and well-being have not been a priority for the child welfare system.
To describe the health outcomes of maltreated children and those in foster care and barriers to transitioning these adolescents to adult systems of care.
We reviewed the literature about pediatric and adult health outcomes for maltreated children, barriers to transition, and recent efforts to improve health and well-being for this population.
The health of child and adult survivors of child maltreatment is poor. Both physical and mental health problems are significant, and many maltreated children have special health care needs. Barriers to care include medical, child welfare, and social issues. Although children often have complex medical problems, they infrequently have a medical home, their complex health care needs are poorly understood by the child welfare system that is responsible for them, and they lack the family supports that most young adults require for success. Recent federal legislation requires states and local child welfare agencies to assess and improve health and well-being for foster children.
Few successful transition data are available for maltreated children and those in foster care, but opportunities for improvement have been highlighted by recent federal legislation.
We estimated the risk of HIV associated with sexually transmitted infection (STI) history during adolescence.
We retrospectively studied a cohort of adolescents (n = 75 273, born in 1985-1993) who ...participated in the Philadelphia High School STD Screening Program between 2003 and 2010. We matched the cohort to STI and HIV surveillance data sets and death certificates and performed Poisson regression to estimate the association between adolescent STI exposures and subsequent HIV diagnosis.
Compared with individuals reporting no STIs during adolescence, adolescents with STIs had an increased risk for subsequent HIV infection (incidence rate ratio IRR for adolescent girls = 2.6; 95% confidence interval CI = 1.5, 4.7; IRR for adolescent boys = 2.3; 95% CI = 1.7, 3.1). Risk increased with number of STIs. The risk of subsequent HIV infection was more than 3 times as high among those with multiple gonococcal infections during adolescence as among those with none.
Effective interventions that reduce adolescent STIs are needed to avert future STI and HIV acquisition. Focusing on adolescents with gonococcal infections or multiple STIs might have the greatest impact on future HIV risk.
Background: Many patients use emergency departments (EDs) for primary care. Previous studies have found that patient characteristics affect ED utilization. However, such studies have led to few ...policy changes. Objectives: We sought to determine whether Medicaid patients' ED use is associated with characteristics of their primary care practices. Research Design: This was a cohort study. Subjects: A total of 57,850 patients, assigned to 353 primary care practices affiliated with a Medicaid HMO, were included. Measures: Predictor variables were characteristics of primary care practices, which were measured by visiting each practice. The outcome variable was ED use adjusted for patient characteristics. Results: On average, patients made 0.80 ED visits/person/yr. Patients from practices with more than 12 evening hours/wk used the ED 20% less than patients from practices without evening hours. A higher ratio of the number of active patients per clinician-hour of practice time was associated with more ED use. When more Medicaid patients were in a practice, these patients used the ED more frequently. Other factors associated with ED use included equipment for the care of asthma and presence of nurse practitioners and physician assistants. Discussion: Modifiable characteristics of primary care practices were associated with ED use. Because the observational design of this study does not allow definitive conclusions about causality, future studies should include intervention trials to determine whether changing practice characteristics can reduce ED use. Conclusions: Improving primary care access and scope of services may reduce ED use. Focusing on systems issues rather than patient characteristics may be a more productive strategy to improve appropriate use of emergency medical care.
Collaboration among diverse stakeholders involved in the value transformation of health care requires consistent use of terminology. The objective of this study was to reach consensus definitions for ...the terms
value-based care
,
value-based payment
, and
population health
. A modified Delphi process was conducted from February 2017 to July 2017. An in-person panel meeting was followed by 3 rounds of surveys. Panelists anonymously rated individual components of definitions and full definitions on a 9-point Likert scale. Definitions were modified in an iterative process based on results of each survey round. Participants were a panel of 18 national leaders representing population health, health care delivery, academic medicine, payers, patient advocacy, and health care foundations. Main measures were survey ratings of definition components and definitions. At the conclusion of round 3, consensus was reached on the following definition for value-based payment, with 13 of 18 panelists (72.2%) assigning a high rating (7– 9) and 1 of 18 (5.6%) assigning a low rating (1–3): “Value-based payment aligns reimbursement with achievement of value-based care (health outcomes/cost) in a defined population with providers held accountable for achieving financial goals and health outcomes. Value-based payment encourages optimal care delivery, including coordination across healthcare disciplines and between the health care system and community resources, to improve health outcomes, for both individuals and populations.” The iterative process elucidated specific areas of agreement and disagreement for value-based care and population health but did not reach consensus. Policy makers cannot assume uniform interpretation of other concepts underlying health care reform efforts.
The purpose of this work was to explore the knowledge, attitudes, and beliefs of urban, minority adolescent girls about intention to use emergency contraception pills and to identify barriers to ...emergency contraception pill use.
