Biomedical subjects

Kelly Kelleher

Publications and source records attributed to Kelly Kelleher.

17 recordsLinked to original sources

PubMed2006

The story behind the story: physician skepticism about relying on clinical information technologies to reduce medical errors.

PURPOSE: In order to better understand physicians' perspectives about the use of clinical information technology (CIT) to reduce medical errors, we asked physicians about opportunities and issues around clinical use of computerized physician order entry (CPOE) systems, order sets within CPOE, and handheld computers (HHCs). METHODS: We conducted 10 focus groups including 71 physicians involved in technology implementation efforts across the US between April 2002 and February 2005. RESULTS: Two major themes emerged across focus groups around reliance on CIT to reduce errors: (1) can it work? and (2) at what cost to the medical profession? Within the first theme, physicians expressed concern about the appropriateness of physician-directed CIT as a solution for medical errors, concerns regarding the current technical capabilities and level of technical support for CIT solutions, and concern about the introduction of new errors. Within the second theme, physicians were particularly concerned about time efficiency and workload redistribution associated with the introduction of CIT. Across focus groups, physicians tended to generalize about the role of all IT in their lives, potentially biasing opinions about specific technologies. CONCLUSIONS: Health care organizations attempting to promote physician use of CIT are advised to deepen consideration of physicians' perspectives about technology adoption and use in order to address their concerns, reduce skepticism, and increase the likelihood of implementation success.

Attitude to Computers↗

PubMed2006

Empirical evaluation of the generalizability of the sample from the multimodal treatment study for ADHD.

Randomized controlled trials (RCTs) are criticized for the questionable generalizability of their patient samples to real world populations. This study compared the demographic and clinical characteristics of children from the Multimodal Treatment Study of Children with ADHD (MTA) to those from the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study and the National Health and Nutrition Examination Survey (NHANES). On the whole, we found no compelling evidence against the representativeness of the MTA sample, but the limited power from MECA and NHANES may have lead to noteworthy differences between datasets being statistically nonsignificant.

Adolescent↗

PubMed2006

Implementation of evidence-based practices for children in four countries: a project of the World Psychiatric Association.

OBJECTIVE: The present study examined implementation issues in adopting cognitive-behavioral therapies in routine clinical settings in four countries reflecting diverse cultures, languages, settings, and traditions. METHOD: A Director's Systems Survey was administered prior to program implementation and one year later. Therapist ratings on attitudes about evidence-based practices and satisfaction were also gathered. RESULTS: All sites reported successful adoption of the program, although significant variations existed in fiscal support, family involvement, prior experience with cognitive-behavioral therapies, and plans for sustainability. Therapists' ratings indicated overall satisfaction with the implementation of the project. Findings from the Director's Systems Survey pointed to five factors facilitating implementation: 1) early adoption and guidance by innovative leaders (i.e., the Directors); 2) attention to the "fit" between the intervention model and local practices; 3) attention to front-end implementation processes (e.g., cultural adaptation, translation, training, fiscal issues); 4) attention to back-end processes early in the project (e.g., sustainability); and 5) establishing strong relationships with multiple stakeholders within the program setting. CONCLUSIONS: The implementation issues here mirror those identified in other studies of evidence-based practices uptake. Some of the obstacles to implementation of evidence-based practices may be generic, whereas issues such as the impact of political/economic instability, availability of translated materials, constitute unique stressors that differentially affect implementation efforts within specific countries.

Child↗

PubMed2006

Do antidepressants cause suicidality in children? A Bayesian meta-analysis.

