Feasibility of evaluating the CHIPRA care quality measures in electronic health record data

The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) includes provisions for identifying standardized pediatric care quality measures. These 24 "CHIPRA measures" were designed to be evaluated by using claims data from health insurance plan populations. Such data have limited ability to evaluate population health, especially among uninsured people. The rapid expansion of data from electronic health records (EHRs) may help address this limitation by augmenting claims data in care quality assessments. We outline how to operationalize many of the CHIPRA measures for application in EHR data through a case study of a network of >40 outpatient community health centers in 2009-2010 with a single EHR. We assess the differences seen when applying the original claims-based versus adapted EHR-based specifications, using 2 CHIPRA measures (Chlamydia screening among sexually active female patients; BMI percentile documentation) as examples. Sixteen of the original CHIPRA measures could feasibly be evaluated in this dataset. Three main adaptations were necessary (specifying a visit-based population denominator, calculating some pregnancy-related factors by using EHR data, substituting for medication dispense data). Although it is feasible to adapt many of the CHIPRA measures for use in outpatient EHR data, information is gained and lost depending on how numerators and denominators are specified. We suggest first steps toward application of the CHIPRA measures in uninsured populations, and in EHR data. The results highlight the importance of considering the limitations of the original CHIPRA measures in care quality evaluations.     

Special requirements of electronic health record systems in pediatrics

Some functions of an electronic health record system are much more important in providing pediatric care than in adult care. Pediatricians commonly complain about the absence of these "pediatric functions" when they are not available in electronic health record systems. To stimulate electronic health record system vendors to recognize and incorporate pediatric functionality into pediatric electronic health record systems, this clinical report reviews the major functions of importance to child health care providers. Also reviewed are important but less critical functions, any of which might be of major importance in a particular clinical context. The major areas described here are immunization management, growth tracking, medication dosing, data norms, and privacy in special pediatric populations. The American Academy of Pediatrics believes that if the functions described in this document are supported in all electronic health record systems, these systems will be more useful for patients of all ages.     

Television's influence on children's diet and physical activity

Understanding the impact of TV on children's diet and physical activity is important for developing strategies to prevent obesity and sedentary lifestyles. Determining parents' perceptions of television's influence on children's dietary intake and physical activity may provide useful information on this important topic. A questionnaire was developed to assess viewing habits and child requests for food and sport items advertised on TV. It was administered to 66 mothers of children, ages 3-8. Foods that children requested because they had seen them on TV paralleled the frequencies with which these foods were advertised on TV. Weekly viewing hours correlated significantly with (a) reported requests by children and purchases by parents of foods influenced by TV, and (b) children's caloric intake. Children's requests for sport items and physical activities were not significantly correlated with the number of hours of TV viewing. It appears from these data that parents perceive that television influences family purchasing patterns through the mechanism of their children's requests.     

Accuracy of parental and child's report of changes in symptoms of childhood asthma

This cohort study was conducted to evaluate the accuracy of parental and child's reports of changes in asthma symptoms. Fifty three asthmatic children and their parents were interviewed at enrollment and after 4 and 8 weeks. The outcomes were parental and child's reports of changes in asthma symptoms, changes in mean daily symptom scores and changes in pulmonary function. Among patients 6 to 10 years old, parental reports correlated more strongly than child's reports with changes in mean daily symptom scores (r: 0.54 vs 0.23). In patients aged 11 years or older, parental and child's reports correlated comparably with changes in mean daily symptom scores (r 0.63 vs 0.57). In both age groups, neither parental nor child's reports correlated significantly with changes in pulmonary function. The relatively low coefficient of correlation between parental,child report with symptom score suggests that these may not be very accurate reflections of change in asthma status. Nevertheless, for the age group 6 to 10 year, parental reports are more reliable than child reports, while both are comparable in the age group 11-18 years.     

The relationship between socio-economic status, parental support and adolescent physical activity

Aim: To examine: 1) the association between socio-economic status and adolescent physical activity; 2) to assess links between mothers' and fathers' social support and adolescents' physical activity. Methods: Participants were 326 urban adolescents and their parents. Physical activity was measured using a 7-d physical activity recall. Socio-economic status and parents' social support was assessed using questionnaires. Results: Boys were significantly more active than girls, and fathers' explicit modelling towards boys was higher compared to girls. In contrast, fathers' and mothers' logistic support was significantly higher towards their daughters. Social class and fathers' and mothers' social support were significantly related to adolescent self-reported physical activity. Fathers' explicit modelling was the strongest predictor of adolescent physical activity, predicting 13.5% of the total variance. Social class, fathers' logistic support and mothers' explicit modelling were also significant predictors, accounting for additional 14% of the variance in adolescents' weekly physical activity.
Conclusion: Parental support and social class are positively related to physical activity in Estonian adolescents.     

