Bio

Clinical Focus

  • Pediatrics

Academic Appointments

Administrative Appointments

  • Co-Director, Center for Policy, Outcomes and Prevention (2013 - Present)
  • Co-Director, Fellowship in Academic General Pediatrics (2012 - Present)
  • Chief, Division of General Pediatrics (2014 - Present)

Boards, Advisory Committees, Professional Organizations

  • Council Member, Society for Pediatric Research (2011 - Present)

Professional Education

  • Board Certification: American Board of Pediatrics, Pediatrics (2016)
  • Residency: Stanford University General Surgery Residency CA
  • Internship: Stanford University General Surgery Residency CA
  • Medical Education: Stanford University School of Medicine (1994) CA

Contact

    Fax: (650) 725-2592
  • Complex Primary Care Clinic 730 Welch Rd Palo Alto, CA 94304
    • Tel: (650) 721-6073
    Fax: (650) 724-4001

Links

Research & Scholarship

Current Research and Scholarly Interests

As a general pediatrician with a joint appointment in the Center for Health Policy and Primary Care Outcomes Research, my research focuses on the field of health literacy. Informed by social cognitive theory, I conduct interdisciplinary research to understand child and parent health literacy as potentially modifiable determinants of child health disparities. I am principal investigator on an NICHD-funded, multi-site, randomized controlled trial to assess the efficacy of a low-literacy, early-childhood intervention designed to prevent obesity in the first two years of life. I recently completed a community-based, participatory research study to examine the effectiveness of child health promotion delivered across a large network of early child-care centers in underserved communities (www.jumpstartforhealth.org). The aim of my current scholarship is to apply the health-literacy model to attenuate disparities for children with chronic illness and special health care needs.

My work is informed by a public-health perspective and by delivering front-line care in underserved communities. Between 2006 and 2011, I served as Medical Director of Children’s Medical Services South Florida, a Florida state agency that coordinates care for more than 10,000 low-income children with special health care needs. I founded Stanford's Reach Out and Read program, and for ten years served as Medical Director for Reach Out and Read Florida, a pediatric-clinic-based program that provides books and early-literacy promotion to more than 200,000 underserved children. Prior to joining the Stanord faculty, I co-directed the Jay Weiss Center for Social Medicine and Health Equity, which fosters a scholarly community committed to addressing global health inequities through community-based participatory research. I have served as an advisor to the Institute of Medicine, the Centers for Disease Control and Prevention, the American Academy of Pediatrics, the Academic Pediatric Association, and the American Cancer Society. Fluent in Spanish, I maintain an active general pediatrics practice, serving an socioeconomically disadvantaged population of patients, with a focus on behavioral health, obesity prevention, post-NICU care of premature infants, and the care of complex chronic conditions.

Clinical Trials

  • Addressing Health Literacy and Numeracy to Prevent Childhood Obesity Not Recruiting

    In 2003, Surgeon General Richard Carmona suggested that low health literacy is "one of the largest contributors to our nation's epidemic of overweight and obesity." Over 26% of preschool children are now overweight or obese, and children who are overweight by age 24 months are five times as likely as non-overweight children to become overweight adolescents. The aim of the study is to assess the efficacy of a low-literacy/numeracy-oriented intervention aimed at teaching pediatric resident physicians to promote healthy family lifestyles and prevent overweight among young children (age 0-2) and their families in under-resourced communities.

    Stanford is currently not accepting patients for this trial.

    View full details

  • GoalKeeper: Intelligent Information Sharing for Children With Medical Complexity Not Recruiting

    This proposal addresses the major challenge of improving health outcomes for children with cancer and other complex conditions, for whom the effectiveness of outpatient care depends on care coordination across a diverse group of caregivers that includes parents, community support organizations and pediatric care providers. The investigators have developed GoalKeeper, a prototype system for supporting care coordination across multiple care providers. The primary aim of the clinical trial is to assess the potential for this new system, GoalKeeper, to improve meaningful use of goal-centered care plans in the care of children with cancer and other complex chronic conditions.

    Stanford is currently not accepting patients for this trial.

    View full details

  • Greenlight Plus Study: Approaches to Early Childhood Obesity Prevention Not Recruiting

    A randomized controlled trial enrolling 900 parent-infant dyads (English and Spanish speaking) comparing Greenlight (control), a behavioral intervention focusing on nutrition, physical activity, media use, and sleep as compared to Greenlight Plus (intervention) which includes the above materials plus a health information technology (HIT) intervention aimed at supporting family goal-setting and behavior change during well-child checks throughout the first 2 years of life.

    Stanford is currently not accepting patients for this trial.

    View full details

Teaching

2020-21 Courses

Stanford Advisees

Publications

All Publications

  • Infant television watching predicts toddler television watching in a low-income population. Academic pediatrics Hish, A. J., Wood, C. T., Howard, J. B., Flower, K. B., Yin, H. S., Rothman, R. L., Delamater, A. M., Sanders, L. M., Bian, A., Schildcrout, J. S., Perrin, E. M. 2020

    Abstract

    OBJECTIVES: This study examines the development of active television (TV) watching behaviors across the first 2 years of life in a racially and ethnically diverse, low-income cohort and identifies caregiver and child predictors of early TV watching.METHODS: We used longitudinal data from infants enrolled in the active control group (N?=?235; 39% Latino; 29% black; 15% white) of Greenlight, a cluster randomized multi-site trial to prevent childhood obesity. At preventive health visits from 2 months to 2 years, caregivers were asked: "How much time does [child's first name] spend watching television each day?" Proportional odds models and linear regression analyses were used to assess associations among TV introduction age, active TV watching amount at 2 years, and sociodemographic factors.RESULTS: 68% of children watched TV by 6 months, and 88% by 2 years. Age of TV introduction predicted amount of daily active TV watching at 2 years, with a mean time of 93 minutes if starting at 2 months; 64 minutes if starting at 4 or 6 months; and 42 minutes if starting after 6 months. Factors predicting earlier introduction included lower income, fewer children in household, care away from home, male sex, and non-Latino ethnicity of child.CONCLUSIONS: Many caregivers report that their infants actively watch TV in the first 6 months of life. Earlier TV watching is related to sociodemographic factors yet predicts more daily TV watching at 2 years even controlling those factors. Interventions to limit early TV watching should be initiated in infancy.

    View details for DOI 10.1016/j.acap.2020.11.002

    View details for PubMedID 33161116

  • Parent Perspectives in Shared Decision-Making for Children With Medical Complexity ACADEMIC PEDIATRICS Lin, J. L., Clark, C. L., Halpern-Felsher, B., Bennett, P. N., Assis-Hassid, S., Amir, O., Nunez, Y., Cleary, N., Gehrmann, S., Grosz, B. J., Sanders, L. M. 2020; 20 (8): 1101?8

    View details for Web of Science ID 000587738600013

  • Relationship Between Parental Locus of Control and Childhood Injury. The journal of primary prevention Schilling, S., Ritter, V. S., Skinner, A., Yin, H. S., Sanders, L. M., Rothman, R. L., Delamater, A. M., Perrin, E. M. 2020

    Abstract

    Although pediatricians routinely counsel parents about preventing childhood injuries, we know little about parents' locus of control (LOC) in regards to preventing their children from being injured. We performed an observational analysis of sociodemographic differences in LOC for injury prevention, as measured by four items adapted from the Parental Health Beliefs Scales, in English- and Spanish-speaking parents of infants participating in the treatment arm of an obesity prevention study. First, we examined associations of parental LOC for injury prevention at the time their children were 2months old with parents' age, race/ethnicity, income, and education. Next, we analyzed time trends for repeated LOC measures when the children were 2, 6, 9, 12, and 24months old. Last, we examined the association between injury-related LOC items and children's injury (yes/no) at each time point. Of 452 parents, those with lower incomes had both lower internal and higher external LOC. Lower educational achievement was associated with higher external LOC. Both internal and external LOC scores decreased over time. Injuries were more common in children whose parents endorsed low internal and high external LOC. Future studies should examine whether primary care-based interventions can increase parents' sense of control over their children's safety and whether that, in turn, is associated with lower injury rates.Clinical Trial Registration: NCT01040897.

    View details for DOI 10.1007/s10935-020-00615-y

    View details for PubMedID 33104944

  • Effects of Breastfeeding, Formula Feeding, and Complementary Feeding on Rapid Weight Gain in the First Year of Life. Academic pediatrics Wood, C. T., Witt, W. P., Skinner, A. C., Yin, H. S., Rothman, R. L., Sanders, L. M., Delamater, A. M., Flower, K. B., Kay, M. C., Perrin, E. M. 2020

    Abstract

    OBJECTIVE: To determine whether proportion of breast versus formula feeding, and timing of complementary food introduction affect the odds of rapid gain in weight status in a diverse sample of infants.METHODS: Using data from Greenlight Intervention Study, we analyzed the effects of type of milk feeding (breastfeeding, formula, or mixed feeding) from the 2 to 6 month well visits, and the introduction of complementary foods before 4 months on rapid increase in weight-for-age z-score (WAZ) and weight-for-length z-score (WLZ) before 12 months using multivariable logistic regression models.RESULTS: Of the 865 infants enrolled, 469 had complete data on all variables of interest, and 41% and 33% of those infants had rapid increases in WAZ and WLZ, respectively. Odds of rapid increase in WAZ remained lowest for infants breastfeeding from 2 to 6 months (aOR 0.34; 95% CI: 0.17, 0.69) when compared to infants who were formula fed. Adjusted for feeding, introduction of complementary foods after 4 months was associated with decreased odds of rapid increase in WLZ (aOR 0.64; 95% CI: 0.42, 0.96).CONCLUSION: Feeding typified by predominant breastfeeding and delaying introduction of complementary foods after 4 months reduces the odds of rapid increases in WAZ and WLZ in the first year of life.

    View details for DOI 10.1016/j.acap.2020.09.009

    View details for PubMedID 32961335

  • Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder. JAMA pediatrics Loe, I. M., Kakar, P. A., Sanders, L. M. 2020

    View details for DOI 10.1001/jamapediatrics.2020.2218

    View details for PubMedID 32777021

  • Assessing Diet Quality in a Racially and Ethnically Diverse Cohort of Low-Income Toddlers. Journal of pediatric gastroenterology and nutrition Kay, M. C., Silver, H. J., Yin, H. S., Flower, K. B., Rothman, R. L., Sanders, L. M., Delamater, A. M., Perrin, E. M. 2020

    Abstract

    BACKGROUND: Low-income racially and ethnically diverse children are at higher risk for obesity compared with their counterparts; yet, few studies have assessed their diet quality.OBJECTIVE: To evaluate the diet quality of a racially and ethnically diverse cohort of 2-year-olds using the Healthy Eating Index (HEI)-2010.METHODS: We used 24-hour dietary recall data from caregivers of toddlers (24-34 months) at 4 pediatric resident clinics that participated in the Greenlight Study to calculate compliance with the Dietary Guidelines for Americans (DGA) using total HEI score (range 0-100) and 12 component scores.RESULTS: Participants (n?=?231) were mostly Hispanic (57%) or non-Hispanic black (27%) and from low-income families. Mean HEI-2010 score was 62.8 (SD 10.5). Though not significant, Hispanics had the highest HEI score. Toddlers of caregivers without obesity, older than 35 years and born outside the U.S. had higher HEI scores. Most had high HEI component scores for dairy, fruit, and protein foods, but few achieved maximum scores, particularly for whole grains (13%), vegetables (10%), and fatty acid ratio (7%).CONCLUSION: Despite scores reflective of DGA recommendations for fruit, dairy and protein foods, toddlers in this diverse sample had low quality diets as measured by the HEI, driven largely by low component scores for whole grains, vegetables and ratio of unsaturated to saturated fatty acids.

    View details for DOI 10.1097/MPG.0000000000002871

    View details for PubMedID 32740532

  • Parent perspectives in shared decision-making for children with medical complexity. Academic pediatrics Lin, J. L., Clark, C. L., Halpern-Felsher, B., Bennett, P. N., Assis-Hassid, S., Amir, O., Nunez, Y. C., Cleary, N. M., Gehrmann, S., Grosz, B. J., Sanders, L. M. 2020

    Abstract

    OBJECTIVE: Shared decision-making (SDM) may improve outcomes for children with medical complexity (CMC). CMC have lower rates of SDM than other children, but little is known about how to improve SDM for CMC. The objective of this study is to describe parent perspectives of SDM for CMC and identify opportunities to improve elements of SDM specific to this vulnerable population.METHODS: Interviews with parents of CMC explored SDM preferences and experiences. Eligible parents were ?18 years old, English- or Spanish-speaking, with a CMC < 12 years old. Interviews were recorded, transcribed, and analyzed by independent coders for shared themes using modified grounded theory. Codes were developed using an iterative process, beginning with open-coding of a subset of transcripts followed by discussion with all team members, and distillation into preliminary codes. Subsequent coding reviews were conducted until no new themes emerged and existing themes were fully explored.RESULTS: We conducted interviews with 32 parents (27 in English, mean parent age 34 years, SD=7; mean child age 4 years, SD=4; 50% with household income <$50,000, 47% with low health literacy) in inpatient and outpatient settings. Three categories of themes emerged: participant, knowledge, and context. Key opportunities to improve SDM included: providing a shared decision timeline, purposefully integrating patient preferences and values, and addressing uncertainty in decisions.CONCLUSION: Our results provide insight into parent experiences with SDM for CMC. We identified unique opportunities to improve SDM for CMC that will inform future research and interventions to improve SDM for CMC.

    View details for DOI 10.1016/j.acap.2020.06.008

    View details for PubMedID 32540424

  • Are Low-Income, Diverse Mothers Able to Meet Breastfeeding Intentions After 2 Months of Breastfeeding? Breastfeeding medicine : the official journal of the Academy of Breastfeeding Medicine Kay, M. C., Cholera, R., Flower, K. B., Yin, H. S., Rothman, R. L., Sanders, L. M., Delamater, A. M., Perrin, E. M. 2020

    Abstract

    Background: Little is known about intended breastfeeding duration of women who initiate breastfeeding. We describe the association between intended and actual breastfeeding duration among low-income, diverse mothers who report maintaining breastfeeding for the first 2 months postpartum. Materials and Methods: We included mothers (64% Hispanic, 17% non-Hispanic black) participating in Greenlight, a cluster randomized childhood obesity prevention trial, who were providing breast milk at the 2-month preventive service visit and reported intended breastfeeding duration at this visit. Breastfeeding status was assessed at subsequent visits, up to 24 months. Poisson regression with a robust variance estimator was used to estimate risk ratios and 95% confidence intervals for meeting breastfeeding intentions. Covariates included race/ethnicity, income, receiving benefits from the Special Supplemental Nutrition Assistance Program for Women, Infants and Children (WIC), education, age, employment, depression, maternal obesity, U.S. born, whether infant was first born, and study site. Results: Median intended breastfeeding duration was 11.5 months (interquartile range [IQR]: 6-12) and median actual breastfeeding duration was 8.6 months (IQR: 4-14) (n=349). Approximately half (49%) met intended breastfeeding duration. Breastfeeding duration differed based on milk type provided at the 2-month visit in that mothers providing mostly or only breast milk had increased likelihood of meeting breastfeeding intentions. Regardless of milk type provided at 2 months, the longer a mother intended to breastfeed, the less likely she was to meet her breastfeeding intentions. Conclusions: In this diverse sample of women less than half met breastfeeding intentions despite maintaining breastfeeding for 2 months. Understanding factors that prevent mothers from attaining intended breastfeeding duration is critical to improving breastfeeding outcomes, especially in low income and ethnic minority populations.

    View details for DOI 10.1089/bfm.2020.0025

    View details for PubMedID 32357088

  • Associations Between Food Insecurity and Parental Feeding Behaviors of Toddlers. Academic pediatrics Orr, C. J., Ravanbakht, S., Flower, K. B., Yin, H. S., Rothman, R. L., Sanders, L. M., Delamater, A., Perrin, E. M. 2020

    Abstract

    We examined associations between household food insecurity status and parental feeding behavior, weight perception, and child weight status in a diverse sample of young children.Cross-sectional analysis of 2-year old children in Greenlight, a cluster randomized trial to prevent childhood obesity. The exposure was food insecurity, defined as a positive response to a validated screen. Outcomes were parent feeding behaviors/beliefs measured by the Child Feeding Questionnaire and child weight status. T-tests and linear regression were used to assess associations between food insecurity and each outcome. We adjusted for child sex, race/ethnicity, parent education, employment, site, number of children in the home, and WIC status.503 households (37%) were food insecure. After adjusting for covariates, parents from insecure households reported more pressuring feeding behaviors (mean factor score 3.2 compared to food secure parents mean factor score 2.9, p=0.01) and were more worried about their child becoming overweight (mean factor score 2.3 vs 2.0; p=0.02). No differences were observed in monitoring or restrictive feeding behaviors. After adjusting for covariates, there was no difference in weight status or prevalence of overweight/obesity of children or parents based on household food insecurity status.Parents from food insecure households reported more pressuring feeding behaviors. This finding underscores the need to address food insecurity and potentially prevent harmful effects on child feeding. Parents in food insecure households might benefit from linkage with resources and education to develop healthier feeding behaviors.

    View details for DOI 10.1016/j.acap.2020.05.020

    View details for PubMedID 32492577

  • Assessing Diet Quality in a Racially and Ethnically Diverse Cohort of Low-income Toddlers. Journal of pediatric gastroenterology and nutrition Kay, M. C., Silver, H. J., Yin, H. S., Flower, K. B., Rothman, R. L., Sanders, L. M., Delamater, A. M., Perrin, E. M. 2020; 71 (5): 679?85

    Abstract

    Low-income racially and ethnically diverse children are at higher risk for obesity compared with their counterparts; yet, few studies have assessed their diet quality.The aim of the study was to evaluate the diet quality of a racially and ethnically diverse cohort of 2-year-olds using the Healthy Eating Index (HEI)-2010.We used 24-hour dietary recall data from caregivers of toddlers (24-34 months) at 4 pediatric resident clinics that participated in the Greenlight Study to calculate compliance with the Dietary Guidelines for Americans (DGA) using total HEI score (range 0-100) and 12 component scores.Participants (n?=?231) were mostly Hispanic (57%) or non-Hispanic black (27%) and from low-income families. Mean HEI-2010 score was 62.8 (standard deviation [SD] 10.5). Though not significant, Hispanics had the highest HEI score. Toddlers of caregivers without obesity, older than 35 years and born outside the United States had higher HEI scores. Most had high HEI component scores for dairy, fruit, and protein foods, but few achieved maximum scores, particularly for whole grains (13%), vegetables (10%), and fatty acid ratio (7%).Despite scores reflective of DGA recommendations for fruit, dairy and protein foods, toddlers in this diverse sample had low quality diets as measured by the HEI, driven largely by low component scores for whole grains, vegetables, and ratio of unsaturated to saturated fatty acids.

    View details for DOI 10.1097/MPG.0000000000002871

    View details for PubMedID 33093378

  • Do health literacy disparities explain racial disparities in family-centered care for youths with special health care needs? Patient education and counseling Chisolm, D. J., Keedy, H. E., Dolce, M., Chavez, L., Abrams, M. A., Sanders, L. 2020

    Abstract

    To explore the relationship among youth health literacy, parental health literacy, and family-centered care (FCC) for youth with special health care needs (YSHCN) and assess potential racial disparities.HL and FCC were assessed in 486 Medicaid-enrolled YSHCN (ages 12-18) and their healthcare-responsible parent/caregiver. Analyses assessed racial differences in HL and FCC for parents and youth using logistic regression.Half of youth and over 80 percent of parents had adequate HL (REALM score ?62). Adequate HL was significantly lower in African Americans (AA) for both YSHCN and parents. Only 57 % of parents and 29 % of YSHCN reported FCC. AA YSHCN reported significantly lower levels of FCC compared to White YSHCN. AA parents trended lower for FCC compared to Whites, though the disparity was not significant. AA youth and parents had significantly lower odds of reporting that doctors spent enough time with them compared to Whites.Results suggest that AA and those with less than adequate health literacy experience lower FCC, however the relationship between race and health literacy does not explain the racial disparity in FCC.Provider time spent focused on HL may not reduce the racial disparity in FCC, but opportunities for improvement exist.

    View details for DOI 10.1016/j.pec.2020.09.023

    View details for PubMedID 32994106

  • Telehealth Opportunities and Challenges for Managing Pediatric Obesity. Pediatric clinics of North America Cueto, V., Sanders, L. M. 2020; 67 (4): 647?54

    Abstract

    Telehealth is well positioned to address the common challenges of providing high-quality care to children and adolescents with obesity. The potential benefits of telehealth for pediatric obesity are applicable across the full spectrum of care from diagnosis and assessment to ongoing management. This article reviews the emerging field of telehealth for the treatment of pediatric obesity. The challenges of the current approach to pediatric obesity care are explored, and the potential benefits of incorporating and implementing telehealth in this field are presented. The care of pediatric patients with obesity is particularly well suited for telehealth.

    View details for DOI 10.1016/j.pcl.2020.04.007

    View details for PubMedID 32650862

  • Parents' Use of Technologies for Health Management: A Health Literacy Perspective ACADEMIC PEDIATRICS Meyers, N., Glick, A. F., Mendelsohn, A. L., Parker, R. M., Sanders, L. M., Wolf, M. S., Bailey, S., Dreyer, B. P., Velazquez, J. J., Yin, H. 2020; 20 (1): 23?30

    View details for DOI 10.1016/j.acap.2019.01.008

    View details for Web of Science ID 000508287800007

  • Advancing a More Health-Literate Approach to Patient Safety. The Journal of pediatrics Sanders, L. M. 2019

    View details for DOI 10.1016/j.jpeds.2019.07.003

    View details for PubMedID 31474427

  • Disparities in Inpatient Intensity of End-of-Life Care for Complex Chronic Conditions PEDIATRICS Johnston, E. E., Bogetz, J., Saynina, O., Chamberlain, L. J., Bhatia, S., Sanders, L. 2019; 143 (5)

    View details for DOI 10.1542/peds.2018-2228

    View details for Web of Science ID 000474923900009

  • Disparities in Inpatient Intensity of End-of-Life Care for Complex Chronic Conditions. Pediatrics Johnston, E. E., Bogetz, J., Saynina, O., Chamberlain, L. J., Bhatia, S., Sanders, L. 2019

    Abstract

    BACKGROUND: Children with complex chronic conditions (CCCs) require a disproportionate share of health care services and have high mortality rates, but little is known about their end-of-life care.METHODS: We performed a retrospective population-based analysis using a California State administrative database of children aged 1 to 21 years with a CCC who died of disease-related causes between 2000 and 2013. Rates of and sociodemographic and clinical factors associated with previously defined inpatient end-of-life intensity indicators were determined. The intensity indicators included: (1) hospital death, (2) receipt of a medically intense intervention within 30 days of death (ICU admission, cardiopulmonary resuscitation, hemodialysis, and/or intubation), and (3) having ?2 intensity markers (including hospital death).RESULTS: There were 8654 children in the study population with a mean death age of 11.8 years (SD 6.8). The 3 most common CCC categories were neuromuscular (47%), malignancy (43%), and cardiovascular (42%). Sixty-six percent of the children died in the hospital, 36% had a medically intense intervention in the last 30 days of life, and 35% had ?2 intensity markers. Living in a low-income neighborhood was associated with increased odds of hospital death, a medically intense intervention, and ?2 intensity markers. Hispanic and "other" race and/or ethnicity were associated with hospital death and ?2 intensity markers. Age 15 to 21 years was associated with hospital death, a medically intense intervention, and ?2 intensity markers.CONCLUSIONS: Sociodemographic disparities in the intensity of end-of-life care for children with CCCs raise concerns about whether all children are receiving high-quality and goal-concordant end-of-life care.

    View details for PubMedID 30971431

  • Parents' Use of Technologies for Health Management: A Health Literacy Perspective. Academic pediatrics Meyers, N., Glick, A. F., Mendelsohn, A. L., Parker, R. M., Sanders, L. M., Wolf, M. S., Bailey, S., Dreyer, B. P., Velazquez, J. J., Yin, H. S. 2019

    Abstract

    OBJECTIVE: Parent use of technology to manage child health issues has the potential to improve access and health outcomes. Few studies have examined how parent health literacy affects usage of Internet and cell phone technologies for health management.METHODS: Cross-sectional analysis of data collected as part of a randomized controlled experiment in 3 urban pediatric clinics. English- and Spanish-speaking parents (n=858) of children ?8 years answered questions regarding use of and preferences related to Internet and cell phone technologies. Parent health literacy was measured using the Newest Vital Sign.RESULTS: The majority of parents were high Internet (70.2%) and cell phone (85.1%) utilizers (multiple times a day). 75.1% had limited health literacy (32.1% marginal, 43.0% low). Parents with higher health literacy had greater Internet and cell phone use (adequate vs. low: AOR=1.7[1.2-2.5]) and were more likely to use them for health management (AOR=1.5[1.2-1.8]); those with higher health literacy were more likely to use the Internet for provider communication (adequate vs. marginal vs. low: 25.0 vs. 18.0 vs. 12.0%, p=0.001) and health-related cell phone apps (40.6 vs. 29.7 vs. 16.4%, p<0.001). Overall preference for using technology for provider communication was high (70%) and did not differ by health literacy, although Internet and cell phone apps were preferred by higher literacy parents; no differences seen for texting.CONCLUSIONS: Health literacy-associated disparities in parent use of Internet and cell phone technologies exist, but parents' desire for use of these technologies for provider communication was overall high and did not differ by health literacy.

