Publications by authors named "Andrew D Racine"

49 Publications

Children's Hospitals: We Get What We Pay For.

Authors:
Andrew D Racine

Pediatrics 2021 Mar;147(3)

Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York; and

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http://dx.doi.org/10.1542/peds.2020-043521DOI Listing
March 2021

Association of Race and Ethnicity With Comorbidities and Survival Among Patients With COVID-19 at an Urban Medical Center in New York.

JAMA Netw Open 2020 09 1;3(9):e2019795. Epub 2020 Sep 1.

Department of Pediatrics, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.

Importance: As of May 11, 2020, there have been more than 290 000 deaths worldwide from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19). Risk-adjusted differences in outcomes among patients of differing ethnicity and race categories are not well characterized.

Objectives: To investigate whether presenting comorbidities in patients with COVID-19 in New York City differed by race/ethnicity and whether case fatality rates varied among different ethnic and racial groups, controlling for presenting comorbidities and other risk factors.

Design, Setting, And Participants: This cohort study included 5902 patients who presented for care to the Montefiore Medical Center, a large urban academic medical center in the Bronx, New York, between March 14 and April 15, 2020, and tested positive for SARS-CoV-2 on reverse transcription quantitative polymerase chain reaction assay. Final data collection was April 27, 2020.

Exposures: Patient characteristics, including self-identified ethnicity/race, age, sex, socioeconomic status, and medical comorbidities, were tabulated.

Main Outcomes And Measures: Overall survival. Associations between patient demographic characteristics, comorbidities, and race/ethnicity were examined using χ2 tests, and the association with survival was assessed using univariable and multivariable Cox proportional hazards regression, based on time from positive COVID-19 test.

Results: Of 9268 patients who were tested, 5902 ethnically diverse patients (63.7%) had SARS-CoV-2. Of these, 3129 patients (53.0%) were women, and the median (interquartile range) age was 58 (44-71) years. A total of 918 patients (15.5%) died within the study time frame. Overall, 1905 patients (32.3%) identified as Hispanic; 1935 (32.8%), non-Hispanic Black; 509 (8.6%), non-Hispanic White; and 171 (2.9%), Asian; the death rates were 16.2% (309), 17.2% (333), 20.0% (102), and 17.0% (29), respectively (P = .25). Hispanic and non-Hispanic Black patients had a higher proportion of more than 2 medical comorbidities with 654 (34.3%) and 764 (39.5%), respectively, compared with 147 (28.9%) among non-Hispanic White patients (P < .001). Hispanic and non-Hispanic Black patients were also more likely to test positive for COVID-19 than White patients, with 1905 of 2919 Hispanic patients (65.3%), 1935 of 2823 non-Hispanic Black patients (68.5%), and 509 of 960 non-Hispanic White patients (53.0%) having positive test results for SARS-CoV-2 (P < .001). While controlling for age, sex, socioeconomic status and comorbidities, patients identifying as Hispanic (hazard ratio, 0.77; 95% CI, 0.61-0.98; P = .03) or non-Hispanic Black (hazard ratio, 0.69; 95% CI, 0.55-0.87; P = .002) had slightly improved survival compared with non-Hispanic White patients.

Conclusions And Relevance: In this cohort study of patients with COVID-19 who presented for care at the same urban medical center, non-Hispanic Black and Hispanic patients did not experience worse risk-adjusted outcomes compared with their White counterparts. This finding is important for understanding the observed population differences in mortality by race/ethnicity reported elsewhere.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.19795DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7519416PMC
September 2020

Commercial insurance delays direct-acting antiviral treatment for hepatitis C kidney transplantation into uninfected recipients.

Transpl Infect Dis 2021 Feb 3;23(1):e13449. Epub 2020 Sep 3.

Albert Einstein College of Medicine, Bronx, NY, USA.

Introduction: The advent of direct-acting antivirals (DAAs) has created an avenue for transplantation of hepatitis C virus (HCV)-infected donors into uninfected recipients (D+/R-). The donor transmission of HCV is then countered by DAA administration during the post-operative period. However, initiation of DAA treatment is ultimately dictated by insurance companies.

Methods: A retrospective chart review of 52 D+/R- kidney recipients who underwent DAA treatment post-transplant was performed. Patients were grouped according to their prescription coverage plans, managed by either commercial or government pharmacy benefit managers (PBMs).

Results: Thirty-nine patients had government PBMs and 13 had commercial PBMs. Demographics were similar between the two groups. All patients developed HCV viremia, but cleared the virus after treatment with DAA. Patients with government PBMs were treated earlier compared to those with commercial PBMs (11 days vs 26 days, P = .01). Longer time to DAA initiation resulted in higher peak viral loads (β = 0.39, R  = .15, P = .01) and longer time to HCV viral load clearance (β = 0.41, R  = .17, P = .01).

