Dr. Wang is the Director of Center for Policy, Outcomes and Prevention. Prior to coming to Stanford in 2011, he was a faculty member at Boston University Schools of Medicine and Public Health. His other professional experiences include working as a management consultant with McKinsey and Company and serving as the project manager for Taiwan's National Health Insurance Reform Task-force. His current interests include: 1) COVID-19 related policies; 2) developing tools for assessing and improving the value of healthcare; 3) facilitating the use of mobile technology in improving quality of care; 4) supporting competency-based medical education curriculum, and 5) engaging in healthcare delivery and payment reforms.
Professor - University Medical Line, Pediatrics - General Pediatrics
Professor - University Medical Line, Health Policy
Faculty Affiliate, Institute for Human-Centered Artificial Intelligence (HAI)
Director, Center for Policy, Outcomes and Prevention (2014 - Present)
Co-director, PCHA-UHA Research and Learning Collaborative (2016 - Present)
Co-Chair, Mobile Health and Other Technologies, Stanford Center for Population Health Sciences (2015 - Present)
Co-director, Academic General Pediatrics Fellowship (2012 - Present)
Honors & Awards
Young Clinician Research Award for Transformative Innovation in Healthcare Research, Center for Integration of Medicine and Innovative Technology, Boston Consortium Hospitals (2010)
NIH Director's New Innovator Award, National Institutes of Health (2011)
Etteldorf Distinguished Visiting Professor, University of Tennessee/ St Jude Chidren’s Research Hospital (2013)
Fellowship: UCLA Health Sciences (2003) CA
Board Certification: American Board of Pediatrics, Pediatrics (2002)
Residency: UCSF Pediatric Residency (1999) CA
Medical Education: Harvard Medical School (1996) MA
Undergraduate, MIT (1992)
MD, Harvard Medical School (1996)
mini-MBA, McKinsey and Company, Management Consulting (1999)
Fellowship, Robert Wood Johnson Clinical Scholars Program, Health Services Research (2003)
PhD, RAND, Health Policy (2006)
Fellowship, National Research Service Award, Health Services Research (2006)
Mobile Strategy to Reduce the Risk of Recurrent Preterm Birth
Preterm births are defined as delivery prior to 37 weeks gestation and account for 35% of infant deaths in the first year of life. Early preterm birth are deliveries prior to 32 weeks gestation and account for more than 70% of neonatal deaths and 36.1% of overall infant mortality. Women who have delivered a preterm infant and who have a short pregnancy interval (time between giving birth and subsequent conception) have an increased risk of preterm birth in subsequent pregnancies. The investigators hope to understand if a mobile health strategy can be used to reduce spontaneous preterm births via improved patient engagement, care coordination, and adherence to recommended care vs a traditional paper-based health strategy.
Independent Studies (7)
- Directed Reading in Health Research and Policy
HRP 299 (Aut, Win, Spr, Sum)
- Directed Reading in Pediatrics
PEDS 299 (Aut, Win, Spr, Sum)
- Early Clinical Experience
PEDS 280 (Aut, Win, Spr, Sum)
- Graduate Research
HRP 399 (Aut, Win, Spr, Sum)
- Graduate Research
PEDS 399 (Aut, Win, Spr, Sum)
- Medical Scholars Research
PEDS 370 (Aut, Win, Spr, Sum)
- Undergraduate Directed Reading/Research
PEDS 199 (Aut, Win, Spr, Sum)
- Directed Reading in Health Research and Policy
- Healthcare Disparities in Gastroesophageal Reflux Disease for Hispanic and Latino Americans: A Solution-Oriented Approach for Improvement. The American journal of gastroenterology 2022
Childhood Handwashing Habit Formation and Later COVID-19 Preventive Practices: A Cohort Study.
This study identified developmental patterns of handwashing habit formation during childhood and examined their associations with later COVID-19 preventive practices.We used data from the Taiwan Birth Cohort Study, which included 11 254 adolescents with complete data on childhood handwashing behavior and age-15 COVID-19 survey items. Bias-adjusted 3-step latent class analysis was used to test study hypotheses.The rates of handwashing and mask-wearing during the pandemic were 63.8% and 93.8%, respectively. Five distinct patterns of handwashing habit formation were identified: early formation (14.89%), delayed formation (17.73%), gradual formation (42.98%), inconsistent formation (9.78%), and nonformation (14.62%). Compared with adolescents with an early formation pattern of handwashing habits, those with other patterns exhibited lower odds ratios (ORs) of handwashing during COVID-19; these ORs were 0.67 (95% confidence interval [CI], 0.49-0.85), 0.60 (95% CI, 0.44-0.77), 0.29 (95% CI, 0.08-0.49), and 0.21 (95% CI, 0.01-0.40) for those with delayed formation, gradual formation, inconsistent formation, and nonformation patterns, respectively. Moreover, relative to that of adolescents with the early formation pattern, mask-wearing was less common among adolescents with gradual formation, inconsistent formation, and nonformation patterns, with ORs of 0.54 (95% CI, 0.16-0.92), 0.50 (95% CI, 0.03-0.96), and 0.26 (95% CI, 0.00-0.65), respectively.The early formation of hygienic habits is associated with higher adherence to pandemic preventive practices among adolescents. Our findings suggest that interventions to promote hygienic behaviors can start as early as age 3 through the introduction of healthy habits such as handwashing.
View details for DOI 10.1016/j.acap.2022.05.014
View details for PubMedID 35863735
View details for PubMedCentralID PMC9290330
Development and Validation of Age-Specific Resilience Instruments for Early Childhood Assessment: A Taiwan Birth Cohort Study.
We sought to develop and validate age-specific instruments for measuring early childhood resilience at ages 3, 5 and 8 in the Taiwan Birth Cohort Study, a national longitudinal study.Using data from 18,553 mother-infant pairs, we conducted exploratory factor analysis (EFA) on a simple random half of our sample. We then used the remaining half of these data for confirmatory factor analysis (CFA) to further assess the fit of three CFA models (i.e., first-order, second-order, and bifactor). Psychometric properties, distributions, and inter-item and inter-factor correlations of each instrument were also evaluated.EFA and CFA showed that the bifactor model of resilience (which included a general resilience factor and five specific factors) had the best fit for all three resilience scales, with 19 items at year 3, 18 items at year 5, and 19 items at year 8. All three resilience scales showed good psychometric properties, including construct validity, internal consistency, and normal distributions. For predictive validity, we found that in the face of adversity (measured by the High Risk Family Score), individuals with high resilience scores at age 3 had better general health scores at ages 3, 5, and 8 compared to those with low resilience scores.We describe the development and validation of age-appropriate survey instruments to assess resilience in young children at the population level. These instruments can be used to better understand how resilience can impact child health over time, and to identify key factors that can foster resilience.
View details for DOI 10.1016/j.acap.2022.06.002
View details for PubMedID 35691535
Parents' Experiences and Needs Regarding Infant Sickle Cell Trait Results.
Sickle cell trait (SCT) has reproductive implications and can rarely cause health problems. SCT counseling improves parent knowledge but is infrequently received by children with SCT compared with children with cystic fibrosis carrier status. There are no national guidelines on SCT disclosure timing, frequency, or counseling content. Parents' experiences with SCT disclosure and counseling are poorly understood but could inform the development of guidelines. We explored parents' experiences with and desires for SCT disclosure and counseling for their infants with SCT identified via newborn screening.Parents of infants 2 to 12 months old with SCT were recruited through a state newborn screening program for semistructured interviews to explore their experiences with and desires for SCT disclosure and counseling. Inductive thematic analysis was conducted.Sixteen interviews were completed from January to August 2020. Most parents reported that SCT disclosure occurred soon after birth, in person, and by the child's physician. Five themes were identified: parent knowledge before child's SCT disclosure, family planning, the dynamics of SCT disclosure and counseling, emotions and actions after SCT disclosure, and parent desires for the SCT disclosure and counseling process. Two primary parent desires were revealed. Parents want more information about SCT, particularly rare symptomatology, and they want SCT counseling repeated once the child approaches adolescence.Parents report receiving their child's SCT diagnosis in the early newborn period from their child's doctor but indicate they receive incomplete information. Opportunities exist in primary care pediatrics to better align SCT disclosure timing and counseling content with parent desires.
View details for DOI 10.1542/peds.2021-053454
View details for PubMedID 35441211
Feasibility of Specimen Self-collection in Young Children Undergoing SARS-CoV-2 Surveillance for In-Person Learning.
