<p><strong>INTRODUCTION: </strong>Low-income child populations remain under-vaccinated. Our objective was to determine differences in the relative importance of maternal health literacy and socio-demographic characteristics that often change during early childhood on up-to-date (UTD) immunization status among a low-income population.</p>

<p><strong>METHODS: </strong>We performed secondary data analysis of a longitudinal prospective cohort study of 744 Medicaid-eligible mother-infant dyads recruited at the time of the infant's birth from an inner-city hospital in the United States and surveyed every 6 months for 24 months. Our primary outcome was infant UTD status at 24 months abstracted from a citywide registry. We assessed maternal health literacy with the Test of Functional Health Literacy in Adults (short version). We collected socio-demographic information via surveys at birth and every 6 months. We compared predictors of UTD status at 3, 7, and 24 months.</p>

<p><strong>RESULTS: </strong>The cohort consisted of primarily African-American (81.5%) mothers with adequate health literacy (73.9%). Immunizations were UTD among 56.7% of infants at 24 months of age. Maternal health literacy was not a significant predictor of UTD immunization status. Instead, adjusted results showed that significant predictors of not-UTD status at 24 months were lack of a consistent health care location or "medical home" (OR 0.17, 95%CI 0.18-0.37), inadequate prenatal care (OR 0.48, 95%CI 0.25-0.95), and prior not-UTD status (OR 0.31, 95%CI 0.20-0.47). Notably, all upper confidence limits are less than 1.0 for these variables. Health care location type (e.g., hospital-affiliate, community-based, none) was a significant predictor of vaccine status at age 3 months, 7 months, and 24 months.</p>

<p><strong>CONCLUSIONS: </strong>Investing in efforts to support early establishment of a medical home to obtain comprehensive coordinated preventive care, including providing recommended vaccines on schedule, is a prudent strategy to improve vaccination status at the population level.</p>

<p><strong>OBJECTIVE: </strong>To identify parent, child, community, and health care provider characteristics associated with early intervention (EI) referral and multidisciplinary evaluation (MDE) by EI.</p>

<p><strong>METHODS: </strong>We conducted a mixed methods secondary analysis of data from a randomized controlled trial of a developmental screening program in 4 urban primary care practices. Children &lt;30 months of age not currently enrolled in EI and their parents were included. Using logistic regression, we tested whether parent, child, community, and health care provider characteristics were associated with EI referral and MDE completion. We also conducted qualitative interviews with 9 pediatricians. Interviews were recorded, transcribed, and coded. We identified themes using modified grounded theory.</p>

<p><strong>RESULTS: </strong>Of 2083 participating children, 434 (21%) were identified with a developmental concern. A total of 253 children (58%) with a developmental concern were referred to EI. A total of 129 children (30%) received an MDE. Failure in 2 or more domains on developmental assessments was associated with EI referral (adjusted odds ratio [AOR] 3.15, 95% confidence interval [CI] 1.89-5.24) and completed MDE (AOR 2.16, 95% CI 1.19-3.93). Faxed referral to EI, as opposed to just giving families a phone number to call was associated with MDE completion (AOR 2.94, 95% CI 1.48-5.84). Pediatricians reported that office processes, family preference, and whether they thought parents understood the developmental screening tool influenced the EI referral process.</p>

<p><strong>CONCLUSIONS: </strong>In an urban setting, one third of children with a developmental concern were not referred to EI, and two thirds of children with a developmental concern were not evaluated by EI. Our results suggest that practice-based strategies that more closely connect the medical home with EI such as electronic transmission of referrals (e.g., faxing referrals) may improve completion rates of EI evaluation.</p>

