National efforts to improve the value of health care must include graduate medical education (GME) if they are to succeed. Proposals to teach residents to provide value-based care have come from the Medicare Payment Advisory Commission (MedPAC), the Accreditation Council for Graduate Medical Education (ACGME) and the American College of Physicians (ACP). Such proposals skip a key step: residency programs currently lack a clear strategy to prepare residents to assess and deliver value-based care. In this article, we present the VALUE Framework for programs to utilize to teach residents to assess and deliver value-based care for their patients. We then present more than 20 opportunities for residency programs to incorporate training in value-based care.
medical education; residency training; graduate medical education; value; health care value; value-based care
In the United States, therapeutic vaccines may provide considerable benefit to cancer patients. Yet, there has been no assessment of whether vaccines currently in the research and development pipeline reflect the burden of disease and current survival patterns for different malignancies. The authors used data from the National Cancer Institute, Surveillance Epidemiology and End Results (SEER) database, and clinicaltrials.gov registry to characterize the vaccine development pipeline with respect to 5 measures of disease burden and treatment effectiveness for cancer: annual incidence, annual mortality, five-year survival rate, recent change in five-year survival (1999-2006 vs 1990-1992), and five-year mortality estimate (=annual incidence*[1 - 5-yr survival rate]). In 2011, the authors identified 231 active clinical trials for therapeutic cancer vaccines. Of these trials, 81 vaccines are currently in Phase I, 140 in Phase II, and 10 vaccines in Phase III. Vaccine trials for melanoma are most common (n=40), followed by breast cancer (34), lung cancer (30), and prostate cancer (22). Correlation analyses revealed that only annual cancer incidence is significantly associated with current therapeutic cancer vaccine trial activity (r=.60; p=.003). Annual mortality, 5-year survival rate and 5-year mortality estimates were not associated with vaccine trial activity. The authors conclude that therapeutic cancer vaccine clinical trials correspond with disease incidence in the U.S., but not with measures of mortality and survival that reflect the effectiveness of currently available treatment modalities. Future development of therapeutic vaccines for cancer may benefit patients more if there is stronger complementarity with other therapeutic options.
cancer; clinical trials; immunotherapy; incidence; mortality; vaccine
We aimed to characterize patterns in the timing of initial emergency procedures for patients with open tibia fracture and examine the relationship between initial procedure timing and in-hospital amputation.
Data were analyzed from the Nationwide Inpatient Sample, 2003–2009. Adult patients were included if they had a primary diagnosis code of open tibia fracture. Patients were excluded for the following: transferred from or to another hospital, an immediate amputation was performed, more than one amputation was performed, no emergency procedure was documented, or treated at a facility that did not perform any amputations. We evaluated the association between timing of the first procedure and the outcome of amputation using multiple logistic regression, controlled for patient risk factors and hospital characteristics.
Of 7,560 patients included in the analysis, 1.3% (n=99 patients) underwent amputation on hospital day 2 or later. The majority of patients (52.6%) underwent first operative procedure on day 0 or 1. In adjusted analyses, timing of first operative procedure beyond the day of admission is associated with more than three times greater odds of amputation (day 1 OR 3.81, 95% CI 1.80–8.07).
Delay of first operative procedure beyond the day of admission appears to be associated with a significantly increased probability of amputation in patients with open tibia fracture. All practitioners involved in the management of patients with open tibia fracture should seek a solution for any barrier, other than medical stability of the patient, of achieving early operative intervention.