    View details for PubMedID 30862511

  • Health Care System Factors Associated with Transition Preparation in Youth with Special Health Care Needs POPULATION HEALTH MANAGEMENT McKenzie, R., Sanders, L., Bhattacharya, J., Bundorf, M. 2019; 22 (1): 63?73

    View details for DOI 10.1089/pop.2018.0027

    View details for Web of Science ID 000463371500010

  • Development and use of an adjusted nurse staffing metric in the neonatal intensive care unit. Health services research Tawfik, D. S., Profit, J., Lake, E. T., Liu, J. B., Sanders, L. M., Phibbs, C. S. 2019

    Abstract

    To develop a nurse staffing prediction model and evaluate deviation from predicted nurse staffing as a contributor to patient outcomes.Secondary data collection conducted 2017-2018, using the California Office of Statewide Health Planning and Development and the California Perinatal Quality Care Collaborative databases. We included 276 054 infants born 2008-2016 and cared for in 99 California neonatal intensive care units (NICUs).Repeated-measures observational study. We developed a nurse staffing prediction model using machine learning and hierarchical linear regression and then quantified deviation from predicted nurse staffing in relation to health care-associated infections, length of stay, and mortality using hierarchical logistic and linear regression.We linked NICU-level nurse staffing and organizational data to patient-level risk factors and outcomes using unique identifiers for NICUs and patients.An 11-factor prediction model explained 35 percent of the nurse staffing variation among NICUs. Higher-than-predicted nurse staffing was associated with decreased risk-adjusted odds of health care-associated infection (OR: 0.79, 95% CI: 0.63-0.98), but not with length of stay or mortality.Organizational and patient factors explain much of the variation in nurse staffing. Higher-than-predicted nurse staffing was associated with fewer infections. Prospective studies are needed to determine causality and to quantify the impact of staffing reforms on health outcomes.

    View details for DOI 10.1111/1475-6773.13249

    View details for PubMedID 31869865

  • Pneumonia Prevention Strategies for Children With Neurologic Impairment. Pediatrics Lin, J. L., Van Haren, K., Rigdon, J., Saynina, O., Song, H., Buu, M. C., Thakur, Y., Srinivas, N., Asch, S. M., Sanders, L. M. 2019

    Abstract

    Children with neurologic impairment (NI) face high risk of recurrent severe pneumonia, with prevention strategies of unknown effectiveness. We evaluated the comparative effectiveness of secondary prevention strategies for severe pneumonia in children with NI.We included children enrolled in California Children's Services between July 1, 2009, and June 30, 2014, with NI and 1 pneumonia hospitalization. We examined associations between subsequent pneumonia hospitalization and expert-recommended prevention strategies: dental care, oral secretion management, gastric acid suppression, gastrostomy tube placement, chest physiotherapy, outpatient antibiotics before index hospitalization, and clinic visit before or after index hospitalization. We used a 1:2 propensity score matched model to adjust for covariates, including sociodemographics, medical complexity, and severity of index hospitalization.Among 3632 children with NI and index pneumonia hospitalization, 1362 (37.5%) had subsequent pneumonia hospitalization. Only dental care was associated with decreased risk of subsequent pneumonia hospitalization (adjusted odds ratio [aOR]: 0.64; 95% confidence interval [CI]: 0.49-0.85). Exposures associated with increased risk included gastrostomy tube placement (aOR: 2.15; 95% CI: 1.63-2.85), chest physiotherapy (aOR: 2.03; 95% CI: 1.29-3.20), outpatient antibiotics before hospitalization (aOR: 1.42; 95% CI: 1.06-1.92), clinic visit before (aOR: 1.30; 95% CI: 1.11-1.52), and after index hospitalization (aOR: 1.72; 95% CI: 1.35-2.20).Dental care was associated with decreased recurrence of severe pneumonia. Several strategies, including gastrostomy tube placement, were associated with increased recurrence, possibly due to unresolved confounding by indication. Our results support a clinical trial of dental care to prevent severe pneumonia in children with NI.

    View details for DOI 10.1542/peds.2019-0543

    View details for PubMedID 31537634

  • Hospitalization Patterns for Inpatient Surgery and Procedures in California:2000 ? 2016 Anesthesia and Analgesia Muffly, M. K., Honkanen, A., Scheinker, D., Wang, T., Saynina, O., Singleton, M. A., , Wang, C. J., Sanders, L. M. 2019

    View details for DOI 10.1213/ANE.0000000000004552

  • Neighborhood Commute to Work Times and Self-Reported Caregiver Health Behaviors and Food Access ACADEMIC PEDIATRICS White, M. J., Yin, H., Rothman, R. L., Sanders, L. M., Delamater, A., Flower, K., Perrin, E. M. 2019; 19 (1): 74?79

    Abstract

    Time spent commuting is associated with obesity. The objective of this study was to assess the relationship between neighborhood-level commute to work (CTW) times and self-reported health behaviors and food access.We conducted a cross-sectional analysis of caregivers with infants as part of the Greenlight Study, a multisite obesity trial in Chapel Hill, New York City, Nashville, and Miami. ZIP code-based commuting estimates were determined using the US Census American Community Survey. Self-reported health behaviors and food access data were collected by directed interview. Logistic and linear regression models were used to determine associations between neighborhood CTW times and health behaviors and food access.The average neighborhood CTW time for all ZIP codes was 29 minutes (n?=?846). Caregivers in longer CTW time neighborhoods were more likely to endorse fewer food choices (adjusted odds ratio [AOR], 1.39; 95% confidence interval [CI], 1.15-1.69; P?=?.001) and difficulty accessing markets with fresh produce (AOR, 1.51; 95% CI, 1.02-2.25; P?=?.04). Neighborhood CTW time >30 minutes was associated with less caregiver physical activity (AOR, 0.58; 95% CI, 0.34-0.98; P?=?.044). Neighborhood CTW time was inversely related to infant television time (adjusted mean, 399 minutes/day for ?30 minutes and 256 minutes/day for >30 minutes; P?=?.025). New York families in longer CTW neighborhoods were more likely to report difficulty accessing markets with fresh produce (AOR, 1.80; 95% CI, 1.03-3.14; P?=?.039).Neighborhood CTW time is associated with several self-reported health behaviors and perceived food access among caregivers with children. Neighborhood CTW times may represent city-specific features, including transportation infrastructure, which may impact the health of families.

    View details for PubMedID 30041009

  • Identifying and Advancing Best Practices for the Chock for updates Labeling and Dosing of Pediatric Liquid Medications: Progress and Challenges ACADEMIC PEDIATRICS Yin, H., Vuong, C., Parker, R. M., Sanders, L. M., Mendelsohn, A. L., Dreyer, B. P., Velazquez, J. J., Wolf, M. S. 2019; 19 (1): 1?3

    View details for PubMedID 30096446

  • Parental Feeding Beliefs and Practices and Household Food Insecurity in Infancy ACADEMIC PEDIATRICS Orr, C. J., Ben -Davies, M., Ravanbakht, S. N., Yin, H., Sanders, L. M., Rothman, R. L., Delamater, A. M., Wood, C. T., Perrin, E. M. 2019; 19 (1): 80?89

    Abstract

    Food insecurity is associated with childhood obesity possibly mediated through caregiver feeding practices and beliefs. We examined if caregiver feeding practices differed by household food security status in a diverse sample of infants. We hypothesized that feeding practices differ based on food security status.Included in the baseline cross-sectional analysis of data from a randomized controlled trial to prevent obesity were 842 caregivers of 2-month-old infants presenting for well-child care at 4 academic institutions. Food insecurity exposure was based on an affirmative answer to 1 of 2 items in a 2-item validated questionnaire. Chi-square tests examined the association between parent feeding practices and food security status. Logistic regression adjusted for covariates. Differences in caregiver feeding practices by food security status and race/ethnicity were explored with an interaction term (food security status x race/ethnicity).Forty-three percent of families screened as food insecure. In adjusted logistic regression, parents from food-insecure households were more likely to endorse that "the best way to make an infant stop crying is to feed him or her" (adjusted odds ratio [aOR], 1.72; 95% confidence interval [CI], 1.28-2.29) and "when my baby cries, I immediately feed him or her" (aOR, 1.40; 95% CI, 1.06-1.83). Food-insecure caregivers less frequently endorsed paying attention to their baby when he or she is full or hungry (OR, 0.57; 95% CI, 0.34-0.96). Racial/ethnic differences in beliefs and behaviors were observed by food security status.During early infancy, feeding practices differed among caregivers by household food security status. Further research is needed to examine whether these practices are associated with increased risk of obesity and obesity-related morbidity.

    View details for PubMedID 30248471

  • A Brochure to Improve Understanding of Incomplete Mammogram Results Among Black Women at a Public Hospital in Miami, Florida SOUTHERN MEDICAL JOURNAL Marcus, E. N., Sanders, L. M., Jones, B. A., Koru-Sengul, T. 2019; 112 (1): 1?7

    View details for DOI 10.14423/SMJ.0000000000000919

    View details for Web of Science ID 000455050000001

  • Parent Dosing Tool Use, Beliefs, and Access: A Health Literacy Perspective. The Journal of pediatrics Williams, T. A., Wolf, M. S., Parker, R. M., Sanders, L. M., Bailey, S., Mendelsohn, A. L., Dreyer, B. P., Velazquez, J. J., Yin, H. S. 2019

    Abstract

    To assess parent decision-making regarding dosing tools, a known contributor to medication dosing errors, by evaluating parent dosing tool use, beliefs, and access, and the role of health literacy, with a focus on dosing cups, which are associated with an increased risk of multifold overdose.Cross-sectional analysis of data collected for randomized controlled study in 3 urban pediatric clinics. English/Spanish-speaking parents (n = 493) of children ?8 years of age enrolled.reported tool use, beliefs, and access. Predictor variable: health literacy (Newest Vital Sign; limited [0-3], adequate [4-6]). Multiple logistic regression analyses conducted.Over two-thirds of parents had limited health literacy. Oral syringes (62%) and dosing cups (22%) were most commonly used. Overall, 24% believed dosing cups were the best tool type for dosing accuracy; 99% reported having access to ?1 dosing tools with standard measurement markings. Parents with limited health literacy had greater odds of dosing cup use (limited vs adequate: aOR = 2.4 [1.2-4.6]). Parents who believed that dosing cups are best for accuracy had greater odds of dosing cup use (aOR = 16.3 [9.0-29.3]); this belief mediated health literacy-effects on dosing cup use.Factors associated with dosing tool choice, including parent health literacy and beliefs are important to consider in the design of interventions to reduce dosing errors; future larger-scale studies addressing this issue are needed.

    View details for DOI 10.1016/j.jpeds.2019.08.017

    View details for PubMedID 31604631

  • Impact of a Mobile App-Based Health Coaching and Behavior Change Program on Participant Engagement and Weight Status of Overweight and Obese Children: Retrospective Cohort Study. JMIR mHealth and uHealth Cueto, V., Wang, C. J., Sanders, L. M. 2019; 7 (11): e14458

    Abstract

    Effective treatment of obesity in children and adolescents traditionally requires frequent in-person contact, and it is often limited by low participant engagement. Mobile health tools may offer alternative models that enhance participant engagement.The aim of this study was to assess child engagement over time, with a mobile app-based health coaching and behavior change program for weight management, and to examine the association between engagement and change in weight status.This was a retrospective cohort study of user data from Kurbo, a commercial program that provides weekly individual coaching via video chat and supports self-monitoring of health behaviors through a mobile app. Study participants included users of Kurbo between March 2015 and March 2017, who were 5 to 18 years old and who were overweight or obese (body mass index; BMI ? 85th percentile or ? 95th percentile) at baseline. The primary outcome, engagement, was defined as the total number of health coaching sessions received. The secondary outcome was change in weight status, defined as the change in BMI as a percentage of the 95th percentile (%BMIp95). Analyses of outcome measures were compared across three initial commitment period groups: 4 weeks, 12 to 16 weeks, or 24 weeks. Multivariable linear regression models were constructed to adjust outcomes for the independent variables of sex, age group (5-11 years, 12-14 years, and 15-18 years), and commitment period. A sensitivity analysis was conducted, excluding a subset of participants involuntarily assigned to the 12- to 16-week commitment period by an employer or health plan.A total of 1120 participants were included in analyses. At baseline, participants had a mean age of 12 years (SD 2.5), mean BMI percentile of 96.6 (SD 3.1), mean %BMIp95 of 114.5 (SD 16.5), and they were predominantly female 68.04% (762/1120). Participant distribution across commitment periods was 26.07% (292/1120) for 4 weeks, 61.61% (690/1120) for 12-16 weeks, and 12.32% (138/1120) for 24 weeks. The median coaching sessions (interquartile range) received were 8 (3-16) for the 4-week group, 9 (5-12) for the 12- to 16-week group, and 19 (11-25) for the 24-week group (P<.001). Adjusted for sex and age group, participants in the 4- and 12-week groups participated in -8.03 (95% CI -10.19 to -5.87) and -9.34 (95% CI -11.31 to -7.39) fewer coaching sessions, compared with those in the 24-week group (P<.001). Adjusted for commitment period, sex, and age group, the overall mean change in %BMIp95 was -0.21 (95% CI -0.25 to -0.17) per additional coaching session (P<.001).Among overweight and obese children using a mobile app-based health coaching and behavior change program, increased engagement was associated with longer voluntary commitment periods, and increased number of coaching sessions was associated with decreased weight status.

    View details for DOI 10.2196/14458

    View details for PubMedID 31730041

  • A Brochure to Improve Understanding of Incomplete Mammogram Results Among Black Women at a Public Hospital in Miami, Florida. Southern medical journal Marcus, E. N., Sanders, L. M., Jones, B. A., Koru-Sengul, T. 2019; 112 (1): 1?7

    Abstract

    OBJECTIVES: Black women are at increased risk of being called back for additional studies after a screening mammogram. With focus group input, we developed a brochure to improve awareness of the frequency of abnormal results. This study explored the brochure's acceptability and effect on understanding risk and breast cancer fears among black mammography patients at an urban safety-net breast imaging center in Miami, Florida.METHODS: A randomized controlled trial of the brochure (plus the standard result notification letter) versus usual care (standard notification letter alone). Black English-speaking women with an incomplete mammography result were randomized to the intervention or control group. Consenting participants completed a telephone questionnaire. Outcomes included awareness of result, anxiety level, and brochure acceptability. The chi2 or Fisher exact test was used and a univariate logistic regression was performed for intervention and control odds ratios.RESULTS: A total of 106 women were randomly selected to receive the brochure plus the letter or the letter alone. One chose to opt out; a minimum of three attempts were made to reach each of the remaining 105 women by telephone. Verbal communication was established with 59 of the randomized women, and 51 of those women agreed to participate in a survey to evaluate the brochure. There was no significant difference between the surveyed groups in knowledge of the result and follow-up plan. Surveyed intervention subjects were more likely to agree that "it is very common for women to have to follow up after a mammogram" (odds ratio [OR] 25.91, P = 0.029) and less likely to agree with the statement "getting a follow-up mammogram is scary" (OR 0.24, P = 0.021). Most intervention subjects said the pamphlet helped them understand their result "a lot" (79%, 19) and viewed it as "extremely" or "mostly" clear (96%, 23). Intervention subjects also voiced greater awareness of a telephone number they could call for more information about cancer (OR 11.38, P = 0.029).CONCLUSIONS: A culturally tailored brochure explaining the frequency of abnormal mammograms was well received by women at a large safety-net health system. Pilot testing suggests that it may improve patient perception of risk and awareness of informational resources. This strategy should be considered to enhance result communication.

    View details for PubMedID 30608622

  • End-of-Life Care Intensity in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation: A Population-Level Analysis. Journal of clinical oncology : official journal of the American Society of Clinical Oncology Johnston, E. E., Muffly, L., Alvarez, E., Saynina, O., Sanders, L. M., Bhatia, S., Chamberlain, L. J. 2018: JCO2018780957

    Abstract

    Purpose Intensity of end-of-life care receives much attention in oncology because of concerns that high-intensity care is inconsistent with patient goals, leads to worse caregiver outcomes, and is expensive. Little is known about such care in those undergoing allogeneic hematopoietic cell transplantation (HCT), a population at high risk for morbidity and mortality. Patients and Methods We conducted a population-based analysis of patients who died between 2000 and 2013, within 1 year of undergoing an inpatient allogeneic HCT using California administrative data. Previously validated markers of intensity were examined and included: hospital death, intensive care unit (ICU) admission, and procedures such as intubation and cardiopulmonary resuscitation at end of life. Multivariable logistic regression models determined clinical and sociodemographic factors associated with: hospital death, a medically intense intervention (ICU admission, cardiopulmonary resuscitation, hemodialysis, intubation), and ? two intensity markers. Results Of the 2,135 patients in the study population, 377 were pediatric patients (age ? 21 years), 461 were young adults (age 22 to 39 years), and 1,297 were adults (age ? 40 years). The most common intensity markers were: hospital death (83%), ICU admission (49%), and intubation (45%). Medical intensity varied according to age, underlying diagnosis, and presence of comorbidities at time of HCT. Patients with higher-intensity end-of-life care included patients age 15 to 21 years and 30 to 59 years, patients with acute lymphoblastic leukemia, and those with comorbidities at time of HCT. Conclusion Patients dying within 1 year of inpatient allogeneic HCT are receiving medically intense end-of-life care with variations related to age, underlying diagnosis, and presence of comorbidities at time of HCT. Future studies need to determine if these patterns are consistent with patient and family goals.

    View details for PubMedID 30183467

  • Immigration Policy: Valuing Children ACADEMIC PEDIATRICS Mendoza, F. S., Cueto, V., Lawrence, D., Sanders, L., Weintraub, D. 2018; 18 (7): 723?25

    View details for Web of Science ID 000443532400001

  • Policy priorities for child health: results from a membership survey of the Society for Pediatric Research PEDIATRIC RESEARCH Shah, S., Balasubramaniam, V., Brumberg, H. L., Sanders, L. 2018; 84 (1): 6?9

    View details for PubMedID 29915410

  • Immigration Policy: Valuing Children. Academic pediatrics Mendoza, F. S., Cueto, V., Lawrence, D., Sanders, L., Weintraub, D. 2018

    View details for PubMedID 29966712

  • Health Care System Factors Associated with Transition Preparation in Youth with Special Health Care Needs. Population health management McKenzie, R. B., Sanders, L., Bhattacharya, J., Bundorf, M. K. 2018

    Abstract

    The aim of this study was to assess: (1) the proportion of youth with special health care needs (YSHCN) with adequate transition preparation, (2) whether transition preparation differs by individual, condition-related and health care system-related factors, and (3) whether specific components of the medical home are associated with adequate transition preparation. The authors conducted a cross-sectional analysis of the 2009-2010 National Survey of Children with Special Health Care Needs, which surveyed a nationally representative sample of 17,114 parents of YSHCN ages 12 to 18 years. Adequate transition preparation was based on positive responses to questions about transition to an adult provider, changing health care needs, maintaining insurance coverage, and if providers encouraged YSHCN to take responsibility for health care needs. Weighted descriptive, bivariate and multivariate analyses were conducted to determine the association between patient and health care system factors and adequate transition preparation. Overall, 32.1% of YSHCN had adequate transition preparation. Older age, female sex, income ?400% of the poverty level, lack of medical complexity, and having shared decision making, family-centered care, and effective care coordination were associated with increased odds of transition preparation. The majority of YSHCN do not receive adequate transition preparation and younger, male adolescents with medical complexity were less likely to receive transition preparation. Different patterns of disparities were identified for each subcomponent measure of transition preparation, which may help target at-risk populations for specific services. Efforts to improve transition preparation should leverage specific components of the medical home including care coordination, shared decision making, and family-centered care.

    View details for PubMedID 29957127

  • How gaps in policy implementation cause public health malpractice LANCET Javier, J. R., Brumberg, H. L., Sanders, L., Hannon, T. S., Shah, S., Soc Pediat Res Advocacy Comm 2018; 391 (10138): 2414

    View details for PubMedID 29916382

  • Inpatient Utilization and Disparities: The Last Year of Life of Adolescent and Young Adult Oncology Patients in California CANCER Johnston, E. E., Alvarez, E., Saynina, O., Sanders, L. M., Bhatia, S., Chamberlain, L. J. 2018; 124 (8): 1819?27

    Abstract

    Studies of adolescent and young adult (AYA) oncology end-of-life care utilization are critical because cancer is the leading cause of nonaccidental AYA death and end-of-life care contributes significantly to health care expenditures. This study was designed to determine the quantity of and disparities in inpatient utilization in the last year of life of AYAs with cancer.The California Office of Statewide Health Planning and Development administrative discharge database, linked to death certificates, was used to perform a population-based analysis of cancer patients aged 15 to 39 years who died in 2000-2011. The number of hospital days and the inpatient costs were determined for each patient in the last year of his or her life, as were clinical and sociodemographic factors associated with high inpatient utilization. Admission patterns as death approached were also evaluated.The 12,883 patients were admitted for 40 days on average in the last year of life, and this cost $151,072 per patient in inpatient costs. As death approached, the admission rates and the percentage of all admissions occurring at nonspecialty centers increased. Five percent of patients used 20% of bed days in the last year (high utilizers). Factors associated with high utilization included younger age (15-30 years), Hispanic ethnicity, non-health maintenance organization insurance, and hematologic malignancies.AYA oncology decedents were admitted for 40 days in their last year of life. Subgroups with high utilization had distinct sociodemographic and clinical characteristics, and nonspecialty center admissions increased as death approached. This demonstrates the need for palliative care at nonspecialty centers. Future studies need to determine whether these patterns are goal-concurrent, include high utilizers, and monitor the effects of health care reform. Cancer 2018;124:1819-27. © 2018 American Cancer Society.

    View details for PubMedID 29393967

    View details for PubMedCentralID PMC5891351

  • E-Health Care: Promise or Peril for Chronic Illness JOURNAL OF PEDIATRICS Sanders, L. M. 2018; 195: 15

    View details for PubMedID 29331325

  • Leveraging Medical Conferences and Webinars for Hands-On Clinical Quality Improvement: An Intervention to Improve Health Literacy-Informed Communication in Pediatrics AMERICAN JOURNAL OF MEDICAL QUALITY Shaikh, U., Yin, H., Mistry, K. B., Randolph, G. D., Sanders, L. M., Ferguson, L. E. 2018; 33 (2): 213?15

    View details for PubMedID 28709388

  • Status Complexicus? The Emergence of Pediatric Complex Care PEDIATRICS Cohen, E., Berry, J. G., Sanders, L., Schor, E. L., Wise, P. H. 2018; 141: S202?S211

    Abstract

    Discourse about childhood chronic conditions has transitioned in the last decade from focusing primarily on broad groups of children with special health care needs to concentrating in large part on smaller groups of children with medical complexity (CMC). Although a variety of definitions have been applied, the term CMC has most commonly been defined as children and youth with serious chronic conditions, substantial functional limitations, increased health and other service needs, and increased health care costs. The increasing attention paid to CMC has occurred because these children are growing in impact, represent a disproportionate share of health system costs, and require policy and programmatic interventions that differ in many ways from broader groups of children with special health care needs. But will this change in focus lead to meaningful changes in outcomes for children with serious chronic diseases, or is the pediatric community simply adopting terminology with resonance in adult-focused health systems? In this article, we will explore the implications of the rapid emergence of pediatric complex care in child health services practice and research. As an emerging field, pediatric care systems should thoughtfully and rapidly develop evidence-based solutions to the new challenges of caring for CMC, including (1) clearer definitions of the target population, (2) a more appropriate incorporation of components of care that occur outside of hospitals, and (3) a more comprehensive outcomes measurement framework, including the recognition of potential limitations of cost containment as a target for improved care for CMC.

    View details for PubMedID 29496971

  • Models of Care Delivery for Children With Medical Complexity PEDIATRICS Pordes, E., Gordon, J., Sanders, L. M., Cohen, E. 2018; 141: S212?S223

    Abstract

    Children with medical complexity (CMC) are a subset of children and youth with special health care needs with high resource use and health care costs. Novel care delivery models in which care coordination and other services to CMC are provided are a focus of national and local health care and policy initiatives. Current models of care for CMC can be grouped into 3 main categories: (1) primary care-centered models, (2) consultative- or comanagement-centered models, and (3) episode-based models. Each model has unique advantages and disadvantages. Evaluations of these models have demonstrated positive outcomes, but most studies have limited generalizability for broader populations of CMC. A lack of standardized outcomes and population definitions for CMC hinders assessment of the comparative effectiveness of different models of care and identification of which components of the models lead to positive outcomes. Ongoing challenges include inadequate support for family caregivers and threats to the sustainability of models of care. Collaboration among key stakeholders (patients, families, providers, payers, and policy makers) is needed to address the gaps in care and create best practice guidelines to ensure the delivery of high-value care for CMC.

