OBJECTIVE: To assess the relationship between posthospitalization prescription fills for recommended asthma discharge medication classes and subsequent hospital readmission.

STUDY DESIGN: This was a retrospective cohort analysis of Medicaid Analytic Extract files from 12 geographically diverse states from 2005-2007. We linked inpatient hospitalization, outpatient, and prescription claims records for children ages 2-18 years with an index hospitalization for asthma to identify those who filled a short-acting beta agonist, oral corticosteroid, or inhaled corticosteroid within 3 days of discharge. We used a multivariable extended Cox model to investigate the association of recommended medication fills and hospital readmission within 90 days.

RESULTS: Of 31,658 children hospitalized, 55% filled a beta agonist prescription, 57% an oral steroid, and 37% an inhaled steroid. Readmission occurred for 1.3% of patients by 14 days and 6.3% by 90 days. Adjusting for patient and billing provider factors, beta agonist (hazard ratio [HR] 0.67, 95% CI 0.51, 0.87) and inhaled steroid (HR 0.59, 95% CI 0.42, 0.85) fill were associated with a reduction in readmission at 14 days. Between 15 and 90 days, inhaled steroid fill was associated with decreased readmission (HR 0.87, 95% CI 0.77, 0.98). Patients who filled all 3 medications had the lowest readmission hazard within both intervals.

CONCLUSIONS: Filling of beta agonists and inhaled steroids was associated with diminished hazard of early readmission. For inhaled steroids, this effect persisted up to 90 days. Efforts to improve discharge care for asthma should include enhancing recommended discharge medication fill rates.

<p>Evidence for the effectiveness of masking on SARS-CoV-2 transmission at the individual level has accumulated, but the additional benefit of community-level mandates is less certain. In this observational study of matched cohorts from 394 US counties between March 21 and October 20, 2020, we estimated the association between county-level public masking mandates and daily COVID-19 case incidence. On average, the daily case incidence per 100,000 people in masked counties compared with unmasked counties declined by 23&nbsp;percent at four weeks, 33&nbsp;percent at six weeks, and 16&nbsp;percent across six weeks postintervention. The beneficial effect varied across regions of different population densities and political leanings. The most concentrated effects of masking mandates were seen in urban counties; the benefit of the mandates was potentially stronger within Republican-leaning counties. Although benefits were not equally distributed in all regions, masking mandates conferred benefit in reducing community case incidence during an early period of the COVID-19 pandemic.</p>

<p>Interest in the mathematical modeling of infectious diseases has increased due to the COVID-19 pandemic. However, many medical students do not have the required background in coding or mathematics to engage optimally in this approach. System dynamics is a methodology for implementing mathematical models as easy-to-understand stock-flow diagrams. Remarkably, creating stock-flow diagrams is the same process as creating the equivalent differential equations. Yet, its visual nature makes the process simple and intuitive. We demonstrate the simplicity of system dynamics by applying it to epidemic models including a model of COVID-19 mutation. We then discuss the ease with which far more complex models can be produced by implementing a model comprising eight differential equations of a Chikungunya epidemic from the literature. Finally, we discuss the learning environment in which the teaching of the epidemic modeling occurs. We advocate the widespread use of system dynamics to empower those who are engaged in infectious disease epidemiology, regardless of their mathematical background.</p>

<p><strong>OBJECTIVES: </strong>A relatively small proportion of children with asthma account for an outsized proportion of health care use. Our goal was to use quality improvement methodology to reduce repeat emergency department (ED) and inpatient care for patients with frequent asthma-related hospitalization.</p>

<p><strong>METHODS: </strong>Children ages 2 to 17 with ≥3 asthma-related hospitalizations in the previous year who received primary care at 3 in-network clinics were eligible to receive a bundle of 4 services including (1) a high-risk asthma screener and tailored education, (2) referral to a clinic-based asthma community health worker program, (3) facilitated discharge medication filling, and (4) expedited follow-up with an allergy or pulmonology specialist. Statistical process control charts were used to estimate the impact of the intervention on monthly 30-day revisits to the ED or hospital. We then conducted a difference-in-differences analysis to compare changes between those receiving the intervention and a contemporaneous comparison group.</p>

<p><strong>RESULTS: </strong>From May 1, 2016, to April 30, 2017, we enrolled 79 patients in the intervention, and 128 patients constituted the control group. Among the eligible population, the average monthly proportion of children experiencing a revisit to the ED and hospital within 30 days declined by 38%, from a historical baseline of 24% to 15%. Difference-in-differences analysis demonstrated 11.0 fewer 30-day revisits per 100 patients per month among intervention recipients relative to controls (95% confidence interval: -20.2 to -1.8; = .02).</p>

<p><strong>CONCLUSIONS: </strong>A multidisciplinary quality improvement intervention reduced health care use in a high-risk asthma population, which was confirmed by using quasi-experimental methodology. In this study, we provide a framework to analyze broader interventions targeted to frequently hospitalized populations.</p>