JAMA network open
2022; 5 (2): e2148988
There is an urgent need to assess the feasibility of COVID-19 surveillance measures in educational settings.To assess whether young children can feasibly self-collect SARS-CoV-2 samples for surveillance testing over the course of an academic year.This prospective pilot cohort study was conducted from September 10, 2020, to June 10, 2021, at a K-8 school in San Mateo County, California. The research consisted of quantitative data collection efforts: (1) demographic data collected, (2) student sample self-collection error rates, and (3) student sample self-collection time durations. Students were enrolled in a hybrid learning model, a teaching model in which students were taught in person and online, with students having the option to attend virtually as needed. Data were collected under waiver of consent from students participating in weekly SARS-CoV-2 testing.Errors over time for self-collection of nasal swabs such as contaminated swabs and inadequate or shallow swabbing; time taken for sample collection.Of 296 participants, 148 (50.0%) were boys and 148 (50.0%) were girls. A total of 87 participants (29.2%) identified as Asian; 2 (0.6%), Black or African American; 13 (4.4%), Hispanic/Latinx; 103 (34.6%), non-Hispanic White; 87 (29.2%), multiracial; and 6 (2.0%), other. The median school grade was fourth grade. From September 2020 to March 2021, a total of 4203 samples were obtained from 221 students on a weekly basis, while data on error rates were collected. Errors occurred in 2.7% (n = 107; 95% CI, 2.2%-3.2%) of student encounters, with the highest rate occurring on the first day of testing (20 [10.2%]). There was an overall decrease in error rates over time. From April to June 2021, a total of 2021 samples were obtained from 296 students on a weekly basis while data on encounter lengths were collected. Between April and June 2021, 193 encounters were timed. The mean duration of each encounter was 70 seconds (95% CI, 66.4-73.7 seconds).Mastery of self-collected lower nasal swabs is possible for children 5 years and older. Testing duration can be condensed once students gain proficiency in testing procedures. Scalability for larger schools is possible if consideration is given to the resource-intensive nature of the testing and the setting's weather patterns.
View details for DOI 10.1001/jamanetworkopen.2021.48988
View details for PubMedID 35175340
- Contact-tracing app curbs the spread of COVID NATURE 2021: 336-337
PretermConnect: Leveraging mobile technology to mitigate social disadvantage in the NICU and beyond.
Seminars in perinatology
Preterm birth (PTB) - delivery prior to 37-weeks gestation - disproportionately affects low-income and minority populations and leads to substantial infant morbidity and mortality. The time following a PTB represents an optimal window for targeted interventions that encourage mothers to prioritize their own health and that of their babies. Healthcare teams can leverage digital strategies to address maternal and infant needs in this postpartum period, both in the neonatal intensive care unit and beyond. We therefore developed PretermConnect, a mobile app designed to educate, engage, and empower women at risk for PTB. This article describes the participant-centered design approach of PretermConnect, with preliminary findings from focus groups and co-design sessions in different community settings and suggested future directions for mobile technologies in population health. Apps such as PretermConnect can mitigate social disadvantage by serving as remote monitoring tools, providing social support, preventing recurrent PTB and lowering infant mortality rates.
View details for DOI 10.1016/j.semperi.2021.151413
View details for PubMedID 33888330
- Considerations and a call to action for the use of noncontact forehead infrared handheld thermometers during the COVID-19 pandemic. Journal of global health 2021; 11: 03023
Prospective Pilot Study Evaluating SARS-CoV-2 Transmission-Limiting Measures in an On-Site School.
The purpose of our study is to evaluate the feasibility and reliability of a comprehensive set of preventive measures in limiting secondary transmission of COVID-19 in schools.A prospective cohort study was conducted to evaluate SARS-CoV-2 transmission in an independent K-8 school in San Mateo County, California. The research was conducted between September 14, 2020 through March 22, 2021 and consisted of: (1) demographic and epidemiological questionnaires; (2) daily symptom reporting; (3) weekly RT-PCR testing; and (4) periodic on-site qualitative observations.180 (79%) students and 63 (74%) on-site staff/contractors were enrolled. Participants reported symptoms in 144 (<1%) daily surveys of the 19,409 collected. Among those who reported symptoms and exposures, none tested positive during the 22-week study period. Of all participants, a total of 6 tested positive for SARS-CoV-2 at least once by RT-PCR; all were asymptomatic at time of testing. No in-school transmission occurred. Mask adherence was high among all grades, and incidents of improper mask use mostly occurred during non-instruction time. Physical distancing was well-enforced during class time and snack breaks, although adherence during non-instruction time waned as the school year progressed.Our comprehensive, prospective study following COVID-19 transmission over 22 weeks in a K-8 school demonstrates that: (1) surveillance testing is important for detecting asymptomatic infections in schools; (2) monitoring symptoms may not be necessary and/or sufficient for COVID-19; and (3) younger children can adhere to key mitigation measures (e.g., masking) which have the potential to limit transmission.
View details for DOI 10.1016/j.acap.2021.11.019
View details for PubMedID 34896273
Influence of health beliefs on adherence to COVID-19 preventative practices: an online international study via social media.
Journal of medical Internet research
Health behavior is influenced by culture and social context. However, there are limited data evaluating the scope of these influences on COVID-19 response.This study aimed to compare handwashing and social distancing practices in different countries and evaluate practice predictors using the health belief model.From April 11th to May 1st, 2020, we conducted an online, cross-sectional survey disseminated internationally via social media. Participants were adults aged 18 years or older from four different countries: The United States, Mexico, Hong Kong (China), and Taiwan. Primary outcomes were self-reported handwashing and social distancing practices during COVID-19. Predictors included constructs of the health belief model, including perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action. Associations of these constructs with behavioral outcomes were assessed by multivariable logistic regression.We analyzed a total of 71,851 participants, with 3,070 from the United States, 3,946 from Mexico, 1,201 from Hong Kong (China), and 63,634 from Taiwan. Of these countries, respondents from the U.S. adhered to the most social distancing practices (chi-squared test = 2169.7, P<.001), while respondents from Taiwan performed the most handwashing (chi-squared test = 309.8, P<.001). Multivariable logistic regression analyses indicated that self-efficacy was a positive predictor for handwashing (OR [95% CI]; U.S. = 1.58 [1.21-2.07]; Mexico = 1.54 [1.21-1.96]; Hong Kong = 2.48 [1.80-3.44]; Taiwan = 2.30 [2.21-2.39]) and social distancing practices (U.S. = 1.77 [1.24-2.49]; Mexico = 1.77 [1.40-2.25]; Hong Kong = 3.25 [2.32-4.62]; Taiwan = 2.58 [2.47-2.68]) in all countries. Handwashing was positively associated with perceived susceptibility in Mexico, Hong Kong, and Taiwan, while social distancing was positively associated with perceived severity in the U.S., Mexico, and Taiwan.Social media recruitment strategies can be used to reach a large audience during a pandemic. Self-efficacy was the strongest predictor for handwashing and social distancing. Policies that address relevant health beliefs can facilitate adoption of necessary actions for preventing COVID-19. Our findings may be explained by the timing of government policies, the number of cases reported in each country, individual beliefs, and cultural context.
View details for DOI 10.2196/23720
View details for PubMedID 33571103
The early detection of immunoglobulins via optical-based lateral flow immunoassay platform in COVID-19 pandemic.
2021; 16 (7): e0254486
The coronavirus disease (COVID-19) is the global public health challenge currently persisting at a grand scale. A method that meets the rapid quantitative detection of antibodies to assess the body's immune response from natural COVID-19 illness or vaccines' effects is urgently needed. In the present study, an attempt was made to integrate a newly designed spectrometer to the COVID-19 test strip procedure; this augmentation provides the quantitative capacity to a lateral flow immunoassay (LFIA). Optical interpretation of results by quantitative α index, rather than visual qualification, can be done quickly, in 5-10 minutes. The developed product was compared with several other serological IgM/IgG antibody reagents on the market by recruiting 111 participants suspected of having COVID-19 infection from March to May 2020 in a hospital. Taking RT-PCR as the diagnostic gold standard, the quantitative spectral LIFA platform could correctly detect all 12 COVID-19 patients. Concerning RT-PCR negative patients, all three antibody testing methods found positive cases. The optical-based platform exhibited the ability of early detection of immunoglobulins of RT-PCR negative patients. There was an apparent trend that elevation of IgM levels in the acute phase of infection; then IgG levels rose later. It exhibited the risk of a false-negative diagnosis of RT-PCR in COVID-19 testing. The significant detection ability of this new optical-based platform demonstrated clinical potential.
View details for DOI 10.1371/journal.pone.0254486
View details for PubMedID 34283860
- Operational Considerations on the American Academy of Pediatrics Guidance for K-12 School Reentry. JAMA pediatrics 2020
An impact-oriented approach to epidemiological modeling
J Gen Intern Med
View details for DOI 10.1007/s11606-020-06230-1
- The Power of Telehealth Has Been Unleashed. Pediatric clinics of North America 2020; 67 (4): xvii-xviii
The Opportunities for Telehealth in Pediatric Practice and Public Health.
Pediatric clinics of North America
2020; 67 (4): 603–11
Telehealth can be delivered asynchronously, synchronously, or through remote patient monitoring. The cost of telehealth, patient use, and effectiveness vary by the technology deployed and by specialty. Telehealth use requires patient and provider adaptability. The improvement of telehealth is restricted by state and federal policies as well as privacy and security concerns. Current telehealth literature provides more consistent evidence of benefits for communication and counseling, and from remote patient monitoring of chronic conditions. However, the benefits and costs of telehealth programs are highly dependent on the technology used, the medical condition studied, and the health care context.
View details for DOI 10.1016/j.pcl.2020.03.001
View details for PubMedID 32650856
- An Impact-Oriented Approach to Epidemiological Modeling. Journal of general internal medicine 2020
Design, Adoption, Implementation, Scalability, and Sustainability of Telehealth Programs.