BACKGROUND: To quantify the risk of suicidal behavior/ideation (suicidality) for children who use antidepressants, the FDA collected randomized placebo-controlled trials of antidepressant efficacy in children. Although none of the 4487 children completed suicide, 1.7% exhibited suicidality. The FDA meta-analyzed these studies and found sufficient evidence of an increased risk to require a black-box warning on antidepressants for children. PURPOSE: The FDA considered different drug formulations and psychiatric diagnoses to be equivalent in their effect on suicidality. If this assumption does not hold, the FDA analysis may have underestimated the variance of the risk estimate. We investigate the consequences of relaxing these assumptions. METHODS: We extend the FDA analysis using a Bayesian hierarchical model that allows for a study-level component of variability and facilitates extensive sensitivity analyses. RESULTS: We found an association between antidepressant use and an increased risk of suicidality in studies where the diagnosis was major depressive disorder (odds ratio 2.3 [1.3, 3.8]), and where the antidepressant was an SSRI (odds ratio 2.2 [1.3, 3.6]). We did not find evidence for such an association in the complement sets of trials. Although the results based on the hierarchical model are insensitive to model perturbations, the robustness of the FDA's meta-analysis to model assumptions is less clear. These data have limited generalizability due to exclusion of patients with baseline risk of suicide and the use of relatively short duration trials. CONCLUSIONS: Because of model specification and interpretation issues raised in this paper, we conclude that the evidence supporting a causal link between antidepressant use and suicidality in children is weak. The use of Bayesian hierarchical models for meta-analysis has facilitated the incorporation of potentially important sources of variability and the use of sensitivity analysis to assess the consequences of model specifications and their impact on important regulatory decisions.

Antidepressive Agents↗

PubMed2005

Nonfatal injuries among US children with disabling conditions.

OBJECTIVES: We investigated the risk of nonfatal injury in US children with disabilities. Disability was defined as a long-term reduction in the ability to conduct social role activities, such as school or play, because of a chronic physical or mental condition. METHODS: Among 57 909 children aged 5-17 years who participated in the 2000-2002 National Health Interview Survey, we identified 312 children with vision/hearing disabilities, 711 with mental retardation, 603 with attention-deficit/hyperactivity disorder (ADD/HD), and 403 with chronic asthma. We compared nonfatal injuries in the past 3 months between children with disabling conditions and those without using injury rates and logistic regression analyses. RESULTS: Compared with children without a disability, a higher percentage of children with disabilities reported nonfatal injuries (4.2% for vision disability, 3.2% for mental retardation, 4.5% for attention-deficit/hyperactivity disorder, and 5.7% for asthma vs 2.5% for healthy children). After we controlled for confounding effects of sociodemographic variables, children with disabilities, with the exception of mental retardation, had a statistically significantly higher injury risk than those without disabling conditions. CONCLUSIONS: Children with a disabling condition from vision/hearing disability, ADD/HD, or chronic asthma had a significantly higher risk for nonfatal injuries compared with children without a disabling condition. These data underscore the need to promote injury control and prevention programs targeting children with disabilities.

Adolescent↗

PubMed2005

Utilization of evidence-based computerized order sets in pediatrics.

Little is known about utilization of different evidence-based order sets within computerized physician order entry (CPOE) systems. We designed a retrospective study of resident and attending physician order set utilization to evaluate the use of three evidence-based computerized order sets (asthma, post-appendectomy care, and community-acquired pneumonia (CAP)), and examine patient and admission characteristics associated with order set utilization in pediatrics. We studied all 529 asthma patients, 277 appendectomy patients, and 210 CAP patients admitted between 1 November 2001 and 30 November 2003 during implementation of standardized order sets at a large, independent, not-for-profit pediatric institution. We analyzed order set utilization for the three order sets and tested the relationship between order set use and potential factors associated with utilization. Order set utilization varied by condition (X(2)=339.2, p<0.001), with the asthma order set use rate highest (88.1%), followed by appendectomy order set utilization (79.4%), and substantially lower CAP order set use (21.1%). We found that trends in order set utilization also varied by condition. Only the asthma order set showed a trend of increasing use after implementation (z= -3.02, p=0.002). In addition, factors associated with order set utilization varied. Uses of the asthma and post-appendectomy order sets were associated with factors such as admission unit and case complexity. CAP order set utilization was associated with case complexity but not admission source. We conclude that health services organizations looking to implement computerized order sets to reduce unnecessary practice variation while promoting best practices must consider the different factors that may influence the use of each order set rather than relying on a one-size-fits-all implementation strategy. Further, issues such as the level of physician involvement in order set development and consensus around order set content may be particularly important factors influencing order set utilization.

