Member, Cardiovascular Institute
Director, Emergency and Primary Care Services, Children's Hospital, Boston (1981 - 1985)
Director, Harvard Institute for Reproductive and Child Health, Harvard Medical School (1992 - 1996)
Director, Social and Health Policy Research, Boston Medical Center (1996 - 2003)
Vice-Chief, Division of Social Medicine and Health Inequalities Department of Medicine, Brigham and Womens Hospital (2003 - 2004)
Director, Center for Policy, Outcomes and Prevention (2004 - Present)
Richard E. Behrman Professor of Child Health and Society, Stanford University (2005 - Present)
Honors & Awards
William Root Lecturer and AOA Visiting Professor, Kansas University School of Medicine (2003)
Anne E. Dyson Memorial Award Visiting Professor, University Rochester School of Medicine (2002)
Richard and Millie Brock Award for Contributions to Pediatrics, New York Academy of Medicine (2001)
Franklin Delano Roosevelt Award, The March of Dimes (1995)
Young Professional Award,, American Public Health Association (1988)
Charles L. Horn Prize for Leadership in Medicine, Cornell University Medical College (1978)
A.B. awarded summa cum laude,, Cornell University (1974)
Susan Packard Orr Lecturer, Lucile Packard Childrens Hospital (2006)
2006 Hugh and Alison Westgate Award in Justice and International Pediatrics, Minnesota Childrens Hospital (2006)
George A. Silver Memorial Lecture, George Washington University School of Medicine (2007)
Center for Latin American Studies
WSD HANDA Center for Human Rights and International Justice
A.B., Cornell University, Latin American Studies (1974)
M.D., Cornell Univ Medical College, Medicine (1978)
M.P.H., Harvard School of Public Health, General Studies (1978)
Community and International Work
Opportunities for Student Involvement
Current Research and Scholarly Interests
He is a health policy and outcomes researcher whose work has focused on children's health; health-outcomes disparities by race, ethnicity and socioeconomic status; the interaction of genetics and the environment as these factors influence child and maternal health; and the impact of medical technology on disparities in health outcomes.
- Global Public Health
HUMBIO 129S (Win)
- Making Things Happen in the Real World: Leadership and Implementation
IPS 216 (Spr)
- Service Learning Practicum
EDUC 98 (Spr)
Independent Studies (14)
- Capstone Project: Human Rights Minor
HUMRTS 199 (Spr)
- Directed Reading in Health Research and Policy
HRP 299 (Aut, Win, Spr, Sum)
- Directed Reading in Pediatrics
PEDS 299 (Aut, Win, Spr, Sum)
- Directed Reading/Special Projects
HUMBIO 199 (Aut, Win, Spr)
- 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)
HUMBIO 194 (Aut, Win, Spr)
- Medical Scholars Research
HRP 370 (Aut, Win, Spr)
- Medical Scholars Research
PEDS 370 (Aut, Win, Spr, Sum)
- Research in Human Biology
HUMBIO 193 (Aut, Win)
- Senior Tutorial in Human Biology
HUMBIO 198 (Win)
- Undergraduate Directed Reading/Research
PEDS 199 (Aut, Win, Spr, Sum)
- Undergraduate Research
HRP 199 (Win, Spr)
- Capstone Project: Human Rights Minor
Prior Year Courses
- Advanced Seminar in Health and Security
HUMBIO 126A (Win)
- Global Public Health
HUMBIO 129S (Win)
- Making Things Happen in the Real World: Leadership and Implementation
IPS 216 (Spr)
- Global Public Health
HUMBIO 129S (Win)
- Advanced Seminar in Health and Security
Undergraduate Major Advisor
Health Care Utilization and Costs of Publicly-Insured Children with Diabetes in California.
journal of pediatrics
2015; 167 (2): 449-54 e6
To examine diabetes-related health care utilization and costs for a population-based sample of children with presumed type 1 diabetes (T1D) enrolled in the California Children's Services program.Our data source was the California Children's Services claims data for the period July 1, 2009, to June 30, 2012. We studied a sample of 652 children aged 0-21 years who were continuously enrolled for at least 365 days, had an outpatient visit for T1D, and were taking insulin.Compared with the younger age groups, individuals in the 19-21 year age group had the highest rates of hospitalization, T1D-specific bed-days, and emergency department visits. The overall median cost for this population was $7654. The overall median costs per year (and proportion of total costs) were $5603 (59%) for hospitalizations, $58 (0.4%) for emergency department visits, $144 (1.3%) for outpatient utilization, $2930 (23%) for insulin, and $1579 (13%) for blood glucose monitoring supplies. For those who used them, the median cost of pumps was an additional $2162.Further studies are needed to provide more insight into patterns of care and adverse health outcomes for children with T1D as they transition into young adulthood. The costs of insulin, glucose monitoring supplies, and pump therapy for children with T1D is substantial and may factor into future policy considerations regarding coverage and cost-sharing with families.
View details for DOI 10.1016/j.jpeds.2015.04.067
View details for PubMedID 26028286
Strategic governance: Addressing neonatal mortality in situations of political instability and weak governance
SEMINARS IN PERINATOLOGY
2015; 39 (5): 387-392
Neonatal mortality is increasingly concentrated globally in situations of conflict and political instability. In 1991, countries with high levels of political instability accounted for approximately 10% of all neonatal deaths worldwide; in 2013, this figure had grown to 31%. This has generated a "grand divergence" between those countries showing progress in neonatal mortality reduction compared to those lagging behind. We present new analyses demonstrating associations of neonatal mortality with political instability (r = 0.55) and poor governance (r = 0.70). However, heterogeneity in these relationships suggests that progress is possible in addressing neonatal mortality even in the midst of political instability and poor governance. In order to address neonatal mortality more effectively in such situations, we must better understand how specific elements of "strategic governance"-the minimal conditions of political stability and governance required for health service implementation-can be leveraged for successful introduction of specific health services. Thus, a more strategic approach to policy and program implementation in situations of conflict and political instability could lead to major accelerations in neonatal mortality reduction globally. However, this will require new cross-disciplinary collaborations among public health professionals, political scientists, and country actors.
View details for DOI 10.1053/j.semperi.2015.06.008
View details for Web of Science ID 000359877300008
View details for PubMedID 26166561
- Outpatient Pharmacy Expenditures for Children With Serious Chronic Illness in California, 2010-2012. JAMA 2015; 314 (4): 405-407
Variation in Use of Pediatric Cardiology Subspecialty Care A Total Population Study in California, 1983 to 2011
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
2015; 66 (1): 37-44
American Academy of Pediatrics guidelines emphasize regionalized systems of care for pediatric chronic illness. There remains a paucity of information on the status of regionalized systems of care for pediatric congenital heart disease (CHD).This study evaluated variations in use of pediatric cardiology specialty care centers (PCSCC) for pediatric patients with CHD in California between 1983 and 2011.We performed a retrospective, total population analysis of pediatric CHD patients using the California Office of Statewide Health Planning and Development unmasked database. PCSCCs were identified by California's Title V program.There were 164,310 discharges meeting inclusion criterion. Discharges from PCSCCs grew from 58% to 88% between 1983 and 2011. Regionalized care was highest for surgical (96%) versus nonsurgical (71%) admissions. Admissions with a public payer increased from 42% (1983) to 61% (2011). Total bed days nearly doubled, and median length of stay increased from 2 to 3 days (nonspecialty care) and from 4 to 5 days (specialty care). There was a decrease in the pediatric CHD in-hospital death rate from 5.1 to 2.3 per 100,000 between 1983 and 2011, and a shift toward a larger percent of deaths occurring in the newborn period.California's inpatient regionalized specialty care of pediatric CHD has increased substantially since 1983, especially for surgical CHD discharges. The death rate has decreased, the number of bed days has increased, and a large proportion of these discharges now have public payers. Health care reform efforts must consider these shifts while protecting advances in regionalization of pediatric CHD care.
View details for DOI 10.1016/j.jacc.2015.04.053
View details for Web of Science ID 000357417900006
View details for PubMedID 26139056
Spatial and temporal patterns in preterm birth in the United States
2015; 77 (6): 836-844
Despite years of research, the etiologies of preterm birth remain unclear. In order to help generate new research hypotheses, this study explored spatial and temporal patterns of preterm birth in a large, total-population dataset.Data on 145 million US births in 3,000 counties from the Natality Files of the National Center for Health Statistics for 1971-2011 were examined. State trends in early (<34 wk) and late (34-36 wk) preterm birth rates were compared. K-means cluster analyses were conducted to identify gestational age distribution patterns for all US counties over time.A weak association was observed between state trends in <34 wk birth rates and the initial absolute <34 wk birth rate. Significant associations were observed between trends in <34 wk and 34-36 wk birth rates and between white and African American <34 wk births. Periodicity was observed in county-level trends in <34 wk birth rates. Cluster analyses identified periods of significant heterogeneity and homogeneity in gestational age distributional trends for US counties.The observed geographic and temporal patterns suggest periodicity and complex, shared influences among preterm birth rates in the United States. These patterns could provide insight into promising hypotheses for further research.
View details for DOI 10.1038/pr.2015.55
View details for Web of Science ID 000354755000017
View details for PubMedID 25760546
Trends in utilization of specialty care centers in california for adults with congenital heart disease.
American journal of cardiology
2015; 115 (9): 1298-1304
The American College of Cardiology and American Heart Association guidelines recommend that management of adult congenital heart disease (ACHD) be coordinated by specialty ACHD centers and that ACHD surgery for patients with moderate or complex congenital heart disease (CHD) be performed by surgeons with expertise and training in CHD. Given this, the aim of this study was to determine the proportion of ACHD surgery performed at specialty ACHD centers and to identify factors associated with ACHD surgery being performed outside of specialty centers. This retrospective population analysis used California's Office of Statewide Health Planning and Development's discharge database to analyze ACHD cardiac surgery (in patients 21 to 65 years of age) in California from 2000 to 2011. Designation as a "specialty ACHD center" was defined on the basis of a national ACHD directory. A total of 4,611 ACHD procedures were identified. The proportion of procedures in patients with moderate and complex CHD delivered at specialty centers increased from 46% to 71% from 2000 to 2011. In multivariate analysis among those discharges for ACHD surgery in patients with moderate or complex CHD, performance of surgery outside a specialty center was more likely to be associated with patients who were older, Hispanic, insured by health maintenance organizations, and living farther from a specialty center. In conclusion, although the proportion of ACHD surgery for moderate or complex CHD being performed at specialty ACHD centers has been increasing, 1 in 4 patients undergo surgery at nonspecialty centers. Increased awareness of ACHD care guidelines and of the patient characteristics associated with differential access to ACHD centers may help improve the delivery of appropriate care for all adults with CHD.
View details for DOI 10.1016/j.amjcard.2015.02.013
View details for PubMedID 25765587
- Variations in inpatient pediatric anesthesia in California from 2000 to 2009: a caseload and geographic analysis PEDIATRIC ANESTHESIA 2014; 24 (12): 1295-1301
Maternal prepregnancy body mass index and risk of spontaneous preterm birth.
Paediatric and perinatal epidemiology
2014; 28 (4): 302-311
Findings from studies examining risk of preterm birth associated with elevated prepregnancy body mass index (BMI) have been inconsistent.Within a large population-based cohort, we explored associations between prepregnancy BMI and spontaneous preterm birth across a spectrum of BMI, gestational age, and racial/ethnic categories. We analysed data for 989 687 singleton births in California, 2007-09. Preterm birth was grouped as 20-23, 24-27, 28-31, or 32-36 weeks gestation (compared with 37-41 weeks). BMI was categorised as <18.5 (underweight); 18.5-24.9 (normal); 25.0-29.9 (overweight); 30.0-34.9 (obese I); 35.0-39.9 (obese II); and ≥40.0 (obese III). We assessed associations between BMI and spontaneous preterm birth of varying severity among non-Hispanic White, Hispanic, and non-Hispanic Black women.Analyses of mothers without hypertension and diabetes, adjusted for age, education, height, and prenatal care initiation, showed obesity categories I-III to be associated with increased risk of spontaneous preterm birth at 20-23 and 24-27 weeks among those of parity 1 in each race/ethnic group. Relative risks for obese III and preterm birth at 20-23 weeks were 6.29 [95% confidence interval (CI) 3.06, 12.9], 4.34 [95% CI 2.30, 8.16], and 4.45 [95% CI 2.53, 7.82] for non-Hispanic Whites, non-Hispanic Blacks, and Hispanics, respectively. A similar, but lower risk, pattern was observed for women of parity ≥2 and preterm birth at 20-23 weeks. Underweight was associated with modest risks for preterm birth at ≥24 weeks among women in each racial/ethnic group regardless of parity.The association between women's prepregnancy BMI and risk of spontaneous preterm birth is complex and is influenced by race/ethnicity, gestational age, and parity.
View details for DOI 10.1111/ppe.12125
View details for PubMedID 24810721
- Quantifying and Exploiting the Age Dependence in the Effect of Supplementary Food for Child Undernutrition PLOS ONE 2014; 9 (6)
Hospitalizations of Children with Autism Increased from 1999 to 2009
JOURNAL OF AUTISM AND DEVELOPMENTAL DISORDERS
2014; 44 (5): 1087-1094
We performed a retrospective analysis of hospital discharges for children with autism, in comparison to children with cerebral palsy, Down syndrome, mental retardation/intellectual disability, and the general population. Hospitalizations for autism increased nearly threefold over 10 years, especially at the oldest ages, while hospitalizations for the other groups did not change. Leading discharge diagnoses for each age group in children with autism included mental health and nervous system disorders. Older age, Caucasian ethnicity, and living in a region with a high number of pediatric beds predicted hospitalizations associated with mental health diagnoses. These findings underscore the need for comprehensive clinical services that address the complex needs of children with autism to prevent costly hospitalizations.
View details for DOI 10.1007/s10803-013-1965-x
View details for Web of Science ID 000336330200009
View details for PubMedID 24122446
Increased utilization of pediatric specialty care: a population study of pediatric oncology inpatients in california.
Journal of pediatric hematology/oncology
2014; 36 (2): 99-107
To examine inpatient utilization of pediatric cancer specialty centers (PCSCs) by pediatric oncology patients.We performed a retrospective (1999 to 2010) population-based analysis of oncology hospitalizations for pediatric patients aged 0 through 18 years using the California Office of Statewide Health Planning and Development database. Logistic regression examined hospitalization at 29 PCSCs and variables of age, sex, tumor type, payer, race, income, and distance to admission site.Analysis of 103,961 pediatric oncology discharges revealed that 93% occurred at PCSCs. These sites experienced a 20% increase in pediatric oncology discharges, conversely non-PCSCs exhibited a 70% decrease (P<0.0001). Multivariate analyses revealed increased utilization with young age (odds ratio [OR], 4.58; 95% CI, 3.88-5.42), African American (OR, 1.26; 95% CI, 1.11-1.43), and middle income (OR, 1.36; 95% CI, 1.29-1.45). Decreased utilization was seen for females (OR, 0.88; 95% CI, 0.84-0.93) and Hispanics (OR, 0.72; 95% CI, 0.68-0.77). Payer and proximity were not significantly associated with change in utilization. Tumor types less likely to utilize a PCSC included germ cell, solid, and central nervous system tumors. Adolescents were >3 times less likely to be treated at a PCSC.Inpatient pediatric oncology care in California has become increasingly regionalized with the vast majority of patients accessing PCSCs. However, variability in hospitalizations of adolescent patients and children not treated in PCSCs deserve further evaluation.