Legal, ethical, and financial dilemmas in electronic health record adoption and use

Electronic health records (EHRs) facilitate several innovations capable of reforming health care. Despite their promise, many currently unanswered legal, ethical, and financial questions threaten the widespread adoption and use of EHRs. Key legal dilemmas that must be addressed in the near-term pertain to the extent of clinicians' responsibilities for reviewing the entire computer-accessible clinical synopsis from multiple clinicians and institutions, the liabilities posed by overriding clinical decision support warnings and alerts, and mechanisms for clinicians to publically report potential EHR safety issues. Ethical dilemmas that need additional discussion relate to opt-out provisions that exclude patients from electronic record storage, sale of deidentified patient data by EHR vendors, adolescent control of access to their data, and use of electronic data repositories to redesign the nation's health care delivery and payment mechanisms on the basis of statistical analyses. Finally, one overwhelming financial question is who should pay for EHR implementation because most users and current owners of these systems will not receive the majority of benefits. The authors recommend that key stakeholders begin discussing these issues in a national forum. These actions can help identify and prioritize solutions to the key legal, ethical, and financial dilemmas discussed, so that widespread, safe, effective, interoperable EHRs can help transform health care.     

Parental report of outdoor playtime as a measure of physical activity in preschool-aged children

BACKGROUND: Keeping young children physically active is an important strategy to promote their health and well-being. To our knowledge, survey measures of physical activity in preschool-aged children are unavailable. Time spent playing outdoors is a potential surrogate measure of physical activity in preschoolers, but parental-report measures of outdoor playtime have not been evaluated. OBJECTIVE: To compare a direct measure of physical activity in preschool-aged children with 2 parental-report measures of children's outdoor playtime. MAIN OUTCOME MEASURES: Three days of recording with a 3-dimensional accelerometer were used to directly measure physical activity in 250 preschool-aged children. We calculated each child's average vector magnitude per minute while awake. Parental report of outdoor playtime was measured in 2 ways: (1). the score from a checklist used to record outdoor playtime over 3 days and (2). a recall of the usual minutes of daily outdoor playtime during the prior month. We calculated Spearman rank correlation coefficients among these 3 measures. RESULTS: The mean age of the children was 44 months, 87.7% were white, and 12.3% were black. Parents reported that their children spent a mean (+/-SD) of 146 (+/-113) minutes playing outdoors each day. Physical activity as measured by the accelerometer was significantly correlated to the time spent playing outdoors, as measured by the checklist (r = 0.33, P <.001) and recall (r = 0.20, P =.003). CONCLUSION: Parental-report measures of outdoor playtime were significantly correlated to a direct measure of physical activity in preschool-aged children, and are worthy of future evaluation as a survey measure.     

The joint influence of diet and increased physical activity in obese children

The authors performed a three week treatment and examination of 20 children with obesity of non-endocrine origin, and they compared the examination results with those of healthy children. The treatment of the obese children consisted of a diet and an individually determined training programme. In the course of the examinations it was established that the weight of the obese children decreased, their physical working capacity increased, their glucose and fat metabolism showed a tendency to improve. On the basis of all their findings authors wish to stress the importance of the primary and secondary prevention of cardio-vascular diseases as early as in childhood.     

Comparison of pedometer and accelerometer measures of physical activity in preschool children

In this study, daily step counts were recorded for 4 consecutive days in 129 four- and five-year-old children. To compare daily Yamax Digiwalker step counts with minutes of engagement in moderate to vigorous physical activity (MVPA), concurrent accelerometer data were collected in a random subsample (n = 76). The average daily step count was 9,980 (+/- 2,605). Step counts and MVPA minutes were strongly correlated (r = .73, p < .001). The daily step count of 13,874, equating to 1-hr MVPA engagement, was reached by 8% of the children. Daily step counts in preschool children give valid information on physical activity levels-daily step counts in preschoolers are low.     

Role of physical activity on health in children and adolescents

This past century has been characterized by enormous advances in almost all aspects of human achievement. A person born at the beginning of the 20th century and still alive has witnessed more technical evolution than occurred during the preceding millions of years of the Homo family. Previously we were adapted to a life‐style as hunters‐gatherers. Now, after a short spell in an agrarian culture, we have in some “privileged” societies ended up in an urbanized, highly technologic society dominated by a sedentary life‐style. Previously when a child had matured enough to understand the message of a teacher, education began, and boys learned from a “retired” hunter. Today, there is an emphasis on chronological age more or less irrespective of maturity, body dimensions, functioning or intellectual potential. “Vertical” contact with the older generation has now more or less been replaced by a “horizontal” one of individuals of the same age. Furthermore, the educational, physical, physiological and social situation of a young individual has changed dramatically within a few decades from a life‐style of activity to one more reminiscent of Homo Sedentarius. The consequences of this enormous uncontrolled trial with whole generations of young people are still to manifest themselves. This paper is a commentary from a physiological‐medical perspective.     

