Rita Mangione-smith | University of Washington (original) (raw)

Papers by Rita Mangione-smith

Research paper thumbnail of Parent expectations for antibiotics: Who are the public health campaigns failing to reach?

Objective: This study investigates the relationship of 'online commentary' (contemporaneous physi... more Objective: This study investigates the relationship of 'online commentary' (contemporaneous physician comments about physical examination [PE] findings) with (i) parent questioning of the treatment recommendation and (ii) inappropriate antibiotic prescribing. Methods: A nested cross-sectional study of 522 encounters motivated by upper respiratory symptoms in 27 California pediatric practices (38 pediatricians). Physicians completed a post-visit survey regarding physical examination findings, diagnosis, treatment, and whether they perceived the parent as expecting an antibiotic. Taped encounters were coded for 'problem' online commentary (PE findings discussed as significant or clearly abnormal) and 'no problem' online commentary (PE findings discussed reassuringly as normal or insignificant). Results: Online commentary during the PE occurred in 71% of visits with viral diagnoses (n = 261). Compared to similar cases with 'no problem' online commentary, 'problem' comments were associated with a 13% greater probability of parents questioning a non-antibiotic treatment plan (95% CI 0-26%, p = .05,) and a 27% (95% CI: 2-52%, p < .05) greater probability of an inappropriate antibiotic prescription. Conclusion: With viral illnesses, problematic online comments are associated with more pediatricianparent conflict over non-antibiotic treatment recommendations. This may increase inappropriate antibiotic prescribing. Practice implications: In viral cases, physicians should consider avoiding the use of problematic online commentary.

Research paper thumbnail of The Effectiveness of Family-Centered Transition Processes From Hospital Settings to Home: A Review of the Literature

Hospital pediatrics, 2015

The quality of care transitions is of growing concern because of a high incidence of postdischarg... more The quality of care transitions is of growing concern because of a high incidence of postdischarge adverse events, poor communication with patients, and inadequate information transfer between providers. The objective of this study was to conduct a targeted literature review of studies examining the effectiveness of family-centered transition processes from hospital- and emergency department (ED)-to-home for improving patient health outcomes and health care utilization. We conducted an electronic search (2001-2012) of PubMed, CINAHL, Cochrane, PsycInfo, Embase, and Web of Science databases. Included were experimental studies of hospital and ED-to-home transition interventions in pediatric and adult populations meeting the following inclusion criteria: studies evaluating hospital or ED-to-home transition interventions, study interventions involving patients/families, studies measuring outcomes ≤30 days after discharge, and US studies. Transition processes, principal outcome measures ...

Research paper thumbnail of An observational study of antibiotic prescribing behavior and the Hawthorne effect

Health services research, 2002

To assess whether prospective, observational study procedures, including questionnaires and audio... more To assess whether prospective, observational study procedures, including questionnaires and audio recording, are associated with different patterns of physician diagnostic decision making and antibiotic prescribing. (1) Survey data from a prospective observational study of treatment patterns for children with acute upper respiratory illnesses (10/96-3/97) and (2) retrospective medical record abstraction data of nonobserved encounters for the same problems occurring during (10/96-3/97) and one year after (10/97-3/98) the observational study period. Ten pediatricians in two community practices were studied. Patterns of diagnoses recorded in the medical record and antibiotics ordered for visits occurring outside of the observational study (same time period and one year later) were compared with the pattern of diagnoses and antibiotics ordered during the observational study. For the observational study (10/96-2/97), diagnosis and treatment choices were obtained from questionnaires compl...

Research paper thumbnail of Developing Measures for Pediatric Quality: Methods and Experiences of the CHIPRA Pediatric Quality Measures Program Grantees

Academic Pediatrics, 2014

Monitoring quality is an important way of understanding how the health care system is serving chi... more Monitoring quality is an important way of understanding how the health care system is serving children and families. The Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Pediatric Quality Measures Program (PQMP) funded efforts to develop and enhance measures to assess care for children and adolescents. We describe the processes used by the PQMP grantees to develop measures to assess the health care of children and adolescents in Medicaid and the Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Health Insurance Program. Key steps in the measures development process include identifying concepts, reviewing and synthesizing evidence, prioritizing concepts, defining how measures should be calculated, and measure testing. Stakeholder engagement throughout the process is critical. Case studies illustrate how PQMP grantees adapted the process to respond to the nature of measures they were charged to develop and overcome challenges encountered. PQMP grantees used varied approaches to measures development but faced common challenges, some specific to the field of pediatrics and some general to all quality measures. Major challenges included the limited evidence base, data systems difficult or unsuited for measures reporting, and conflicting stakeholder priorities. As part of the PQMP, grantees were able to explore innovative methods to overcome measurement challenges, including new approaches to building the evidence base and stakeholder consensus, integration of alternative data sources, and implementation of new testing methods. As a result, the PQMP has developed new quality measures for pediatric care while also building an infrastructure, expertise, and enhanced methods for measures development that promise to provide more relevant and meaningful tools for improving the quality of children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s health care.