View details for DOI 10.1097/01.mph.0000438027.07467.f1
View details for PubMedID 24517965
Governance and health in the Arab world
2014; 383 (9914): 343-355
Since late 2010, the Arab world has entered a tumultuous period of change, with populations demanding more inclusive and accountable government. The region is characterised by weak political institutions, which exclude large proportions of their populations from political representation and government services. Building on work in political science and economics, we assess the extent to which the quality of governance, or the extent of electoral democracy, relates to adult, infant, and maternal mortality, and to the perceived accessibility and improvement of health services. We compiled a dataset from the World Bank, WHO, Institute for Health Metrics and Evaluation, Arab Barometer Survey, and other sources to measure changes in demographics, health status, and governance in the Arab World from 1980 to 2010. We suggest an association between more effective government and average reductions in mortality in this period; however, there does not seem to be any relation between the extent of democracy and mortality reductions. The movements for changing governance in the region threaten access to services in the short term, forcing migration and increasing the vulnerability of some populations. In view of the patterns observed in the available data, and the published literature, we suggest that efforts to improve government effectiveness and to reduce corruption are more plausibly linked to population health improvements than are efforts to democratise. However, these patterns are based on restricted mortality data, leaving out subjective health metrics, quality of life, and disease-specific data. To better guide efforts to transform political and economic institutions, more data are needed for health-care access, health-care quality, health status, and access to services of marginalised groups.
View details for DOI 10.1016/S0140-6736(13)62185-6
View details for Web of Science ID 000330212600034
View details for PubMedID 24452043
- Population-Level Correlates of Preterm Delivery among Black and White Women in the U.S. PloS one 2014; 9 (4)
Population-level correlates of preterm delivery among black and white women in the U.S.
2014; 9 (4)
This study examined the ability of social, demographic, environmental and health-related factors to explain geographic variability in preterm delivery among black and white women in the US and whether these factors explain black-white disparities in preterm delivery.We examined county-level prevalence of preterm delivery (20-31 or 32-36 weeks gestation) among singletons born 1998-2002. We conducted multivariable linear regression analysis to estimate the association of selected variables with preterm delivery separately for each preterm/race-ethnicity group.The prevalence of preterm delivery varied two- to three-fold across U.S. counties, and the distributions were strikingly distinct for blacks and whites. Among births to blacks, regression models explained 46% of the variability in county-level risk of delivery at 20-31 weeks and 55% for delivery at 32-36 weeks (based on R-squared values). Respective percentages for whites were 67% and 71%. Models included socio-environmental/demographic and health-related variables and explained similar amounts of variability overall.Much of the geographic variability in preterm delivery in the US can be explained by socioeconomic, demographic and health-related characteristics of the population, but less so for blacks than whites.
View details for DOI 10.1371/journal.pone.0094153
View details for PubMedID 24740117
View details for PubMedCentralID PMC3989227
- The Transformation of Child Health Research Innovation, Market Failure, and the Public Good JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 2013; 309 (17): 1779-1780
Transdisciplinary translational science and the case of preterm birth
JOURNAL OF PERINATOLOGY
2013; 33 (4): 251-258
Medical researchers have called for new forms of translational science that can solve complex medical problems. Mainstream science has made complementary calls for heterogeneous teams of collaborators who conduct transdisciplinary research so as to solve complex social problems. Is transdisciplinary translational science what the medical community needs? What challenges must the medical community overcome to successfully implement this new form of translational science? This article makes several contributions. First, it clarifies the concept of transdisciplinary research and distinguishes it from other forms of collaboration. Second, it presents an example of a complex medical problem and a concrete effort to solve it through transdisciplinary collaboration: for example, the problem of preterm birth and the March of Dimes effort to form a transdisciplinary research center that synthesizes knowledge on it. The presentation of this example grounds discussion on new medical research models and reveals potential means by which they can be judged and evaluated. Third, this article identifies the challenges to forming transdisciplines and the practices that overcome them. Departments, universities and disciplines tend to form intellectual silos and adopt reductionist approaches. Forming a more integrated (or 'constructionist'), problem-based science reflective of transdisciplinary research requires the adoption of novel practices to overcome these obstacles.
View details for DOI 10.1038/jp.2012.133
View details for Web of Science ID 000316833300001
View details for PubMedID 23079774
View details for PubMedCentralID PMC3613736
The Utility of Childhood and Adolescent Obesity Assessment in Relation to Adult
MEDICAL DECISION MAKING
2013; 33 (2): 163-175
High childhood obesity prevalence has raised concerns about future adult health, generating calls for obesity screening of young children.To estimate how well childhood obesity predicts adult obesity and to forecast obesity-related health of future US adults.Longitudinal statistical analyses; microsimulations combining multiple data sets.National Longitudinal Survey of Youth, Population Study of Income Dynamics, and National Health and Nutrition Evaluation Surveys.The authors estimated test characteristics and predictive values of childhood body mass index to identify 2-, 5-, 10-, and 15 year-olds who will become obese adults. The authors constructed models relating childhood body mass index to obesity-related diseases through middle age stratified by sex and race.Twelve percent of 18-year-olds were obese. While screening at age 5 would miss 50% of those who become obese adults, screening at age 15 would miss 9%. The predictive value of obesity screening below age 10 was low even when maternal obesity was included as a predictor. Obesity at age 5 was a substantially worse predictor of health in middle age than was obesity at age 15. For example, the relative risk of developing diabetes as adults for obese white male 15-year-olds was 4.5 versus otherwise similar nonobese 15-year-olds. For obese 5-year-olds, the relative risk was 1.6.Main results do not include Hispanics due to sample size. Past relationships between childhood and adult obesity and health may change in the future.Early childhood obesity assessment adds limited information to later childhood assessment. Targeted later childhood approaches or universal strategies to prevent unhealthy weight gain should be considered.
View details for DOI 10.1177/0272989X12447240
View details for Web of Science ID 000316684200006
View details for PubMedID 22647830
Public Policy Implications of Promoting Growth
KARGER. 2013: 199–206
Translating the new science of growth into constructive policy will not happen naturally. Rather, the emerging science will need to be reframed to address certain core policy requirements. First, the complexity of early genetic and environmental interactions should be respected as their impact may vary in different, real-world settings. Second, the scale of impact is important to gauge as early-life interactions, while real, may not account for a large portion of later outcomes. Third, judgments regarding critical periods and the amenability of early-life influences to later intervention should be made cautiously as the etiologic nature or timing of early-life interactions do not, per se, determine if their life course effects are amenable to later interventions. Fourth, there is a need for incremental efficacy, such that the new science significantly enhances the impact of extant policy-based interventions. Finally, the translation of the new developmental science into policy should be viewed in a historical context and responsive to social and cultural needs. This provides a basis for reframing the new science of growth in a manner that best ensures that the science receives the constructive policy response it so urgently demands.
View details for DOI 10.1159/000342617
View details for Web of Science ID 000315539400022
View details for PubMedID 23502155
- Leveraging information technology to improve control of neglected tropical diseases. PLoS neglected tropical diseases 2013; 7 (11)
Predictors of Hospitalization After an Emergency Department Visit for California Youths With Psychiatric Disorders
2012; 63 (9): 896-905
This study examined patient, hospital, and county characteristics associated with hospitalization after emergency department visits for pediatric mental health problems.Retrospective analysis of emergency department encounters (N=324,997) of youths age five years to 17 years with psychiatric diagnoses was conducted with 2005-2009 California Office of Statewide Health Planning and Development emergency department statewide data.For youths with any psychiatric diagnosis, 23.4% of emergency department encounters resulted in hospitalization. In these cases, hospitalization largely was predicted by clinical need. Nonclinical factors that decreased the likelihood of hospitalization included demographic characteristics (such as younger age, lack of insurance, and rural residence) and resource characteristics (private hospital ownership, lack of psychiatric consultation in the emergency department, and lack of pediatric psychiatric beds). For youths with a significant psychiatric diagnosis plus a suicide attempt, 53.8% of emergency department encounters resulted in hospitalization. In these presumably more life-threatening cases, nonclinical factors that decreased the likelihood of hospitalization persisted: demographic characteristics (lack of insurance and rural residence) and resource characteristics (public hospital ownership, lack of psychiatric consultation, and lack of pediatric psychiatric beds).Mental health service delivery can improve only by addressing nonclinical demographic and resource obstacles that independently decrease the likelihood of hospitalization after an emergency department visit for a mental health issue; this is true even for the most severely ill youths-those with a suicide attempt as well as a serious psychiatric diagnosis.
View details for DOI 10.1176/appi.ps.201000482
View details for Web of Science ID 000308841700010
View details for PubMedID 22710574
The association between insurance status and emergency department disposition of injured California children.
Academic emergency medicine
2012; 19 (5): 541-551
This study examined the relationship between insurance status and emergency department (ED) disposition of injured California children.Multivariate regression models were built using data obtained from the 2005 through 2009 California Office of Statewide Health Planning and Development (OSHPD) data sets for all ED visits by injured children younger than 19 years of age.Of 3,519,530 injury-related ED visits, 52% were insured by private, and 36% were insured by public insurance, while 11% of visits were not insured. After adjustment for injury characteristics and demographic variables, publicly insured children had a higher likelihood of admission for mild, moderate, and severe injuries compared to privately insured children (mild injury adjusted odds ratio [AOR] = 1.36, 95% confidence interval [CI] = 1.34 to 1.39; moderate and severe injury AOR = 1.34, 95% CI = 1.28 to 1.41). However, uninsured children were less likely to be admitted for mild, moderate, and severe injuries compared to privately insured children (mild injury AOR = 0.63, 95% CI = 0.61 to 0.66; moderate and severe injury AOR = 0.50, 95% CI = 0.46 to 0.55). While publicly insured children with moderate and severe injuries were as likely as privately insured children to experience an ED death (AOR = 0.91, 95% CI = 0.70 to 1.18), uninsured children with moderate and severe injuries were more likely to die in the ED compared to privately insured children (AOR = 3.11, 95% CI = 2.38 to 4.06).Privately insured, publicly insured, and uninsured injured children have disparate patterns of ED disposition. Policy and clinical efforts are needed to ensure that all injured children receive equitable emergency care.
View details for DOI 10.1111/j.1553-2712.2012.01356.x
View details for PubMedID 22594358
Emerging Technologies and Their Impact on Disability
FUTURE OF CHILDREN
2012; 22 (1): 169-191
Technological innovation is transforming the prevalence and functional impact of child disability, the scale of social disparities in child disability, and perhaps the essential meaning of disability in an increasingly technology-dominated world. In this article, Paul Wise investigates several specific facets of this transformation. He begins by showing how technological change influences the definition of disability, noting that all technology attempts to address some deficiency in human capacity or in the human condition. Wise then looks at the impact of technology on childhood disabilities. Technical improvements in the physical environment, such as better housing, safer roads, and poison-prevention packaging, have significantly reduced childhood injury and disability. Other technological breakthroughs, such as those that identify genetic disorders that may lead to pregnancy termination, raise difficult moral and ethical issues. Technologies that identify potential health risks are also problematic in the absence of any efficient treatment. Wise stresses the imbalance in the existing health care delivery system, which is geared toward treating childhood physical illnesses that are declining in prevalence at a time when mental and emotional conditions, many of which are not yet well understood, are on the rise. This mismatch, Wise says, poses complex challenges to caring for disabled children, particularly in providing them with highly coordinated and integrated systems of care. Technology can also widen social disparities in health care for people, including children with disabilities. As Wise observes, efficacy--the ability of a technology to change health outcomes--is key to understanding the relationship of technology to social disparities. As technological innovation enhances efficacy, access to that technology becomes more important. Health outcomes may improve for those who can afford the technology, for example, but not for others. Hence, as efficacy grows, so too does the burden on society to provide access to technology equitably to all those in need. Without such access, technological innovation will likely expand disparities in child outcomes rather than reduce them.
View details for Web of Science ID 000303139700008
View details for PubMedID 22550690
- The Morality of Saved Lives AMERICAN JOURNAL OF BIOETHICS 2012; 12 (12): 1-2
Access to Pediatric Subspecialty Care: A Population Study of Pediatric Rheumatology Inpatients in California
ARTHRITIS CARE & RESEARCH
2011; 63 (7): 998-1005
To examine trends in the specialty care hospitalization of pediatric rheumatology patients and determine how nonclinical factors influence access.This study used California's Office of Statewide Health Planning and Development discharge database to perform a retrospective population analysis of pediatric rheumatology hospitalizations in California between 1999 and 2007. We used logistic regression to examine the relationship between hospitalization in specialty care centers with a pediatric rheumatologist and nonclinical patient characteristics.A total of 18,641 pediatric discharges revealed that 57% were discharged from a specialty care center with a pediatric rheumatologist. Multivariate analysis showed that the factors associated with increased utilization of specialty care centers with a pediatric rheumatologist were public insurance (odds ratio [OR] 1.62, 95% confidence interval [95% CI] 1.51-1.74; P < 0.0001), being Hispanic (OR 1.29, 95% CI 1.19-1.40; P < 0.0001) or Asian non-Hispanic (OR 1.39, 95% CI 1.26-1.54; P < 0.0001), and high pediatric rheumatology specialty care bed supply (OR 2.79, 95% CI 2.49-3.14; P < 0.0001). A decreased utilization of specialty care centers with a pediatric rheumatologist was seen for patients ages <1 year (OR 0.45, 95% CI 0.40-0.52; P < 0.0001), ages 1-4 years (OR 0.50, 95% CI 0.46-0.55; P < 0.0001), ages 5-9 years (OR 0.68, 95% CI 0.62-0.75; P < 0.0001), ages 15-18 years (OR 0.51, 95% CI 0.47-0.56; P < 0.0001), males (OR 0.75, 95% CI 0.70-0.80; P < 0.0001), and patients residing farther away from a specialty care center with a pediatric rheumatologist (OR 0.57, 95% CI 0.51-0.63; P < 0.0001).Nonclinical factors play an increasingly important role in the hospitalization patterns of pediatric rheumatology patients in California. Understanding these factors is crucial if we are to ensure that the variation in access to care reflects clinical need.
View details for DOI 10.1002/acr.20458
View details for Web of Science ID 000292809200011
View details for PubMedID 21360697
Factors Associated With Trauma Center Use for Elderly Patients With Trauma A Statewide Analysis, 1999-2008
ARCHIVES OF SURGERY
2011; 146 (5): 585-592
To estimate the likelihood of trauma center admission for injured elderly patients with trauma, determine trends in trauma center admissions, and identify factors associated with trauma center use for elderly patients with trauma.Retrospective analysis.Acute care hospitals in California.All patients hospitalized for acute traumatic injuries during the period from January 1, 1999, to December 31, 2008 (n = 430,081). Patients who had scheduled admissions for nonacute or minor trauma were excluded.Likelihood of admission to level I or II trauma center was calculated according to age categories after adjusting for patient and system factors.Of 430,081 patients admitted to California acute care hospitals for trauma-related diagnoses, 27% were older than 65 years. After adjusting for demographic, clinical, and system factors, compared with trauma patients aged 18-25 years, the odds of admission to a trauma center decreased with increasing age; patients aged 26-45 years had lower odds (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.71-0.80) of being admitted to a trauma center for their injuries than did patients 46-65 years of age (OR, 0.57; 95% CI, 0.54-0.60), patients 66-85 years of age (OR, 0.35; 95% CI, 0.30-0.41), and patients older than 85 years (OR, 0.30; 95% CI, 0.25-0.36). Similar patterns were found when stratifying the analysis by trauma type and severity. Living more than 50 miles away from a trauma center (OR, 0.03; 95% CI, 0.01-0.06) and lack of county trauma center (OR, 0.17; 95% CI, 0.09-0.35) were also predictors of not receiving trauma care.Age and likelihood of admission to a trauma center for injured patients were observed to be inversely proportional after controlling for other factors. System-level factors play a major role in determining which injured patients receive trauma care.
