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Biomedical subjects

D Strobino

Publications and source records attributed to D Strobino.

12 recordsLinked to original sources
PubMed2000

Assessing the impact of pediatric-based development services on infants, families, and clinicians: challenges to evaluating the Health Steps Program.

BACKGROUND: Begun in 1996, the Healthy Steps for Young Children Program (HS) is a new model of pediatric practice that incorporates child development specialists and enhanced developmental services for families of young children. HS is for all families, not just those at high-risk. It is expected to strengthen parents' knowledge, attitudes, and behaviors in ways that promote child health and development, and in turn, to lead to improved child outcomes, such as improved language development, increased utilization of well child care, and decreased problem behaviors, hospitalizations, and injuries. The HS evaluation is designed to assess whether HS is successful in achieving the desired outcomes, measure the program's costs, and determine the relation of the program's costs to its outcomes. OBJECTIVE: This article is the first report of the HS evaluation. It describes the evaluation design and characteristics of the HS sites and sample for the evaluation. METHODS: The evaluation is following a cohort of children from birth to age 3 at 15 evaluation sites across the country. The sites represent a range of organizational practice settings that include group practices, hospital-based clinics, and health maintenance organization pediatric clinics. The evaluation design relies on 2 comparison strategies. At 6 randomization design sites, 400 children were randomized to the intervention or control group. At 9 quasi-experimental design sites, a comparison location with a similar organizational setting and patient profile has been selected and up to 200 children are being followed at each of these sites. At each site, 2 developmental specialists (or their full-time equivalents) work as a team with 4 to 8 pediatricians and pediatric nurse practitioners. The specialist conducts office visits (jointly or sequentially with the pediatric clinician) and home visits, assesses children's developmental progress, provides referrals and follow-up to resources in the community, organizes and conducts parent discussion groups, coordinates early reading activities, and maintains a telephone information line for questions about child development and behavior. The evaluation relies on many data sources including self-administered provider surveys, key informant interviews, forms completed by parents at office visits, telephone interviews with parents, medical record reviews, data from each site on program costs and health services use, and an ongoing log of family contacts maintained by each developmental specialist. Analyses for this article are based on enrollment data for the Healthy Steps sample and national data on 1997 US live births. The chi2 goodness-of-fit test was used to evaluate whether the distribution of selected demographic variables, insurance, and infant's birth weight for the Healthy Steps sample was similar to the distributions for US births in 1997. In addition, comparisons were made between intervention and comparison families at the randomization and quasi-experimental evaluation sites. The chi2 test of independence was used to evaluate differences in variables across groups. RESULTS: Throughout a 26-month period, 5565 children enrolled in the evaluation, 2963 (53.2%) children in the intervention group and 2602 (46.8%) in the comparison group. More than 10% of mothers in the Healthy Steps sample are teenagers; 18% have 11 years of education or less; 27% have completed college; 18% are black or African-American; slightly >20% are of Hispanic origin; 36% are single; and close to one-third used Medicaid for their prenatal care. Approximately 7% of infants were low birth weight. When compared with national birth data for the United States as a whole, the Healthy Steps sample seems similarly diverse. However, with the exception of maternal age, the distribution of variables was significantly different from the distribution for US births. There are no differences between intervention and comparison families at randomization sites on any of

Chi-Square Distribution↗
PubMed1999

The relation of parent and provider characteristics to vaccination status of children in private practices and managed care organizations in Maryland.

OBJECTIVES: This study sought to identify provider practices and policies in private pediatric settings that relate to vaccination status, controlling for the characteristics of the children served. METHODS: Vaccination data came from the medical records of 709 randomly selected 2-year-old children at 18 private practices and managed care organizations in Maryland, family data from 466 telephone interviews with the children's parents, and provider characteristics from 18 site questionnaires and 42 individual physician and nurse practitioner questionnaires. Logistic regression and generalized estimating equations were used to estimate the relation of provider characteristics to vaccination status. Three age-appropriate (AA) and two up-to-date (UTD) vaccination status variables characterized successful vaccination. RESULTS: Approximately 70% of the study children were up-to-date by age 2 years for the full vaccination series, excluding hepatitis B vaccine. Family demographic characteristics were the strongest correlates of undervaccination. Neither parents' knowledge and attitudes about immunization nor the children's insurance coverage was statistically related to vaccination status. Site reminder or follow-up systems and provider perceptions about appointment scheduling and receipt of vaccine information from health departments were positively related to vaccination. Concern for liability was associated with a reduced odds of age-appropriate and up-to-date vaccination. CONCLUSIONS: Family demographics strongly correlate with vaccination status; however, they are generally not modifiable. This study's findings encourage providers to operate a tracking system, to remain current on immunization recommendations, to use all clinical encounters to screen and vaccinate children, and to ensure the availability and convenience of vaccination services.

