Ultrasonography in the assessment of developmental dysplasia of the hip.
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Hip Dislocation, Congenital↗
Biomedical subjects
Barbara P Yawn
Publications and source records attributed to Barbara P Yawn.
Immediate and longer term impact of the varicella shortage on children 18 and 24 months of age in a community population.
BACKGROUND: Little is known about the impact of the recent varicella vaccine shortage. To assess the temporal trend in varicella vaccine administration before 18 and 24 months of age in a community cohort of children prior to, during and after the recent varicella vaccine shortage. And to compare the temporal trends in varicella vaccinations to trends of an older, more widely accepted vaccine, the MMR. METHODS: Community population-based birth cohorts were identified who were eligible for the varicella vaccination before, during and after the 2001 to 2002 varicella vaccine shortage. Only children (84% of all) who remained in the community through their second birthday were included. For each child in the cohort, the medical records and immunization registry records from both medical facilities in the county were reviewed to identify the dates and sites for all varicella immunizations given. In addition to varicella immunizations, the dates of all MMR vaccinations were recorded. Additional data abstracted included the child's birth date, gender and dates of any recognized cases of chickenpox up through age 24 months. RESULTS: Of the 2,512 children in the birth cohorts, 50.8% were boys. In the three cohorts combined, 81.1% of the boys and 79.3% of the girls (p = 0.30) received the varicella vaccine by age 24 months. The pre-shortage community rate of varicella immunization was 79.7% by 24 months of age. During the varicella vaccine shortage, the rate of varicella immunization by 24 months fell to 77.2%. Only 6 additional children received a "catch-up" immunization by 36 months of age. In the post shortage period the community 24-month immunization rate rebounded to a level higher than the pre-shortage rate 84.0%. During the almost three years of observation, the MMR immunization rate by age 24 months was constant (87%). CONCLUSION: The varicella shortage was associated with an immediate drop in the 24-month varicella immunizations rate but rebounded quickly to above pre-shortage rates. In this community the only long term impact of the varicella vaccine shortage may be on the small number of children who still had not received catch-up varicella immunizations by 36 months of age.
Age Distribution↗
The risk of hydrosalpinx formation and adnexectomy following tubal ligation and subsequent hysterectomy: a historical cohort study.
OBJECTIVE: The objective of the study was to further investigate a previous finding that tubal sterilization followed by hysterectomy was associated with hydrosalpinx formation. STUDY DESIGN: The Rochester Epidemiology Project (Rochester, MN) was used to identify three cohorts: women who had undergone tubal sterilization and subsequent hysterectomy, women who had undergone tubal sterilization alone, and women who had undergone hysterectomy alone. Four hundred seventy-three charts were reviewed and 337 met inclusion criteria. Patient histories were analyzed prospectively, looking for subsequent adnexal surgery. RESULTS: There was no increased risk of hydrosalpinx formation in patients who had undergone tubal sterilization and hysterectomy, compared with tubal sterilization alone. The proportion of subjects undergoing later adnexectomy for any reason was significantly higher in the hysterectomy groups, compared with the sterilization only group (relative risk 3.5, 95% confidence interval 1.3-9.4). CONCLUSION: This prospective study does not support the previously reported case-control data suggesting that tubal sterilization followed by hysterectomy resulted in an increased risk of hydrosalpinx formation, compared with tubal sterilization alone.
Adnexa Uteri↗
Impact of vaccine economic programs on physician referral of children to public vaccine clinics: a pre-post comparison.
BACKGROUND: The Vaccines for Children (VFC) Program is a major vaccine entitlement program with limited long-term evaluation. The objectives of this study are to evaluate the effect of VFC on physician reported referral of children to public health clinics and on doses administered in the public sector. METHODS: Minnesota and Pennsylvania primary care physicians (n = 164), completed surveys before (e.g., 1993) and after (2003) VFC, rating their likelihood on a scale of 0 (very unlikely) to 10 (very likely) of referring a child to the health department for immunization. RESULTS: The percentage of respondents likely to refer was 60% for an uninsured child, 14% for a child with Medicaid, and 3% for a child with insurance that pays for immunization. Half (55%) of the physicians who did not participate in VFC were likely to refer a Medicaid-insured child, as compared with 6% of those who participated (P < 0.001). Physician likelihood to refer an uninsured child for vaccination, measured on a scale of 0 to 10 where 10 is very likely, decreased by a mean difference of 1.9 (P < 0.001) from pre- to post-VFC. The likelihood to refer a Medicaid-insured child decreased by a mean of 1.2 (P = 0.001). CONCLUSION: Reported out-referral to public clinics decreased over time. In light of increasing immunizations rates, this suggests that more vaccines were being administered in private provider offices.