View details for DOI 10.1001/archsurg.2010.311
View details for Web of Science ID 000290633100024
View details for PubMedID 21242421
- Integrity Matters: Recapturing the Relevance of General Academic Pediatrics ACADEMIC PEDIATRICS 2011; 11 (2): 123-127
- Child Health Policy: Where Are You When We Need You? ACADEMIC PEDIATRICS 2010; 10 (5): 285-286
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
Children with Special Health Care Needs: How Immigrant Status is Related to Health Care Access, Health Care Utilization, and Health Status
MATERNAL AND CHILD HEALTH JOURNAL
2010; 14 (4): 567-579
To compare health care access, utilization, and perceived health status for children with SHCN in immigrant and nonimmigrant families. This cross-sectional study used data from the 2003 California Health Interview Survey to identify 1404 children (ages 0-11) with a special health care need. Chi-square and logistic regression analyses were used to examine relations between immigrant status and health access, utilization, and health status variables. Compared to children with special health care needs (CSHCN) in nonimmigrant families, CSHCN in immigrant families are more likely to be uninsured (10.4 vs. 4.8%), lack a usual source of care (5.9 vs. 1.9%), report a delay in medical care (13.0 vs. 8.1%), and report no visit to the doctor in the past year (6.8 vs. 2.6%). They are less likely to report an emergency room visit in the past year (30.0 vs. 44.0%), yet more likely to report fair or poor perceived health status (33.0 vs. 16.0%). Multivariate analyses suggested that the bivariate findings for children with SHCN in immigrant families largely reflected differences in family socioeconomic status, parent's language, parental education, ethnicity, and children's insurance status. Limited resources, non-English language, and limited health-care use are some of the barriers to staying healthy for CSHCN in immigrant families. Public policies that improve access to existing insurance programs and provide culturally and linguistically appropriate care will likely decrease health and health care disparities for this population.
View details for DOI 10.1007/s10995-009-0487-9
View details for Web of Science ID 000279477400010
View details for PubMedID 19554437
Variation in Specialty Care Hospitalization for Children With Chronic Conditions in California
2010; 125 (6): 1190-1199
Despite the documented utility of regionalized systems of pediatric specialty care, little is known about the actual use of such systems in total populations of chronically ill children. The objective of this study was to evaluate variations and trends in regional patterns of specialty care hospitalization for children with chronic illness in California.Using California's Office of Statewide Health Planning and Development unmasked discharge data set between 1999 and 2007, we performed a retrospective, total-population analysis of variations in specialty care hospitalization for children with chronic illness in California. The main outcome measure was the use of pediatric specialty care centers for hospitalization of children with a chronic condition in California.Analysis of 2 170 102 pediatric discharges revealed that 41% had a chronic condition, and 44% of these were discharged from specialty care centers. Specialty care hospitalization varied by county and type of condition. Multivariate analyses associated increased specialty care center use with public insurance and high pediatric specialty care bed supply. Decreased use of regionalized care was seen for adolescent patients, black, non-Hispanic children, and children who resided in zip codes of low income or were located farther from a regional center of care.Significant variation exists in specialty care hospitalization among chronically ill children in California. These findings suggest a need for greater scrutiny of clinical practices and child health policies that shape patterns of hospitalization of children with serious chronic disease.
View details for DOI 10.1542/peds.2009-1109
View details for Web of Science ID 000278268600013
View details for PubMedID 20439593
Impact of Managed Care on Publicly Insured Children with Special Health Care Needs
2010; 10 (1): 48-55
The aim of this review was to evaluate the impact of managed care on publicly insured children with special health care needs (CSHCN).We conducted a review of the extant literature. Using a formal computerized search, with search terms reflecting 7 specific outcome categories, we summarized study findings and study quality.We identified 13 peer-reviewed articles that evaluated the impact of Medicaid and State Children's Health Insurance program (SCHIP) Managed Care (MSMC) on health services delivery to populations of CSHCN, with all studies observational in design. Considered in total, the available scientific evidence is varied. Findings concerning care access demonstrate a positive effect of MSMC; findings concerning care utilization were mixed. Little information was identified concerning health care quality, satisfaction, costs, or health status, whereas no study yielded evidence on family impact.The available studies suggest that the evaluated record of MSMC for CSHCN has been mixed, with considerable heterogeneity in the definition of CSHCN, program design, and measured outcomes. These findings suggest caution should be exercised in implementing MSMC for CSHCN and that greater emphasis on health outcomes and cost evaluations is warranted.
View details for Web of Science ID 000279188000010
View details for PubMedID 20129481
Disparities in Trauma Center Access Despite Increasing Utilization: Data From California, 1999 to 2006
JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE
2010; 68 (1): 217-224
Although efforts have been made to address disparities in access to trauma care in the past decade, there is little evidence to show if utilization has changed. We use patient-level data to describe the changes in utilization of trauma centers (TCs) in an 8-year period in California.We analyzed all statewide trauma admissions (n = 752,706) using the California Office of Statewide Health Planning and Discharge Patient Discharge Database from the period of 1999 to 2006, and determined the trends in admissions and place of care.The proportion of severe injuries admitted increased by 3.6% (p < 0.05), with a concomitant rise in the proportion of patients with trauma to TCs, from 39.3% (95% CI: 39.0%-39.7%) to 49.7% (49.4%-50.0%). Within the severely injured with injury severity scores (ISS) >15, 82.4% were treated in a TC if they resided in a county with a TC, compared with 30.8% of patients who did not live in a county with a TC. After adjustment, patients living greater than 50 miles away from a TC still had a likelihood ratio of 0.11 (p < 0.0001) of receiving care in a TC compared with those less than 10 miles away. Similarly, even severely injured patients not living in a county with a TC had a likelihood ratio of 0.35 (p < 0.0001) of being admitted to a TC compared with those residing in counties with TCs.Admissions to TCs for all categories of injury severity are increasing. There remains, however, a large disparity in TC care depending on geographical distance and availability of a TC within county.
View details for DOI 10.1097/TA.0b013e3181a0e66d
View details for Web of Science ID 000273585800043
View details for PubMedID 19901854
Confronting social disparities in child health: a critical appraisal of life-course science and research.
2009; 124: S203-11
The utility of the life-course framework to address disparities in child health is based on its ability to integrate the science of child development with the requirements of effective and just public policy. I argue that the life-course framework is best assessed in a historical context and through 4 essential observations. First, early genetic and environmental interactions are complex and influence outcomes in different settings in very different ways. Second, these early-life interactions are themselves subject to considerable later influences and, therefore, may not be highly predictive of later outcomes. Third, the etiologic nature or timing of early-life interactions does not, per se, determine if their life-course effects are amenable to later interventions. Fourth, a highly deterministic view of early-life interactions is not supported by the science and can generate counterproductive approaches to research and policy development. Finally, an alternative approach is proposed on the basis of a "human-capacity" model of the life course that connects the search for underlying basic mechanisms with a policy-based examination of the comparative effectiveness of influences at different developmental stages. This approach suggests an expanded research and policy agenda that might be more capable of generating urgently needed strategies for reducing disparities in child health. Such an approach could ultimately define more comprehensively the power and limits of life-course effects in shaping the social distribution of health outcomes in the real world.
View details for DOI 10.1542/peds.2009-1100H
View details for PubMedID 19861471
- Children of the Recession ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE 2009; 163 (11): 1063-1064
Quality Improvement Strategies for Children With Asthma A Systematic Review
ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE
2009; 163 (6): 572-581
To evaluate the evidence that quality improvement (QI) strategies can improve the processes and outcomes of outpatient pediatric asthma care.Cochrane Effective Practice and Organisation of Care Group database (January 1966 to April 2006), MEDLINE (January 1966 to April 2006), Cochrane Consumers and Communication Group database (January 1966 to May 2006), and bibliographies of retrieved articles.Randomized controlled trials, controlled before-after trials, or interrupted time series trials of English-language QI evaluations.Must have included 1 or more QI strategies for the outpatient management of children with asthma.Clinical status (eg, spirometric measures); functional status (eg, days lost from school); and health services use (eg, hospital admissions).Seventy-nine studies met inclusion criteria: 69 included at least some component of patient education, self-monitoring, or self-management; 13 included some component of organizational change; and 7 included provider education. Self-management interventions increased symptom-free days by approximately 10 days/y (P = .02) and reduced school absenteeism by about 0.1 day/mo (P = .03). Interventions of provider education and those that incorporated organizational changes were likely to report improvements in medication use. Quality improvement interventions that provided multiple educational sessions, had longer durations, and used combinations of instructional modalities were more likely to result in improvements for patients than interventions lacking these characteristics.A variety of QI interventions improve the outcomes and processes of care for children with asthma. Use of similar outcome measures and thorough descriptions of interventions would advance the study of QI for pediatric asthma care.
View details for Web of Science ID 000266566700011
View details for PubMedID 19487615
Quality Improvement Strategies for Children With Asthma A Systematic Review
ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE
2009; 163 (6): E1-E5
View details for Web of Science ID 000266566700016
The Effect of Medicaid Managed Care on Prenatal Care: The Case of Puerto Rico
MATERNAL AND CHILD HEALTH JOURNAL
2009; 13 (2): 187-197
From 1994 to the year 2000 the government of Puerto Rico implemented a health care reform which included the mandatory enrollment of the entire Medicaid eligible population under Medicaid managed care (MMC) plans. This study assessed the effect of MMC on the use, initiation, utilization, and adequacy of prenatal care services over the reform period.Using the vital records of all infants born alive in Puerto Rico from the year 1995-2000, a series of bivariate and multivariate analyses were conducted to assess the effect of insurance status (traditional Medicaid, MMC, private insurance and uninsured) on prenatal care utilization patterns. In order to assess the potential influence of selection bias in generating the health insurance assignments, propensity scores (PS) were estimated and entered into the multivariate regressions.MMC had a generally positive effect on the frequency and adequacy of prenatal care when compared with the experience of women covered by traditional Medicaid. However, the PS analyses suggested that self-selection may have generated part of the observed beneficial effects. Also, MMC reduced but did not eliminate the gap in the amount and adequacy of prenatal care received by pregnant women covered by Medicaid when compared to their counterparts covered by private insurance.The Puerto Rico Health Reform to implement MMC for pregnant women was associated with a general improvement in prenatal care utilization. However, continued progress will be necessary for women covered by Medicaid to reach prenatal care utilization levels experienced by privately insured women.
View details for DOI 10.1007/s10995-008-0345-1
View details for Web of Science ID 000263081300004
View details for PubMedID 18484174
The "etiome": identification and clustering of human disease etiological factors
1st Summit on Translational Bioinformatics
BIOMED CENTRAL LTD. 2009
Both genetic and environmental factors contribute to human diseases. Most common diseases are influenced by a large number of genetic and environmental factors, most of which individually have only a modest effect on the disease. Though genetic contributions are relatively well characterized for some monogenetic diseases, there has been no effort at curating the extensive list of environmental etiological factors.From a comprehensive search of the MeSH annotation of MEDLINE articles, we identified 3,342 environmental etiological factors associated with 3,159 diseases. We also identified 1,100 genes associated with 1,034 complex diseases from the NIH Genetic Association Database (GAD), a database of genetic association studies. 863 diseases have both genetic and environmental etiological factors available. Integrating genetic and environmental factors results in the "etiome", which we define as the comprehensive compendium of disease etiology. Clustering of environmental factors may alert clinicians of the risks of added exposures, or synergy in interventions to alter these factors. Clustering of both genetic and environmental etiological factors puts genes in the context of environment in a quantitative manner.In this paper, we obtained a comprehensive list of associations between disease and environmental factors using MeSH annotation of MEDLINE articles. It serves as a summary of current knowledge between etiological factors and diseases. By combining the environmental etiological factors and genetic factors from GAD, we computed the "etiome" profile for 863 diseases. Comparing diseases across these profiles may have utility for clinical medicine, basic science research, and population-based science.
View details for DOI 10.1186/1471-2105-10-S2-S14
View details for Web of Science ID 000265602500015
View details for PubMedID 19208189
- The Rebirth of Pediatrics PEDIATRICS 2009; 123 (1): 413-416
Variability in Pediatric Utilization of Trauma Facilities in California: 1999 to 2005
ANNALS OF EMERGENCY MEDICINE
2008; 52 (6): 607-615
We identify geographic, system, and socioeconomic differences between injured children cared for within and outside of state-designated trauma centers.This was a nonconcurrent observational study of a population-based sample from the California Office of Statewide Health Planning and Development Public Patient Discharge Database 1999 to 2005. Patients were 1 to 14 years of age, with International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes indicative of trauma. Injury Severity Scores were calculated from ICD-9 codes and categorized into severity categories. Outcomes were hospitalization in a trauma or nontrauma center.Children with severe injury who resided 0 to 10, 11 to 25, 26 to 50, and more than 50 miles from a trauma center were hospitalized in these centers at rates of 80.0%, 71.2%, 51.4%, and 28.5%, respectively. Children with severe injury who were living in a county with a trauma center were hospitalized in these centers at rates of 78.8%, whereas children living in a county without a trauma center were hospitalized in trauma centers at rates of 39.0%. Children with severe injury and public, private non-health maintenance organization (HMO), and HMO insurance were hospitalized in trauma centers at rates of 77.7%, 68.0%, and 55.4%, respectively. Age, injury severity, insurance type, residence in a county with a trauma center, and proximity to a trauma center were identified as predictors of trauma center utilization by logistic regression.We demonstrate considerable variation in the utilization pattern of trauma specialty care for children with moderate and severe injuries. Children with HMO and private insurance are cared for less often in trauma centers than those with public insurance, even after adjustment for other variables. Increased distance to a trauma center, as well as lack of trauma center within a county, also decreases trauma center utilization. These results suggest that assessing trauma center utilization patterns in total populations of children may identify opportunities for improved referral policies and practices as part of a larger effort to ensure high-quality trauma care for all children in need.
View details for DOI 10.1016/j.annemergmed.2008.05.011
View details for Web of Science ID 000261540200002
View details for PubMedID 18562043
TRANSFORMING PRECONCEPTIONAL, PRENATAL, AND INTERCONCEPTIONAL CARE INTO A COMPREHENSIVE COMMITMENT TO WOMEN'S HEALTH
WOMENS HEALTH ISSUES
2008; 18 (6): S13-S18
Preconception and interconception care respond to the growing body of evidence that many of the most important determinants of birth outcomes may exist before pregnancy occurs. In this sense, the strategy of extending prenatal care into the preconception and interconception periods marks a useful step in reforming the public health approach to improving birth outcomes. However, although helpful in underscoring the continuity of risk that can ultimately find expression in adverse birth outcomes, the concern is that without greater critical attention these relatively new care constructs have the potential to undermine rather than strengthen a comprehensive system of women's health care.