Age Factors↗
PubMed1998

Have professional recommendations and consumer demand altered pediatric practice regarding child development?

OBJECTIVE: Amid growing consumer demand and professional society recommendations for more information on early childhood development, current practices of pediatricians in regard to children's development remain largely unknown. We investigate whether there are differences in provider practices and satisfaction with regard to children's development (based on length of time in practice). DESIGN: A self-reported survey was conducted of physicians at 30 pediatric practices participating in the Healthy Steps for Young Children Program. Healthy Steps is a national program to enhance the developmental potential of young children. Comparisons were made among physicians categorized as in training (n = 88), recently in practice (completing residency from 1984 to 1996, n = 69), or more experienced (completing residency prior to 1984, n = 52). PRINCIPAL FINDINGS: Relative to those recently in practice and in training, more experienced pediatricians spend less time in well-baby visits in the first 2 months of life. One-third of physicians conduct family risk assessments, half complete routine developmental screening, and over half do safety risk assessments in the first 2 months of life. There were few differences by provider experience in the topics covered under anticipatory guidance for new parents. Nearly all discussed infant car seats, sleep position, feeding practices, and temperament, but less than half routinely discussed domestic violence, and between half and three-quarters discussed infant bathing, maternal depression, and appropriate discipline practices. While all three groups of physicians were satisfied with the amount of time to discuss growth and development and parenting issues, more experienced physicians were more satisfied with their own and their staff's abilities to meet new parents' needs on these issues. Factors that over one-third of physicians reported affected their ability to deliver the best-quality care were shortage of support staff, limited referral sources, managed-care restrictions on referrals for special services, excessive paperwork, and lack of time for follow up, teaching parents, and answering questions. Physicians in recent practice were more likely than more experienced physicians to cite reimbursement concerns and limited staff to address the needs of parents regarding development. CONCLUSIONS: Most pediatricians do not conduct routine developmental screening in the first 2 months of life, and most discuss safety, as opposed to developmental and mental health, concerns with parents of newborns. Pediatricians with more experience believe they are better meeting new parents' needs and are less likely to cite systems and organizational factors as limiting their ability to deliver high-quality care.

Child↗
PubMed1997

Are immunizations an incentive for well-child visits?

OBJECTIVE: To assess the beliefs of parents and the visit patterns of their children to determine whether immunizations act as an incentive to use well-child care. DESIGN AND METHODS: Medical record audits provided data on immunizations and well-child visits. Two questions from a parent interview were used to identify 4 groups of parents: (1) motivated and (2) unmotivated to keep a well-child care appointment regardless of whether immunizations are scheduled, (3) vaccine-motivated and (4) checkup-motivated (parents who were influenced negatively by the prospect of receiving vaccinations). The percentage of children with a visit at each age window for well-child visits and the percentage up-to-date for their immunizations at given ages were compared across the 4 groups. The 4 groups were also compared for other parental attitudes about immunizations and well-child visits, and on sociodemographic and access characteristics. RESULTS: Most (73.3%) of the 502 parents surveyed were classified as motivated and 5% as unmotivated to keep a well-child care appointment regardless of whether an immunization was scheduled. Only 18.3% were categorized as vaccine-motivated and 3.4% as checkup-motivated. For all 4 groups, there was no discernible difference in attendance between immunization and nonimmunization visits. Attendance in the windows for well-child visits and percentage of children up-to-date on immunizations declined with increasing age. CONCLUSIONS: In this inner-city population, attendance patterns at visits did not support the incentive hypothesis. This finding should reassure clinicians that providing immunizations outside of regular well-child care visits will not necessarily decrease attendance at visits for well-child care.

