Early childhood home visiting services aim to support child and family health and development, yet challenges engaging and retaining families persist. One promising strategy to improve family engagement involves enhancing the capacity of the home visiting workforce to partner with families to set and implement service goals that align with families' needs and preferences. This study examined implementation of 'Goal Plan Strategies' (GPS), a training and coaching innovation designed to improve family-centered goal planning. Aims were to evaluate (1) the extent to which training and eight sessions of audio-based coaching were implemented with fidelity, (2) whether coaching fidelity was associated with home visitors' perceptions of coaching and confidence using goal planning strategies, and (3) whether GPS was perceived as feasible, acceptable, and useful by coaches and home visitors. Home visitors (N = 22) and coaches (N = 10) took part in GPS and completed surveys, session logs, and interviews. Training and coaching sessions were observed and coded for fidelity (e.g., dose, adherence, quality). GPS was implemented with high levels of fidelity. Findings support feasibility, acceptability, and usefulness of GPS, overall, and suggest the need to examine coaching dosage and overlap with other implementation supports more closely. Findings highlight the benefits of audio-based coaching, mentoring of coaches, and observational measures of implementation fidelity.

Evidence-based maternal and early childhood home visiting (EBHV) may support health and well-being among families headed by a caregiver with an intellectual disability or other learning difference. Little is known about tools EBHV staff can use to identify caregivers with learning differences and inform service delivery strategies. Investigators used a two-step stakeholder-engaged approach to identify screening tools that are feasible, acceptable, and useful in the EBHV context. In the first step, authors conducted a scoping review to identify validated screening tools. Data describing the studies and tools were extracted and synthesized. In the second step, an established Stakeholder Advisory Group gave two rounds of feedback on the feasibility, acceptability, and usefulness of each tool for the EBHV context. Most identified tools were verbal or written questionnaires developed outside the United States. Only one tool was developed for parents or other caregivers. Overall, tools had limited psychometric evidence. Stakeholders expressed concerns about potentially stigmatizing language of some items within tools, suggesting that adaptations may be needed for tools to be acceptable in the EBHV context. Investigators concluded that there are few valid and reliable screening tools to identify learning differences that are brief and can be used by paraprofessionals with no prior expertise. Additional research is needed to further validate, adapt, or develop a tool that is feasible, acceptable, and useful for the EBHV context.

OBJECTIVETo determine the cost-effectiveness of an intervention that successfully reduced rapid repeated births within 2 years of an index birth to adolescent mothers.DESIGNRandomized, controlled trial conducted from February 2003 to October 2007.SETTINGHome-based intervention with participants recruited from 5 urban clinics that provide care to low-income African American communities.PARTICIPANTSTwo hundred thirty-five pregnant teenagers (n = 235) aged 18 years or younger who were at 24 or more weeks of gestation at recruitment were followed up for 27 months.INTERVENTIONSParticipants were randomly assigned to usual care (n = 68) or 1 of 2 home-based interventions conducted by community outreach workers: (1) computer-assisted motivational intervention (CAMI) conducted quarterly with additional visits (CAMI+ [n = 80]) or (2) CAMI only (n = 87), a single-component motivational intervention conducted quarterly.MAIN OUTCOMESAdditional births by 24 months post partum determined from birth certificates, total and weighted mean intervention costs, cost per participant, and incremental cost-effectiveness ratios, defined as cost per prevented repeated birth.RESULTSRelative to usual care, CAMI significantly reduced repeated births (adjusted odds ratio, 0.47; 95% confidence interval, 0.22-0.97). Mean intervention costs per adolescent were $2064, with incremental cost-effectiveness ratios per prevented repeated birth of $21 895 (unadjusted), $17 388 (adjusted), and $13 687 for a high-risk subgroup termed newly insured (eligible for but not enrolled in public insurance).CONCLUSIONSThe CAMI costs and cost-effectiveness compare favorably with other effective programs aimed at preventing repeated teenage births. Replication of these results in broader samples of adolescents would provide policy guidance for what works, for whom, and at what cost.