Conclusions: D+/R- transplantation offers patients an alternative strategy to increase access. However, treatment can be profoundly delayed by a third-party payer authorization process that may be subjecting patients to unnecessary risks and worsened outcomes.
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http://dx.doi.org/10.1111/tid.13449DOI Listing
February 2021

Case Fatality Rate of Cancer Patients with COVID-19 in a New York Hospital System.

Cancer Discov 2020 07 1;10(7):935-941. Epub 2020 May 1.

Department of Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.

Patients with cancer are presumed to be at increased risk from COVID-19 infection-related fatality due to underlying malignancy, treatment-related immunosuppression, or increased comorbidities. A total of 218 COVID-19-positive patients from March 18, 2020, to April 8, 2020, with a malignant diagnosis were identified. A total of 61 (28%) patients with cancer died from COVID-19 with a case fatality rate (CFR) of 37% (20/54) for hematologic malignancies and 25% (41/164) for solid malignancies. Six of 11 (55%) patients with lung cancer died from COVID-19 disease. Increased mortality was significantly associated with older age, multiple comorbidities, need for ICU support, and elevated levels of D-dimer, lactate dehydrogenase, and lactate in multivariate analysis. Age-adjusted CFRs in patients with cancer compared with noncancer patients at our institution and New York City reported a significant increase in case fatality for patients with cancer. These data suggest the need for proactive strategies to reduce likelihood of infection and improve early identification in this vulnerable patient population. SIGNIFICANCE: COVID-19 in patients with cancer is associated with a significantly increased risk of case fatality, suggesting the need for proactive strategies to reduce likelihood of infection and improve early identification in this vulnerable patient population..
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http://dx.doi.org/10.1158/2159-8290.CD-20-0516DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7334098PMC
July 2020

Risk of Wrong-Patient Orders Among Multiple vs Singleton Births in the Neonatal Intensive Care Units of 2 Integrated Health Care Systems.

JAMA Pediatr 2019 Aug 26. Epub 2019 Aug 26.

Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Importance: Multiple-birth infants in neonatal intensive care units (NICUs) have nearly identical patient identifiers and may be at greater risk of wrong-patient order errors compared with singleton-birth infants.

Objectives: To assess the risk of wrong-patient orders among multiple-birth infants and singletons receiving care in the NICU and to examine the proportion of wrong-patient orders between multiple-birth infants and siblings (intrafamilial errors) and between multiple-birth infants and nonsiblings (extrafamilial errors).

Design, Setting, And Participants: A retrospective cohort study was conducted in 6 NICUs of 2 large, integrated health care systems in New York City that used distinct temporary names for newborns per the requirements of The Joint Commission. Data were collected from 4 NICUs at New York-Presbyterian Hospital from January 1, 2012, to December 31, 2015, and 2 NICUs at Montefiore Health System from July 1, 2013, to June 30, 2015. Data were analyzed from May 1, 2017, to December 31, 2017. All infants in the 6 NICUs for whom electronic orders were placed during the study periods were included.

Main Outcomes And Measures: Wrong-patient electronic orders were identified using the Wrong-Patient Retract-and-Reorder (RAR) Measure. This measure was used to detect RAR events, which are defined as 1 or more orders placed for a patient that are retracted (ie, canceled) by the same clinician within 10 minutes, then reordered by the same clinician for a different patient within the next 10 minutes.

Results: A total of 10 819 infants were included: 85.5% were singleton-birth infants and 14.5% were multiple-birth infants (male, 55.8%; female, 44.2%). The overall wrong-patient order rate was significantly higher among multiple-birth infants than among singleton-birth infants (66.0 vs 41.7 RAR events per 100 000 orders, respectively; adjusted odds ratio, 1.75; 95% CI, 1.39-2.20; P < .001). The rate of extrafamilial RAR events among multiple-birth infants (36.1 per 100 000 orders) was similar to that of singleton-birth infants (41.7 per 100 000 orders). The excess risk among multiple-birth infants (29.9 per 100 000 orders) appears to be owing to intrafamilial RAR events. The risk increased as the number of siblings receiving care in the NICU increased; a wrong-patient order error occurred in 1 in 7 sets of twin births and in 1 in 3 sets of higher-order multiple births.

Conclusions And Relevance: This study suggests that multiple-birth status in the NICU is associated with significantly increased risk of wrong-patient orders compared with singleton-birth status. This excess risk appears to be owing to misidentification between siblings. These results suggest that a distinct naming convention as required by The Joint Commission may provide insufficient protection against identification errors among multiple-birth infants. Strategies to reduce this risk include using given names at birth, changing from temporary to given names when available, and encouraging parents to select names for multiple births before they are born when acceptable to families.
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http://dx.doi.org/10.1001/jamapediatrics.2019.2733DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6714004PMC
August 2019

Parental Tobacco Counseling in the Well-Child Visit-A Method With Enhanced Effectiveness but Nowhere to Go.

