OBJECTIVE: To examine developmental and behavioral status of children in child welfare (CW) over time, by intensity of CW involvement using a national probability sample.

METHODS: As part of the National Survey of Child and Adolescent Well-being (NSCAW), data were collected on 1,049 children 12-47 months old investigated by CW agencies for possible abuse or neglect. Analyses used descriptive statistics to characterize developmental and behavioral status across four domains (developmental/cognitive, language, adaptive functioning, and behavior) by intensity of CW involvement (in-home with CW services, in-home with no CW services or out-of-home care) over time. Multivariate analyses were used to examine the relationship between independent variables (age, gender, home environment, race/ethnicity, maltreatment history, intensity of CW involvement) and follow-up domain scores.

RESULTS: On average, children improved in developmental/cognitive, communication/language status over time, but these improvements did not differ by intensity of CW involvement. Analyses revealed a positive relationship between the home environment and change in language and adaptive behavior standard scores over time, and few predictors of change in behavioral status. An interaction between intensity of CW involvement and initial developmental/cognitive status was present.

CONCLUSIONS: Across domains, intensity of CW involvement does not appear to have a significant effect on change in developmental and behavioral status, although out-of-home care does have differential relationships with children's developmental/cognitive status for those with very low initial cognitive/developmental status. Facilitating development in children in CW may require supportive, enriched care environments both for children remaining at home and those in foster care. P

RACTICE IMPLICATIONS: Toddler and preschool age children known to child welfare are likely to have difficulties with development whether they are removed from their homes or not. It would be helpful if child welfare workers were trained to screen for developmental, language, adaptive behavior and behavioral difficulties in children in foster care, and those remaining at home. Additional support for biological, foster, and kinship caregivers in encouraging development is important for the attainment of critical developmental skills, especially for children with developmental difficulties.

Background

Fewer women than men undergo implantable cardioverter defibrillator (ICD) implantation for the primary prevention of sudden cardiac death. The criteria used to select patients for ICD implantation may be more permissive among men than for women. We hypothesized that women who undergo primary prevention ICD implantation more often meet strict trial enrollment criteria for this therapy.

Methods

We studied 59,812 patients in the National Cardiovascular Data Registry ICD registry undergoing initial primary prevention ICD placement between January 2005 and April 2007. Patients were classified as meeting or not meeting enrollment criteria of either the MADIT-II or SCD-HeFT trials. Multivariable analyses assessed the association between gender and concordance with trial criteria adjusting for demographic, clinical, and system characteristics.

Results

Among the cohort, 27% (n = 16,072) were women. Overall, 85.2% of women and 84.5% of men met enrollment criteria of either trial (P = .05). In multivariable analyses, women were equally likely to meet trial criteria (OR 1.04, 95% CI 0.99-1.10) than men. Significantly more women than men met the trial enrollment criteria among patients older than age 65 (86.6% of women vs 85.3% of men, OR 1.11, 95% CI 1.03-1.19), but this difference was not found among younger patients (82.5% of women vs 83.0% of men, OR 0.97, 95% CI 0.89-1.07).

Conclusions

In a national cohort undergoing primary prevention ICD implantation, older women were only slightly more likely then men to meet the enrollment criteria for MADIT II or SCD-HeFT. Relative overutilization in men is not an important explanation for gender differences in ICD implantation.

BACKGROUND: Previous research has provided evidence that socioeconomic status has an impact on invasive treatments use after acute myocardial infarction. In this paper, we compare the socioeconomic inequality in the use of high-technology diagnosis and treatment after acute myocardial infarction between the US, Quebec and Belgium paying special attention to financial incentives and regulations as explanatory factors.

METHODS: We examined hospital-discharge abstracts for all patients older than 65 who were admitted to hospitals during the 1993-1998 period in the US, Quebec and Belgium with a primary diagnosis of acute myocardial infarction. Patients' income data were imputed from the median incomes of their residential area. For each country, we compared the risk-adjusted probability of undergoing each procedure between socioeconomic categories measured by the patient's area median income.

RESULTS: Our findings indicate that income-related inequality exists in the use of high-technology treatment and diagnosis techniques that is not justified by differences in patients' health characteristics. Those inequalities are largely explained, in the US and Quebec, by inequalities in distances to hospitals with on-site cardiac facilities. However, in both Belgium and the US, inequalities persist among patients admitted to hospitals with on-site cardiac facilities, rejecting the hospital location effect as the single explanation for inequalities. Meanwhile, inequality levels diverge across countries (higher in the US and in Belgium, extremely low in Quebec).

CONCLUSIONS: The findings support the hypothesis that income-related inequality in treatment for AMI exists and is likely to be affected by a country's system of health care.