<p>Publicly financed insurance programs are tasked with maintaining coverage for eligible children, but published measures to assess coverage have not been evaluated. Therefore, we sought to identify and categorize measures of health insurance continuity for children and adolescents. We conducted a systematic review of Medline and HealthStar databases, review of reference lists of eligible articles, and contact with experts. We categorized measures into 8 domains based on a conceptual framework. We identified 147 measures from 84 eligible articles. Most measures evaluated the following domains: always insured (41%), repeatedly uninsured (36%), and transition out of coverage (29%), while fewer assessed single gap in coverage, always uninsured, transition into coverage, change in coverage, and eligibility. Only 18% of measures assessed associations between continuity of coverage and child and adolescent health outcomes. These results suggest that a number of measures of continuity of coverage exist, but few measures have assessed impact on outcomes.</p>

<p><strong>BACKGROUND: </strong>Research is needed to identify challenges to developmental screening and strategies for screening in an urban pediatric setting.</p>

<p><strong>METHODS: </strong>Parents of young children and clinicians at four urban pediatric practices participated in focus groups prior to implementation of screening. Participants were queried regarding attitudes, social norms, and barriers to developmental screening. Using information from the focus groups, workflow strategies were developed for implementing screening. Referral rates and satisfaction with screening were gathered at the conclusion.</p>

<p><strong>RESULTS: </strong>Six focus groups of parents and clinicians were conducted. Major themes identified included 1) parents desired greater input on child development and increased time with physicians, 2) physicians did not fully trust parental input, 3) physicians preferred clinical acumen over screening tools, and 4) physicians lacked time and training to conduct screening. For the intervention, developmental screening was implemented at the 9-, 18-, 24-, and 30-month well visits using the Ages &amp; Stages Questionnaire-II and the Modified Checklist for Toddlers. 1397 (98% of eligible) children under 36 months old were enrolled, and 1184 (84%) were screened at least once. 1002 parents (85%) completed a survey at the conclusion of the screening trial. Most parents reported no difficulty completing the screens (99%), felt the screens covered important areas of child development (98%), and felt they learned about their child's strengths and limitations (88%).</p>

<p><strong>CONCLUSIONS: </strong>Developmental screening in urban low-income practices is feasible and acceptable, but requires strategies to capture parental input, provide training, facilitate referrals, and develop workflow procedures and electronic decision support.</p>

<p>We sought to assess the association between parental depressive symptoms and school attendance and emergency department (ED) use among children with and without chronic health conditions. Secondary analysis of the 1997-2004 National Health Interview Survey, a nationally representative survey. Parental depressive symptoms were measured by three questions assessing sadness, hopelessness, or worthlessness in the past month. Children with and without asthma or attention-deficit/hyperactivity disorder (ADHD) were identified, and their school attendance and ED visits were reported by adult household respondents. Children with information on parental depressive symptoms, health conditions, and services use were eligible. We incorporated weights available in the survey for each eligible child to reflect the complex sampling design. 104,930 eligible children were identified. The point prevalence of parental depressive symptoms was low (1.8 %, 95 % CI 1.7-2.0), but greater among children with asthma (2.7 %, 95 % CI 2.4-3.0) and ADHD (3.8 %, 95 % CI 3.2-4.4) than among other children (1.6 %, 95 % CI 1.5-1.7). After adjustment for potential confounders, children whose parents reported depressive symptoms most or all of the time were more likely to report an ED visit (adjusted incident rate ratio [IRR] 1.18, 95 % CI 1.06-1.32) or school absence (adjusted IRR 1.36, 95 % CI 1.14-1.63) than children whose parents did not. The effect of parental depressive symptoms was not modified by child health conditions. Parental depressive symptoms were adversely associated with school attendance and ED use in children. These results suggest the importance of measuring depressive symptoms among adult caregivers of children.</p>

<p><strong>OBJECTIVE: </strong>To determine the effectiveness of developmental screening on the identification of developmental delays, early intervention (EI) referrals, and EI eligibility.</p>