    View details for PubMedID 29496972

  • The Patient Protection and Affordable Care Act dependent coverage expansion: Disparities in impact among young adult oncology patients CANCER Alvarez, E. M., Keegan, T. H., Johnston, E. E., Haile, R., Sanders, L., Wise, P. H., Saynina, O., Chamberlain, L. J. 2018; 124 (1): 110?17

    Abstract

    Private health insurance is associated with improved outcomes in patients with cancer. However, to the authors' knowledge, little is known regarding the impact of the Patient Protection and Affordable Care Act Dependent Coverage Expansion (ACA-DCE), which extended private insurance to young adults (to age 26 years) beginning in 2010, on the insurance status of young adults with cancer.The current study was a retrospective, population-based analysis of hospitalized young adult oncology patients (aged 22-30 years) in California during 2006 through 2014 (11,062 patients). Multivariable regression analyses examined factors associated with having private insurance. Results were presented as adjusted odds ratios and 95% confidence intervals. A difference-in-difference analysis examined the influence of the ACA-DCE on insurance coverage by race/ethnicity and federal poverty level.Multivariable regression demonstrated that patients of black and Hispanic race/ethnicity were less likely to have private insurance before and after the ACA-DCE, compared with white patients. Younger age (22-25 years) was associated with having private insurance after implementation of the ACA-DCE (odds ratio, 1.20; 95% confidence interval, 1.06-1.35). In the difference-in-difference analysis, private insurance increased among white patients aged 22 to 25 years who were living in medium-income (2006-2009: 64.6% vs 2011-2014: 69.1%; P = .003) and high-income (80.4% vs 82%; P = .043) zip codes and among Asians aged 22 to 25 years living in high-income zip codes (73.2 vs 85.7%; P = .022). Private insurance decreased for all Hispanic patients aged 22 to 25 years between the 2 time periods.The ACA-DCE provision increased insurance coverage, but not among all patients. Private insurance increased for white and Asian patients in higher income neighborhoods, potentially widening social disparities in private insurance coverage among young adults with cancer. Cancer 2018;124:110-7. © 2017 American Cancer Society.

    View details for PubMedID 28940423

  • In-Person Interpreter Use and Hospital Length of Stay among Infants with Low Birth Weight. International journal of environmental research and public health Eneriz-Wiemer, M., Sanders, L. M., McIntyre, M., Mendoza, F. S., Do, D. P., Wang, C. J. 2018; 15 (8)

    Abstract

    To ensure timely appropriate care for low-birth-weight (LBW) infants, healthcare providers must communicate effectively with parents, even when language barriers exist. We sought to evaluate whether non-English primary language (NEPL) and professional in-person interpreter use were associated with differential hospital length of stay for LBW infants, who may incur high healthcare costs. We analyzed data for 2047 infants born between 1 January 2008 and 30 April 2013 with weight <2500 g at one hospital with high NEPL prevalence. We evaluated relationships of NEPL and in-person interpreter use on length of stay, adjusting for medical severity. Overall, 396 (19%) had NEPL parents. Fifty-three percent of NEPL parents had documented interpreter use. Length of stay ranged from 1 to 195 days (median 11). Infants of NEPL parents with no interpreter use had a 49% shorter length of stay (adjusted incidence rate ratio (IRR) 0.51, 95% confidence interval (CI) 0.43?0.61) compared to English-speakers. Infants of parents with NEPL and low interpreter use (<25% of hospital days) had a 26% longer length of stay (adjusted IRR 1.26, 95% CI 1.06?1.51). NEPL and high interpreter use (>25% of hospital days) showed a trend for an even longer length of stay. Unmeasured clinical and social/cultural factors may contribute to differences in length of stay.

    View details for PubMedID 30044374

  • Shared Decision Making among Children with Medical Complexity: Results from a Population-Based Survey. The Journal of pediatrics Lin, J. L., Cohen, E., Sanders, L. M. 2018; 192: 216?22

    Abstract

    To compare the rates of shared decision making (SDM) reported by parents of children with medical complexity (CMC) with the rates of SDM reported by parents of noncomplex children with special health care needs (CSHCN).We examined the 2009-2010 National Survey of Children with Special Health Care Needs, a representative survey of 40 242 parents of CSHCN. CMC was defined as needing or using more medical care than usual, seeing 2 or more subspecialists, and positive response on at least 3 other items on the CSHCN screener. We identified 3 subgroups each of CMC and noncomplex CSHCN by sentinel diagnoses: asthma, seizures, and other diagnoses. SDM was defined as a binary composite variable, derived from 4 discrete items. We constructed 4 stepwise multivariable models to assess the relative odds of SDM, adjusted for sociodemographic characteristics (age, income, language, race, ethnicity, and marital status), behavioral comorbidity, family-centered care, and patient-centered medical home.The study population included 39 876 respondents. Compared with noncomplex CSHCN, CMC had a lower likelihood of SDM (aOR, 0.76; 95% CI, 0.64-0.91), which persisted in diagnostic subgroups: CMC with asthma (aOR, 0.67; 95% CI, 0.49-0.92) and CMC with other diagnoses (aOR, 0.74; 95% CI, 0.58-0.94), but not CMC with seizures (aOR, 0.95; 95% CI, 0.59-1.51).SDM is less common for CSHCN with complex needs than those without complex needs. Health system interventions targeting future-oriented care planning may improve SDM for CMC.

    View details for PubMedID 29102046

  • Shared decision making among children with medical complexity: results from a population-based survey The Journal of Pediatrics Lin, J. L., Cohen, E., Sanders, L. M. 2018: 216?22

    Abstract

    To compare the rates of shared decision making (SDM) reported by parents of children with medical complexity (CMC) with the rates of SDM reported by parents of noncomplex children with special health care needs (CSHCN).We examined the 2009-2010 National Survey of Children with Special Health Care Needs, a representative survey of 40 242 parents of CSHCN. CMC was defined as needing or using more medical care than usual, seeing 2 or more subspecialists, and positive response on at least 3 other items on the CSHCN screener. We identified 3 subgroups each of CMC and noncomplex CSHCN by sentinel diagnoses: asthma, seizures, and other diagnoses. SDM was defined as a binary composite variable, derived from 4 discrete items. We constructed 4 stepwise multivariable models to assess the relative odds of SDM, adjusted for sociodemographic characteristics (age, income, language, race, ethnicity, and marital status), behavioral comorbidity, family-centered care, and patient-centered medical home.The study population included 39 876 respondents. Compared with noncomplex CSHCN, CMC had a lower likelihood of SDM (aOR, 0.76; 95% CI, 0.64-0.91), which persisted in diagnostic subgroups: CMC with asthma (aOR, 0.67; 95% CI, 0.49-0.92) and CMC with other diagnoses (aOR, 0.74; 95% CI, 0.58-0.94), but not CMC with seizures (aOR, 0.95; 95% CI, 0.59-1.51).SDM is less common for CSHCN with complex needs than those without complex needs. Health system interventions targeting future-oriented care planning may improve SDM for CMC.

    View details for DOI 10.1016/j.jpeds.2017.09.001

    View details for PubMedCentralID PMC5732902

  • In-Person Interpreter Use and Hospital Length of Stay among Infants with Low Birth Weight International Journal of Environmental Research and Public Health Eneriz-Wiemer, M., Sanders, L., McIntrye, M., Mendoza, F., Do, D., Wang, C. 2018; 15 (8)

    Abstract

    To ensure timely appropriate care for low-birth-weight (LBW) infants, healthcare providers must communicate effectively with parents, even when language barriers exist. We sought to evaluate whether non-English primary language (NEPL) and professional in-person interpreter use were associated with differential hospital length of stay for LBW infants, who may incur high healthcare costs. We analyzed data for 2047 infants born between 1 January 2008 and 30 April 2013 with weight <2500 g at one hospital with high NEPL prevalence. We evaluated relationships of NEPL and in-person interpreter use on length of stay, adjusting for medical severity. Overall, 396 (19%) had NEPL parents. Fifty-three percent of NEPL parents had documented interpreter use. Length of stay ranged from 1 to 195 days (median 11). Infants of NEPL parents with no interpreter use had a 49% shorter length of stay (adjusted incidence rate ratio (IRR) 0.51, 95% confidence interval (CI) 0.43?0.61) compared to English-speakers. Infants of parents with NEPL and low interpreter use (<25% of hospital days) had a 26% longer length of stay (adjusted IRR 1.26, 95% CI 1.06?1.51). NEPL and high interpreter use (>25% of hospital days) showed a trend for an even longer length of stay. Unmeasured clinical and social/cultural factors may contribute to differences in length of stay.

    View details for DOI 10.3390/ijerph15081570

    View details for PubMedCentralID PMC6121500

  • Disparities in location of death of adolescents and young adults with cancer: A longitudinal, population study in California CANCER Rajeshuni, N., Johnston, E. E., Saynina, O., Sanders, L. M., Chamberlain, L. J. 2017; 123 (21): 4178?84

    Abstract

    Patients with a terminal illness should have access to their chosen location of death. Cancer is the leading cause of non-accidental death among adolescents and young adults (AYAs; those aged 15-39 years). Although surveys have suggested that a majority of these patients prefer a home death, to the authors' knowledge, little is known regarding their barriers to accessing their preferred location of death. As a first step, the authors sought to determine, across a large population, 20-year trends in the location of death among AYA patients with cancer.Using the Vital Statistics Death Certificate Database of the California Office of Statewide Health Planning and Development, the authors performed a retrospective, population-based analysis of California patients with cancer aged 15 to 39 years who died between 1989 and 2011. Sociodemographic and clinical factors associated with hospital death were examined using multivariable logistic regression.Of 30,573 AYA oncology decedents, 57% died in a hospital, 33% died at home, and 10% died in other locations (eg, hospice facility or nursing facility). Between 1989 and 1994, hospital death rates decreased from 68.3% to 53.6% and at-home death rates increased from 16.8% to 35.5%. Between 1995 and 2011, these rates were stable. Those individuals who were more likely to die in a hospital were those aged <30 years, of minority race, of Hispanic ethnicity, who lived ?10 miles from a specialty center, and who had a diagnosis of leukemia or lymphoma.Overall, the majority of AYA cancer deaths occurred in a hospital, with a 5-year shift to more in-home deaths that abated after 1995. In-hospital deaths were more common among younger patients, patients of minority race/ethnicities, and those with a leukemia or lymphoma diagnosis. Further study is needed to determine whether these rates and disparities are consistent with patient preferences. Cancer 2017;123:4178-4184. © 2017 American Cancer Society.

    View details for PubMedID 28700812

  • Disparities in the Intensity of End-of-Life Care for Children With Cancer PEDIATRICS Johnston, E. E., Alvarez, E., Saynina, O., Sanders, L., Bhatia, S., Chamberlain, L. J. 2017; 140 (4)

    Abstract

    Many adult patients with cancer who know they are dying choose less intense care; additionally, high-intensity care is associated with worse caregiver outcomes. Little is known about intensity of end-of-life care in children with cancer.By using the California Office of Statewide Health Planning and Development administrative database, we performed a population-based analysis of patients with cancer aged 0 to 21 who died between 2000 and 2011. Rates of and sociodemographic and clinical factors associated with previously-defined end-of-life intensity indicators were determined. The intensity indicators included an intense medical intervention (cardiopulmonary resuscitation, intubation, ICU admission, or hemodialysis) within 30 days of death, intravenous chemotherapy within 14 days of death, and hospital death.The 3732 patients were 34% non-Hispanic white, and 41% had hematologic malignancies. The most prevalent intensity indicators were hospital death (63%) and ICU admission (20%). Sixty-five percent had ?1 intensity indicator, 23% ?2, and 22% ?1 intense medical intervention. There was a bimodal association between age and intensity: ages <5 years and 15 to 21 years was associated with intense care. Patients with hematologic malignancies were more likely to have high-intensity end-of-life care, as were patients from underrepresented minorities, those who lived closer to the hospital, those who received care at a nonspecialty center (neither Children's Oncology Group nor National Cancer Institute Designated Cancer Center), and those receiving care after 2008.Nearly two-thirds of children who died of cancer experienced intense end-of-life care. Further research needs to determine if these rates and disparities are consistent with patient and/or family goals.

    View details for PubMedID 28963112

  • End-of-Life Intensity for Adolescents and Young Adults With Cancer: A Californian Population-Based Study That Shows Disparities JOURNAL OF ONCOLOGY PRACTICE Johnston, E. E., Alvarez, E., Saynina, O., Sanders, L., Bhatia, S., Chamberlain, L. J. 2017; 13 (9): E770?E781

    Abstract

    Cancer is the leading cause of nonaccidental death among adolescents and young adults (AYAs). High-intensity end-of-life care is expensive and may not be consistent with patient goals. However, the intensity of end-of-life care for AYA decedents with cancer-especially the effect of care received at specialty versus nonspecialty centers-remains understudied.We conducted a retrospective, population-based analysis with the California administrative discharge database that is linked to death certificates. The cohort included Californians age 15 to 39 years who died between 2000 and 2011 with cancer. Intense end-of-life interventions included readmission, admission to an intensive care unit, intubation in the last month of life, and in-hospital death. Specialty centers were defined as Children's Oncology Group centers and National Cancer Institute-designated comprehensive cancer centers.Of the 12,938 AYA cancer decedents, 59% received at least one intense end-of-life care intervention, and 30% received two or more. Patients treated at nonspecialty centers were more likely than those at specialty-care centers to receive two or more intense interventions (odds ratio [OR], 1.46; 95% CI, 1.32 to 1.62). Sociodemographic and clinical factors associated with two or more intense interventions included minority race/ethnicity (Black [OR, 1.35, 95% CI, 1.17 to 1.56]; Hispanic [OR, 1.24; 95% CI, 1.12 to 1.36]; non-Hispanic white: reference), younger age (15 to 21 years [OR, 1.36; 95% CI, 1.19 to 1.56; 22 to 29 years [OR,1.26; 95% CI,1.14 to 1.39]; ? 30 years: reference), and hematologic malignancies (OR, 1.53; 95% CI, 1.41 to 1.66; solid tumors: reference).Thirty percent of AYA cancer decedents received two or more high-intensity end-of-life interventions. In addition to sociodemographic and clinical characteristics, hospitalization in a nonspecialty center was associated with high-intensity end-of-life care. Additional research is needed to determine if these disparities are consistent with patient preference.

    View details for PubMedID 28829692

    View details for PubMedCentralID PMC5598313

  • Pictograms, Units and Dosing Tools, and Parent Medication Errors: A Randomized Study PEDIATRICS Yin, H., Parker, R. M., Sanders, L. M., Mendelsohn, A., Dreyer, B. P., Bailey, S., Patel, D. A., Jimenez, J. J., Kim, K. A., Jacobson, K., Smith, M. J., Hedlund, L., Meyers, N., McFadden, T., Wolf, M. S. 2017; 140 (1)

    View details for DOI 10.1542/peds.2016-3237

    View details for Web of Science ID 000404482500013

  • Inpatient Hospital Factors and Resident Time With Patients and Families PEDIATRICS Destino, L. A., Valentine, M., Sheikhi, F. H., Starmer, A. J., Landrigan, C. P., Sanders, L. 2017; 139 (5)

    Abstract

    To define hospital factors associated with proportion of time spent by pediatric residents in direct patient care.We assessed 6222 hours of time-motion observations from a representative sample of 483 pediatric-resident physicians delivering inpatient care across 9 pediatric institutions. The primary outcome was percentage of direct patient care time (DPCT) during a single observation session (710 sessions). We used one-way analysis of variance to assess a significant difference in the mean percentage of DPCT between hospitals. We used the intraclass correlation coefficient analysis to determine within- versus between-hospital variations. We compared hospital characteristics of observation sessions with ?12% DPCT to characteristics of sessions with <12% DPCT (12% is the DPCT in recent resident trainee time-motion studies). We conducted mixed-effects regression analysis to allow for clustering of sessions within hospitals and accounted for correlation of responses across hospital.Mean proportion of physician DPCT was 13.2% (SD = 8.6; range, 0.2%-49.5%). DPCT was significantly different between hospitals (P < .001). The intraclass correlation coefficient was 0.25, indicating more within-hospital than between-hospital variation. Observation sessions with ?12% DPCT were more likely to occur at hospitals with Magnet designation (odds ratio [OR] = 3.45, P = .006), lower medical complexity (OR = 2.57, P = .04), and higher patient-to-trainee ratios (OR = 2.48, P = .05).On average, trainees spend <8 minutes per hour in DPCT. Variation exists in DPCT between hospitals. A less complex case mix, increased patient volume, and Magnet designation were independently associated with increased DPCT.

    View details for DOI 10.1542/peds.2016-3011

    View details for PubMedID 28557735

  • Liquid Medication Dosing Errors by Hispanic Parents: Role of Health Literacy and English Proficiency ACADEMIC PEDIATRICS Harris, L. M., Dreyer, B. P., Mendelsohn, A. L., Bailey, S. C., Sanders, L. M., Wolf, M. S., Parker, R. M., Patel, D. A., Kim, K. Y., Jimenez, J. J., Jacobson, K., Smith, M., Yin, S. 2017; 17 (4): 403-410

    Abstract

    Hispanic parents in the United States are disproportionately affected by low health literacy and limited English proficiency (LEP). We examined associations between health literacy, LEP, and liquid medication dosing errors in Hispanic parents.Cross-sectional analysis of data from a multisite randomized controlled experiment to identify best practices for the labeling/dosing of pediatric liquid medications (SAFE Rx for Kids study); 3 urban pediatric clinics. Analyses were limited to Hispanic parents of children aged ?8 years with health literacy and LEP data (n = 1126). Parents were randomized to 1 of 5 groups that varied by pairing of units of measurement on the label/dosing tool. Each parent measured 9 doses (3 amounts [2.5, 5, 7.5 mL] using 3 tools [2 syringes in 0.2 or 0.5 mL increments, and 1 cup]) in random order. Dependent variable was a dosing error of >20% dose deviation. Predictor variables included health literacy (Newest Vital Sign) (limited = 0-3; adequate = 4-6) and LEP (speaks English less than "very well").A total of 83.1% made dosing errors (mean [SD] errors per parent = 2.2 [1.9]). Parents with limited health literacy and LEP had the greatest odds of making a dosing error compared to parents with adequate health literacy who were English proficient (trials with errors per parent = 28.8 vs 12.9%; adjusted odds ratio = 2.2 [95% confidence interval 1.7-2.8]). Parents with limited health literacy who were English proficient were also more likely to make errors (trials with errors per parent = 18.8%; adjusted odds ratio = 1.4 [95% confidence interval 1.1-1.9]).Dosing errors are common among Hispanic parents; those with both LEP and limited health literacy are at particular risk. Further study is needed to examine how the redesign of medication labels and dosing tools could reduce literacy- and language-associated disparities in dosing errors.

    View details for Web of Science ID 000401298200010

    View details for PubMedID 28477800

  • Parent Preferences and Perceptions of mLs and Teaspoons: Role of Health Literacy and Experience. Academic pediatrics Torres, A., Parker, R. M., Sanders, L. M., Wolf, M. S., Bailey, S., Patel, D. A., Jimenez, J. J., Kim, K. A., Dreyer, B. P., Mendelsohn, A., Yin, H. S. 2017

    Abstract

    A recent American Academy of Pediatrics policy statement recommends milliliter-exclusive dosing for pediatric liquid medications. Little is known about parent preferences regarding units, perceptions about moving to milliliters only, and the role of health literacy and prior milliliter-dosing experience.Cross-sectional analysis of data collected as part of a randomized controlled study in 3 urban pediatric clinics (SAFE Rx for Kids study). English- and Spanish-speaking parents (n = 493) of children aged ?8 years were randomized to 1 of 4 study arms and given labels and dosing tools which varied in label instruction format (text plus pictogram, text only) and units (milliliter only ["mL"], milliliter/teaspoon ["mL"/"tsp"]). Outcomes included teaspoon preference in dosing instructions and perceived difficulty with milliliter-only dosing. The predictor variable was health literacy (Newest Vital Sign; low [0-1], marginal [2-3], adequate [4-6]). The mediating variable was prior milliliter-dosing experience.Over two-thirds of parents had low or marginal health literacy. The majority (>70%) preferred to use milliliters, perceived milliliter-only dosing to be easy, and had prior milliliter-dosing experience; 11.5% had a teaspoon preference, 18.1% perceived milliliter-only dosing will be difficult, and 17.7% had no prior milliliter-dosing experience. Parents with lower health literacy had a higher odds of having a teaspoon preference (low vs adequate: adjusted odds ratio [AOR] = 2.9 [95% confidence interval [CI] 1.3-6.2]), and greater odds of perceiving difficulty with milliliter-only dosing (low vs adequate: AOR = 13.9 [95% CI 4.8-40.6], marginal vs adequate: AOR = 7.1 [95% CI 2.5-20.4]). Lack of experience with milliliter dosing partially mediated the impact of health literacy.Most parents were comfortable with milliliter-only dosing. Parents with low health literacy were more likely to perceive milliliter-only dosing to be difficult; educational efforts will need to target this group to ensure safe medication use.

    View details for DOI 10.1016/j.acap.2017.04.001

    View details for PubMedID 28400304

  • Families as Partners in Hospital Error and Adverse Event Surveillance. JAMA pediatrics Khan, A., Coffey, M., Litterer, K. P., Baird, J. D., Furtak, S. L., Garcia, B. M., Ashland, M. A., Calaman, S., Kuzma, N. C., O'Toole, J. K., Patel, A., Rosenbluth, G., Destino, L. A., Everhart, J. L., Good, B. P., Hepps, J. H., Dalal, A. K., Lipsitz, S. R., Yoon, C. S., Zigmont, K. R., Srivastava, R., Starmer, A. J., Sectish, T. C., Spector, N. D., West, D. C., Landrigan, C. P., Allair, B. K., Alminde, C., Alvarado-Little, W., Atsatt, M., Aylor, M. E., Bale, J. F., Balmer, D., Barton, K. T., Beck, C., Bismilla, Z., Blankenberg, R. L., Chandler, D., Choudhary, A., Christensen, E., Coghlan-McDonald, S., Cole, F. S., Corless, E., Cray, S., Da Silva, R., Dahale, D., Dreyer, B., Growdon, A. S., Gubler, L., Guiot, A., Harris, R., Haskell, H., Kocolas, I., Kruvand, E., Lane, M. M., Langrish, K., Ledford, C. J., Lewis, K., Lopreiato, J. O., Maloney, C. G., Mangan, A., Markle, P., Mendoza, F., Micalizzi, D. A., Mittal, V., Obermeyer, M., O'Donnell, K. A., Ottolini, M., Patel, S. J., Pickler, R., Rogers, J. E., Sanders, L. M., Sauder, K., Shah, S. S., Sharma, M., Simpkin, A., Subramony, A., Thompson, E. D., Trueman, L., Trujillo, T., Turmelle, M. P., Warnick, C., Welch, C., White, A. J., Wien, M. F., Winn, A. S., Wintch, S., Wolf, M., Yin, H. S., Yu, C. E. 2017

    Abstract

    Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection.To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports.We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; ?, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient.Error and AE rates.Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P?=?.006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates.Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.

    View details for DOI 10.1001/jamapediatrics.2016.4812

    View details for PubMedID 28241211

  • Adolescent and young adult oncology patients: Disparities in access to specialized cancer centers. Cancer Alvarez, E., Keegan, T., Johnston, E. E., Haile, R., Sanders, L., Saynina, O., Chamberlain, L. J. 2017

    Abstract

    Adolescents and young adults (AYAs) ages 15 to 39 years with cancer continue to experience disparate survival outcomes compared with their younger and older counterparts. This may be caused in part by differential access to specialized cancer centers (SCCs), because treatment at SCCs has been associated with improved overall survival. The authors examined social and clinical factors associated with AYA use of SCCs (defined as Children's Oncology Group-designated or National Cancer Institute-designated centers).A retrospective, population-based analysis was performed on all hospital admissions of AYA oncology patients in California during 1991 through 2014 (n?=?127,250) using the Office of Statewide Health Planning and Development database. Multivariable logistic regression analyses examined the contribution of social and clinical factors on always receiving care from an SCC (vs sometimes or never). Results are presented as adjusted odds ratios (ORs) and 95% confidence intervals (CIs).Over the past 20 years, the percentage of patients always receiving inpatient care at an SCC increased over time (from 27% in 1991 to 43% in 2014). In multivariable regression analyses, AYA patients were less likely to always receive care from an SCC if they had public insurance (OR, 0.64; 95% CI, 0.62-0.66), were uninsured (OR, 0.51; 95% CI, 0.46-0.56), were Hispanic (OR, 0.88; 95% CI, 0.85-0.91), lived?>?5 miles from an SCC, or had a diagnosis other than leukemia and central nervous system tumors.Receiving care at an SCC was influenced by insurance, race/ethnicity, geography, and tumor type. Identifying the barriers associated with decreased SCC use is an important first step toward improving outcomes in AYA oncology patients. Cancer 2017. © 2017 American Cancer Society.