We conducted an in-depth, semistructured interview study of healthy, urban-dwelling, English-speaking 15- to 19-year-old black adolescents seeking care in a children's hospital emergency department. Purposive sampling was used to recruit sexually active and nonsexually active adolescents and those with and without a history of pregnancy. Enrollment continued until saturation of key themes was achieved. Participants returned after their emergency department visit for a 1-hour interview. The interview consisted of semistructured questions based on the theory of planned behavior constructs: attitudes (including knowledge), subjective norms, and perceived behavioral control, as well as demographic data collection. Interviews were recorded and transcribed. Transcripts were coded by 2 members of the study team by using a modified grounded-theory method.
Thirty interviews were required for saturation. Mean participant age was 16.4 years; 53% reported being sexually active, and 17% reported a history of pregnancy. Specific knowledge gaps exist about emergency contraception pills, including misconceptions about the recommended time frame for taking the medication. Several major themes were noted for each of the constructs. Intention to use emergency contraception pills is affected by the conflicting attitudes that the emergency contraception pill works faster than birth control pills and that those who use emergency contraception pills are irresponsible; family and friends are important influences and have uninformed but generally supportive opinions; and adolescents have a perception of limited behavioral control because of their young age and concerns about confidentiality.
Urban, minority adolescent girls have misconceptions about emergency contraception pills, are affected by the opinions of those close to them, and express concern about specific barriers. These findings can inform specific interventions aimed at addressing the barriers to emergency contraception pill use that are of most importance to this population of young women.
To elucidate which components of peer norms influence the process of sexual initiation for young adolescents. Design. Prospective cohort study. Setting. Fourteen elementary and middle schools in an ...urban public school district. Participants. The 1389 sixth-grade students who completed the questionnaire at the beginning (time 1) and at the end (time 2) of the school year comprise the study sample. Mean age at time 1 was 11.7 years.
Of students entering the sixth grade, 30% (n = 416) reported having already initiated sexual intercourse, 5% (n = 74) reported initiating sexual intercourse during the sixth-grade school year (initiated group), and 63% (n = 873) reported not having initiated sexual intercourse by the end of the sixth-grade school year (never group). Demographic comparisons revealed that students in the initiated group were significantly more likely than students in the never group to be older (11.9 years vs 11.6 years), male (58% vs 37%), African-American (70% vs 51%), attending a poorer school (87% vs 85%), and living in an area with a high proportion of single-parent families (45% vs 41%). Self-reports and reports of peers' participation in nonsexual risk behaviors were more common for students in the initiated group. Students in the initiated group were more likely than students in the never group to perceive: 1) a high prevalence of sexual initiation among peers; 2) social gains associated with early sexual intercourse; and 3) younger age of peers' sexual initiation. Students in the never group were more likely to believe that sexually-experienced 12-year-old boys would be negatively stigmatized compared with students in the initiated group. Three predictive models were developed to test the relationship between peer norms and the process of initiation. These models demonstrate that the strongest predictor of sexual initiation in sixth grade is having high intention to do so at the beginning of sixth grade. The strongest predictor of high intention is belief that most friends have already had sexual intercourse. Perceptions of social gain and stigma for sexually-experienced 12-year-old boys act independently of intention to decrease risk of early sexual initiation.
Early sexual intercourse is not an unplanned experience for many teens. Decisions about initiation are strongly bound to social context with peers playing an important role in creating a sense of normative behavior. Specific components of peer norms impact the process of sexual initiation in both positive and negative ways. Interventions aimed at delaying the onset of sexual initiation need to focus on cohort norms as well as on an individual's perceptions and behaviors.
Objective To determine availability of and test whether on-site mental health providers (MHP) is associated with greater odds of reported mental health consultation and referral among primary care ...pediatricians. Methods Pediatricians were identified from the American Medical Association's 2004 physician directory and stratified by region. Six hundred were randomly selected to receive a mail survey. The main independent variable was on-site MHP. The dependent variable was reported frequency (4-point rating) of mental health consultation and referral. Estimates were weighted to account for survey design and nonresponse. Results Overall response rate was 51%. The majority of respondents were male (56%), age ≥46 years old (59%), white (68%), and practicing in suburban locations (52%). Approximately half reported consultation with (44%) or referral to (51%) MHP always or often, but a few (17%) reported on-site MHP. After adjustment for demographic and practice characteristics, pediatricians with on-site MHP were more likely to consult (odds ratio OR 6.58, 95% confidence interval 95% CI 3.55- 12.18) or refer (OR 4.25, 95% CI 2.19–8.22) than those without on-site MHP. Among those without on-site MHP, pediatricians with greater practice burden were less likely to consult (OR 0.69, 95% CI 0.48–0.99) or refer (OR 0.75, 95% CI 0.54–1.04) than those with lesser burden. Conclusions Most pediatricians in the United States experienced practice-related burdens that limit mental health collaboration, but those with co-located services reported a greater likelihood of consultation and referral. Policy changes that encourage co-location of mental health services and limit practice burden may facilitate mental health consultation and referral.
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