PURPOSE:One-quarter of adolescent mothers bear another child within 2 years, compounding their risk of poorer medical, educational, economic, and parenting outcomes. Most efforts to prevent rapid subsequent birth to teenagers have been unsuccessful but have seldom addressed motivational processes. METHODS:We conducted a randomized trial to determine the effectiveness of a computer-assisted motivational intervention (CAMI) in preventing rapid subsequent birth to adolescent mothers. Pregnant teenagers (N = 235), aged 18 years and older who were at more than 24 weeks' gestation, were recruited from urban prenatal clinics serving low-income, predominantly African American communities. After completing baseline assessments, they were randomly assigned to 3 groups: (1) those in CAMI plus enhanced home visit (n = 80) received a multi-component home-based intervention (CAMI+); (2) those in CAMI-only (n = 87) received a single component home-based intervention; (3) and those in usual-care control (n = 68) received standard usual care. Teens in both intervention groups received CAMI sessions at quarterly intervals until 2 years' postpartum. Those in the CAMI+ group also received monthly home visits with parenting education and support. CAMI algorithms, based on the transtheoretical model, assessed sexual relationships and contraception-use intentions and behaviors, and readiness to engage in pregnancy prevention. Trained interventionists used CAMI risk summaries to guide motivational interviewing. Repeat birth by 24 months' postpartum was measured with birth certificates. RESULTS:Intent-to-treat analysis indicated that the CAMI+ group compared with the usual-care control group exhibited a trend toward lower birth rates (13.8% vs 25.0%; P = .08), whereas the CAMI-only group did not (17.2% vs 25.0%; P = .32). Controlling for baseline group differences, the hazard ratio (HR) for repeat birth was significantly lower for the CAMI+ group than it was with the usual-care group (HR = 0.45; 95% CI, 0.21-0.98). We developed complier average causal effects models to produce unbiased estimates of intervention effects accounting for variable participation. Completing 2 or more CAMI sessions significantly reduced the risk of repeat birth in both groups: CAMI+ (HR = 0.40; 95% CI, 0.16-0.98) and CAMI-only (HR = 0.19; 95% CI, 0.05-0.69). CONCLUSIONS:Receipt of 2 or more CAMI sessions, either alone or within a multicomponent home-based intervention, reduced the risk of rapid subsequent birth to adolescent mothers.

OBJECTIVE:To examine whether depressive symptoms are a risk factor for a subsequent pregnancy in adolescent mothers.DESIGN:Secondary analysis from a longitudinal risk-reduction intervention.SETTING:Five community-based prenatal sites in Baltimore, Maryland.PARTICIPANTS:Two hundred sixty-nine consenting teens, predominantly African American and with low income, who received prenatal care at any of the 5 community-based prenatal sites and completed follow-up questionnaires at 1 or 2 years post partum. Intervention Baseline depressive symptoms were measured with the Center for Epidemiological Studies Depression Scale. Outcome Measure Occurrence of and time to subsequent pregnancy by 2 years post partum.RESULTS:Among teens completing at least 1 follow-up questionnaire, baseline depressive symptoms were present in 46%. A subsequent pregnancy by 2 years post partum was experienced by 49%, with a mean (SD) time to first subsequent pregnancy of 11.4 (5.8) months. Depressive symptoms were associated with increased risk of subsequent pregnancy in both unadjusted models (hazard ratio, 1.44; 95% confidence interval, 1.01-2.03) and adjusted models (hazard ratio, 1.44; 95% confidence interval, 1.00-2.01).CONCLUSIONS:Depressive symptoms may be an independent risk factor for subsequent pregnancy in African American adolescent mothers. Because depression is treatable, future studies should evaluate whether improved recognition and treatment of adolescent depression reduces the risk of rapid subsequent pregnancy.

