Project Title: Arguing for a two-generation model of care to prevent child maltreatment
Faculty Mentor’s Name: Dr. Melissa Bright
Student Name: Elizabeth Cox
Child maltreatment affects an alarmingly high number of children in the US and requires a new model of prevention and care to address this emerging disease burden. Backed by theoretical and empirical evidence, we argue for a coordinated and integrated system of surveillance, screening, and evidence-based intervention for child maltreatment risk factors starting during the prenatal period and extending through infancy. The empirical evidence supports this model in five key ways: 1) Prenatal and primary care provide ideal timing and opportunity (Besier, et al. 2012), 2) Prenatal and primary care are ideal for dissemination of evidence-based interventions (Harden, et al. 2016), 3) Family violence and child maltreatment are intergenerational (Putnam-Hornstein, et al. 2015), 4) Two-generation models of care benefit both mom and baby (Glied, et al. 2014), and 5) Investing early helps the community (The Lancet, 2016).
In the current health care system, expectant mothers seek care from their Obstetrician/Gynecologists or Family Medicine physician; infants most often receive care separately from a Pediatrician with little information passed from maternal to infant health records except for perinatal infection risks. By expanding the view of prenatal care to include reducing the risk of child abuse and neglect, plus promoting offspring wellbeing, and expanding the view of pediatric care to include maternal experiences and risks, we improve the wellbeing of the family as a whole. Most recently, there has been an effort to address these concerns by coordinating group prenatal care and group postnatal care visits, which permits mothers and infants to have longer encounters with their physician in a group setting.
Project Title: Describing the social and developmental trajectory of infants diagnosed w/ neonatal abstinence syndrome
Faculty Mentor’s Name: Dr. Melissa Bright
Student Name: Shelby Murphy
The current opioid epidemic in the US is a public health crisis. In addition to the direct effects of opioid misuse on users, there are several indirect effects. A primary example is the effects on children whose parents are opioid addicted. For instance, unborn babies whose mothers have opioids in their system are at-risk of Neonatal abstinence syndrome (NAS) once born. NAS is a withdrawal syndrome consisting of behavioral and physical symptoms in a newborn. The literature on neonatal outcomes associated with NAS is significant and growing. What is less known, however, is the social and long term developmental outcomes for these infants after leaving the hospital. (Bagley 2014); ( Kocherlakota 2019)
Many factors will play a role in the future outcome of diagnosed children from both a clinical stand point and social/ environmental dynamics. Factors that have previously been studied in relation to NAS include neonatal treatment given (extent of pharmacological treatment vs. non-pharmacologic treatment), maternal Finnegan score, breast-feeding, and pediatric follow-up care. ( Jansson 2019) ; ( Oji-Mmuo 2019). These factors remain important because of the noted variety of care in NAS that still exists. (Wood 2019). As stated previously social and developmental outcomes and factors affecting these children’s outcomes have been less studied. These include but are not limited to, removal from the home, and age of first removal from the home. We hypothesize that these will play a role in future pediatric outcomes as well.
In the current project we aim to expand the literature on social and long term developmental outcomes of children with NAS by examining the natural history of children who were diagnosed with NAS to better understand the social and environmental factors that may contribute to future outcomes. We will create a unique, multi-source dataset of medical record data as well as data from the Departments of Health (DOH) and Children and Families (DCF).
Project Title: Developing and Implementing a Nutrition Counseling Framework for Family Medicine Providers
Faculty Mentor’s Name: Dr. Danielle Nelson
Student Name: Alyssa Sanchez
Nutrition counseling is provided to far fewer patients than could benefit from this intervention, despite physician acknowledgement of the role of diet in health maintenance and disease prevention and that patients desire that their physicians counsel them about nutrition. Studies investigating this disparity reveal that physician barriers to providing nutrition counseling are multiple and varied, suggesting that a multifaceted approach may be needed to bridge the gap between physician belief in the health promoting impact of nutrition and actual delivery of nutrition counseling.
In the primary phase of this project, healthcare team members and patients were surveyed to explore barriers to nutrition counseling, barriers to healthy eating choices, and perceptions surrounding nutrition counseling. A nutrition counseling resource guide containing patient education handouts, patient resources, and provider resources was developed and distributed within the UF Community Health and Family Medicine department.
This follow-up project seeks to explore 1.) the utility and efficacy of the nutrition counseling resource guide, and/or 2.) the relationships between provider barriers to nutrition counseling, patient barriers to healthy eating choices, and perceptions of both patients and providers surrounding nutrition counseling.