amputation; debridement; emergent procedures; lower extremity reconstruction; lower extremity trauma; open tibial fracture
Costs of completing the recommended immunization schedule have increased over the last decade. Access to prophylactic vaccines may become limited due to financing obstacles within current delivery systems. Vaccine prices reflect research and development expenses incurred by vaccine manufacturers, including costs associated with evaluating candidate vaccines in human subjects. If the number of subjects in clinical trials is increasing over time and associated with vaccine price, this may help explain increases in prices of vaccine series. We examined whether: (A) the initial public- and private-sector prices for recommended prophylactic vaccine series licensed and recommended in the US increased from 2000–2011, (B) the number of human subjects per licensed vaccine increased during the time period, and (C) the number of human subjects was associated with the initial public–and private–sector prices of the vaccine series. In regression analyses of 13 vaccines, approval year was not significantly associated with the number of human subjects, initial public-sector prices, or initial private-sector prices. While the number of phase II subjects was not significantly associated with prices, the numbers of phase III and combined late phase (phases II + III) subjects were significantly associated with initial public- and private-sector series prices (p < 0.05). The association between number of subjects and initial prices demonstrated diminishing marginal increases in price with increasing numbers of subjects. These findings may help guide the number of subjects required by the FDA in clinical trials, in order to reduce expenses for manufacturers and thereby help mitigate increases in initial vaccine series prices.
vaccines; clinical trials; human subjects; price; research and development
To determine whether hospital discharges for intussusception in children younger than 1 year have changed since the reintroduction of rotavirus vaccine in the United States.
Serial cross-sectional analysis.
Children younger than 1 year with a discharge diagnosis of intussusception identified in the Kids’ Inpatient Database, a series of nationally representative data sets of pediatric hospital discharges in the United States with 4 available years prior to vaccine reintroduction (1997, 2000, 2003, and 2006) and 1 year after (2009).
Hospital discharge before vs after rotavirus vaccine reintroduction.
Total number and rate of hospital discharges for infants younger than 1 year with a diagnosis of intussusception (International Classification of Diseases, Ninth Revision, Clinical Modification code 560.0).
From 1997 to 2006, there was no change in the total number of hospital discharges for intussusception, with a small decrease in the rate of intussusception discharges (41.6 [95% CI, 36.7–46.5] to 36.5 [95% CI, 31.7–41.2] per 100 000 infants). Based on the trend, the predicted rate of discharges for intussusception in 2009 was 36.0 (95% CI, 30.2–41.8) per 100 000 infants. The measured rate of hospital discharges for intussusception in 2009 was 33.3 (95% CI, 29.0–37.6) per 100 000 infants.
The reintroduction of rotavirus vaccine since 2006 has not resulted in a detectable increase in the number of hospital discharges for intussusception among US infants.
The objectives of this study are (1) to compare the prevalence of a medical home between children with public and private insurance across states, (2) to investigate the association between a medical home and state health care characteristics for children with public and private insurance. We performed a cross-sectional analysis of the 2007 National Survey of Children’s Health, estimating the prevalence of parents’ report of a medical home and its components for publicly- and privately-insured children in all 50 states and the District of Columbia. We then performed a series of random-effects multilevel logistic regression models to assess the associations between a medical home and insurance type, individual sociodemographic characteristics, and state level characteristics/policies. The prevalence of a medical home varied significantly across states for both publicly- and privately-insured children (ranges: 33–63 % and 57–76 %, respectively). Compared to privately-insured children, publicly-insured children had a lower prevalence of a medical home in all states (public–private difference: 5–34 %). Low prevalence of a medical home was driven primarily by less family-centered care. Variation across states and differences by insurance type were largely attributable to lower reports of a medical home among traditionally vulnerable groups of children, including racial/ethnic minorities and non-English primary language speakers. The prevalence of a medical home was not associated with state level characteristics/policies. There are significant disparities between states in parents’ report of a medical home for their children, especially for publicly-insured children. Interventions seeking to address these disparities will need to target family-centered care for traditionally vulnerable populations of children.
Medical home; Public insurance; Disparities; Health policy; National Survey of Children’s Health
To identify factors that might influence physicians' referrals of obese adolescents to pediatric multidisciplinary weight management (PMWM) programs.
Survey of a national sample of 375 pediatricians (PDs) and 375 family physicians (FPs) explored program availability, referral history, desired services, and when in the course of treatment physicians would refer. Differences were examined via c2 tests.