<p><strong>METHODS: </strong>This randomized controlled, parallel-group trial was conducted from December 2008 to June 2010 in 4 urban pediatric practices. Children were eligible if they were &lt;30 months old, term, without congenital malformations or genetic syndromes, not in foster care, and not enrolled in EI. Children were randomized to receive 1 of the following: (1) developmental screening using Ages and Stages Questionnaire-II (ASQ-II and Modified Checklist for Autism in Toddlers (M-CHAT) with office staff assistance, (2) developmental screening using ASQ-II and M-CHAT without office staff assistance, or (3) developmental surveillance using age-appropriate milestones at well visits. Outcomes were assessed using an intention-to-treat analysis.</p>

<p><strong>RESULTS: </strong>A total of 2103 children were enrolled. Most were African-American with family incomes less than $30,000. Children in either screening arm were more likely to be identified with delays (23.0% and 26.8% vs 13.0%; P &lt; .001), referred to EI (19.9% and 17.5% vs 10.2%; P &lt; .001), and eligible for EI services (7.0% and 5.3% vs 3.0%; P &lt; .001) than children in the surveillance arm. Children in the screening arms incurred a shorter time to identification, EI referral, and EI evaluation than children in the surveillance arm.</p>

<p><strong>CONCLUSIONS: </strong>Children who participated in a developmental screening program were more likely to be identified with developmental delays, referred to EI, and eligible for EI services in a timelier fashion than children who received surveillance alone. These results support policies endorsing developmental screening.</p>

<p><strong>OBJECTIVES: </strong>Hospital crowding adversely affects access to emergent and elective care, quality and safety, patient and staff satisfaction, and trainee education. Reliable and valid measurements are crucial to operational planning and improvement, but traditional measures of hospital utilization may not accurately describe dynamic demand at hospitals. The goal of this study was to determine how effectively traditional measures express demand for hospital services and to describe the dynamic nature of patient flow in children's hospitals compared with alternative measures.</p>

<p><strong>METHODS: </strong>This was a retrospective administrative data review conducted at an urban, tertiary care children's hospital. A total of 28045 inpatients (22310 from fiscal year 2008 and 5735 from 2 months in the fall of 2009 during the H1N1 influenza surge [October 16, 2009-November 18, 2009]) were reviewed. Admission-discharge-transfer data were abstracted from a total of 14 months (1 fiscal year and a separate 2 months including an influenza surge). Hourly hospital census and occupancy were determined. Measures of mean and median length of stay (LOS) were compared. Turnover was calculated by summing admissions, discharges, and interunit transfers. Coefficient of variation (SD/mean) was used to describe variation.</p>

<p><strong>RESULTS: </strong>Midnight occupancy was generally closer to minimum occupancy than peak. Peak was usually between 10 AM and 12 PM and was a mean of 40/% points higher than midnight (but as large as 13% points). Median LOS was 58% shorter than average LOS. There was a high level of turnover, and patient-days did not express the wide variation in how demand was generated by day of week.</p>

<p><strong>CONCLUSIONS: </strong>Traditional metrics for hospital utilization do not accurately express the true extent and dynamic nature of patient flow and inpatient demand at a children's hospital. Hospitals and government regulatory agencies should consider additional means of measuring utilization to accurately determine demand, including its variation, and thus assist in budgeting, staffing, and capacity planning.</p>

<p><strong>BACKGROUND: </strong>The pediatric intensive care unit (PICU), with limited number of beds and resource-intensive services, is a key component of patient flow. Because the PICU is a crossroads for many patients, transfer or discharge delays can negatively impact a patient's clinical status and efficiency.</p>

<p><strong>OBJECTIVE: </strong>The objective of this study was to describe, using direct observation, PICU bed utilization.</p>

<p><strong>METHODS: </strong>We conducted a real-time, prospective observational study in a convenience sample of days in the PICU of an urban, tertiary-care children's hospital.</p>