Project Title: Pediatric Concussion Recovery
Faculty Mentor’s Name: Dr. James Clugston
Student Name: Lauren von Zabern
There are approximately 1.1-1.9 concussions per year in children ages 0-18 due to recreational or sports activity.1 This includes both concussions diagnosed by a medical professional and ones that went undiagnosed. 1 In contrast to adults, younger people have a higher risk for more severe TBIs with prolonged recoveries. 2 There is much concern surrounding the long-term effects of concussions, especially for children and adolescents. However, conclusive evidence on this subject is lacking due to a scarcity of long-term prospective studies.3
The specific aim of this project is to examine the relationship between the severity, number and duration of concussion symptoms with cognitive, social and emotional functioning over a period of 1-1.5 years.
This project will use data obtained from a longitudinal study at Lurie Children’s Hospital of Chicago. The study follows, over a period of three years, 486 patients ages 8-17 who presented to the Lurie Children’s tertiary care concussion clinic. Data was collected using retrospective chart reviews, baseline surveys, and follow up surveys given at 6-month intervals. I will use data regarding duration and severity of concussions symptoms as well as data from Neuro-QoL questionnaires, PROMIS questionnaires and other surveys, regarding cognitive function, stigma, peer relationships, anxiety, depression, school performance, and mental health. By the summer of 2019, the initial, the 6-month follow up, the 12-month follow up, and possibly the 18-month follow up data will be available for me to analyze.
Project Title: Referral rate in a family medicine residency program: How does it compare to other practices?
Faculty Mentor’s Name: Dr. Peter Carek
Student’s Name: Hamza El Ayadi
Referral rates and patterns by family physicians for ancillary testing and to specialists have significant impact on numerous aspects of medical care, including the quality and cost of care provided. The appropriate use of referrals decreases diagnostic uncertainty and assists with the institution of appropriate treatment. Alternatively, the inappropriate use of referrals can be costly and inefficient as additional and unnecessary tests, procedures, and treatments may be ordered. In general, patients who are referred to specialists tend to incur greater health care spending compared to those who remain within primary care, even after adjusting for health status.
Additionally, the referral pattern of family physicians can be used to guide medical educational activities and curriculum. For instance, a high rate of referrals to dermatology from a clinic associated with a residency program may indicate the needs for additional didactic and clinic instruction in the area of skin care.
Substantial variation in primary care physician referral rates is present. The variation in referral rates is mainly associated with factors related to the patient (presenting problem, patient expectations, degree of morbidity), provider characteristics (such as type of training, years of experience, experience in treating the condition affecting patient, and certainty of diagnosis). Other physician factors include practice style, technical orientation of care, fear of malpractice suits, and practice environment. Specialist characteristics (such as perceived clinical skill, prior interactions, availability, and “returning” the patient to the referring physician) also influence the variation in referral rates. Finally, the community in which the provider practices helps to determine decisions to refer.
At present, the referral rate from a family medicine practice has not been extensively studied. The specific aim of this project is to examine the referral rate and pattern of a family medicine practice associated with a department of family medicine at a large academic institution and compare rates based upon specific practice characteristics.
Project Title: Understanding health disparities in birth outcomes
Faculty Mentor’s Name: Dr. Melissa Bright
Student’s Name: Govind Kallumkal
It is well known that race and ethnicity have an effect on outcomes of pregnant women and their children. One important example is seen in a lower birthweight associated with babies born of mothers facing racism during pregnancy. Assistive measures given to these patients can help bridge the gap that exists due to socioeconomic and ethnic differences. However, if these measures are not given, this is not possible. The study would like to identify why ethnicity is not always categorized properly or in some cases at all, and how this process could be improved.
The Mother-Infant Dyad Screening Study (MIDSS) aimed to capture a census of infants born at our institution in 2015. It was created retrospectively by cohorting all the infants whose health record was associated with a Current Procedural Terminology (CPT) code related to an initial newborn or neonatal hospitalization in 2015. Using CPT codes to identify this population of dyads, we screened 2,064 infants. The primary exclusion criterion was having no associated birth encounter in the health record (i.e. a misclassification of CPT code). Twins, infants with congenital anomalies, and duplicate health records were also excluded. This led to a final cohort of 948 maternal infant dyads in the MIDSS cohort. One of the unintentional but alarming findings from this study was the poor fill rate of race/ethnicity in the medical data as well as the inconsistencies between chart and self-reported data.
This poor fill rate, in concurrence with the inconsistencies between chart-reported and self-reported data is alarming in that women which qualify for additional assistance and monitoring during gestation are not receiving care that would be optimal for a successful pregnancy and birth. Identification of why this is occurring, how it is affecting womens’ care, and how it can in turn be improved is of importance.
The specific aims of this proposed project are
1.) Identify how race/ethnicity are identified in society and medicine.
2.) Identify how ethnicity is documented in medicine.
3.) Quantify and analyze patient categorization within the UF Health System.
4.) Identify how race/ethnicity characterization should be done in best practice.