Pediatric clinics of North America
2020; 67 (4): 675–82
Telehealth and telemedicine services can be a solution for improving accessibility and reducing the cost of health care. Challenges remain in designing, implementing, and sustainably scaling telehealth solutions. Research is lacking on the health impacts and cost-effectiveness of telehealth; more data are needed in the evaluation of telehealth programs, adjusting for potential participant bias and extending the time frame of evaluating impact. In addition, rethinking and addressing the economic incentives and payment for telehealth services, as well as the medical-legal framework for provider competition across geographic regions (and jurisdictions), are needed for greater adoption of telehealth services.
View details for DOI 10.1016/j.pcl.2020.04.011
View details for PubMedID 32650866
Workforce Shortage for Retinopathy of Prematurity Care and Emerging Role of Telehealth and Artificial Intelligence.
Pediatric clinics of North America
2020; 67 (4): 725–33
Retinopathy of prematurity (ROP) is the leading cause of childhood blindness in very-low-birthweight and very preterm infants in the United States. With improved survival of smaller babies, more infants are at risk for ROP, yet there is an increasing shortage of providers to screen and treat ROP. Through a literature review of new and emerging technologies, screening criteria, and analysis of a national survey of pediatric ophthalmologists and retinal specialists, the authors found the shortage of ophthalmology workforce for ROP a serious and growing concern. When used appropriately, emerging technologies have the potential to mitigate gaps in the ROP workforce.
View details for DOI 10.1016/j.pcl.2020.04.012
View details for PubMedID 32650869
Connected Pediatric Primary Care for At-Risk Children.
Pediatric clinics of North America
2020; 67 (4): 665–73
Age-specific recommendations contain extensive information that cannot be presented adequately in pediatric preventative care visits. Parental guidance is important, especially for children with social and/or medical risks, but existing evidence-based interventions tend to be resource intensive and difficult to scale. Because the use of mobile technology is now prevalent even among low-income families, the benefits of utilizing the Internet and mobile apps to improve parental guidance are active areas of research. Analyses of patient-generated data from mobile apps may help identify effective ways to use social influences, social learning, and social networks for improving population health.
View details for DOI 10.1016/j.pcl.2020.04.010
View details for PubMedID 32650865
Child Health and Telehealth in Global, Underresourced Settings.
Pediatric clinics of North America
2020; 67 (4): 773–81
Telehealth has improved delivery of health care worldwide by improving access to and the quality of health care and by improving the global shortage of health professionals through collaboration and training. Although many telehealth efforts have been reported in adult health care settings, it is important to examine telehealth efforts in the pediatric setting. Children who are most commonly ill and malnourished are often those of underserved populations of the developing world. This article examines current uses of pediatric telehealth in a global setting and discusses key approaches to how telehealth may become successfully integrated and scaled in those settings.
View details for DOI 10.1016/j.pcl.2020.04.014
View details for PubMedID 32650872
- How Community and Unity Can Help Americans Survive. Journal of general internal medicine 2020
Video consultations in primary and specialist care during the covid-19 pandemic and beyond
British Medical Journal
View details for DOI 10.1136/bmj.m3945
Managing medication supply chain during the COVID-19 pandemic: key lessons from Taiwan
View details for DOI 10.1016/j.japh.2020.08.029
How to Safely Reopen Colleges and Universities During COVID-19: Experiences from Taiwan
Annals of Internal Medicine
View details for DOI 10.7326/M20-2927
How to Prevent and Manage Hospital-Based Infections During Coronavirus Outbreaks: Five Lessons from Taiwan
Journal of Hospital Medicine
View details for DOI 10.12788/jhm.3452
Healthy Hearts via Live Video Conferencing: An Exercise and Diet Intervention in Pediatric Heart Transplant Patients
View details for DOI 10.1161/JAHA.119.013816
Ethics and Governance for Digital Disease Surveillance
2020; 368 (6494): 951-954
View details for DOI 10.1126/science.abb9045
Primary Care Providers in California and Florida Report Low Confidence in Providing Type 1 Diabetes Care.
Clinical diabetes : a publication of the American Diabetes Association
2020; 38 (2): 159–65
People with type 1 diabetes may receive a significant portion of their care from primary care providers (PCPs). To understand the involvement of PCPs in delivering type 1 diabetes care, we performed surveys in California and Florida, two of the most populous and diverse states in the United States. PCPs fill insulin prescriptions but report low confidence in providing type 1 diabetes care and difficulty accessing specialty referrals to endocrinologists.
View details for DOI 10.2337/cd19-0060
View details for PubMedID 32327888
View details for PubMedCentralID PMC7164993
- Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing. JAMA 2020
Associations Between Body Fat, Muscle Mass, and Nonalcoholic Fatty Liver Disease: A Population-Based Study.
2019; 3 (8): 1061–72
Nonalcoholic fatty liver disease (NAFLD) is one of the most common forms of liver disease worldwide and has emerged as a significant public health concern in China. A better understanding of the etiology of NAFLD can inform effective management strategies for this disease. We examined factors associated with NAFLD in two districts of Hangzhou, China, focusing on the relationship of regional body fat distribution, muscle mass, and NAFLD. We used baseline data to carry out a cross-sectional analysis among 3,589 participants from the Wellness Living Laboratory (WELL) China study, a longitudinal population-based study that aims to investigate and promote well-being among the Chinese population. NAFLD was defined using the widely validated fatty liver index (FLI). Multivariate logistic regressions were performed to assess independent associations between NAFLD and metabolic risk factors (e.g., insulin resistance) and dual x-ray absorptiometry (DXA)-derived measures (e.g., android fat ratio [AFR] and skeletal muscle index [SMI]). Of the 3,589 participants, 476 (13.3%) were classified as having FLI-defined NAFLD (FLI ≥60). Among those, 58.0% were men. According to our analysis, AFR (odds ratio [OR], 10.0; 95% confidence interval [CI], 5.8-18.5), insulin resistance (OR, 4.0; 95% CI, 3.0-5.3), high alanine aminotransferase levels (OR, 7.6; 95% CI, 5.8-10.0), smoking (OR, 2.0; 95% CI, 1.4-3.0), and male sex (OR, 2.9; 95% CI, 2.0-4.2) were positively associated with NAFLD risk, while SMI (OR, 0.1; 95% CI, 0.07-0.13) was inversely associated with NAFLD risk. Conclusion: In addition to known metabolic risk factors, DXA-derived AFR and SMI may provide additional insights to the understanding of NAFLD. Interventions that aim to decrease AFR and increase SMI may be important to reduce the burden of NAFLD in this population.
View details for DOI 10.1002/hep4.1392
View details for PubMedID 31388627
Keys to academic success for under-represented minority young investigators: recommendations from the Research in Academic Pediatrics Initiative on Diversity (RAPID) National Advisory Committee.
International journal for equity in health
2019; 18 (1): 93
BACKGROUND: Although Latinos, African-Americans, and American Indians/Alaska Natives comprise 34% of Americans, these under-represented minorities (URMs) account for only 7% of US medical-school faculty. Even when URMs become faculty, they face many substantial challenges to success. Little has been published, however, on keys to academic success for URM young faculty investigators.METHODS: The Research in Academic Pediatrics Initiative on Diversity (RAPID) goal is to enhance the professional advancement of URM junior faculty pursuing research careers in general academic pediatrics. One important RAPID component is the annual mentoring/career-development conference, which targets URM residents, fellows, and junior faculty, and has included 62 URM participants since its 2013 inception. A conference highlight is the panel discussion on keys to academic success for URM young investigators, conducted by the RAPID National Advisory Committee, a diverse group of leading senior researchers. The article aim was to provide a guide to academic success for URM young investigators using the 2018 RAPID Conference panel discussion. A modified Delphi technique was used to provide a systematic approach to obtaining answers to six key questions using an expert panel: the single most important key to success for URM young investigators; ensuring optimal mentorship; how to respond when patients/families say, "I don't want you to see my child because you are ____"; best strategies for maximizing funding success; how to balance serving on time-consuming committees with enough time to advance research/career objectives; and the single thing you wish someone had told you which would have substantially enhanced your success early on.RESULTS/CONCLUSIONS: This is the first published practical guide on keys to academic success for URM young investigators. Identified keys to success included having multiple mentors, writing prolifically, being tenaciously persistent, having mentors who are invested in you, dealing with families who do not want you to care for their child because of your race/ethnicity by seeking to understand the reasons and debriefing with colleagues, seeking non-traditional funding streams, balancing committee work with having enough time to advance one's research and career by using these opportunities to generate scholarly products, and asking for all needed resources when negotiating for new jobs.
View details for DOI 10.1186/s12939-019-0995-1
View details for PubMedID 31215424
Telehealth requires expansion of physicians' communication competencies training
2019; 41 (6): 714–15
We are in the midst of transformation of health systems where remote consulting (via video, telephone, email, and mobile messaging) is soon to become the dominant mode of consultation. Most of the literature on telehealth omits mentioning the need for telehealth communication competencies. Yet evidence base has been growing about how critical this training is - whether from clinical communication research or litigation claims analysis. In this article, we are calling for an urgent expansion of communication skills curricula to encompass these new telehealth domains from medical schools, specialty trainings to CMEs.
