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Gabriel J Escobar

Publications and source records attributed to Gabriel J Escobar.

26 records · Page 2Linked to original sources
PubMed2003

Perinatal substance abuse intervention in obstetric clinics decreases adverse neonatal outcomes.

OBJECTIVE: To evaluate the effect of Early Start, a managed care organization's obstetric clinic-based perinatal substance abuse treatment program, on neonatal outcomes. STUDY DESIGN: Study subjects were 6774 female Kaiser Permanente members who delivered babies between July 1, 1995 and June 30, 1998 and were screened by completing prenatal substance abuse screening questionnaires and urine toxicology screening tests. Four groups were compared: substance abusers screened, assessed, and treated by Early Start ("SAT," n=782); substance abusers screened and assessed by Early Start who had no follow-up treatment ("SA," n=348); substance abusers who were only screened ("S," n=262); and controls who screened negative ("C," n=5382). RESULTS: Infants of SAT women had assisted ventilation rates (1.5%) similar to control infants (1.4%), but lower than the SA (4.0%, p=0.01) and S groups (3.1%, p=0.12). Similar patterns were found for low birth weight and preterm delivery. CONCLUSION: Improved neonatal outcomes were found among babies whose mothers received substance abuse treatment integrated with prenatal care. The babies of SAT women did as well as control infants on rates of assisted ventilation, low birth weight, and preterm delivery. They had lower rates of these three neonatal outcomes than infants of either SA or S women.

Adult↗
PubMed2003

What is the best measure of maternal complications of term pregnancy: ongoing pregnancies or pregnancies delivered?

OBJECTIVE: The purpose of this study was to determine whether rates of hypertensive disorders of pregnancy increase beyond 37 weeks of gestation and to address how best to analyze these rates. STUDY DESIGN: This was a retrospective cohort study of all women delivered beyond 37 weeks' gestational age from 1995 to 1999 at all Kaiser Permanente Medical Care Program delivery hospitals in Northern California. Rates of gestational hypertension, preeclampsia, and eclampsia were calculated by use of both pregnancy delivered (PD) and ongoing pregnancy (OP) as the denominator. Bivariate and multivariate analyses were conducted with use of P<.05 to indicate statistical significance. RESULTS: Among the 135,560 women in this cohort, the rates of gestational hypertension, preeclampsia, and eclampsia were the same or decreased from 37 to 43 weeks' gestation using PD, but all three increased when calculated according to OP (P<.01). CONCLUSION: We found that among complications of pregnancy that are diagnosed ante partum, use of a different denominator led to contradictory conclusions. When hypertensive disorders of pregnancy are analyzed, ongoing pregnancies should be used as the denominator.

Adult↗
PubMed2003

Phototherapy use in jaundiced newborns in a large managed care organization: do clinicians adhere to the guideline?

OBJECTIVE: In 1994, the American Academy of Pediatrics (AAP) published a practice guideline with age-specific thresholds for phototherapy for healthy term newborns with hyperbilirubinemia. The purpose of this study was to examine adherence to the guideline in a large managed care organization. METHODS: We conducted a retrospective cross-sectional analysis of linked computerized databases from 11 Northern California Kaiser Permanente Medical Care Program hospitals. Newborn infants included were at least 37 weeks of gestation, had birth weights of at least 2500 g, and were born between January 1, 1995, and December 31, 1996. The primary outcome variable for the study was receipt of phototherapy according to the guideline. Total serum bilirubin (TSB) and infant age in hours at the time of bilirubin measurement were used to classify infants into 3 groups according to the AAP guideline: recommend phototherapy (R), consider phototherapy (C), and did not recommend phototherapy (N). Group R included infants with TSB levels of at least 15 mg/dL before 48 hours of age, at least 18 mg/dL before 72 hours, or at least 20 mg/dL after 72 hours. Group C included infants not in group R, with TSB levels of at least 12 mg/dL before 48 hours, 15 mg/dL before 72 hours, or at least 17 mg/dL after 72 hours. Group N included infants who were in neither group R nor group C and also did not have significant jaundice before 24 hours of age. Phototherapy codes from electronic databases were validated by chart review for a subset of 550 infants. RESULTS: Compared with chart review, phototherapy codes in the database were 94.4% sensitive (95% confidence interval [CI]: 89.1%-97.5%) and 100% specific (95% CI: 99.25%-100%). Among the 47 801 infants eligible, 2.3% received phototherapy. Phototherapy was administered to 54% of 1194 infants in group R (range across hospitals: 27%-77%), 16% of 2245 infants in group C (range: 5%-37%), and 0.2% of 44 362 infants in group N (range: 0.1%-0.6%). The predictors of phototherapy for group R, the group for whom phototherapy was recommended, determined by logistic regression were increasing TSB levels (odds ratio [OR]: 1.6/mg/dL; 95% CI: 1.4-1.7), reaching the AAP threshold at 24 to 47.9 hours of age compared with 48 hours or more (OR: 7.1; 95% CI: 4.3-11.9), gestational age of 37 weeks compared with 38 weeks or more (OR: 1.6; 95% CI: 1.1-2.3), age when phototherapy was first recommended (OR: 0.7/d; 95% CI: 0.6-0.8), and facility of birth (OR: 0.2-2.7). The facility of birth was a strong predictor of phototherapy use in all groups (R, C, and N). CONCLUSIONS: Clinicians provided phototherapy to only 54% of term infants with hyperbilirubinemia for whom it was recommended by the AAP. There is marked interhospital variation in phototherapy use in this large managed care system. Improved adherence to the guideline would require only a slight increase in the total rate of phototherapy use if unnecessary use for infants with lower levels of TSB were simultaneously decreased.

