Effect of a Computer-Based Decision Support Intervention on Autism Spectrum Disorder Screening in Pediatric Primary Care Clinics: A Cluster Randomized Clinical Trial

Importance: Universal early screening for autism spectrum disorder (ASD) is recommended but not routinely performed. Objective: To determine whether computer-automated screening and clinical decision support can improve ASD screening rates in pediatric primary care practices. Design, Setting, and Participants: This cluster randomized clinical trial, conducted between November 16, 2010, and November 21, 2012, compared ASD screening rates among a random sample of 274 children aged 18 to 24 months in urban pediatric clinics of an inner-city county hospital system with or without an ASD screening module built into an existing decision support software system. Statistical analyses were conducted from February 6, 2017, to June 1, 2018. Interventions: Four clinics were matched in pairs based on patient volume and race/ethnicity, then randomized within pairs. Decision support with the Child Health Improvement Through Computer Automation system (CHICA) was integrated with workflow and with the electronic health record in intervention clinics. Main Outcomes and Measures: The main outcome was screening rates among children aged 18 to 24 months. Because the intervention was discontinued among children aged 18 months at the request of the participating clinics, only results for those aged 24 months were collected and analyzed. Rates of positive screening results, clinicians' response rates to screening results in the computer system, and new cases of ASD identified were also measured. Main results were controlled for race/ethnicity and intracluster correlation. Results: Two clinics were randomized to receive the intervention, and 2 served as controls. Records from 274 children (101 girls, 162 boys, and 11 missing information on sex; age range, 23-30 months) were reviewed (138 in the intervention clinics and 136 in the control clinics). Of 263 children, 242 (92.0%) were enrolled in Medicaid, 138 (52.5%) were African American, and 96 (36.5%) were Hispanic. Screening rates in the intervention clinics increased from 0% (95% CI, 0%-5.5%) at baseline to 68.4% (13 of 19) (95% CI, 43.4%-87.4%) in 6 months and to 100% (18 of 18) (95% CI, 81.5%-100%) in 24 months. Control clinics had no significant increase in screening rates (baseline, 7 of 64 children [10.9%]; 6-24 months after the intervention, 11 of 72 children [15.3%]; P = .46). Screening results were positive for 265 of 980 children (27.0%) screened by CHICA during the study period. Among the 265 patients with positive screening results, physicians indicated any response in CHICA in 151 (57.0%). Two children in the intervention group received a new diagnosis of ASD within the time frame of the study. Conclusions and Relevance: The findings suggest that computer automation, when integrated with clinical workflow and the electronic health record, increases screening of children for ASD, but follow-up by physicians is still flawed. Automation of the subsequent workup is still needed

Comparison of Risk of Recrudescent Fever in Children With Kawasaki Disease Treated With Intravenous Immunoglobulin and Low-Dose vs High-Dose Aspirin