Child↗
Measuring asthma quality in primary care: can we develop better measures?
OBJECTIVE: Asthma is common and commonly under-treated. Currently quality indicators often do not provide specific directions for areas of improvement. This work lays the foundation for a quality improvement initiative that provides practice-specific feedback related directly to clinical activities completed for individual patients with asthma. METHODS: Medical record review using a group of quality assessment elements developed from previous medical record review studies of asthma care and the NAEPP asthma care guidelines. RESULTS: For 500 school children ages 5-18 yr who made one or more asthma visits in the year of interest, the frequency of daytime asthma symptoms were recorded in 54% of patients' medical records at any time during a one-year period, while nighttime symptom frequency was recorded in 33%. Only 12% of medical records recorded any information on missed work, school or activity days. Nine percent recorded information or acknowledged any asthma "triggers". Asthma severity level was documented in only an additional 4% of the children's records. Most medical records documented prescribed asthma medications and dosages (85%) but few recorded the medications or dosages the patients were actually taking. CONCLUSIONS: Many medical records do not include the basic clinical information required to assess asthma severity, adherence to asthma therapy or the response to therapy. This lack of information makes implementation of asthma care guidelines impossible. Therefore, these measures may be useful baseline quality indicators to begin the process of improving asthma care.
Adolescent↗
Asthma screening, case identification and treatment in school-based programs.
PURPOSE OF REVIEW: Asthma is an important health problem in school-aged children and schools seem an obvious site to find and work with under-recognized and under-treated asthma. Teachers and coaches often must deal with asthma-related symptoms or emergencies requiring knowledge, skills, and written plans and policies. In 2005, school-based asthma work focused on two areas: identification of unrecognized asthma and management of under-treated asthma. RECENT FINDINGS: Effective school-based screening requires a simple, effective screening tool. Three new asthma screening tools continue to identify more false-positive than true positive cases of asthma. Public health experts question whether asthma even fits the usual criteria for 'screening' because it does not have an asymptomatic phase. 'Case-finding' is presented as a better use of resources, allowing schools to focus on children with asthma that has been diagnosed but remains symptomatic. No school-based program based on letters, reminders, or recommendations sent to parents or community physicians changed asthma care. Three reports describe programs designed to supplement usual asthma care by providing in-school interventions, but none appeared ready for implementation in all schools in the USA. A major barrier was the continuing lack of school nurses, who must have asthma-related education and medical support to provide school-based asthma management. SUMMARY: Schools continue to be a site for asthma interventions but few of the programs, even the most intensive, influence children's asthma-related health. Most programs require modifications and further evaluation, and all require careful assessment of the burden on schools.
Asthma↗
Comparison of parent and student responses to asthma surveys: students grades 3-12 and their parents from a suburban private school setting.
Schools are being called upon to help address asthma, a common problem in school-aged children. School-based asthma programs need information about asthma diagnoses, asthma symptoms, and asthma's impact on school attendance. Parent or student surveys are the most common method of collecting these data. However, medical literature offers little guidance to help schools determine whether parents or students are the most appropriate and effective source of asthma-related information. This study compares student and parent responses to the same set of asthma-related questions. In general, parents and students have a high level of agreement in reporting the absence of an asthma diagnosis or asthma symptoms. When parents and students disagreed, students reported many more asthmalike symptoms, especially symptoms with exercise and symptoms at night, than did their parents. The disparity in student and parent symptom reporting did not vary by age of the student. Students appear to provide the most sensitive measure of asthma-related problems.
Adolescent↗
Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force.