Response rate was 67%. More PDs than FPs reported having a PMWM program available (46% vs 10%, P < .01). More PDs (PD 83% vs FP 53%, P < .01) and female physicians (88% vs 65%, P < .01) reported having made a referral. Most physicians wanted coordinated diet, activity, and behavioral therapy (79%). Almost all physicians indicated they would refer when unsure of what else to do, or if requested by the patient/parent.
PMWM program referrals appear limited by availability. These data also suggest physicians may be reticent to refer. Further work should examine whether this affects patient outcomes.
obesity; adolescents; primary care physicians; multidisciplinary care; weight management programs
To evaluate national trends in hospitalizations and hospital charges associated with diabetes over a recent 14-year period.
We evaluated hospital discharges with a primary or secondary diagnosis of diabetes (250.xx)in the Nationwide Inpatient Sample (1993–2006). Outcomes included population-adjusted estimates of hospital discharges and hospital charges (2006 $U.S.).
Overall, discharges associated with diabetes increased 65.3% (1,384/100,000 in 1993, 2,288/100,000 in 2006) over the 14-year period (p < 0.001 test for trend). The largest increase in hospitalizations occurred among adults 30–39 years of age, representing a 102% increase. Among young adults, increases among women were ∼1.3 times greater compared with men, for the 20–29 year (63% vs. 46%) and 30–39 year (118% vs. 85%) age groups, even after excluding pregnancy-related hospitalizations. Overall, women had higher rates of hospitalizations associated with diabetes compared with men, but there was evidence of an age by sex interaction, with higher rates of hospitalizations among women in the younger age groups and among men in the older age groups. Annual inflation-adjusted total charges for hospitalizations with diabetes increased 220% over the period.
Large increases in diabetes hospitalizations occurring among adults aged 30–39 years and young women signal a shift in the hospital burden of diabetes.
A Rh(I)-catalyzed cyclocarbonylation reaction of allenol esters has been examined and its synthetic viability established for the conversion of trisubstituted allenes to bicyclo-[4.3.0], and -[5.3.0] skeletons possessing an α-acetoxy cyclopentadienone. Tetrasubstituted allenol acetates gave elimination products, providing examples of a cyclocarbonylation reaction between an alkyne and a latent cumulene or cumulene equivalent. Cleavage of the acetate affords a free hydroxyl group illustrating the utility of this method for accessing α-hydroxy carbonyls from allenol esters.
Whether lumbar punctures (LPs) should be performed routinely for term newborns suspected of having early onset neonatal sepsis (EONS) is subject to debate. It is unclear whether variations in performance of LPs for EONS may be associated with patient, hospital, insurance or regional factors. Our objective was to identify characteristics associated with the practice of performing LPs for suspected EONS in a nationally representative sample.
Utilizing data from the 2003, 2006 and 2009 Kids’ Inpatient Database (KID) compiled by the Agency for Healthcare Research and Quality, we examined the frequency and characteristics of term, normal-birth weight newborns receiving an LP for EONS. Survey-weighting was applied for national estimates and used in chi squared and multivariable regression analysis.
In 2009, there were 13,694 discharges for term newborns that underwent LPs for apparent EONS. Newborns having LPs performed were more likely to be covered by Medicaid vs. private insurance (51.9 vs. 45.1 percent; p < 0.001), be born in urban vs. rural hospitals (94.8 vs. 87.3 percent; p < 0.001), teaching vs. non-teaching (60.8 vs. 43.1 percent; p < 0.001) and children’s hospitals vs. non-children’s (23.0 vs. 11.2 percent; p < 0.001). Lastly, newborns having LPs performed were disproportionately born in the Northeast census region (p = 0.03). In multi-year adjusted analysis, infants with Medicaid coverage, and those born in urban or teaching hospitals, consistently had higher odds of having an LP performed.