View details for DOI 10.1016/j.whi.2008.07.014
View details for Web of Science ID 000262091300004
View details for PubMedID 18951817
Using linked data to assess patterns of Early Intervention (EI) referral among very low birth weight infants
10th Annual Maternal and Child Health Epidemiology Conference
SPRINGER/PLENUM PUBLISHERS. 2008: 24–33
Access to Early Intervention (EI) services may improve cognitive and behavioral outcomes in very low birth weight infants, but few states have population-based data to evaluate EI outreach efforts. We analyzed Massachusetts (MA) infants born weighing <1,200 g to identify maternal and birth characteristics that predicted EI referral and timing of referral.MA birth and hospital discharge records (Jan. 1998-Sept. 2000) were linked to EI referral records (Jan. 1998-Sept. 2003) via probabilistic and deterministic methods (88% linkage). Timing of EI referral among infants weighing <1,200 g was examined by infant and maternal characteristics using categorical (0-12 months, 12-36 months, or no referral) time comparisons in the crude analysis. Survival functions calculating median time to referral, and adjusted hazard ratios (HR) with 95% confidence intervals (CI) were calculated for continuous time comparisons of EI referral from birth to 36 months.Of 1,233 infants weighing <1,200 g, 93.2% were referred to EI. After risk adjustment, referral was more likely among multiple-birth infants (HR = 1.17, 95%CI 1.06-1.30) and less likely among infants <28 weeks (HR = 0.70; 95%CI 0.64-0.77) or with low Apgar scores (<5 at 5 min; HR = 0.75; 95%CI 0.62-0.92). EI referrals were lower for infants of black non-Hispanic mothers, and mothers without private insurance (HR = 0.85; 95%CI 0.74-0.98 and HR = 0.77; 95%CI 0.68-0.86, respectively).In MA, most infants born <1,200 g are referred to EI, but disparities exist. Analysis of linked population-based health and developmental services can inform programs in order to reduce disparities and improve access for all high-risk infants.
View details for DOI 10.1007/s10995-007-0227-y
View details for Web of Science ID 000251867600003
View details for PubMedID 17562149
The relationship of immigrant status with access, utilization, and health status for children with asthma
2007; 7 (6): 421-430
Despite their high levels of poverty and less access to health care, children in immigrant families have better than expected health outcomes compared with children in nonimmigrant families. However, this observation has not been confirmed in children with chronic illness. The objective of this study was to determine whether children with asthma in immigrant families have better than expected health status than children with asthma in nonimmigrant families.Data from the 2001 and 2003 California Health Interview Survey (CHIS) were used to identify 2600 children, aged 1 to 11, with physician-diagnosed asthma. Bivariate analyses and logistic regression were performed to examine health care access, utilization, and health status measures by our primary independent variable, immigrant family status.Compared with children with asthma in nonimmigrant families, children with asthma in immigrant families are more likely to lack a usual source of care (2.6% vs 1.0%; P < .05), report a delay in medical care (8.9% vs 5.2%; P < .01), and report no visit to the doctor in the past year (7.0% vs 3.8%; P < .05). They are less likely to report asthma symptoms (60.8% vs 74.4%; P < .01) and an emergency room visit in the past year (14.1% vs 21.1%; P < .01), yet more likely to report fair or poor perceived health status (25.0% vs 10.5%; P < .01). Multivariate models revealed that the relationship of immigrant status with health measures was complex. These models suggested that lack of insurance and poverty was associated with reduced access and utilization. Children in immigrant families were less likely to visit the emergency room for asthma in the past year (odds ratio 0.58, confidence interval, 0.36-0.93). Poverty was associated with having a limitation in function and fair or poor perceived health, whereas non-English interview language was associated with less limitation in function but greater levels of fair or poor perceived health.Clinicians should be aware of important barriers to care that may exist for immigrant families who are poor, uninsured, and non-English speakers. Reduced health care access and utilization by children with asthma in immigrant families requires policy attention. Further research should examine barriers to care as well as parental perceptions of health for children with asthma in immigrant families.
View details for Web of Science ID 000251638400005
View details for PubMedID 17996835
The future pediatrician: The challenge of chronic illness
JOURNAL OF PEDIATRICS
2007; 151 (5): S6-S10
To relate the changing epidemiology of childhood to current patterns of pediatric practice in the United States, a critical literature review and selected analyses of national datasets, including the National Health Interview Survey, the National Hospital Discharge Survey, and National Vital Statistics System, were conducted. Trends over the past several decades suggest that the incidence of serious acute illness in children has fallen while the prevalence of chronic disease has risen. These trends have resulted in a growing concentration of serious childhood morbidity and mortality into chronic disorders. Current pediatric practice structures appear to be poorly suited to meet the growing demands of chronic disease in children and likely will require major reform in organization, financing, and training.
View details for DOI 10.1016/Jpeds.2007.08.013
View details for Web of Science ID 000250915000003
View details for PubMedID 17950322
Inhalational, gastrointestinal, and cutaneous anthrax in children
ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE
2007; 161 (9): 896-905
To systematically review all published case reports of children with anthrax to evaluate the predictors of disease progression and mortality.Fourteen selected journal indexes (1900-1966), MEDLINE (1966-2005), and the bibliographies of all retrieved articles.Case reports (any language) of anthrax in persons younger than 18 years published between January 1, 1900, and December 31, 2005. Main Exposures Cases with symptoms and culture or Gram stain or autopsy evidence of anthrax infection.Disease progression, treatment responses, and mortality.Of 2499 potentially relevant articles, 73 case reports of pediatric anthrax (5 inhalational cases, 22 gastrointestinal cases, 37 cutaneous cases, 6 cases of primary meningoencephalitis, and 3 atypical cases) met the inclusion criteria. Only 10% of the patients were younger than 2 years, and 24% were girls. Of the few children with inhalational anthrax, none had nonheadache neurologic symptoms, a key finding that distinguishes adult inhalational anthrax from more common illnesses, such as influenza. Overall, observed mortality was 60% (3 of 5) for inhalational anthrax, 65% (13 of 20) for gastrointestinal anthrax, 14% (5 of 37) for cutaneous anthrax, and 100% (6 of 6) for primary meningoencephalitis. Nineteen of the 30 children (63%) who received penicillin-based antibiotics survived, and 9 of the 11 children (82%) who received anthrax antiserum survived.The clinical presentation of children with anthrax is varied. The mortality rate is high in children with inhalational anthrax, gastrointestinal anthrax, and anthrax meningoencephalitis. Rapid diagnosis and effective treatment of anthrax in children requires recognition of the broad spectrum of clinical presentations of pediatric anthrax.
View details for Web of Science ID 000249156800013
View details for PubMedID 17768291
- The UNICEF report on child well-being AMBULATORY PEDIATRICS 2007; 7 (4): 265-266
Families' health-related social problems and missed referral opportunities
2007; 119 (6): E1332-E1341
The objectives of this study were to characterize (1) families' cumulative burden of health-related social problems regarding access to health care, housing, food security, income security, and intimate partner violence; (2) families' experiences regarding screening and referral for social problems; and (3) parental acceptability of screening and referral.We surveyed 205 parents of children who were 0 to 6 years of age and attended 2 urban pediatric clinics for a well-child visit using a self-administered, computer-based questionnaire. The questionnaire included previously validated questions about health-related social problems and new questions about screening and referral in the past 12 months.A total of 205 (79%) of 260 eligible families participated. Eighty-two percent of families reported > or = 1 health-related social problem; 54% experienced problems in > or = 2 social domains. Families experienced similar types and frequencies of problems despite demographic differences between clinics. One third of families reported no screening in any domain in the previous 12 months. Of 205 families, 143 (70%) identified at least 1 need for a referral; 101 (49%) expressed > or = 1 unmet referral need. Of families who reported receiving referrals, 115 referrals were received by 79 families; of the referrals made, 63% (73 of 115) led to contact with the referral agency, and 82% (60 of 73) of the referral agencies were considered helpful. A computer-based system in a pediatrician's office for future screening and referral for health-related social problems was deemed acceptable by 92% of parents.Urban children and families reported a significant burden of health-related social problems yet infrequent pediatric screening or referral for these problems. Of families who reported receiving referrals, a majority contacted the recommended agencies and found them helpful. This study also demonstrates the feasibility of using a computer-based questionnaire to identify health-related social problems in a routine outpatient clinic setting.
View details for DOI 10.1542/peds.2006-1505
View details for Web of Science ID 000246948900078
View details for PubMedID 17545363
Trauma center utilization for children in California 1998-2004: Trends and areas for further analysis
ACADEMIC EMERGENCY MEDICINE
2007; 14 (4): 309-315
While it is known that trauma systems improve the outcome of injury in children, there is a paucity of information regarding trauma system function amid changes in policies and health care financing that affect emergency medical systems for children.To describe the trends in the proportion of pediatric trauma patients acutely hospitalized in trauma-designated versus non-trauma-designated hospitals.This was a retrospective observational study of a population-based cohort obtained by secondary analysis of a publicly available data set: the California Office of Statewide Health Planning and Development Patient Discharge Database from 1998 to 2004. Patients were included in the analysis if they were 0-19 years old, had International Classification of Disease, Ninth Revision (ICD-9) diagnostic codes and E-codes indicative of trauma, had an unscheduled admission, and were discharged from a general acute care hospital (N = 111,566). Proportions of patients hospitalized in trauma-designated hospitals versus non-trauma-designated hospitals were calculated for Injury Severity Score and death. Injury Severity Scores were calculated from ICD-9 codes. Primary outcomes were hospitalization in a trauma center and death two or more days after hospitalization.Over the study period, the proportion of children aged 0-14 years with acute trauma requiring hospitalization and who were cared for in trauma-designated hospitals increased from 55% (95% confidence interval [CI] = 54% to 56%) in 1998 to 66% (95% CI = 65% to 67%) in 2004 (p < 0.01). For children aged 15-19 years, the proportion increased from 55% (95% CI = 54% to 57%) in 1998 to 74% (95% CI = 72% to 75%) in 2004 (p < 0.0001). When trauma discharges were stratified by injury severity, the proportion of children with severe injury who were hospitalized in trauma-designated hospitals increased from 69% (95% CI = 66% to 72%) in 1998 to 84% (95% CI = 82% to 87%) in 2004, a rate higher than in children with moderate injury (59% [95% CI = 58% to 61%] in 1998 and 75% [95% CI = 74% to 76%] in 2004) and mild injury (51% [95% CI = 50% to 52%] in 1998 and 63% [95% CI = 62% to 64%] in 2004) (p < 0.0001 for each injury severity category and both age groups). Of the hospitalized children who died two or more days after injury (n = 502), 18.1% died in non-trauma-designated hospitals (p < 0.002 for children aged 0-14 years; p = 0.346 for children aged 15-19 years).An increasing majority of children with trauma were cared for in trauma-designated hospitals over the study period. However, 23% of children with severe injuries, and 18.1% of pediatric deaths more than two days after injury, were cared for in non-trauma-designated hospitals. These findings demonstrate an important opportunity for improvement. If we can characterize those children who do not access the trauma system despite severe injury or death, we will be able to design clinical protocols and implement policies that ensure access to appropriate regional trauma care for all children in need.
View details for DOI 10.1197/j.aem.2006.11.012
View details for Web of Science ID 000245579300003
View details for PubMedID 17296799
Crossing the Medicaid-private insurance divide: The case of EPSDT
2007; 26 (2): 382-393
Contained in the Deficit Reduction Act of 2005 is a provision that could greatly affect Medicaid's signature child health coverage standard, embodied since 1967 in the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit. Whether the core child health and developmental principles that have been EPSDT's touchstone for four decades will continue to guide Medicaid depends on whether and how these principles will be incorporated into states' coverage reforms.
View details for DOI 10.1377/hlthaff.26.2.382
View details for Web of Science ID 000244763500009
View details for PubMedID 17339664
Pediatric anthrax: implications for bioterrorism preparedness.
Evidence report/technology assessment
To systematically review the literature about children with anthrax to describe their clinical course, treatment responses, and the predictors of disease progression and mortality.MEDLINE (1966-2005), 14 selected journal indexes (1900-1966) and bibliographies of all retrieved articles.We sought case reports of pediatric anthrax published between 1900 and 2005 meeting predefined criteria. We abstracted three types of data from the English-language reports: (1) Patient information (e.g., age, gender, nationality), (2) symptom and disease progression information (e.g., whether the patient developed meningitis); (3) treatment information (e.g., treatments received, year of treatment). We compared the clinical symptoms and disease progression variables for the pediatric cases with data on adult anthrax cases reviewed previously.We identified 246 titles of potentially relevant articles from our MEDLINE(R) search and 2253 additional references from our manual search of the bibliographies of retrieved articles and the indexes of the 14 selected journals. We included 62 case reports of pediatric anthrax including two inhalational cases, 20 gastrointestinal cases, 37 cutaneous cases, and three atypical cases. Anthrax is a relatively common and historically well-recognized disease and yet rarely reported among children, suggesting the possibility of significant under-diagnosis, underreporting, and/or publication bias. Children with anthrax present with a wide range of clinical signs and symptoms, which differ somewhat from the presenting features of adults with anthrax. Like adults, children with gastrointestinal anthrax have two distinct clinical presentations: Upper tract disease characterized by dysphagia and oropharyngeal findings and lower tract disease characterized by fever, abdominal pain, and nausea and vomiting. Additionally, children with inhalational disease may have "atypical" presentations including primary meningoencephalitis. Children with inhalational anthrax have abnormal chest roentgenograms; however, children with other forms of anthrax usually have normal roentgenograms. Nineteen of the 30 children (63%) who received penicillin-based antibiotics survived; whereas nine of 11 children (82%) who received anthrax antiserum survived.There is a broad spectrum of clinical signs and symptoms associated with pediatric anthrax. The limited data available regarding disease progression and treatment responses for children infected with anthrax suggest some differences from adult populations. Preparedness planning efforts should specifically address the needs of pediatric victims.
View details for PubMedID 17764208
Intergenerational health disparities: Socioeconomic status, women's health conditions, and child behavior problems
PUBLIC HEALTH REPORTS
2005; 120 (4): 399-408
Relatively little is known about the intergenerational mechanisms that lead to social disparities in child health. We examined whether the association between low socioeconomic status (SES) and child behavior problems is mediated by maternal health conditions and behavior.Prospective cohort data (1979-1998) on 2,677 children and their mothers were obtained from the National Longitudinal Survey of Youth. SES, the Child Behavior Problems Index (BPI), and maternal smoking, depressive symptoms, and alcohol use before, during, and after pregnancy were examined.Lower income and lower maternal education were associated with increased child BPI scores. Adjustment for maternal smoking, depressive symptoms, and alcohol use attenuated the associations between SES and child BPI by 26% to 49%. These maternal health conditions often occurred together, persisted over time, and were associated with the mother's own childhood SES and pre-pregnancy health.Social disparities in women's health conditions may help shape the likelihood of behavior problems in the subsequent generation. Improved public health programs and services for disadvantaged women across the lifecourse may not only address their own urgent health needs, but reduce social disparities in the health and well-being of their children.
View details for Web of Science ID 000230046800007
View details for PubMedID 16025720
The "Lost boys of Sudan" - Functional and behavioral health of unaccompanied refugee minors resettled in the United States
Annual Meeting of the Pediatric-Academic-Societies/Society-for-Pediatric-Research
AMER MEDICAL ASSOC. 2005: 585–91
To assess the functional and behavioral health of unaccompanied Sudanese refugee minors approximately 1 year after resettlement in the United States.A descriptive survey.Local refugee foster care programs affiliated with the US Unaccompanied Refugee Minors Program.A total of 304 Sudanese refugee minors enrolled in the US Unaccompanied Refugee Minors Program.Health outcomes were assessed using the Harvard Trauma Questionnaire and the Child Health Questionnaire. Outcomes included the diagnosis of posttraumatic stress disorder and scores on all Child Health Questionnaire subscales and global single-item assessments.Twenty percent of the minors had a diagnosis of posttraumatic stress disorder and were more likely to have lower (worse) scores on all the Child Health Questionnaire subscales. Low functional and behavioral health scores were seen mainly in functioning in the home and in subjective health ratings. Social isolation and history of personal injury were associated with posttraumatic stress disorder.Unaccompanied Sudanese minors have done well in general. The minors function well in school and in activities; however, behavioral and emotional problems manifest in their home lives and emotional states. The subset of children with traumatic symptoms had characteristics that may distinguish them from their peers and that may inform future resettlement services for unaccompanied minors in the United States.