JAMA Pediatr 2019 Aug 12. Epub 2019 Aug 12.

Pediatrics, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York.

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http://dx.doi.org/10.1001/jamapediatrics.2019.2659DOI Listing
August 2019

Screening and Referral for Low-Income Families' Social Determinants of Health by US Pediatricians.

Acad Pediatr 2019 Nov - Dec;19(8):875-883. Epub 2019 May 23.

Montefiore Health System and Albert Einstein College of Medicine, Pediatrics, Bronx, NY (AD Racine).

Objective: To measure the frequency US pediatricians report screening and referring for social needs and identify pediatrician and practice-level predictors for screening and referral.

Methods: Data were from the American Academy of Pediatrics Periodic Survey for October 2014 to March 2015 with a response rate of 46.6% (732/1570). Respondents reported on: 1) routine screening of low-income families for social needs, 2) attitudes toward screening, and 3) referral of low-income families for community resources. Results were analyzed by pediatrician and practice characteristics.

Results: Although most pediatricians (61.6%) thought that screening is important, fewer (39.9%) reported that screening is feasible or felt prepared addressing families' social needs (20.2%). The topics that pediatricians reported routinely asking low-income families about at visits (defined as ≥50% visits) were need for childcare (41.5%) and transportation barriers (28.4%). Pediatricians were less likely to report asking about housing (18.7%), food (18.6%), and utilities/heating (14.0%) insecurity. In multivariable analyses, pediatricians were more likely to report both that they screen and refer when they reported having more patients in financial hardship and having someone in the practice with the responsibility to connect low-income families to community services. Pediatricians who endorsed the importance of screening and who reported being prepared were also more likely to screen/refer.

Conclusions: A minority of pediatricians report routinely screening for social needs. Pediatricians were more likely to report that they screen and refer if they had positive attitudes toward the importance of screening, felt prepared, and had support staff to assist families in need.
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http://dx.doi.org/10.1016/j.acap.2019.05.125DOI Listing
August 2020

Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order Errors: A Randomized Clinical Trial.

JAMA 2019 05;321(18):1780-1787

Division of Hospital Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, Bronx, New York.

Importance: Recommendations in the United States suggest limiting the number of patient records displayed in an electronic health record (EHR) to 1 at a time, although little evidence supports this recommendation.

Objective: To assess the risk of wrong-patient orders in an EHR configuration limiting clinicians to 1 record vs allowing up to 4 records opened concurrently.

Design, Setting, And Participants: This randomized clinical trial included 3356 clinicians at a large health system in New York and was conducted from October 2015 to April 2017 in emergency department, inpatient, and outpatient settings.

Interventions: Clinicians were randomly assigned in a 1:1 ratio to an EHR configuration limiting to 1 patient record open at a time (restricted; n = 1669) or allowing up to 4 records open concurrently (unrestricted; n = 1687).

Main Outcomes And Measures: The unit of analysis was the order session, a series of orders placed by a clinician for a single patient. The primary outcome was order sessions that included 1 or more wrong-patient orders identified by the Wrong-Patient Retract-and-Reorder measure (an electronic query that identifies orders placed for a patient, retracted, and then reordered shortly thereafter by the same clinician for a different patient).

Results: Among the 3356 clinicians who were randomized (mean [SD] age, 43.1 [12.5] years; mean [SD] experience at study site, 6.5 [6.0] years; 1894 females [56.4%]), all provided order data and were included in the analysis. The study included 12 140 298 orders, in 4 486 631 order sessions, placed for 543 490 patients. There was no significant difference in wrong-patient order sessions per 100 000 in the restricted vs unrestricted group, respectively, overall (90.7 vs 88.0; odds ratio [OR], 1.03 [95% CI, 0.90-1.20]; P = .60) or in any setting (ED: 157.8 vs 161.3, OR, 1.00 [95% CI, 0.83-1.20], P = .96; inpatient: 185.6 vs 185.1, OR, 0.99 [95% CI, 0.89-1.11]; P = .86; or outpatient: 7.9 vs 8.2, OR, 0.94 [95% CI, 0.70-1.28], P = .71). The effect did not differ among settings (P for interaction = .99). In the unrestricted group overall, 66.2% of the order sessions were completed with 1 record open, including 34.5% of ED, 53.7% of inpatient, and 83.4% of outpatient order sessions.

Conclusions And Relevance: A strategy that limited clinicians to 1 EHR patient record open compared with a strategy that allowed up to 4 records open concurrently did not reduce the proportion of wrong-patient order errors. However, clinicians in the unrestricted group placed most orders with a single record open, limiting the power of the study to determine whether reducing the number of records open when placing orders reduces the risk of wrong-patient order errors.