View details for DOI 10.1080/0142159X.2018.1481284
View details for Web of Science ID 000483250200019
View details for PubMedID 29944031
- Healthy hearts in pediatric heart transplant patients with an exercise and diet intervention via live video conferencing-Design and rationale PEDIATRIC TRANSPLANTATION 2019; 23 (1)
Impact of a Mobile App-Based Health Coaching and Behavior Change Program on Participant Engagement and Weight Status of Overweight and Obese Children: Retrospective Cohort Study
JMIR MHEALTH AND UHEALTH
2019; 7 (10): e14458
View details for DOI 10.2196/14458
“Following Through”: Addressing the Racial Inequality for Preterm Infants and Their Families
View details for DOI 10.1038/s41390-019-0602-6
Hospitalization Patterns for Inpatient Surgery and Procedures in California:2000 – 2016
Anesthesia and Analgesia
View details for DOI 10.1213/ANE.0000000000004552
Variation in Primary Care Management of Attention-Deficit/Hyperactivity Disorder by Primary Care Providers
View details for DOI 10.1016/j.acap.2019.11.016
Digital health at fifteen: more human (more needed).
2019; 17 (1): 62
There is growing appreciation that the success of digital health - whether digital tools, digital interventions or technology-based change strategies - is linked to the extent to which human factors are considered throughout design, development and implementation. A shift in focus to individuals as users and consumers of digital health highlights the capacity of the field to respond to secular developments, such as the adoption of person-centred care and consumer health technologies. We argue that this project is not only incomplete, but is fundamentally 'uncompletable' in the face of a highly dynamic landscape of both technological and human challenges. These challenges include the effects of consumerist, technology-supported care on care delivery, the rapid growth of digital users in low-income and middle-income countries and the impacts of machine learning. Digital health research will create most value by retaining a clear focus on the role of human factors in maximising health benefit, by helping health systems to anticipate and understand the person-centred effects of technology changes and by advocating strongly for the autonomy, rights and safety of consumers.
View details for PubMedID 30879466
View details for PubMedCentralID PMC6421699
- Theory-Based Health Behavior Interventions for Pediatric Chronic Disease Management A Systeindtic Review JAMA PEDIATRICS 2018; 172 (12): 1177–86
- Parents' Knowledge and Education of Retinopathy of Prematurity in Four California Neonatal Intensive Care Units AMERICAN JOURNAL OF OPHTHALMOLOGY 2018; 191: 7–13
Specialized Care without the Subspecialist: A Value Opportunity for Secondary Care.
Children (Basel, Switzerland)
2018; 5 (6)
An underutilized value strategy that may reduce unnecessary subspecialty involvement in pediatric healthcare targets the high-quality care of children with common chronic conditions such as obesity, asthma, or attention deficit hyperactivity disorder within primary care settings. In this commentary, we propose that "secondary care", defined as specialized visits delivered by primary care providers, a general pediatrician, or other primary care providers, can obtain the knowledge, skill and, over time, the experience to manage one or more of these common chronic conditions by creating clinical time and space to provide condition-focused care. This care model promotes familiarity, comfort, proximity to home, and leverages the provider's expertise and connections with community-based resources. Evidence is provided to prove that, with multi-disciplinary and subspecialist support, this model of care can improve the quality, decrease the costs, and improve the provider's satisfaction with care.
View details for PubMedID 29866987
View details for PubMedCentralID PMC6025251
In-Person Interpreter Use and Hospital Length of Stay among Infants with Low Birth Weight
International Journal of Environmental Research and Public Health
2018; 15 (8)
To ensure timely appropriate care for low-birth-weight (LBW) infants, healthcare providers must communicate effectively with parents, even when language barriers exist. We sought to evaluate whether non-English primary language (NEPL) and professional in-person interpreter use were associated with differential hospital length of stay for LBW infants, who may incur high healthcare costs. We analyzed data for 2047 infants born between 1 January 2008 and 30 April 2013 with weight <2500 g at one hospital with high NEPL prevalence. We evaluated relationships of NEPL and in-person interpreter use on length of stay, adjusting for medical severity. Overall, 396 (19%) had NEPL parents. Fifty-three percent of NEPL parents had documented interpreter use. Length of stay ranged from 1 to 195 days (median 11). Infants of NEPL parents with no interpreter use had a 49% shorter length of stay (adjusted incidence rate ratio (IRR) 0.51, 95% confidence interval (CI) 0.43⁻0.61) compared to English-speakers. Infants of parents with NEPL and low interpreter use (<25% of hospital days) had a 26% longer length of stay (adjusted IRR 1.26, 95% CI 1.06⁻1.51). NEPL and high interpreter use (>25% of hospital days) showed a trend for an even longer length of stay. Unmeasured clinical and social/cultural factors may contribute to differences in length of stay.
View details for DOI 10.3390/ijerph15081570
View details for PubMedCentralID PMC6121500
- Managed Care, Hospital Characteristics, and Inpatient Utilization for Sickle Cell Disease Patients. Journal of general internal medicine 2018; 33 (12): 2053–55
Outcomes of Follow-up Visits After Bronchiolitis Hospitalizations.
View details for PubMedID 29379947
- Association of a Bundled-Payment Program With Cost and Outcomes in Full-Cycle Breast Cancer Care JAMA ONCOLOGY 2017; 3 (3): 327-334
Using a Medical Intranet of Things System to Prevent Bed Falls in an Acute Care Hospital: A Pilot Study.
Journal of medical Internet research
2017; 19 (5): e150
Hospitalized patients in the United States experience falls at a rate of 2.6 to 17.1 per 1000 patient-days, with the majority occurring when a patient is moving to, from, and around the bed. Each fall with injury costs an average of US $14,000.The aim was to conduct a technology evaluation, including feasibility, usability, and user experience, of a medical sensor-based Intranet of things (IoT) system in facilitating nursing response to bed exits in an acute care hospital.Patients 18 years and older with a Morse fall score of 45 or greater were recruited from a 35-bed medical-surgical ward in a 317-bed Massachusetts teaching hospital. Eligible patients were recruited between August 4, 2015 and July 31, 2016. Participants received a sensor pad placed between the top of their mattress and bed sheet. The sensor pad was positioned to monitor movement from patients' shoulders to their thighs. The SensableCare System was evaluated for monitoring patient movement and delivering timely alerts to nursing staff via mobile devices when there appeared to be a bed-exit attempt. Sensor pad data were collected automatically from the system. The primary outcomes included number of falls, time to turn off bed-exit alerts, and the number of attempted bed-exit events. Data on patient falls were collected by clinical research assistants and confirmed with the unit nurse manager. Explanatory variables included room locations (zones 1-3), day of the week, nursing shift, and Morse Fall Scale (ie, positive fall history, positive secondary diagnosis, positive ambulatory aid, weak impaired gait/transfer, positive IV/saline lock, mentally forgets limitations). We also assessed user experience via nurse focus groups. Qualitative data regarding staff interactions with the system were collected during two focus groups with 25 total nurses, each lasting approximately 1.5 hours.A total of 91 patients used the system for 234.0 patient-days and experienced no bed falls during the study period. On average, patients were assisted/returned to bed 46 seconds after the alert system was triggered. Response times were longer during the overnight nursing shift versus day shift (P=.005), but were independent of the patient's location on the unit. Focus groups revealed that nurses found the system integrated well into the clinical nursing workflow and the alerts were helpful in patient monitoring.A medical IoT system can be integrated into the existing nursing workflow and may reduce patient bed fall risk in acute care hospitals, a high priority but an elusive patient safety challenge. By using an alerting system that sends notifications directly to nurses' mobile devices, nurses can equally respond to unassisted bed-exit attempts wherever patients are located on the ward. Further study, including a fully powered randomized controlled trial, is needed to assess effectiveness across hospital settings.
View details for PubMedID 28473306
View details for PubMedCentralID PMC5438463
Why do Patients Forget to Take Immunosuppression Medications and Miss Appointments: Can a Mobile Phone App Help?
JMIR public health and surveillance
2016; 2 (1): e15
Kidney transplant recipients must adhere to their immunosuppressive medication regimen. However, non-adherence remains a major problem.The aim of this paper is to determine how kidney transplant recipients remember to take their medications, and assess their perception and beliefs about adherence to immunosuppressive medications and barriers to medication adherence. In addition, we aim to assess perception and beliefs about willingness to use a hypothetical, mobile phone app to improve adherence.We conducted a qualitative study that included an average of three home or workplace visits of kidney transplant recipients (N=16) from a single urban transplant center.The qualitative study revealed that transplant recipients understood the importance of taking their immunosuppressive medications and this motivated them to take their medications. The visits showed that most participants have incorporated medication use into their daily lives and that any minor deviation from daily routines could result in non-adherence. Participants also reported other barriers to adherence. All participants were interested in using an app to remind them to take their medication; however, they reported potential barriers to using the app.Although kidney transplant recipients understood the importance of medication adherence, there were significant barriers to maintaining adherence. Participants also reported interest in using a mobile phone app.