BACKGROUND: Developmental dysplasia of the hip (DDH) represents a spectrum of anatomic abnormalities that can result in permanent disability. OBJECTIVE: We sought to gather and synthesize the published evidence regarding screening for DDH by primary care providers. METHODS: We performed a systematic review of the literature by using a best-evidence approach as used by the US Preventive Services Task Force. The review focused on screening relevant to primary care in infants from birth to 6 months of age and on interventions used in infants before 1 year of age. RESULTS: The literature on screening and interventions for DDH suffers from significant methodologic shortcomings. No published trials directly link screening to improved functional outcomes. Clinical examination and ultrasound identify somewhat different groups of newborns who are at risk for DDH. A significant proportion of hip abnormalities identified through clinical examination or ultrasound in the newborn period will spontaneously resolve. Very few studies examine the functional outcomes of patients who have undergone therapy for DDH. Because of the high rate and unpredictable nature of spontaneous resolution of DDH and the absence of rigorous comparative studies, the effectiveness of interventions is not known. All surgical and nonsurgical interventions have been associated with avascular necrosis of the femoral head, the most common and most severe harm associated with all treatments of DDH. CONCLUSIONS: Screening with clinical examination or ultrasound can identify newborns at increased risk for DDH, but because of the high rate of spontaneous resolution of neonatal hip instability and dysplasia and the lack of evidence of the effectiveness of intervention on functional outcomes, the net benefits of screening are not clear.
Early Diagnosis↗
Assessment of asthma severity and asthma control in children.
National and international guidelines for asthma recommend the assessment and documentation of severity as the basis for patient management. However, studies show that there are problems with application of the severity assessment to children in clinical practice. More recently, asthma control has been introduced as a method to assess the adequacy of current treatment and inform asthma management. In this article we review the application and limitations of the severity assessment and the asthma-control tools that have been tested for use in children. A system of using asthma severity for disease assessment in the absence of treatment and using asthma-control assessment to guide management decisions while a child is receiving treatment appears to be a promising approach to tailor treatment to improve care and outcomes for children with asthma.
Asthma↗
Silent pain sufferers.
OBJECTIVE: To evaluate the proportion and characteristics of patients with chronic pain who do not seek treatment and assess whether these patients have unmet pain care needs. PATIENTS AND METHODS: We performed a cross-sectional survey of residents of Olmsted County, Minnesota, from March through June 2004, with additional visit and diagnosis data from the Rochester Epidemiology Project database. Study participants were a random, population-based sample of eligible adult (>30 years) residents of Olmsted County with at least 1 visit to a local health care facility in the past 3 years. RESULTS: Of the 5897 eligible participants, 3575 people (60.6%) responded. Of the respondents who reported pain of more than 3 months' duration, 497 (22.4%) of the 2211 patients stated that they had not informed their physician about their pain. Of these silent sufferers, 70.6% (351/497) reported having moderate or severe pain, 49.2% (243/497) reported having frequent pain (>8 days per month), and 40.6% (202/497) met both criteria. Silent sufferers also reported that pain interfered with their general activity and sleep to a level only slightly less than the chronic pain sufferers who reported discussing their pain with a physician. Silent sufferers made an average of 5.2 ambulatory physician visits per year, which was less than those who sought physician help for their pain (8.6 ambulatory visits per year; P < .001). Men and younger participants were more likely to be silent about their pain (P < .001). CONCLUSION: More than 1 in 5 people with chronic pain did not seek physician care for their pain. This group is unknown to physicians and therefore represents an unreported patient group with an unmet need for pain care.
Adaptation, Psychological↗
International Primary Care Respiratory Group (IPCRG) Guidelines: diagnosis of respiratory diseases in primary care.
This Diagnosis paper constitutes the second of the IPCRG Guideline papers on the management of chronic respiratory diseases in primary care. Primary care health professionals are usually the first point of contact for patients who can present a wide range of initial symptoms which may or may not constitute their first presentation of a chronic disease such as asthma, COPD, or rhinitis. This paper is focussed upon the early identification and diagnosis of chronic respiratory diseases in primary care. It uses a symptom-based approach, and includes original questionnaires and diagnostic guides to help the primary care clinician proceed systematically through the diagnostic process.
Adult↗
A community-based study of stroke incidence after myocardial infarction.