We found pronounced variation in LPs performed for EONS, even when adjusting for clinical conditions that would prompt LPs. These findings indicate practice variations in newborn care that merit further examination and explanation.
Neonatal; Sepsis; Lumbar puncture; Variation; Early onset neonatal sepsis
To compare the prevalence of a medical home for children with public versus private insurance and identify components of the medical home that contribute to any differences.
We performed a secondary data analysis of the 2007 National Survey of Children’s Health. A medical home was defined as meeting each of 5 components: 1) usual source of care; 2) personal doctor/nurse; 3) family-centered care; 4) care coordination, if needed; and 5) no problems getting a referral, if needed. We estimated the national prevalence of the medical home and its components for children with public versus private insurance. Comparisons were made using logistic regression, unadjusted and adjusted for sociodemographic factors.
67% of privately-insured children met all 5 components of the medical home, compared with only 45% of publicly-insured children (p<.001). The gap in medical home prevalence between public and private groups remained significant after controlling for sociodemographic characteristics (public vs. private adjusted odds ratio [AOR]: 0.82 [95% CI 0.73 – 0.92]). Over 90% of children in both groups reported having a usual source of care and a personal doctor/nurse. Only 58% of publicly-insured children reported family-centered care, compared with 76% of privately-insured children (p<0.001). This difference was significant after adjustment for sociodemographic characteristics (public vs. private AOR: 0.90 [95% CI 0.77 – 0.99]).
Significant medical home disparities exist between publicly- and privately-insured children, driven primarily by disparities in family-centered care. Efforts to promote the medical home must recognize and address determinants of family-centered care.
medical home; family-centered care; public insurance; National Survey of Children’s Health
The objective was to describe the characteristics of pediatric discharges associated with long-term mechanical ventilation (LTMV) compared with those with complex chronic conditions (CCCs), and evaluate trends over time in health care utilization for the discharges associated with LTMV.
The Kids' Inpatient Database, compiled by the Agency for Healthcare Research and Quality, was used. Routine newborn care was excluded. Discharges associated with LTMV were identified by using the International Classification of Diseases, Ninth Revision, code v46.1x and compared with discharges associated with CCCs in 2006 using simple regression and χ2 analyses. Trends in LTMV-associated discharges from 2000 to 2006 were assessed using variance-weighted least squares regression.
In 2006, there were an estimated 7812 discharges associated with LTMV. Compared with discharges for children with CCCs, LTMV discharges had significantly higher mortality, longer lengths of stay, higher mean charges, more emergency department admissions, and more discharges to long-term care. From 2000 to 2006, there was a 55% increase in the number of LTMV discharges and a concurrent 70% increase in aggregate hospital charges. The majority of LTMV discharges occurred in children 4 years old and younger, and ∼50% of the aggregate charges were for children younger than 1 year.
Discharges for children associated with LTMV require substantively greater inpatient resource use than other children with CCCs. As the number of discharges and associated aggregate charges increase over time, additional research must examine patterns of care for specific clinical subgroups of LTMV, especially children aged 4 years and younger.
mechanical ventilation; respiratory failure; utilization; hospitalization; Kids' Inpatient Database
To examine the associations between depression in fathers of 1-year-old children and specific positive and negative parenting behaviors discussed by pediatric providers at well-child visits.
We performed a cross-sectional secondary analysis by using interview data from 1746 fathers of 1-year-old children in the Fragile Families and Child Wellbeing Study. Positive parenting behaviors included fathers' reports of playing games, singing songs, and reading stories to their children ≥3 days in a typical week. Negative parenting behavior included fathers' reports of spanking their 1-year-old children in the previous month. Depression was assessed by using the World Health Organization Composite International Diagnostic Interview Short Form. Weighted bivariate and multivariate analyses of parenting behaviors were performed while controlling for demographics and paternal substance abuse.