Research paper thumbnail of Validity and responsiveness of the pediatric quality of life inventory (PedsQL) 4.0 generic core scales in the pediatric inpatient setting

JAMA pediatrics, 2014

Validated patient-reported outcomes responsive to clinical change are needed to evaluate the effe... more Validated patient-reported outcomes responsive to clinical change are needed to evaluate the effectiveness of quality improvement interventions. To evaluate responsiveness, construct validity, and predictive validity of the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales in the pediatric inpatient setting. Prospective, cohort study of parents and caregivers of patients 1 month to 18 years old (n = 4637) and patients 13 to 18 years old (n = 359) admitted to Seattle Children's Hospital between October 1, 2011, and December 31, 2013. Of 7184 eligible participants invited to complete the survey, 4637 (64.5%) completed the PedsQL on admission, and of these 2694 (58.1%) completed the follow-up survey 2 to 8 weeks after discharge. Responsiveness was assessed by calculating improvement scores (difference between follow-up and admission scores). Construct validity was examined by comparing the mean improvement scores for known groups differing by medical complexity. ...

Research paper thumbnail of Using Medicaid and CHIP claims data to support pediatric quality measurement: lessons from 3 centers of excellence in measure development

Academic pediatrics

We sought to explore the claims data-related issues relevant to quality measure development for M... more We sought to explore the claims data-related issues relevant to quality measure development for Medicaid and the Children's Health Insurance Program (CHIP), illustrating the challenges encountered and solutions developed around 3 distinct performance measure topics: care coordination for children with complex needs, quality of care for high-prevalence conditions, and hospital readmissions. Each of 3 centers of excellence presents an example that illustrates the challenges of using claims data for quality measurement. Our Centers of Excellence in pediatric quality measurement used innovative methods to develop algorithms that use Medicaid claims data to identify children with complex needs; overcome some shortcomings of existing data for measuring quality of care for common conditions such as otitis media; and identify readmissions after hospitalizations for lower respiratory infections. Our experience constructing quality measure specifications using claims data suggests that it...

Research paper thumbnail of The Quality of Ambulatory Care Delivered to Children in the United States

New England Journal of Medicine, 2007

Methods We assessed the extent to which care processes recommended for pediatric out- patients ar... more Methods We assessed the extent to which care processes recommended for pediatric out- patients are delivered. Quality indicators were developed with the use of the RAND- UCLA modified Delphi method. Parents of 1536 children who were randomly se- lected from 12 metropolitan areas provided written informed consent to obtain medical records from all providers who had seen the children during

Research paper thumbnail of Impact of English Proficiency on Care Experiences in a Pediatric Emergency Department

Academic pediatrics, Jan 4, 2014

To compare emergency department care experiences of Spanish-speaking, limited-English-proficient ... more To compare emergency department care experiences of Spanish-speaking, limited-English-proficient (SSLEP) and English-proficient (EP) parents and to assess how SSLEP care experiences vary by parent-perceived interpretation accuracy. The National Research Corporation Picker Institute's Family Experience Survey (FES) was administered from November 26, 2010, to July 17, 2011, to 478 EP and 152 SSLEP parents. Problem scores for 3 FES dimensions were calculated: information/education, partnership with clinicians, and access/coordination of care. Adjusted associations between language proficiency (SSLEP vs EP) and dimension problem scores were examined by multivariate Poisson regression. Unadjusted Poisson regression analysis was used to examine the association between perceived interpretation accuracy and FES problem scores for SSLEP parents who received interpretation. SSLEP parents had a higher risk of reporting problems with access/coordination of care compared to EP parents (risk ...

Research paper thumbnail of Online commentary during the physical examination: a communication tool for avoiding inappropriate antibiotic prescribing?

Social Science & Medicine, 2003

A previously identified communication behavior, online commentary, is physician talk that describ... more A previously identified communication behavior, online commentary, is physician talk that describes what he/she is seeing, feeling, or hearing during the physical examination of the patient. The investigators who identified this communication behavior hypothesized that its use may be associated with successful physician resistance to perceived or actual patient expectations for inappropriate antibiotic medication. This paper examines the relationship between actual and perceived parental expectations for antibiotics and physician use of online commentary as well as the relationship between online commentary use and the physician's prescribing decision. We conducted a prospective observational study in two private pediatric practices. Study procedures included a pre-visit parent survey, audiotaping of study consultations, and post-visit surveys of the participating physicians. Ten pediatricians participated (participation rate=77%) and 306 eligible parents participated (participation rate=86%) who were attending sick visits for their children with upper respiratory tract infections between October 1996 and March 1997. The main outcomes measured were the proportion of consultations with online commentary and the proportion of consultations where antibiotics were prescribed. Two primary types of online commentaries were observed: (1) online commentary suggestive of a problematic finding on physical examination that might require antibiotic treatment ('problem' online commentary), e.g., ''That cough sounds very chesty''; and (2) online commentary that indicated the physical examination findings were not problematic and antibiotics were probably not necessary ('no problem' online commentary), e.g., ''Her throat is only slightly red''. For presumed viral cases where the physician thought the parent expected to receive antibiotics, if the physician used at least some 'problem' online commentary, he/she prescribed antibiotics in 91% (10/11) of cases. Conversely, when the physician exclusively employed 'no problem' online commentary, antibiotics were prescribed 27% (4/15) of the time (p ¼ 0:07). Use of 'no problem' online commentary did not add significantly to visit length. 'No problem' online commentary is a communication technique that may provide an effective and efficient method for resisting perceived expectations to prescribe antibiotics. r