Trial Registration: clinicaltrials.gov Identifier: NCT02876588.
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http://dx.doi.org/10.1001/jama.2019.3698DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6518341PMC
May 2019

Contextual Factors Associated With Quality Improvement Success in a Multisite Ambulatory Setting.

J Healthc Qual 2019 Sep/Oct;41(5):317-328

The Model for Understanding Success in Quality (MUSIQ) is a framework of contextual factors for quality improvement (QI) projects. We sought to determine which MUSIQ contextual factors were associated with successful QI initiatives. In a cross-sectional survey study, at a 21-site, ambulatory, urban primary care network, a modified MUSIQ survey tool questionnaire was administered to QI team members. The primary analysis associated objective measures of QI success with MUSIQ contextual factors. Objective QI success was defined as reaching goal percentages of adult patients with diabetes achieving glycated hemoglobin less than 8% and/or pediatric patients who had received combination toddler vaccines. Objective outcomes were compared with a subjective, self-reported outcome measure of QI success because previous literature found subjective outcomes were associated with specific MUSIQ factors. In the 143 survey responses collected, across 21 sites, no contextual factors from the MUSIQ survey were associated with either the adult or pediatric objective measure of QI project success. In a post hoc analysis, objective and subjective measures of success were often not associated and/or negatively correlated. In conclusion, contextual factors were not associated with objective measures of QI outcomes, in contrast to previous studies finding associations with subjective QI outcome measures.
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http://dx.doi.org/10.1097/JHQ.0000000000000186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6679818PMC
July 2020

Effect of Mental Health Screening and Integrated Mental Health on Adolescent Depression-Coded Visits.

Clin Pediatr (Phila) 2019 04 9;58(4):437-445. Epub 2019 Jan 9.

1 The Children's Hospital at Montefiore, Bronx, NY, USA.

Adolescent depression causes morbidity and is underdiagnosed. It is unclear how mental health screening and integrated mental health practitioners change adolescent depression identification. We conducted a retrospective primary care network natural cohort study where 10 out of 19 practices implemented mental health screening, followed by the remaining 9 practices implementing mental health screening with less coaching and support. Afterward, a different subset of 8 practices implemented integrated mental health practitioners. Percentages of depression-coded adolescent visits were compared between practices (1) with and without mental health screening and (2) with and without integrated mental health practitioners, using difference-in-differences analyses. The incidence of depression-coded visits increased more in practices that performed mental health screening (ratio of odds ratios = 1.22; 95% confidence interval =1.00-1.49) and more in practices with integrated mental health practitioners (ratio of odds ratios = 1.58; 95% confidence interval = 1.30-1.93). Adolescent mental health screening and integrated mental health practitioners increase depression-coded visits in primary care.
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http://dx.doi.org/10.1177/0009922818821889DOI Listing
April 2019

Confronting the Nonmedical Costs of Childhood Hospitalizations.

Authors:
Andrew D Racine

Pediatrics 2018 09 13;142(3). Epub 2018 Aug 13.

Albert Einstein College of Medicine and Montefiore Health System, New York City, New York

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http://dx.doi.org/10.1542/peds.2018-1844DOI Listing
September 2018

United States Pediatricians' Attitudes Regarding Public Policies for Low-Income Children and Their Profession's Advocacy Priorities.

Acad Pediatr 2018 Sep - Oct;18(7):783-788. Epub 2018 Apr 11.

NYU School of Medicine, Pediatrics, New York, NY.

Objective: To examine pediatricians' attitudes toward public policies for low-income children and the advocacy efforts for the American Academy of Pediatrics (AAP).

Methods: Data from the AAP Periodic Survey in October 2014 to March 2015 were used. Respondents ranked 1) attitudes toward government programs, and 2) attitudes toward AAP policies on: income support, housing, education, job training, food, and health care. Results were analyzed according to age, gender, practice location, practice region, type of practice setting, and percent of patients with economic hardship.

Results: Response rate was 47% (n = 650). Most respondents reported that for children, the government should guarantee health insurance (88.9%), and food and shelter (90.0%). Most also reported that the government should guarantee health insurance (68.9%) and food and shelter (63.9%) for every citizen and to take care of people who cannot take care of themselves. There was variation among the level of support on the basis of practice setting. In multivariable analyses related to supporting the role of government for children and citizens, not being from the Northeast was associated with lower odds of support of children as well as citizens; primary care practices in rural areas were less supportive of government involvement related to all citizens but similar for children; and those younger than 40 and 50 to 59 years of age were more supportive of government guaranteeing enough to eat and a place to sleep for children. More than 55% supported the AAP advocating for income support, housing, education, and access to health care.

Conclusions: Pediatricians strongly support government policies that affect child poverty and the provision of basic needs to families. This support should be used to inform professional organizations, advocates, and policy-makers focused on children and families.
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http://dx.doi.org/10.1016/j.acap.2018.04.003DOI Listing
November 2019

Increased Medicaid Payment and Participation by Office-Based Primary Care Pediatricians.