Importance: Timely initiation of intravenous immunoglobulin plus aspirin is necessary for decreasing the risk of recrudescent fever and coronary artery abnormalities in children with Kawasaki disease (KD). The optimal dose of aspirin, however, remains unclear. Objective: To evaluate whether initial treatment with low-dose compared with high-dose aspirin in children with KD is associated with an increase in fever recrudescence. Design, Setting, and Participants: A retrospective cohort study of 260 children with KD at Riley Hospital for Children, Indianapolis, Indiana, between January 1, 2007, and December 31, 2018, was conducted. Children aged 0 to 18 years with a first episode of KD, identified by International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes treated within 10 days of symptom onset with high-dose intravenous immunoglobulin plus aspirin were eligible. Patients who received an alternative diagnosis, experienced a second episode of KD, did not receive intravenous immunoglobulin plus aspirin for initial treatment, were not treated within 10 days of symptoms, or had incomplete records were excluded. Exposures: High-dose (≥10 mg/kg/d) or low-dose (<10 mg/kg/d) aspirin therapy. Main Outcomes and Measures: The primary outcome was recrudescent fever necessitating retreatment of KD. The secondary outcomes were coronary artery abnormalities and hospital length of stay. Results: Among the 260 patients included, the median (interquartile range) age was 2.5 (1.6-4.3) years, 103 (39.6%) were girls, 166 (63.8%) were non-Hispanic white, 57 (21.9%) were African American, 22 (8.5%) were Asian, 11 (4.2%) were Hispanic, and 4 (1.5%) were of unknown race/ethnicity. One hundred-forty-two patients (54.6%) were treated with low-dose aspirin. There was no association between recrudescent fever and aspirin dose, with 39 children (27.5%) having recrudescent fever in the low-dose group compared with 26 children (22.0%) in the high-dose group (odds ratio [OR], 1.34; 95% CI, 0.76-2.37; P = .31), with similar results after adjusting for potential confounding variables (OR, 1.63; 95% CI, 0.89-2.97; P = .11). In a subset analysis of 167 children with complete KD, however, there was nearly a 2-fold difference in the odds of recrudescent fever with low-dose aspirin (OR, 1.87; 95% CI, 0.82-4.23; P = .14), although this difference did not reach statistical significance. In addition, no association was identified between treatment group and coronary artery abnormalities (low-dose, 7.4% vs high-dose, 9.4%; OR, 0.86; 95% CI, 0.48-1.55; P = .62) or median (interquartile range) length of stay (3 [3-5] days for both groups; P = .27). Conclusions and Relevance: In this study, low-dose aspirin for the initial treatment of children with KD was not associated with fever recrudescence or coronary artery abnormalities. Given the potential benefits, further study of low-dose aspirin to detect potentially clinically relevant outcome differences is warranted to inform treatment decisions and guideline development

Dysmenorrhea Symptom-Based Phenotypes: A Replication and Extension Study

BACKGROUND: Dysmenorrhea is a prevalent pain condition among women and a risk factor for other chronic pain conditions. Individuals vary in dysmenorrhea pain severity, the number of painful sites, and co-occurring gastrointestinal symptoms. Three dysmenorrhea symptom-based phenotypes were previously identified using latent class analysis; however, there is a need to validate these in an independent sample, so they can be used in mechanistic and interventional research. There also is a need to further characterize dysmenorrhea symptom-based phenotypes in terms of demographic, clinical, and psychobehavioral characteristics so they can be used to inform precision dysmenorrhea treatment. OBJECTIVES: The study objectives were to: (a) determine whether the same dysmenorrhea symptom-based phenotypes would be found in a new sample; (b) determine whether including demographic, clinical, and psychobehavioral covariates in latent class analyses would change individuals’ phenotype memberships; and (c) investigate relationships between dysmenorrhea symptom-based phenotypes and demographic, clinical, and psychobehavioral characteristics. METHODS: This cross-sectional survey study included 678 women (aged 14 to 42 years) with dysmenorrhea. Participants reported dysmenorrhea symptom severity, demographic, clinical (comorbid chronic pain and gynecological conditions), and psychobehavioral characteristics (perceived stress, anxiety, depression, sleep disturbance, and pain catastrophizing). We used latent class analysis to identify symptom-based phenotypes. We compared analyses with and without covariates (i.e., demographic, clinical, and psychobehavioral characteristics) to determine if individuals’ phenotype memberships changed. We then examined associations between phenotypes and demographic, clinical, and psychobehavioral characteristics. RESULTS: We reproduced three dysmenorrhea symptom-based phenotypes: the “mild localized pain” phenotype (characterized by mild abdominal cramps), the “severe localized pain” phenotype (characterized by severe abdominal cramps), and the “multiple severe symptoms” phenotype (characterized by severe pain at multiple locations and gastrointestinal symptoms). Analyses with and without covariates had little effect on individuals’ phenotype membership. Race, comorbid chronic pain condition, endometriosis, and pain catastrophizing were significantly associated with the dysmenorrhea phenotypes. DISCUSSION: Findings provide a foundation to further study mechanisms of dysmenorrhea symptom heterogeneity and develop dysmenorrhea precision treatments. The three dysmenorrhea symptom-based phenotypes were validated in a second sample. Demographic, clinical, and psychobehavioral factors were associated with dysmenorrhea symptom-based phenotypes

Pattern and frequency of neurological and neurosurgical care of adult inpatients and outpatients at a tertiary referral hospital in Kenya