Bilirubin↗
PubMed2003

Infants with bilirubin levels of 30 mg/dL or more in a large managed care organization.

OBJECTIVE: To describe the incidence, etiology, treatment, and outcome of newborns with total serum bilirubin (TSB) levels >or=30 mg/dL (513 micro mol/L). DESIGN: Population-based case series. SETTING: Eleven Northern California Kaiser Permanente Medical Care Program hospitals and 1 affiliated hospital. PATIENTS: Eleven infants with TSB levels of >or=30 mg/dL in the first 30 days after birth, identified using computer databases from a cohort of 111,009 infants born 1995-1998. OUTCOME MEASURES: Clinical data from the birth hospitalization, rehospitalization, and outpatient visits in all infants; psychometric testing at age 5 (N = 3), neurologic examinations by child neurologists at age 5 (N = 3), or primary care providers (N = 7; mean age: 2.2 years); Parent Evaluation of Developmental Status (N = 8; mean age: 4.2 years). RESULTS: Maximum TSB levels of the 11 infants ranged from 30.7 to 45.5 mg/dL (525 micro mol/L to 778 micro mol/L; mean: 34.9 mg/dL [597 micro mol/L]). Four were born at 35 to 36 weeks gestation, and 7 were exclusively breastfed. Two had apparent isoimmunization; the etiology for the other 9 remained obscure, although only 4 were tested for glucose-6-phosphate dehydrogenase deficiency and 1 was bacteremic. None had acute neurologic symptoms. All received phototherapy and 5 received exchange transfusions. One infant died of sudden infant death syndrome; there was no kernicterus at autopsy. Two were lost to follow-up but were neurologically normal when last seen for checkups at 18 and 43 months. One child was receiving speech therapy at age 3. There were no significant parental concerns or abnormalities in the other children. CONCLUSIONS: In this setting, TSB levels >or=30 mg/dL were rare and generally unaccompanied by acute symptoms. Although we did not observe serious neurodevelopmental sequelae in this small sample, additional studies are required to quantify the known, significant risk of kernicterus in infants with very high TSB levels.

Adult↗
PubMed2003

Clinician support and psychosocial risk factors associated with breastfeeding discontinuation.

OBJECTIVE: Breastfeeding rates fall short of goals set in Healthy People 2010 and other national recommendations. The current, national breastfeeding continuation rate of 29% at 6 months lags behind the Healthy People 2010 goal of 50%. The objective of this study was to evaluate associations between breastfeeding discontinuation at 2 and 12 weeks postpartum and clinician support, maternal physical and mental health status, workplace issues, and other factors amenable to intervention. METHODS: A prospective cohort study was conducted of low-risk mothers and infants who were in a health maintenance organization and enrolled in a randomized, controlled trial of home visits. Mothers were interviewed in person at 1 to 2 days postpartum and by telephone at 2 and 12 weeks. Logistic regression modeling was performed to assess the independent effects of the predictors of interest, adjusting for sociodemographic and other confounding variables. RESULTS: Of the 1163 mother-newborn pairs in the cohort, 1007 (87%) initiated breastfeeding, 872 (75%) were breastfeeding at the 2-week interview, and 646 (55%) were breastfeeding at the 12-week interview. In the final multivariate models, breastfeeding discontinuation at 2 weeks was associated with lack of confidence in ability to breastfeed at the 1- to 2-day interview (odds ratio [OR]: 2.8; 95% confidence interval [CI]: 1.02-7.6), early breastfeeding problems (OR: 1.5; 95% CI: 1.1-1.97), Asian race/ethnicity (OR: 2.6; 95% CI: 1.1-5.7), and lower maternal education (OR: 1.5; 95% CI: 1.2-1.9). Mothers were much less likely to discontinue breastfeeding at 12 weeks postpartum if they reported (during the 12-week interview) having received encouragement from their clinician to breastfeed (OR: 0.6; 95% CI: 0.4-0.8). Breastfeeding discontinuation at 12 weeks was also associated with demographic factors and maternal depressive symptoms (OR: 1.18; 95% CI: 1.01-1.37) and returning to work or school by 12 weeks postpartum (OR: 2.4; 95% CI: 1.8-3.3). CONCLUSIONS: Our results indicate that support from clinicians and maternal depressive symptoms are associated with breastfeeding duration. Attention to these issues may help to promote breastfeeding continuation among mothers who initiate. Policies to enhance scheduling flexibility and privacy for breastfeeding mothers at work or school may also be important, given the elevated risk of discontinuation associated with return to work or school.