Pediatrics 2018 01;141(1)

Department of Pediatrics, Albert Einstein College of Medicine, Montefiore Health System, Bronx, New York.

Background And Objectives: Whether the Medicaid primary care payment increase of 2013 to 2014 changed physician participation remains unanswered amid conflicting evidence. In this study, we assess national and state-level changes in Medicaid participation by office-based primary care pediatricians before and after the payment increase.

Methods: Using bivariate statistical analysis, we compared survey data collected from 2011 to 2012 and 2015 to 2016 by the American Academy of Pediatrics from state-stratified random samples of pediatrician members.

Results: By 4 of 5 indicators, Medicaid participation increased nationally from 2011 and 2012 to 2015 and 2016 ( = 10 395). Those accepting at least some new patients insured by Medicaid increased 3.0 percentage points (ppts) to 77.4%. Those accepting all new patients insured by Medicaid increased 5.9 ppts to 43.3%, and those accepting these patients at least as often as new privately insured patients increased 5.7 ppts to 55.6%. The average percent of patients insured by Medicaid per provider panel increased 6.0 ppts to 31.3%. Nonparticipants dropped 2.1 ppts to 14.6%. Of the 27 studied states, 16 gained in participation by 1 or more indicators, 11 gained by 2 or more, and 3 gained by all 5.

Conclusions: Office-based primary care pediatricians increased their Medicaid participation after the payment increase, in large part by expanding their Medicaid panel percentage. Continued monitoring of physician participation in Medicaid at the national and state levels is vital for guiding policy to optimize timely access to appropriate health care for >37 million children insured by Medicaid.
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http://dx.doi.org/10.1542/peds.2017-2570DOI Listing
January 2018

A Learning Collaborative Approach to Improve Primary Care STI Screening.

Clin Pediatr (Phila) 2018 07 13;57(8):895-903. Epub 2017 Oct 13.

1 Albert Einstein College of Medicine, Bronx, NY, USA.

The Bronx Ongoing Pediatric Screening (BOPS) project sought to improve screening for sexual activity and sexually transmitted infections (gonorrhea and chlamydia [GCC] and HIV) in a primary care network, employing a modified learning collaborative, real-time clinical data feedback to practices, improvement coaching, and a pay-for-quality monetary incentive. Outcomes are compared for 11 BOPS-participating sites and 10 non-participating sites. The quarterly median rate for documenting sexual activity status increased from 55% to 88% (BOPS sites) and from 13% to 74% (non-BOPS sites). GCC screening of sexually active youth increased at BOPS and non-BOPS sites. Screening at non-health care maintenance visits improved more at BOPS than non-BOPS sites. Data from nonparticipating sites suggests that introduction of an adolescent EMR template or other factors improved screening rates regardless of BOPS participation; BOPS activities appear to promote additional improvement of screening during non-health maintenance visits.
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http://dx.doi.org/10.1177/0009922817733702DOI Listing
July 2018

Providers and patients face-to-face: what is the time?

Authors:
Andrew D Racine

Isr J Health Policy Res 2017 10 10;6(1):54. Epub 2017 Oct 10.

Montefiore Health System, Bronx, New York, USA.

Background: The frequency of visiting primary care providers and the duration of those visits varies substantially by patient demographics and across different developed countries. The significance of a cumulative measure of this time spent with providers in face-to-face visits is not well understood.

Commentary: In a recent IJHPR issue Nathan and co-authors have suggested a new metric for capturing the cumulative time spent annually in face-to-face encounters between providers and patients. The annual accumulated duration of time (AADC) of visits was constructed using a 2% random sample of adult patients from the Clalit health plan in Israel for the year 2012. The authors calculated the mean AADC to be 65.7 min with average visit durations of 7.6 min. A presumption underlying this analysis is that the metric captures the magnitude of activity devoted to eliciting relevant clinical information, synthesizing the significance of those data, and communicating the importance of that thinking to patients so that they might make informed decisions regarding their health care. But measuring the time spent with a provider is but a surrogate marker of these activities and the lack of correlation between time spent with providers and health outcomes suggests that as a surrogate it may not be that robust a measure. It is possible that what is being captured through this metric is the influence of economic incentives faced by individual practitioners and the structure of health care financing in different societies rather than a portrait either of clinical complexity or quality of care.

Conclusions: The advent of this new measure of cumulative provider time with patients signals the importance of accurate measurement as a vital first step in understanding the meaning of data but reminds us of an obligation to inquire beyond the measurements themselves to arrive at appropriate policy-relevant conclusions.
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http://dx.doi.org/10.1186/s13584-017-0180-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5634890PMC
October 2017

Risk Adjustments Based on Socioeconomic Status in Pediatrics: Adjusting Our Expectations.

Pediatrics 2017 11 3;140(5). Epub 2017 Oct 3.