Adolescent↗

PubMed2005

Somatic symptoms of depression in elderly patients with medical comorbidities.

OBJECTIVE: Somatic symptoms of depression such as fatigue create a diagnostic dilemma when assessing an older patient with medical comorbidities, since chronic medical illnesses may produce similar symptoms. Alternatively, somatic symptoms attributed to medical illness may actually be caused by depression. These analyses were designed to determine if somatic symptoms in older patients are more strongly associated with chronic physical problems or with depression. DESIGN: Reanalysis of data from an observational study of depression in primary care and a randomized trial of paroxetine and nortriptyline for the treatment of major depression. Patients were evaluated with a structured diagnostic interview and a battery of psychiatric, physical, and psychosocial measures. PARTICIPANTS: Two hundred and forty eight primary care and psychiatric patients aged >or= 60 years. METHODS: Associations among depression, somatization, and chronic physical problems were examined using correlations and regression modeling. RESULTS: Two somatization measures, the Asberg Side Effects Rating Scale and the Utvalg for Kliniske Undersogelser (UKU), were significantly associated with psychological symptoms of depression (r = 0.73 and r = 0.76, p < 0.0001) but not with medical comorbidities (r = 0.02, p = 0.16 and r = 0.10, p = 0.78). In multiple regression models, psychological symptoms of depression remained significant predictors of somatization (p < 0.0001) after controlling for age, gender, and medical comorbidities. CONCLUSIONS: In older patients with medical disorders and multiple somatic complaints, clinicians should consider the possibility of depression. Rating scales emphasizing somatic symptoms associated with depression may provide a more accurate measure of depression severity than those excluding such symptoms.

Aged↗

PubMed2005

Health care access after injury by insurance type in a pediatric population.

OBJECTIVES: Previous studies demonstrate discrepancies in health care access by insurance status for routine, discretionary care. It is unknown whether these discrepancies in health care utilization by insurance status persist in urgent/emergent circumstances. We used injury as a sentinel event to represent urgent/emergent medical conditions to examine the relationship with insurance type. METHODS: Using the 2000, 2001, and 2002 National Health Interview Survey, we examined medical care sought after 1847 injuries among children younger than 18 years. We performed univariate analyses to explore the relationship of insurance type and demographic variables with medical care sought. We then conducted multivariate logistical regression analysis to assess the association of insurance type with only making a telephone call and with being hospitalized while controlling for confounding variables. There was no direct measure in injury severity in these data. RESULTS: Although uninsured children had the lowest percentage of head injuries, there was no significant difference in body part injured by insurance type. While controlling for potentially confounding variables, there were no significant differences for making only a telephone call after an injury by insurance type [OR (95% CI): 1.29 (0.45-3.72) for private insurance; 1.13 (0.28-4.62) for other insurance types; 0.69 (0.08-6.33) for uninsured; Medicaid as the reference]. However, uninsured children had a significantly increased likelihood of being hospitalized after an injury [OR (95% CI): 4.07 (1.13-14.66) compared with 2.21 (0.73-6.63) for privately insured; 1.61 (0.47-5.55) for other insurance types; Medicaid as the reference]. CONCLUSIONS: While controlling for potentially confounding variables, there was no relationship between type of insurance and only making a telephone call after an injury. However, uninsured children were significantly more likely to be hospitalized after an injury than insured children. This latter relationship differs from overall patterns of health care utilization by insurance type.