Research paper thumbnail of The Relationship Between Perceived Parental Expectations and Pediatrician Antimicrobial Prescribing Behavior

PEDIATRICS, 1999

Despite growing concern over the escalating antimicrobial resistance problem, physicians continue... more Despite growing concern over the escalating antimicrobial resistance problem, physicians continue to inappropriately prescribe. It has been suggested that a major determinant of pediatrician antimicrobial prescribing behavior is the parental expectation that a prescription will be provided. To explore the extent to which parental previsit expectations and physician perceptions of those expectations are associated with inappropriate antimicrobial prescribing; and to explore the relationship between fulfillment of expectations and parental visit-specific satisfaction. Previsit and postvisit survey of parents and postvisit survey of physicians. Two private pediatric practices, one community based and one university based. Ten physicians (response rate = 77%), and a consecutive sample of 306 eligible parents (response rate = 86%) who were attending sick visits for their children between October 1996 and March 1997. Parents were screened for eligibility in the waiting rooms of the two practices and were invited to participate if they spoke and read English and their child was 2 to 10 years old, had a presenting complaint of ear pain, throat pain, cough, or congestion, was off antimicrobial therapy for the past 2 weeks, and was seeing one of the participating physicians. Antimicrobial prescribing decision, probability of assigning a bacterial diagnosis, and parental visit-specific satisfaction. Based on multivariate analysis, physicians&#39; perceptions of parental expectations for antimicrobials was the only significant predictor of prescribing antimicrobials for conditions of presumed viral etiology; when physicians thought a parent wanted an antimicrobial, they prescribed them 62% of the time versus 7% of the time when they did not think the parent wanted antimicrobials. However, physician antimicrobial prescribing behavior was not associated with actual parental expectations for receiving antimicrobials. In addition, when physicians thought the parent wanted an antimicrobial, they were also significantly more likely to give a bacterial diagnosis (70% of the time versus 31% of the time). Failure to meet parental expectations regarding communication events during the visit was the only significant predictor of parental satisfaction. Failure to provide expected antimicrobials did not affect satisfaction. The antibiotic resistance epidemic should lead to immediate replication of this study in a larger more generalizable population. If inaccurate physician perceptions of parent desires for antimicrobials for viral infections are confirmed, then an intervention to change the way physicians acquire this set of perceptions should be undertaken.

Research paper thumbnail of Evidence Assessment of the Accuracy of Methods of Diagnosing Middle Ear Effusion in Children With Otitis Media With Effusion

PEDIATRICS, 2003

We report the findings of an evidence assessment on the accuracy of methods of diagnosing middle ... more We report the findings of an evidence assessment on the accuracy of methods of diagnosing middle ear effusion in children with otitis media with effusion (OME). We searched Medline (1966-January 2000), the Cochrane Library (through January 2000), and Embase (1980-January 2000) and identified additional articles from reference lists in proceedings, published articles, reports, and guidelines. Excluded were nonhuman studies; case reports; editorials; letters; reviews; practice guidelines; non-English-language publications; and studies on patients with immunodeficiencies, craniofacial anomalies (including cleft palate), primary mucosal disorders, or genetic conditions. From each eligible study, we calculated the sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and prevalence of OME in the cohort. We determined the number of studies for each comparison of a diagnostic method and a reference standard listed within the scope of our assessment. For comparisons with 3 or more studies, we derived random effects estimates of sensitivity, specificity, and prevalence rate. Using the pooled estimates, we plotted the performance of each diagnostic test in terms of sensitivity and (1 - specificity) and identified the best performer among the tests included in the comparison. Among 8 diagnostic methods, pneumatic otoscopy had the best apparent performance with a sensitivity of 94% (95% confidence interval: 92%-96%) and a specificity of 80% (95% confidence interval: 75%-86%). However, examiner qualifications were reported inconsistently, and training was not specified. The finding that pneumatic otoscopy can do as well as or better than tympanometry and acoustic reflectometry has significant practical implications. For the typical clinician, pneumatic otoscopy should be easier to use than other diagnostic methods. The important question may be what degree of training will be needed for the clinician to be as effective with pneumatic otoscopy as were the examiners in the studies reviewed in this report.