Overall, 7% of fathers had depression. In bivariate analyses, depressed fathers were more likely than nondepressed fathers to report spanking their 1-year-old children in the previous month (41% compared with 13%; P < .01). In multivariate analyses, depressed fathers were less likely to report reading to their children ≥3 days in a typical week (adjusted odds ratio: 0.38 [95% confidence interval: 0.15–0.98]) and much more likely to report spanking (adjusted odds ratio: 3.92 [95% confidence interval: 1.23–12.5]). Seventy-seven percent of depressed fathers reported talking to their children's doctor in the previous year.
Paternal depression is associated with parenting behaviors relevant to well-child visits. Pediatric providers should consider screening fathers for depression, discussing specific parenting behaviors (eg, reading to children and appropriate discipline), and referring for treatment if appropriate.
fathers; depression; parenting
As the United States' (US) health system seeks more efficient and value-based care models, geographically distinct observation units (OUs) may become an integral part of hospital-based care for children.
To systematically review the literature and evaluate the structure and function of pediatric OUs in the US.
Searches were conducted in Medline, Web of Science, CINAHL, HCAB, Lexis Nexis, National Guideline Clearinghouse and Cochrane Reviews through February 2009, with review of select bibliographies.
English language peer-reviewed publications on pediatric OU care in the US.
Two authors independently determined study eligibility. Studies were graded using a 5-level quality assessment tool. Data were extracted using a standardized form.
21 studies met inclusion criteria: 2 randomized trials, 2 prospective observational, 12 retrospective cohort, 2 before and after, and 3 descriptive studies. Studies present data on more than 22,000 children cared for in OUs, most at large academic centers. This systematic review provides a descriptive overview of the structure and function of pediatric OUs in the US. Despite seemingly straightforward outcomes for OU care, significant heterogeneity in the reporting of length of stay, admission rates, return visit rates, and costs precluded our ability to conduct meta-analyses. We propose standard outcome measures and future directions for pediatric OU research.
Future research using consistent outcome measures will be critical to determining whether OUs can improve the quality and cost of providing care to children requiring observation-length stays.
Hospitalization; Emergency Department; Observation Unit; Pediatric; Review
Family support is important in diabetes self-management. However, children as providers of support have received little attention. This study examines the role of children in their parents’ diabetes self-management, diet, and exercise.
This research used community-based participatory research principles. Researchers conducted semi-structured parallel interviews of 24 Latino and African-American adults with diabetes and with a child (age 10–17 years) in their home (2004–06). Interviews were transcribed, coded, and analyzed for themes (2004–07).
Adults and children perceived that children play many roles related to adults’ diabetes self-management. Parents described children as monitoring parents’ dietary intake and reminding them what they should not be eating. Some children helped with shopping and meal preparation. Families described children reminding parents to exercise and exercising with their parent. Children reminded parents about medications and assisted with tasks such as checking blood sugar. Parents and children perceived that children played a role in tempting parents to stray from their diabetes diet, because children's diets included food that parents desired but tried to avoid.
Children and parents perceived that children have many roles in both supporting and undermining adults’ diabetes self-management. There is more to learn about the bidirectional relationships between adults and children in this setting and the most beneficial roles children can play. Health-care providers should encourage family lifestyle change, strengthen social support for families and direct children toward roles that are beneficial for both parent and child and do not place an unreasonable level of responsibility on the child.
Although recent trends in obesity have been well documented, generational patterns of obesity from early childhood through adulthood across birth cohorts, which account for the recent epidemic of childhood obesity, have not been well described. Such trends may have implications for the prevalence of obesity-associated conditions among population subgroups, including type 2 diabetes.
Our objective was to evaluate trajectories of obesity over the life course for the US population, overall and by gender and race.
Design, Setting, and Participants
We conducted an age, period, and birth cohort analysis of obesity for US individuals who participated in the National Health and Nutrition Examination Surveys (1971-2006).
Main Outcome Measures
Obesity was defined as a body mass index ≥ 95th percentile for individuals aged 2-16 years or ≥ 30 kg/m2 among individuals older than 16 years. Age was represented by the age of the individual at each NHANES survey, period was defined by the year midpoint of each survey, and cohort was calculated by subtracting age from period.