Objective: To describe the patterns and burden of neurological and neurosurgical disorders at a national tertiary level referral hospital in western Kenya. Methods: We conducted a three-month period prevalence study. We recruited consecutive adult patients seeking neurological-neurosurgical care in both inpatient and outpatient settings at Moi Teaching and Referral Hospital. Results: 833 participants were included. The age range was between 19 year and 99 years (mean age = 45.3 years). The most common diagnoses among neurology inpatients were meningitis (12%), ischemic stroke (11.0%) and epilepsy/seizure (6.7%). Among neurology outpatients, epilepsy (35.1%) and ischemic stroke (18.8%) were the most common diagnoses. The most common neurosurgery inpatient diagnosis was hemorrhagic stroke (16.3%) and among outpatients, the most common diagnoses were traumatic brain injury (17.4%) and hemorrhagic stroke (16.3%). Overall, 471 (56.5%) patients underwent HIV testing, of which, 89 (18.9%) were HIV positive and 382 (81.1%) were HIV negative. Thirty-one inpatient deaths (male 58%), attributable to neurological and neurosurgical disorders, occurred during the study period. Meningitis was the most common cause of death. Conclusions: The findings suggest that meningitis, stroke, epilepsy, and traumatic brain injury were the most common diagnosis. More resources and efforts should be directed towards prevention, diagnosis and management of these conditions in the region

Follow-up of Mothers with Suspected Postpartum Depression from Pediatrics Clinics

Purpose Pediatric providers are increasingly screening for postpartum depression (PD), yet, it is unknown how often mothers comply with recommendations to seek treatment. The objectives were to describe the rate at which mothers with suspected PD seek treatment and explore factors that predict help-seeking behavior. Design and methods Mothers were recruited from four pediatric clinics after identification using the Child Health Improvement through Computer Automation (CHICA) system. Mothers with a positive screen were invited to participate in a telephone interview between January 2012 and December 2014. Mothers reported if they sought treatment or called a community resource. Results 73 of 133 eligible mothers participated (55% response rate). Fifty women recalled a recommendation to seek help. Only 43.8% (32/73) made a follow-up appointment with an adult provider and even fewer kept the appointment. Conclusion A majority of mothers suspected of having PD recalled a referral for further intervention; yet, less than half took action. Further investigation of barriers of help-seeking behavior is warranted

Symptoms-Based Phenotypes Among Women With Dysmenorrhea: A Latent Class Analysis

Dysmenorrhea is highly prevalent and may increase women’s risk for developing other chronic pain conditions. Although it is highly variable, symptom-based dysmenorrhea phenotypes have not been identified. The study aims were to identify symptom-based dysmenorrhea phenotypes and examine their relationships with demographic and clinical characteristics. In a cross-sectional study, 762 women with dysmenorrhea rated severity of 14 dysmenorrhea-related symptoms. Using latent class analysis, we identified three distinctive phenotypes. Women in the “mild localized pain” phenotype (n=202, 26.51%) had mild abdominal cramps and dull abdominal pain/discomfort. Women in the “severe localized pain” phenotype (n=412 54.07%) had severe abdominal cramps. Women in the “multiple severe symptoms” phenotype (n=148, 19.42%) had severe pain at multiple locations and multiple gastrointestinal symptoms. Race, ethnicity, age, and comorbid chronic pain conditions were significantly associated with phenotypes. Identification of these symptom-based phenotypes provides a foundation for research examining genotype-phenotype associations, etiologic mechanisms, and/or variability in treatment responses

Using HCAHPS data to model correlates of medication understanding at hospital discharge

Background: Hospitals are challenged to improve hospital transitions to home and are held accountable through public reporting. Design: This cross-sectional study used patients’ self-reported experience data from the publicly reported Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to describe correlates of medication understanding at hospital discharge, using data collected from adult patients discharged from one Midwestern community hospital (N=154). Results: The final logistic regression model included four correlates of medication understanding: 1) nurse always communicates well, 2) physician always communicates well, 3) new prescriptions during hospital stay, and 4) very good or better mental health, and these classified 72.6% of the cases. Significant correlates of the patient strongly agreeing that they understood discharge medications were the “nurse always communicates well” (odds ratio =3.10, 95% confidence interval: 1.25, 7.66) and “very good or better self-perceived mental health” (odds ratio =2.17, 95% confidence interval: 1.02, 4.64). Conclusion: HCAHPS data can be used to model correlates of medication understanding, which are then useful for evaluating intervention effects following quality improvement

