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Children's Outcomes Research Program
Research
Development of Systems for Transporting Clinical Information Electronically Between Health Care Delivery Systems in Colorado
COR and COHO jointly convened a clinical informatics working group in October 2003. This group included the chief medical informatics officers of the University of Colorado Denver-affiliated institutions, as well as other informatics experts on campus and in partner institutions. Using COHO/COR program expertise and administrative support, members of this group applied successfully for two highly competitive grants to develop and deploy a system for transporting clinical information electronically between health care delivery systems in Colorado. Funding was initially obtained from the Foundation for eHealth Initiative (David W. Kaplan, MD, MPH, PI - $600,000), which contributed to obtaining another larger grant from the Agency for Healthcare Research and Quality (Arthur Davidson, MD, MSPH, PI - $5,000,000). These projects illustrate the ability of COR and COHO to jointly convene technical experts and researchers around topics of common interest, resulting in successful grant proposals consistent with the COR/COHO mission.
The Colorado Immunization Information System (Immunization Registry)
The Colorado State Immunization Registry or Colorado Immunization Information System (CIIS) was developed by COR investigators and is operated as a COR activity under the Colorado Infant Immunization Act (CRS Sec. 25-5-1701 et seq), pursuant to a contract with the Colorado Department of Public Health and Environment (CDPHE). By November 2004, the COR Immunization Registry contained over 52% of Colorado children under six years old. The successful establishment of an electronic registry, in addition to laying the foundation for numerous initiatives to improve Colorado's dismal immunization rates, provides COR investigators Allison Kempe, MD, MPH, and Matthew F. Daley, MD, with the infrastructure to carry out research activities.
Immunization-Related Research Activities
Recently, Drs. Kempe and Daley completed their grant to study the uptake of new and targeted vaccines, including the barriers and facilitators to their uptake. In this three-year grant (2001-2004) they studied the introduction of a new conjugate pneumococcal vaccine in The Children's Hospital Child Health Clinic, private pediatrician offices and rural family medicine offices. They subsequently obtained a two-year grant (2003-2005) from the CDC to identify and target barriers to influenza immunization in 6- to 23-month-olds. The findings of this study were especially relevant given the epidemic of influenza in 2003-2004 and the shortage of vaccine in 2004-2005. Their paper describing the effectiveness of a reminder recall for influenza vaccine for high-risk children was published by Pediatrics without delay because of its immediate importance to clinicians and policymakers. A team of COR/COHO investigators led by Allison Kempe, MD, MPH, in collaboration with the Prevention Research Center in the UCD Department of Preventive Medicine, received new CDC funding ($900,000 over three years) to become the national center for conducting survey research in immunization policy issues.
Simon Hambidge, MD, PhD, has obtained a Robert Wood Johnson Generalist Physician Faculty Scholars Grant to study interventions to improve immunization levels in children within the Denver Health primary care system. The overall aim of the project Caring For Kids is to increase receipt of a broad array of childhood preventive health services in a population of inner city children. Specific hypotheses concerning risk factors for infant under-immunization, lack of receipt of well-child care and childhood injuries will be tested. This study will first examine these risk factors in a defined population of inner city children, using a historical cohort. Finally, through the use of a randomized, controlled trial in a prospective birth cohort, it will test an intervention, based on the evidence gathered from the initial study phases, to increase immunization rates and well-child care delivery in those children most at risk for "falling through the cracks." These studies will be conducted in the Denver Health community health network, which is the largest integrated community health care system in the United States.
Drs. James Todd and Marsha Anderson have analyzed Colorado Hospital Association data to calculate vaccine preventable disease (VPD) rates for pertussis, S. pneumoniae, chickenpox and influenza according to insurance status as well as geographic area. Their data documents significantly higher VPD rates in children who are either uninsured or on public insurance programs (Medicaid and Child Health Plan) compared to privately insured children. Their report also presents a map of the state displaying VPD rates and identifies areas of the state with the highest rates. This data is essential for developing state immunization policies and a statewide plan to improve our rates.
Studies of Anticipatory Guidance
The current primary care approach to pediatric preventive care is being reassessed. Greater emphasis is being placed on the fact that one-third of children are unprepared to start kindergarten and are not ready to learn. Brief developmental interventions often have limited success, while more effective intensive programs are impractical. Interventions that can be easily integrated into pediatric primary care to motivate parents to do more talking and encouraging may solve this dilemma. COR investigators Stephen Berman, MD, and Bonnie W. Camp, MD, PhD, completed a single-blinded, randomized controlled trial that compared the effects of the Language Power (LP) intervention developed by Bonnie Camp for Bright Beginnings and an injury prevention active control program (comparative control) on parental behaviors and the McArthur vocabulary score. The study design of this random control trial also provided an opportunity to determine the effectiveness of reviewing AAP TIPP (The Injury Prevention Program) injury prevention material during well-child care visits to reduce the risk of preventable injury.