Research paper thumbnail of Pediatric Medical Complexity Algorithm: A New Method to Stratify Children by Medical Complexity

Research paper thumbnail of Influence of race and socioeconomic status on engagement in pediatric primary care

Patient Education and Counseling, 2012

Objective-To understand the association of race/ethnicity with engagement in pediatric primary ca... more Objective-To understand the association of race/ethnicity with engagement in pediatric primary care and examine how any racial/ethnic disparities are influenced by socioeconomic status.

Research paper thumbnail of Reducing inappropriate antibiotics prescribing: The role of online commentary on physical examination findings

Patient Education and Counseling, 2010

Objective: This study investigates the relationship of 'online commentary' (contemporaneous physi... more Objective: This study investigates the relationship of 'online commentary' (contemporaneous physician comments about physical examination [PE] findings) with (i) parent questioning of the treatment recommendation and (ii) inappropriate antibiotic prescribing. Methods: A nested cross-sectional study of 522 encounters motivated by upper respiratory symptoms in 27 California pediatric practices (38 pediatricians). Physicians completed a post-visit survey regarding physical examination findings, diagnosis, treatment, and whether they perceived the parent as expecting an antibiotic. Taped encounters were coded for 'problem' online commentary (PE findings discussed as significant or clearly abnormal) and 'no problem' online commentary (PE findings discussed reassuringly as normal or insignificant). Results: Online commentary during the PE occurred in 73% of visits with viral diagnoses (n = 261). Compared to similar cases with 'no problem' online commentary, 'problem' comments were associated with a 13% greater probability of parents questioning a non-antibiotic treatment plan (95% CI 0-26%, p = .05,) and a 27% (95% CI: 2-52%, p < .05) greater probability of an inappropriate antibiotic prescription. Conclusion: With viral illnesses, problematic online comments are associated with more pediatricianparent conflict over non-antibiotic treatment recommendations. This may increase inappropriate antibiotic prescribing. Practice implications: In viral cases, physicians should consider avoiding the use of problematic online commentary.

Research paper thumbnail of Ruling Out the Need for Antibiotics

Archives of Pediatrics & Adolescent Medicine, 2006

Objectives: To examine the relationships among physician-parent communication practices, physicia... more Objectives: To examine the relationships among physician-parent communication practices, physicians' perceptions of parental expectations for antibiotic treatment, and inappropriate antibiotic prescribing for viral upper respiratory tract infections.

Research paper thumbnail of The Price of Pruritus

Archives of Pediatrics & Adolescent Medicine, 2005

Background: Atopic dermatitis is a common skin disorder that most often begins in infancy. Sleep ... more Background: Atopic dermatitis is a common skin disorder that most often begins in infancy. Sleep disturbances in children with atopic dermatitis are likely due to itching and scratching and not only impact the afflicted child but may also affect the entire family. Sleep characteristics in young children with atopic dermatitis and their families have not been thoroughly investigated.

Research paper thumbnail of Identifying Children’s Health Care Quality Measures for Medicaid and CHIP: An Evidence-Informed, Publicly Transparent Expert Process

Academic Pediatrics, 2011

OBJECTIVE: To describe the process used to identify the recommended core set of quality measures ... more OBJECTIVE: To describe the process used to identify the recommended core set of quality measures as mandated by the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) and provide an overview of the measures selected.

Research paper thumbnail of Parent Expectations for Antibiotics, Physician-Parent Communication, and Satisfaction

To explore how parents communicate their preferences for antibiotics to their child&#39;s phy... more To explore how parents communicate their preferences for antibiotics to their child&#39;s physician and to examine whether physicians can communicate why antibiotics are not being prescribed in a way that maintains satisfaction with the visit. Previsit survey of parents, audiotaping of the study encounters, and a postvisit survey of parents and physicians. Two private pediatric practices. Ten physicians (response rate = 77%) and a consecutive sample of 295 eligible parents (response rate = 86%) who attended acute care visits for their children between October 1996 and March 1997. Physician-perceived pressure to prescribe antibiotics and parental visit-specific satisfaction. Fifty percent of parents expressed a previsit expectation for antibiotics. Among these parents, only 1% made a direct verbal request for them. Even when no direct requests for antibiotics were made, physicians still perceived an expectation for antibiotics 34% of the time. Among parents who did not receive expected antibiotics, those offered a contingency plan from the physician (i.e., the possibility of receiving antibiotics in the future if their child did not get better) had a higher mean satisfaction score than parents not receiving a contingency plan (76 vs. 58.9; P&lt;.05). Physicians should consider providing a contingency plan to parents who expect antibiotics for their children when there is no clinical indication. Further study is needed to determine how parents indirectly communicate their desire for antibiotics and what additional communication techniques physicians can use to resist the overprescribing of antibiotics.