View details for DOI 10.2196/publichealth.5285
View details for PubMedID 27227150
View details for PubMedCentralID PMC4869221
Quality Indicator Development for Positive Screen Follow-up for Sickle Cell Disease and Trait.
American journal of preventive medicine
2016; 51 (1 Suppl 1): S48–54
Extensive variation exists in the follow-up of positive screens for sickle cell disease. Limited quality indicators exist to measure if the public health goals of screening-early initiation of treatment and enrollment to care-are being achieved. This manuscript focuses on the development of quality indicators related to the follow-up care for individuals identified with sickle cell disease and trait through screening processes. The authors used a modified Delphi method to develop the indicators. The process included a comprehensive literature review with rating of the evidence followed by ratings of draft indicators by an expert panel held in September 2012. The expert panel was nominated by leaders of various professional societies, the Health Resources and Services Administration, and the National Heart, Lung, and Blood Institute and met face to face to discuss and rate each indicator. The panel recommended nine quality indicators focused on key aspects of follow-up care for individuals with positive screens for sickle cell disease and trait. Public health programs and healthcare institutions can use these indicators to assess the quality of follow-up care and provide a basis for improvement efforts to ensure appropriate family education, early initiation of treatment, and appropriate referral to care for individuals identified with sickle cell disease and trait.
View details for PubMedID 27320465
- Medical Device Market Silicon Valley – Economics for Success” (Chinese book published in Taiwan) http://www.drmaster.com.tw. 2016: 247
Understanding Barriers to Early Intervention Services for Preterm Infants: Lessons From Two States
2015; 15 (4): 430-438
To explore existing barriers and challenges to Early Intervention (EI) referral, enrollment, and service provision for very low birth weight (VLBW; <1500 g) infants.We conducted 10 focus groups with parents of VLBW children (n = 44) and 32 interviews with key informants from EI (n = 7), neonatal intensive care units (n = 17), and outpatient clinics (n = 8) at 6 sites in 2 states. We used grounded theory to identify themes about gaps in services.Both parents and providers found EI helpful. However, they also identified gaps in the current EI system at the levels of eligibility, referral, family receptivity, and service provision and coordination with medical care. Inadequate funding and variable procedures for evaluation may affect children's eligibility. Referrals can be missed as a result of simple oversight or communication failure among hospitals, EI, and families; referral outcomes often are not formally tracked. Families may not be receptive to services as a result of wariness of home visits, social stressors, denial about potential developmental delays, or lack of understanding of the benefits of EI. Once a child is deemed eligible, services may be delayed or terminated early, and EI providers may have little specialized training. Communication and coordination with the child's medical care team is often limited.Systemic barriers, including funding and staffing issues, state and federal regulations, and communication with families and medical providers, have led to gaps in the EI system. The chronic care model may serve as a framework for integrating community-based interventions like EI with medical care for VLBW children and other vulnerable populations.
View details for Web of Science ID 000357363400011
View details for PubMedID 26142069
View details for PubMedCentralID PMC4862651
- Sickle Cell Disease Treatment Demonstration Program Congressional Report Health Resources and Services Administration’s Contract HHSH250201000022C . 2014
- The HIPAA conundrum in the era of mobile health and communications. JAMA-the journal of the American Medical Association 2013; 310 (11): 1121-1122
Pasteurized human donor milk use among US level 3 neonatal intensive care units.
Journal of human lactation
2013; 29 (3): 381-389
Pasteurized human donor milk (DM) is recommended by the World Health Organization and American Academy of Pediatrics for preterm infants when mother's own milk is unavailable, yet the extent and predictors of use and criteria for use in US neonatal intensive care units (NICUs) are unknown.This study aimed to evaluate current DM use in US level 3 NICUs and predictors and criteria of use.We sent mail surveys to 302 US level 3 NICU directors. We used multivariable logistic regression to analyze predictors of DM use.Survey response rate was 60%, and 76 of 182 (42%) directors reported DM use. Among DM users, 30% have used DM < 2 years and 55% for 2 to 5 years. Among nonusers, 63% were uncertain of turnaround time when ordering DM, 36% were unclear what guidelines milk banks followed, and 31% were unsure of parent receptiveness. In multivariate analyses, > 800 annual admissions (odds ratio [OR], 4.11; 95% confidence interval [CI], 1.43-11.82; reference ≤ 400 admissions) and location in the Midwest (OR, 3.02; 95% CI, 1.17-7.76) and West (OR, 6.33; 95% CI, 2.28-15.57; reference Northeast) were positively associated with DM use; safety-net hospitals (> 75% Medicaid insurance) were negatively associated (OR, 0.35; 95% CI, 0.14-0.89).Pasteurized human donor milk use is rapidly emerging among US level 3 NICUs. Larger NICUs and those in the West and Midwest were more likely to use DM, while safety-net hospitals were less likely to use DM. Lack of knowledge by medical directors of accessibility, safety, and parental receptiveness may be barriers to DM use.
View details for DOI 10.1177/0890334413492909
View details for PubMedID 23764482
Language in Medical Documentation Reply
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
2013; 309 (10): 984-984
View details for Web of Science ID 000315938700019
Quality-of-Care Indicators for Infantile Spasms
JOURNAL OF CHILD NEUROLOGY
2013; 28 (1): 13-20
We developed a comprehensive set of quality-of-care indicators for the management of children with infantile spasms in the United States, encompassing evaluation, diagnosis, treatment, and prevention and management of side effects and comorbidities. The indicators were developed using the RAND/UCLA Modified Delphi Method. After a focused review of the literature and guidelines by the study team, an expert panel (nominated by leaders of Child Neurology Society, American Epilepsy Society, and National Institute for Neurologic Disorders) rated the draft indicators anonymously, met face-to-face to discuss each indicator, and rerated the revised indicators on validity, feasibility, and importance. The panel recommended 21 indicators, of which 8 were identified as most likely to have a large positive impact on improving quality of life and/or health outcomes for children with infantile spasms. The proposed indicators can be used to assess and document variations and gaps in quality-of-care and inform future research and quality improvement interventions.
View details for DOI 10.1177/0883073812443590
View details for PubMedID 22566712
- Medical Documentation in the Electronic Era JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 2012; 308 (20): 2091-2092
Improving Preterm Ophthalmologic Care in the Era of Accountable Care Organizations
ARCHIVES OF OPHTHALMOLOGY
2012; 130 (11): 1433-1440
OBJECTIVES To understand retinopathy of prematurity (ROP) follow-up care for preterm very low-birth-weight infants (VLBW; <1500 g) in the context of the chronic care model and identify opportunities for improvement under accountable care organizations. METHODS We conducted focus groups and interviews with parents (N = 47) of VLBW infants and interviews with neonatal intensive care unit and ophthalmologic providers (N = 28) at 6 sites in Massachusetts and South Carolina. Themes are reported according to consolidated criteria for reporting qualitative research guidelines. RESULTS Respondents perceived that legal liability and low reimbursement contributed to shortages of ROP providers. Some neonatal intensive care units offered subsidies to attract ophthalmologic providers or delayed transfers to institutions that could not provide ROP examinations and/or treatment. Sites used variable practices for coordinating ROP care. Even at sites with a tracking database and a dedicated ROP coordinator, significant time was required to ensure that examinations and treatment occurred as scheduled. Parents' ability to manage their children's health care was limited by parental understanding of ROP, feeling overwhelmed by the infant's care, and unmet needs for resources to address social stressors. CONCLUSIONS Under accountable care organizations, hospitals and ophthalmology practices should share responsibility for ensuring coordinated ROP care to mitigate liability concerns. To promote integrated care, reimbursement for ROP care should be bundled to include screening, diagnosis, treatment, and appropriate follow-up. Clinical information systems should be enhanced to increase efficiency and limit lapses in care. Self-management tools and connections to community resources could help promote families' attendance of follow-up appointments.
View details for DOI 10.1001/archophthalmol.2012.1890
View details for Web of Science ID 000310986700009
View details for PubMedID 22777426
Maternal note-taking and infant care: a pilot randomised controlled trial
ARCHIVES OF DISEASE IN CHILDHOOD
2012; 97 (10): 916-918
A pilot randomised controlled trial was conducted with postpartum mothers to assess the feasibility and impact of note-taking during newborn teaching. Controls received standard teaching; the intervention group received pen and paper to take notes. Subjects were called 2 days post-discharge to assess infant sleep position, breastfeeding, car seat use, satisfaction and information recall.126 mothers were randomised. There was a consistent trend that intervention subjects were more likely to report infant supine sleep position (88% vs 78%, relative risks (RR) 1.13; 95% CI 0.95 to 1.34), breastfeeding (96% vs 86%, RR 1.11; 95% CI 0.99 to 1.25) and correct car seat use (98% vs 87%, RR 1.12; 95% CI 1.00 to 1.25). Satisfaction and information recall did not differ. Among first-time mothers, intervention subjects were significantly more likely to report infant supine sleep position (95% vs 65%, RR 1.46; 95% CI 1.06 to 2.00).Maternal note-taking is feasible and potentially efficacious in promoting desirable infant care.