Recent birth cohorts are becoming obese in greater proportions for a given age, and are experiencing a greater duration of obesity over their lifetime. For example, whereas the 1966-75 and 1976-85 birth cohorts had reached an estimated obesity prevalence of at least 20% by 20-29 years of age, this level was only reached by 30-39 years for the 1946-55 and 1956-65 birth cohorts, by 40-49 years for the 1936-45 birth cohort, and by 50-59 years of age for the 1926-35 birth cohort. Trends are particularly pronounced for female compared with male, and black compared with white cohorts.
The increasing cumulative exposure to excess weight over the lifetime of recent birth cohorts will likely have profound implications for future rates of type 2 diabetes, and mortality within the US population.
obesity; trends; birth cohort; childhood; life course
The purpose of this study was to evaluate risk factors for antepartum depressive symptoms that can be assessed in routine obstetric care. We evaluated articles in the Englishlanguage literature from 1980 through 2008. Studies were selected if they evaluated the association between antepartum depressive symptoms and ≥1 risk factors. For each risk factor, 2 blinded, independent reviewers evaluated the overall trend of evidence. In total, 57 studies met eligibility criteria. Maternal anxiety, life stress, history of depression, lack of social support, unintended pregnancy, Medicaid insurance, domestic violence, lower income, lower education, smoking, single status, and poor relationship quality were associated with a greater likelihood of antepartum depressive symptoms in bivariate analyses. Life stress, lack of social support, and domestic violence continued to demonstrate a significant association in multivariate analyses. Our results demonstrate several correlates that are consistently related to an increased risk of depressive symptoms during pregnancy.
depression; pregnancy; risk factor
Brief hospitalizations for children may constitute an opportunity to provide care in an alternative setting such as an observation unit. The goal of this study was to characterize recent national trends in brief inpatient stays for children in the United States.
Using the Nationwide Inpatient Sample from 1993–2003, we analyzed hospital discharges among children <18 years of age, excluding births, deaths, and transfers. Hospitalizations with lengths of stay of 0 and 1 night were designated as “high turnover.” Serial cross-sectional analyses were conducted to compare the proportion of high-turnover stays across and within years according to patient and hospital-level characteristics. Diagnosis-related groups and hospital charges associated with these observation-length stays were examined.
In 2003, there were an estimated 441 363 high-turnover hospitalizations compared with 388 701 in 1993. The proportion of high-turnover stays increased from 24.9% in 1993 to 29.9% in 1999 and has remained ≥30.0% since that time. Diagnosis-related groups for high-turnover stays reflect common pediatric medical and surgical conditions requiring hospitalization, including respiratory illness, gastrointestinal/metabolic disorders, seizure/headache, and appendectomy. Significant increases in the proportion of high-turnover stays during the study period were noted across patient and hospital-level characteristics, including age group, payer, hospital location, teaching status, bed size, and admission source. High-turnover stays contributed $1.3 billion (22%) to aggregate hospital charges in 2003, an increase from $494 million (12%) in 1993.
Consistently since 1999, nearly one third of children hospitalized in the United States experience a high-turnover stay. These high-turnover cases constitute hospitalizations, that may be eligible for care in an alternative setting. Observation units provide 1 model for an efficient and cost-effective alternative to inpatient care, in which resources and provider interactions with patients and each other are geared toward shorter stays with more timely discharge processes.
observation medicine; children; emergency department; hospitalization; length of stay
The purpose of this work was to identify the proportions of publicly (Medicaid and State Child Health Insurance Program) insured and uninsured children who did not identify a usual source of care from 1998 to 2006, spanning the State Children’s Health Insurance Program (1997 to present) and the President’s Health Center Initiative (2002 to present), and to characterize unmet medical need as it relates to insurance and a usual source of care for publicly insured and uninsured children.