Research paper thumbnail of Parent expectations for antibiotics: Who are the public health campaigns failing to reach?

Objective: This study investigates the relationship of 'online commentary' (contemporaneous physi... more Objective: This study investigates the relationship of 'online commentary' (contemporaneous physician comments about physical examination [PE] findings) with (i) parent questioning of the treatment recommendation and (ii) inappropriate antibiotic prescribing. Methods: A nested cross-sectional study of 522 encounters motivated by upper respiratory symptoms in 27 California pediatric practices (38 pediatricians). Physicians completed a post-visit survey regarding physical examination findings, diagnosis, treatment, and whether they perceived the parent as expecting an antibiotic. Taped encounters were coded for 'problem' online commentary (PE findings discussed as significant or clearly abnormal) and 'no problem' online commentary (PE findings discussed reassuringly as normal or insignificant). Results: Online commentary during the PE occurred in 71% of visits with viral diagnoses (n = 261). Compared to similar cases with 'no problem' online commentary, 'problem' comments were associated with a 13% greater probability of parents questioning a non-antibiotic treatment plan (95% CI 0-26%, p = .05,) and a 27% (95% CI: 2-52%, p < .05) greater probability of an inappropriate antibiotic prescription. Conclusion: With viral illnesses, problematic online comments are associated with more pediatricianparent conflict over non-antibiotic treatment recommendations. This may increase inappropriate antibiotic prescribing. Practice implications: In viral cases, physicians should consider avoiding the use of problematic online commentary.

Research paper thumbnail of The Effectiveness of Family-Centered Transition Processes From Hospital Settings to Home: A Review of the Literature

Hospital pediatrics, 2015

The quality of care transitions is of growing concern because of a high incidence of postdischarg... more The quality of care transitions is of growing concern because of a high incidence of postdischarge adverse events, poor communication with patients, and inadequate information transfer between providers. The objective of this study was to conduct a targeted literature review of studies examining the effectiveness of family-centered transition processes from hospital- and emergency department (ED)-to-home for improving patient health outcomes and health care utilization. We conducted an electronic search (2001-2012) of PubMed, CINAHL, Cochrane, PsycInfo, Embase, and Web of Science databases. Included were experimental studies of hospital and ED-to-home transition interventions in pediatric and adult populations meeting the following inclusion criteria: studies evaluating hospital or ED-to-home transition interventions, study interventions involving patients/families, studies measuring outcomes ≤30 days after discharge, and US studies. Transition processes, principal outcome measures ...

Research paper thumbnail of An observational study of antibiotic prescribing behavior and the Hawthorne effect

Health services research, 2002

To assess whether prospective, observational study procedures, including questionnaires and audio... more To assess whether prospective, observational study procedures, including questionnaires and audio recording, are associated with different patterns of physician diagnostic decision making and antibiotic prescribing. (1) Survey data from a prospective observational study of treatment patterns for children with acute upper respiratory illnesses (10/96-3/97) and (2) retrospective medical record abstraction data of nonobserved encounters for the same problems occurring during (10/96-3/97) and one year after (10/97-3/98) the observational study period. Ten pediatricians in two community practices were studied. Patterns of diagnoses recorded in the medical record and antibiotics ordered for visits occurring outside of the observational study (same time period and one year later) were compared with the pattern of diagnoses and antibiotics ordered during the observational study. For the observational study (10/96-2/97), diagnosis and treatment choices were obtained from questionnaires compl...

Research paper thumbnail of Developing Measures for Pediatric Quality: Methods and Experiences of the CHIPRA Pediatric Quality Measures Program Grantees

Academic Pediatrics, 2014

Monitoring quality is an important way of understanding how the health care system is serving chi... more Monitoring quality is an important way of understanding how the health care system is serving children and families. The Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Pediatric Quality Measures Program (PQMP) funded efforts to develop and enhance measures to assess care for children and adolescents. We describe the processes used by the PQMP grantees to develop measures to assess the health care of children and adolescents in Medicaid and the Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Health Insurance Program. Key steps in the measures development process include identifying concepts, reviewing and synthesizing evidence, prioritizing concepts, defining how measures should be calculated, and measure testing. Stakeholder engagement throughout the process is critical. Case studies illustrate how PQMP grantees adapted the process to respond to the nature of measures they were charged to develop and overcome challenges encountered. PQMP grantees used varied approaches to measures development but faced common challenges, some specific to the field of pediatrics and some general to all quality measures. Major challenges included the limited evidence base, data systems difficult or unsuited for measures reporting, and conflicting stakeholder priorities. As part of the PQMP, grantees were able to explore innovative methods to overcome measurement challenges, including new approaches to building the evidence base and stakeholder consensus, integration of alternative data sources, and implementation of new testing methods. As a result, the PQMP has developed new quality measures for pediatric care while also building an infrastructure, expertise, and enhanced methods for measures development that promise to provide more relevant and meaningful tools for improving the quality of children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s health care.