BACKGROUND: The rate of stroke after myocardial infarction (MI) remains unclear. OBJECTIVES: To examine the rate of stroke after incident MI; compare it with that observed in the population of Rochester, Minnesota; determine how the rate of stroke after MI has changed over time; and examine the impact of stroke on survival after incident MI. DESIGN: Community-based cohort. SETTING: Olmsted County, Minnesota. PARTICIPANTS: Persons with incident (first-ever) MI between 1979 and 1998. MEASUREMENTS: Ischemic or hemorrhagic stroke in hospitalized and nonhospitalized patients that was identified by screening of the medical record for stroke diagnostic codes and subsequent stroke confirmation by physician review of the recorded event. Medical record review was used to ascertain baseline characteristics and death. RESULTS: A total of 2160 persons with incident MI were hospitalized between 1979 and 1998 and followed for a median of 5.6 years (range, 0 to 22.2 years). The rate of stroke was 22.6 per 1000 person-months (95% CI, 16.3 to 30.6 per 1000 person-months) during the first 30 days after MI, corresponding to a 44-fold increase (standardized morbidity ratio, 44 [95% CI, 32 to 59]) risk for stroke in the population of Rochester, Minnesota. The risk for stroke remained 2 to 3 times higher than expected during the first 3 years after MI. Older age, previous stroke, and diabetes increased the risk for stroke, which did not decline over the study period. Strokes were associated with a large increase in the risk for death after MI (hazard ratio, 2.89 [CI, 2.44 to 3.43]). LIMITATIONS: Findings may not be generalizable to different populations. The authors measured outcomes by reviewing medical records. CONCLUSIONS: In the community, the risk for stroke is markedly increased after MI, particularly early after MI, compared with the expected risk in population without MI. Stroke is associated with a large increase in the risk for death after MI.
Aged↗
Asthma management: are GINA guidelines appropriate for daily clinical practice?
An international group of primary care asthma experts, as well as pulmonologists and allergists from Europe and the US, met to discuss asthma management focused on the primary care office. This paper summarizes their discussions. Accuracy of diagnosis and appropriateness of treatment is variable depending on the clinical circumstances and patient group. The value of classifying patients based on baseline or static asthma severity scores remains controversial, and asthma management decisions based on symptom control appear to have greater practical utility in a primary care setting. Furthermore, it must be recognized that patients, caregivers and physicians may have differing, and possibly conflicting, goals for therapy. There are many initiatives to improve the quality of asthma management, for example, primary care-focused guidelines being developed by the International Primary Care Respiratory Group, and several groups are working on asthma control scores. In addition, new therapies may improve the options available for increasing compliance and reducing side effects. In conclusion, asthma management should be patient-focused, with outcomes relevant to improving the quality of life for people with asthma.
Journal Article↗
Interrater reliability: completing the methods description in medical records review studies.
In medical records review studies, information on the interrater reliability (IRR) of the data is seldom reported. This study assesses the IRR of data collected for a complex medical records review study. Elements selected for determining IRR included "demographic" data that require copying explicit information (e.g., gender, birth date), "free-text" data that require identifying and copying (e.g., chief complaints and diagnoses), and data that require abstractor judgment in determining what to record (e.g., whether heart disease was considered). Rates of agreement were assessed by the greatest number of answers (one to all n) that were the same. The IRR scores improved over time. At 1 month, the reliability for demographic data elements was very good, for free-text data elements was good, but for data elements requiring abstractor judgment was unacceptable (only 3.4 of six answers agreed, on average). All assessments after 6 months showed very good to excellent IRR. This study demonstrates that IRR can be evaluated and summarized, providing important information to the study investigators and to the consumer for assessing the reliability of the data and therefore the validity of the study results and conclusions. IRR information should be required for all large medical records studies.
Documentation↗
Using the ecology model to describe the impact of asthma on patterns of health care.
BACKGROUND: Asthma changes both the volume and patterns of healthcare of affected people. Most studies of asthma health care utilization have been done in selected insured populations or in a single site such as the emergency department. Asthma is an ambulatory sensitive care condition making it important to understand the relationship between care in all sites across the health service spectrum. Asthma is also more common in people with fewer economic resources making it important to include people across all types of insurance and no insurance categories. The ecology of medical care model may provide a useful framework to describe the use of health services in people with asthma compared to those without asthma and identify subgroups with apparent gaps in care. METHODS: This is a case-control study using the 1999 U.S. Medical Expenditure Panel Survey. Cases are school-aged children (6 to 17 years) and young adults (18 to 44 years) with self-reported asthma. Controls are from the same age groups who have no self-reported asthma. Descriptive analyses and risk ratios are placed within the ecology of medical care model and used to describe and compare the healthcare contact of cases and controls across multiple settings. RESULTS: In 1999, the presence of asthma significantly increased the likelihood of an ambulatory care visit by 20 to 30% and more than doubled the likelihood of making one or more visits to the emergency department (ED). Yet, 18.8% of children and 14.5% of adults with asthma (over a million Americans) had no ambulatory care visits for asthma. About one in 20 to 35 people with asthma (5.2% of children and 3.6% of adults) were seen in the ED or hospital but had no prior or follow-up ambulatory care visits. These Americans were more likely to be uninsured, have no usual source of care and live in metropolitan areas. CONCLUSION: The ecology model confirmed that having asthma changes the likelihood and pattern of care for Americans. More importantly, the ecology model identified a subgroup with asthma who sought only emergent or hospital services.