View details for DOI 10.1136/archdischild-2012-302289
View details for Web of Science ID 000309056100018
View details for PubMedID 22806235
Hemoglobinopathy Learning Collaborative: Using Quality Improvement (QI) to Achieve Equity in Health Care Quality, Coordination, and Outcomes for Sickle Cell Disease
JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED
2012; 23 (3): 34-48
Care and outcomes for individuals living with sickle cell disease (SCD) vary across institutions and communities. The Hemoglobinopathy Learning Collaborative (HLC) seeks to improve outcomes across the life course through improvement science. Faculty identified five key drivers of improved outcomes: a strong community network; knowledgeable, proactive individuals, families and providers; reliable identification and follow-up; seamless co-management between primary and specialty care; and appropriate treatment for acute episodes. Using a modified Delphi process, we selected improvement measures aligned with the drivers. Data are collected via a Web-based system linked to a reporting portal. Participating teams include consumers, community organizations and primary and specialty care providers. This commentary reviews the context of SCD in the U.S.; describes the framework, measures, and technology infrastructure already created for the HLC; reports on the early experience of teams; highlights the initiative's challenges and opportunities; and reflects on its implications in the setting of health reform.
View details for Web of Science ID 000307413700007
View details for PubMedID 22864486
Setting the Agenda for Quality Improvement in Pediatric Sickle Cell Disease
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
2012; 104 (7-8): 337-341
Despite recent scientific advances, children with sickle cell disease (SCD) continue to experience high mortality and significant morbidity, in part due to variations in the care provided. We sought to identify and compare drivers for quality improvement among clinical staff and parents of children with SCD.We interviewed clinical staff across care settings in an urban teaching hospital to elicit their perspectives on improving care for children with SCD. Concurrently, we invited parents of children with SCD to participate in focus groups to identify their needs. Findings are reported according to Consolidated Criteria for Reporting Qualitative Research guidelines.We conducted 29 interviews with clinical staff and 4 focus groups with parents. Both groups identified the need for effective communication of relevant patient information across disciplines as a key area for improvement. Clinical staff cited standardization of care delivery as a top priority through increased accessibility of pertinent clinical information, enhanced pain assessment and management, and improved availability of clinical decision-making tools. Parents listed the need for increased community awareness about SCD, including school and day care staff, enhanced parental education and peer support, and self-management skills for their children as opportunities to improve pediatric SCD care.Identifying drivers for quality improvement is a critical first step in transforming the care provided to children with SCD. Using a systematic approach that includes eliciting the perspectives of both clinicians and parents may significantly enhance the development of a patient-centered quality improvement agenda.
View details for Web of Science ID 000309845900003
View details for PubMedID 23092048
Electronic Health Record Technology Reply
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
2012; 307 (21): 2256-2256
View details for Web of Science ID 000304801700013
- Integrating Technology Into Health Care What Will It Take? JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 2012; 307 (6): 569-570
A Proposed Framework for Understanding the Forces behind Legislation of Universal Health InsuranceuLessons from Ten Countries
HEALTH SERVICES RESEARCH
2011; 46 (6): 2101-2118
To understand the forces propelling countries to legislate universal health insurance. DATA SOURCE/STUDY DESIGN: Descriptive review and exploratory synthesis of historic data on economic, geographic, socio-demographic, and political factors.We searched under "insurance, health" on MEDLINE and Google Scholar, and we reviewed relevant books and articles via a snowball approach.Ten countries with universal health insurance were studied. For the five countries that passed final universal insurance laws prior to 1958, we found that two forces of "historical context" (i.e., social solidarity and historic patterns), one "ongoing dynamic force" (political pressures), and "one uniqueness of the moment" force (legislative permissiveness) played a major role. For the five countries that passed final legislation between 1967 and 2010, the predominant factors were two "ongoing dynamic forces" (economic pressures and political pressures) and one "uniqueness of the moment" force (leadership). In general, countries in the former group made steady progress, whereas those in the latter group progressed in abrupt leaps.The lessons of more recent successes-almost all of which were achieved via abrupt leaps-strongly indicate the importance of leadership in taking advantage of generalized economic and political pressures to achieve universal health insurance.
View details for DOI 10.1111/j.1475-6773.2011.01320.x
View details for Web of Science ID 000297244200005
View details for PubMedID 22092227
Management of Children With Sickle Cell Disease: A Comprehensive Review of the Literature
2011; 128 (6): E1552-E1574
Sickle cell disease (SCD) affects 70 000 to 100 000 people in the United States, and 2000 infants are born with the disease each year. The purpose of this study was to review the quality of the literature for preventive interventions and treatment of complications for children with SCD to facilitate the use of evidence-based medicine in clinical practice and identify areas in need of additional research.We searched the Ovid Medline database and the Cochrane Library for articles published between January 1995 and April 2010 for English-language abstracts on 28 topics thought to be important for the care of children with SCD. We also added pertinent references cited by studies identified in our search. Each abstract was reviewed independently by 2 authors. Data from articles retrieved for full review were abstracted by using a common form.There were 3188 abstracts screened, and 321 articles underwent full review. Twenty-six articles (<1% of abstracts initially screened), which consisted of 25 randomized controlled trials and 1 meta-analysis, were rated as having level I evidence. Eighteen of the 28 topics selected for this review did not have level I evidence studies published. The management and prevention of pain episodes accounted for more than one-third of the level I studies.Although significant strides have been made in the care of children with SCD in the past 2 decades, more research needs to be performed, especially for acute events associated with SCD, to ensure that the health and well-being of children with SCD continues to improve.
View details for DOI 10.1542/peds.2010-3686
View details for Web of Science ID 000298131400023
View details for PubMedID 22123880
Communication of Urgent Public Health Messages to Urban Populations: Lessons From the Massachusetts Water Main Break
DISASTER MEDICINE AND PUBLIC HEALTH PREPAREDNESS
2011; 5 (3): 235-241
To study when and how an urgent public health message about a boil-water order reached an urban population after the Massachusetts water main break.In-person surveys were conducted in waiting areas of clinics and emergency departments at a large urban safety net hospital within 1 week of the event.Of 533 respondents, 97% were aware of the order; 34% of those who lived in affected cities or towns were potentially exposed to contaminated water. Among those who were aware, 98% took action. Respondents first received the message through word of mouth (33%), television (25%), cellular telephone calls (20%), landline calls (10%), and other modes of communication (12%). In multivariate analyses, foreign-born respondents and those who lived outside the city of Boston had a higher risk of exposure to contaminated water. New modes (eg, cellular telephones) were used more commonly by females and younger individuals (ages 18 to 34). Individuals who did not speak English at home were more likely to receive the message through their personal networks.Given the increasing prevalence of cellular telephone use, public officials should encourage residents to register landline and cellular telephone for emergency alerts and must develop creative ways to reach immigrants and non-English-speaking groups quickly via personal networks.
View details for Web of Science ID 000296362300012
View details for PubMedID 22003141
Quality-of-Care Indicators for Children With Sickle Cell Disease
2011; 128 (3): 484-493
To develop a set of quality-of-care indicators for the management of children with sickle cell disease (SCD) who are cared for in a variety of settings by addressing the broad spectrum of complications relevant to their illness.We used the Rand/University of California Los Angeles appropriateness method, a modified Delphi method, to develop the indicators. The process included a comprehensive literature review with ratings of the evidence and 2 rounds of anonymous ratings by an expert panel (nominated by leaders of various US academic societies and the National Heart, Lung, and Blood Institute). The panelists met face-to-face to discuss each indicator in between the 2 rounds.The panel recommended 41 indicators that cover 18 topics; 17 indicators described routine health care maintenance, 15 described acute or subacute care, and 9 described chronic care. The panel identified 8 indicators most likely to have a large positive effect on improving quality of life and/or health outcomes for children with SCD, which covered 6 topics: timely assessment and treatment of pain and fever; comprehensive planning; penicillin prophylaxis; transfusion; and the transition to adult care.Children with SCD are at risk for serious morbidities and early mortality, yet efforts to assess and improve the quality of their care have been limited compared with other chronic childhood conditions. This set of 41 indicators can be used to assess quality of care and provide a starting point for quality-improvement efforts.
View details for DOI 10.1542/peds.2010-1791
View details for Web of Science ID 000295406100043
View details for PubMedID 21844055
Translating scientific advances to improved outcomes for children with sickle cell disease: a timely opportunity.
Pediatric blood & cancer
2011; 56 (7): 1005-1008
Despite the recent advances made in the care of children with sickle cell disease (SCD), premature mortality, especially among older children and young adults, remains a hallmark of this disease. The lack of survival gains highlights the translational gap of implementing innovations found efficacious in the controlled trial setting into routine clinical practice. Health services research (HSR) examines the most effective ways to finance, organize, and deliver high quality care in an equitable manner. To date, HSR has been underutilized as a means to improve the outcomes for children with SCD. Emerging national priorities in health care delivery, new sources of funding, and evolving electronic data collection systems for patients with SCD have provided a unique opportunity to overcome the translational gap in pediatric SCD. The purpose of this article is to provide a comprehensive HSR agenda to create patient-specific evidence of clinical effectiveness for interventions used in the routine care setting, understand the barriers faced by clinicians to providing high quality care, assess and improve the interactions of patients with the health care system, and measure the quality of care delivered to increase survival for all children and young adults with SCD.