PURPOSE Adolescent mothers are at risk for rapidly becoming pregnant again and for depression, school dropout, and poor parenting. We evaluated the impact of a community-based home-visiting program on these outcomes and on linking the adolescents with primary care. METHODS Pregnant adolescents aged 12 to 18 years, predominantly with low incomes and of African American race, were recruited from urban prenatal care sites and randomly assigned to home visiting or usual care. Trained home visitors, recruited from local communities, were paired with each adolescent and provided services through the child’s second birthday. They delivered a parenting curriculum, encouraged contraceptive use, connected the teen with primary care, and promoted school continuation. Research assistants collected data via structured interviews at baseline and at 1 and 2 years of follow-up using validated instruments to measure parenting (Adult-Adolescent Parenting Inventory) and depression (Center for Epidemiologic Studies Depression). School status and repeat pregnancy were self-reported. We measured program impact over time with intention-to-treat analyses using generalized estimating equations (GEE). RESULTS Of 122 eligible pregnant adolescents, 84 consented, completed baseline assessments, and were randomized to a home-visited group (n = 44) or a control group (n = 40). Eighty-three percent completed year 1 or year 2 follow-up assessments, or both. With GEE, controlling for baseline differences, follow-up parenting scores for home-visited teens were 5.5 points higher than those for control teens (95% confidence interval, 0.5–10.4 points; P = .03) and their adjusted odds of school continuation were 3.5 times greater (95% confidence interval, 1.1–11.8; P <.05). The program did not have any impact on repeat pregnancy, depression, or linkage with primary care. CONCLUSIONS This community-based home-visiting program improved adolescent mothers’ parenting attitudes and school continuation, but it did not reduce their odds of repeat pregnancy or depression or achieve coordination with primary care. Coordinated care may require explicit mechanisms to promote communication between the community program and primary care.

19528 Chemotherapy Administration Associated Errors Before and After Use of Electronic Order Entry and Decision Support Background: Chemotherapy administration is an important part of oncology practice and as treatment plans have evolved, their complexity has increased. Our practice has developed a software program that incorporates decision support and safety checks. Here we report the errors we have noted before and after utilization of this system. Methods: Drug administration errors are tracked through a mandatory “incident report” process that requires staff to report whenever an error is recognized. All reports from 2003 (the year before utilization of the chemotherapy software) and 2006 were reviewed. We compared the number and type of errors from the two time periods. Results: • Statistically significant *increase or † decrease at alpha level 0.05. • 1rate is expressed per 100,000 treatments • 2 “Other” errors are those which could not be classified otherwise and had no impact on the patient Conclusions: The frequency of recognized errors associated with chemotherapy administration is very low (0.03%) and while still unacceptable, much lower than the 5% reported for medication administration in general. (Kaushal, Arch Int Med 163:1409 2003) A computerized software support system did not make a statistically significant change in the total frequency of administration errors but did significantly decrease wrong drug errors even as the complexity of treatment protocols increased. A class of error “Planned Drug Missed” was recognized because of a formal declaration of treatment plan. There may be significant reporting bias consequent to increased recognition and subsequent reporting of errors when a computerized system and formal declaration of treatment plan is in place. However, no matter the system, the human/computer interface remains a potential source of error. [Table: see text] No significant financial relationships to disclose.

BACKGROUNDAdolescent pregnancy is associated with increased school dropout rates. Dropping out amplifies the probability of persistent social and economic disadvantage. Whether school-based health centers might help reduce school absenteeism and dropout rates in this group has not been well studied.OBJECTIVETo examine the association of school-based prenatal services on school attendance and dropout rates.METHODSIn this retrospective cohort study, using school rosters from an alternative school, we identified adolescents aged 18 years or younger who delivered a baby between July 1, 1995, and August 30, 1997, in Baltimore, Md. We linked school records spanning 3 years with medical records and birth certificates. School variables such as attendance and dropout rates were examined in relation to the teen's year of pregnancy and prenatal care setting (school-based vs non-school-based). Hierarchical logistic regression was used to examine effects of school-based prenatal care on dropout and promotion or graduation rates, with adjustment for baseline group differences.RESULTSWe identified 431 predominantly African American, low-income adolescents who attended the alternative school in their pregnancy school year. In the year prior to pregnancy, most performed poorly in school and had significant absenteeism. During their pregnancy school year, teens receiving school-based prenatal care were absent 12 fewer days, as compared with those receiving non-school-based care (P =.001), and their dropout rate was half that of those receiving non-school-based care (6% vs 15%; P =.02). Hierarchical logistic regression analyses, with adjustment for baseline prepregnancy differences, demonstrated that teens receiving school-based prenatal care were less likely to drop out of school during the pregnancy year (adjusted odds ratio, 0.39; 95% confidence interval, 0.15-0.99; P =.048).CONCLUSIONSAbsenteeism and dropout rates were reduced for pregnant adolescents receiving prenatal care at a school-based health center in an urban alternative school. Findings underscore the importance of funding and evaluating school-based health centers and other interventions that may ameliorate negative outcomes among childbearing adolescents.