Department of Economics and Finance, Baruch College, City University of New York, New York, New York; and.

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http://dx.doi.org/10.1542/peds.2017-2608DOI Listing
November 2017

Comparing Two Models of Integrated Behavioral Health Programs in Pediatric Primary Care.

Child Adolesc Psychiatr Clin N Am 2017 10;26(4):815-828

Pediatric Behavioral Health Services, Montefiore Medical Group, 200 Corporate Boulevard South, Suite 175, Yonkers, NY 10701, USA.

This study examined how to design, staff, and evaluate the feasibility of 2 different models of integrated behavioral health programs in pediatric primary care across primary care sites in the Bronx, NY. Results suggest that the Behavioral Health Integration Program model of pediatric integrated care is feasible and that hiring behavioral health staff with specific training in pediatric, evidence-informed behavioral health treatments may be a critical variable in increasing outcomes such as referral rates, self-reported competency, and satisfaction.
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http://dx.doi.org/10.1016/j.chc.2017.06.009DOI Listing
October 2017

Extending the Social Justice Call to Treatment Outcomes-Reply.

Authors:
Andrew D Racine

JAMA Pediatr 2017 09;171(9):913-914

Montefiore Health System, Bronx, New York.

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http://dx.doi.org/10.1001/jamapediatrics.2017.1912DOI Listing
September 2017

Evaluating Serial Strategies for Preventing Wrong-Patient Orders in the NICU.

Pediatrics 2017 May;139(5)

Division of Hospital Medicine.

Background: NICU patients have characteristics believed to increase their risk for wrong-patient errors; however, little is known about the frequency of wrong-patient errors in the NICU or about effective interventions for preventing these errors. We conducted a quality improvement study to evaluate the frequency of wrong-patient orders in the NICU and to assess the effectiveness of an ID reentry intervention and a distinct naming convention (eg, "Wendysgirl") for reducing these errors, using non-NICU pediatric units as a comparator.

Methods: Using a validated measure, we examined the rate of wrong-patient orders in NICU and non-NICU pediatric units during 3 periods: baseline (before implementing interventions), ID reentry intervention (reentry of patient identifiers before placing orders), and combined intervention (addition of a distinct naming convention for newborns).

Results: We reviewed >850 000 NICU orders and >3.5 million non-NICU pediatric orders during the 7-year study period. At baseline, wrong-patient orders were more frequent in NICU than in non-NICU pediatric units (117.2 vs 74.9 per 100 000 orders, respectively; odds ratio 1.56; 95% confidence interval, 1.34-1.82). The ID reentry intervention reduced the frequency of errors in the NICU to 60.2 per 100 000 (48.7% reduction; < .001). The combined ID reentry and distinct naming interventions yielded an additional decrease to 45.6 per 100 000 (61.1% reduction from baseline; < .001).

Conclusions: The risk of wrong-patient orders in the NICU was significantly higher than in non-NICU pediatric units. Implementation of a combined ID reentry intervention and distinct naming convention greatly reduced this risk.
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http://dx.doi.org/10.1542/peds.2016-2863DOI Listing
May 2017

Social Justice and the Provision of Health Care for Poor Children.

Authors:
Andrew D Racine

JAMA Pediatr 2017 04;171(4):316-317

Albert Einstein College of Medicine, Office of the President, Montefiore Health System, Bronx, New York.

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http://dx.doi.org/10.1001/jamapediatrics.2016.4567DOI Listing
April 2017

Trends in Access to Health Care Services for US Children: 2000-2014.

Pediatrics 2016 12 15;138(6). Epub 2016 Nov 15.

Department of Research, American Academy of Pediatrics, Elk Grove Village, Illinois; and

Background And Objective: Recent years have witnessed substantial gains in health insurance coverage for children, but few studies have examined trends across a diverse set of access indicators. We examine US children's access to health services and whether trends vary by race/ethnicity and income.

Methods: Analysis of 178 038 children ages 0 to 17 from the 2000 to 2014 National Health Interview Survey. Trends are examined for health insurance and 5 access indicators: no well-child visit in the year, no doctor office visit, no dental visit, no usual source of care, and unmet health needs. Logistic regression models add controls for sociodemographics and child health status. Statistical interactions test whether trends vary by race/ethnicity and income.

Results: Among all children, uninsured rates declined from 12.1% in 2000 to 5.3% in 2014, with improvement across all 5 access indicators. Along with steep declines in the uninsured rate, Hispanic children had sizeable improvement for no doctor office (19.8% to 11.9%), no dental visit (43.2% to 21.8%), and no usual source of care (13.9% to 6.3%). Black children and those in poor and near-poor families also had large gains. Results from adjusted statistical interaction models showed more improvement for black and Hispanic children versus whites for 3 of 5 access indicators and for children in poor and near-poor families for 4 of 5 access indicators.