View details for Web of Science ID 000229448300013
View details for PubMedID 15939860
- Creating an analytic voice in the policy storm AMBULATORY PEDIATRICS 2005; 5 (1): 45-46
The transformation of child health in the United States
Conference on the Future of Pediatric Training
PROJECT HOPE. 2004: 9–25
Social trends and medical progress have fueled major changes in the epidemiology of child health in the United States. Injuries remain a major contributor to childhood illness and death. However, among noninjury causes, chronic illness now accounts for the majority of children's hospital days and deaths. Although mortality rates for all children have fallen dramatically, social disparities persist. Approximately half of all excess deaths among African American children occur during infancy, primarily from extremely premature births, and the remaining portion, primarily from homicide and serious chronic conditions. These challenges may require changes in today's child health practices and policies.
View details for DOI 10.1377/hlthaff.23.5.9
View details for Web of Science ID 000224027800002
View details for PubMedID 15495347
- Low-income mothers' experience with poor health, hardship, work, and violence - Implications for policy VIOLENCE AGAINST WOMEN 2003; 9 (10): 1231-1244
Framework as metaphor: the promise and peril of MCH life-course perspectives.
Maternal and child health journal
2003; 7 (3): 151-156
Life-course analytic frameworks expressly link the determinants of health and illness across the lifespan. Such frameworks could serve as a foundation for integrating child and adult health policies by emphasizing the potential that social and biologic processes early in life can find clinical expression as adult-onset disease. However, there are elements of these frameworks that can be misinterpreted in ways that obscure scientific processes and fragment rather than integrate health policies. First, casting early life influences as determining rather than merely influencing adult health obscures the complexity of social and biologic etiologies over a lifetime and diminishes the impact of events in adolescence and adult life. Second, oversimplifying the impact of early influences on adult disease tends to imply that such processes are particularly unamenable to clinical and public health interventions, a suggestion without an empirical basis and likely to undermine pleas for enhanced access to such interventions. Third, exaggerating early life events as being highly deterministic of adult illness in order to shift societal resources from the elderly towards children can generate unnecessary antagonisms between potentially allied constituencies. Together, these considerations suggest that the utility of life-course frameworks will depend upon cautious interpretation and an ongoing process of active refinement.
View details for PubMedID 14509410
The anatomy of a disparity in infant mortality
ANNUAL REVIEW OF PUBLIC HEALTH
2003; 24: 341-362
This article suggests that while disparities in infant mortality have been longstanding, the mechanisms of disparity creation are undergoing intense change. This dynamic character is explored by first developing an analytic model that examines the interaction between social factors and the public health and clinical capacity to intervene. Disparities in infant mortality are then broken down into their component parts and linked to specific arenas of intervention. Disparities in postneonatal mortality are being shaped by differential access to interventions designed to prevent infant death from congenital anomalies and the Sudden Infant Death Syndrome. Disparities in neonatal mortality are primarily determined by factors that influence the birthrate of extremely premature infants and access to specialized obstetrical and pediatric care. This analysis suggests that the epidemiology and social meaning of disparities in infant mortality are intensely dynamic and increasingly reflect the interaction between social forces and technical innovation.
View details for DOI 10.1146/annurev.publhealth.24.100901.140816
View details for Web of Science ID 000185094600018
View details for PubMedID 12471271
- The State Children's Health Insurance Program - Effective but vulnerable ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE 2002; 156 (12): 1175-1176
- The data are in: Health matters in welfare policy AMERICAN JOURNAL OF PUBLIC HEALTH 2002; 92 (9): 1392-1395
Welfare to work? Impact of maternal health on employment
AMERICAN JOURNAL OF PUBLIC HEALTH
2002; 92 (9): 1462-1468
This study investigated whether health problems among poor mothers of chronically ill children affect their ability to obtain and maintain employment.Mothers of children with chronic illnesses were surveyed at clinical and welfare agency sites in San Antonio, Tex.There were distinct health differences according to mothers' TANF and employment status. Mothers without TANF experience reported better physical and mental health and less domestic violence and substance use than did those who had TANF experience. Those not currently working had higher rates of physical and mental health problems.Poor maternal health is associated with need for cash assistance and health insurance. Policymakers must recognize that social policies promoting employment will fail if they do not address the health needs of poor women and children.
View details for Web of Science ID 000177661900021
View details for PubMedID 12197974
Relationships between welfare status, health insurance status, and health and medical care among children with asthma
AMERICAN JOURNAL OF PUBLIC HEALTH
2002; 92 (9): 1446-1452
This study evaluated the relationships between health insurance and welfare status and the health and medical care of children with asthma.Parents of children with asthma aged 2 to 12 years were interviewed at 6 urban clinical sites and 2 welfare offices.Children whose families had applied for but were denied welfare had more asthma symptoms than did children whose families had had no contact with the welfare system. Poorer mental health in parents was associated with more asthma symptoms and higher rates of health care use in their children. Parents of uninsured and transiently insured children identified more barriers to health care than did parents whose children were insured.Children whose families have applied for welfare and children who are uninsured are at high risk medically and may require additional services to improve health outcomes.
View details for Web of Science ID 000177661900018
View details for PubMedID 12197971
Employment barriers among welfare recipients and applicants with chronically ill children
AMERICAN JOURNAL OF PUBLIC HEALTH
2002; 92 (9): 1453-1457
This study evaluated the association of chronic child illness with parental employment among individuals who have had contact with the welfare system.Parents of children with chronic illnesses were interviewed.Current and former welfare recipients and welfare applicants were more likely than those with no contact with the welfare system to report that their children's illnesses adversely affected their employment. Logistic regression analyses showed that current and former receipt of welfare, pending welfare application, and high rates of child health care use were predictors of unemployment.Welfare recipients and applicants with chronically ill children face substantial barriers to employment, including high child health care use rates and missed work. The welfare reform reauthorization scheduled to occur later in 2002 should address the implications of chronic child illness for parental employment.
View details for Web of Science ID 000177661900019
View details for PubMedID 12197972
Chronic illness among poor children enrolled in the temporary assistance for needy families program
AMERICAN JOURNAL OF PUBLIC HEALTH
2002; 92 (9): 1458-1461
This study assessed chronic child illness among recipients of Temporary Assistance for Needy Families (TANF) benefits and poor families not receiving benefits.Data from the 1998 National Health Interview Survey were used to examine chronic child illness, enrollment in TANF, health insurance status, and selected access indicators.One quarter of TANF-enrolled children had chronic illnesses. Unenrolled children were 3 times as likely as TANF-enrolled children to be uninsured. Among the chronically ill, 31.7% of unenrolled and 14.3% of enrolled children experienced gaps in insurance coverage that were associated with access barriers.Welfare policies should consider the effects of chronic illness and gaps in insurance coverage on the health of poor children.
View details for Web of Science ID 000177661900020
View details for PubMedID 12197973
Women's health after pregnancy and child outcomes at age 3 years: A prospective cohort study
AMERICAN JOURNAL OF PUBLIC HEALTH
2002; 92 (8): 1312-1318
This study examined the persistence and comorbidity of women's physical and mental health conditions after pregnancy and the association of these conditions with child outcomes.A national cohort of women who recently gave birth were surveyed in 1988 and again in 1991. We examined longitudinal data on maternal poor physical health, depressive symptoms, and smoking, and maternal report of child outcomes (at age approximately 3 years).Women's poor physical health and smoking had strong, graded associations with children's physical health and behavior problems, whereas women's depressive symptoms were associated with children's delayed language and behavior problems.Substantial persistence and comorbidity of women's health conditions exist after pregnancy with adverse effects on early child outcomes. Child health professionals should support services and policies that promote women's health outside the context of pregnancy.
View details for Web of Science ID 000177109800028
View details for PubMedID 12144990
Knowledge of welfare reform program provisions among families of children with chronic conditions
AMERICAN JOURNAL OF PUBLIC HEALTH
2002; 92 (2): 228-230
This study examined the knowledge of and application for health-related welfare program provisions among beneficiaries with children who have chronic conditions.We administered a survey to 143 parents of children aged 3 to 16 years with asthma or sickle cell anemia in 2 clinical settings.Respondents indicated incomplete knowledge of work requirements (69.9%) and work exemptions (50.3%). Applications for work exemptions were rare, even among Supplemental Security Income recipients (30%).Welfare beneficiaries with children who have chronic conditions show limited knowledge and use of program provisions, placing them at risk for penalties or benefit termination.
View details for Web of Science ID 000173558000021
View details for PubMedID 11818296
Maternal cigarette smoking, metabolic gene polymorphism, and infant birth weight
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
2002; 287 (2): 195-202
Little is known about genetic susceptibility to cigarette smoke in relation to adverse pregnancy outcomes.To investigate whether the association between maternal cigarette smoking and infant birth weight differs by polymorphisms of 2 maternal metabolic genes: CYP1A1 and GSTT1.Case-control study conducted in 1998-2000 among 741 mothers (174 ever smokers and 567 never smokers) who delivered singleton live births at Boston Medical Center. A total of 207 cases were preterm or low-birth-weight infants and 534 were non-low-birth-weight, full-term infants (control).Birth weight, gestation, fetal growth by smoking status and CYP1A1 MspI (AA vs Aa and aa, where Aa and aa were combined because of small numbers of aa and similar results), and GSTT1 (present vs absent) genotypes.Without consideration of genotype, continuous maternal smoking during pregnancy was associated with a mean reduction of 377 g (SE, 89 g) in birth weight (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.2-3.7). When CYP1A1 genotype was considered, the estimated reduction in birth weight was 252 g (SE, 111 g) for the AA genotype group (n = 75; OR, 1.3; 95% CI, 0.6-2.6), but was 520 g (SE, 124 g) for the Aa/aa genotype group (n = 43 for Aa, n = 6 for aa; OR, 3.2; 95% CI, 1.6-6.4). When GSTT1 genotype was considered, the estimated reduction in birth weight was 285 g (SE, 99 g) (OR, 1.7; 95% CI, 0.9-3.2) and 642 g (SE, 154 g) (OR, 3.5; 95% CI, 1.5-8.3) for the present and absent genotype groups, respectively. When both CYP1A1 and GSTT1 genotypes were considered, the greatest reduction in birth weight was found among smoking mothers with the CYP1A1 Aa/aa and GSTT1 absent genotypes (-1285 g; SE, 234 g; P<.001). Among never smokers, genotype did not independently confer an adverse effect. A similar pattern emerged in analyses stratified by maternal ethnicity and in analyses for gestation.In our study, maternal CYP1A1 and GSTT1 genotypes modified the association between maternal cigarette smoking and infant birth weight, suggesting an interaction between metabolic genes and cigarette smoking.
View details for Web of Science ID 000173114900021
View details for PubMedID 11779261
Welfare, women, and children: it's time for doctors to speak out.
Journal of the American Medical Women's Association (1972)
2002; 57 (1): 3-?
View details for PubMedID 11905487
State welfare reform policies and maternal and child health services: a national study.
Maternal and child health journal
2001; 5 (3): 199-206
Welfare reform (Personal Responsibility and Work Opportunity Reconciliation Act of 1996) resulted in dramatic policy changes, including health-related requirements and the administrative separation of cash assistance from Medicaid. We were interested in determining if changes in welfare and health policies had had an impact on state MCH services and programs.We conducted a survey in fall 1999 of state MCH Title V directors. Trained interviewers administered the telephone survey over a 3-month period. MCH directors from all 50 states, Washington, DC, and Puerto Rico participated (n = 52; response rate = 100%).Among the most noteworthy findings is that similar proportions of respondents reported that welfare policy changes had either helped (46%) or hindered (42%) the agency's work, with most of the positive impact attributed to increased funding. MCH data linkages with welfare and other social programs were low. Despite welfare reform's emphasis on work, limited services and exemptions were available for mothers with CSHCN. Almost no efforts have been undertaken to specifically address the needs of substance abusers in the context of new welfare policies.Few MCH agencies have developed programs to address the special needs of women receiving TANF who either have health problems themselves or have children with health problems. Recommendations including increased MCH and family planning funding and improved coordination between TANF and MCH to facilitate linkages and services are put forth in light of reauthorization of PRWORA.
View details for PubMedID 11605725
Molecular epidemiology of preterm delivery: methodology and challenges
PAEDIATRIC AND PERINATAL EPIDEMIOLOGY
2001; 15: 63-77
Preterm delivery (PTD) appears to be a complex trait determined by both genetic and environmental factors. Few studies have examined genetic influence on PTD. The overall goal of our study is to examine major candidate genes of PTD and to test gene-environment interactions. Our study includes 500 preterm trios, including 500 preterm babies and their parents and 500 maternal age-matched term controls. We will perform the transmission/disequilibrium test (TDT) on candidate genes thought to be important in each of the four biological pathways of PTD: (1) decidual chorioamionotic inflammation: interleukin 1 (IL-1), IL-6, and tumour necrosis factor (TNF); (2) maternal and fetal stress: corticotropin-releasing hormone (CRH); (3) uteroplacental vascular lesions: methylenetereahydrofolate reductase (MTHFR); and (4) susceptibility to environmental toxins: GSTM1, GSTT1, CYP1A1, CYP2D6, CYP2E1, NAT2, NQO1, ALDH2, and EPHX. We will also perform standard case-control analyses on the 500 preterm cases and 500 term controls to examine gene-environment interactions. The major environmental, nutritional and social factors as well as clinical variables known or suspected to be associated with PTD will be used to test for gene-environment interactions. This study integrates epidemiological and clinical data as well as genetic markers along major pathogenic pathways of PTD. The findings from this study should improve our understanding of genetic influences on PTD and gene-environment interactions.
View details for Web of Science ID 000170483900008
View details for PubMedID 11520401
State income inequality, household income, and maternal mental and physical health: cross sectional national survey
BRITISH MEDICAL JOURNAL
2000; 321 (7272): 1311-1315
To examine the association of state income inequality and individual household income with the mental and physical health of women with young children.Cross sectional study. Individual level data (outcomes, income, and other sociodemographic covariates) from a 1991 follow up survey of a birth cohort established in 1988. State level income inequality calculated from the income distribution of each state from 1990 US census.United States, 1991. Participants: Nationally representative stratified random sample of 8060 women who gave birth in 1988 and were successfully contacted (89%) in 1991.Depressive symptoms (Center for Epidemiologic Studies depression score >15) and self rated health19% of women reported depressive symptoms, and 7.5% reported fair or poor health. Compared with women in the highest fifth of distribution of household income, women in the lowest fifth were more likely to report depressive symptoms (33% v 9%, P<0.001) and fair or poor health (15% v 2%, P<0. 001). Compared with low income women in states with low income inequality, low income women in states with high income inequality had a higher risk of depressive symptoms (odds ratio 1.6, 95% confidence interval 1.0 to 2.6) and fair or poor health (1.8, 0.9 to 3.5).High income inequality confers an increased risk of poor mental and physical health, particularly among the poorest women. Both income inequality and household income are important for health in this population.