Oral acyclovir has been demonstrated to prevent reactivation of herpes simplex virus (HSV) infections when administered prophylactically to autologous bone marrow transplant (BMT) recipients or patients undergoing stem cell rescue therapy. Oral valacyclovir, which is converted in the body to acyclovir, has greater oral bioavailability than oral acyclovir and compared with oral acyclovir yields similar acyclovir plasma concentrations with less frequent (twice-daily) dosing. This study compared the efficacy of oral valacyclovir with that of oral acyclovir at preventing HSV mucositis in BMT recipients. A total of 60 HSV-1-positive patients scheduled for BMT or stem cell rescue therapy were treated prophylactically with valacyclovir 500 mg twice daily until resolution of neutropenia. Data from these patients were compared with those of a historical control group of 60 patients who had received acyclovir 600 mg every 6 h until resolution of neutropenia or acyclovir 125 mg/m(2) intravenously every 6 h. The results show that none of the patients developed oral or oropharyngeal HSV infection while receiving either treatment. Of the 60 patients receiving valacyclovir, 38 (63%) completed treatment without the need for intravenous acyclovir compared with 12 of 60 (20%) patients in the acyclovir group. Additionally, the total number of doses of drug administered to the valacyclovir group was significantly less than the number received by patients in the acyclovir group. No serious adverse events occurred in either group of patients. This study demonstrates that oral valacyclovir and acyclovir are comparably effective and safe in preventing reactivation of HSV infections in autologous BMT and stem cell recipients. The less frequent dosing schedule with valacyclovir compared with acyclovir offers a potential advantage for patients undergoing BMT who frequently suffer with severe mucositis and have difficulty taking oral medications.

Purpose: Problems with access to care have been associated with increased Emergency Department (ED) use by adolescents. This study describes ED use by pregnant adolescents and examines associated factors including the role of school-based health centers (SBHCs). Methods: Using school rosters and hospital clinic databases, we identified a group of 779 pregnant adolescents ≤18 years old who resided in a large urban city, delivered a baby between 7/1/95–8/30/97, and who received prenatal care in a school-based health center or in non-school-based settings. Retrospective data from linked medical records, school records, birth certificates, and Medicaid claims were collected. We examined demographics, median household income, parity, school status, pregnancy risk including chronic medical problems, prenatal care setting (school-based vs. non-school-based), number of ED visits, ICD-9 codes for each visit, and timing of ED visit(s) in relation to delivery. Using logistic regression we computed models predicting the odds of an ED visit during pregnancy adjusted for variables significantly associated with ED use at the bivariate level. Results: Of the 779 pregnant teens identified, 683 (88%) were covered by Medicaid insurance and claims data were available for them. There were no significant differences in age, race, SES, parity, school status, and medical and pregnancy risk between teens with and without Medicaid insurance. The mean age of our sample was 15.9 years, 93% were African-American, 84% were in school, 13% had a prior birth, and 9% were classified as having a high risk pregnancy. One hundred eight (16%) received prenatal care in a SBHC. Overall, 130 teens (19%) made ≥1 ED visit (202 visits total) during the 12 months prior to delivery. Almost half of these visits occurred in the three months prior to conception and trauma was the most common diagnosis (20% of visits). For those ED visits that occurred during pregnancy (29% 1st trimester, 21% 2nd trimester, 13% 3rd trimester), the most common diagnoses were related to factors associated with pregnancy (39%) followed by trauma (17%), non-specified pain (16%), non-STI infections (15%), and STIs (6%). ED use during pregnancy was negatively associated with SES, but positively associated with parity and medical and pregnancy risk. ED use was not associated with age, race, or school status. Half as many teens receiving prenatal care in a SBHC compared to non-school-based settings made an ED visit (11% vs. 21%; p = .02). In multivariate models, adjusting for baseline differences and medical and pregnancy risk, the odds of an ED visit during pregnancy were 2.4 times greater for teens receiving non-school-based care (95% CI 1.2–4.7; p = .01) and 1.7 times greater if their pregnancy was high risk (95% CI 1.3–2.2; p < .001). Conclusions: While problem acuity was not measured in this study, among this cohort of pregnant teenagers with a usual source of care, a significant number used the ED for care. ED use appears to be inversely associated with SES and most common among those with higher pregnancy risk and those who receive non-school-based prenatal care.