Conclusions: Children's access to health services has improved since 2000 with greater gains in vulnerable population groups. Findings support a need for continued support of health insurance for all children.
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http://dx.doi.org/10.1542/peds.2016-2176DOI Listing
December 2016

Primary Care Providers as Mental Health Counselors: Views from Urban, Minority Adolescents.

J Health Care Poor Underserved 2016 ;27(3):1053-63

Objective: To examine urban, minority adolescents' preferences for receiving guidance for mental health (MH) issues from primary care providers (PCPs) or from mental health providers (MHPs).

Methods: Adolescents (13-21 years) from three community clinics and one school-based health center (SBHC) in the Bronx, N.Y. completed anonymous surveys. Characteristics of adolescents who preferred the PCP vs. MHP and adolescents' attitudes about the PCP vs. the MHP were compared.

Results: Adolescents (N=135), mean age 16 years, majority Hispanic participated. Although 85% strongly agreed or agreed that their PCP was knowledgeable about MH, 57% preferred to talk to a MHP. Those who preferred the MHP were younger, attend a SBHC, and trust information on MH from a MHP. Those who preferred the PCP were more likely to report feeling comfortable talking to their PCP about MH.

Conclusions: Although the majority preferred a MHP, PCPs appeared to be an acceptable alternative for MH care.
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http://dx.doi.org/10.1353/hpu.2016.0129DOI Listing
April 2018

Buying a Better Baby: Unconditional Income Transfers and Birth Outcomes.

Authors:
Andrew D Racine

Pediatrics 2016 06 13;137(6). Epub 2016 May 13.

Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York

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http://dx.doi.org/10.1542/peds.2015-4673DOI Listing
June 2016

Child Poverty and the Health Care System.

Authors:
Andrew D Racine

Acad Pediatr 2016 Apr;16(3 Suppl):S83-9

Albert Einstein College of Medicine and the Montefiore Health System, Bronx, NY. Electronic address:

The persistence of child poverty in the United States and the pervasive health consequences it engenders present unique challenges to the health care system. Human capital theory and empirical observation suggest that the increased disease burden experienced by poor children originates from social conditions that provide suboptimal educational, nutritional, environmental, and parental inputs to good health. Faced with the resultant excess rates of pediatric morbidity, the US health care system has developed a variety of compensatory strategies. In the first instance, Medicaid, the federal-state governmental finance system designed to assure health insurance coverage for poor children, has increased its eligibility thresholds and expanded its benefits to allow greater access to health services for this vulnerable population. A second arm of response involves a gradual reengineering of health care delivery at the practice level, including the dissemination of patient-centered medical homes, the use of team-based approaches to care, and the expansion of care management beyond the practice to reach deep into the community. Third is a series of recent experiments involving the federal government and state Medicaid programs that includes payment reforms of various kinds, enhanced reporting, concentration on high-risk populations, and intensive case management. Fourth, pediatric practices have begun to make use of specific tools that permit the identification and referral of children facing social stresses arising from poverty. Finally, constituencies within the health care system participate in enhanced advocacy efforts to raise awareness of poverty as a distinct threat to child health and to press for public policy responses such as minimum wage increases, expansion of tax credits, paid family leave, universal preschool education, and other priorities focused on child poverty.
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http://dx.doi.org/10.1016/j.acap.2015.12.002DOI Listing
April 2016

Early Child Social-Emotional Problems and Child Obesity: Exploring the Protective Role of a Primary Care-Based General Parenting Intervention.

J Dev Behav Pediatr 2015 Oct;36(8):594-604

*Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY; †Division of General Pediatrics, Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY.

Objective: To determine whether early social-emotional problems are associated with child feeding practices, maternal-child feeding styles, and child obesity at age 5 years, in the context of a primary care-based brief general parenting intervention led by an integrated behavioral health specialist to offer developmental monitoring, on-site intervention, and/or referrals.

Methods: A retrospective cohort study was conducted of mothers with 5-year-old children previously screened using the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) during the first 3 years of life. ASQ:SE scores were dichotomized "not at risk" versus "at risk." "At risk" subjects were further classified as participating or not participating in the intervention. Regression analyses were performed to determine relationships between social-emotional problems and feeding practices, feeding styles, and weight status at age 5 years based on participation, controlling for potential confounders and using "not at risk" as a reference group.

Results: Compared with children "not at risk," children "at risk-no participation" were more likely to be obese at age 5 years (adjusted odds ratio, 3.12; 95% confidence interval, 1.03 to 9.45). Their mothers were less likely to exhibit restriction and limit setting and more likely to pressure to eat than mothers in the "not at risk" group. Children "at risk-participation" did not demonstrate differences in weight status compared with children "not at risk."