View details for DOI 10.1002/pbc.23059
View details for PubMedID 21488152
Can State Early Intervention Programs Meet the Increased Demand of Children Suspected of Having Autism Spectrum Disorders?
JOURNAL OF DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS
2010; 31 (6): 469-476
To determine whether Early Intervention programs have the capacity to accommodate the expected increase in referrals following the American Academy of Pediatrics' 2007 recommendation for universal screening of 18- and 24-month-old children for Autism Spectrum Disorders (ASD).We conducted a telephone survey of all state and territory early. Intervention coordinators about the demand for ASD evaluations, services, and program capacity. We used multivariate models to examine state-level factors associated with the capacity to serve children with ASD.Fifty-two of the 57 coordinators (91%) responded to the survey. Most states reported an increase in demand for ASD-related evaluations (65%) and services (58%) since 2007. In addition, 46% reported that their current capacity poses a challenge to meeting the 45-day time limit for creating the Individualized Family Service Plan. Many states reported that they have shortages of ASD-related personnel, including behavioral therapists (89%), speech-language pathologists (82%), and occupational therapists (79%). Among states that reported the number of service hours (n = 34) 44% indicated that children with ASD receive 5 or fewer weekly service hours. Multivariate models showed that states with a higher percentage of African-American and Latino children were more likely to have provider shortages whereas states with higher population densities were more likely to offer a greater number of service hours.Many Early Intervention programs may not have the capability to address the expected increase in demand for ASD services. Early Intervention programs will likely need enhanced resources to provide all children with suspected ASD with appropriate evaluations and services.
View details for DOI 10.1097/DBP.0b013e3181e56db2
View details for Web of Science ID 000279648300002
View details for PubMedID 20585267
- Payment Reform for Safety-Net Institutions -- Improving Quality and Outcomes. NEW ENGLAND JOURNAL OF MEDICINE 2009; 361 (19): 1821-1823
Perceptions of Standards-based Electronic Prescribing Systems as Implemented in Outpatient Primary Care: A Physician Survey
Annual Conference of the Agency-for-Healthcare-Research-and-Quality
BMJ PUBLISHING GROUP. 2009: 493–502
OBJECTIVE To compare the experiences of e-prescribing users and nonusers regarding prescription safety and workload and to assess the use of information from two e-prescribing standards (for medication history and formulary and benefit information), as they are implemented. DESIGN Cross-sectional survey of physicians who either had installed or were awaiting installation of one of two commercial e-prescribing systems. MEASUREMENTS Perceptions about medication history and formulary and benefit information among all respondents, and among e-prescribing users, experiences with system usability, job performance impact, and amount of e-prescribing. RESULTS Of 395 eligible physicians, 228 (58%) completed the survey. E-prescribers (n = 139) were more likely than non-e-prescribers (n = 89) to perceive that they could identify clinically important drug-drug interactions (83 versus 67%, p = 0.004) but not that they could identify prescriptions from other providers (65 versus 60%, p = 0.49). They also perceived no significant difference in calls about drug coverage problems (76 versus 71% reported getting 10 or fewer such calls per week; p = 0.43). Most e-prescribers reported high satisfaction with their systems, but 17% had stopped using the system and another 46% said they sometimes reverted to handwriting for prescriptions that they could write electronically. The volume of e-prescribing was correlated with perceptions that it enhanced job performance, whereas quitting was associated with perceptions of poor usability. CONCLUSIONS E-prescribing users reported patient safety benefits but they did not perceive the enhanced benefits expected from using standardized medication history or formulary and benefit information. Additional work is needed for these standards to have the desired effects.
View details for DOI 10.1197/jamia.M2998
View details for Web of Science ID 000267995500009
View details for PubMedID 19390106
Factors Influencing the Enrollment of Eligible Extremely-Low-Birth-Weight Children in the Part C Early Intervention Program
2009; 9 (4): 283-287
To determine whether eligible extremely-low-birth-weight children (<1000 g) were enrolled in the federally enacted, state-coordinated Early Intervention (EI) program intended to help children with developmental delay or disability regardless of parental income, and the factors associated with enrollment.Retrospective analysis of 884 EI-eligible ELBW children born in South Carolina with birth weight 401 to 999 g, gestation > or =24 weeks, and survival for the first 120 days of life. We created a linked data set with data from Early Intervention (1996-2001), Vital Records (1996-1998), death certificates, and Medicaid. Each child was followed from birth to 3 years old, the program eligibility period.A total of 54% of ELBW children were enrolled in EI at any time from birth to 36 months. Even among children ever enrolled in Medicaid (83% of all ELBW children), only 63% were enrolled in EI. Being born in a multiple gestational birth, having heavier birth weight (750 to 999 g), and having ever enrolled in Medicaid were positively associated with EI enrollment. Among Medicaid patients for whom perinatal data were available, additional risk adjustment showed that EI enrollment was more likely with birth in level 3 hospitals, birth weight 750 to 999 g, Neonatal Medical Index severity level V (most severe), and longer initial length of hospital stay.Only about half of eligible ELBW children in South Carolina were enrolled-much lower than reported elsewhere. Efforts are needed to understand why eligible infants are not being enrolled and to develop strategies to remedy the situation.
View details for Web of Science ID 000275913200014
View details for PubMedID 19482532
Quality indicators and quality assessment in child health
ARCHIVES OF DISEASE IN CHILDHOOD
2009; 94 (6): 458-463
Quality indicators are systematically developed statements that can be used to assess the appropriateness of specific healthcare decisions, services and outcomes. In this review, the range and type of indicators that have been developed for children in the UK and USA by prominent governmental agencies and private organisations are highlighted. These indicators are classified in an effort to identify areas of child health that may lack quality measures. The current state of health information technology in both countries is reviewed, since these systems are vital to quality efforts. Finally, several recommendations are proposed to advance the quality indicator development agenda for children. The convergence of quality measurement and indicator development, a growing scientific evidence base and integrated information systems in healthcare may lead to substantial improvements for child health in the 21st century.
View details for DOI 10.1136/adc.2008.137893
View details for Web of Science ID 000266272100014
View details for PubMedID 19307196
View details for PubMedCentralID PMC2774840
Adherence to Quality Indicators and Survival in Patients With Breast Cancer
2009; 47 (2): 217-225
International initiatives increasingly advocate physician adherence to clinical protocols that have been shown to improve outcomes, yet the process-outcome relationship for adhering to breast cancer care protocol is unknown.This study explores whether 100% adherence to a set of quality indicators applied to individuals with breast cancer is associated with better survival.Ten quality indicators (4 diagnosis-related and 6 treatment-related indicators) were used to measure the quality of care in 1378 breast cancer patients treated from 1995 to 2001. Adherence to each indicator was based on the number of procedures performed divided by the number of patients eligible for that procedure. The main analysis of adherence was dichotomous (ie, 100% adherence vs. <100% adherence).The outcome measures studied were 5-year overall survival and progression-free survival, calculated using the Kaplan-Meier method. The Cox's proportional hazard regression model was used for univariate and multivariate analyses.Most patients received care that demonstrated good adherence to the quality indicators. Multivariate analysis revealed that 100% adherence to entire set of quality indicators was significantly associated with better overall survival [hazard ratio (HR): 0.46; 95% confidence interval (CI): 0.33-0.63] and progression-free survival (HR 0.51; 95% CI, 0.39-0.67). One hundred percent adherence to treatment indicators alone was also associated with statistically significant improvements in overall and progression-free survivals.Our study strongly supports that 100% adherence to evidence supported quality-of-care indicators is associated with better survival rates for breast cancer patients and should be a priority for practitioners.
View details for Web of Science ID 000262913200012
View details for PubMedID 19169123
- Koo Foundation Sun Yat-Sen Cancer Center: Breast Cancer Care in Taiwan Harvard Business Review 2009
Variation in electronic prescribing implementation among twelve ambulatory practices
JOURNAL OF GENERAL INTERNAL MEDICINE
2008; 23 (4): 364-371
Electronic prescribing has been advocated as an important tool for improving the safety and quality of medication use in ambulatory settings. However, widespread adoption of e-prescribing in ambulatory settings has yet to be realized. The determinants of successful implementation and use in these settings are not well understood.To describe the practice characteristics associated with implementation and use of e-prescribing in ambulatory settings.Multi-method qualitative case study of ambulatory practices before and after e-prescribing implementation.Sixteen physicians and 31 staff members working in 12 practices scheduled for implementation of an e-prescribing program and purposively sampled to ensure a mix of practice size and physician specialty.Field researchers used observational and interview techniques to collect data on prescription-related clinical workflow, information technology experience, and expectations.Five practices fully implemented e-prescribing, 3 installed but with only some prescribers or staff members using the program, 2 installed and then discontinued use, 2 failed to install. Compared to practice members in other groups, members of successful practices exhibited greater familiarity with the capabilities of health information technologies and had more modest expectations about the benefits likely to accrue from e-prescribing. Members of unsuccessful practices reported limited understanding of e-prescribing capabilities, expected that the program would increase the speed of clinical care and reported difficulties with technical aspects of the implementation and insufficient technical support.Practice leaders should plan implementation carefully, ensuring that practice members prepare for the effective integration of this technology into clinical workflow.