Baltimore↗
PubMed1996

The contribution of missed opportunities to childhood underimmunization in Baltimore.

OBJECTIVE: To determine the community-wide incidence of missed opportunities to vaccinate, to describe the clinical settings in which they occur, and to estimate the impact of missed opportunities on immunization coverage. DESIGN AND METHODS: We abstracted outpatient medical records from a random, community-based sample of 2-year-old children whose residence was inner-city Baltimore. The date of each vaccine and the date, diagnoses, and temperature at each visit were collected for 502 children at 98 different provider sites. MAIN OUTCOME MEASURES: Missed opportunities to vaccinate and up-to-date vaccination status. RESULTS: By 24 months of age, 75% of the children had at least one missed opportunity and only 55% were up-to-date for the 4:3:1 series. Missed opportunities occurred at more than one third of eligible visits for each vaccine, including > 20% of preventative care visits. Diagnoses commonly associated with missed opportunities were "well child," otitis media, upper respiratory infection, gastroenteritis, skin infection, and resolving illness. If no missed opportunities had occurred, 73% of the children would have been up-to-date by 24 months. CONCLUSIONS: Missed opportunities occurred commonly at providers serving inner-city children in Baltimore and represent a major factor in underimmunization. Reduction of missed opportunities by accurate screening at all visits and adherence to the contraindication guidelines is a provider-based, low-cost method to increase immunization coverage.

Baltimore↗
PubMed1996

Parental attitudes do not explain underimmunization.

OBJECTIVE: This article describes the results of a community-based study to determine the effect of family knowledge and attitudes on the immunization rates of a random sample of children younger than 2 years in the poorest census tracts of Baltimore. DESIGN AND METHODS: The two sources of data were (1) parent interviews that provided data on knowledge, attitudes, and beliefs related to immunization and sociodemographic characteristics, and (2) medical record audits from which data on immunization status were obtained. The protection motivation theory, a model of behavioral change, was used to select the variables to assess the relation of parental attitudes with immunization status. A multivariate logistic regression analysis included only variables found to be significantly associated with immunization outcome in the preliminary analysis. RESULTS: Mothers were well informed and generally had favorable attitudes toward immunizations. Immunization status was more strongly associated with the sociodemographic characteristics of the children than with the protection motivation theory variables. Only two protection motivation theory variables were associated with more than one immunization outcome. The children of mothers who perceived that timing of vaccination did not matter were less likely to be immunized than children of care takers who thought that it did matter and children whose parents believed in the safety of multiple immunizations were less likely to be immunized than children whose parents did not hold this belief. CONCLUSIONS: In this study, parents' attitudes and beliefs had little effect on their children's immunization levels. Interventions intended to heighten parental awareness about immunization may have little impact. In poor urban neighborhoods, African-American children whose mothers are young, have multiple siblings, and do not use the Women, Infants and Children program may be at highest risk for delayed immunization.

Adult↗
PubMed1995

A strategic framework for infant mortality reduction: implications for "Healthy Start".

The high infant mortality rate in the United States, especially in urban areas, remains a major federal concern. Four strategies for reducing infant mortality in cities participating in the federal ¿Healthy Start¿ are reducing high-risk pregnancies; reducing the incidence of low birthweight and preterm births; improving birthweight-specific survival; and reducing specific causes of post-neonatal mortality. Estimates of the impact of known interventions indicate that the reduction in infant mortality would be large for only one strategy: improving birthweight-specific survival. Most interventions yield a 2 percent reduction, or less, in mortality and when combined, would amount to about 30 percent. This strategic model provides a realistic framework to assess the impact of the Healthy Start demonstration and is useful in highlighting the interventions most likely to reduce infant mortality in a population.

Child Health Services↗
PubMed1995

The demand for childhood immunizations: results from the Baltimore Immunization Study.

In spite of the net social benefits of childhood vaccines, a substantial proportion of American children do not receive their full complement of immunizations by their second birthday. Designing policies and programs that increase the rate of completed immunizations in preschool children requires an understanding of the factors which contribute to the timely receipt of immunizations. In this paper, we estimate a model of demand for immunizations for preschool children. Our results suggest that household resources, the child's usual source of care, and other "convenience factors" significantly influence the successful completion of the immunization schedule.