<p><strong>RESULTS: </strong>Among 824 observed hours, 19,887 bed-hours were recorded, with 82% being for critical care services and 18% for non-critical care services. Fourteen activities accounted for 95% of bed-hours. Among 200 hours when the PICU was at full capacity, 75% of the time included at least 1 bed that was used for non-critical care services; 37% of the time at least 2 beds. The mean waiting time for a floor bed assignment was 9 hours (median, 5.5 hours) and accounted for 4.62% of all bed-hours observed.</p>

<p><strong>CONCLUSIONS: </strong>The PICU delivered critical care services most of the time, but periods of non-critical care services represented a significant amount of time. In particular, periods with no bed available for new patients were associated with at least 1 or more PICU beds being used for non-critical care activities. The method should be reproducible in other settings to learn more about the structure and processes of care and patient flow and to make improvements.</p>

<p>To determine if maternal health literacy influences early infant immunization status. Longitudinal prospective cohort study of 506 Medicaid-eligible mother-infant dyads. Immunization status at age 3 and 7&nbsp;months was assessed in relation to maternal health literacy measured at birth using the Test of Functional Health Literacy in Adults (short version). Multivariable logistic regression quantified the effect of maternal health literacy on immunization status adjusting for the relevant covariates. The cohort consists of primarily African-American (87%), single (87%) mothers (mean age 23.4&nbsp;years). Health literacy was inadequate or marginal among 24% of mothers. Immunizations were up-to-date among 73% of infants at age 3&nbsp;months and 43% at 7&nbsp;months. Maternal health literacy was not significantly associated with immunization status at either 3 or 7&nbsp;months. In multivariable analysis, compared to infants who had delayed immunizations at 3&nbsp;months, infants with up-to-date immunizations at 3&nbsp;months were 11.3 times (95%CI 6.0-21.3) more likely to be up-to-date at 7&nbsp;months. The only strong predictors of up-to-date immunization status at 3&nbsp;months were maternal education (high school graduate or beyond) and attending a hospital-affiliated clinic. Though maternal health literacy is not associated with immunization status in this cohort, later immunization status is most strongly predicted by immunization status at 3&nbsp;months. These results further support the importance of intervening from an early age to ensure that infants are fully protected against vaccine preventable diseases.</p>

<p><strong>OBJECTIVE: </strong>We identified maternal, provider, and community predictors among infants for late initiation of immunizations.</p>

<p><strong>METHODS: </strong>We performed a retrospective cohort study of infants born between January 1, 2002, and December 31, 2004, in Philadelphia, Pennsylvania. Primary outcomes were age in days at first office-based immunization and status as a late starter (i.e., initiating office-based immunizations after 90 days of age). Candidate predictors included sociodemographic and prenatal characteristics, immunization provider practice type and size, and neighborhood factors. We performed hierarchical logistic regression and Cox regression models to identify independent predictors for being a late starter and prolonged time to first immunization.</p>

<p><strong>RESULTS: </strong>Of the 65,519 infants from this birth cohort in Philadelphia's immunization registry, 54,429 (88.1%) were included in analysis and 12.6% of these were late starters. Infants whose mothers were younger, received less than five prenatal visits, had less than a high school education, had more than two children, and who smoked cigarettes prenatally were significantly more likely to be late starters. Receiving care at hospital/university-based or public health clinics was also significantly associated with likelihood of being a late starter. Neither distance between infant's residence and practice nor neighborhood socioeconomic indicators was independently associated with the outcomes. Common risk factor profiles based on practice type and four maternal characteristics were found to reliably identify infant risk.</p>

<p><strong>CONCLUSIONS: </strong>Maternal receipt of fewer prenatal care visits, younger maternal age, higher birth order, and receiving care at public health clinics were the strongest predictors of being a late starter and time to first immunization. Risk factor profiles based on information already collected at birth can be used to identify higher-risk infants. Early intervention and potentially partnering with prenatal care providers may be key strategies for preventing underimmunization.</p>