View details for Web of Science ID 000165561600023
View details for PubMedID 11090512
- Implications of welfare reform for child health: Emerging challenges for clinical practice and policy PEDIATRICS 2000; 106 (5): 1117-1125
State welfare reform policies and declines in health insurance
AMERICAN JOURNAL OF PUBLIC HEALTH
2000; 90 (6): 900-908
This study sought to determine whether there is a relationship between state policies on Temporary Assistance to Needy Families (TANF), declines in both TANF and Medicaid caseloads, and the rise in the number of uninsured.Extant data sources of state TANF policies, TANF and Medicaid participation, and uninsurance rates were analyzed, with the state as the unit of analysis. The independent variables included state TANF policies that directly address receipt of benefits or relate to health; dependent variables included changes in state TANF enrollment, Medicaid enrollment, and health insurance status since the enactment of the law.In the bivariate analysis, declines in Medicaid were associated with sanction for work noncompliance, lack of a child care guarantee, and strategies to deter TANF enrollment; this last factor was also associated with increased uninsurance. In the multivariate analysis, lack of a child care guarantee and deterrent strategies predicted TANF declines; deterrent strategies predicted Medicaid decline and uninsurance increases.This analysis suggests that policies deterring TANF enrollment may contribute to declines in Medicaid and increased uninsurance. To maintain health insurance for the poor, policymakers should consider revising policies that deter TANF enrollment.
View details for Web of Science ID 000087335800015
View details for PubMedID 10846507
The impact of managed care insurance on use of lower-mortality hospitals by children undergoing cardiac surgery in California
2000; 105 (6): 1271-1278
Managed care plans aggressively seek to contain costs, but few data are available regarding their impact on access to high quality care for their members.To assess the impact of managed care health insurance on use of lower-mortality hospitals for children undergoing heart surgery in California.Retrospective cohort study using state-mandated hospital discharge datasets.Pediatric cardiovascular surgical centers in California.Five thousand seventy-one children admitted for open cardiac surgical procedures during 1992-1994.Hospitals were divided into lower- and higher-mortality groups according to adjusted surgical mortality. Using multivariate logistic regression analysis to control for medical, socioeconomic, demographic, and distance factors, children with managed care insurance were less likely to be admitted to a lower-mortality hospital for surgery relative to children with indemnity insurance (odds ratio:.53; 95% confidence interval:.45,.63). Similar findings resulted when the analysis was stratified by race/ethnicity. In addition, length of stay, a correlate of health care costs, was no longer for children admitted to lower-mortality centers than for those at higher-mortality centers (adjusted difference:.54 days shorter at lower-mortality centers; 95% confidence interval: -1.50,. 41).During this study, children with managed care insurance had significantly reduced use of lower-mortality hospitals for pediatric heart surgery in California compared with children with indemnity insurance. Further study is necessary to determine the mechanisms of this apparent insurance-specific inequity.
View details for Web of Science ID 000087441400029
View details for PubMedID 10835068
- Antibiotics without prescription: "bacterial or medical resistance"? LANCET 2000; 355 (9214): 1480-1480
The impact of welfare reform policies on Child Protective Services: A national study
JOURNAL OF SOCIAL ISSUES
2000; 56 (4): 799-809
View details for Web of Science ID 000166328300012
Assessing the effects of welfare reform policies on reproductive and infant health
AMERICAN JOURNAL OF PUBLIC HEALTH
1999; 89 (10): 1514-1521
The welfare reform law of 1996 marked a historical moment in US policy toward the poor by ending the entitlement to cash assistance, by requiring work, and by establishing time limits. This article examines the potential impact on the health of women and children, the primary recipients of welfare benefits.The authors outline the reproductive health outcomes most likely to be sensitive to welfare policies, identify indicators that might be used to assess these outcomes, review empirical evidence, and suggest specific methods and data sources.State welfare requirements could improve health outcomes or deter families from Medicaid and food stamps, as well as income support, thus worsening health outcomes. National and state data may prove useful in detecting these effects; however, new data sources may be required for specific health-related questions.Assessing the effects of welfare policies on reproductive and infant health is possible, although challenging. Reauthorization of the legislation is required in 2002; it is essential that the consequences for health be included in the next round of public debate.
View details for Web of Science ID 000082752700011
View details for PubMedID 10511833
Efficacy and justice: the importance of medical research and tertiary care to social disparities in infant mortality.
Journal of perinatology
1999; 19 (6): S24-7
View details for PubMedID 10685292
Implementation of Fetal and Infant Mortality Review (FIMR): experience from the national Healthy Start program.
Maternal and child health journal
1999; 3 (3): 141-150
The implementation of the Fetal and Infant Mortality Review (FIMR) process was examined as part of the evaluation of the national Healthy Start program, a federal program designed to reduce infant mortality in several communities. The implementation of the FIMR process over the 5-year funding period is described in terms of productivity, barriers and facilitators to implementation, and project expenditures.Data were derived from grant continuation applications and personal interviews with program staff to produce a qualitative description.As of the summer of 1996, 14 of the 15 Healthy Start sites in the national evaluation had successfully implemented the FIMR process. Most sites had developed a two-tiered review process for examination of case data in which a review by health and social services professionals was followed by community review. In the period 1993 to 1995, the percentage of fetal and infant deaths reviewed had a median of 34% with a range of 4-79% across the sites at a cost of $600 to $3400 per death reviewed. Recommendations were variably implemented.The FIMR process provides an important opportunity to contribute to the knowledge base regarding infant mortality in these communities. The process, however, has important logistical requirements and may require substantial financial resources that may affect implementation of confidential inquiries into infant mortality and other health problems.
View details for PubMedID 10746753
The scope of unmet maternal health needs in pediatric settings
1999; 103 (3): 576-581
Previous work has focused attention on the prevalence of specific maternal health problems known to affect children, such as smoking or depression. However, the cumulative health burden experienced by mothers and the potential for a practical pediatric health services response have not been examined. The aims of this study were to characterize: 1) the prevalence and cumulative burden of maternal health behaviors and conditions, 2) maternal access to a source of comprehensive adult primary care, and 3) maternal perceptions of a pediatric role in screening and referral.We surveyed 559 consecutive women bringing a child 18 months of age or less to one of four pediatric primary care sites between July 1996 and May 1997. The pediatric sites included one outpatient program in an academic hospital, one in a community health center, and two in-staff model practices of a managed care organization (these last two were combined for analysis). The self-administered questionnaire contained previously validated questions to assess health behaviors and conditions (smoking, alcohol abuse, depression, violence, risk for unintended pregnancy, serious illness, self-reported health) and access to care (regular source, regular provider, health insurance, care delayed or not received). Maternal attitudes toward a pediatric role in screening and referral were also elicited.In the three settings, response rates ranged from 75% to 84%. The average age of the women ranged from 25.1 to 32. 1 years and the average age of the children ranged from 6.5 to 8.0 months. Across the settings, the percentage of women reporting at least one health condition (66%-74%) was similarly high, despite significant demographic differences among sites. Many women reported more than one condition (31%-37%); among all women who smoked, 33% also screened positive for alcohol abuse, 31% for emotional or physical abuse, and 48% for depression. Access to comprehensive adult primary care was variable with 23% to 58% of women reporting one or more barriers depending on the site. Across all sites, >85% of mothers reported they would "not mind" or "would welcome" a pediatric role in screening and referral.Two-thirds of women bringing their children for pediatric care had health problems regardless of the site of care. Many women also reported substantial barriers to comprehensive health care. Most women reported acceptance of a pediatric role in screening and referral. Given the range and depth of maternal health needs, strategies to connect or reconnect mothers to comprehensive adult primary care from a variety of pediatric settings should be explored.
View details for Web of Science ID 000078960100007
View details for PubMedID 10049959
- Topics for our times: Welfare reform and women's health AMERICAN JOURNAL OF PUBLIC HEALTH 1998; 88 (7): 1017-1018
Policies towards pregnancy and addiction - Sticks without carrots
Conference on Cocaine - Effects on the Developing Brain
NEW YORK ACAD SCIENCES. 1998: 335–340
Throughout this century in the United States, tension has existed between those who believe drug abuse is best combatted through the criminal justice system and those who emphasize a medical/public health model of prevention and treatment. In the last decade this debate has centered around the person of the pregnant addict. The former have construed her addiction as willful harm to the fetus punishable on criminal and child abuse grounds. The latter have countered that pregnancy is a moment of increased motivation for treatment and focused on expansion and improvement of treatment options. Both managed care and welfare reform have exacerbated conditions between these opposing policy approaches. The addicted woman is increasingly caught between policies that punish her drug use without options for overcoming addiction.
View details for Web of Science ID 000074931100028
View details for PubMedID 9668420
National survey of the states: Policies and practices regarding drug-using pregnant women
AMERICAN JOURNAL OF PUBLIC HEALTH
1998; 88 (1): 117-119
This study assessed the impact of national policy shifts on state policies and practices regarding substance-using mothers.A 1995 telephone survey of substance abuse and child protective services directors in all 50 states and the District of Columbia was compared with a similar 1992 survey.There have been significant increases in state interventions for drug-using pregnant women (e.g., criminal prosecution, toxicology testing of women and neonates). Federal resources for treatment and oversight are being replaced by state control of reduced funds for treatment.The earlier policy of expanding treatment for addicted women is being replaced by reduction of services and increased state intervention.
View details for Web of Science ID 000073804800023
View details for PubMedID 9584016
War experiences and distress symptoms of Bosnian children
1997; 100 (5): 873-878
The war in Bosnia has had a tremendous impact on civilians. Little is known about the impact of modern warfare on children. This survey documents the nature and frequency of war-related experiences among Bosnian children and describes their manifestations of selected psychological sequelae.A cross-sectional survey of 364 internally displaced 6- to 12-year-old children and their parents living in central Bosnian collectives was conducted during the war. Parents were surveyed for their children's war experiences; the children were surveyed for war-related distress symptoms.The children were exposed to virtually all of the surveyed war-related experiences. The majority had faced separations from family, bereavement, close contact with war and combat, and extreme deprivation. The prevalence and severity of experiences were not significantly related to a child's gender, wealth, or age, but were related to their region of residence, with children from the region of Sarajevo having the highest prevalence of experiences. Almost 94% of the children met Diagnostic and Statistical Manual of Mental Disorders, 4th ed, criteria for posttraumatic stress disorder. Significant life activity affecting sadness and anxiety were reported by 90.6% and 95.5% of the children, respectively. High levels of other symptoms surveyed were also found. Children with greater symptoms had witnessed the death, injury, or torture of a member of their nuclear family, were older, and came from a large city.The war-related experiences of the children studied were both varied and severe, and were associated with a variety of psychological sequelae. This experience underscores the vulnerability of civilians in areas of conflict and the need to address the effects of war on the mental health of children.
View details for Web of Science ID A1997YD73900016
View details for PubMedID 9346989
Fertility therapy and the risk of very low birth weight
OBSTETRICS AND GYNECOLOGY
1997; 90 (4): 600-605
To test the hypothesis of an association between maternal infertility therapy and the risk of very low birth weight (VLBW), defined as birth weight less than 1500 g, independent of the risk of multiple births, and to estimate the contribution of infertility therapy to the national incidence of VLBW.The National Maternal and Infant Health Survey conducted in 1988 was used to develop statistics describing outcomes among this birth cohort and to construct logistic regression models evaluating fertility therapy as an independent risk factor for VLBW.An estimated 10.1% of live births and 18.2% of VLBW births nationally were associated with either maternal subfertility or infertility therapy (6.8% and 11.4%, respectively). The risk of VLBW among women concerned with subfertility (i.e., receiving diagnostic testing or advice on timing intercourse) was 1.4 (95% confidence interval [CI] 1.1, 1.9), whereas that for women undergoing therapeutic interventions (ie, ovarian stimulation, surgery, in vitro fertilization, or artificial insemination) was 2.6 (95% CI 2.1, 3.2). Accounting for effects of multiple gestation, maternal age, and a history of miscarriage, the odds ratios for the concerned and therapy groups were 1.5 (95% CI 1.1, 1.9) and 2.0 (95% CI 1.5, 2.5), respectively. Black women were less likely to use fertility therapy but more likely to experience a therapy-related VLBW.Fertility therapy is associated with an important portion of all VLBW and with an elevated risk of VLBW, related only in part to an increased risk of multiple gestations. Women expressing concern about subfertility but not receiving therapy are also at increased risk of VLBW, suggesting that a history of infertility may mediate part of the risk associated with fertility therapy.
View details for Web of Science ID A1997XX74500023
View details for PubMedID 9380323
Home uterine activity monitoring in the prevention of very low birth weight
PUBLIC HEALTH REPORTS
1997; 112 (5): 433-439
Despite controversy regarding the efficacy of home uterine activity monitoring (HUAM), it is currently licensed for detection of preterm labor in women with previous preterm deliveries. In practice, however, it is being more widely utilized in an effort to prevent preterm delivery. This study seeks to determine which group of mothers delivering very low birth weight (VLBW) infants would have qualified for HUAM given three different sets of criteria and in which women it could have been used to help prolong gestation.The authors reviewed the medical records of mothers of VLBW infants born in five U.S. locations (N = 1440), retrospectively applying three sets of eligibility criteria for HUAM use: (a) the current FDA licensing criterion for use of HUAM, a previous preterm birth; (b) indication for HUAM commonly cited in published reports; (c) a broad set of criteria based on the presence of any reproductive or medical conditions that might predispose to premature delivery. The authors then analyzed the conditions precipitating delivery for each group to determine whether delivery might have been prevented with HUAM and tocolytic therapy.Only 4.4% of the total group of women delivering VLBW infants would have been eligible for HUAM under the FDA criterion and might potentially have benefited from this technology. If extremely broad criteria had been applied to identify those eligible for monitoring, under which almost 80% of all women who delivered VLBW infants would have been monitored, only 20.3% of the total group would have been found eligible and would potentially have benefited. If such broad criteria were applied to all pregnant women, a sizable proportion of pregnancies would be monitored at great expense with small potential clinical benefit.Because VLBW births are usually precipitated by conditions that are unlikely to benefit from HUAM, this technology will have little impact on reducing VLBW and neonatal mortality rates. More comprehensive preventive strategies should be sought.
View details for Web of Science ID A1997XW23600028
View details for PubMedID 9323396
Maternal and infant health - Effects of moderate reductions in postpartum length of stay
Annual Meeting of the Association-for-Health-Services-Research
AMER MEDICAL ASSOC. 1997: 915–21
The Newborns' and Mothers' Health Protection Act of 1996 prohibits payers from restricting "benefits for any hospital length of stay in connection with childbirth for the mother or newborn child, following a normal vaginal delivery, to less than 48 hours." The law recognizes the basic right of women and physicians to make decisions about aptness of discharge timing.To provide data as a basis for decisions about aptness of discharge timing by studying the effect of voluntary, moderate reductions in length of postpartum hospital stay on an array of maternal and infant health outcomes.A prospective cohort study. Patients were surveyed by telephone at 3 and 8 weeks postpartum.A teaching hospital where 38% of the patients are in a managed care health plan with a noncompulsory reduced stay program offering enhanced prepartum and postpartum services, including home visits.Consecutive mothers discharged after vaginal delivery during a 3-month period.The outcomes were health services use within 21 days, breast-feeding, depression, sense of competence, and satisfaction with care. Multivariate analyses adjusted for sociodemographic factors, payer status, services, and social support.Of 1364 eligible patients, 1200 (88%) were surveyed at 3 weeks; of these 1200, 1015 (85%) were resurveyed at 8 weeks. The mean length of stay was 41.9 hours (SD, 12.2 hours). Of patients going home in 30 hours or less, 60.8% belonged to a managed care health plan. The length of stay was not related to the outcomes, except that women hospitalized shorter than 48 hours had more emergency department visits than those staying 40 to 48 hours (adjusted odds ratio, 5.78; 95% confidence interval, 1.19-28.05).When adequate postpartum outpatient care is accessible, a moderately shorter length of postpartum stay after an uncomplicated vaginal delivery had no adverse effect on an array of outcomes. Researchers and policy makers should seek to better define the content of postpartum services necessary for achieving optimal outcomes for women and newborns; funding should be available to provide such services, regardless of the setting in which they are provided.