One of the most cost-effective pediatric preventive care interventions would be to promote successful breastfeeding during the first six months of life. Data documents that Hispanic mothers are less likely than whites to breastfeed during this period. Maya Bunik, MD, a participant in our Primary Care Research Faculty Development program and Allison Kempe, MD, MPH, have obtained grant funding from the CDC and the CDPHE to study the impact of a telephone breastfeeding support program during the two to four weeks after hospital discharge from the maternity service.
Respiratory Diseases, Asthma and Dermatology
Monica Federico, MD, a pediatric pulmonologist, carried out a study of asthma management in children in Denver metropolitan schools. Currently, she is designing a study, with assistance from COR staff, to evaluate a phone-based asthma management program compared to usual care. Patients will be recruited from the TCH emergency room and inpatient ward and then randomized to receive the program in order to see if the program can reduce this risk. Additional areas of potential future research include: 1) asthma outcomes, including health care utilization and quality of life in the general pediatric and resident-based clinics before and after the outpatient asthma pathway is implemented; 2) screening families and caregivers for depression at each clinic visit for asthma; 3) comparing phone-based asthma management to specialist care and to pathway-based care; 4) comparing outcomes at private pediatricians' offices to those at hospital-based clinics before and after the pathway; 5) using additional markers of disease to manage asthma and comparing the outcomes to managing asthma based on current guidelines.
Allan Arbuckle, MD, a pediatric dermatology fellow, and Stephen Berman, MD, collaborated with Lori Crane, PhD, to carry out a qualitative survey of health professional attitudes to weekly dressing changes under anesthesia for children with dystrophic epidermolysis bullosa. The study included structured interviews with nurses, anesthesiologists, pediatricians, dermatologists, ethicists and social workers who were involved with two children who received this therapy. The findings will be used to decide whether to replicate this intensive therapy in the future.
Health Care Delivery and Organizational Activities
During the past decade, the number of children living in out-of-home placements has risen dramatically. These children may be in foster care, formal kinship care (adjudicated by social services) or informal kinship care. Sara Carpenter, MD, in collaboration with Robert Clyman, MD, and Stephen Berman, MD, has studied the differences in utilization of medical and mental health services among these three types of out-of-home placements and children living with parents, using a national survey designed to be a representational sample of all children. This study was funded by the Robert Wood Johnson Foundation. Dr. Carpenter's work has important health policy implications for the delivery of medical and mental health services to this very high-risk and vulnerable population.
Marion Sills, MD, MPH, has also been working with a national dataset to study the impact of mental illness on health care expenditures related to both medical and mental health services. Following two years in the Primary Care Research Faculty Development program, Dr. Sills is now in the COHO Clinical Scholars research program.
Drs. James Todd and Stephen Berman have been collaborating extensively on a series of studies on the Colorado public child health insurance programs (Medicaid and Child Health Plan) as well as the uninsured. The first area of study involved a 2003 survey of Colorado pediatricians that documented a serious erosion in the willingness of pediatricians in private practice to accept children with Medicaid and the important role low Medicaid payments play in deciding not to accept new Medicaid patients. These findings, which have important health policy implications for Colorado, were published in The Children's Hospital State of Colorado report. This report has been distributed to all Colorado state legislators.
A second area of study involved a detailed analysis of published Colorado HEDIS (Health Plan Employer Data and Information Set) data for 1999, 2001, 2002 and 2003 to determine whether Colorado children enrolled in managed care programs with an assigned primary care physician (PCP) versus the unassigned-fee-for-service (UFFS) program were more likely to have any type of visit with a PCP, to have recommended preventive health care visits and to be fully immunized.
The third area of study involved a population-based analysis of hospitalization data for children from the Colorado Hospital Association database from 1995-2003, using health insurance coverage estimates from the US Census Bureau to address this issue. The results show that children with public or no insurance have much higher hospital charges and significantly higher hospitalization rates overall, as well as higher admission rates for those with chronic illness, asthma, diabetes, appendectomy and vaccine-preventable disease. In aggregate, there was an excess of charges of over $34 million in 2003. Since these children often do not have a medical home, they were more often admitted from the emergency room. These findings document substantially greater hospital charges and morbidity for children with public or no insurance and suggest the opportunity for improved health outcomes and decreased costs for underinsured children if private insurance standards of a medical home and hospital care could be achieved that would offer more consistent prevention and acute care within a continuity setting.
Stephen Berman, MD, and colleagues M. Douglas Jones, Jr., MD; Ellen Elias, MD; Michael Rannie, Clinical Coordinator for Decision Support; and Len Dryer, Chief Financial Office of TCH, analyzed the TCH administrative database to determine direct costs, total costs and payments by type of service for 365 days following an index visit associated with hospital ambulatory and inpatient services for children with multisystem disorders followed by a comprehensive primary care clinic. The investigators studied the effect of enrollment in a hospital-based comprehensive primary care clinic on ambulatory and inpatient utilization patterns and expenditures. Enrollment in a comprehensive primary care program was associated with a decreased length of stay for nonintensive care hospitalizations and with increased use of surgical services. These findings relate to the need to improve the care processes for children with special health care needs. This has been highlighted by an Institution of Medicine report on priorit areas for research coauthored by Dr. Berman.
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