<p>To compare hospital-based utilization for early childhood injuries between program recipients and local-area comparison families following statewide implementation of an evidence-based home visitation program, and to describe site-level program variation. Propensity score matching on baseline characteristics was used to create a retrospective cohort of Nurse-Family Partnership (NFP) clients and local area matched comparison women. The main outcome, a count of injury visit episodes, was enumerated from Medicaid claims for injuries examined in an emergency department or hospital setting during the first 2 years of life of children born to included subjects. Generalized linear models with a Poisson distribution examined the association between injury episode counts and NFP participation, controlling for other non-injury utilization and stratifying by individual agency catchment area in a fixed effects analysis. The children of NFP clients were more likely in aggregate to have higher rates of injury visits in the first 2 years of life than the children of comparison women (415.2/1,000 vs. 364.2/1,000, P &lt; 0.0001). Significantly higher rates of visits among children of NFP clients for superficial injuries (156.6/1,000 vs. 132.6/1,000, P &lt; 0.0001) principally accounted for the attributable difference in injury visit rates between groups. Among more serious injuries, no significant difference in injury visit rates was found between NFP clients and comparison women. The proportion of children with at least one injury visit varied from 14.5 to 42.5% among individual sites. Contrary to prior randomized trial data, no reductions in utilization for serious early childhood injuries were demonstrated following statewide implementation of an evidence-based home visitation program. Significant program variation on outcomes underscores the challenges to successful implementation.</p>

<p><b>BACKGROUND: </b>The influence of community context on the effectiveness of evidence-based maternal and child home visitation programs following implementation is poorly understood. This study compared prenatal smoking cessation between home visitation program recipients and local-area comparison women across 24 implementation sites within one state, while also estimating the independent effect of community smoking norms on smoking cessation behavior.</p><p><b>METHODS: </b>Retrospective cohort design using propensity score matching of Nurse-Family Partnership (NFP) clients and local-area matched comparison women who smoked cigarettes in the first trimester of pregnancy. Birth certificate data were used to classify smoking status. The main outcome measure was smoking cessation in the third trimester of pregnancy. Multivariable logistic regression analysis examined, over two time periods, the association of NFP exposure and the association of baseline county prenatal smoking rate on prenatal smoking cessation.</p><p><b>RESULTS: </b>The association of NFP participation and prenatal smoking cessation was stronger in a later implementation period (35.5% for NFP clients vs. 27.5% for comparison women, p &lt; 0.001) than in an earlier implementation period (28.4% vs. 25.8%, p = 0.114). Cessation was also negatively associated with county prenatal smoking rate, controlling for NFP program effect, (OR = 0.84 per 5 percentage point change in county smoking rate, p = 0.002).</p><p><b>CONCLUSIONS: </b>Following a statewide implementation, program recipients of NFP demonstrated increased smoking cessation compared to comparison women, with a stronger program effect in later years. The significant association of county smoking rate with cessation suggests that community behavioral norms may present a challenge for evidence-based programs as models are translated into diverse communities.</p>

<p>Little is known about how the challenges faced by caregivers influence the variation in social, emotional, and behavioral (SEB) outcomes of youth placed in kinship versus non-relative foster care. This study examined SEB symptoms among youth in kinship and non-relative foster care settings, hypothesizing that changes in caregiver depression would modify children's change in behavior over time. Child Behavior Checklist (CBCL) assessments of 199 children placed with kinship and non-relative foster care providers in a Mid-Atlantic city were conducted at time of placement and 6-12 months post-placement. Linear regression estimated CBCL change scores for youth across placement type and caregiver depression trajectories. Kinship caregivers were more likely to become depressed or remained depressed than non-relative foster caregivers. Youth in kinship care always exhibited better change in SEB outcomes than youth in non-relative foster care, but these positive outcomes were principally observed among families where caregivers demonstrated a reduction in depression over time or were never depressed. Adjusted change scores for non-relative foster care youth were always negative, with the most negative scores among youth whose caregivers became depressed over time. Caregiver well-being may modify the influence of placement setting on SEB outcomes for youth placed into out-of-home care. Findings lend to policy relevance for child welfare systems that seek kinship settings as a panacea to the challenges faced by youth, without allocating resources to address caregiver needs.</p>

<p>Randomized controlled trials are the "gold standard" for estimating the causal effects of treatments. However, it is often not feasible to conduct such a trial because of ethical concerns or budgetary constraints. We expand upon an approach to the analysis of observational data sets that mimics a sequence of randomized studies by implementing propensity score models within each trial to achieve covariate balance, using weighting and matching. The methods are illustrated using data from a safety study of the relationship between second-generation antipsychotics and type 2 diabetes (outcome) in Medicaid-insured children aged 10-18 years across the United States from 2003 to 2007. Challenges in this data set include a rare outcome, a rare exposure, substantial and important differences between exposure groups, and a very large sample size. </p>

<p>In 2011, the American Academy of Pediatrics (AAP) and NHLBI recommended universal cholesterol testing at age 9 to 11 years, discussing 2 rationales. The first rationale was identification of familial hypercholesterolemia, a severe disease with a prevalence of ≈ 1:300. The long-term safety and benefits of cholesteral-lowering medications for youth with severe hypercholesterolemia have been established. These known benefits increase the value of early disease identification. The second rationale was identification of less severe dyslipidemias associated with pediatric obesity that may represent a modifiable risk for cardiovascular disease. Before 2011, pediatric cholesterol testing was most common among children with known cardiovascular risks, particularly obesity. Questions remain about the role of universal testing in pediatrics, and the United States Preventive Services Task Force has not endorsed universal testing. This uncertainty may influence guideline uptake.</p>

<p>Prior reports examining cholesterol testing in pediatric cohorts predate the 2011 guideline, evaluate specific efforts to adopt the guideline, or were unable to evaluate other cardiovascular risk factors that may be associated with testing. This study asks whether, and to what extent, universal testing has been adopted since the 2011 guideline.</p>