Adult↗
The 2002 United States varicella vaccine shortage and physician recommendations for vaccination.
BACKGROUND: The US experienced a shortage of varicella vaccine in 2002, leading to the concerns about its impact. METHODS: 204 Minnesota and Pennsylvania physicians, most (164) of whom were interviewed in 1999 on the topic of varicella vaccine, responded to a 2003 survey. RESULTS: Although 67% were aware of the 2002 varicella vaccine shortage, 24% experienced it and only 45% were aware of the 2002 temporary change in national vaccination recommendations. In response, more vaccinated until the supply was exhausted (59%) than postponed vaccination as recommended (41%). Most (91%) reported that the shortage did not change their likelihood of recommending vaccine. From 1999 to 2003, the percentage of physicians highly likely to recommend vaccination increased from 73% to 82% for children 12-18 months old (P < 0.01). In 2003, more physicians believed that it was likely for secondary skin infections to occur following varicella disease and for parents to request vaccination than in 1999 (P < 0.01). Almost all (93%) physicians in both years believed that serious side effects were unlikely. CONCLUSIONS: Over half of physicians were unaware of the change in vaccine recommendations due to the shortage and many did not follow that change, suggesting the need for a different strategy.
Chickenpox↗
Asthma among rural Minnesota adolescents.
This study examined the prevalence of and risk factors for wheezing and asthma in rural Minnesota adolescents. A survey querying about wheezing, asthma, farm residence, and other respiratory-related factors was administered to all 9th to 11th grade students (N = 13,490) in a stratified, random sample of high schools in rural Minnesota. Nearly one in 8 (12.6%) students reported ever-diagnosed asthma, and 9.2% reported current asthma. Students living on farms reported less wheezing and asthma than rural non-farm students. Obesity and smoking were associated with wheezing and asthma in all rural adolescents. Asthma rates increased with age among girls and may be largely accounted for by simultaneous increases in smoking rates. Despite the apparent protective effect of farm residence, asthma remains a significant public health issue among rural Minnesota adolescents.
Adolescent↗
Identification of optimal electrocardiographic criteria for the diagnosis of unrecognized myocardial infarction: a population-based study.
BACKGROUND: Despite using the same tool (ECG), the proportion of myocardial infarctions that goes unrecognized varies from 20% to 60% in population-based studies. The reasons for such wide variations have not been studied. We sought to evaluate the effect of ECG-MI criteria and study methodology on the prevalence of unrecognized myocardial infarction (UMI) and to identify the optimal ECG-MI criteria for UMI detection in epidemiologic studies. METHODS: A random population-based sample of 2042 adults, age > or = 45 years, underwent history, medical record abstraction and ECG. Six different ECG-MI criteria and two subjective recognized myocardial infarction (RMI) identification criteria, from different published studies, were applied to the same survey ECG. The operating test characteristics of different criteria were compared with the objective criterion standard of a RMI by Gillum criteria. RESULTS: The UMI proportion estimates varied from 32% to 61% due to variation in ECG-MI criteria, while keeping the study population, MI recognition criteria, and ECG constant. Subjective criteria for MI recognition had limited value (positive predictive value of 44-93%) in picking up RMI. Depending on the ECG abnormality used to define MI, ECG reading had widely varying sensitivity (21-37%; P < 0.0001) with consistently high specificity (92-97%) for detection of RMI. CONCLUSIONS: The prevalence estimates of UMI vary widely and are strongly dependent on the ECG-MI and MI recognition criteria. Future studies of UMI should explicitly recognize this variation and select the ECG-MI criteria that match their study aims.
Cross-Sectional Studies↗