Research paper thumbnail of Validity and responsiveness of the pediatric quality of life inventory (PedsQL) 4.0 generic core scales in the pediatric inpatient setting

JAMA pediatrics, 2014

Validated patient-reported outcomes responsive to clinical change are needed to evaluate the effe... more Validated patient-reported outcomes responsive to clinical change are needed to evaluate the effectiveness of quality improvement interventions. To evaluate responsiveness, construct validity, and predictive validity of the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales in the pediatric inpatient setting. Prospective, cohort study of parents and caregivers of patients 1 month to 18 years old (n = 4637) and patients 13 to 18 years old (n = 359) admitted to Seattle Children's Hospital between October 1, 2011, and December 31, 2013. Of 7184 eligible participants invited to complete the survey, 4637 (64.5%) completed the PedsQL on admission, and of these 2694 (58.1%) completed the follow-up survey 2 to 8 weeks after discharge. Responsiveness was assessed by calculating improvement scores (difference between follow-up and admission scores). Construct validity was examined by comparing the mean improvement scores for known groups differing by medical complexity. ...

Research paper thumbnail of Using Medicaid and CHIP claims data to support pediatric quality measurement: lessons from 3 centers of excellence in measure development

Academic pediatrics

We sought to explore the claims data-related issues relevant to quality measure development for M... more We sought to explore the claims data-related issues relevant to quality measure development for Medicaid and the Children's Health Insurance Program (CHIP), illustrating the challenges encountered and solutions developed around 3 distinct performance measure topics: care coordination for children with complex needs, quality of care for high-prevalence conditions, and hospital readmissions. Each of 3 centers of excellence presents an example that illustrates the challenges of using claims data for quality measurement. Our Centers of Excellence in pediatric quality measurement used innovative methods to develop algorithms that use Medicaid claims data to identify children with complex needs; overcome some shortcomings of existing data for measuring quality of care for common conditions such as otitis media; and identify readmissions after hospitalizations for lower respiratory infections. Our experience constructing quality measure specifications using claims data suggests that it...

Research paper thumbnail of The Quality of Ambulatory Care Delivered to Children in the United States

New England Journal of Medicine, 2007

Methods We assessed the extent to which care processes recommended for pediatric out- patients ar... more Methods We assessed the extent to which care processes recommended for pediatric out- patients are delivered. Quality indicators were developed with the use of the RAND- UCLA modified Delphi method. Parents of 1536 children who were randomly se- lected from 12 metropolitan areas provided written informed consent to obtain medical records from all providers who had seen the children during

Research paper thumbnail of Impact of English Proficiency on Care Experiences in a Pediatric Emergency Department

Academic pediatrics, Jan 4, 2014

To compare emergency department care experiences of Spanish-speaking, limited-English-proficient ... more To compare emergency department care experiences of Spanish-speaking, limited-English-proficient (SSLEP) and English-proficient (EP) parents and to assess how SSLEP care experiences vary by parent-perceived interpretation accuracy. The National Research Corporation Picker Institute's Family Experience Survey (FES) was administered from November 26, 2010, to July 17, 2011, to 478 EP and 152 SSLEP parents. Problem scores for 3 FES dimensions were calculated: information/education, partnership with clinicians, and access/coordination of care. Adjusted associations between language proficiency (SSLEP vs EP) and dimension problem scores were examined by multivariate Poisson regression. Unadjusted Poisson regression analysis was used to examine the association between perceived interpretation accuracy and FES problem scores for SSLEP parents who received interpretation. SSLEP parents had a higher risk of reporting problems with access/coordination of care compared to EP parents (risk ...

Research paper thumbnail of Online commentary during the physical examination: a communication tool for avoiding inappropriate antibiotic prescribing?

Social Science & Medicine, 2003

A previously identified communication behavior, online commentary, is physician talk that describ... more A previously identified communication behavior, online commentary, is physician talk that describes what he/she is seeing, feeling, or hearing during the physical examination of the patient. The investigators who identified this communication behavior hypothesized that its use may be associated with successful physician resistance to perceived or actual patient expectations for inappropriate antibiotic medication. This paper examines the relationship between actual and perceived parental expectations for antibiotics and physician use of online commentary as well as the relationship between online commentary use and the physician's prescribing decision. We conducted a prospective observational study in two private pediatric practices. Study procedures included a pre-visit parent survey, audiotaping of study consultations, and post-visit surveys of the participating physicians. Ten pediatricians participated (participation rate=77%) and 306 eligible parents participated (participation rate=86%) who were attending sick visits for their children with upper respiratory tract infections between October 1996 and March 1997. The main outcomes measured were the proportion of consultations with online commentary and the proportion of consultations where antibiotics were prescribed. Two primary types of online commentaries were observed: (1) online commentary suggestive of a problematic finding on physical examination that might require antibiotic treatment ('problem' online commentary), e.g., ''That cough sounds very chesty''; and (2) online commentary that indicated the physical examination findings were not problematic and antibiotics were probably not necessary ('no problem' online commentary), e.g., ''Her throat is only slightly red''. For presumed viral cases where the physician thought the parent expected to receive antibiotics, if the physician used at least some 'problem' online commentary, he/she prescribed antibiotics in 91% (10/11) of cases. Conversely, when the physician exclusively employed 'no problem' online commentary, antibiotics were prescribed 27% (4/15) of the time (p ¼ 0:07). Use of 'no problem' online commentary did not add significantly to visit length. 'No problem' online commentary is a communication technique that may provide an effective and efficient method for resisting perceived expectations to prescribe antibiotics. r