Adherence to physical activity and electronic media guidelines in Australian pre-school children

The aim of this study was to determine compliance with the National Association for Sport and Physical Education (NASPE) guideline for physical activity and American Academy of Pediatrics (AAP) recommendation for electronic media use among urban pre-school children in two large cities on the East Coast of Australia. Cross-sectional data were collected from 266 parents. Time spent using electronic media (watching television, DVDs or on the computer) and in physical activity were parent reported. The proportion who met each guideline was calculated. 56 per cent and 79% of children met the NASPE guideline on weekdays and weekends, respectively, while 73% and 70% met the AAP recommendation on weekdays and weekends, with no difference between boys and girls. A substantial minority do not meet physical activity and electronic media use recommendations, highlighting the need to better understand what factors contribute to physical activity and electronic media use among this group of pre-schoolers.     

Long term health implications of fitness and physical activity patterns.

Northern Ireland has the highest incidence of coronary heart disease (CHD) in the world. The physical fitness, activity patterns, health knowledge, attitudes, and dietary habits of a random, stratified sample of 3211 Northern Irish children, comprising 1540 boys and 1671 girls, age range 11-18 years were examined. At all ages boys were significantly more active than girls. The most important finding was an appreciable decline in physical activity levels after the age of 14 years reaching extremely low levels in older girls. While 75% of exercise taken was not related to school, physical education classes constituted the only exercise taken by one third of pupils. Girls had healthier nutritional habits and were more inclined to employ weight control measures than boys. There was a preponderance of children with a higher body mass index indicating a tendency to obesity in the child population. Over 20% of school leavers of both sexes regularly smoked cigarettes and 20% regularly drank alcohol. The postulated relationship between childhood inactivity, adult sedentary lifestyle, and increased risk of CHD raises serious cause for concern regarding the future cardiovascular health of many children.     

Children's physical activity and psychological health: the relevance of intensity

Aim: To examine the relevance of physical activity intensity when assessing the relationship between activity and psychological health in 9–10-year-old children.
Methods: Activity was assessed by accelerometry in 57 boys (n = 23) and girls (n = 34). Total activity and time spent in very light (≤1.9 METs) through to vigorous activity (≥6 METs) were recorded. Psychological health inventories to assess anxiety, depression and aspects of self-worth were completed.
Results: Time accumulated in very light activity had positive correlations with anxiety and depression (r > 0.30, p < 0.05) and negative correlations with aspects of physical self-worth (r > −0.29, p < 0.05). Time accumulated in vigorous activity had negative correlations with anxiety and behavioural conduct (r > −0.30, p < 0.05) and positive correlation with aspects of physical self-worth (r > 0.28, p < 0.05). Children spending over 4 h in very light intensity activity had more negative psychological profiles than children spending under 4 h at this intensity.
Conclusion: Aspects of psychological health were negatively correlated with very light intensity activity and positively correlated with vigorous intensity activity. Further research should investigate whether reducing time spent in very light intensity activity and increasing time spent in vigorous intensity activity improves psychological health in children.     

Measuring and validating physical activity and sedentary behavior comparing a parental questionnaire to accelerometer data and diaries

Accurately measuring children's physical activity and their sedentary behavior is challenging. The present study compared 189 parental responses to a questionnaire surveying physical activity and sedentary behavior of children aged 6-14 years, to accelerometer outputs and time activity diaries for the same group. Responses were analyzed taking age, sex and maternal education into account. Correlation coefficients between questionnaire reports and accelerometer-based physical activity across all age groups were acceptable (up to r = .55). Yet, adjustment for age markedly attenuated these associations, suggesting concomitant influences of biological and behavioral processes linked to age. The comparisons of general time indications in the questionnaire with 24h-diary records suggested that parents tended to under- and over-report single activities, possibly due to social desirability. We conclude that physical activity questionnaires need to be designed for specific age groups and be administered in combination with objective measurements.     

Issues in measuring quality of life in childhood cancer: measures, proxies, and parental mental health

The relationship between child- and parent-reported quality of life (QOL) and the effects of parental mental health, illness stressors, and child vulnerability was explored using two measures of QOL: the Pediatric Cancer Quality Life-32 (Varni et al., 1998a) and the Disquol (Eiser, Cotter, Oades, Seamark, & Smith, 1999). Thirty-two children with acute lymphoblastic leukaemia (mean age = 8.92 years) and 36 parents completed measures of QOL when attending routine clinic. In addition, parents also completed the General Health Questionnaire (GHQ-28), perception of the child's vulnerability, and illness-related stressors. Significant correlations were found between the overall scores on the two child-completed QOL measures, with a range of poor, moderate to good correlations found between the individual subscales. Poor to moderate concordance was found between child and parent reports. Children who self-reported poorer QOL had mothers who were more depressed. Parents who reported poorer QOL for their child reported more illness stressors and perceived their child as being more vulnerable. Assumptions that concordance between child and parent ratings of QOL is a necessary requirement for new measures of QOL are challenged.