View details for Web of Science ID A1997XW19800009
View details for PubMedID 9308869
Mandatory testing of pregnant women and newborns: HIV, drug use, and welfare policy.
The Fordham urban law journal
1997; 24 (4): 749-755
View details for PubMedID 12455509
Risk status at discharge and cause of death for postneonatal infant deaths: A total population study
1997; 99 (3): 338-344
To obtain population-based, clinical information regarding potentially modifiable factors contributing to death during the postneonatal period (28 to 364 days), we examined all postneonatal infant deaths in four areas of the United States to determine: (1) the cause of death from clinical and autopsy data rather than vital statistics, (2) whether death occurred during initial hospitalization or after discharge, and (3) the portion of postneonatal mortality attributable to infants who left the hospital with identified high-risk medical conditions.Retrospective medical record review of all postneonatal infant deaths with birth weights greater than 500 g (total N = 386) born to mothers residing in: (1) the city of Boston (1984 and 1985, N = 55), (2) the city of St Louis and contiguous areas (1985 and 1986, N = 123), (3) San Diego County (1985, N = 112), and (4) the state of Maine (1984 and 1985, N = 96). Deaths were identified using linked birth and death vital statistics, and medical record audits of infants' and mothers' charts were performed. Causes of death were obtained from medical record review in conjunction with autopsy if performed (72%, N = 278), medical record alone (17%, N = 67), or vital statistics if no other source was available (11%, N = 41). The medical conditions at the time of discharge for each infant were reviewed and, if judged to confer an increased risk of morbidity or mortality, were classified as high risk.The causes of death were sudden infant death syndrome (47%, N = 181), congenital conditions (20%, N = 77), prematurity-related conditions (11%, N = 43), infections (9%, N = 34), external causes (including injuries, drownings, ingestions, and burns) (7%, N = 25), and other (6%, N = 23). In 24% of congenital and 25% to 44% of prematurity-related deaths, infection was the acute or associated cause of death. Infants born to black mothers were more likely than those born to white mothers to die during the postneonatal period of all major causes of death (7.3 per 1000 vs 3.0 per 1000). Overall, 18% (N = 68) of deaths occurred to infants who never left the hospital; 79% (N = 305) of the infants were discharged before death; and discharge status was unknown in 3% (N = 13). Eighty-one percent of all infants with prematurity-related postneonatal deaths were never discharged, and of the total infants who were initially discharged, only 1% (N = 4) subsequently died of prematurity-related causes. Of all postneonatal deaths, only 16% (N = 62) left the hospital with identified high-risk medical conditions.These findings suggest that the etiology of postneonatal mortality is heterogeneous, with significant complexity in attributing specific causes of death and making designations of "preventability." The vast majority of infants who died of prematurity-related postneonatal causes never left the hospital, and only a small percentage of all infants that left the hospital before death were identified as being at high medical risk. Therefore, strategies for further decreasing postneonatal mortality must link high-risk follow-up programs to more comprehensive strategies that address risk throughout pregnancy and early childhood.
View details for Web of Science ID A1997WR14700004
View details for PubMedID 9041284
- Ethics in context AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY 1997; 176 (3): 732-732
Inadequate hepatitis B vaccination of adolescents and adults at an urban community health center
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
1997; 89 (2): 86-92
Hepatitis B remains a major public health problem in the United States, but public vaccination policy has targeted infants rather than the high-risk adults who constitute the vast majority of patients at imminent risk of infection. The effects of this policy were studied at a community health center in Boston. Adolescents and adults who attended a community health center between January 1, 1992 and May 31, 1993 and had human immunodeficiency virus (HIV) or another sexually transmitted disease (STD)--indications for vaccination according to the Centers for Disease Control and Prevention--were identified through chart review. The vaccination rate and missed opportunities were determined. In addition, directors of Boston health centers were surveyed on hepatitis B vaccine at their clinics. Of 178 individuals with HIV or another STD and without serologic evidence of prior exposure to hepatitis B, two (1.1%) received the vaccine. There were 342 missed opportunities. Only two of 14 medical directors said their clinics routinely offered vaccine to individuals with STDs. The medical directors rated financial barriers as more important obstacles to hepatitis B vaccination than nonfinancial barriers. These results indicate that many high-risk adolescents and adults do not receive a preventive intervention that is federally recommended, potentially life saving, and cost effective. Inadequate public funding for vaccine may be a key barrier for this population.
View details for Web of Science ID A1997WH30700002
View details for PubMedID 9046761
The first injustice: Socioeconomic disparities, health services technology, and infant mortality
ANNUAL REVIEW OF SOCIOLOGY
1997; 23: 147-170
"Infant mortality has long been viewed as a synoptic indicator of the health and social condition of a population. In this article we examine critically the structure of this reflective capacity with a particular emphasis on how new health care technologies may have altered traditional pathways of social influence.... Current patterns of infant mortality in the United States provide a useful illustration of the dynamic interaction of underlying social forces and technological innovation in determining trends in health outcomes. We review the implications of this perspective for [future] sociological research into disparate infant mortality...."
View details for Web of Science ID A1997XR65000007
View details for PubMedID 12348279
Racial disparities in outcomes of military and civilian births in California
ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE
1996; 150 (10): 1062-1067
To examine racial disparities in prenatal care utilization, birth weight, and fetal and neonatal mortality in a population for whom financial barriers to health care services are minimal.Using linked birth, fetal death, and infant death certificate files, we examined prenatal care utilization, birth weight distribution, and fetal and neonatal mortality rates for all white and black births occurring in military hospitals in California from January 1, 1981, to December 31, 1985. These patterns were compared with the experience of their civilian counterparts during the same time period.Black mothers had higher percentages of births occurring in teenaged and unmarried mothers than did white mothers in military and civilian populations. First-trimester prenatal care initiation was lower for blacks in the military (relative risk, 0.79; 95% confidence interval, 0.75-0.82) and civilian (relative risk, 0.51; 95% confidence interval, 0.50-0.52) populations. However, the scale of the disparity in prenatal care utilization was significantly smaller (P < .001) in the military group. Rates of low birth weight and fetal and neonatal mortality among blacks were elevated in the military and civilian groups. However, the racial disparity in low birth weight was significantly smaller in the military group (P < .01 and P < .001, respectively).In populations with decreased financial barriers to health care, racial disparities in prenatal care use and low birth weight were reduced. However, the persistence of significant disparities suggests that more comprehensive strategies will be required to ensure equity in birth and neonatal outcome.
View details for Web of Science ID A1996VM05900010
View details for PubMedID 8859139
The influence of the wider use of surfactant therapy on neonatal mortality among blacks and whites
NEW ENGLAND JOURNAL OF MEDICINE
1996; 334 (25): 1635-1640
Surfactant therapy reduces morbidity and mortality among premature infants with the respiratory distress syndrome (RDS). Fetal pulmonary surfactant matures more slowly in white than in black fetuses, and therefore RDS is more prevalent among whites than among blacks. We reasoned that the increased use of surfactant after its approval by the Food and Drug Administration (FDA) in 1990 might have reduced neonatal mortality more among whites than among blacks.We merged vital-statistics information for all 1563 infants with very low birth weights (500 to 1500 g) born from 1987 through 1989 or in 1991 and 1992 to residents of St. Louis with clinical data from the four neonatal intensive care units in the St. Louis area; we then compared neonatal mortality during two periods, one before and one after the FDA's approval of surfactant for clinical use (1987 through 1989 and 1991 through 1992).The use of surfactant increased by a factor of 10 between 1987 through 1989 and 1991 through 1992. The neonatal mortality rate among all very-low-birth-weight infants decreased 17 percent, from 220.3 deaths per 1000 very-low-birth-weight babies born alive (in 1987 through 1989) to 183.9 per 1000 (in 1991 through 1992; P = 0.07). This decrease was due to a 41 percent reduction in the mortality rate among white newborns with very low birth weights (from 261.5 per 1000 to 155.5 per 1000; P = 0.003). In contrast, among black infants, the mortality rate for very-low-birth-weight infants did not change significantly (195.6 per 1000 and 196.8 per 1000). The relative risk of death among black newborns with very low birth weights as compared with white newborns with similar weights was 0.7 from 1987 through 1989 and 1.3 from 1991 through 1992 (P = 0.02). The differences in mortality were not explained by differences in access to surfactant therapy, by differences in mortality between black and white infants who received surfactant, or by differences in the use of antenatal corticosteroid therapy.After surfactant therapy for RDS became generally available, neonatal mortality improved more for white than for black infants with very low birth weights.
View details for Web of Science ID A1996UQ70600004
View details for PubMedID 8628359
Efforts to reduce perinatal mortality, HIV, and drug addiction: surveys of the states.
Journal of the American Medical Women's Association (1972)
1995; 50 (5): 164-166
View details for PubMedID 7499705
The importance of extreme prematurity and low birthweight to US neonatal mortality patterns: implications for prenatal care and women's health.
Journal of the American Medical Women's Association (1972)
1995; 50 (5): 152-155
In order to frame the appropriateness of neonatal mortality reduction efforts that begin only after pregnancy is recognized, this study examined the relative contributions of different gestational age and birthweight groups to total neonatal mortality and to racial disparities in neonatal mortality in the United States.Using the national linked birth/infant death data set for the 1988 cohort, the relative contributions of different birthweight and gestational age groups to national neonatal mortality rates were calculated. The relative contributions of these groups to the racial disparity in neonatal mortality were also assessed.Very low birthweight infants (< 1,500 g) accounted for 1.2% of all births, but 64.2% of all neonatal deaths. The very low birthweight rate for whites was 0.93%, while that for blacks was 2.79% with the contribution of this group to neonatal mortality higher for blacks than whites. Infants less than 1,000 g contributed more than 80% of the racial disparity in neonatal mortality.Neonatal mortality patterns in the United States have become highly dependent on infants with gestational ages that approach the second trimester. Preventing neonatal mortality by enhancing care only after pregnancy has been recognized, therefore, may be limited. Strategies that link prenatal care to broader initiatives to improve the health of women regardless of pregnancy status may be more effective.
View details for PubMedID 7499702
MORTALITY-RATES AMONG 15- TO 44-YEAR-OLD WOMEN IN BOSTON - LOOKING BEYOND REPRODUCTIVE STATUS
AMERICAN JOURNAL OF PUBLIC HEALTH
1995; 85 (8): 1135-1138
Mortality rates were examined for Boston women, aged 15 to 44, from 1980 to 1989. There were 1234 deaths, with a rate of 787.8/100,000 for the decade. Leading causes were cancer, accidents, heart disease, homicide, suicide, and chronic liver disease. After age adjustment, African-American women in this age group were 2.3 times more likely to die than White women. Deaths at least partly attributable to smoking and alcohol amounted to 29.8% and 31.9%, respectively. Mortality was found to be related more directly to the general well-being of young women than to their reproductive status, and many deaths were preventable. African-American/White disparities were most likely linked to social factors. These findings suggest that health needs of reproductive-age women transcend reproductive health and require comprehensive interventions.
View details for Web of Science ID A1995RN32000025
View details for PubMedID 7625513
THE IMPACT OF EXTREME PREMATURITY AND CONGENITAL-ANOMALIES ON THE INTERPRETATION OF INTERNATIONAL COMPARISONS OF INFANT-MORTALITY
OBSTETRICS AND GYNECOLOGY
1995; 85 (6): 941-946
To identify the potential impact that different definitions of live births and practice patterns have on infant mortality rates in England and Wales, France, Japan, and the United States.United States data were obtained from the 1986 linked national birth-infant death cohort, and those for the other countries came from either published sources or directly from the Ministries of Health.In 1986 in the United States, infants weighing less than 1 kg accounted for 36% of deaths (32% white and 46% black); 32% resulted from fatal congenital anomalies. These rates were much higher in both categories than in England and Wales in 1990 (24 and 22%, respectively), France in 1990 (15 and 25%, respectively), and Japan in 1991 (9% for infants weighing less than 1 kg, percentage of fatal congenital anomalies unknown). These cases are more likely to be excluded from infant mortality statistics in their countries than in the United States.In 1990, the United States infant mortality rate was 9.2 per 1000 live births, ranking the United States 19th internationally. However, infant mortality provides a poor comparative measure of reproductive outcome because there are enormous regional and international differences in clinical practices and in the way live births are classified. Future international and state comparisons of reproductive health should standardize the definition of a live birth and fatal congenital anomaly, and use weight-specific fetal-infant mortality ratios and perinatal statistics.
View details for Web of Science ID A1995QZ91800007
View details for PubMedID 7770264
Child Beauty, Child Rights and the Devaluation of Women.
Health and human rights
1995; 1 (4): 472–76
View details for PubMedID 10393800
- FINDING COMMON GROUND - THE NECESSITY OF AN INTEGRATED AGENDA FOR WOMENS AND CHILDRENS HEALTH JOURNAL OF LAW MEDICINE & ETHICS 1994; 22 (3): 262-269
THE ACCESSIBILITY OF DRUG-TREATMENT FOR PREGNANT-WOMEN - A SURVEY OF PROGRAMS IN 5 CITIES
AMERICAN JOURNAL OF PUBLIC HEALTH
1994; 84 (10): 1658-1661
Through simulated calls to 294 drug treatment programs in five cities, this study investigated access for pregnant women and compared New York City's provision of services in 1989 to that in 1993. In all sites, the majority of programs accepted pregnant women. There was also a marked improvement in the availability of services in New York City. Yet options were more limited for Medicaid recipients and women needing child care, and an appointment or referral for prenatal care was usually not offered. Although the door for treatment may be opening for pregnant women, institutional barriers still remain.
View details for Web of Science ID A1994PM43500023
View details for PubMedID 7943491
- WHAT YOU MEASURE IS WHAT YOU GET - PRENATAL-CARE AND WOMENS HEALTH AMERICAN JOURNAL OF PUBLIC HEALTH 1994; 84 (9): 1374-1375
COMMUNITY STUDY OF INFANT-MORTALITY IN SAN-DIEGO COUNTY
JOURNAL OF TROPICAL PEDIATRICS
1994; 40 (3): 172-178
Infant mortality in San Diego County (USA) in 1988 was 6.9 per 1000 live births. This rate had remained unchanged since 1980. It rose to 8.3 in 1989 and fell to 7.0 in 1990. This study describes the results of an investigation into the causes of infant mortality during 1985. A total of 333 infant deaths were recorded. Nearly half the neonatal deaths were related to perinatal causes and more than half the post-neonatal deaths were attributed to the Sudden Infant Death Syndrome. Two-thirds of all infant deaths occurred in the neonatal period. The contribution of factors in the maternal background and those related to care during labour, as well as postnatally, is described.
View details for Web of Science ID A1994NY33300010
View details for PubMedID 8078117
- HEALTH-CARE REFORM AND THE SPECIAL NEEDS OF CHILDREN PEDIATRICS 1994; 93 (3): 504-506
MODEL PROGRAMS ADDRESSING PERINATAL DRUG EXPOSURE AND HUMAN-IMMUNODEFICIENCY-VIRUS INFECTION - INTEGRATING WOMENS AND CHILDRENS NEEDS
BULLETIN OF THE NEW YORK ACADEMY OF MEDICINE
1994; 71 (2): 236-251
Many of the efforts to address perinatal drug exposure and human immunodeficiency virus infection have been influenced by a perspective of conflict between the interests of mother and infant. This article highlights several programs that integrate women's and children's services while dealing with these health issues. It discusses the challenges encountered by these programs, such as funding restrictions, institutional barriers, professional attitudes, regulatory constraints, and local political issues. It presents strategies for overcoming these barriers including the creative coordination of funding streams, innovative relationships with child protective agencies, effective collaboration with other agencies, and advocacy on behalf of clients and programs, and makes recommendations for certain policy changes, which could foster the development of programs that serve women and children together.