Research paper thumbnail of The Relationship Between Perceived Parental Expectations and Pediatrician Antimicrobial Prescribing Behavior

PEDIATRICS, 1999

Despite growing concern over the escalating antimicrobial resistance problem, physicians continue... more Despite growing concern over the escalating antimicrobial resistance problem, physicians continue to inappropriately prescribe. It has been suggested that a major determinant of pediatrician antimicrobial prescribing behavior is the parental expectation that a prescription will be provided. To explore the extent to which parental previsit expectations and physician perceptions of those expectations are associated with inappropriate antimicrobial prescribing; and to explore the relationship between fulfillment of expectations and parental visit-specific satisfaction. Previsit and postvisit survey of parents and postvisit survey of physicians. Two private pediatric practices, one community based and one university based. Ten physicians (response rate = 77%), and a consecutive sample of 306 eligible parents (response rate = 86%) who were attending sick visits for their children between October 1996 and March 1997. Parents were screened for eligibility in the waiting rooms of the two practices and were invited to participate if they spoke and read English and their child was 2 to 10 years old, had a presenting complaint of ear pain, throat pain, cough, or congestion, was off antimicrobial therapy for the past 2 weeks, and was seeing one of the participating physicians. Antimicrobial prescribing decision, probability of assigning a bacterial diagnosis, and parental visit-specific satisfaction. Based on multivariate analysis, physicians&#39; perceptions of parental expectations for antimicrobials was the only significant predictor of prescribing antimicrobials for conditions of presumed viral etiology; when physicians thought a parent wanted an antimicrobial, they prescribed them 62% of the time versus 7% of the time when they did not think the parent wanted antimicrobials. However, physician antimicrobial prescribing behavior was not associated with actual parental expectations for receiving antimicrobials. In addition, when physicians thought the parent wanted an antimicrobial, they were also significantly more likely to give a bacterial diagnosis (70% of the time versus 31% of the time). Failure to meet parental expectations regarding communication events during the visit was the only significant predictor of parental satisfaction. Failure to provide expected antimicrobials did not affect satisfaction. The antibiotic resistance epidemic should lead to immediate replication of this study in a larger more generalizable population. If inaccurate physician perceptions of parent desires for antimicrobials for viral infections are confirmed, then an intervention to change the way physicians acquire this set of perceptions should be undertaken.

Research paper thumbnail of Evidence Assessment of the Accuracy of Methods of Diagnosing Middle Ear Effusion in Children With Otitis Media With Effusion

PEDIATRICS, 2003

We report the findings of an evidence assessment on the accuracy of methods of diagnosing middle ... more We report the findings of an evidence assessment on the accuracy of methods of diagnosing middle ear effusion in children with otitis media with effusion (OME). We searched Medline (1966-January 2000), the Cochrane Library (through January 2000), and Embase (1980-January 2000) and identified additional articles from reference lists in proceedings, published articles, reports, and guidelines. Excluded were nonhuman studies; case reports; editorials; letters; reviews; practice guidelines; non-English-language publications; and studies on patients with immunodeficiencies, craniofacial anomalies (including cleft palate), primary mucosal disorders, or genetic conditions. From each eligible study, we calculated the sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and prevalence of OME in the cohort. We determined the number of studies for each comparison of a diagnostic method and a reference standard listed within the scope of our assessment. For comparisons with 3 or more studies, we derived random effects estimates of sensitivity, specificity, and prevalence rate. Using the pooled estimates, we plotted the performance of each diagnostic test in terms of sensitivity and (1 - specificity) and identified the best performer among the tests included in the comparison. Among 8 diagnostic methods, pneumatic otoscopy had the best apparent performance with a sensitivity of 94% (95% confidence interval: 92%-96%) and a specificity of 80% (95% confidence interval: 75%-86%). However, examiner qualifications were reported inconsistently, and training was not specified. The finding that pneumatic otoscopy can do as well as or better than tympanometry and acoustic reflectometry has significant practical implications. For the typical clinician, pneumatic otoscopy should be easier to use than other diagnostic methods. The important question may be what degree of training will be needed for the clinician to be as effective with pneumatic otoscopy as were the examiners in the studies reviewed in this report.