Adult↗
PubMed1994

Do provider practices conform to the new pediatric immunization standards?

OBJECTIVE: Standards for pediatric immunization practices were issued by the Centers for Disease Control and Prevention, Atlanta, Ga, in May 1992. This article provides baseline data on immunization practices related to eight of the standards. DESIGN: Survey of pediatric providers before publication of the standards. SETTING: Baltimore, Md. PARTICIPANTS: Forty of the 41 health centers, clinics, and private practices serving children in designated high-risk census tracts participated in the survey. One hundred seventy-three of the 251 eligible physicians and nurse practitioners at the sites responded. MAIN OUTCOME MEASURES: Conformity with the eight standards was measured as a percentage of either sites or physicians and nurse practitioners across the sites. RESULTS: Conformity with the standards varied, ranging from nearly universal conformity with the need to educate parents and guardians about immunizations (standard 5) to less than 3% for simultaneous administration of all vaccine doses when a child is first eligible (standard 8). For most of the standards, considerable variability was found between and within public and private sites. CONCLUSIONS: Providers often followed practices that did not conform to the new standards (prior to issuance). Some of the standards are ambiguous and require clarification before they can be fully applied. The impact of the standards on immunization rates and pediatric primary health care has yet to be tested empirically.

Baltimore↗
PubMed1989

Preterm and term fetal cardiac and movement responses to vibratory acoustic stimulation.

To assess fetal response to vibratory acoustic stimulation, 24 preterm (group A; less than 36 weeks' gestation) and 30 term (group B; greater than or equal to 36 weeks' gestation) pregnancies were studied. Study variables were perceived fetal movement, fetal heart rate, and fetal heart rate pattern. Observer- and patient-perceived fetal movement responses were noted in most cases but were slightly more common in term patients (group A: + fetal movement, patient 87.5%/observer 87.5%) group B: + fetal movement, patient 96.7%/observer 90%). Baseline changes in fetal heart rate (greater than or equal to 10 beats/min) were observed in 46% of preterm fetuses and 70% of term fetuses. Tachycardia (fetal heart rate greater than 160 beats/min) was a common finding in both groups. In group A, tachycardia after vibratory acoustic stimulation persisted more than 1 minute in 29.2% and more than 5 minutes in 12.5% of patients. In group B tachycardia beyond 1 and 5 minutes was noted in 73.3% and 50% of patients, respectively. A significant shift to "awake" fetal heart rate patterns occurred in both groups; 29% to 79% was noted in group A (p less than 0.001) and 46.7% to 90% in group B (p less than 0.001). When vibratory acoustic stimulation was used, the high occurrence of increased baseline, tachycardia, and emergence of unusual fetal heart rate patterns must be recognized to adequately interpret fetal heart rate tracings.

Acoustic Stimulation↗
PubMedDate not supplied

A comparison of visits and practices of nurse-midwives and obstetrician-gynecologists in ambulatory care settings.

With more than 5 million patient visits annually, certified nurse-midwives (CNMs) substantially contribute to women's health care in the United States. The objective of this study was to describe ambulatory visits and practices of CNMs, and compare them with those of obstetrician-gynecologists (OB/GYNs). Sources of population-based data used to compare characteristics of provider visits were three national surveys of CNMs and two National Ambulatory Medical Care Surveys of physicians. When a subset of 4,305 visits to CNMs in 1991 and 1992 were compared to 5,473 visits to OB/GYNs in similar office-based ambulatory care settings in 1989 and 1990, it was found that a larger proportion of CNM visits were made by women who were publicly insured and below age 25. The majority of visits to CNMs were for maternity care; the majority of visits to OB/GYNs were for gynecologic and/or family planning concerns. Face-to-face visit time was longer for CNMs, and involved more client education or counseling. This population-based comparison suggests that CNMs and OB/GYNs provide ambulatory care for women with diverse demographic characteristics and differing clinical service needs. Enhancing collaborative practice could improve health care access for women, which would be especially beneficial for those who are underserved and vulnerable.

Ambulatory Care Facilities↗