Adult↗
PubMed2002

Jaundice noted in the first 24 hours after birth in a managed care organization.

OBJECTIVE: To investigate the significance of jaundice noted in the first 24 hours after birth in a community setting. DESIGN: Supplementary analyses of a nested case-control study. SETTING: Northern California Kaiser Permanente Medical Care Program. PATIENTS: Six hundred thirty-one randomly selected newborns (controls) and 140 cases with total serum bilirubin levels of 25 mg/dL (428 micro mol/L) or higher from a cohort of 105 384 newborns of at least 2000 g birth weight and at least 36 weeks' gestational age, born between January 1, 1995, and December 31, 1998. MAIN OUTCOME MEASURES: Notations of jaundice in the medical record, timing and results of bilirubin testing, use of phototherapy, and development of bilirubin levels of 25 mg/dL or higher. RESULTS: Among the controls, the cumulative probability of a notation of jaundice (corrected for early hospital discharge using survival analysis) was 2.8% within 18 hours and 6.7% within 24 hours. In these newborns, cumulative proportions that had bilirubin levels measured were 38% within 12 hours and 43% within 24 hours of when jaundice was first noted. About 40% of bilirubin levels measured within 24 hours were above the estimated 95th percentile for age. Compared with newborns not noted to be jaundiced on the first day, newborns noted to be jaundiced within 24 hours were more likely to receive phototherapy (18.9% vs 1.7%; relative risk, 10.1; 95% confidence interval, 4.2-24.4) and to develop a bilirubin level of 25 mg/dL or higher (odds ratio, 2.9; 95% confidence interval, 1.6-5.2), but the absolute risk increase for total serum bilirubin levels of 25 mg/dL or higher was 0.2%. CONCLUSION: Jaundice noted in the medical record in the first 24 hours after birth was uncommon and often clinically significant in this setting, but other factors also need to be considered in determining its importance.

Bilirubin↗
PubMed2002

Rehospitalization for neonatal dehydration: a nested case-control study.

OBJECTIVES: To determine the incidence of neonatal dehydration leading to rehospitalization, whether clinical and health services data could predict its occurrence, and the outcome of dehydrated infants. METHODS: We employed a retrospective case-control design nested within a cohort of 51 383 newborns weighing 2000 g or more, with a gestational age of 36 weeks or more born at 11 Kaiser Permanente hospitals during 1995 and 1996. Cases were 110 infants who were rehospitalized within 15 days of discharge with dehydration, and who either had 12% or greater weight loss or a serum sodium level of 150 mEq/L or greater. Controls were 402 randomly selected infants. We reviewed subjects' paper medical records and telephoned their families at 24 to 36 months of age to ascertain neurological outcomes. RESULTS: Rehospitalization for dehydration occurred in 2.1 per 1000 live births (95% confidence interval [CI], 1.8-2.6). Among vaginal births, the most important risk factors were being born of a first-time mother (adjusted odds ratio [AOR], 5.5; 95% CI, 3.1-9.6); exclusive breastfeeding (AOR, 11.2; 95% CI, 3.9-32.6); maternal age equal to or older than 35 years (AOR, 3.0; 95% CI, 1.5-6.0); and gestational age younger than 39 weeks (AOR, 2.0, 95% CI, 1.2-3.5). Among cesarean births, having a birth hospitalization length of stay less than 48 hours was associated with dehydration (odds ratio [OR], 14.8; 95% CI, 1.4-154.1). Adherence to the American Academy of Pediatrics follow-up guideline did not decrease risk of readmission. Among surviving infants, 1 of 110 cases and 12 of 400 controls had evidence of possible neurological problems 24 to 36 months after discharge (P =.3). No cases of limb gangrene, amputation, or intracranial infarction occurred. CONCLUSIONS: In this population with good access to medical care, serious sequelae of neonatal dehydration are rare. Interventions to decrease the frequency of neonatal dehydration should focus on first-time mothers and those who breastfeed exclusively.

Birth Weight↗