Research paper thumbnail of Pediatric Medical Complexity Algorithm: A New Method to Stratify Children by Medical Complexity

Research paper thumbnail of Influence of race and socioeconomic status on engagement in pediatric primary care

Patient Education and Counseling, 2012

Objective-To understand the association of race/ethnicity with engagement in pediatric primary ca... more Objective-To understand the association of race/ethnicity with engagement in pediatric primary care and examine how any racial/ethnic disparities are influenced by socioeconomic status.

Research paper thumbnail of Reducing inappropriate antibiotics prescribing: The role of online commentary on physical examination findings

Patient Education and Counseling, 2010

Objective: This study investigates the relationship of 'online commentary' (contemporaneous physi... more Objective: This study investigates the relationship of 'online commentary' (contemporaneous physician comments about physical examination [PE] findings) with (i) parent questioning of the treatment recommendation and (ii) inappropriate antibiotic prescribing. Methods: A nested cross-sectional study of 522 encounters motivated by upper respiratory symptoms in 27 California pediatric practices (38 pediatricians). Physicians completed a post-visit survey regarding physical examination findings, diagnosis, treatment, and whether they perceived the parent as expecting an antibiotic. Taped encounters were coded for 'problem' online commentary (PE findings discussed as significant or clearly abnormal) and 'no problem' online commentary (PE findings discussed reassuringly as normal or insignificant). Results: Online commentary during the PE occurred in 73% of visits with viral diagnoses (n = 261). Compared to similar cases with 'no problem' online commentary, 'problem' comments were associated with a 13% greater probability of parents questioning a non-antibiotic treatment plan (95% CI 0-26%, p = .05,) and a 27% (95% CI: 2-52%, p < .05) greater probability of an inappropriate antibiotic prescription. Conclusion: With viral illnesses, problematic online comments are associated with more pediatricianparent conflict over non-antibiotic treatment recommendations. This may increase inappropriate antibiotic prescribing. Practice implications: In viral cases, physicians should consider avoiding the use of problematic online commentary.

Research paper thumbnail of Ruling Out the Need for Antibiotics

Archives of Pediatrics & Adolescent Medicine, 2006

Objectives: To examine the relationships among physician-parent communication practices, physicia... more Objectives: To examine the relationships among physician-parent communication practices, physicians' perceptions of parental expectations for antibiotic treatment, and inappropriate antibiotic prescribing for viral upper respiratory tract infections.

Research paper thumbnail of The Price of Pruritus

Archives of Pediatrics & Adolescent Medicine, 2005

Background: Atopic dermatitis is a common skin disorder that most often begins in infancy. Sleep ... more Background: Atopic dermatitis is a common skin disorder that most often begins in infancy. Sleep disturbances in children with atopic dermatitis are likely due to itching and scratching and not only impact the afflicted child but may also affect the entire family. Sleep characteristics in young children with atopic dermatitis and their families have not been thoroughly investigated.

Research paper thumbnail of Identifying Children’s Health Care Quality Measures for Medicaid and CHIP: An Evidence-Informed, Publicly Transparent Expert Process

Academic Pediatrics, 2011

OBJECTIVE: To describe the process used to identify the recommended core set of quality measures ... more OBJECTIVE: To describe the process used to identify the recommended core set of quality measures as mandated by the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) and provide an overview of the measures selected.

Research paper thumbnail of Parent Expectations for Antibiotics, Physician-Parent Communication, and Satisfaction

To explore how parents communicate their preferences for antibiotics to their child&#39;s phy... more To explore how parents communicate their preferences for antibiotics to their child&#39;s physician and to examine whether physicians can communicate why antibiotics are not being prescribed in a way that maintains satisfaction with the visit. Previsit survey of parents, audiotaping of the study encounters, and a postvisit survey of parents and physicians. Two private pediatric practices. Ten physicians (response rate = 77%) and a consecutive sample of 295 eligible parents (response rate = 86%) who attended acute care visits for their children between October 1996 and March 1997. Physician-perceived pressure to prescribe antibiotics and parental visit-specific satisfaction. Fifty percent of parents expressed a previsit expectation for antibiotics. Among these parents, only 1% made a direct verbal request for them. Even when no direct requests for antibiotics were made, physicians still perceived an expectation for antibiotics 34% of the time. Among parents who did not receive expected antibiotics, those offered a contingency plan from the physician (i.e., the possibility of receiving antibiotics in the future if their child did not get better) had a higher mean satisfaction score than parents not receiving a contingency plan (76 vs. 58.9; P&lt;.05). Physicians should consider providing a contingency plan to parents who expect antibiotics for their children when there is no clinical indication. Further study is needed to determine how parents indirectly communicate their desire for antibiotics and what additional communication techniques physicians can use to resist the overprescribing of antibiotics.