Why has diagnostic testing, and in particular diagnostic imaging, increased to such a high level in the United States? I would argue that it is a combination of our medical culture (and our human nature) to eliminate uncertainty, scientific and technical advances leading to new and improved noninvasive tests, substantial barriers to evaluating the value of each test, and patient preference. Combined, these factors have likely contributed to an exponential growth in testing (particularly imaging) in recent years and are the areas that must be addressed if we wish to provide more efficient care.

Purpose. Mathematical and simulation models are increasingly used to plan for and evaluate health sector responses to disasters, yet no clear consensus exists regarding best practices for the design, conduct, and reporting of such models. The authors examined a large selection of published health sector disaster response models to generate a set of best practice guidelines for such models.

Methods. The authors reviewed a spectrum of published disaster response models addressing public health or health care delivery, focusing in particular on the type of disaster and response decisions considered, decision makers targeted, choice of outcomes evaluated, modeling methodology, and reporting format. They developed initial recommendations for best practices for creating and reporting such models and refined these guidelines after soliciting feedback from response modeling experts and from members of the Society for Medical Decision Making.

Results. The authors propose 6 recommendations for model construction and reporting, inspired by the most exemplary models: health sector disaster response models should address real-world problems, be designed for maximum usability by response planners, strike the appropriate balance between simplicity and complexity, include appropriate outcomes that extend beyond those considered in traditional cost-effectiveness analyses, and be designed to evaluate the many uncertainties inherent in disaster response. Finally, good model reporting is particularly critical for disaster response models.

Conclusions. Quantitative models are critical tools for planning effective health sector responses to disasters. The proposed recommendations can increase the applicability and interpretability of future models, thereby improving strategic, tactical, and operational aspects of preparedness planning and response.

Clinical research presents health care providers with information on the natural history and clinical presentations of disease as well as diagnostic and treatment options. Consumers, patients, and caregivers also require this information to decide how to evaluate and treat their conditions. All too often, the information necessary to inform these medical decisions is incomplete or unavailable, resulting in more than half of the treatments delivered today lacking clear evidence of effectiveness.

Comparative effectiveness research (CER) identifies what works best for which patients under what circumstances. Congress, in the American Recovery and Reinvestment Act (ARRA) of 2009, tasked the Institute of Medicine (IOM) to recommend national priorities for research questions to be addressed by CER and supported by ARRA funds. In its 2009 report, Initial National Priorities for Comparative Effectiveness Research, the authoring committee establishes a working definition of CER, develops a priority list of research topics to be undertaken with ARRA funding using broad stakeholder input, and identifies the necessary requirements to support a robust and sustainable CER enterprise. The full list of priorities and recommendations can be found in the below report brief.

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.

Objective To evaluate the evidence that quality improvement (QI) strategies can improve the processes and outcomes of outpatient pediatric asthma care.

Data Sources 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.

Study Selection Randomized controlled trials, controlled before-after trials, or interrupted time series trials of English-language QI evaluations.

Interventions Must have included 1 or more QI strategies for the outpatient management of children with asthma.

Main Outcome Measures Clinical status (eg, spirometric measures); functional status (eg, days lost from school); and health services use (eg, hospital admissions).

Results 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.

Conclusions 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.

Abstract

Some people find it more difficult to delay rewards than others. In three experiments, we tested a "future self-continuity" hypothesis that individual differences in the perception of one's present self as continuous with a future self would be associated with measures of saving in the laboratory and everyday life. Higher future self-continuity (assessed by a novel index) predicted reduced discounting of future rewards in a laboratory task, more matches in adjectival descriptions of present and future selves, and greater lifetime accumulation of financial assets (even after controlling for age and education). In addition to demonstrating the reliability and validity of the future self-continuity index, these findings are consistent with the notion that increased future self-continuity might promote saving for the future.

Objective: The study examined the influence of parent involvement and family factors on body mass index (BMI) change in a pediatric obesity treatment program.

Methods: A total of 104 children and their caregivers were examined during a 12-week obesity intervention. Participants (mean age = 11.42 years; SD = 2.83) and their caregivers completed measures of family environment and depression prior to enrollment. Children's BMI and parental involvement were rated weekly during the intervention. Logistic regressions were conducted to examine the role of sociodemographic factors, family characteristics, and parent involvement on weight.

Results: Children with the lowest parent involvement were less likely to lose any weight or have clinically significant (>/=2 kg) weight loss. Demographics and family factors did not predict BMI change. Parent involvement related to ethnicity, absences and physical activity.

Conclusions: Parental involvement may be helpful in identifying who is likely to do well in a weight loss program.