    View details for DOI 10.1002/cncr.30562

    View details for PubMedID 28241089

  • Care coordination for children with special health care needs: a cohort study ITALIAN JOURNAL OF PEDIATRICS Zanello, E., Calugi, S., Sanders, L. M., Lenzi, J., Faldella, G., Rucci, P., Fantini, M. 2017; 43: 18

    Abstract

    Care coordination is widely recognized as a key element of care for patients with chronic and complex medical conditions and their families. In care for children with special health care needs the Family Pediatrician (FP) plays a central role as care coordinator. This study aims to evaluate the FPs' activities of care coordination for children with special health care needs in the pediatric primary care setting, using an on-line measurement tool.Within the prospective cohort study SpeNK (Special Needs Kids), newborns and children with special health care needs were recruited at discharge from three hospital facilities in Bologna province, from October 1st 2012 to September 30th 2014. Their FPs were invited to complete a questionnaire (SpeNK-FP) at each encounter for the patient during a 9-month period after hospital discharge. SpeNK-FP was developed by adapting the Care Coordination Measurement Tool (CCMT©) developed by Antonelli et al., to the Italian organizational context. The outcome of interest, derived from the questionnaire, is inappropriate use of services.Forty FPs completed assessments for 49 children at each of 382 clinical encounters. The majority of children (71.4%) had special health care needs, without complicating social issues. FPs reported "no need for care coordination" in 50.8% of the encounters and 41.1% of records about patient needs requiring care coordination. The most common activity implemented to meet children's needs was telephone contact with a medical provider. According to FPs, 80% of encounters prevented inappropriate services use. In multivariate regression, pediatric-specialist contact (telephone or in person) was associated with reduced odds of physician report of preventable hospitalization (OR?=?0.06, 95% CI 0.01-0.42, p?=?0.005).The study shows the potential for FPs in Italy to serve as care coordinators and facilitate the implementation of integrated care pathways for children with special health care needs.

    View details for PubMedID 28257651

    View details for PubMedCentralID PMC5347827

  • Satisfaction With Communication In Primary Care For Spanish-Speaking And English-Speaking Parents. Academic pediatrics Flower, K. B., Skinner, A. C., Yin, H. S., Rothman, R. L., Sanders, L. M., Delamater, A., Perrin, E. M. 2017

    Abstract

    Effective communication with primary care physicians is important yet incompletely understood for Spanish-speaking parents. We predicted lower satisfaction among Spanish-speaking compared to English-speaking Latino and non-Latino parents.Cross-sectional analysis at 2-month well visits within the Greenlight study at 4 pediatric resident clinics. Parents reported satisfaction with 14 physician communication items using the validated Communication Assessment Tool (CAT). High satisfaction was defined as "excellent" on each CAT item. Mean estimations compared satisfaction for communication items among Spanish- and English-speaking Latinos and non-Latinos. We used generalized linear regression modeling, adjusted for parent age, education, income, and clinic site. Among Spanish-speaking parents, we compared visits conducted in Spanish with and without an interpreter, and in English.Compared to English-speaking Latino (n = 127) and non-Latino parents (n = 432), fewer Spanish-speaking parents (n = 303) reported satisfaction with 14 communication items. No significant differences were found between English-speaking Latinos and non-Latinos. Greatest differences were found in the use of a greeting that made the parent comfortable (59.4% of Spanish-speaking Latinos endorsing "excellent" vs 77.5% English-speaking Latinos, P < .01) and discussing follow-up (62.5% of Spanish-speaking Latinos vs 79.8% English-speaking Latinos, P < .01). After adjusting for parent age, education, income, and study site, Spanish-speaking Latinos were still less likely to report high satisfaction with these communication items. Satisfaction was not different among Spanish-speaking parents when the physician spoke Spanish versus used an interpreter.Satisfaction with physician communication was associated with language but not ethnicity. Spanish-speaking parents less frequently report satisfaction with communication, and innovative solutions to enhance communication quality are needed.

    View details for DOI 10.1016/j.acap.2017.01.005

    View details for PubMedID 28104488

  • Pictograms, Units and Dosing Tools, and Parent Medication Errors: A Randomized Study. Pediatrics Yin, H. S., Parker, R. M., Sanders, L. M., Mendelsohn, A., Dreyer, B. P., Bailey, S. C., Patel, D. A., Jimenez, J. J., Kim, K. A., Jacobson, K., Smith, M. C., Hedlund, L., Meyers, N., McFadden, T., Wolf, M. S. 2017; 140 (1)

    Abstract

    Poorly designed labels and dosing tools contribute to dosing errors. We examined the degree to which errors could be reduced with pictographic diagrams, milliliter-only units, and provision of tools more closely matched to prescribed volumes.This study involved a randomized controlled experiment in 3 pediatric clinics. English- and Spanish-speaking parents (n = 491) of children ?8 years old were randomly assigned to 1 of 4 groups and given labels and dosing tools that varied in label instruction format (text and pictogram, or text only) and units (milliliter-only ["mL"] or milliliter/teaspoon ["mL/tsp"]). Each parent measured 9 doses of liquid medication (3 amounts [2, 7.5, and 10 mL] and 3 tools [1 cup, 2 syringes (5- and 10-mL capacities)]) in random order. The primary outcome was dosing error (>20% deviation), and large error (>2× dose).We found that 83.5% of parents made ?1 dosing error (overdosing was present in 12.1% of errors) and 29.3% of parents made ?1 large error (>2× dose). The greatest impact on errors resulted from the provision of tools more closely matched to prescribed dose volumes. For the 2-mL dose, the fewest errors were seen with the 5-mL syringe (5- vs 10-mL syringe: adjusted odds ratio [aOR] = 0.3 [95% confidence interval: 0.2-0.4]; cup versus 10-mL syringe: aOR = 7.5 [5.7-10.0]). For the 7.5-mL dose, the fewest errors were with the 10-mL syringe, which did not necessitate measurement of multiple instrument-fulls (5- vs 10-mL syringe: aOR = 4.0 [3.0-5.4]; cup versus 10-mL syringe: aOR = 2.1 [1.5-2.9]). Milliliter/teaspoon was associated with more errors than milliliter-only (aOR = 1.3 [1.05-1.6]). Parents who received text only (versus text and pictogram) instructions or milliliter/teaspoon (versus milliliter-only) labels and tools made more large errors (aOR = 1.9 [1.1-3.3], aOR = 2.5 [1.4-4.6], respectively).Provision of dosing tools more closely matched to prescribed dose volumes is an especially promising strategy for reducing pediatric dosing errors.

    View details for PubMedID 28759396

  • Lost in translation: Medication labeling for immigrant families JOURNAL OF THE AMERICAN PHARMACISTS ASSOCIATION Smith, M., Yin, H., Sanders, L. M. 2016; 56 (6): 677?79

    Abstract

    To identify the patient-safety hazards of current medication labeling standards for immigrant and language-minority families.The Latino population in the United States has increased by more than 40% over the past decade and the total child population born to Latino parents will surpass one-half of the population in many states. With recent health care and immigration policies, this demographic shift has a disproportional effect on the Latino families. Research shows that recent Latin American immigrants face disparities when encountering the U.S. pharmacy system. A review of these disparities shows how new policies should be informed when considering new pharmacy regulations to better address the cultural needs of recent Latin American families to improve medication understanding and adherence.To date, research and regulatory requirements for medication safety in the United States have attended insufficiently to the patient-safety risk inherent in providing complex English-language labels to non-English-speaking families, many of whom have limited literacy in their native language. As families move, this patient-safety risk is increased by shifts in pharmacies, which often have different medication-labeling standards. It is important to examine how recent immigrant parents are addressing the medication needs for their children based on their cultural norms and how those cultural practices and acculturation into the U.S. health care system may affect their risk for injury. New research and policy efforts may help to address these barriers to safe medication use.

    View details for DOI 10.1016/j.japh.2016.07.002

    View details for Web of Science ID 000389758900015

    View details for PubMedID 27836127

    View details for PubMedCentralID PMC5648594

  • Effect of Medication Label Units of Measure on Parent Choice of Dosing Tool: A Randomized Experiment. Academic pediatrics Yin, H. S., Parker, R. M., Sanders, L. M., Dreyer, B. P., Mendelsohn, A., Bailey, S., Patel, D. A., Jimenez, J. J., Kim, K. A., Jacobson, K., Hedlund, L., Landa, R., Maness, L., Tailor Raythatha, P., McFadden, T., Wolf, M. S. 2016; 16 (8): 734-741

    Abstract

    Some experts recommend eliminating "teaspoon" and "tablespoon" terms from pediatric medication dosing instructions, because these terms could inadvertently encourage use of nonstandard tools (ie, kitchen spoons), which are associated with dosing errors. We examined whether use of "teaspoon" or "tsp" on prescription labels affects parents' choice of dosing tools, and the role of health literacy and language.Analysis of data collected as part of a controlled experiment (SAFE Rx for Kids [Safe Administration For Every Prescription for Kids] study), which randomized English- and Spanish-speaking parents (n = 2110) of children 8 years of age and younger to 1 of 5 groups, which varied in unit of measurement pairings on medication labels and dosing tools. Outcome assessed was parent self-reported choice of dosing tool. Parent health literacy was measured using the Newest Vital Sign.Seventy-seven percent had limited health literacy (36.0% low, 41.0% marginal); 35.0% completed assessments in Spanish. Overall, 27.7% who viewed labels containing either "tsp" or "teaspoon" units (alone or with "mL") chose nonstandard dosing tools (ie, kitchen teaspoon, kitchen tablespoon), compared with 8.3% who viewed "mL"-only labels (adjusted odds ratio [AOR] = 4.4 [95% confidence interval (CI), 3.3-5.8]). Odds varied based on whether "teaspoon" was spelled out or abbreviated ("teaspoon"-alone: AOR = 5.3 [95% CI, 3.8-7.3]); "teaspoon" with mL: AOR = 4.7 [95% CI, 3.3-6.5]; "tsp" with mL: AOR = 3.3 [95% CI, 2.4-4.7]; P < .001). Similar findings were noted across health literacy and language groups.Use of teaspoon units ("teaspoon" or "tsp") on prescription labels is associated with increased likelihood of parent choice of nonstandard dosing tools. Future studies might be helpful to examine the real-world effect of eliminating teaspoon units from medication labels, and identify additional strategies to promote the safe use of pediatric liquid medications.

    View details for DOI 10.1016/j.acap.2016.04.012

    View details for PubMedID 27155289

    View details for PubMedCentralID PMC5077678

  • Health care for children with diabetes mellitus from low-income families in Ontario and California: a population-based cohort study. CMAJ open Kaiser, S. V., Sundaram, V., Cohen, E., Shulman, R., Guan, J., Sanders, L., Guttmann, A. 2016; 4 (4): E729-E736

    Abstract

    Children with diabetes mellitus in low-income families have poor outcomes, but little is known as to how this relates to healthcare system structure. Our objective was to gain insight into how best to structure health systems to serve these children by describing their health care use in 2 health system models: a Canadian model, with an organized diabetes care network that includes generalists, and an American model, with targeted support services for children from low-income families.We performed a population-based retrospective cohort study involving children aged 1-17 years with type 1 diabetes mellitus. We used administrative data from between 2009 and 2012 from the California Children's Services program and Ontario. We used Ontario Drug Benefit Program enrolment to identify children from low-income families. Proportions of children receiving 2 or more routine diabetes visits per year were compared using ?2 tests, and diabetes-complication hospital admission rates were compared using direct standardization.More California children from low-income families (n = 4922) received routine care for diabetes from pediatric endocrinologists (63.9% v. 26.9%, p < 0.001) and used insulin pumps (22.8% v. 16.4%, p < 0.001) than Ontario children (n = 2050).California children from low-income families were less likely than Ontario children to receive 2 visits for routine diabetes care per year (64.7% v. 75.7%, p < 0.001), and had slightly higher per-patient year hospital admission rates for diabetes complications (absolute differences 0.02, 95% confidence interval [CI] 0.02-0.02, for boys; 0.03, 95% CI 0.03-0.03, for girls).Ontario children from low-income families received more routine diabetes care than did California children from low-income families. Both groups of children had clinically comparable rates of hospital admission for diabetes complications. Diabetes care networks that integrate generalists may play a role in improving access and outcomes for the growing population of children with diabetes.

    View details for DOI 10.9778/cmajo.20160075

    View details for PubMedID 28018888

    View details for PubMedCentralID PMC5173459

  • Liquid Medication Errors and Dosing Tools: A Randomized Controlled Experiment PEDIATRICS Yin, H. S., Parker, R. M., Sanders, L. M., Dreyer, B. P., Mendelsohn, A. L., Bailey, S., Patel, D. A., Jimenez, J. J., Kim, K. A., Jacobson, K., Hedlund, L., Smith, M. C., Harris, L. M., McFadden, T., Wolf, M. S. 2016; 138 (4)

    View details for DOI 10.1542/peds.2016-0357

    View details for Web of Science ID 000384317700019

  • Racial and Ethnic Differences in Injury Prevention Behaviors Among Caregivers of Infants. American journal of preventive medicine Heerman, W. J., Perrin, E. M., Sanders, L. M., Yin, H. S., Coyne-Beasley, T., Bronaugh, A. B., Barkin, S. L., Rothman, R. L. 2016; 51 (4): 411-418

    Abstract

    African American and Latino children experience higher rates of traumatic injury and mortality, but the extent to which parents of different races and ethnicities disparately enact injury prevention behaviors has not been fully characterized. The objective of this study is to evaluate the association between caregiver race/ethnicity and adherence to injury prevention recommendations.This was a cross-sectional analysis of caregiver-reported baseline data from the Greenlight study, a cluster-randomized pediatric obesity prevention trial. Data were collected between 2010 and 2012 in four academic pediatric practices and analyzed in 2015. Non-adherence to injury prevention recommendations was based on five domains: car seat safety, sleeping safety, fire safety, hot water safety, and fall prevention.Among 864 caregiver-infant pairs (17.7% white, non-Hispanic; 49.9% Hispanic; 27.7% black, non-Hispanic; 4.7 % other, non-Hispanic), mean number of non-adherent injury prevention behaviors was 1.8 (SD=0.9). In adjusted regression, Hispanic caregivers had higher odds of non-adherence to car seat safety (AOR=2.1, 95% CI=1.2, 3.8), and lower odds of non-adherence with fall prevention (AOR=0.4, 95% CI=0.3, 0.7) compared with whites. Black, non-Hispanic caregivers had higher odds of non-adherence to car seat safety (AOR=2.4, 95% CI=1.3, 4.4) and sleeping safety (AOR=2.1, 95% CI=1.3, 3.2), but lower odds of fall prevention non-adherence (AOR=0.5, 95% CI=0.3, 0.8) compared with whites.A high prevalence of non-adherence to recommended injury prevention behaviors is common across racial/ethnic categories for caregivers of infants among a diverse sample of families from low-SES backgrounds.

    View details for DOI 10.1016/j.amepre.2016.04.020

    View details for PubMedID 27291075

  • Parent Language: A Predictor for Neurodevelopmental Follow-up Care Among Infants With Very Low Birth Weight. Academic pediatrics Eneriz-Wiemer, M., Saynina, O., Sundaram, V., Lee, H. C., Bhattacharya, J., Sanders, L. M. 2016; 16 (7): 645-652

    Abstract

    Preterm/very low birth weight infants may suffer neurodevelopmental delays. Pediatricians should monitor neurodevelopment and pursue timely referrals. Yet parents who speak non-English primary languages (NEPL) report worse health care communication and fewer appropriate specialty referrals for their children. We sought to determine whether infants of NEPL parents receive recommended outpatient follow-up care for neurodevelopment. We hypothesized that these infants received less care than infants of English speakers.We linked paid claims from California Children's Services to clinical data from California Perinatal Quality Care Collaborative (58% linkage rate, 1541 subjects) for publicly insured infants with birth weight <1500 g or gestational age ?32 weeks. Our primary outcomes were completion of 1) preventive visits and 2) ophthalmology visits; and receipt of 3) influenza vaccination and 4) palivizumab. To compare group differences, we also assessed 5) hospital length of stay and 6) readmissions. Analyses were adjusted for medical severity and sociodemographic characteristics.A total of 433 infants (28%) had NEPL parents. Infants of NEPL parents had 38% higher odds of receiving influenza vaccination (95% confidence interval 9-75, P = .008) and completed 8% more preventive visits (95% confidence interval 1-64, P = .019) than infants of English speakers. Infants of NEPL parents did not have longer lengths of stay or more readmissions.Infants of NEPL parents were more likely than infants of English speakers to receive some aspects of recommended outpatient follow-up care. Regardless of language, all infants received far lower rates of follow-up care than recommended by national guidelines. Future study should address the causes of these gaps.

    View details for DOI 10.1016/j.acap.2016.04.004

    View details for PubMedID 27130810

  • Parental Perceptions of Weight During the First Year of Life. Academic pediatrics Brown, C. L., Skinner, A. C., Yin, H. S., Rothman, R. L., Sanders, L. M., Delamater, A. M., Ravanbakht, S. N., Perrin, E. M. 2016; 16 (6): 558-564

    Abstract

    More than half of parents underestimate their overweight child's weight; however, previous research focuses on children older than 2 years of age. The objective of this study was to assess whether parents of 2- to 12-month-old infants are able to accurately perceive their children's weight status.We performed a cross-sectional analysis of data collected from the Greenlight study, a cluster randomized obesity prevention trial, at 4 pediatric clinics serving diverse and low-income populations. Infants' length and weight were measured at well-child checks, and parents completed questionnaires including demographic characteristics and perception of their children's weight. Weight-for-length (WFL) percentile at the fifth to ?95 was considered healthy weight and WFL percentile >95th was considered overweight. We used chi-squared tests to compare accuracy according to weight category and performed logistic regression analysis to assess accuracy at each time point.Approximately 85% to 90% of infants (n = 853 at 2 months, n = 563 at 12 months) were at a healthy WFL at all measurement times, and parents of these infants were more likely to have an accurate perception of their child's weight (accuracy 89%-95%) than overweight children (accuracy 7%-26%; P < .001 across time points). Approximately 10% of healthy weight infants were perceived as underweight by their parents at all time points. At 12 months, mothers who were overweight were significantly more likely to underestimate their child's weight status (P = .008).In our diverse and low-income sample, parents of overweight infants infrequently know that their infants are overweight. Future studies should examine how perception is related to feeding habits and weight status over time.

    View details for DOI 10.1016/j.acap.2016.03.005

    View details for PubMedID 27002214

    View details for PubMedCentralID PMC4976024

  • Infant Sleep and Parent Health Literacy ACADEMIC PEDIATRICS Bathory, E., Tomopoulos, S., Rothman, R., Sanders, L., Perrin, E. M., Mendelsohn, A., Dreyer, B., Cerra, M., Yin, H. S. 2016; 16 (6): 550-557

    Abstract

    Child sleep problems are prevalent and have been linked to poor behavior, worse school performance, and obesity. Low health literacy (HL) is associated with suboptimal parenting practices and worse health outcomes, but the relationship between parent HL and child sleep-related issues is not known. We examined the association between parent HL and child sleep-related issues.This was a cross-sectional analysis of data from caregivers enrolled in a cluster randomized trial of a primary care-based child obesity prevention program in 4 pediatric clinics. Parent HL was assessed using the Short Test of Functional Health Literacy in Adults. At the 9-month well-child visit, sleep-related factors were assessed: presence of TV in room where child sleeps, regular naptimes and bedtimes (?5 days/wk), low daytime and nighttime sleep duration (>1 SD below mean on the basis of national data). Multiple logistic regression analyses were performed.We enrolled 557 caregivers of 9-month-old children (49.7% Hispanic, 26.9% black, 56.2% <$20,000 annual income); 49.6% reported having a TV in the room where their child sleeps; 26.6% did not have regular naptimes norbedtimes. Median sleep duration was 2.3 (interquartile range, 1.5-3.0) hours (daytime), and 9.0 (interquartile range, 8.0-10.0) hours (night) (30.2% low daytime; 20.3% low nighttime sleep duration). Children of parents with low HL were more likely to have a bedroom TV (66.7% vs 47.7%, P = .01; adjusted odds ratio, 2.2; 95% confidence interval, 1.1-4.3) and low night-time sleep (37.0% vs 18.5%; P = .002; adjusted odds ratio, 2.4; 95% confidence interval, 1.2-4.8).Low parent HL is associated with TV in the bedroom and low night sleep duration. Additional study is needed to further explore these associations and intervention strategies to address child sleep problems.

    View details for Web of Science ID 000381063900009

    View details for PubMedID 26979779

  • Small-for-Gestational-Age Births are Associated with Maternal Relationship Status: A Population-Wide Analysis MATERNAL AND CHILD HEALTH JOURNAL Steinberg, J. R., Sanders, L., Cousens, S. 2016; 20 (8): 1651-1661

    Abstract

    Objectives To examine the association between maternal relationship status during pregnancy and infant birth outcomes. Methods Observational study of the National Longitudinal Survey of Youth 1979, a nationally representative sample of 12,686 men and women between the ages of 14 and 21. We used data from surveys of women reporting childbirth between 1979 and 2004. Relationship status was defined as relationship with an opposite-sex partner in the child's birth year. Relationship stability was defined as the consistency in relationship status in the 1 year before, of, and after the child's birth. Childbirth outcome included small-for-gestational age (SGA) infant. We applied random effects logistic regression models to assess the association between relationship status and stability and childbirth outcome-adjusting for maternal race, infant sex, history of miscarriage, employment, maternal age, multiparity, cohort-entry year, household poverty status, and tobacco use. Results The study included 4439 women with 8348 live births. In fully adjusted models, term SGA infants were more commonly born to partnered women (AOR 1.81; 95 % CI 1.20-2.73) and unmarried women (AOR 1.82; CI 1.34-2.47; LRT p value 0.0001), compared to married women. SGA infants were also more commonly born in unstable relationships (AOR 1.72; 95 % CI 1.14-2.63; LRT p value 0.01) compared to stable relationships. Conclusions for Practice Maternal relationship status and stability during pregnancy is independently associated with risk of SGA infant birth.

    View details for DOI 10.1007/s10995-016-1964-6

    View details for Web of Science ID 000379347900009

    View details for PubMedID 27007984

  • Bottle Size and Weight Gain in Formula-Fed Infants PEDIATRICS Wood, C. T., Skinner, A. C., Yin, H. S., Rothman, R. L., Sanders, L. M., Delamater, A. M., Perrin, E. M. 2016; 138 (1)

    Abstract

    Formula-fed infants may be at greater risk for overfeeding and rapid weight gain. Different size bottles are used for feeding infants, although little is known about whether bottle size is related to weight gain in bottle-fed infants.Data from the Greenlight Intervention Study, a cluster randomized trial to prevent childhood obesity at 4 pediatric resident clinics, were used to analyze the exposure to regular (<6 oz) or large (?6 oz) bottle size at the 2-month visit on changes in weight, weight-for-age z score (WAZ), and weight-for-length z score (WLZ) at the 6-month visit. Using multivariable regression, we adjusted for potential confounders (birth weight, gender, age, weight measures at 2 months, parent race/ethnicity, education, household income and size, time between 2- and 6-month visits, and first child status).Forty-five percent (n = 386; 41% black, 35% Hispanic, 23% white, 2% other) of infants at the 2-month visit were exclusively formula-fed, and 44% used large (?6 oz) bottles. Infants whose parents fed with large bottles had 0.21 kg (95% confidence interval [CI]: 0.05 to 0.37) more weight change, 0.24 U (95% CI: 0.07 to 0.41) more change in WAZ, and 0.31 U (95% CI: 0.08 to 0.54) more change in WLZ during this period than infants fed with regular bottles.Using a large bottle in early infancy independently contributed to greater weight gain and change in WLZ at the 6-month visit. Although growth in infancy is complex, bottle size may be a modifiable risk factor for rapid infant weight gain and later obesity among exclusively formula-fed infants.

    View details for DOI 10.1542/peds.2015-4538

    View details for Web of Science ID 000378853100026

    View details for PubMedID 27273748

    View details for PubMedCentralID PMC4925078

  • Parent Health Literacy, Depression, and Risk for Pediatric Injury PEDIATRICS Cheng, E. R., Bauer, N. S., Downs, S. M., Sanders, L. M. 2016; 138 (1)

    Abstract

    Population-wide research on the impact of parent health literacy to children's health outcomes is limited. We assessed the relationship of low parent health literacy to a range of pediatric health risks within a large cohort of primary care patients.Data were from 17?845 English- and Spanish-speaking parents of children aged ?7 years presenting for well-child care. We used a 3-item screener to measure health literacy. Outcomes included secondhand smoke exposure, asthma treatment nonadherence, parent depression, child-rearing practices, injury prevention, and parent first-aid knowledge. We summarized study variables with descriptive statistics and then performed multivariable logistic regression to identify associations between low parent literacy and our dependent measures.Mean child age was 4.8 years (SD 3.7); 36.5% of parent respondents had low health literacy. In models adjusted for child gender, race/ethnicity, insurance, age, and parent language preference, low parent health literacy was related to a range of pediatric health risks, including parent depression (adjusted odds ratio [AOR] 1.32; 95% confidence interval 1.18-1.48), firearm access (AOR 1.68; 1.49-1.89), not having a working smoke detector (AOR 3.54; 2.74-4.58), and lack of first-aid knowledge about choking (AOR 1.67; 1.44-1.93) and burns (AOR 1.45; 1.29-1.63). Children of parents with low health literacy were also more likely to watch >2 hours of television per day (AOR 1.27; 1.17-1.36).Low parent health literacy is independently and significantly related to parent depression, child television viewing, and at-risk family behaviors associated with child injury. Use of low-literacy approaches to health-behavior interventions may be essential to address common child morbidities.