Bleeding Risk, Physical Functioning, and Non-use of Anticoagulation Among Patients with Stroke and Atrial Fibrillation

Background: Atrial fibrillation (AF) is common among people with stroke. Anticoagulation medications can be used to manage the deleterious impact of AF after stroke, however may not be prescribed due to concerns about post-stroke falls and decreased functioning. Thus, the purpose of this study was to identify, among people with stroke and AF, predictors of anticoagulation prescription at hospital discharge. Methods: This is a secondary analysis of a retrospective cohort study of data retrieved via medical records, including: National Institutes of Health Stroke Scale score; Functional Independence Measure (FIM) motor score (motor or physical function); ambulation on 2nd day of hospitalization; Morse Falls Scale (fall risk); and HAS-BLED score (Hypertension; Abnormal renal and liver function; Stroke; Bleeding; Labile INRs; Elderly > 65; and Drugs or alcohol). Data analyses included bivariate comparisons between people with and without anticoagulation at discharge. Logistic-regression modeling was used to assess predictors of discharge anti-coagulation. Results: There were 334 subjects included in the analyses, average age was 75 years old. Anticoagulation was prescribed at discharge for 235 (70%) of patients. In the adjusted regression analyses, only the FIM motor score (adjusted OR = 1.015, 95%CI 1.001-1.028) and the HAS-BLED score (adjusted OR = 0.36, 95%CI 0.22-0.58) were significantly associated with anticoagulation prescription at discharge. Conclusion: It appears that in this sample, post-stroke anti-coagulation decisions appear to be made based on clinical factors associated with bleed risk and motor deficits or physical functioning. However, opportunities may exist for improving clinician documentation of specific reasoning for non-anticoagulation prescription

Exploring the Relationships Among Social Support, Patient Activation, and Pain-Related Outcomes

Objective Social support has been linked to more effective pain adaptation. The relationship between social support and other relevant constructs is less well understood. Chief among these is patient activation, which has robust links to effective self-management, yet has not been well studied in chronic pain. We sought to better understand these relationships in an effort to inform future intervention strategies for patients with chronic pain. Methods Using baseline data from a clinical trial with patients with chronic pain (N = 213), we analyzed the relationships among perceived social support and patient activation, depression, anxiety, general health perceptions, pain centrality, pain catastrophizing, and pain intensity and interference. Multiple linear regression was used to examine the effect of social support on outcomes. Patient activation was explored as a mediator of the effect of social support on outcomes. Results Social support was significantly associated with all outcomes except pain. Social support explained the greatest variance in patient activation (squared semi-partial correlation = 0.081), followed by depression (0.073) and general health perceptions (0.072). Patient activation was not found to be a significant mediator of the effect of social support on pain-related outcomes. Conclusions These findings provide insight into the roles of patient activation and social support in chronic pain management. Although patient activation did not mediate the relationship between social support and outcomes, this study is an important step toward gaining a more complete understanding of constructs thought to be related to pain self-management and points to the need to advance theory in this area to guide future research. Such work is needed to optimize interventions for patients with chronic pain

Development and Testing of the Dysmenorrhea Symptom Interference (DSI) Scale

Dysmenorrhea affects most reproductive-age women and increases the risk of future pain. To evaluate dysmenorrhea interventions, validated outcome measures are needed. In this two-phase study, we developed and tested the dysmenorrhea symptom interference scale. During the scale-development phase (n = 30), we created a nine-item scale based on qualitative data from cognitive interviews. During the scale-testing phase (n = 686), we evaluated reliability, validity, and responsiveness to change. The scale measures how dysmenorrhea symptoms interfere with physical, mental, and social activities. Internal consistency was strong with Cronbach's α > 0.9. Test-retest reliability was acceptable (r = 0.8). The scale showed satisfactory content validity, construct validity (supported by confirmatory factor analysis), concurrent validity, and responsiveness to change. The minimally important difference was 0.3 points on a scale with a possible total score ranging from 1 to 5. This new psychometrically sound scale can be used in research and clinical practice to facilitate the measurement and management of dysmenorrhea