View details for Web of Science ID A1994PY43600008
View details for PubMedID 19313104
CONFRONTING RACIAL DISPARITIES IN INFANT-MORTALITY - RECONCILING SCIENCE AND POLITICS
AMERICAN JOURNAL OF PREVENTIVE MEDICINE
1993; 9 (6): 7-16
The public debate surrounding disparities in infant mortality has resulted from a profound failure to seek a common wisdom. Because of its essential social roots, infant mortality will always remain the province of fundamental ideological and political conflict. However, without a more integrated analytic approach, progress in reducing disparate infant mortality will remain limited by internecine struggles for disciplinary purview and false claims of societal relevance. For in the end, the struggle to address disparate infant mortality will be advanced best by integrated technical and political strategies that recognize that the pursuits of efficacy and justice are inextricably linked.
View details for Web of Science ID A1993MR85100003
View details for PubMedID 8123287
Current opinion in pediatrics
1993; 5 (5): 552-557
Infant mortality continues to be a major public health issue in the United States. Although some preventive strategies for neonatal mortality are emerging for congenital malformations, notably neural tube defects, the prevention of preterm deliveries among disadvantaged populations remains elusive, suggesting the need for different approaches to women's health needs. Despite the lack of success in preventing preterm birth, neonatal mortality rates continued to decline substantially, a decline attributed to improvements in neonatal intensive care associated with surfactant use. The increasing survival of very preterm infants continues to raise questions about their longer term outcomes especially with several recent studies on difficulties in school, and about the need for postdischarge developmental interventions. Attempts to decrease postneonatal mortality received marked attention with the recommendations for specific positioning to prevent sudden infant death syndrome and heightened attention to increased immunization completion rates. The dismal ranking of the United States in infant mortality rates among industrialized countries, however, continues to present a social policy challenge.
View details for PubMedID 8287078
Medicare and Medicaid.
The state of health care in America
The federal Medicare and Medicaid programs were established as safety nets for the elderly, disabled, and most disadvantaged members of our society. Today, both programs are plagued by increasing demand and diminishing resources, and both are attempting to find ways to care for current and future beneficiaries.
View details for PubMedID 10168062
NOISE OR FUGUE - SEEKING THE LOGIC OF CHILD HEALTH INDICATORS
1992; 30 (6): 323-329
Despite improvements in many child health indicators, several important ones, including the racial disparity in infant mortality, have not improved in recent years. A focus on dramatic but rare risk factors has distracted attention away from the primary determinants of these indicators. An analytic model to assess these indicators identifies three interacting determinates: (a) social well-being, (b) our technical capacity to reduce the risk that low social status conveys, and (c) our performance in providing access to this technical capacity. These three determinants can move independently and can, therefore, mask important trends in social status and the impact of programs and policies.
View details for Web of Science ID A1992KD84300005
View details for PubMedID 1474908
CLINICAL DETERMINANTS OF THE RACIAL DISPARITY IN VERY-LOW-BIRTH-WEIGHT
NEW ENGLAND JOURNAL OF MEDICINE
1992; 327 (14): 969-973
Although the risk of very low birth weight (less than 1500 g) is more than twice as high among blacks as among whites in the United States, the clinical conditions associated with this disparity remain poorly explored.We reviewed the medical records of over 98 percent of all infants weighing 500 to 1499 g who were born in Boston during the period 1980 through 1985 (687 infants), in St. Louis in 1985 and 1986 (397 infants), and in two health districts in Mississippi in 1984 and 1985 (215 infants). The medical records of the infants' mothers were also reviewed. These data were linked to birth-certificate files. During the study periods, there were 49,196 live births in Boston, 16,232 in St. Louis, and 16,332 in the Mississippi districts. The relative risk of very low birth weight among black infants as compared with white infants ranged from 2.3 to 3.2 in the three areas. The higher proportion of black infants with very low birth weights was related to an elevated risk in their mothers of major conditions associated with very low birth weight, primarily chorioamnionitis or premature rupture of the amniotic membrane (associated with 38.0 percent of the excess proportion of black infants with very low birth weights [95 percent confidence interval, 31.3 to 45.4 percent]); idiopathic preterm labor (20.9 percent of the excess [95 percent confidence interval, 16.0 to 26.4 percent]); hypertensive disorders (12.3 percent [95 percent confidence interval, 8.6 to 16.6]); and hemorrhage (9.8 percent [95 percent confidence interval, 5.5 to 13.5]).The higher proportion of black infants with very low birth weights is associated with a greater frequency of all major maternal conditions precipitating delivery among black women. Reductions in the disparity in birth weight between blacks and whites are not likely to result from any single clinical intervention but, rather, from comprehensive preventive strategies.
View details for Web of Science ID A1992JQ22500001
View details for PubMedID 1518548
- INFANT-MORTALITY AS A SOCIAL MIRROR NEW ENGLAND JOURNAL OF MEDICINE 1992; 326 (23): 1558-1560
MATERNAL SMOKING AND CHILDHOOD MORTALITY AND MORBIDITY
International Symposium on the Control of Tobacco-related Cancers and Other Diseases
OXFORD UNIV PRESS. 1992: 159–166
View details for Web of Science ID A1992BA88C00016
From the Surgeon General, US Public Health Service.
JAMA : the journal of the American Medical Association
1991; 266 (6): 770-?
View details for PubMedID 1865514
From the Surgeon General, US Public Health Service.
JAMA : the journal of the American Medical Association
1991; 265 (11): 1364-?
View details for PubMedID 1999874
- HISPANIC HEALTH - TIME FOR DATA, TIME FOR ACTION JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 1991; 265 (2): 253-255
BRAIN ENERGY-METABOLISM - CELL BODY OR SYNAPSE - GENERAL DISCUSSION
SYMP ON EXPLORING BRAIN FUNCTIONAL ANATOMY WITH POSITRON TOMOGRAPHY
JOHN WILEY & SONS LTD. 1991: 43–51
View details for Web of Science ID A1991BU85G00004
BACTEREMIA IN AN AMBULATORY SETTING - IMPROVED OUTCOME IN CHILDREN TREATED WITH ANTIBIOTICS
AMERICAN JOURNAL OF DISEASES OF CHILDREN
1990; 144 (11): 1195-1199
We undertook a study of 414 bacteremic patients (167 with Haemophilus influenzae and 247 with Streptococcus pneumoniae bacteremia) to evaluate their clinical presentation, laboratory and clinical results, and subsequent outcomes. Patients with H influenzae bacteremia were more likely to have soft-tissue foci, poorer clinical appearance at presentation, and be at higher risk for subsequent serious focal infections, persistent bacteremia, and subsequent hospital admissions than patients with S pneumoniae. Patients with H influenzae bacteremia had a 21.1-fold increase in risk of meningitis (95% confidence interval [CI] of 3.8 to 78.0) compared with those with S pneumoniae. The odds ratio for initial lumbar puncture was 5.25 (95% CI [1.1-23.6]). Ambulatory patients treated with antibiotics at presentation were less likely to develop new serious soft-tissue infections, persistent bacteremia, or to require subsequent hospital admissions than untreated patients. The effect of treatment was greater for patients with S pneumoniae than those with H influenzae. Careful follow-up and reevaluation of patients with presumptive bacteremia is essential because treated and untreated patients can still develop serious soft-tissue infections.
View details for Web of Science ID A1990EG62700014
View details for PubMedID 2239857
Poverty, technology and recent trends in the United States infant mortality rate.
Paediatric and perinatal epidemiology
1990; 4 (4): 390-401
View details for PubMedID 2267180
FINAL REPORT OF THE UNITED-STATES-DEPARTMENT-OF-HEALTH-AND-HUMAN-SERVICES SECRETARYS WORK GROUP ON PEDIATRIC HUMAN IMMUNODEFICIENCY VIRUS-INFECTION AND DISEASE - CONTENT AND IMPLICATIONS
1989; 84 (3): 547-555
Human immunodeficiency virus (HIV) disease is increasing rapidly in the ranks of the leading causes of death among children. It is already the ninth leading cause of death among children 1 to 4 years of age and the seventh in young people between the ages of 15 and 24 years. If current trends continue, AIDS can be expected to move into the top five leading causes of death in the pediatric and adolescent age group in the next 3 or 4 years. To address this problem and also to provide focus for the US Department of Health and Human Services activities dealing with pediatric AIDS, an intradepartmental work group was established as a central health and human services component. This was done to ensure the best possible use of federal resources on behalf of children and adolescents with AIDS. Its recommendations are the basis of this report.
View details for Web of Science ID A1989AN65500024
View details for PubMedID 2671915
- WHAT DO REGIONAL VARIATIONS IN THE RATES OF HOSPITALIZATION OF CHILDREN REALLY MEAN NEW ENGLAND JOURNAL OF MEDICINE 1989; 320 (18): 1209-1211
POVERTY AND CHILD HEALTH
PEDIATRIC CLINICS OF NORTH AMERICA
1988; 35 (6): 1169-1186
Poverty is now more heavily concentrated in children than at any other time in U.S. history. Poverty's influence on child health is pervasive and creates a variety of clinical challenges. This discussion reviews the clinical expression of poverty in childhood and assesses our clinical and political capacity to reduce its tragic impact.
View details for Web of Science ID A1988R232700002
View details for PubMedID 3059293
Interpretation of indices of fetal pulmonary maturity by gestational age.
Paediatric and perinatal epidemiology
1988; 2 (4): 360-364
View details for PubMedID 3244554
INFANT-MORTALITY INCREASE DESPITE HIGH ACCESS TO TERTIARY CARE - AN EVOLVING RELATIONSHIP AMONG INFANT-MORTALITY, HEALTH-CARE, AND SOCIOECONOMIC CHANGE
1988; 81 (4): 542-548
In this study, the determinants of an apparent increase in the infant mortality rate of an urban population with high access to tertiary neonatal care are reviewed. For a 4-year period (1980 to 1983), all infant deaths (n = 422) of the 32,329 births to residents of the City of Boston were analyzed through linked vital statistics data and a review of medical records. A significant increase in the infant mortality rate occurred in 1982 due to increases in three components of the infant mortality rate: the birth rate of very low birth weight infants (less than 1,500 g), the neonatal mortality rate of normal birth weight infants (greater than or equal to 2,500 g), and the mortality rate of infants dying during the postneonatal period (28 to 365 days). These increases were associated with inadequate levels of prenatal care. Although transient, the impact of the observed alterations in these infant mortality rate components was enhanced by a more long-standing phenomenon: the stabilization of mortality rates for low birth weight infants. This stabilization allowed the increases in other component rates to be expressed more fully than in previous years. In this report a mechanism is shown whereby fully regionalized neonatal care ultimately may confer to the infant mortality rate a heightened sensitivity to socioeconomic conditions and levels of adequate prenatal care.
View details for Web of Science ID A1988M915500009
View details for PubMedID 3353187
THE IMPACT OF BOTTLE BILL LEGISLATION ON THE INCIDENCE OF LACERATIONS IN CHILDHOOD
AMERICAN JOURNAL OF PUBLIC HEALTH
1986; 76 (10): 1243-1244
We studied the effect of legislation requiring deposits for beverage containers on the incidence of lacerations in urban children. Records of emergency room visits for lacerations and fractures were reviewed for three years pre-legislation (1980-82) and the immediate post-legislation period (1983). The incidence of total sutured lacerations did not change substantially after the legislation, but glass-related lacerations fell by 60 per cent, due to a reduced incidence in lacerations occurring outside of the home.
View details for Web of Science ID A1986E074100015
View details for PubMedID 3752330
- MIDWIFERY AND MEDICINE IN AMERICA - THE STRUGGLE FOR JUSTICE IN INFANT HEALTH JOURNAL OF NURSE-MIDWIFERY 1986; 31 (5): 219-223
RACIAL AND SOCIOECONOMIC DISPARITIES IN CHILDHOOD MORTALITY IN BOSTON
NEW ENGLAND JOURNAL OF MEDICINE
1985; 313 (6): 360-366
We examined racial and income-related patterns of mortality from birth through adolescence in Boston, where residents have high access to tertiary medical care. Childhood mortality was significantly higher among black children (odds ratio, 1.24; P less than 0.05) and low-income children (odds ratio, 1.47; P less than 0.001). Socioeconomic effects varied for different age groups and causes of death. The largest relative disparity occurred in the neonatal and postneonatal periods, and the smallest in adolescence. Of the total racial differential in neonatal mortality (6.88 deaths per 1000 live births), 51.2 per cent occurred in premature infants, 13.4 per cent in term infants who were small for their gestational age, and 25.9 per cent in neonates who were both premature and small for their age. Black neonatal mortality was elevated at all income levels. Beyond the neonatal period, mortality from respiratory disease, fire, and homicide had strong inverse relationships with income, and mortality from injuries to the occupants of motor vehicles was directly related to income. These data suggest that despite access to tertiary medical services, substantial social differentiation in mortality may exist throughout childhood. Equity in childhood survival will probably require policies that emphasize preventive goals.
View details for Web of Science ID A1985ANG6700005
View details for PubMedID 4010752
Evaluation of the febrile child under 2 years of age.
journal of emergency medicine
1984; 1 (4): 299-305
Unlike older children and adults, fever in young children may reflect serious underlying disease despite the lack of associated findings on physical examination. Laboratory examinations may provide important information in the management of these children. The recent literature suggests a systematic approach to the evaluation and management of the young febrile child.
View details for PubMedID 6501842
Ethics and the ED nurse: triage in emergency services.
Journal of emergency nursing
1981; 7 (3): 118-119
View details for PubMedID 7029060
DECISION-MAKING IN AMINOGLYCOSIDE THERAPY - DISCUSSION
JOURNAL OF ANTIMICROBIAL CHEMOTHERAPY
1981; 8: 51-56
View details for Web of Science ID A1981LY64600008
DECISION-MAKING IN AMINOGLYCOSIDE THERAPY - DISCUSSION
JOURNAL OF ANTIMICROBIAL CHEMOTHERAPY
1981; 8: 151-153
View details for Web of Science ID A1981LY64600019
FLOW-VOLUME LOOPS IN NEWBORN-INFANTS
CRITICAL CARE MEDICINE
1980; 8 (2): 61-63
Flow-volume loops were obtained during the performance of crying vital capacity (CVC) maneuvers in 31 infants, 18 of whom had hyaline membrane disease (HMD). Both healthy and distressed infants had flow-volume loops resembling those found in adults with variable intrathoracic obstruction of the central airways. Flow rates during inspiration and expiration increased as the CVC increased. Infants with HMD had narrower inspiratory loops and attained peak expiratory flow later than nondistressed infants, but these differences were not statistically significant. Vocalizations, loss of lung recoil associated with loss of lung volume, and partial collapse of intrathoracic airways may all contribute to the shape of the flow-volume loop in infants.
View details for Web of Science ID A1980JE34000002
View details for PubMedID 7353388
PROCEEDINGS OF A SYMPOSIUM HELD AT THE ROYAL-COLLEGE-OF-PHYSICIANS, LONDON, SEPTEMBER 21 AND 22, 1978 - PANEL DISCUSSION - SESSION 1
POSTGRADUATE MEDICAL JOURNAL
1979; 55: 32-34
View details for Web of Science ID A1979JG75300008