    View details for PubMedID 27273749

  • Outpatient Care Preceding Hospitalization for Diabetic Ketoacidosis PEDIATRICS Crossen, S. S., Wilson, D. M., Saynina, O., Sanders, L. M. 2016; 137 (6)

    Abstract

    To identify patterns of outpatient care associated with diabetic ketoacidosis (DKA) among pediatric patients with type 1 diabetes (T1D).Retrospective cohort study using Medicaid claims data from 2009 to 2012 for children with T1D enrolled ?365 consecutive days in California Children's Services, a Title V program for low-income children with chronic disease. Outcome was DKA hospitalization >30 days after enrollment. Outpatient visits to primary care, endocrinology, pharmacies, and emergency departments (EDs) were assessed during the 6 months before an index date: either date of first DKA hospitalization or end of enrollment for those without DKA. Univariate and multivariate analysis was used to evaluate independent associations between DKA and outpatient care at clinically meaningful intervals preceding the index date.Among 5263 children with T1D, 16.7% experienced DKA during the study period. Patients with DKA were more likely to have had an ED visit (adjusted odds ratio [aOR] 3.99, 95% confidence interval [CI]: 2.60-6.13) or a nonpreventive primary care visit (aOR 1.35, 95% CI: 1.01-1.79) within 14 days before the index date, and less likely to have visited an endocrinologist (aOR 0.76, 95% CI: 0.65-0.89) within the preceding 120 days. Preventive visits and pharmacy claims were not associated with DKA.For children with T1D, recent ED visits and long intervals without subspecialty care are important signals of impending DKA. Combined with other known risk factors, these health-use indicators could be used to inform clinical and case management interventions that aim to prevent DKA hospitalizations.

    View details for DOI 10.1542/peds.2015-3497

    View details for PubMedID 27207491

  • Confirmatory factor analysis of the Infant Feeding Styles Questionnaire in Latino families. Appetite Wood, C. T., Perreira, K. M., Perrin, E. M., Yin, H. S., Rothman, R. L., Sanders, L. M., Delamater, A. M., Bentley, M. E., Bronaugh, A. B., Thompson, A. L. 2016; 100: 118-125

    Abstract

    Parent feeding practices affect risk of obesity in children. Latino children are at higher risk of obesity than the general population, yet valid measure of feeding practices, one of which is the Infant Feeding Styles Questionnaire (IFSQ), have not been formally validated in Spanish.To validate the IFSQ among Latino families, we conducted confirmatory factor analysis of pressuring, restrictive, and responsive feeding constructs from the IFSQ.The IFSQ was administered at the 12-month visit in the Greenlight study, a multi-center cluster randomized trial to prevent obesity. Parents were included if they were of Latino origin (n = 303) and completed an English or Spanish language modified IFSQ (without the indulgence construct). Scores from nine sub-constructs of the IFSQ were compared between English and Spanish language versions. We tested reliability with Cronbach's alpha coefficients and performed confirmatory factor analysis to examine factor loadings and goodness of fit characteristics, modifying constructs to achieve best fit.Of 303 parents completing the IFSQ, 84% were born outside the US, and 74% completed the IFSQ in Spanish. Reliability coefficients ranged from 0.28 to 0.61 for the laissez-faire sub-constructs and from 0.58 to 0.83 for the pressuring, restrictive, and responsive sub-constructs. Results for all coefficients were similar between participants responding to an English and Spanish version of the IFSQ. Goodness of fit indices ranged from CFI 0.82-1 and RMSEA 0.00-0.31, and the model performed best in pressuring-soothing (CFI 1.0, RMSEA 0.00) and restrictive-amount (CFI 0.98, RMSEA 0.1) sub-constructs.In a sample of Latino families, pressuring, restrictive, and responsive constructs performed well. The modified IFSQ in both English and Spanish-speaking Latino families may be used to assess parenting behaviors related to early obesity risk in this at-risk population.

    View details for DOI 10.1016/j.appet.2016.02.018

    View details for PubMedID 26876910

    View details for PubMedCentralID PMC4799737

  • Association Between Bottle Size and Formula Intake in 2-Month-Old Infants ACADEMIC PEDIATRICS Wood, C. T., Skinner, A. C., Yin, H. S., Rothman, R. L., Sanders, L. M., Delamater, A., Ravanbakht, S. N., Perrin, E. M. 2016; 16 (3): 254-259

    Abstract

    To determine range of bottle sizes used and examine the relationship between bottle size and total daily consumption of infant formula.Cross-sectional analysis of baseline data collected as part of Greenlight, a cluster randomized trial to prevent childhood obesity at 4 pediatric resident clinics. The Greenlight study included healthy, term infants. For our analysis, parents of exclusively formula-fed infants reported volume per feed, number of feeds per day, and bottle size, which was dichotomized into small (<6 oz) or large (?6 oz). We identified determinants of bottle size, and then examined relationships between bottle size and volume fed with log-transformed ordinary least squares regression, adjusting for infant age, sex, birth weight, current weight, race/ethnicity, and enrollment in Special Supplemental Nutrition Program for Women, Infants, and Children.Of 865 participants in the Greenlight study, 44% (n = 378; 21.8% white, 40.6% black, 35.3% Hispanic, 2.4% other) of infants were exclusively formula fed at 2 months. Median volume per day was 30 oz (interquartile range 12), and 46.0% of infants were fed with large bottles. Adjusted for covariates, parents using larger bottles reported feeding 4 oz more formula per day (34.2 oz, 95% confidence interval 33.5-34.9 vs 29.7 oz, 95% confidence interval 29.2-30.3, P = .03).Among exclusively formula-fed infants, use of a larger bottle is associated with parental report of more formula intake compared to infants fed with smaller bottles. If infants fed with larger bottles receive more formula, these infants may be overfed and consequently at risk for obesity.

    View details for Web of Science ID 000373417500007

    View details for PubMedID 26525989

  • Assessing Differences in Mortality Rates and Risk Factors Between Hispanic and Non-Hispanic Patients With Cystic Fibrosis in California CHEST Buu, M. C., Sanders, L. M., Mayo, J. A., Milla, C. E., Wise, P. H. 2016; 149 (2): 380-389

    Abstract

    Over the past 30 years, therapeutic advances have extended the median life span of patients with cystic fibrosis (CF). Hispanic patients are a vulnerable subpopulation with high of prevalence of risk factors for worse health outcomes. The consequences of these differences on health outcomes have not been well described. The objective of this study is to characterize the difference in health outcomes, including mortality rate, between Hispanic and non-Hispanic patients with CF.Retrospective analysis of CF Foundation patient registry data of California residents with CF, diagnosed during or after 1991, from 1991-2010. Ethnicity was self-reported. Primary outcome was mortality. Hazard ratios were estimated from a Cox regression model, stratified by gender and adjusted for socioeconomic status, clinical risk factors, and year of diagnosis.Of 1719, 485 (28.2%) self-identified as Hispanic. Eighty-five deaths occurred, with an overall mortality rate of 4.9%. Unadjusted mortality rate was higher among Hispanic patients than non-Hispanic patients (9.1% vs. 3.3%, p<0.0001). Compared with non-Hispanic patients, Hispanic patients had lower survival rate 18 years post-diagnosis (75.9% vs. 91.5%, p<0.0001). Adjusted for socioeconomic status and clinical risk factors, Hispanic patients had increased rate of death compared to non-Hispanic patients (HR 2.81, 95% CI 1.70-4.63).Hispanic patients with CF have a higher mortality rate than non-Hispanic patients, even after adjusting for socioeconomic status and clinical severity. Further investigation of mechanism for the measured difference in lung function will help inform interventions and improve the health of all CF patients.

    View details for DOI 10.1378/chest.14-2189

    View details for Web of Science ID 000369660400021

  • Psychosocial Health, e-Health Literacy, and Perceptions of e-Health as Predictors and Moderators of e-Health Use Among Caregivers of Children with Special Healthcare Needs TELEMEDICINE AND E-HEALTH Sarkar, M., Sanders, L. M., Kelleher, K. J., Chisolm, D. J. 2016; 22 (2): 123-131

    View details for DOI 10.1089/tmj.2015.0028

    View details for Web of Science ID 000375124100004

  • Communities Putting Prevention to Work: Results of an Obesity Prevention Initiative in Child Care Facilities JOURNAL OF RESEARCH IN CHILDHOOD EDUCATION Natale, R., Camejo, S., Sanders, L. M. 2016; 30 (3): 306?19

    View details for DOI 10.1080/02568543.2016.1178672

    View details for Web of Science ID 000391018000004

  • Liquid Medication Errors and Dosing Tools: A Randomized Controlled Experiment. Pediatrics Yin, H. S., Parker, R. M., Sanders, L. M., Dreyer, B. P., Mendelsohn, A. L., Bailey, S., Patel, D. A., Jimenez, J. J., Kim, K. A., Jacobson, K., Hedlund, L., Smith, M. C., Maness Harris, L., McFadden, T., Wolf, M. S. 2016; 138 (4)

    Abstract

    Poorly designed labels and packaging are key contributors to medication errors. To identify attributes of labels and dosing tools that could be improved, we examined the extent to which dosing error rates are affected by tool characteristics (ie, type, marking complexity) and discordance between units of measurement on labels and dosing tools; along with differences by health literacy and language.Randomized controlled experiment in 3 urban pediatric clinics. English- or Spanish-speaking parents (n = 2110) of children ?8 years old were randomly assigned to 1 of 5 study arms and given labels and dosing tools that varied in unit pairings. Each parent measured 9 doses of medication (3 amounts [2.5, 5, and 7.5 mL] and 3 tools [1 cup, 2 syringes (0.2- and 0.5-mL increments)]), in random order. Outcome assessed was dosing error (>20% deviation; large error defined as > 2 times the dose).A total of 84.4% of parents made ?1 dosing error (21.0% ?1 large error). More errors were seen with cups than syringes (adjusted odds ratio = 4.6; 95% confidence interval, 4.2-5.1) across health literacy and language groups (P < .001 for interactions), especially for smaller doses. No differences in error rates were seen between the 2 syringe types. Use of a teaspoon-only label (with a milliliter and teaspoon tool) was associated with more errors than when milliliter-only labels and tools were used (adjusted odds ratio = 1.2; 95% confidence interval, 1.01-1.4).Recommending oral syringes over cups, particularly for smaller doses, should be part of a comprehensive pediatric labeling and dosing strategy to reduce medication errors.

    View details for PubMedID 27621414

  • Training Health Care Professionals for 21st-Century Practice: A Systematic Review of Educational Interventions on Chronic Care ACADEMIC MEDICINE Bogetz, J. F., Rassbach, C. E., Bereknyei, S., Mendoza, F. S., Sanders, L. M., Braddock, C. H. 2015; 90 (11): 1561-1572

    Abstract

    To systematically review the evidence for high-quality and effective educational strategies to train health care professionals across the education continuum on chronic disease care.A search of English-language publications and conference proceedings was performed in November 2013 and updated in April 2014. Studies that evaluated a newly developed curriculum targeting chronic disease care with learner outcomes were included. Two primary reviewers and one adjudicating reviewer evaluated the studies and assessed their quality using the validated Medical Education Research Study Quality Instrument (MERSQI). Studies were also mapped onto elements of Wagner's chronic care model (CCM) to evaluate their use of established evidence-based models for chronic care delivery. Miller's classification of clinical competence was used to assess the quality of learner achievements for each educational intervention.A total of 672 articles were found for this review. Twenty-two met criteria for data extraction. The majority of studies were of moderate quality according to MERSQI scoring. Only three studies reported both learner and patient outcomes. The highest-quality studies incorporated more elements of Wagner's CCM and showed high-level learner competence according to Miller's classification. Successful interventions redesigned health care delivery systems to include team-based care, emphasized training of health care professionals on patient self-management, and included learner-based quality improvement initiatives.The growing number of children and adults with chronic disease necessitates improved educational interventions for health care professionals that involve evidence-based models for restructuring chronic care delivery, aim for high-level learner behavioral outcomes, and evolve through quality improvement initiatives.

    View details for DOI 10.1097/ACM.0000000000000773

    View details for PubMedID 26039140

  • Predictors of Health Literacy and Numeracy Concordance Among Adolescents With Special Health Care Needs and Their Parents JOURNAL OF HEALTH COMMUNICATION Chisolm, D. J., Sarkar, M., Kelleher, K. J., Sanders, L. M. 2015; 20: 43-49

    Abstract

    Parent and teen health literacies (HLs) are employed as teens with chronic illnesses transition to health self-management and the adult health system. This study explores the relationships between parent and teen HL. Teens ages 12-18 with chronic conditions and their parents, sampled from a pediatric Medicaid accountable care organization, completed an interview assessing HL and self-reported competence with written and numerical health information. Rates of teen and parent HL, degree of concordance, and the relationship between concordance and teen-reported competence with health materials were measured. Half (52%) of teens had adequate HL, 62% of teens reported competence with written health materials, and 69% reported competence with numerical information. The correlation between parent and teen HL was modest but significant (? = 0.13, p = .03): 47% of parent-teen dyads were concordant for adequate HL, and 10% were concordant for inadequate HL. Adequate teen HL was associated with parental adequate HL and parental education. Discordance was associated with self-reported competence with written material and numerical material. More than half of parent-teen dyads had at least 1 member with less than adequate HL, and parent-teen HL concordance was associated with teen perception of HL. These findings support the consideration of both independent and dyad HL levels in adolescent care.

    View details for DOI 10.1080/10810730.2015.1058443

    View details for Web of Science ID 000363690000006

    View details for PubMedID 26513030

    View details for PubMedCentralID PMC4699417

  • Early Literacy Promotion in the Digital Age. Pediatric clinics of North America Navsaria, D., Sanders, L. M. 2015; 62 (5): 1273-1295

    Abstract

    School readiness and educational success is strongly mediated by early literacy skills. In both exam-room and community-based settings, child-health providers can affect the trajectory of early literacy by implementing evidence-based, culturally appropriate interventions that support child development, parenting skills, and child-caregiver interaction. Despite limited research on the subject, these interventions should also attend to the evolving role of digital-media exposure (both positive and negative) on the developmental health of children.

    View details for DOI 10.1016/j.pcl.2015.06.002

    View details for PubMedID 26318952

  • Patient-centered medical home for patients with complex congenital heart disease. Current opinion in pediatrics Fernandes, S. M., Sanders, L. M. 2015; 27 (5): 581-586

    Abstract

    Originally conceived by pediatricians as a model for the care of children with special healthcare needs, the 'patient-centered medical home' (PCMH) has been identified by the Affordable Care Act as a model for all future outpatient care delivery. Although few studies have demonstrated its efficacy in improving care for children with congenital heart disease (CHD), access to a PCMH is likely to improve CHD-patient outcomes, including global function and quality of life, while reducing healthcare costs.To date, most patients with complex CHD have their care anchored in cardiology subspecialty-care clinics, which lack many of the attributes of a PCMH. Given that many of these patients have noncardiac morbidities, including neurocognitive impairment and multiorgan dysfunction, we believe such patients will benefit from a PCMH model of care based on primary care.The PCMH based on primary care for patients with complex CHD could result in improved clinical outcomes, improved patient satisfaction and quality of life as well as decreased healthcare costs. Policy and practice reform are required to increase CHD-patient access to a PCMH, based on primary-care settings.

    View details for DOI 10.1097/MOP.0000000000000258

    View details for PubMedID 26348668

  • Psychosocial Health, e-Health Literacy, and Perceptions of e-Health as Predictors and Moderators of e-Health Use Among Caregivers of Children with Special Healthcare Needs. Telemedicine journal and e-health : the official journal of the American Telemedicine Association Sarkar, M., Sanders, L. M., Kelleher, K. J., Chisolm, D. J. 2015: -?

    Abstract

    In this study, we explored the relationships between the psychosocial health of caregivers of children with special healthcare needs and their e-health use. Additionally, the analysis examined moderating effects of a caregiver's perceptions of e-health and his or her e-health literacy on the associations among four domains of psychosocial health and e-health use.To date, 313 caregivers of children, 12-18 years of age, with special healthcare needs have been recruited. Covariate-adjusted multivariable regressions determined associations between psychosocial health domains of caregivers and e-health use. E-health literacy and perceptions of e-health were further tested as moderators of the relationship between psychosocial health and e-health use.Among the caregiver population, 31% had problems with social functioning, 36.1% with communication, 43.3% with family relationships, and 46.3% with worrying for their child. After adjusting for demographic variables, e-health use was associated with poorer levels of social functioning, communication, worry, and family relationship. E-health use was also associated with e-health literacy. Perceptions of e-health significantly moderated the relationships among social functioning, communication, and e-health, with the relationship being significantly stronger in caregivers with more positive perceptions of e-health.Caregivers of children with special healthcare needs have notable levels of psychosocial challenges and those challenges are associated with their e-health resource seeking. Although e-health interventions, including ones that focus on child health education and caregiver support, may be the future of healthcare, a concerted effort is needed to educate caregivers about the benefits of e-health.

    View details for PubMedID 26295487

  • Health Care Utilization and Costs of Publicly-Insured Children with Diabetes in California. journal of pediatrics Lee, J. M., Sundaram, V., Sanders, L., Chamberlain, L., Wise, P. 2015; 167 (2): 449-54 e6

    Abstract

    To examine diabetes-related health care utilization and costs for a population-based sample of children with presumed type 1 diabetes (T1D) enrolled in the California Children's Services program.Our data source was the California Children's Services claims data for the period July 1, 2009, to June 30, 2012. We studied a sample of 652 children aged 0-21 years who were continuously enrolled for at least 365 days, had an outpatient visit for T1D, and were taking insulin.Compared with the younger age groups, individuals in the 19-21 year age group had the highest rates of hospitalization, T1D-specific bed-days, and emergency department visits. The overall median cost for this population was $7654. The overall median costs per year (and proportion of total costs) were $5603 (59%) for hospitalizations, $58 (0.4%) for emergency department visits, $144 (1.3%) for outpatient utilization, $2930 (23%) for insulin, and $1579 (13%) for blood glucose monitoring supplies. For those who used them, the median cost of pumps was an additional $2162.Further studies are needed to provide more insight into patterns of care and adverse health outcomes for children with T1D as they transition into young adulthood. The costs of insulin, glucose monitoring supplies, and pump therapy for children with T1D is substantial and may factor into future policy considerations regarding coverage and cost-sharing with families.

    View details for DOI 10.1016/j.jpeds.2015.04.067

    View details for PubMedID 26028286

  • Health Care Utilization and Costs of Publicly-Insured Children with Diabetes in California. journal of pediatrics Lee, J. M., Sundaram, V., Sanders, L., Chamberlain, L., Wise, P. 2015; 167 (2): 449-454 e6

    Abstract

    To examine diabetes-related health care utilization and costs for a population-based sample of children with presumed type 1 diabetes (T1D) enrolled in the California Children's Services program.Our data source was the California Children's Services claims data for the period July 1, 2009, to June 30, 2012. We studied a sample of 652 children aged 0-21 years who were continuously enrolled for at least 365 days, had an outpatient visit for T1D, and were taking insulin.Compared with the younger age groups, individuals in the 19-21 year age group had the highest rates of hospitalization, T1D-specific bed-days, and emergency department visits. The overall median cost for this population was $7654. The overall median costs per year (and proportion of total costs) were $5603 (59%) for hospitalizations, $58 (0.4%) for emergency department visits, $144 (1.3%) for outpatient utilization, $2930 (23%) for insulin, and $1579 (13%) for blood glucose monitoring supplies. For those who used them, the median cost of pumps was an additional $2162.Further studies are needed to provide more insight into patterns of care and adverse health outcomes for children with T1D as they transition into young adulthood. The costs of insulin, glucose monitoring supplies, and pump therapy for children with T1D is substantial and may factor into future policy considerations regarding coverage and cost-sharing with families.

    View details for DOI 10.1016/j.jpeds.2015.04.067

    View details for PubMedID 26028286

  • Outpatient Pharmacy Expenditures for Children With Serious Chronic Illness in California, 2010-2012. JAMA Swenson, S. M., Chamberlain, L. J., Sanders, L. M., Sundaram, V., Wise, P. H. 2015; 314 (4): 405-407

    View details for DOI 10.1001/jama.2015.7169

    View details for PubMedID 26219060

  • Variation in Use of Pediatric Cardiology Subspecialty Care A Total Population Study in California, 1983 to 2011 JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Chamberlain, L. J., Fernandes, S. M., Saynina, O., Grady, S., Sanders, L., Staves, K., Wise, P. H. 2015; 66 (1): 37-44

    Abstract

    American Academy of Pediatrics guidelines emphasize regionalized systems of care for pediatric chronic illness. There remains a paucity of information on the status of regionalized systems of care for pediatric congenital heart disease (CHD).This study evaluated variations in use of pediatric cardiology specialty care centers (PCSCC) for pediatric patients with CHD in California between 1983 and 2011.We performed a retrospective, total population analysis of pediatric CHD patients using the California Office of Statewide Health Planning and Development unmasked database. PCSCCs were identified by California's Title V program.There were 164,310 discharges meeting inclusion criterion. Discharges from PCSCCs grew from 58% to 88% between 1983 and 2011. Regionalized care was highest for surgical (96%) versus nonsurgical (71%) admissions. Admissions with a public payer increased from 42% (1983) to 61% (2011). Total bed days nearly doubled, and median length of stay increased from 2 to 3 days (nonspecialty care) and from 4 to 5 days (specialty care). There was a decrease in the pediatric CHD in-hospital death rate from 5.1 to 2.3 per 100,000 between 1983 and 2011, and a shift toward a larger percent of deaths occurring in the newborn period.California's inpatient regionalized specialty care of pediatric CHD has increased substantially since 1983, especially for surgical CHD discharges. The death rate has decreased, the number of bed days has increased, and a large proportion of these discharges now have public payers. Health care reform efforts must consider these shifts while protecting advances in regionalization of pediatric CHD care.

    View details for DOI 10.1016/j.jacc.2015.04.053

    View details for PubMedID 26139056

  • Outcomes of a Randomized Controlled Educational Intervention to Train Pediatric Residents on Caring for Children With Special Health Care Needs CLINICAL PEDIATRICS Bogetz, J. F., Gabhart, J. M., Rassbach, C. E., Sanders, L. M., Mendoza, F. S., Bergman, D. A., Blankenburg, R. L. 2015; 54 (7): 659-666

    Abstract

    Objective. To evaluate an innovative curriculum meeting new pediatric residency education guidelines, Special Care Optimization for Patients and Education (SCOPE). Methods. Residents were randomized to intervention (n = 23) or control (n = 25) groups. Intervention residents participated in SCOPE, pairing them with a child with special health care needs (CSHCN) and faculty mentor to make a home visit, complete care coordination toolkits, and participate in case discussions. The primary outcome was resident self-efficacy in nine skills in caring for CSHCN. Secondary outcomes included curriculum feasibility/acceptance, resident attitudes, and family satisfaction. Results. Response rates were ?65%. Intervention residents improved in their self-efficacy for setting patient-centered goals compared with controls (mean change on 4-point Likert-type scale, 1.36 vs 0.56, P < .05). SCOPE was feasible/acceptable, residents had improved attitudes toward CSHCN, and families reported high satisfaction. Conclusion. SCOPE may serve as a model for efforts to increase residents' self-efficacy in their care of patients with chronic disease.

    View details for DOI 10.1177/0009922814564050

    View details for PubMedID 25561698

  • Trends in utilization of specialty care centers in california for adults with congenital heart disease. American journal of cardiology Fernandes, S. M., Chamberlain, L. J., Grady, S., Saynina, O., Opotowsky, A. R., Sanders, L., Wise, P. H. 2015; 115 (9): 1298-1304

    Abstract

    The American College of Cardiology and American Heart Association guidelines recommend that management of adult congenital heart disease (ACHD) be coordinated by specialty ACHD centers and that ACHD surgery for patients with moderate or complex congenital heart disease (CHD) be performed by surgeons with expertise and training in CHD. Given this, the aim of this study was to determine the proportion of ACHD surgery performed at specialty ACHD centers and to identify factors associated with ACHD surgery being performed outside of specialty centers. This retrospective population analysis used California's Office of Statewide Health Planning and Development's discharge database to analyze ACHD cardiac surgery (in patients 21 to 65 years of age) in California from 2000 to 2011. Designation as a "specialty ACHD center" was defined on the basis of a national ACHD directory. A total of 4,611 ACHD procedures were identified. The proportion of procedures in patients with moderate and complex CHD delivered at specialty centers increased from 46% to 71% from 2000 to 2011. In multivariate analysis among those discharges for ACHD surgery in patients with moderate or complex CHD, performance of surgery outside a specialty center was more likely to be associated with patients who were older, Hispanic, insured by health maintenance organizations, and living farther from a specialty center. In conclusion, although the proportion of ACHD surgery for moderate or complex CHD being performed at specialty ACHD centers has been increasing, 1 in 4 patients undergo surgery at nonspecialty centers. Increased awareness of ACHD care guidelines and of the patient characteristics associated with differential access to ACHD centers may help improve the delivery of appropriate care for all adults with CHD.