Purpose: To examine and compare access to care, comprehensiveness of care, and birth outcomes for teenagers receiving prenatal care in comprehensive adolescent pregnancy programs (CAPPS) in two different settings: school-based vs. hospital-based.Methods: Retrospective cohort study using existing data sources: medical records and birth certificates. Using school rosters and hospital clinic databases, we identified pregnant adolescents :5 18 years old who delivered a baby between July 1, 1995 and August 30, 1997 and who received prenatal care in a school-based CAPP (SBCAPP) or hospital-based CAPP (HB-CAPP). Process of care measures (prenatal care adequacy and comprehensive care) and outcomes (low birth weight) were examined by site of care. Logistic regression models were computed to predict the odds of low birth weight by site of prenatal care, adjusting for prenatal care adequacy, comprehensive care, and possible confounders including baseline maternal characteristics.Results: Three-hundred-ninety eligible teens were identified. Mean age was 15.9 years, 93% were African-American, 84% in school, 13% had a prior birth, and 11% were cigarette smokers. Teens receiving care in the SBCAPP were significantly younger and more likely to be in school than those in the HB-CAPP. Overall, the two groups had similar low rates of prenatal care adequacy, but compared with teens in the SB-CAPP, those in the HB-CAPP were 1.5 times less likely to receive comprehensive care. Logistic regression analyses adjusting for baseline maternal differences showed that HB-CAPP teens were more than three times as likely to deliver a low birth weight infant compared with SB-CAPP teens (AOR 3.75; 95% CI 1.05-13.36). The increased odds of low birth weight for HB-CAPP teens attenuated when prenatal care was adequate and comprehensive (AOR-HBCAPP: 2.31, 95% CI 0.65- 8.24).Conclusions: School-based prenatal care was associated with significantly lower odds of low birth weight compared with HB-CAPP care. Although selection bias may be a factor in this observational study, our findings suggest that these improved birth outcomes may be mediated through prenatal care adequacy and provision of comprehensive care. (C) Society for Adolescent Medicine, 2003.

Background: Children of adolescent mothers may suffer because of parenting inadequacies. The use of volunteer home visitors to enhance parenting skills has not been well studied.Objective: To evaluate the effect of a volunteer model home visitation program on adolescent parenting outcomes.Design: Randomized trial with assignment to home visitation or control group.Setting: Urban, African American community Participants: Adolescents aged 12 to 18 years at 28 or more weeks' gestation or who had delivered a baby in the past 6 months were recruited between February 1996 and August 1999.Intervention: Volunteers were recruited from the community and trained to implement a parenting curriculum during weekly home visits. Each volunteer was paired with one teenager.Main Outcome Measure: Validated instruments measuring parenting stress, parenting behaviors, and mental health.Results: A total of 232 teenagers were successfully randomized to home visitation and control groups. At baseline, the groups were comparable on demographic, social support, and mental health measures. Almost half the teenagers had poor mental health at baseline, and high rates persisted at follow-up in both groups. in multivariate models, the home visitation group demonstrated significantly better parenting behavior scores at follow-up than did the control group (P = .01) but showed no differences in parenting stress or mental health.Conclusions: The volunteer home visitation program significantly improved some parenting outcomes but not parental distress or poor mental health. Volunteers may be an effective means of providing parenting education, but interventions that include specific means of addressing poor mental health are likely to have greater effects.

sin acetate for primary enuresis (58.9% vs 37.4%); (2) request an office visit for a child with nasal stuffiness, fever, and no other symptoms (69.8% vs 63.3%); (3) rec- ommend a chest x-ray for a child with productive cough, tachypnea, and rales at the right base (51.3% vs 47.7%); (4) refer a 4-year-old child with eczema and seasonal asthma to an allergist (64.3% vs 59.2%, ); and (5) refer a child with recurring suppurative otitis media to an oto- laryngologist (49.7% vs 33.9%). However, family prac- titioners are significantly less likely than pediatricians to order a sepsis workup on a 6-week-old infant with a tem- perature of 38.3°C (66.4% vs 81.1%). Physician at- tributes, practice characteristics, referral patterns, and geo- graphical traits explain little of these differences in practice style.