Adolescent↗

PubMed2005

Skiing- and snowboarding-related injuries treated in U.S. emergency departments, 2002.

BACKGROUND: This study aims to describe the characteristics of skiing- and snowboarding-related injuries treated in U.S. emergency departments (EDs). METHODS: Skiing- and snowboarding-related injuries collected by the National Electronic Injury Surveillance System in 2002 were analyzed. Data regarding skiing and snowboarding participation were used to calculate injury rates by age group and activity (skiing versus snowboarding). RESULTS: An estimated 77,300 (95% CI = 11,600-143,000) skiing- and 62,000 (95% CI = 32,800-91,200) snowboarding-related injuries were treated in U.S. hospital EDs in 2002. Wrist injuries (17.9%) and arm injuries (16.6%) among snowboarders and knee injuries (22.7%) among skiers were the most common injuries. The age groups that have the highest skiing-related injury rates were the 55-64 years (29.0 per 1,000 participants), the 65+ years (21.7 per 1,000 participants), and the 45-54 years (15.5 per 1,000 participants). The age groups that have the highest snowboarding-related injuries were the 10-13 years (15.9 per 1,000 participants), the 14-17 years (15.0 per 1,000 participants), and the 18-24 years (13.5 per 1,000 participants). Traumatic brain injury (TBI) rates were higher among older skiers, 55-64 years (2.15 per 1,000 participants), and younger skiers, 10-13 years (1.69 per 1,000 participants). CONCLUSIONS: Our study is the first to demonstrate that older skiers are at highest risk for injury. Adolescents are at highest risk for snowboarding-related injury. Prevention of TBI should be a top injury control priority among skiers and snowboarders.

Adolescent↗

PubMed2005

Developing effective physician leaders: changing cultures and transforming organizations.

In this article, the authors discuss the problematic issue of transformational change in the face of cultural conflict between the worlds of clinical care and organizational leadership, and describe a case study of organizational cultural change facilitated through a physician leadership development program. A locally developed physician leadership program can be extremely effective at both improving physicians' leadership skills and increasing understanding of the strategic goals and direction of the organization. The transformational change required for physicians to develop and appreciate business and leadership skills can be supported and encouraged in a leadership development program that includes the components of careful curriculum design, program monitoring, and opportunities to apply new skills in practice. For Columbus Children's Hospital, Columbus, Ohio, this organizational transformational change effort was successfully achieved when a new medical leadership development program helped academic and community physicians to become involved in organizational leadership. The authors describe the background and development of this program and provide results of their evaluation of the program, with discussion of future extensions to the program.

Academic Medical Centers↗

PubMed2004

Intimate partner violence among female caregivers of children reported for child maltreatment.

OBJECTIVE: The purpose of this study was to determine the prevalence and correlates of intimate partner violence among female caregivers of children reported to child protective services. METHOD: Data were derived from the National Survey of Child and Adolescent Well-Being, a national probability study of children investigated for child abuse and neglect in the United States. Caregivers were interviewed about demographic characteristics, mental health, substance use, and physical violence by a partner. RESULTS: The lifetime and past year prevalence of intimate partner violence was 44.8 and 29.0%, respectively. Caregiver major depression and history of prior reports of child maltreatment were strongly associated with violence against women. CONCLUSIONS: The findings highlight the need for effective screening and identification of intimate partner violence in families in which child maltreatment has occurred.

Adult↗

PubMed2004

Exploratory evidence on the market for effective depression care in Pittsburgh.