    View details for DOI 10.1016/j.amjcard.2015.02.013

    View details for PubMedID 25765587

  • The Relationship Between Acculturation and Infant Feeding Styles in a Latino Population OBESITY Dancel, L. D., Perrin, E., Yin, H. S., Sanders, L., Delamater, A., Perreira, K. M., Bronaugh, A. B., Eden, S., Shintani, A., Rothman, R. L. 2015; 23 (4): 840-846

    Abstract

    To assess the relationship between parental acculturation and infant feeding style in a sample of Latino parents.A post hoc analysis was performed using data from an ongoing four-site randomized controlled trial to promote early childhood obesity prevention. Cross-sectional data of parent-child dyads at the 12-month well-child visit who self-reported their Latino ethnicity were analyzed. The Short Acculturation Scale for Hispanics (SASH) and a subset of the Infant Feeding Style Questionnaire (IFSQ) that assessed four primary feeding styles were administered. SASH level (low vs. high) with each feeding style was compared by analyses.Complete SASH data were available for 398 of 431 Latino dyads. Median SASH score was 1.8 (IQR 1.4-2.7); 82% of participants had low acculturation (score?

    View details for DOI 10.1002/oby.20986

    View details for Web of Science ID 000351832400019

    View details for PubMedID 25755135

  • Assessing differences in mortality rates and risk factors between Hispanic and non-Hispanic patients with cystic fibrosis in California. Chest Buu, M. C., Sanders, L. M., Mayo, J., Milla, C. E., Wise, P. H. 2015

    Abstract

    Over the past 30 years, therapeutic advances have extended the median life span of patients with cystic fibrosis (CF). Hispanic patients are a vulnerable subpopulation with high of prevalence of risk factors for worse health outcomes. The consequences of these differences on health outcomes have not been well described. The objective of this study is to characterize the difference in health outcomes, including mortality rate, between Hispanic and non-Hispanic patients with CF.Retrospective analysis of CF Foundation patient registry data of California residents with CF, diagnosed during or after 1991, from 1991-2010. Ethnicity was self-reported. Primary outcome was mortality. Hazard ratios were estimated from a Cox regression model, stratified by gender and adjusted for socioeconomic status, clinical risk factors, and year of diagnosis.Of 1719, 485 (28.2%) self-identified as Hispanic. Eighty-five deaths occurred, with an overall mortality rate of 4.9%. Unadjusted mortality rate was higher among Hispanic patients than non-Hispanic patients (9.1% vs. 3.3%, p<0.0001). Compared with non-Hispanic patients, Hispanic patients had lower survival rate 18 years post-diagnosis (75.9% vs. 91.5%, p<0.0001). Adjusted for socioeconomic status and clinical risk factors, Hispanic patients had increased rate of death compared to non-Hispanic patients (HR 2.81, 95% CI 1.70-4.63).Hispanic patients with CF have a higher mortality rate than non-Hispanic patients, even after adjusting for socioeconomic status and clinical severity. Further investigation of mechanism for the measured difference in lung function will help inform interventions and improve the health of all CF patients.

    View details for PubMedID 26086984

  • Teaching Health Advocacy to Medical Students: A Comparison Study JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE Belkowitz, J., Sanders, L. M., Zhang, C., Agarwal, G., Lichtstein, D., Mechaber, A. J., Chung, E. K. 2014; 20 (6): E10-E19

    Abstract

    Many encourage service learning and health advocacy training in medical student education, but related evaluation is limited.To assess (1) impact of a required community health advocacy training for medical students on student attitudes, knowledge, and skills; (2) student characteristics associated with higher advocacy knowledge and skills; and (3) perspectives of community-based organizations (CBOs).Cross-sectional surveys.University of Miami Miller School of Medicine (UMMSM) Regional Medical Campus and main campus.Medical students at both UMMSM campuses.Required community health advocacy training for first- and second-year students including classroom experiences and hands-on project in partnership with a CBO.Student characteristics, health advocacy-related attitudes, self-reported and objective knowledge, and skills. Scores were compared between campuses, with multivariable modeling adjusting for individual student characteristics. Community-based organization perspectives were assessed via separate surveys.Ninety-eight (77%) regional campus students (intervention group) and 139 (30%) main campus students (comparison group) completed surveys. Versus the comparison group, the intervention group reported greater: mean knowledge of community health needs: 34.6 versus 31.1 (range: 11-44, P < .01), knowledge about CBOs: 3.0 versus 2.7 (range 1-4, P < .01) and knowledge of community resources: 5.4 versus 2.3 (range, 0-11, P < .01), and mean skill scores: 12.7 versus 10.5 (score range: 4-16, P < .01), following the intervention. Using adjusted analysis across both groups, female gender was associated with higher attitudes score. High level of previous community involvement was associated with higher attitude and skill scores. Higher self-reported educational debt was associated with higher skill scores. Community-based organization perspectives included high satisfaction and a desire to influence the training of future physicians.Medical student advocacy training in partnership with community-based organizations could be beneficial in improving student advocacy knowledge and skills in addressing community health issues and in developing sustainable community partnerships.

    View details for DOI 10.1097/PHH.0000000000000031

    View details for Web of Science ID 000343127500002

  • Assessing Patient Experiences in the Pediatric Patient-Centered Medical Home: A Comparison of Two Instruments MATERNAL AND CHILD HEALTH JOURNAL Knapp, C., Chakravorty, S., Madden, V., Baron-Lee, J., Gubernick, R., Kairys, S., Pelaez-Velez, C., Sanders, L. M., Thompson, L. 2014; 18 (9): 2124-2133

    Abstract

    The Patient-Centered Medical Home (PCMH) is a model of care that has been promoted as a way to transform a broken primary care system in the US. However, in order to convince more practices to make the transformation and to properly reimburse practices who are PCMHs, valid and reliable data are needed. Data that capture patient experiences in a PCMH is valuable, but which instrument should be used remains unclear. Our study aims to compare the validity and reliability of two national PCMH instruments. Telephone surveys were conducted with children who receive care from 20 pediatric practices across Florida (n = 990). All of the children are eligible for Medicaid or the Children's Health Insurance Program. Analyses were conducted to compare the Consumer Assessment of Health Plan Survey-Patient-Centered Medical Home (CAHPS-PCMH) and the National Survey of Children with Special Health Care Needs (NS-CSHCN) medical home domain. Respondents were mainly White non-Hispanic, female, under 35 years old, and from a two-parent household. The NS-CSHCN outperformed the CAHPS-PCMH in regard to scale reliability (Cronbach's alpha coefficients all ?0.81 vs. 0.56-0.85, respectively). In regard to item-domain convergence and discriminant validity the CAHPS-PCMH fared better than the NS-CSHCN (range of convergence 0.66-0.93 vs. 0.32-1.00). The CAHPS-PCMH did not correspond to the scale structure in construct validity testing. Neither instrument performed well in the known-groups validity tests. No clear best instrument was determined. Further revision and calibration may be needed to accurately assess patient experiences in the PCMH.

    View details for DOI 10.1007/s10995-014-1460-9

    View details for Web of Science ID 000343929300012

  • Teaching health advocacy to medical students: a comparison study. Journal of public health management and practice Belkowitz, J., Sanders, L. M., Zhang, C., Agarwal, G., Lichtstein, D., Mechaber, A. J., Chung, E. K. 2014; 20 (6): E10-9

    Abstract

    Many encourage service learning and health advocacy training in medical student education, but related evaluation is limited.To assess (1) impact of a required community health advocacy training for medical students on student attitudes, knowledge, and skills; (2) student characteristics associated with higher advocacy knowledge and skills; and (3) perspectives of community-based organizations (CBOs).Cross-sectional surveys.University of Miami Miller School of Medicine (UMMSM) Regional Medical Campus and main campus.Medical students at both UMMSM campuses.Required community health advocacy training for first- and second-year students including classroom experiences and hands-on project in partnership with a CBO.Student characteristics, health advocacy-related attitudes, self-reported and objective knowledge, and skills. Scores were compared between campuses, with multivariable modeling adjusting for individual student characteristics. Community-based organization perspectives were assessed via separate surveys.Ninety-eight (77%) regional campus students (intervention group) and 139 (30%) main campus students (comparison group) completed surveys. Versus the comparison group, the intervention group reported greater: mean knowledge of community health needs: 34.6 versus 31.1 (range: 11-44, P < .01), knowledge about CBOs: 3.0 versus 2.7 (range 1-4, P < .01) and knowledge of community resources: 5.4 versus 2.3 (range, 0-11, P < .01), and mean skill scores: 12.7 versus 10.5 (score range: 4-16, P < .01), following the intervention. Using adjusted analysis across both groups, female gender was associated with higher attitudes score. High level of previous community involvement was associated with higher attitude and skill scores. Higher self-reported educational debt was associated with higher skill scores. Community-based organization perspectives included high satisfaction and a desire to influence the training of future physicians.Medical student advocacy training in partnership with community-based organizations could be beneficial in improving student advocacy knowledge and skills in addressing community health issues and in developing sustainable community partnerships.

    View details for DOI 10.1097/PHH.0000000000000031

    View details for PubMedID 24322841

  • Characteristics and Direct Costs of Academic Pediatric Subspecialty Outpatient No-Show Events JOURNAL FOR HEALTHCARE QUALITY Perez, F. D., Xie, J., Sin, A., Tsai, R., Sanders, L., Cox, K., Haberland, C. A., Park, K. T. 2014; 36 (4): 32-42

    Abstract

    BACKGROUND: Clinic no shows (NS) create a lost opportunity for provider-patient interaction and impose a financial burden to the healthcare system and on society. We aimed to: (1) to determine the clinical and demographic factors associated with increased NS rates at a children's hospital's subsubspecialty clinics and (2) to estimate the direct institutional financial costs associated with NS events. METHODS: A comprehensive database was generated from all clinic encounters for 15 subspecialty outpatient clinics (five surgical and 10 medical) between September 12, 2005 and December 30, 2010. Multivariate logistic regressions were performed to identify the variables associated with NS events. Direct costs of NS events were estimated using annual revenue for each clinic. RESULTS: A total of 284,275 encounters and 17,024 NS events were available for analysis. Public insurance coverage (Medicaid and Title V), compared to private insurance or self-pay status, was associated with an increased likelihood NS (OR 2.19, 95% CI 2.10-2.28, p < 0.0005 for Medicaid; OR 1.56, 95% CI 1.50-1.62, p < 0.0005 for Title V). Compared to patients 21-30 years of age, patients <12 years (OR 2.08, 95% CI 1.77-2.45, p < 0.0005) had increased likelihood of NS. Scheduled visits with medical subspecialists were more likely than surgical subspecialty visits to result in a NS (OR 1.69, 95% CI 1.63-1.75, p < 0.0005). The predicted annualized lost revenue associated with NS visits was estimated at $730,000 from the 15 clinics analyzed, approximately $210 per NS event. CONCLUSION: Pediatric subspecialty NS events are common, costly, and potentially preventable.

    View details for Web of Science ID 000348450800003

    View details for PubMedID 23551280

  • "Greenlight study": a controlled trial of low-literacy, early childhood obesity prevention. Pediatrics Sanders, L. M., Perrin, E. M., Yin, H. S., Bronaugh, A., Rothman, R. L. 2014; 133 (6): e1724-37

    Abstract

    Children who become overweight by age 2 years have significantly greater risks of long-term health problems, and children in low-income communities, where rates of low adult literacy are highest, are at increased risk of developing obesity. The objective of the Greenlight Intervention Study is to assess the effectiveness of a low-literacy, primary-care intervention on the reduction of early childhood obesity. At 4 primary-care pediatric residency training sites across the US, 865 infant-parent dyads were enrolled at the 2-month well-child checkup and are being followed through the 24-month well-child checkup. Two sites were randomly assigned to the intervention, and the other sites were assigned to an attention-control arm, implementing the American Academy of Pediatrics' The Injury Prevention Program. The intervention consists of an interactive educational toolkit, including low-literacy materials designed for use during well-child visits, and a clinician-centered curriculum for providing low-literacy guidance on obesity prevention. The study is powered to detect a 10% difference in the number of children overweight (BMI > 85%) at 24 months. Other outcome measures include observed physician-parent communication, as well as parent-reported information on child dietary intake, physical activity, and injury-prevention behaviors. The study is designed to inform evidence-based standards for early childhood obesity prevention, and more generally to inform optimal approaches for low-literacy messages and health literacy training in primary preventive care. This article describes the conceptual model, study design, intervention content, and baseline characteristics of the study population.

    View details for DOI 10.1542/peds.2013-3867

    View details for PubMedID 24819570

    View details for PubMedCentralID PMC4035594

  • How do Breast Imaging Centers Communicate Results to Women with Limited English Proficiency and Other Barriers to Care? JOURNAL OF IMMIGRANT AND MINORITY HEALTH Marcus, E. N., Koru-Sengul, T., Miao, F., Yepes, M., Sanders, L. 2014; 16 (3): 401-408

    Abstract

    Research suggests that women with Limited English Proficiency (LEP) and ethnic minority women are at increased risk of being inadequately informed of their mammogram result. The purpose of this study is to explore breast imaging centers' communication practices and assess how these centers accommodate women with low literacy and LEP. A 35-question survey was distributed to a national association of more than 700 breast health centers. Descriptive analysis of the overall sample and Fisher's exact or Chi squared testing to distinguish differences between subgroups were performed. Respondents from 206 centers completed questionnaires. 29% of respondents stated that more than a quarter of their patients were black, 27% of respondents stated that more than a quarter of their patients were Hispanic/Latina, and 13% of respondents stated that more than a quarter of their patients had LEP. Overall, 18% of respondents reported they do not routinely telephone patients with results, 15% do not have multilingual staff or translators available to answer questions, and 69% send result letters in English only. Of note, 69% use patient navigators. Centers reported systemic strengths and barriers to clear communication of mammography results. Our findings are consistent with past investigations identifying a general need to improve the communication of breast imaging results and suggesting that result notification letters alone are inadequate in ensuring that every woman understands her personal results and follow-up plan.

    View details for DOI 10.1007/s10903-012-9771-7

    View details for Web of Science ID 000335771700010

    View details for PubMedID 23324987

  • Health Literacy and Injury Prevention Behaviors Among Caregivers of Infants AMERICAN JOURNAL OF PREVENTIVE MEDICINE Heerman, W. J., Perrin, E. M., Yin, H. S., Sanders, L. M., Eden, S. K., Shintani, A., Coyne-Beasley, T., Bronaugh, A. B., Barkin, S. L., Rothman, R. L. 2014; 46 (5): 449-456

    Abstract

    Unintentional injury is a leading cause of infant mortality.To examine the role of caregiver health literacy in infant injury prevention behaviors.A cross-sectional analysis of data collected in 2010-2012 from a randomized trial at four pediatric clinics was performed in 2012-2013. Caregiver health literacy was assessed with the Short Test of Functional Health Literacy in Adults. Caregiver-reported adherence to American Academy of Pediatrics-recommended injury prevention behaviors was assessed across seven domains: (1) car seat position; (2) car seat use; (3) sleeping safety; (4) fire safety; (5) hot water safety; (6) fall prevention; and (7) firearm safety.Data were analyzed from 844 English- and Spanish-speaking caregivers of 2-month-old children. Many caregivers were non-adherent with injury prevention guidelines, regardless of health literacy. Notably, 42.6% inappropriately placed their children in the prone position to sleep, and 88.6% did not have their hot water heater set <120°F. Eleven percent of caregivers were categorized as having low health literacy. Low caregiver health literacy, compared to adequate health literacy, was significantly associated with increased odds of caregiver non-adherence with recommended behaviors for car seat position (AOR=3.4, 95% CI=1.6, 7.1) and fire safety (AOR=2.0, 95% CI=1.02, 4.1) recommendations. Caregivers with low health literacy were less likely to be non-adherent to fall prevention recommendations (AOR=0.5, 95% CI=0.2, 0.9).Non-adherence to injury prevention guidelines was common. Low caregiver health literacy was significantly associated with some injury prevention behaviors. Future interventions should consider the role of health literacy in promoting injury prevention.

    View details for DOI 10.1016/j.amepre.2014.01.005

    View details for Web of Science ID 000334768400004

    View details for PubMedID 24745634

    View details for PubMedCentralID PMC4040284

  • Measurement of Parental Self-Efficacy for Diabetes Management in Young Children CHILDRENS HEALTH CARE Marchante, A. N., Pulgaron, E. R., Daigre, A., Patino-Fernandez, A. M., Sanchez, J., Sanders, L. M., Delamater, A. M. 2014; 43 (2): 110-119

    View details for DOI 10.1080/02739615.2014.849957

    View details for Web of Science ID 000334265900003

  • Racial and Ethnic Differences Associated With Feeding- and Activity- Related Behaviors in Infants PEDIATRICS Perrin, E. M., Rothman, R. L., Sanders, L. M., Skinner, A. C., Eden, S. K., Shintani, A., Throop, E. M., Yin, H. S. 2014; 133 (4): E857-E867

    Abstract

    To examine parental reports of feeding and activity behaviors in a cohort of parents of 2-month-olds and how they differ by race/ethnicity.Parents participating in Greenlight, a cluster, randomized trial of obesity prevention at 4 health centers, were queried at enrollment about feeding and activity behaviors thought to increase obesity risk. Unadjusted associations between race/ethnicity and the outcomes of interest were performed by using Pearson ?(2) and Kruskal-Wallis tests. Adjusted analyses were performed by using proportional odds logistic regressions.Eight hundred sixty-three parents (50% Hispanic, 27% black, 18% white; 86% Medicaid) were enrolled. Exclusive formula feeding was more than twice as common (45%) as exclusive breastfeeding (19%); 12% had already introduced solid food; 43% put infants to bed with bottles; 23% propped bottles; 20% always fed when the infant cried; 38% always tried to get children to finish milk; 90% were exposed to television (mean, 346 minutes/day); 50% reported active television watching (mean, 25 minutes/day); and 66% did not meet "tummy time" recommendations. Compared with white parents, black parents were more likely to put children to bed with a bottle (adjusted odds ratio [aOR] = 1.97, P < .004; bottle propping, aOR = 3.1, P < .001), and report more television watching (aOR = 1.6, P = .034). Hispanic parents were more likely than white parents to encourage children to finish feeding (aOR = 1.9, P = .007), bottle propping (aOR = 2.5, P = .009), and report less tummy time (aOR = 0.6, P = .037).Behaviors thought to relate to later obesity were highly prevalent in this large, diverse sample and varied by race/ethnicity, suggesting the importance of early and culturally-adapted interventions.

    View details for DOI 10.1542/peds.2013-1326

    View details for Web of Science ID 000335343500033

    View details for PubMedID 24639273

    View details for PubMedCentralID PMC3966498

  • Parental limited English proficiency and health outcomes for children with special health care needs: a systematic review. Academic pediatrics Eneriz-Wiemer, M., Sanders, L. M., Barr, D. A., Mendoza, F. S. 2014; 14 (2): 128-136

    Abstract

    One in 10 US adults of childbearing age has limited English proficiency (LEP). Parental LEP is associated with worse health outcomes among healthy children. The relationship of parental LEP to health outcomes for children with special health care needs (CSHCN) has not been systematically reviewed.To conduct a systematic review of peer-reviewed literature examining relationships between parental LEP and health outcomes for CSHCN.PubMed, Scopus, Cochrane Library, Social Science Abstracts, bibliographies of included studies. Key search term categories: language, child, special health care needs, and health outcomes.US studies published between 1964 and 2012 were included if: 1) subjects were CSHCN; 2) studies included some measure of parental LEP; 3) at least 1 outcome measure of child health status, access, utilization, costs, or quality; and 4) primary or secondary data analysis.Three trained reviewers independently screened studies and extracted data. Two separate reviewers appraised studies for methodological rigor and quality.From 2765 titles and abstracts, 31 studies met eligibility criteria. Five studies assessed child health status, 12 assessed access, 8 assessed utilization, 2 assessed costs, and 14 assessed quality. Nearly all (29 of 31) studies used only parent- or child-reported outcome measures, rather than objective measures. LEP parents were substantially more likely than English-proficient parents to report that their CSHCN were uninsured and had no usual source of care or medical home. LEP parents were also less likely to report family-centered care and satisfaction with care. Disparities persisted for children with LEP parents after adjustment for ethnicity and socioeconomic status.Parental LEP is independently associated with worse health care access and quality for CSHCN. Health care providers should recognize LEP as an independent risk factor for poor health outcomes among CSHCN. Emerging models of chronic disease care should integrate and evaluate interventions that target access and quality disparities for LEP families.

    View details for DOI 10.1016/j.acap.2013.10.003

    View details for PubMedID 24602575

  • Parent health literacy and "obesogenic" feeding and physical activity-related infant care behaviors. journal of pediatrics Yin, H. S., Sanders, L. M., Rothman, R. L., Shustak, R., Eden, S. K., Shintani, A., Cerra, M. E., Cruzatte, E. F., Perrin, E. M. 2014; 164 (3): 577-583 e1

    Abstract

    To examine the relationship between parent health literacy and "obesogenic" infant care behaviors.Cross-sectional analysis of baseline data from a cluster randomized controlled trial of a primary care-based early childhood obesity prevention program (Greenlight). English- and Spanish-speaking parents of 2-month-old children were enrolled (n = 844). The primary predictor variable was parent health literacy (Short Test of Functional Health Literacy in Adults; adequate ?23; low <23). Primary outcome variables involving self-reported obesogenic behaviors were: (1) feeding content (more formula than breast milk, sweet drinks, early solid food introduction), and feeding style-related behaviors (pressuring to finish, laissez-faire bottle propping/television [TV] watching while feeding, nonresponsiveness in letting child decide amount to eat); and (2) physical activity (tummy time, TV). Multivariate logistic regression analyses (binary, proportional odds models) performed adjusting for child sex, out-of-home care, Women, Infants, and Children program status, parent age, race/ethnicity, language, number of adults/children in home, income, and site.Eleven percent of parents were categorized as having low health literacy. Low health literacy significantly increased the odds of a parent reporting that they feed more formula than breast milk, (aOR = 2.0 [95% CI: 1.2-3.5]), immediately feed when their child cries (aOR = 1.8 [1.1-2.8]), bottle prop (aOR = 1.8 [1.002-3.1]), any infant TV watching (aOR = 1.8 [1.1-3.0]), and inadequate tummy time (<30 min/d), (aOR = 3.0 [1.5-5.8]).Low parent health literacy is associated with certain obesogenic infant care behaviors. These behaviors may be modifiable targets for low health literacy-focused interventions to help reduce childhood obesity.

    View details for DOI 10.1016/j.jpeds.2013.11.014

    View details for PubMedID 24370343

    View details for PubMedCentralID PMC3943839

  • Parental Limited English Proficiency and Health Outcomes for Children With Special Health Care Needs: A Systematic Review ACADEMIC PEDIATRICS Eneriz-Wiemer, M., Sanders, L. M., Barr, D. A., Mendoza, F. S. 2014; 14 (2): 128-136

    Abstract

    One in 10 US adults of childbearing age has limited English proficiency (LEP). Parental LEP is associated with worse health outcomes among healthy children. The relationship of parental LEP to health outcomes for children with special health care needs (CSHCN) has not been systematically reviewed.To conduct a systematic review of peer-reviewed literature examining relationships between parental LEP and health outcomes for CSHCN.PubMed, Scopus, Cochrane Library, Social Science Abstracts, bibliographies of included studies. Key search term categories: language, child, special health care needs, and health outcomes.US studies published between 1964 and 2012 were included if: 1) subjects were CSHCN; 2) studies included some measure of parental LEP; 3) at least 1 outcome measure of child health status, access, utilization, costs, or quality; and 4) primary or secondary data analysis.Three trained reviewers independently screened studies and extracted data. Two separate reviewers appraised studies for methodological rigor and quality.From 2765 titles and abstracts, 31 studies met eligibility criteria. Five studies assessed child health status, 12 assessed access, 8 assessed utilization, 2 assessed costs, and 14 assessed quality. Nearly all (29 of 31) studies used only parent- or child-reported outcome measures, rather than objective measures. LEP parents were substantially more likely than English-proficient parents to report that their CSHCN were uninsured and had no usual source of care or medical home. LEP parents were also less likely to report family-centered care and satisfaction with care. Disparities persisted for children with LEP parents after adjustment for ethnicity and socioeconomic status.Parental LEP is independently associated with worse health care access and quality for CSHCN. Health care providers should recognize LEP as an independent risk factor for poor health outcomes among CSHCN. Emerging models of chronic disease care should integrate and evaluate interventions that target access and quality disparities for LEP families.