Conclusion: Early social-emotional problems, unmitigated by intervention, were related to several feeding styles and to obesity at age 5 years. Further study is needed to understand how a general parenting intervention may be protective against obesity.
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http://dx.doi.org/10.1097/DBP.0000000000000212DOI Listing
October 2015

A Critical Review of the Marketing Claims of Infant Formula Products in the United States.

Clin Pediatr (Phila) 2016 May 7;55(5):437-42. Epub 2015 Jun 7.

Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA.

A highly competitive infant formula market has resulted in direct-to-consumer marketing intended to promote the sale of modified formulas that claim to ameliorate common infant feeding problems. The claims associated with these marketing campaigns are not evaluated with reference to clinical evidence by the Food and Drug Administration. We aimed to describe the language of claims made on formula labels and compare it with the evidence in systematic reviews. Of the 22 product labels we identified, 13 product labels included claims about colic and gastrointestinal symptoms. There is insufficient evidence to support the claims that removing or reducing lactose, using hydrolyzed or soy protein or adding pre-/probiotics to formula benefits infants with fussiness, gas, or colic yet claims like "soy for fussiness and gas" encourage parents who perceive their infants to be fussy to purchase modified formula. Increased regulation of infant formula claims is warranted.
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http://dx.doi.org/10.1177/0009922815589913DOI Listing
May 2016

Enriching our understanding of the effects of childhood poverty: lessons from Bangladesh.

Authors:
Andrew D Racine

Pediatrics 2014 Oct;134(4):e1171-3

Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York

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http://dx.doi.org/10.1542/peds.2014-1375DOI Listing
October 2014

Children's Health Insurance Program (CHIP): accomplishments, challenges, and policy recommendations.

Pediatrics 2014 Mar 27;133(3):e784-93. Epub 2014 Jan 27.

Sixteen years ago, the 105th Congress, responding to the needs of 10 million children in the United States who lacked health insurance, created the State Children's Health Insurance Program (SCHIP) as part of the Balanced Budget Act of 1997. Enacted as Title XXI of the Social Security Act, the Children's Health Insurance Program (CHIP; or SCHIP as it has been known at some points) provided states with federal assistance to create programs specifically designed for children from families with incomes that exceeded Medicaid thresholds but that were insufficient to enable them to afford private health insurance. Congress provided $40 billion in block grants over 10 years for states to expand their existing Medicaid programs to cover the intended populations, to erect new stand-alone SCHIP programs for these children, or to effect some combination of both options. Congress reauthorized CHIP once in 2009 under the Children's Health Insurance Program Reauthorization Act and extended its life further within provisions of the Patient Protection and Affordable Care Act of 2010. The purpose of this statement is to review the features of CHIP as it has evolved over the 16 years of its existence; to summarize what is known about the effects that the program has had on coverage, access, health status, and disparities among participants; to identify challenges that remain with respect to insuring this group of vulnerable children, including the impact that provisions of the new Affordable Care Act will have on the issue of health insurance coverage for near-poor children after 2015; and to offer recommendations on how to expand and strengthen the national commitment to provide health insurance to all children regardless of means.
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http://dx.doi.org/10.1542/peds.2013-4059DOI Listing
March 2014

Impact of newborn follow-up visit timing on subsequent ED visits and hospital readmissions: an instrumental variable analysis.

Acad Pediatr 2014 Jan-Feb;14(1):84-91

Montefiore Medical Center and Montefiore Medical Group, Bronx, NY.

Objective: To determine whether newborn first outpatient visit (FOV) within 3 days of discharge is associated with reduced rates of emergency department (ED) visits and hospital readmissions.

Methods: Retrospective cohort analysis was performed of all newborns who were born and had outpatient follow-up within a large academic medical center to determine whether they had ED visits or hospital readmission within 2 weeks after hospital discharge. Multivariable regression using an instrumental variable for timing of FOV was conducted to estimate the relationship between FOV within 3 days of discharge and ED visits and hospital readmissions within 2 weeks of discharge, adjusting for potential confounders. Stratified analyses assessed this relationship in subpopulations with medical or social risk factors.

Results: Of 3282 newborns, 178 (5%) had 1 or more ED visits or hospital readmissions within 2 weeks of hospital discharge. FOV within 3 days was not significantly associated with ED visits and readmissions in the instrumental variable analysis (IVA) (-0.035, P = .11) or the ordinary least squares analysis (OLS) (0.006, P = .52). The difference in coefficients between these analyses, however, suggests that IVA successfully adjusted for some unmeasured bias. In stratified analyses, only newborns born to African American mothers or discharged by family medicine providers demonstrated a significant relationship between FOV within 3 days and reduced odds of ED visits and readmissions.

Conclusions: No significant relationship between outpatient visit timing and ED visits and hospital readmissions was found. Further study is needed to assess the impact of early outpatient visits on other newborn outcomes.
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http://dx.doi.org/10.1016/j.acap.2013.09.010DOI Listing
April 2015