We conducted a secondary data analysis of multiple years of the National Health Interview Survey. We identified the proportion of publicly insured and uninsured children aged 0 to 17 years who did not identify a usual source of care and stratified according to the site of care. We described the odds of reporting an unmet medical need according to insurance status and usual source of care, compared with privately insured children with a usual source of care. Sample weights were used to derive national estimates.
From 1998 through 2006, there were significant increases in the proportions of children enrolled in Medicaid (16.7%–24.5%) and the State Child Health Insurance Program (2.0%–5.3%). The proportion of uninsured children has remained stable from 2002 to 2006 at ~10%. However, the proportion of uninsured reporting no usual source of care increased from 17.8% to 23.3%. Hispanic children had significant increases in the proportions of the uninsured and reporting no usual source of care by 2006. Hispanics constituted the largest proportion in both groups. Uninsured children and children without a usual source of care reported the highest odds of unmet need. Among the insured, publicly insured children had twice the odds of reporting an unmet need compared with privately insured children.
During the State Child Health Insurance Program and the President’s Health Center Initiative, growing proportions of uninsured children reported no usual source of care. Unmet medical need was the highest for the uninsured and those without a usual source of care. These findings suggest that initiatives designed to improve access to care must combine broadened insurance coverage with enhanced access to usual sources of care.
usual source of care; Medicaid; SCHIP; uninsured; children; health center
As an increasing number of patients with chronic conditions of childhood survive to adulthood, experts recommend that young adults with chronic conditions transfer from child-focused to adult-focused primary care. Little, however, is known about how comfortable physicians are caring for this population.
To assess the comfort of general internists and general pediatricians in treating young adult patients with chronic illnesses originating in childhood as well as the factors associated with comfort.
In a random sample, 1288 of 2434 eligible US general internists and pediatricians completed a mailed survey (response rate = 53%).
We measured respondents’ comfort level in providing primary care for a patient with sickle cell disease (SCD) or cystic fibrosis (CF). We also measured levels of disease familiarity, training and subspecialty support, as well as individual physician characteristics.
Fifteen percent of general internists reported being comfortable as the primary care provider for adults with CF and 32% reported being comfortable providing primary care for adults with SCD, compared with 38% of pediatricians for CF ( < .001) and 35% for SCD ( > 0.05). Less than half of general internists felt that their specialty should take primary care responsibility for adult patients with CF and SCD.
A majority of general internists and pediatricians are not comfortable providing primary care for young adults with chronic illnesses of childhood origin, such as CF and SCD. Efforts to increase treatment comfort among providers may help with the transition to adult-focused care for the growing numbers of young adults with complex chronic conditions.
transitional care; cystic fibrosis; sickle cell disease; young adults; adolescents; children with special health care needs; primary care; childhood diseases; health care transitions
To examine off-label utilization and costs of antihypertensive drugs in children using a national sample of prescription claims.
2002 Medstat MarketScan Database, a national sample of outpatient prescription claims of children ≤18 years old enrolled in private, employer-sponsored health plans.
Main Outcome Measures
Off-label use of antihypertensive drugs by patient age and costs of antihypertensives calculated as mean cost per child per 30-day fill.
One-half of the index antihypertensive prescription claims were off-label, based on minimum age criteria. Boys were more likely (56%) than girls (46%) to be prescribed off-label antihypertensives (p<0.001). Children aged ≥12 years were more likely to be prescribed off-label antihypertensives (53%) compared with children aged ≤5 (46%) and 6–11 years (42%, p<0.001). Off-label use varied significantly by class of antihypertensive drugs (p<0.001). Overall, off-label antihypertensives were significantly more expensive than on-label antihypertensives.
Despite availability of often less expensive on-label alternatives for the same class of antihypertensive drugs, off-label antihypertensive drugs were prescribed frequently in children. These findings underscore the potential clinical and economic implications of common off-label prescribing, for children, their parents, physicians and payers.
off-label; FDA; hypertension; antihypertensive drugs; children