    View details for Web of Science ID 000333142500005

    View details for PubMedID 24602575

  • Association between medical home characteristics and staff professional experiences in pediatric practices. Archives of public health = Archives belges de santé publique Knapp, C., Chakravorty, S., Madden, V., Baron-Lee, J., Gubernick, R., Kairys, S., Pelaez-Velez, C., Sanders, L. M., Thompson, L. 2014; 72 (1): 36-?

    Abstract

    The patient-centered medical home (PCMH) model has been touted as a potential way to improve primary care. As more PCMH projects are undertaken it is critical to understand professional experiences as staff are key in implementing and maintaining the necessary changes. A paucity of information on staff experiences is available, and our study aims to fill that critical gap in the literature.Eligible pediatric practices were invited to participate in the Florida Pediatric Medical Home Demonstration Project out which 20 practices were selected. Eligibility criteria included a minimum of 100 children with special health care needs and participation in Medicaid, a Medicaid health plan, or Florida KidCare. Survey data were collected from staff working in these 20 pediatric practices across Florida. Ware's seven-point scale assessed satisfaction and burnout was measured using the six-point Maslach scale. The Medical Home Index measured the practice's medical home characteristics. Descriptive and multivariate analyses were conducted. In total, 170 staff members completed the survey and the response rate was 42.6%.Staff members reported high job satisfaction (mean 5.54; SD 1.26) and average burnout. Multivariate analyses suggest that care coordination is positively associated (b?=?0.75) and community outreach is negatively associated (b?=?-0.18) with job satisfaction. Quality improvement and organizational capacity are positively associated with increased staff burnout (OR?=?1.37, 5.89, respectively). Chronic condition and data management are associated with lower burnout (OR?=?0.05 and 0.20, respectively). Across all models adaptive reserve, or the ability to make and sustain change, is associated with higher job satisfaction and lower staff burnout.Staff experiences in the transition to becoming a PCMH are important. Although our study is cross-sectional, it provides some insight about how medical home, staff and practice characteristics are associated with job satisfaction and burnout. Many PCMH initiatives include facilitation and it should assist staff on how to adapt to change. Unless staff needs are addressed a PCMH may be threatened by fatigue, burnout, and low morale.

    View details for DOI 10.1186/2049-3258-72-36

    View details for PubMedID 25364502

    View details for PubMedCentralID PMC4216343

  • Glycemic control in young children with diabetes: The role of parental health literacy PATIENT EDUCATION AND COUNSELING Pulgaron, E. R., Sanders, L. M., Patino-Fernandez, A. M., Wile, D., Sanchez, J., Rothman, R. L., Delamater, A. M. 2014; 94 (1): 67-70

    Abstract

    This cross sectional study examined the relationship between parental health literacy (HL), diabetes related numeracy, and parental perceived diabetes self-efficacy on glycemic control in a sample of young children with Type 1 DM.Seventy primary caregivers of children (age 3-9 years) with Type 1 DM were recruited and surveyed at diabetes outpatient clinic visits. Patients' medical histories were obtained by medical chart review.Parental diabetes related numeracy (r=-.52, p<01), but not reading skills (r=-.25, p=NS) were inversely correlated with the child's glycemic control (HbA1c). Parental perceived diabetes self-efficacy was also negatively correlated to their child's HbA1c (r=-.47, p<01). When numeracy and parental perceived diabetes self-efficacy were included as predictors of HbA1c, the model was significant (F=12.93, p<.01) with both numeracy (?=-.46, p<.01) and parental perceived diabetes self-efficacy (?=-.36, p=.01) as significant predictors of HbA1c.Data from this study highlight the importance of considering the role of parental numeracy, in health outcomes for children with Type 1 DM.Practitioners should assess parental health literacy and consider intervention when needed.

    View details for DOI 10.1016/j.pec.2013.09.002

    View details for Web of Science ID 000329887300010

    View details for PubMedID 24091252

    View details for PubMedCentralID PMC3865071

  • Family, community and clinic collaboration to treat overweight and obese children: Stanford GOALS-A randomized controlled trial of a three-year, multi-component, multi-level, multi-setting intervention. Contemporary clinical trials Robinson, T. N., Matheson, D., Desai, M., Wilson, D. M., Weintraub, D. L., Haskell, W. L., McClain, A., McClure, S., A Banda, J., Sanders, L. M., Haydel, K. F., Killen, J. D. 2013; 36 (2): 421-435

    Abstract

    To test the effects of a three-year, community-based, multi-component, multi-level, multi-setting (MMM) approach for treating overweight and obese children.Two-arm, parallel group, randomized controlled trial with measures at baseline, 12, 24, and 36months after randomization.Seven through eleven year old, overweight and obese children (BMI?85th percentile) and their parents/caregivers recruited from community locations in low-income, primarily Latino neighborhoods in Northern California.Families are randomized to the MMM intervention versus a community health education active-placebo comparison intervention. Interventions last for three years for each participant. The MMM intervention includes a community-based after school team sports program designed specifically for overweight and obese children, a home-based family intervention to reduce screen time, alter the home food/eating environment, and promote self-regulatory skills for eating and activity behavior change, and a primary care behavioral counseling intervention linked to the community and home interventions. The active-placebo comparison intervention includes semi-annual health education home visits, monthly health education newsletters for children and for parents/guardians, and a series of community-based health education events for families.Body mass index trajectory over the three-year study. Secondary outcome measures include waist circumference, triceps skinfold thickness, accelerometer-measured physical activity, 24-hour dietary recalls, screen time and other sedentary behaviors, blood pressure, fasting lipids, glucose, insulin, hemoglobin A1c, C-reactive protein, alanine aminotransferase, and psychosocial measures.The Stanford GOALS trial is testing the efficacy of a novel community-based multi-component, multi-level, multi-setting treatment for childhood overweight and obesity in low-income, Latino families.

    View details for DOI 10.1016/j.cct.2013.09.001

    View details for PubMedID 24028942

  • Impact of specific medical interventions in early childhood on increasing the prevalence of later intellectual disability. JAMA pediatrics Brosco, J. P., Sanders, L. M., Dowling, M., Guez, G. 2013; 167 (6): 544-548

    Abstract

    For the past 100 years, medicine in industrialized nations has become increasingly focused on specific medical interventions designed to improve the health of individual patients. Substantial evidence suggests that broader improvements in public health, nutrition, and economic well-being are more salient than medical or surgical interventions for the remarkable decrease in infant and child deaths since 1900. Less is known about the impact of specific medical interventions on morbidity such as intellectual disability (ID).To explore the impact of medical interventions in early childhood on increasing the prevalence of later ID, as reported in the literature from 1950 through 2000.We reviewed the medical literature and other data from 1950 through 2000 to construct estimates of the condition-specific prevalence of ID over time. We further explored the existing literature to document historically relevant influences on condition-specific prevalence, including the introduction of effective interventions, the timing of these introductions, and the likelihood of their widespread use.Twentieth century United States and Western Europe.Populations of children who received a life-saving intervention within the first 5 years of life and were evaluated for ID after 5 years of age.Case-specific prevalence of ID from 1950 through 2000.Low birth weight is associated with approximately 10% to 15% of the total prevalence of ID. No other new medical therapies introduced during this period were associated with a clinically significant increase in ID prevalence.Previous research has shown that specific medical interventions, such as newborn screening for congenital thyroid deficiency and phenylketonuria, have decreased the prevalence of ID approximately 16% in the United States since 1950. These results suggest that other medical interventions, particularly the advent of intensive care technologies, have also increased the prevalence of ID.

    View details for DOI 10.1001/jamapediatrics.2013.1379

    View details for PubMedID 23699900

  • FACTORS AFFECTING THE HEALTH LITERACY OF HISPANIC ADULTS LIVING IN THE US Chakkalaka, R., Sanders, L., Yin, S., Perrin, E. M., Rothman, R. L. SPRINGER. 2013: S76

    View details for Web of Science ID 000331939300180

  • The Association of Acculturation and Health Literacy, Numeracy and Health-Related Skills in Spanish-speaking Caregivers of Young Children JOURNAL OF IMMIGRANT AND MINORITY HEALTH Ciampa, P. J., White, R. O., Perrin, E. M., Yin, H. S., Sanders, L. M., Gayle, E. A., Rothman, R. L. 2013; 15 (3): 492-498

    Abstract

    Little is known about the relationship among acculturation, literacy, and health skills in Latino caregivers of young children. Latino caregivers of children < 30 months seeking primary care at four medical centers were administered measures of acculturation (SASH), functional health literacy (STOFHLA), numeracy (WRAT-3) and health-related skills (PHLAT Spanish). Child anthropomorphics and immunization status were ascertained by chart review. Caregivers (N = 184) with a median age of 27 years (IQR: 23-32) participated; 89.1% were mothers, and 97.1% had low acculturation. Lower SASH scores were significantly correlated (P < 0.01) with lower STOFHLA (? = 0.21), WRAT-3 (? = 0.25), and PHLAT Spanish scores (? = 0.34). SASH scores predicted PHLAT Spanish scores in a multivariable linear regression model that adjusted for the age of child, the age and gender of the caregiver, number of children in the family, the type of health insurance of the caregiver, and study site (adjusted ?: 0.84, 95% CI 0.26-1.42, P = 0.005). This association was attenuated by the addition of literacy (adjusted ?: 0.66, 95% CI 0.11-1.21, P = 0.02) or numeracy (adjusted ?: 0.50, 95% CI -0.04-1.04, P = 0.07) into the model. There was no significant association between acculturation and up-to-date child immunizations or a weight status of overweight/obese. Lower acculturation was associated with worse health literacy and diminished ability to perform child health-related skills. Literacy and numeracy skills attenuated the association between acculturation and child health skills. These associations may help to explain some child health disparities in Latino communities.

    View details for DOI 10.1007/s10903-012-9613-7

    View details for Web of Science ID 000321240400006

    View details for PubMedID 22481307

  • Use of Farmers Markets by Mothers of WIC Recipients, Miami-Dade County, Florida, 2011 PREVENTING CHRONIC DISEASE Grin, B. M., Gayle, T. L., Saravia, D. C., Sanders, L. M. 2013; 10

    Abstract

    Farmers market-based interventions, including the Farmers' Market Nutrition Program of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), represent a promising strategy for improving dietary behaviors in low-income communities. Little is known, however, about the health-related characteristics of low-income parents who frequent farmers markets in urban settings. The objective of this study was to examine the relationship between family-health factors and the use of farmers markets by mothers of WIC recipients.We recruited a convenience sample of mothers of children seeking care at a primary care clinic in a large urban public hospital in Miami, Florida, in 2011 (n = 181 total). The clinic was adjacent to a newly established farmers market at the hospital. Each mother completed an interviewer-administered survey that included self-reported measures of maternal and child health, acculturation, dietary behaviors, food insecurity, and use of farmers markets.Reported use of farmers markets was independently associated with maternal history of diabetes (odds ratio [OR], 6.9; 95% confidence interval [CI], 1.3-38.3) and increased maternal vegetable (but not fruit) consumption (OR, 3.5; 95% CI, 1.5-8.1). Intended future use of farmers markets was independently associated with being unemployed (OR, 2.4; 95% CI, 1.0-5.7), increased maternal vegetable consumption (OR, 2.5; 95% CI, 1.1-5.7), and food insecurity (OR, 3.6; 95% CI, 1.3-10.3).This study provides a snapshot of factors associated with farmers market use in a diverse population of urban low-income families. Understanding these factors may inform public health approaches to increase fresh fruit and vegetable consumption in communities at high risk for preventable chronic conditions.

    View details for DOI 10.5888/pcd10.120178

    View details for Web of Science ID 000329391900005

    View details for PubMedID 23764344

    View details for PubMedCentralID PMC3684356

  • CARDIOVASCULAR SURGERY FOR ADULT CONGENITAL HEART DISEASE: VARIATION IN USE OF SPECIALTY-CARE CENTERS 62nd Annual Scientific Session of the American-College-of-Cardiology Fernandes, S. M., Chamberlain, L., Grady, S., Mayo, J., Optowsky, A., Sanders, L. M., Wise, P. H. ELSEVIER SCIENCE INC. 2013: E506?E506

    View details for Web of Science ID 000316555200506

  • Health Literacy Assessment of Labeling of Pediatric Nonprescription Medications: Examination of Characteristics that May Impair Parent Understanding ACADEMIC PEDIATRICS Yin, H. S., Parker, R. M., Wolf, M. S., Mendelsohn, A. L., Sanders, L. M., Vivar, K. L., Carney, K., Cerra, M. E., Dreyer, B. P. 2012; 12 (4): 288-296

    Abstract

    Poor quality and variability of medication labeling have been cited as key contributors to medication misuse. We assessed the format and content of labels and materials packaged with common pediatric liquid nonprescription medications.Descriptive study. A total of 200 top-selling pediatric oral liquid nonprescription medications (during the 52 weeks ending October 30, 2009) categorized as analgesic, cough/cold, allergy, and gastrointestinal products, with dosing information for children <12 years (representing 99% of U.S. market for these products) were reviewed. The principal display panel (PDP) and FDA Drug Facts panel (side panel) of each bottle, and associated box, if present, were independently examined by 2 abstractors. Outcome measures were content and format of active ingredient information and dosing instructions of the principal display panel and Drug Facts panel.Although almost all products listed active ingredients on the Drug Facts panel (side panel), nearly 1 in 5 (37 [18.5%]) did not list active ingredients on the PDP. When present, mean (SD) font size for PDP active ingredients was 10.7 (5.0), smaller than product brand name (32.1 [15.0]) and flavor (13.1 [4.8]); P < .001. Most products included directions in chart form (bottle: 167 [83.5%], box: 148 [96.1%], P < .001); mean (SD) font size: 5.5 (0.9; bottle), 6.5 (0.5; box), P < .001. Few products expressed dosing instructions in pictographic form: 4 (2.6%) boxes and 0 bottles. Nearly all products included the Food and Drug Administration-mandated sections.The format and content of labels for nonprescription pediatric liquid medications could be improved to facilitate parent understanding of key medication information, including active ingredient information and dosing instructions.

    View details for Web of Science ID 000306620200008

    View details for PubMedID 22579032

  • Assessment of Health Literacy and Numeracy Among Spanish-Speaking Parents of Young Children: Validation of the Spanish Parental Health Literacy Activities Test (PHLAT Spanish) ACADEMIC PEDIATRICS Yin, H. S., Sanders, L. M., Rothman, R. L., Mendelsohn, A. L., Dreyer, B. P., White, R. O., Finkle, J. P., Prendes, S., Perrin, E. M. 2012; 12 (1): 68-74

    Abstract

    To assess the health literacy and numeracy skills of Spanish-speaking parents of young children and to validate a new Spanish language health literacy assessment for parents, the Spanish Parental Health Literacy Activities Test (PHLAT Spanish).Cross-sectional study of Spanish-speaking caregivers of young children (<30 months) enrolled at primary care clinics in 4 academic medical centers. Caregivers were administered the 10-item PHLAT in addition to validated tests of health literacy (S-TOFHLA) and numeracy (WRAT-3 Arithmetic). Psychometric analysis was used to examine item characteristics of the PHLAT-10 Spanish, to assess its correlation with sociodemographics and performance on literacy/numeracy assessments, and to generate a shorter 8-item scale (PHLAT-8).Of 176 caregivers, 77% had adequate health literacy (S-TOFHLA), whereas only 0.6% had 9th grade or greater numeracy skills. Mean PHLAT-10 score was 41.6% (SD 21.1). Fewer than one-half (45.5%) were able to read a liquid antibiotic prescription label and demonstrate how much medication to administer within an oral syringe. Less than one-third (31.8%) were able to interpret a food label to determine whether it met WIC (Special supplemental nutrition program for Women, Infants, and Children) guidelines. Greater PHLAT-10 score was associated with greater years of education (r = 0.49), S-TOFHLA (r = 0.53), and WRAT-3 (r = 0.55) scores (P < .001). Internal reliability was good (Kuder-Richardson coefficient of reliability; KR-20 = 0.61). An 8-item scale was highly correlated with the full 10-item scale (r = 0.97, P < .001), with comparable internal reliability (KR-20 = 0.64).Many Spanish-speaking parents have difficulty performing health-related literacy and numeracy tasks. The Spanish PHLAT demonstrates good psychometric characteristics and may be useful for identifying parents who would benefit from receiving low-literacy child health information.

    View details for Web of Science ID 000299361000012

    View details for PubMedID 22056223

  • Mammography Result Notification Letters: Are They Easy to Read and Understand? JOURNAL OF WOMENS HEALTH Marcus, E. N., Sanders, L. M., Pereyra, M., Del Toro, Y., Romilly, A. P., Yepes, M., Hooper, M. W., Jones, B. A. 2011; 20 (4): 545-551

    Abstract

    Federal law mandates that mammography centers notify women of their result in writing. The purpose of this study is to assess the readability and ease of use of the sample letters provided as a template for the notification letters centers send to patients.This is a cross-sectional analysis of the 43 mammography result notification template letters available from the American College of Radiology and two leading transcription software services. To assess readability, we used the Flesch-Kincaid grade level scale and the Lexile framework. To assess document suitability, we used the Suitability Assessment of Materials (SAM). Acceptable scores were based on established standards: ?6th grade for the Flesch-Kincaid level, ?900 for the Lexile analysis, and ?40% on the SAM scale. Means, standard deviations (SDs), and ranges were calculated by diagnostic category, as indicated by BI-RADS level. The Kruskal-Wallis test was used to assess differences in readability and suitability by diagnostic category.The Flesch Kincaid score ranged from 7.7 to 13.5, with a mean of 10.2. The Lexile score ranged from 880 to 1270, with a mean of 1113. The mean SAM score ranged from 16% to 36%, with a mean of 29%. Mean grade level, Lexile score, and SAM score did not vary significantly by diagnostic category. No single document had an acceptable suitability score, and only two had acceptable Lexile scores. Common deficiencies included use of the passive voice, vague wording, and technical jargon.The letters we analyzed were written at levels too difficult for many patients to understand. Future investigations should explore clearer ways of communicating mammography results.

    View details for DOI 10.1089/jwh.2010.2330

    View details for Web of Science ID 000289460400006

    View details for PubMedID 21428738

  • Evaluation of Consistency in Dosing Directions and Measuring Devices for Pediatric Nonprescription Liquid Medications JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Yin, H. S., Wolf, M. S., Dreyer, B. P., Sanders, L. M., Parker, R. M. 2010; 304 (23): 2595-2602

    Abstract

    In response to reports of unintentional drug overdoses among children given over-the-counter (OTC) liquid medications, in November 2009 the US Food and Drug Administration (FDA) released new voluntary industry guidelines that recommend greater consistency and clarity in OTC medication dosing directions and their accompanying measuring devices.To determine the prevalence of inconsistent dosing directions and measuring devices among popular pediatric OTC medications at the time the FDA's guidance was released.Descriptive study of 200 top-selling pediatric oral liquid OTC medications during the 52 weeks ending October 30, 2009. Sample represents 99% of the US market of analgesic, cough/cold, allergy, and gastrointestinal OTC oral liquid products with dosing information for children younger than 12 years.Inclusion of measuring device, within-product inconsistency between dosing directions on the bottle's label and dose markings on enclosed measuring device, across-product use of nonstandard units and abbreviations, and presence of abbreviation definitions.Measuring devices were packaged with 148 of 200 products (74.0%). Within this subset of 148 products, inconsistencies between the medication's dosing directions and markings on the device were found in 146 cases (98.6%). These included missing markings (n = 36, 24.3%) and superfluous markings (n = 120, 81.1%). Across all products, 11 (5.5%) used atypical units of measurement (eg, drams, cc) for doses listed. Milliliter, teaspoon, and tablespoon units were used for doses in 143 (71.5%), 155 (77.5%), and 37 (18.5%) products, respectively. A nonstandard abbreviation for milliliter (not mL) was used by 97 products. Of the products that included an abbreviation, 163 did not define at least 1 abbreviation.At the time the FDA released its new guidance, top-selling pediatric OTC liquid medications contained highly variable and inconsistent dosing directions and measuring devices.

    View details for DOI 10.1001/jama.2010.1797

    View details for Web of Science ID 000285303400022

    View details for PubMedID 21119074

  • Interventions Aimed at Decreasing Obesity in Children Younger Than 2 Years A Systematic Review ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Ciampa, P. J., Kumar, D., Barkin, S. L., Sanders, L. M., Yin, H. S., Perrin, E. M., Rothman, R. L. 2010; 164 (12): 1098-1104

    Abstract

    To assess the evidence for interventions designed to prevent or reduce overweight and obesity in children younger than 2 years.MEDLINE, the Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, and references from relevant articles.Included were published studies that evaluated an intervention designed to prevent or reduce overweight or obesity in children younger than 2 years.Extracted from eligible studies were measured outcomes, including changes in child weight status, dietary intake, and physical activity and parental attitudes and knowledge about nutrition. Studies were assessed for scientific quality using standard criteria, with an assigned quality score ranging from 0.00 to 2.00 (0.00-0.99 is poor, 1.00-1.49 is fair, and 1.50-2.00 is good).We retrieved 1557 citations; 38 articles were reviewed, and 12 articles representing 10 studies met study inclusion criteria. Eight studies used educational interventions to promote dietary behaviors, and 2 studies used a combination of nutrition education and physical activity. Study settings included home (n = 2), clinic (n = 3), classroom (n = 4), or a combination (n = 1). Intervention durations were generally less than 6 months and had modest success in affecting measures, such as dietary intake and parental attitudes and knowledge about nutrition. No intervention improved child weight status. Studies were of poor or fair quality (median quality score, 0.86; range, 0.28-1.43).Few published studies attempted to intervene among children younger than 2 years to prevent or reduce obesity. Limited evidence suggests that interventions may improve dietary intake and parental attitudes and knowledge about nutrition for children in this age group. For clinically important and sustainable effect, future research should focus on designing rigorous interventions that target young children and their families.

    View details for Web of Science ID 000285009900008

    View details for PubMedID 21135337

  • No Follow-Up After Positive Newborn Screening: Medical Neglect? CHILD MALTREATMENT Merrick, M. T., Butt, S. M., Jent, J. F., Cano, N. M., Lambert, W. F., Chapman, A. V., Griffith, J. F., Ciener, D., Dandes, S. K., Sanders, L. M. 2010; 15 (4): 315-323

    Abstract

    The current study examined medical professionals' behaviors related to reporting medical neglect when a family is noncompliant with follow-up services after a positive newborn screening result. Pediatric medical professionals within an urban medical campus were provided with five case vignettes in relation to different diseases. Medical professionals rated the severity of family noncompliance with follow-up services and indicated whether they would report suspected medical neglect to Child Protective Services (CPS). Physicians were more likely to report medical neglect than the other mandated reporters in the study. Logistic regression analyses found that medical professionals' perceptions of the severity of family noncompliance with services were significantly predictive of decisions to report medical neglect. Respondent gender and the method by which families were notified of screening results also significantly affected reporting behaviors in certain instances. Although all vignettes included information that met legal statutes for reporting neglect, medical professionals indicated that they would only report neglect 40-61% of the time across vignettes. Continued investigation of the rationale behind medical professionals' decision-making process and training protocols designed to improve mandated reporter knowledge and reporting behaviors are needed to further reduce bias and improve objectivity when considering ethical and professional obligations to report medical neglect.

    View details for DOI 10.1177/1077559510384983

    View details for Web of Science ID 000282636800005

    View details for PubMedID 20930180

  • Parental Understanding of Infant Health Information: Health Literacy, Numeracy, and the Parental Health Literacy Activities Test (PHLAT) ACADEMIC PEDIATRICS Kumar, D., Sanders, L., Perrin, E. M., Lokker, N., Patterson, B., Gunn, V., Finkle, J., Franco, V., Choi, L., Rothman, R. L. 2010; 10 (5): 309-316

    Abstract

    To assess parental health literacy and numeracy skills in understanding instructions for caring for young children, and to develop and validate a new parental health literacy scale, the Parental Health Literacy Activities Test (PHLAT).Caregivers of infants (age <13 months) were recruited in a cross-sectional study at pediatric clinics at 3 academic medical centers. Literacy and numeracy skills were assessed with previously validated instruments. Parental health literacy was assessed with the new 20-item PHLAT. Psychometric analyses were performed to assess item characteristics and to generate a shortened, 10-item version (PHLAT-10).A total of 182 caregivers were recruited. Although 99% had adequate literacy skills, only 17% had better than ninth-grade numeracy skills. Mean score on the PHLAT was 68% (standard deviation 18); for example, only 47% of caregivers could correctly describe how to mix infant formula from concentrate, and only 69% could interpret a digital thermometer to determine whether an infant had a fever. Higher performance on the PHLAT was significantly correlated (P < .001) with education, literacy skill, and numeracy level (r = 0.29, 0.38, and 0.55 respectively). Caregivers with higher PHLAT scores were also more likely to interpret age recommendations for cold medications correctly (odds ratio 1.6, 95% confidence interval 1.02, 2.6). Internal reliability on the PHLAT was good (Kuder-Richardson coefficient of reliability = 0.76). The PHLAT-10 also demonstrated good validity and reliability.Many parents do not understand common health information required to care for their infants. The PHLAT and PHLAT-10 have good reliability and validity and may be useful tools for identifying parents who need better communication of health-related instructions.