OBJECTIVE: Despite the existence of effective and relatively cost-effective depression treatments, many depressed patients do not receive appropriate care. The authors assessed opportunities for increasing the rate of effective depression treatment by investigating the market for such treatment in the Pittsburgh area. METHODS: A conceptual framework was developed to evaluate the market for effective depression care. On the basis of the conceptual framework, interviews were conducted with representatives from seven large employers, two medical health insurance carriers, two behavioral health insurance carriers, four primary care providers, and four behavioral health care providers. Respondents were asked to assess the barriers to and opportunities for increasing the rates of depression treatment from their perspectives. RESULTS: The findings suggest that there is currently little demand among purchasers for improving depression care and little interest among insurers and providers for improving care in the absence of purchaser demand. Even stakeholders who identified depression as an important problem could not come to a consensus about who should be responsible for addressing the problem. Employers reported that they look primarily to their vendors to initiate quality improvement efforts, whereas insurers reported that such improvement efforts were more likely to occur if they were initiated by employers who purchase their health plans; providers, in turn, reported feeling powerless to initiate change. CONCLUSIONS: The absence of a clear locus of responsibility for improving depression care lends considerable inertia to the status quo. Because the currently low treatment rates are likely to be socially inefficient, researchers and policy makers should consider strategies to help overcome this inertia.

Catchment Area, Health↗

PubMed2004

Medicaid behavioral health care plan satisfaction and children's service utilization.

This study examines associations between caregivers' satisfaction with children's Medicaid-funded behavioral health care plans and the likelihood that children with severe emotional disturbance receive mental health services. Data are from a multisite study of managed care versus fee-for-service (FFS) settings. In multivariate logistic regression analyses controlling for demographic, environmental, site, and clinical characteristics, plan satisfaction was associated with greater likelihood of subsequent service use regardless of managed care versus FFS setting. Children in managed care plans were less likely to use intensive residential and non-traditional outpatient services. Efforts to increase plan satisfaction may encourage service use, consequently, improving children's behavioral health outcomes.

Caregivers↗

PubMed2003

Preferences for depression advice among low-income women.

OBJECTIVES: Because patient reluctance to discuss depression may influence the success of depression interventions, we assessed preferences for the source of depression advice among high-risk women and factors associated with those preferences. METHODS: The sample included 147 consecutive patients at a hospital-based obstetrics and gynecology clinic. All were age 18-44, on Medicaid and able to complete a previsit survey and postvisit interview. Women were asked "Where would you prefer to get advice on how you are feeling, whether you are sad or worried?" Responses were grouped as the ob/gyn clinic, general medical provider, mental health/substance abuse provider or no professional advice desired. RESULTS: Many women did not want professional advice on depression: 33% said they preferred to get advice from informal sources and 5% preferred no information. A total of 23% of women preferred to discuss depression with the ob/gyn provider, 14% with a general medical provider, and 25% with a mental health or substance abuse provider. Women were more likely to want advice from a health provider (of any type) if they had previously use mental health care (OR = 3.6, p = 0.005) or had at least one chronic health condition (OR = 3.1, p = 0.013). Women were more likely to want advice from the ob/gyn clinic if it was their primary care provider (OR = 41.8, p = 0.002) or if they had high depressive symptoms (OR = 4.8, p = 0.048). CONCLUSIONS: Many women do not want to discuss depression with a health professional, but familiarity with the mental health care system, health status, and relationship with a provider influence women's openness to depression advice.

Adolescent↗

PubMed2003

Assessing primary care performance in an obstetrics/gynecology clinic.