View details for DOI 10.1007/s11606-007-0494-8
View details for Web of Science ID 000254456400004
View details for PubMedID 18373131
Communication of positive newborn screening results for sickle cell disease and sickle cell trait: Variation across states
AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS
2008; 148C (1): 15-22
In the US, all states and the District of Columbia have universal newborn screening (NBS) programs for sickle cell disease (SCD), which also identify sickle cell trait (trait). In this project, we surveyed follow-up coordinators, including one in the District of Columbia and two in Georgia, about protocols for stakeholder notification for SCD and trait. The primary outcomes were total number and type of stakeholder informed of a positive screen. We received 52 completed surveys (100% response). Primary care providers (PCPs) (100%), hematologists (81%), hospitals (73%), and families (40%) were the most commonly notified stakeholders of positive SCD screens, while PCPs (88%), hospitals (63%), and families (37%) were most commonly notified for trait. On average, 3.4 stakeholders were notified for a positive screening for SCD, compared to 2.4 stakeholders for sickle cell trait (P < 0.001). In multivariate analyses for SCD, we found a 2.9% increase in stakeholders notified for each additional year of universal screening mandated in a state (95% CI: 1.4-4.4%). For trait, we found an 8.5% increase in stakeholders notified for each additional follow-up staff (95% CI: 1.3-15.7%), and a 1.3% increase for each additional percent of black births in the state (95% CI: 0.1-2.5%). Wide variation exists in stakeholder notification by NBS programs of positive screenings for SCD and trait. This variation may alter the effectiveness of NBS programs by location of birth.
View details for DOI 10.1002/ajmg.c.30160
View details for Web of Science ID 000253482500003
View details for PubMedID 18200513
Population-based assessments of ophthalmologic and audiologic follow-up in children with very low birth weight enrolled in medicaid: A quality-of-care study
2008; 121 (2): E278-E285
The purpose of our work was to determine whether children with very low birth weight (< 1500 g) who are at high risk for vision and hearing problems and enrolled in Medicaid receive recommended follow-up vision and hearing services and to examine predictors of services.We conducted a retrospective analysis of 2182 children born in South Carolina from 1996 to 1998 with birth weights of 401 to 1499 g, gestations of > or = 24 weeks, and survival of > or = 90 days of life. Receipt of services for Medicaid-enrolled children was assessed by using a linked data set that included files from vital records, death certificates, Medicaid, Chronic Rehabilitative Services, and the Early Intervention Program. We assessed the receipt of hearing rehabilitation by 6 months of age for children with nonconductive hearing loss and routine ophthalmologic examination between ages of 1 and 2 years for all children with very low birth weight. Multivariate logistic regression was restricted to ophthalmologic examinations because of sample size.Among children with very low birth weight with nonconductive hearing loss, 20% received hearing rehabilitation by 6 months of age. Twenty-three percent of children with very low birth weight received an ophthalmologic examination between the ages of 1 and 2 years. Limiting our analysis to children < 1000 g or extending the measurement period to 7 months (hearing) and age 3 years (vision) did not substantially increase the percentage of children receiving the services. The receipt of an ophthalmologic examination was associated positively with Medicaid enrollment by the time of hospital discharge and birth in a level-3 hospital and negatively associated with higher birth weight, an Apgar score of > or = 7, and black maternal race. Among children born at < 1000 g, all of whom were eligible for the Early Intervention Program, the receipt of an ophthalmologic examination was positively associated with program enrollment.There is a shortfall in the provision of critical services for children with very low birth weight. These findings reinforce the Institute of Medicine's concerns regarding inadequate outcome data and health care services for preterm infants and support the importance of enrollment in the Early Intervention Program for children with very low birth weight.
View details for DOI 10.1542/peds.2007-0136
View details for Web of Science ID 000252877600045
View details for PubMedID 18245402
- Picking up where Reform Left off in Taiwan - Response for Davis and Huang Annals of Internal Medicine 2008
- Pilot Testing of Electronic Prescribing Standards Report to the Agency for Healthcare Research and Quality. 2007
- Primary Care Follow-up of Neurodevelopmental Status of Premature Infants Contemporary Pediatrics 2007; 24 (9)
Quality-of-care indicators for the neurodevelopmental follow-up of very low birth weight children: Results of an expert panel process
2006; 117 (6): 2080-2092
To develop a set of quality indicators for the neurodevelopmental follow-up care of very low birth weight (VLBW; <1500 g) children.We reviewed the scientific literature on predictors of neurodevelopmental outcomes for VLBW children and the clinical practice guidelines relevant to their care after hospital discharge. An expert panel with members nominated by the American Academy of Pediatrics, the National Institute of Child Health and Human Development, the Vermont Oxford Network, and the California Children's Service was convened. We used a modified Delphi method to evaluate and select the quality-of-care indicators.The panel recommended a total of 70 indicators in 5 postdischarge follow-up areas: general care; physical health; vision, hearing, speech, and language; developmental and behavioral assessment; and psychosocial issues. Of these, 58 (83%) indicators were in preventive care, 5 (7%) were in acute care, and 7 (10%) were in chronic care.The quality indicators cover follow-up care for VLBW infants with various medical conditions. Given the elevated rates of long-term neurodevelopmental disabilities and the potential impact of poor health care, this new set of indicators provides an opportunity to assess and monitor the quality of follow-up care with the ultimate aim of improving the quality of care for this high-risk population.
View details for Web of Science ID 000237979000027
View details for PubMedID 16740851
Functional characteristics of commercial ambulatory electronic prescribing systems: A field study
JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION
2005; 12 (3): 346-356
To compare the functional capabilities being offered by commercial ambulatory electronic prescribing systems with a set of expert panel recommendations.A descriptive field study of ten commercially available ambulatory electronic prescribing systems, each of which had established a significant market presence. Data were collected from vendors by telephone interview and at sites where the systems were functioning through direct observation of the systems and through personal interviews with prescribers and technical staff.The capabilities of electronic prescribing systems were compared with 60 expert panel recommendations for capabilities that would improve patient safety, health outcomes, or patients' costs. Each recommended capability was judged as having been implemented fully, partially, or not at all by each system to which the recommendation applied. Vendors' claims about capabilities were compared with the capabilities found in the site visits.On average, the systems fully implemented 50% of the recommended capabilities, with individual systems ranging from 26% to 64% implementation. Only 15% of the recommended capabilities were not implemented by any system. Prescribing systems that were part of electronic health records (EHRs) tended to implement more recommendations. Vendors' claims about their systems' capabilities had a 96% sensitivity and a 72% specificity when site visit findings were considered the gold standard.The commercial electronic prescribing marketplace may not be selecting for capabilities that would most benefit patients. Electronic prescribing standards should include minimal functional capabilities, and certification of adherence to standards may need to take place where systems are installed and operating.
View details for DOI 10.1197/jamia.M1759
View details for Web of Science ID 000229384600014
View details for PubMedID 15684122
- Doctors’ Orders: Better Electronic Prescribing Systems Could Improve Care RAND Review. (Summer Issue).. 2005
- Analysis of healthcare interventions that change patient trajectories MG408. 2005
Recommendations for comparing electronic prescribing systems: results of an expert consensus process.
2004: W4-305 17
Commercially available electronic prescribing systems may differ in their effects on patients' health outcomes and on patients' ability to manage costs. An expert panel convened to recommend specific features that would enable electronic prescribing systems to advance these goals. The panel authored sixty recommendations and rated each using a modified Delphi process. Ratings identified fifty-two recommendations as clearly positive for patient safety and health outcomes and forty-three recommendations as achievable in the average clinician's office within three years. Overall, these recommendations offer a synthesis of evidence and expert opinion that can help guide the development of electronic prescribing policy.
View details for PubMedID 15451979
- Insuring Taiwan’s Health The McKinsey Quarterly 2001; 4 (Emerging Markets)
- From Taiwan to Harvard II: So You Want to be a Doctor (Chinese book published in Taiwan) 1999
- From Taiwan to Harvard: Experiences of an Immigrant Student in America (in Chinese) Chiu-Ko and Chien-Hsing Publishing Companies. 1995
- Generation of a High Titre Retroviral Vector Capable of Expressing High Levels of the Human Beta-globin Gene Proceedings of the National Academy of Sciences 1995; 92: 6728-6732
SALIVARY AMYLASE ACTIVITY OF THE AGED
1990; 36 (4): 193-198
Previous studies from America and Japan have reported that salivary amylase activity was reduced in the elderly. In contrast to these studies, a recent Chinese study reported an increase in salivary amylase activity in the aged. Our study examined approximately equal numbers of Chinese and non-Chinese Americans. The concentration of salivary amylase was estimated from the activity obtained with a colormetric coupled assay utilizing 4NP-G7. Activity was found to be increased in the aged. Our data are discussed with respect to the claims of the previous studies.
View details for Web of Science ID A1990EM62300002
View details for PubMedID 1703102