Project Title: Arts in Medicine with Grace Marketplace
Faculty Mentor’s Name: Dr. Grant Harrell
Student’s Name: Haley Stone
The mobile outreach clinic (MOC) provides healthcare to the homeless population at Grace Marketplace on Fridays of every week. In order to facilitate a more hospitable and soothing healthcare environment during MOC hours of operation we would like to incorporate the arts into the waiting area around MOC. Our aim is to provide music, dance and other artistic offerings mainly for adults that encourage a peaceful and healing environment during clinic hours. Options are available to pilot projects at other MOC sites in addition to Grace as well.
Project Title: Epidemiology of norovirus outbreaks in long-term care facilities in Philadelphia
Faculty Mentor’s Name: Dr. Michael Lauzardo
Student’s Name: Hansol Kang
Long-term care facilities include assisted living facilities, nursing homes, and residential care facilities. While these facilities offer important treatment and care, one public health concern related to these long-term care facilities is the occurrence of infectious disease outbreaks. An intrinsic challenge is the need to provide healthcare within a residential setting. These illnesses can be introduced into long-term care facilities by new patients, visitors, and staff. Without early recognition and effective control, infectious agents can spread easily and lead to deadly outbreaks, especially among very young, elderly, and immunocompromised populations. Despite taking preventative measures such as vaccination, antiviral treatment, and infection control, outbreaks remain a public health challenge in long-term care facilities (3).
One of the most common causes of outbreaks in healthcare facilities is norovirus. Norovirus, the leading cause of acute gastroenteritis, is a contagious gastrointestinal tract infection that is associated with diarrhea, vomiting, abdominal pain, and nausea (1). Several characteristics facilitate the transmission of norovirus in healthcare settings. First, norovirus resists killing by many healthcare-grade environmental disinfectants. Second, transmission of norovirus requires a very low inoculum and is easily transferred person-to-person through the fecal-oral route, direct contact, and aerosolization (6). Last, immunity is short-lived, on the timescale of months, and research has yet to develop a norovirus vaccine. While norovirus typically causes a self-limited illness, infection can cause dehydration and electrolyte disturbances. These complications of norovirus infection can exacerbate illnesses in elderly or chronically ill patients. For this reason, it is important that health facilities understand how to prevent and contain norovirus outbreaks.
In this project, we propose studying the characteristics of norovirus outbreaks in long-term care facilities in the Philadelphia area. In Philadelphia, all long-term care facilities are required by public statute to report a cluster of gastrointestinal illness involving 3 or more residents to the Division of Disease Control within the Philadelphia Department of Public Health (PDPH). Using data captured over the past 5 years from a large and diverse urban setting, we hope to use Philadelphia as a model for understanding the factors that predispose long-term care facilities to norovirus outbreaks. We will explore the epidemiologic triad of virus, host, and environment factors as they relate to outbreak occurrence, size, and duration (1). These factors will be used to analyze the distribution and determinants of norovirus outbreaks. In addition, we will assess the efficacy of the public health interventions deployed by PDPH.
This project is significant because it expands our currently limited data on how to control norovirus outbreaks in LTCFs. The study of outbreak epidemiology in long-term care facilities can help define how infectious diseases are introduced and expand within a semi-closed community. By understanding the characteristics of norovirus outbreaks, including occurrence, size, duration, and profile of infected patients, we can identify high-risk populations or facility characteristics that are associated with an increased risk of a prolonged or large norovirus outbreak. This knowledge could guide future efforts to target enhanced preventative measures to patients and institutions at greatest risk. This research would be the first large case study on norovirus outbreaks in a large urban environment that includes comprehensive citywide data as well as a full analysis of public health interventions. This project also includes novel elements of analyzing outbreaks based on patient variables such as socioeconomic background, race, and ethnicity.
- Rachel M Burke, Minesh P Shah, Mary E Wikswo, Leslie Barclay, Anita Kambhampati, Zachary Marsh, Jennifer L Cannon, Umesh D Parashar, Jan Vinjé, Aron J Hall; The Norovirus Epidemiologic Triad: Predictors of Severe Outcomes in US Norovirus Outbreaks, 2009–2016, The Journal of Infectious Diseases, , jiy569, https://doi.org/10.1093/infdis/jiy569
- Geoffrey A Weinberg; Outbreak Epidemiology: One of Many New Frontiers of Norovirus Biology, The Journal of Infectious Diseases, , jiy570, https://doi.org/10.1093/infdis/jiy570
- “Influenza (Flu).” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 30 Oct. 2018, www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm.
- Stone, N.D., Ashraf, M.S., Calder, J., Crnich, C.J., Crossley, K., Drinka, P.J., Gould, C.V., Juthani-Mehta, M., Lautenbach, E., Loeb, M. and MacCannell, T., 2012. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infection Control & Hospital Epidemiology, 33(10), pp.965-977.
- Kambhampati A, Koopmans M, Lopman BA. Burden of norovirus in healthcare facilities and strategies for outbreak control. J Hosp Infect. 2015;89(4):296-301.