OBJECTIVES: Young, low-income women often use ob/gyns for routine care. Yet, little is known about the extent to which these settings achieve primary care goals. This study compared primary care performance among young low-income women using ob/gyns versus other settings as their primary care providers (PCP). METHODS: Anonymous interviews with 158 women on Medical Assistance age 18-44 seen at a university ob/gyn clinic. RESULTS: Sixty women (38.0%) used the ob/gyn setting for primary care, 83 (52.5%) use other places and 15 (9.5%) identified no primary care provider. Compared to women using other places for primary care, women who used the ob/gyn setting as their PCP were younger (OR 0.93, p = .04), had less education (OR 3.9, p = .02), and more frequently had small children (OR 2.8, p = .05) and reported illicit drug use (OR 3.1, p = .05). Performance on first contact care, ongoing care, coordination, and family and community issues did not vary by whether the PCP was an ob/gyn versus another provider, though women with an ob/gyn PCP rated their provider significantly higher on cultural competence. Access to advice on general medical prevention topics differed little by type of PCP; however, women who used the ob/gyn clinic as PCP received advice on more reproductive health, behavioral health, and injury prevention topics, with a mean number of preventive topics of 13.0 (SD 3.6) versus 6.3 (SD 4.1) (p < .01). DISCUSSION: Many young women who rely on hospital-based ob/gyn clinics for primary care may benefit from expanded health promotion efforts. The large portion of young, low-income women using ob/gyn settings for primary care may receive primary care of equal or better quality compared to women using other settings. More research is needed to see if these findings are generalizable.

Adult↗

PubMed2002

Barriers to health care research for children and youth with psychosocial problems.

CONTEXT: The 1999 surgeon general's report on mental health concluded that insufficient attention to mental health disorders is being paid in children's primary medical care services. This lack of attention has occurred despite considerable attention to this issue in the planning documents of many federal agencies. OBJECTIVE: To assess the extent to which federal agencies' portfolios of funded research grants were consistent with the directives for primary care-based mental health services for children and adolescents featured in their planning documents. DATA SOURCE: A cross-sectional review of the 66 749 abstracts listed in the April 2001 Computer Retrieval of Information on Scientific Projects (CRISP) database of currently funded research grants supported by the US Department of Health and Human Services. Abstracts were rated by whether they targeted primary care, examined behavioral or emotional issues, and examined or modified a facet of primary care. DATA SYNTHESIS: Of the 45 022 research abstracts in the CRISP database, 2720 (6%) contained the words children, adolescents, or youth. Sixty-three abstracts contained work on children, adolescents, or youth in primary care (0.14% of the portfolio). Of these 63 abstracts, only 21 (0.05% of the portfolio) addressed behavioral or emotional issues. Of the 21 projects, only 11 examined aspects of the primary care process. When the distribution of child and adult studies on the treatment of depression within primary care settings was examined, it was found that adults received 15 times the research attention compared with children. CONCLUSION: Even though the importance of primary care as a system for identifying and treating behavioral and emotional problems in children has been recognized for more than 20 years, little attention is being paid to this topic in the research portfolios of the National Institutes of Health and other federal agencies that support research.

Adolescent↗

PubMed2002

Primary care referral of children with psychosocial problems.

OBJECTIVES: To examine primary care provider referral patterns for patients with psychosocial problems and to understand the factors that influence whether a mental health referral is made. DESIGN: Secondary analysis of the Child Behavior Study data collected during 1994-1997 from background survey of providers, visit survey of providers and parents, and follow-up survey of parents. SETTING: Two hundred six primary care offices in the United States, Canada, and Puerto Rico. PATIENTS: Four thousand twelve of 21 150 patients aged 4 to 15 years in the Child Behavior Study with a clinician-identified psychosocial problem. MAIN OUTCOME MEASURES: Referral for psychosocial problem at index visit and reported follow-up with mental health care provider within 6 months. RESULTS: Six hundred fifty (16%) of 4012 patients with psychosocial problems were referred at the initial visit. In multivariate analysis, significant factors associated with likelihood of referral included patient factors (severity, type of problem, academic difficulties, prior mental health service use) and family factors (mental health referral of parent); however, none of the provider factors were significant. Clinicians reported frequent barriers to referral and mental health services in the general background survey; however, these factors were rarely reported as influences on individual management decisions. Only 61% of referred families reported that their child saw a mental health care provider in the 6-month period after the initial primary care referral. CONCLUSIONS: Most psychosocial problems are initially managed in primary care without referral. However, referral is an important component of care for patients with severe problems, and many families are not effectively engaged in mental health services, even after a referral is made.

Adolescent↗