    View details for Web of Science ID 000282109700007

    View details for PubMedID 20674532

  • The Lure of Treatment: Expanded Newborn Screening and the Curious Case of Histidinemia PEDIATRICS Brosco, J. P., Sanders, L. M., Dharia, R., Guez, G., Feudtner, C. 2010; 125 (3): 417-419

    View details for DOI 10.1542/peds.2009-2060

    View details for Web of Science ID 000275945700001

    View details for PubMedID 20156889

  • Historical Trends in Low Birth Weight ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Brosco, J. P., Sanders, L. M., Guez, G., Lantos, J. D. 2010; 164 (1): 99-100

    View details for Web of Science ID 000273262900016

    View details for PubMedID 20048251

  • The health literacy of parents in the United States: a nationally representative study. Pediatrics Yin, H. S., Johnson, M., Mendelsohn, A. L., Abrams, M. A., Sanders, L. M., Dreyer, B. P. 2009; 124: S289-98

    Abstract

    To assess the health literacy of US parents and explore the role of health literacy in mediating child health disparities.A cross-sectional study was performed for a nationally representative sample of US parents from the 2003 National Assessment of Adult Literacy. Parent performance on 13 child health-related tasks was assessed by simple weighted analyses. Logistic regression analyses were performed to describe factors associated with low parent health literacy and to explore the relationship between health literacy and self-reported child health insurance status, difficulty understanding over-the-counter medication labeling, and use of food labels.More than 6100 parents made up the sample (representing 72600098 US parents); 28.7% of the parents had below-basic/basic health literacy, 68.4% were unable to enter names and birth dates correctly on a health insurance form, 65.9% were unable to calculate the annual cost of a health insurance policy on the basis of family size, and 46.4% were unable to perform at least 1 of 2 medication-related tasks. Parents with below-basic health literacy were more likely to have a child without health insurance in their household (adjusted odds ratio: 2.4 [95% confidence interval: 1.1-4.9]) compared with parents with proficient health literacy. Parents with below-basic health literacy had 3.4 times the odds (95% confidence interval: 1.6-7.4) of reporting difficulty understanding over-the-counter medication labels. Parent health literacy was associated with nutrition label use in unadjusted analyses but did not retain significance in multivariate analyses. Health literacy accounted for some of the effect of education, racial/ethnic, immigrant-status, linguistic, and income-related disparities.A large proportion of US parents have limited health-literacy skills. Decreasing literacy demands on parents, including simplification of health insurance and other medical forms, as well as medication and food labels, is needed to decrease health care access barriers for children and allow for informed parent decision-making. Addressing low parent health literacy may ameliorate existing child health disparities.

    View details for DOI 10.1542/peds.2009-1162E

    View details for PubMedID 19861483

  • Health literacy and child health promotion: implications for research, clinical care, and public policy. Pediatrics Sanders, L. M., Shaw, J. S., Guez, G., Baur, C., Rudd, R. 2009; 124: S306-14

    Abstract

    The nation's leading sources of morbidity and health disparities (eg, preterm birth, obesity, chronic lung disease, cardiovascular disease, type 2 diabetes, mental health disorders, and cancer) require an evidence-based approach to the delivery of effective preventive care across the life course (eg, prenatal care, primary preventive care, immunizations, physical activity, nutrition, smoking cessation, and early diagnostic screening). Health literacy may be a critical and modifiable factor for improving preventive care and reducing health disparities. Recent studies among adults have established an independent association between lower health literacy and poorer understanding of preventive care information and poor access to preventive care services. Children of parents with higher literacy skills are more likely to have better outcomes in child health promotion and disease prevention. Adult studies in disease prevention have suggested that addressing health literacy would be an efficacious strategy for reducing health disparities. Future initiatives to reduce child health inequities should include health-promotion strategies that meet the health literacy needs of children, adolescents, and their caregivers.

    View details for DOI 10.1542/peds.2009-1162G

    View details for PubMedID 19861485

  • Pediatricians and health literacy: descriptive results from a national survey. Pediatrics Turner, T., Cull, W. L., Bayldon, B., Klass, P., Sanders, L. M., Frintner, M. P., Abrams, M. A., Dreyer, B. 2009; 124: S299-305

    Abstract

    To describe pediatricians' self-reported experiences with health literacy, use of basic and enhanced communication techniques, and perceived barriers to effective communication during office visits.A national, random sample of 1605 nonretired, posttraining American Academy of Pediatrics members were surveyed in 2007 about health literacy and patient communication as part of the Periodic Survey of Fellows. The response rate was 56% (N = 900).Eight-one percent of the pediatricians were aware of a situation in the previous 12 months in which a parent had not sufficiently understood health information that had been delivered to him or her. In addition, 44% of all pediatricians were aware of a communication-related error in patient care within the previous 12 months. Using simple language (99%), repeating key information (92%), and presenting only 2 or 3 concepts at a time (76%) were the most commonly used communication strategies. Enhanced communication techniques recommended by health literacy experts such as teach-back and indicating key points on written educational materials were used less often (23% and 28%, respectively). The most common reported barriers to effective communication were limited time to discuss information (73%), volume of information (65%), and complexity of information (64%). The majority of physicians rated themselves highly in their ability to identify caregiver understanding (64%), but only 21% rated themselves as very good or excellent in identifying a parent with a literacy problem. Fifty-seven percent of the respondents were interested in training to improve communication skills, and 58% reported that they would be very likely to use easy-to-read written materials, if available from the American Academy of Pediatrics.Pediatricians are aware of health literacy-related problems and the need for good communication with families but struggle with time demands to implement these skills. Despite awareness of communication-related errors in patient care, pediatricians report underutilizing enhanced techniques known to improve communication.

    View details for DOI 10.1542/peds.2009-1162F

    View details for PubMedID 19861484

  • Parental Misinterpretations of Over-the-Counter Pediatric Cough and Cold Medication Labels PEDIATRICS Lokker, N., Sanders, L., Perrin, E. M., Kumar, D., Finkle, J., Franco, V., Choi, L., Johnston, P. E., Rothman, R. L. 2009; 123 (6): 1464-1471

    Abstract

    Concerns about the safety and efficacy of over-the-counter cold medications have led to a recent US Food and Drug Administration public health advisory against their use in children <2 years of age. Our goal was to examine caregiver understanding of the age indication of over-the-counter cold medication labels and identify factors, associated with caregiver understanding.Caregivers of infant children (< or =1 year old) were recruited from clinics at 3 institutions. Questions were administered regarding the use of 4 previously common "infant" over-the-counter cold and cough medicines labeled to consult a physician if used in children <2 years of age. Literacy and numeracy skills were assessed with validated instruments.A total of 182 caregivers were recruited; 87% were the infants' mothers. Mean education level was 12.5 years, and 99% had adequate literacy skills, but only 17% had >9th-grade numeracy skills. When examining the front of the product label, 86% of the time parents thought these products were appropriate for use in children <2 years of age. More than 50% of the time, parents stated they would give these over-the-counter products to a 13-month-old child with cold symptoms. Common factors that influenced parental decisions included label saying "infant," graphics (eg, infants, teddy bears, droppers), and dosing directions. Caregivers were influenced by the dosing directions only 47% of the time. Caregivers with lower numeracy skills were more likely to provide inappropriate reasons for giving an over-the-counter medication.Misunderstanding of over-the-counter cold products is common and could result in harm if medications are given inappropriately. Label language and graphics seem to influence inappropriate interpretation of over-the-counter product age indications. Poorer parental numeracy skills may increase the misinterpretation of these products. Opportunities exist for the Food and Drug Administration and manufacturers to revise existing labels to improve parental comprehension and enhance child safety.

    View details for DOI 10.1542/peds.2008-0854

    View details for Web of Science ID 000266319000004

    View details for PubMedID 19482755

  • Literacy and Child Health A Systematic Review ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Sanders, L. M., Federico, S., Klass, P., Abrams, M. A., Dreyer, B. 2009; 163 (2): 131-140

    Abstract

    To assess the prevalence of low health literacy among adolescents, young adults, and child caregivers in the United States, the readability of common child-health information, and the relationship between literacy and child health.MedLine, Educational Resources Information Center, National Library of Medicine, PsychInfo, Harvard Health Literacy Bibliography, and peer-reviewed abstracts from the Pediatric Academic Societies Annual Meetings.A systematic review using the following key words: health literacy, literacy, reading skill, numeracy, and Wide Range Achievement Test.Descriptive studies that used at least 1 valid measure of health literacy, studies that assessed the readability of child health information, and observational or experimental studies that included a validated measure of health literacy, literacy, or numeracy skills and an assessment of child health-related outcomes.A total of 1267 articles were reviewed, and 215 met inclusion and exclusion criteria. At least 1 in 3 adolescents and young adults had low health literacy; most child health information was written above the tenth-grade level. Adjusted for socioeconomic status, adults with low literacy are 1.2 to 4 times more likely to exhibit negative health behaviors that affect child health, adolescents with low literacy are at least twice as likely to exhibit aggressive or antisocial behavior, and chronically ill children who have caregivers with low literacy are twice as likely to use more health services.Low caregiver literacy is common and is associated with poor preventive care behaviors and poor child health outcomes. Future research should aim to ameliorate literacy-associated child health disparities.

    View details for Web of Science ID 000262991800006

    View details for PubMedID 19188645

  • A Prospective Study of Weight and Metabolic Syndrome in Young Hispanic Children CHILDRENS HEALTH CARE Patino-Fernandez, A. M., Delamater, A. M., Sanders, L., Brito, A., Goldberg, R. 2008; 37 (4): 316-332

    View details for DOI 10.1080/02739610802437558

    View details for Web of Science ID 000261018600005

  • Conduct disorder. Pediatrics in review Sanders, L. M., Schaechter, J., Serwint, J. R. 2007; 28 (11): 433-434

    View details for PubMedID 17974708

  • Factors influencing community pediatrics training in residency Annual Meeting of the Pediatric-Academic-Societies/Society-of-Pediatric-Research Minkovitz, C. S., Chandra, A., Solomon, B. S., Sanders, L. M., Grason, H. A., Carraccio, C. MOSBY-ELSEVIER. 2007: 119?20

    View details for DOI 10.1016/j.jpeds.2006.10.047

    View details for Web of Science ID 000244111300001

    View details for PubMedID 17236883

  • Caregiver health literacy and the use of child health services PEDIATRICS Sanders, L. M., Thompson, V. T., Wilkinson, J. D. 2007; 119 (1): E86-E92

    Abstract

    Eighty million US adults have low health literacy, a risk factor for increased health care use among adults. The purpose of this work was to assess the association between caregiver health literacy and the use and cost of child health services.We conducted a cross-sectional study of caregiver-child dyads from a sample of children aged 12 months to 12 years presenting to the pediatric emergency department of an urban, public hospital. Caregiver health literacy was measured by the Short Test of Functional Health Literacy in their preferred language (English or Spanish). Child health care use was measured by a 12-month retrospective review of the public hospital system's electronic database and of state Medicaid billing records for 4 types of visits: preventive care, urgent care, emergency care, and hospital care. Cost of child health care use was provided by Medicaid billing records. Multivariate analysis included caregiver education, age, and language proficiency, as well as child age, special health care needs, ethnicity, and health-insurance coverage.A total of 290 dyads were enrolled in the study. Twenty-two percent of caregivers had low (inadequate or marginal) health literacy. Caregivers with low health literacy were more likely to have less than a high school education, to have limited English proficiency, and to have been born outside the United States. There were no differences in health care use or cost between children of caregivers with low health literacy and children of caregivers with adequate health literacy. Three caregiver characteristics were associated with increased use of child health care services: born outside the United States, age at child's birth <24 years, and limited English proficiency.One in 5 caregivers of young children has low health literacy. Caregiver health literacy, however, was not associated with disparities in the use of child health services in this inner-city, ethnic minority population.

    View details for DOI 10.1542/peds.2005-1738

    View details for Web of Science ID 000243191800013

    View details for PubMedID 17200263

  • Pediatric residents' perceptions of community involvement prior to residency AMBULATORY PEDIATRICS Solomon, B. S., Blaschke, G. S., West, D. C., Pan, R. J., Sanders, L., Swigonski, N., Willis, E., Schwarz, D. 2006; 6 (6): 337-341

    Abstract

    To describe baseline perceptions of first-year pediatric residents of participating in community activities, to determine whether demographic factors are related to perceived benefits and constraints, and to identify factors associated with expected community involvement.Pediatric residents beginning their training in the fall of 2000 to 2003 participated in a 12-item self-administered written survey as part of the national evaluation of the Dyson Community Pediatrics Training Initiative.Of the 612 first-year residents surveyed (90% response rate), most reported they receive personal satisfaction (92%) and gain valuable skills and knowledge (83%) from their involvement in community activities. Less than a quarter felt peer support and professional recognition were benefits. Almost two thirds reported logistics and lost personal time as constraints to community involvement. Compared with their colleagues, older residents (> 29 years) and underrepresented minority residents reported fewer constraints. Most residents (72%) expect moderate to substantial involvement in community activities after graduating. Those expecting greater involvement were more likely to report personal satisfaction, gaining valuable skills and knowledge, peer support, and the opportunity to spend time with like-minded peers as benefits.Pediatric residents beginning their postgraduate training perceive numerous benefits from their participation in community activities and most expect a moderate degree of future community involvement. Residency directors should: 1) consider their trainees' insights from prior community involvement and 2) integrate meaningful community experiences in ways that confront logistic barriers and time constraints.

    View details for Web of Science ID 000242524200007

    View details for PubMedID 17116607

  • Advocacy by any other name would smell as sweet ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Chamberlain, L. J., Sanders, L. M., Takayama, J. I. 2006; 160 (4): 453-453

    View details for Web of Science ID 000236516500024

    View details for PubMedID 16585499

  • Child advocacy training - Curriculum outcomes and resident satisfaction ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Chamberlain, L. J., Sanders, L. M., Takayama, J. I. 2005; 159 (9): 842-847

    Abstract

    Many health problems affecting children today are based in the community and cannot be easily addressed in the office setting. Child advocacy is an effective approach for pediatricians to take.To describe pediatric residents' choices of advocacy topics and interventions.Cross-sectional observational study.Residents from 3 pediatric training programs participated in the Child Advocacy Curriculum, which featured standardized workshops and the development of individual advocacy projects. To evaluate the curriculum, project descriptions and material products were analyzed to determine individual advocacy topics, topic themes, and targets of project interventions. Differences among programs were assessed. Residents also completed an anonymous questionnaire assessing their experience with the Child Advocacy Curriculum.Residents demonstrated a wide range of interests in selecting advocacy topics: 99 residents chose 38 different topics. The most common topic was obesity (13 residents) followed by health care access (9), teen pregnancy prevention (6), and oral health (5). Themes included health promotion and disease prevention, injury prevention, health care access, children with special health care needs, child development, at-risk populations, and the impact of media on child health. The project interventions targeted the local community most frequently (37%), followed by resident education (27%), hospital systems (21%), and public and health policy (15%). The vast majority of participating residents reported a positive experience with the Child Advocacy Curriculum.The wide range of topics and settings in which residents developed projects illustrates residents' extensive interests and ingenuity in applying needed advocacy solutions to complex child health issues.

    View details for Web of Science ID 000231653800007

    View details for PubMedID 16143743

  • Evidence-based community pediatrics: Building a bridge from bedside to neighborhood PEDIATRICS Sanders, L. M., Robinson, T. N., Forster, L. Q., Plax, K., Brosco, J. P., Brito, A. 2005; 115 (4): 1142-1147

    Abstract

    The American Academy of Pediatrics policy statement "The Pediatrician's Role in Community Pediatrics" encourages all pediatricians to partner with their communities to create and disseminate innovative programs that improve child health. This article describes 4 pillars of a bridge to evidence-based community pediatrics for pediatricians interested in pursuing effective community action: (1) collaborate with the community to establish a specific, short-term, health-related goal; (2) identify evidence-based best practice(s) for achieving the shared goal; (3) collaborate with the community to adapt this best practice to the community's unique assets and constraints; and (4) evaluate the project by using appropriate expertise. Practical elements of each pillar are described and illustrated by specific examples from community-based efforts of pediatricians and are accompanied by specific resources to aid pediatricians in their future community health work.

    View details for DOI 10.1542/peds.2004-2825H

    View details for Web of Science ID 000228108800008

    View details for PubMedID 15821298

  • Number of children's books in the home: An indicator of parent health literacy AMBULATORY PEDIATRICS Sanders, L. M., Zacur, G., Haecker, T., Klass, P. 2004; 4 (5): 424-428

    Abstract

    One in 4 US adults have poor health literacy, unable to read and understand written medical information. Current tools that assess health literacy skills are too lengthy to be useful in routine clinical encounters.To determine which of 7 screening questions is most useful for identifying parents with adequate health literacy.A cross-sectional study of an ethnically diverse sample of 163 parents of children aged 12 to 24 months presenting for routine care at 1 of 6 inner-city clinics. Literacy was measured by performance on the Short Test of Functional Health Literacy for Adults, which was categorized as "adequate" or "inadequate or marginal." The 7 screening questions concerned parents' educational achievement, educational expectations for the child, and home literacy environment.Eighty-three percent of respondents had adequate health literacy, which was highest among those who were African American, were born outside the United States, spoke English primarily at home, and had completed high school. Only 2 factors, however, were independently associated with adequate health literacy: more than 10 adults' books or more than 10 children's books in the home. "More than 10 children's books" had a positive predictive value of 91%.Having more than 10 children's books in the home is a useful, independent indicator of adequate parent health literacy. More research is needed, however, to find a better screening tool for identifying parents with increased health literacy needs.

    View details for Web of Science ID 000224035900006

    View details for PubMedID 15369414

  • Efficacy and safety of low-carbohydrate diets - A systematic review JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Bravata, D. M., Sanders, L., Huang, J., Krumholz, H. M., Olkin, I., Gardner, C. D., Bravata, D. M. 2003; 289 (14): 1837-1850

    Abstract

    Low-carbohydrate diets have been popularized without detailed evidence of their efficacy or safety. The literature has no clear consensus as to what amount of carbohydrates per day constitutes a low-carbohydrate diet.To evaluate changes in weight, serum lipids, fasting serum glucose, and fasting serum insulin levels, and blood pressure among adults using low-carbohydrate diets in the outpatient setting.We performed MEDLINE and bibliographic searches for English-language studies published between January 1, 1966, and February 15, 2003, with key words such as low carbohydrate, ketogenic, and diet.We included articles describing adult, outpatient recipients of low-carbohydrate diets of 4 days or more in duration and 500 kcal/d or more, and which reported both carbohydrate content and total calories consumed. Literature searches identified 2609 potentially relevant articles of low-carbohydrate diets. We included 107 articles describing 94 dietary interventions reporting data for 3268 participants; 663 participants received diets of 60 g/d or less of carbohydrates--of whom only 71 received 20 g/d or less of carbohydrates. Study variables (eg, number of participants, design of dietary evaluation), participant variables (eg, age, sex, baseline weight, fasting serum glucose level), diet variables (eg, carbohydrate content, caloric content, duration) were abstracted from each study.Two authors independently reviewed articles meeting inclusion criteria and abstracted data onto pretested abstraction forms.The included studies were highly heterogeneous with respect to design, carbohydrate content (range, 0-901 g/d), total caloric content (range, 525-4629 kcal/d), diet duration (range, 4-365 days), and participant characteristics (eg, baseline weight range, 57-217 kg). No study evaluated diets of 60 g/d or less of carbohydrates in participants with a mean age older than 53.1 years. Only 5 studies (nonrandomized and no comparison groups) evaluated these diets for more than 90 days. Among obese patients, weight loss was associated with longer diet duration (P =.002), restriction of calorie intake (P =.03), but not with reduced carbohydrate content (P =.90). Low-carbohydrate diets had no significant adverse effect on serum lipid, fasting serum glucose, and fasting serum insulin levels, or blood pressure.There is insufficient evidence to make recommendations for or against the use of low-carbohydrate diets, particularly among participants older than age 50 years, for use longer than 90 days, or for diets of 20 g/d or less of carbohydrates. Among the published studies, participant weight loss while using low-carbohydrate diets was principally associated with decreased caloric intake and increased diet duration but not with reduced carbohydrate content.

    View details for PubMedID 12684364

  • Helping Families ImproveSelf-Management of Pediatric Asthma: A Guide for the Primary Care Physician. Pediatric case reviews (Print) Sanders, L. M., McCullough, J. R. 2002; 2 (2): 112-125

    View details for PubMedID 12865688

  • Prescribing books for immigrant children - A pilot study to promote emergent literacy among the children of Hispanic immigrants ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Sanders, L. M., Gershon, T. D., Huffman, L. C., Mendoza, F. S. 2000; 154 (8): 771-777

    Abstract

    To assess book-sharing activities within first-generation Hispanic immigrant families, and to assess the effect of pediatricians giving books to their patients.Survey.Convenience sample of 122 predominantly Hispanic immigrant parents of children aged 2 months to 5 years. Of these parents, 56 had received children's books from the pediatrician, and 66 had not.House staff continuity clinic at a university children's hospital.Frequent Book Sharing (FBS) was defined as a parent's reporting more than 3 days per week of sharing books with the child. Main independent variables included the following: (1) exposure to the Reach Out and Read program, defined as having received a children's book from the pediatrician; (2) socioeconomics, as measured by parents' years of education and Medicaid enrollment; (3) acculturation, as defined by 4 questions relating to parents' proficiency with the English language; (4) parent's country of origin; (5) parent literacy, as measured by a parent's reporting more than 3 days per week of reading alone; (6) parent's age; (7) marital status; (8) household size; (9) child's age; (10) child's sex.Ninety percent of the parents were born outside of the United States (71% in Mexico), 85% spoke Spanish in the home, and 63% had completed less than a high-school education. Seventy-five percent of children's medical insurance was provided by Medi-Cal (Medicaid), and 9% of children were uninsured. Sixty-seven percent spoke exclusively Spanish at home, and 84% of parents want their children to learn to read in both English and Spanish. High FBS was reported among parents whose children had received books from the physician when compared with parents whose children had received no books. The odds ratio (OR) was 3.62 (95% confidence interval [CI], 1.40-9.37; P<.05). Also associated with FBS were parents reading frequently to themselves (OR = 9.52; 95% CI, 2.09-43.27; P<.05) and national origin outside Mexico (OR = 5.54; 95% CI, 1.59-19.27; P<.05). These findings were independent of parent's educational level, parent's employment, parent's age, acculturation, and family size.Pediatricians can promote literacy development among Hispanic immigrant children through the provision of free books at well-child visits. Our findings also suggest the independent effects of adult literacy and child age. Further research is needed to understand the effect of pediatric literacy programs on Hispanic immigrant children, their bilingual environments, and their readiness for school entry. Arch Pediatr Adolesc Med. 2000;154:771-777

    View details for PubMedID 10922272

  • Understanding the practice of ethics consultation: Results of an ethnographic multi-site study JOURNAL OF CLINICAL ETHICS Kelly, S. E., Marshall, P. A., Sanders, L. M., Raffin, T. A., Koenig, B. A. 1997; 8 (2): 136-149

    View details for Web of Science ID A1997XW32500003

    View details for PubMedID 9302631

  • ETHICAL GROUND RULES FOR FETAL TISSUE RESEARCH IN THE POSTMORATORIUM ERA CHEST Sanders, L. M., Raffin, T. A. 1994; 106 (1): 2-4

    View details for Web of Science ID A1994NX37200003

    View details for PubMedID 8020272

  • ETHICS OF FETAL TISSUE-TRANSPLANTATION WESTERN JOURNAL OF MEDICINE Sanders, L. M., Giudice, L., Raffin, T. A. 1993; 159 (3): 400-407

    Abstract

    Now that the Clinton Administration has overturned the ban on federal funding for fetal tissue transplantation, old ethical issues renew their relevance and new ethical issues arise. Is fetal tissue transplantation necessary and beneficial? Are fetal rights violated by the use of fetal tissue in research? Is there a moral danger that the potential of fetal tissue donation will encourage elective abortions? Should pregnant women be allowed to designate specific fetal transplant recipients? What criteria should be used to select fetal tissue transplants? Whose consent should be required for the use of fetal tissue for transplantation? We review the current state of clinical research with fetal tissue transplantation, the legal history of fetal tissue research, the major arguments against the use of fetal tissue for transplantation, and the new postmoratorium ethical dilemmas. We include recommendations for guidelines to govern the medical treatment of fetal tissue in transplantation.

    View details for Web of Science ID A1993MA37000022

    View details for PubMedID 8236984

  • The ethics of withholding and withdrawing critical care. Cambridge quarterly of healthcare ethics Sanders, L. M., Raffin, T. A. 1993; 2 (2): 175-184

    View details for PubMedID 8293207

  • THE ORGAN-DONATION-COMMITTEE - AN ETHICALLY RESPONSIBLE APPROACH TO INCREASING THE ORGAN DONATION RATE CHEST Sanders, L. M., DEVNEY, P., Young, E., Raffin, T. A. 1992; 102 (5): 1572-1577

    View details for Web of Science ID A1992JX20900060

    View details for PubMedID 1424892

Footer Links:

Stanford Medicine Resources: