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Lisa Chamberlain, MD, MPH, Professor of Pediatrics, Associate Chair of Policy and Community and the Arline and Pete Harman Faculty Scholar at Stanford Children's Hospital. Dr. Chamberlain has focused her career on the elimination of child health disparities. She is committed to do this in two ways: 1) transforming the way pediatricians practice by developing and disseminating models of community engaged pediatrics by combining principles from both medicine and public health, and 2) conducting health services research to inform policy.

She founded and co-directs the Stanford Pediatric Advocacy Program to train leaders in Community Pediatrics and Advocacy. She co-founded the California Community Pediatric Collaborative, uniting 14 training programs to advance education addressing pediatric health disparities. The Collaborative has trained over 2,500 pediatricians since 2007 and is an emerging national model, having been replicated across five states. She has disseminated these programs nationally in over 20 invited visiting professorships, keynote speakerships and national conference presentations. In addition to her educational programs and health services research, In 2011 at the height of the Great Recession she founded the Summer Lunch Bridge to address rising hunger rates, which has distributed over 300,000 meals to date. She has authored 54 peer-reviewed publications, she completed her pediatric training at Stanford, a General Academic Fellowship at UCSF/Stanford, and her Masters of Public Health at UC Berkeley.

Clinical Focus

  • Pediatrics

Academic Appointments

Administrative Appointments

  • Associate Chair, Policy & Community Engagement, Department of Pediatrics (2018 - Present)
  • Director of Scholarly Concentration in Community Health, Stanford School of Medicine (2005 - Present)
  • Medical Director, Pediatric Advocacy Program, Stanford School of Medicine and Packard Children's Hospital (2000 - Present)

Honors & Awards

  • The Golden Apple Award for excellence in teaching, Stanford pediatric residents (2004-05)
  • Public Policy and Advocacy Award, Academic Pediatric Association (May 2009)
  • The Physician Advocacy Merit Award, Institute on Medicine as a Profession (November 2008)
  • The HJ Kaiser Foundation Award for Outstanding & Innovative Contributions to Medical Education, Stanford School of Medicine (June 2008)

Professional Education

  • Fellowship: Stanford University Neonatology Fellowship (2003) CA
  • Residency: Stanford University Pediatric Residency (1999) CA
  • Internship: Stanford University Pediatric Residency (1997) CA
  • Medical Education: University of Arizona College of Medicine Office of the Registrar (1996) AZ
  • Board Certification: American Board of Pediatrics, Pediatrics (1999)
  • MPH, Berkeley, Maternal and child health (2000)

Community and International Work

  • Speak up for Kids: Advocacy Committee

    Partnering Organization(s)

    American Academy of Pediatrics

    Populations Served

    Children in northern California


    Bay Area

    Ongoing Project


    Opportunities for Student Involvement


Research & Scholarship

Current Research and Scholarly Interests

Child Health disparities - Projects focus on elucidating the non-clinical factors that impact access to appropriate care for children with chronic illness.

Health Policy - Projects explore the intersection of medicine as a profession and formation of child health policy.


2020-21 Courses


All Publications

  • Clinic-Based School Readiness: A Qualitative Examination of a Text Messaging Intervention JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Connelly, E., Ordaz, Y., Perez, J., De La Cruz, M. M., Chamberlain, L., Bruguera, R., Steinberg, J. R., Harris, S., Foreman, J., Bruce, J. 2021; 32 (2): 43-61
  • Pediatric Departmental Advocacy: Our Experience Addressing the Social Challenges of COVID-19 and Racism. The Journal of pediatrics Ramirez, M. R., Bruce, J. S., Ball, A. J., Gambhir, S., Zabrocka, K., Sahak, O., Dali, S., Jones, K., Chamberlain, L. J. 2020

    View details for DOI 10.1016/j.jpeds.2020.11.048

    View details for PubMedID 33301783

  • A Clinic-Based School Readiness Coaching Intervention for Low-Income Latino Children: An Intervention Study. Clinical pediatrics Peterson, J. W., Huffman, L. C., Bruce, J., Prata, N., Harley, K. G., Chamberlain, L. J. 2020: 9922820941230


    This intervention study assessed school readiness (SR)-related parent behaviors and perceived barriers for Latino parent-child pairs (N = 149, Mage = 4.5) after a clinic-based SR intervention (n = 74) or standard well-child care (n = 75). Intervention was a 1-hour visit with a community health worker (CHW) to assess child SR, model SR interactions, and provide SR tools and resources. Primary outcomes were parent behaviors and barriers collected by phone questionnaire. Regression analyses revealed that parents in the intervention were more likely to tell their child a story and visit the library in the last week and less likely to report barriers of limited SR knowledge. A brief, SR coaching intervention with a CHW increased SR-related parent behaviors and reduced barriers to SR. Evaluation with school entry data is underway.

    View details for DOI 10.1177/0009922820941230

    View details for PubMedID 32696662

  • School Readiness Coaching in the Pediatric Clinic: Latinx Parent Perspectives. Academic pediatrics Peterson, J. W., Almanzar, N. n., Chamberlain, L. J., Huffman, L. n., Butze, T. n., Marin-Nevarez, P. n., Bruce, J. S. 2020


    Children who enter school developmentally ready for kindergarten are more likely to succeed academically, be healthy and lead productive lives. However, low-income and minority children often enter kindergarten behind their more affluent peers. Pediatric clinics, as trusted family partners, are well positioned to provide school readiness (SR) support.To explore Latinx parent perceptions of a clinic-based SR coaching intervention using qualitative methods. Intervention was a 1-hour visit with an SR coach (bilingual community health worker trained to assess child SR, role model SR skills and provide educational tools and community resources).Qualitative theme analysis of Latinx parent semi-structured interviews completed 6-9 months after SR coaching intervention (June 2016 - February 2017). Parent-child pairs received the SR coaching intervention (N=74), post-intervention interviews (N=50) were completed, audio recorded and transcribed. Iterative team-based coding and inductive thematic analysis of interviews were conducted.Three domains emerged and included the SR coaching model, community SR resources, and parent SR knowledge. Sub-themes included 1) Parents valued the one-to-one SR coaching intervention, were receptive to coach recommendations and believed other parents would benefit from SR coaching; 2) Parents tried new early literacy activities with their child; 3) Despite positive intervention effects, parents lacked a comprehensive understanding of SR.A brief clinic-based SR coaching intervention with a bilingual SR coach was well received by low-income Latinx parents and increased parent SR behaviors. Expanded implementation and further quantitative evaluation using school entry child-specific data are needed to quantify effects.

    View details for DOI 10.1016/j.acap.2020.10.009

    View details for PubMedID 33096288

  • Bereaved parents' views on end-of-life care for children with cancer: Quality marker implications. Cancer Johnston, E. E., Molina, J. n., Martinez, I. n., Dionne-Odom, J. N., Currie, E. R., Crowl, T. n., Butterworth, L. n., Chamberlain, L. J., Bhatia, S. n., Rosenberg, A. R. 2020


    End-of-life (EOL) quality markers in adult oncology include home death and intensive care unit avoidance. Corresponding markers are lacking in pediatric oncology. This study was aimed at describing bereaved parents' perspectives of high-quality EOL care in pediatric oncology.This study enrolled a convenience sample of 28 bereaved parents (English- or Spanish-speaking) whose children (0-21 years old) had died of cancer ?6 months before. Semistructured interviews were conducted to elicit parental perceptions of medically intense/quality EOL care. Interviews were recorded and transcribed verbatim (30 hours), and study team consensus and content analyses identified themes related to EOL quality markers. Related quotes were scored on a 5-point Likert scale ranging from 1 (supported comfort care) to 5 (supported medically aggressive care).The children died in 1998-2017 at a mean age of 10 years (SD, 5.2 years); 50% had a solid tumor, and 46% were Spanish-speaking. Themes included 1) home death preference (unless home support was inadequate; median score, 1.6), nonaggressive care (median score, 2.4), and continued anticancer therapy (median score, 3.2); 2) programs/policies that could alleviate barriers limiting a family's time with a dying child (visiting restrictions and financial strains); 3) the need to prepare the family for death (eg, what would happen to the child's body), and 4) perceived abandonment.This is the first qualitative study to identify quality makers for children dying of cancer from bereaved parents' perspectives. Natural death is generally preferred, and quality measures that address barriers to parents' spending time with their children, a lack of preparation for the events surrounding death, and feelings of abandonment are critical. Future studies need to validate these findings and develop targeted interventions.

    View details for DOI 10.1002/cncr.32935

    View details for PubMedID 32383817

  • Policy in pediatric nephrology: successes, failures, and the impact on disparities. Pediatric nephrology (Berlin, Germany) Krissberg, J. R., Sutherland, S. M., Chamberlain, L. J., Wise, P. H. 2020


    Pediatric nephrology has a history rooted in pediatric advocacy and has made numerous contributions to child health policy affecting pediatric kidney diseases. Despite this progress, profound social disparities remain for marginalized and socially vulnerable children with kidney disease. Different risk factors, such as genetic predisposition, environmental factors, social risk factors, or health care access influence the emergence and progression of pediatric kidney disease, as well as access to life-saving interventions, leading to disparate outcomes. This review will summarize the breadth of literature on social determinants of health in children with kidney disease worldwide and highlight policy-based initiatives that mitigate the adverse social factors to generate greater equity in pediatric kidney disease.

    View details for DOI 10.1007/s00467-020-04755-5

    View details for PubMedID 32968856

  • Meeting the Needs of Postpartum Women With and Without a Recent Preterm Birth: Perceptions of Maternal Family Planning in Pediatrics. Maternal and child health journal Congdon, J. L., Trope, L. A., Bruce, J. S., Chung, P. J., Dehlendorf, C., Chamberlain, L. J. 2019


    OBJECTIVES: Women face distinct barriers to meeting their reproductive health needs postpartum, especially women who deliver preterm. Pediatric encounters present unique opportunities to address women's family planning, particularly within 18months of a prior pregnancy, when pregnancy has an elevated risk of an adverse outcome, such as preterm birth. To ensure maternal family planning initiatives are designed in a patient-centered manner, we explored perspectives on addressing reproductive health in a pediatric setting among women with and without a recent preterm delivery.METHODS: We conducted semi-structured, qualitative interviews with 41 women (66% delivered preterm). Women who delivered at any gestational age were interviewed at a pediatric primary care clinic. We also interviewed women whose infants were either in a level II intensive care nursery or attending a high-risk infant follow-up clinic, all of whom had delivered preterm. Data were analyzed using team-based coding and theme analysis.RESULTS: While women's preferred timing and setting for addressing peripartum contraception varied, they largely considered pediatric settings to be an acceptable place to discuss family planning. A few women felt family planning fell outside of the pediatric scope or distracted from the child focus. Women discussed various barriers to accessing family planning care postpartum, including circumstances unique to women who delivered preterm.CONCLUSIONS FOR PRACTICE: Family planning interventions in pediatric settings were overall an acceptable approach to reducing barriers to care among our sample of women who predominantly delivered preterm. These exploratory findings justify further investigation to assess their generalizability and to develop maternal family planning interventions for pediatric settings.

    View details for DOI 10.1007/s10995-019-02829-x

    View details for PubMedID 31875305

  • 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


    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

  • Acute Care Utilization at End of Life in Sickle Cell Disease: Highlighting the Need for a Palliative Approach. Journal of palliative medicine Johnston, E. E., Adesina, O. O., Alvarez, E. n., Amato, H. n., Paulukonis, S. n., Nichols, A. n., Chamberlain, L. J., Bhatia, S. n. 2019


    Background: People with sickle cell disease (SCD) have a life expectancy of <50 years, so understanding their end-of-life care is critical. Objective: We aimed to determine where individuals with SCD were dying and their patterns of care in the year preceding death to highlight end-of-life research priorities and possible opportunities for intervention. Design: Using the California SCD Data Collection Program database (containing administrative data, vital records, and Medicaid claims), we examined people with SCD who died between 2006 and 2015 (cases) at age <80 years and examined their hospital and emergency department (ED) utilization in their last year of life. Comparators included living controls with SCD matched 1:1 based on age, analysis year, insurance, and income. Results: We identified 486 people with SCD (cases) who died at a median age of 45 years (SD: 16 years). Most died in the hospital (63%) and ED (15%). In their last year of life, people with SCD were hospitalized for an average of 42 days (SD: 49 days) over five admissions. Inpatient admissions and ED visits were stable throughout the year until the month before death when acute care utilization sharply increased. In their last year of life, cases had more hospitalizations than controls, but similar ED utilization. Conclusions: People with SCD are dying acutely at a young age and most die in the hospital and the ED. Since clinicians caring for people with SCD currently cannot predict which acute events may be life-threatening, a comprehensive palliative approach to people with SCD must extend beyond chronic pain management and psychosocial support to include advance care planning.

    View details for DOI 10.1089/jpm.2018.0649

    View details for PubMedID 31390292

  • What Do Clinical Environments Say to Our Patients? A Replicable Model for Creative Advocacy. American journal of public health Steinberg, J. R., Ramphos, E., Bruce, J. S., Chamberlain, L. J. 2018; 108 (11): 1509?10

    View details for PubMedID 30303727

  • The Intersection of Health and Education to Address School Readiness of All Children. Pediatrics Peterson, J. W., Loeb, S., Chamberlain, L. J. 2018


    Children who enter kindergarten healthy and ready to learn are more likely to succeed academically. Children at the highest risk for not being ready for school live in poverty and/or with chronic health conditions. High-quality early childhood education (ECE) programs can be used to help kids be ready for school; however, the United States lacks a comprehensive ECE system, with only half of 3- and 4-year-olds being enrolled in preschool, lagging behind 28 high-income countries. As addressing social determinants of health gains prominence in pediatric training and practice, there is increasing interest in addressing ECE disparities. Unfortunately, evidence is lacking for clinically based, early educational interventions. New interventions are being developed asynchronously in pediatrics and education, often without knowledge of the evidence base in the other's literature. In this State-of-the-Art Review, we synthesize the relevant work from the field of education (searchable through the Education Resources Information Center, also known as the "PubMed" of education), combining it with relevant literature in PubMed, to align the fields of pediatrics and education to promote this timely transdisciplinary work. First, we review the education literature to understand the current US achievement gap. Next, we provide an update on the impact of child health on school readiness and explore emerging solutions in education and pediatrics. Finally, we discuss next steps for future transdisciplinary work between the fields of education and pediatrics to improve the health and school readiness of young children.

    View details for PubMedID 30366953

  • Care at specialized cancer centers among young adults with acute lymphoblastic leukemia in California. Leukemia & lymphoma Alvarez, E., Muffly, L., Li, Q., Brunson, A., Wun, T., Chamberlain, L., Keegan, T. 2018; 59 (10): 2482?84

    View details for PubMedID 29424251

  • 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


    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

  • The Advocacy Portfolio: A Standardized Tool for Documenting Physician Advocacy. Academic medicine : journal of the Association of American Medical Colleges Nerlinger, A. L., Shah, A. N., Beck, A. F., Beers, L. S., Wong, S. L., Chamberlain, L. J., Keller, D. 2018; 93 (6): 860?68


    Recent changes in health care delivery systems and in medical training have primed academia for a paradigm shift, with strengthened support for an expanded definition of scholarship. Physicians who consider advocacy to be relevant to their scholarly endeavors need a standardized format to display activities and measure the value of health outcomes to which their work can be attributed. Similar to the Educator Portfolio, the authors here propose the Advocacy Portfolio (AP) to document a scholarly approach to advocacy.Despite common challenges faced in the arguments for both education and advocacy to be viewed as scholarship, the authors highlight inherent differences between the two fields. On the basis of prior literature, the authors propose a broad yet comprehensive set of domains to categorize advocacy activities, including advocacy engagement, knowledge dissemination, community outreach, advocacy teaching/mentoring, and advocacy leadership/administration. Documenting quality, quantity, and a scholarly approach to advocacy within each domain is the first of many steps to establish congruence between advocacy and scholarship for physicians using the AP format.This standardized format can be applied in a variety of settings, from medical training to academic promotion. Such documentation will encourage institutional buy-in by aligning measured outcomes with institutional missions. The AP will also provide physician-advocates with a method to display the impact of advocacy projects on health outcomes for patients and populations. Future challenges to broad application include establishing institutional support and developing consensus regarding criteria by which to evaluate the contributions of advocacy activities to scholarship.

    View details for PubMedID 29298182

  • 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


    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

  • Early Childhood Learning and the Pediatrician: A Qualitative Study Among Diverse, Low-Income Caregivers. Journal of developmental and behavioral pediatrics : JDBP Steinberg, J. R., Bruce, J. S., Marin-Nevarez, P., Phan, K., Merrell, S. B., Chamberlain, L. J. 2018


    OBJECTIVE: School readiness by kindergarten entry is associated with increased high school graduation, decreased juvenile arrest, and better long-term health. Inadequate early childhood learning (ECL) disproportionately affects low-income children. Pediatricians have near-universal access to children younger than 5 years but remain an underused ECL resource. This study examined caregivers' perceptions of ECL, the role of the pediatrician and pediatric office, and the use of community-based ECL resources among diverse, low-income caregivers whose children were not enrolled in preschool.METHODS: Using community-engaged strategies, caregivers were recruited to participate in in-depth focus groups (FGs). Demographic and FG data were collected in English, Spanish, and Vietnamese. Qualitative data were analyzed with iterative transcript-based coding and theme analysis.RESULTS: From June 2015 to August 2015, 69 low-income mothers (n = 46), fathers (n = 8), and grandparents (n = 15) from African-American (33%), Latino (32%), and Vietnamese (35%) communities participated in 12 FGs. Caregivers across groups wanted pediatricians to act as ECL experts and to provide ECL services. Caregivers valued ECL, especially when delivered by trusted sources. Utilization and perception of community ECL resources varied among groups. The greatest variation included different preferences for resource setting, accessibility, and acceptability, especially cultural acceptability. Each individual and groups' unique, and occasionally adverse, experiences and financial and logistical considerations informed ECL preferences.CONCLUSION: This exploratory study brings forth diverse caregivers' perspectives regarding the role of pediatricians in ECL and their desire for pediatricians to be an access point for high-quality, affordable ECL services. Caregivers' preferences regarding ECL programming may inform clinic-based pediatric ECL programming.

    View details for PubMedID 29538187

  • Building a Novel Health Curriculum for Survivors of Intimate Partner Violence Residing at a Transitional Housing Program VIOLENCE AGAINST WOMEN Ragavan, M., Bruce, J., Bair-Merritt, M., Lucha, S., Maya-Silva, J., Stebbins, E., Chamberlain, L. 2018; 24 (3): 266?85


    We used a community-based participatory research approach to develop, implement, and evaluate one of the first health curricula for female intimate partner violence (IPV) survivors residing at a transitional housing program. The curriculum comprised 12 workshops that were developed based on the survivors' experiences, needs, and interests. Evaluation participants included 20 of the 37 women who attended at least one workshop, 12 workshop facilitators, and two housing center staff. Participants found the curriculum to be engaging, interactive, and helpful in building a supportive community. Suggestions for curricular improvement as well as opportunities for further research and curricular development are discussed.

    View details for PubMedID 29332505

  • Evolving Federal and State Health Care Policy: Toward a More Integrated and Comprehensive Care-Delivery System for Children With Medical Complexity PEDIATRICS Langer, C. S., Antonelli, R. C., Chamberlain, L., Pan, R. J., Keller, D. 2018; 141: S259?S265


    Irrespective of any future changes in federal health policy, the momentum to shift from fee-for-service to value-based payment systems is likely to persist. Public and private payers continue to move toward alternative payment models that promote novel care-delivery systems and greater accountability for health outcomes. With a focus on population health, patient-centered medical homes, and care coordination, alternative payment models hold the potential to promote care-delivery systems that address the unique needs of children with medical complexity (CMC), including nonmedical needs and the social determinants of health. Notwithstanding, the implementation of care systems with meaningful quality measures for CMC poses unique and substantive challenges. Stakeholders must view policy options for CMC in the context of transformation within the overall health system to understand how broader health system changes impact care delivery for CMC.

    View details for PubMedID 29496977

  • Parental Attitudes, Behaviors, and Barriers to School Readiness among Parents of Low-Income Latino Children INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH Peterson, J., Bruce, J., Patel, N., Chamberlain, L. J. 2018; 15 (2)


    We sought to explore parental attitudes, behaviors, and barriers regarding school readiness in a county clinic serving low income, Latino children. Between December 2013-September 2014, we conducted a cross sectional survey of parents during 3-6 years well-child appointments about school readiness (SR) across: (1) attitudes/behaviors; (2) barriers; and (3) awareness; and (4) use of local resources. Most parents (n = 210, response rate 95.6%) find it very important/important for their child to know specific skills prior to school: take turns and share (98.5%), use a pencil and count (97.6%), know letters (99.1%), colors (97.1%), and shapes (96.1%). Over 80% of parents find education important and engage in positive SR behaviors: singing, practicing letters, or reading. Major barriers to SR were lack of knowledge for kindergarten readiness, language barriers, access to books at home, constraints on nightly reading, difficulty completing school forms, and limited free time with child. Awareness of local resources such as preschool programs was higher than actual utilization. These low-income, Latino parents value SR but lack knowledge to prepare their child for school and underutilize community resources such as free preschool programs. Pediatricians are uniquely positioned to address these needs, but more evidence-based interventions are needed.

    View details for DOI 10.3390/ijerph15020188

    View details for Web of Science ID 000426721400013

    View details for PubMedID 29364154

    View details for PubMedCentralID PMC5857047

  • 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


    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

  • 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


    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)


    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


    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

  • Intensity of end-of life-care in children with cancer: A population-based study Johnston, E. E., Alvarez, E., Saynina, O., Sanders, L., Bhatia, S., Chamberlain, L. J. AMER SOC CLINICAL ONCOLOGY. 2017
  • Lunch at the library: examination of a community-based approach to addressing summer food insecurity. Public health nutrition Bruce, J. S., De La Cruz, M. M., Moreno, G., Chamberlain, L. J. 2017: 1-10


    To examine a library-based approach to addressing food insecurity through a child and adult summer meal programme. The study examines: (i) risk of household food insecurity among participants; (ii) perspectives on the library meal programme; and (iii) barriers to utilizing other community food resources.Quantitative surveys with adult participants and qualitative semi-structured interviews with a sub-sample of adult participants.Ten libraries using public and private funding to serve meals to children and adults for six to eight weeks in low-income Silicon Valley communities (California, USA) during summer 2015.Adult survey participants (?18 years) were recruited to obtain maximum capture, while a sub-sample of interview participants was recruited through maximum variation purposeful sampling.Survey participants (n 161) were largely Latino (71 %) and Asian (23 %). Forty-one per cent of participants screened positive for risk of food insecurity in the past 12 months. A sub-sample of programme participants engaged in qualitative interviews (n 67). Interviewees reported appreciating the library's child enrichment programmes, resources, and open and welcoming atmosphere. Provision of adult meals was described as building community among library patrons, neighbours and staff. Participants emphasized lack of awareness, misinformation about programmes, structural barriers (i.e. transportation), immigration fears and stigma as barriers to utilizing community food resources.Food insecurity remains high in our study population. Public libraries are ideal locations for community-based meal programmes due to their welcoming and stigma-free environment. Libraries are well positioned to link individuals to other social services given their reputation as trusted community organizations.

    View details for DOI 10.1017/S1368980017000258

    View details for PubMedID 28318465

  • 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


    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

  • The Women, Infants, and Children Food Package and 100% Fruit Juice-Reply. JAMA pediatrics Nagata, J. M., Djafari, J. T., Chamberlain, L. J. 2017; 171 (2): 198-?

    View details for DOI 10.1001/jamapediatrics.2016.4113

    View details for PubMedID 27992622

  • Pediatric Oncology Discharges With Febrile Neutropenia: Variation in Location of Care JOURNAL OF PEDIATRIC HEMATOLOGY ONCOLOGY Alvarez, E., Chamberlain, L. J., Aftandilian, C., Saynina, O., Wise, P. 2017; 39 (1): E1-E7


    We examined the use of Pediatric Cancer Specialty Centers (PCSCs) over time and the length of stay (LOS) in pediatric oncology patients with a diagnosis of febrile neutropenia. PCSCs were defined as Children's Oncology Group and California Children's Services designated centers. We performed a retrospective analysis on all discharges of pediatric (0 to 18) oncology patients with febrile neutropenia in California (1983 to 2011) using the private Office of Statewide Health Planning and Development database. We examined influence of age, sex, race/ethnicity, payer, income, distance, tumor type, and complications on utilization of PCSCs and LOS (SAS 9.2). Analysis of 24,559 pediatric oncology febrile neutropenia discharges showed hospitalizations in PCSCs increasing from 48% in 1983 to 94% in 2011. The adjusted regression analysis showed decreased PCSC utilization for ages 15 to 18, Hispanic patients, and those living >40 miles away. The median PCSC LOS was 9 days compared with 7 days at a non-PCSC (P<0.0001). Discharge from a PCSC was associated with a LOS >8 days after controlling for complications. Inpatient PCSC care for febrile neutropenia in California has increased since 1983. Receiving care at a PCSC is influenced by age, tumor type, ethnicity, geography, and complications.

    View details for DOI 10.1097/MPH.0000000000000716

    View details for Web of Science ID 000391634100001

    View details for PubMedID 27918351

  • High-Expenditure Pharmaceutical Use Among Children in Medicaid. Pediatrics Cohen, E. n., Hall, M. n., Lopert, R. n., Bruen, B. n., Chamberlain, L. J., Bardach, N. n., Gedney, J. n., Zima, B. T., Berry, J. G. 2017; 140 (3)


    Medication use may be a target for quality improvement, cost containment, and research. We aimed to identify medication classes associated with the highest expenditures among pediatric Medicaid enrollees and to characterize the demographic, clinical, and health service use of children prescribed these medications.Retrospective, cross-sectional study of 3?271?081 Medicaid-enrolled children. Outpatient medication spending among high-expenditure medication classes, defined as the 10 most expensive among 261 mutually exclusive medication classes, was determined by using transaction prices paid to pharmacies by Medicaid agencies and managed care plans among prescriptions filled and dispensed in 2013.Outpatient medications accounted for 16.6% of all Medicaid expenditures. The 10 most expensive medication classes accounted for 63.9% of all medication expenditures. Stimulants (amphetamine-type) accounted for both the highest proportion of expenditures (20.6%) and days of medication use (14.0%) among medication classes. Users of medications in the 10 highest-expenditure classes were more likely to have a chronic condition of any complexity (77.9% vs 41.6%), a mental health condition (35.7% vs 11.9%), or a complex chronic condition (9.8% vs 4.3%) than other Medicaid enrollees (all P < .001). The 4 medications with the highest spending were all psychotropic medications. Polypharmacy was common across all high-expenditure classes.Medicaid expenditure on pediatric medicines is concentrated among a relatively small number of medication classes most commonly used in children with chronic conditions. Interventions to improve medication safety and effectiveness and contain costs may benefit from better delineation of the appropriate prescription of these medications.

    View details for PubMedID 28765380

  • Adolescent and Young Adult Oncology Patients with Acute Lymphoblastic Leukemia: Shifting Location of Care over Time Alvarez, E., Muffly, L. S., Li, Q., Brunson, A. M., Wun, T., Chamberlain, L., Keegan, T. AMER SOC HEMATOLOGY. 2016
  • The Option of Replacing the Special Supplemental Nutrition Program for Women, Infants, and Children Fruit Juice Supplements With Fresh Fruits and Vegetables. JAMA pediatrics Nagata, J. M., Djafari, J. T., Chamberlain, L. J. 2016; 170 (9): 823-824

    View details for DOI 10.1001/jamapediatrics.2016.1178

    View details for PubMedID 27399219

  • The Health of Women and Children After Surviving Intimate Partner Violence. Violence against women Ragavan, M., Bruce, J., Lucha, S., Jayaraman, T., Stein, H., Chamberlain, L. 2016


    Few studies have explored the perspectives of survivors of intimate partner violence (IPV) regarding their health and their children's health, their experiences accessing and utilizing health care, and health initiatives that would best serve their families' needs. We facilitated focus groups with female IPV survivors and adolescents who witnessed IPV. Women described their health and their children's health as poor and reported challenges with health care utilization, whereas teenagers generally perceived their health as typical for their age. Participants requested health education workshops, community resources, and social support. This study lays the foundation for further research and the development of health initiatives.

    View details for PubMedID 27411720

  • Redesigning Health Care Practices to Address Childhood Poverty ACADEMIC PEDIATRICS Fierman, A. H., Beck, A. F., Chung, E. K., Tschudy, M. M., Coker, T. R., Mistry, K. B., Siegel, B., Chamberlain, L. J., Conroy, K., Federico, S. G., Flanagan, P. J., Garg, A., Gitterman, B. A., Grace, A. M., Gross, R. S., Hole, M. K., Klass, P., Kraft, C., Kuo, A., Lewis, G., Lobach, K. S., Long, D., Ma, C. T., Messito, M., Navsaria, D., Northrip, K. R., Osman, C., Sadof, M. D., Schickedanz, A. B., Cox, J. 2016; 16 (3): S136-S146


    Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

    View details for Web of Science ID 000373417600023

    View details for PubMedID 27044692

  • Childhood Poverty and Its Effect on Health and Well-being: Enhancing Training for Learners Across the Medical Education Continuum ACADEMIC PEDIATRICS Chamberlain, L. J., Hanson, E. R., Klass, P., Schickedanz, A., Nakhasi, A., Barnes, M. M., Berger, S., Boyd, R. W., Dreyer, B. P., Meyer, D., Navsaria, D., Rao, S., Klein, M. 2016; 16 (3): S155-S162


    Childhood poverty is unacceptably common in the US and threatens the health, development, and lifelong well-being of millions of children. Health care providers should be prepared through medical curricula to directly address the health harms of poverty. In this article, authors from The Child Poverty Education Subcommittee (CPES) of the Academic Pediatric Association Task Force on Child Poverty describe the development of the first such child poverty curriculum for teachers and learners across the medical education continuum.Educators, physicians, trainees, and public health professionals from 25 institutions across the United States and Canada were convened over a 2-year period and addressed 3 goals: 1) define the core competencies of child poverty education, 2) delineate the scope and aims of a child poverty curriculum, and 3) create a child poverty curriculum ready to implement in undergraduate and graduate medical education settings.The CPES identified 4 core domains for the curriculum including the epidemiology of child poverty, poverty-related social determinants of health, pathophysiology of the health effects of poverty, and leadership and action to reduce and prevent poverty's health effects. Workgroups, focused on each domain, developed learning goals and objectives, built interactive learning modules to meet them, and created evaluation and faculty development materials to supplement the core curriculum. An editorial team with representatives from each workgroup coordinated activities and are preparing the final curriculum for national implementation.This comprehensive, standardized child poverty curriculum developed by an international group of educators in pediatrics and experts in the health effects of poverty should prepare medical trainees to address child poverty and improve the health of poor children.

    View details for Web of Science ID 000373417600025

    View details for PubMedID 27044694

  • Determinants of Health and Pediatric Primary Care Practices PEDIATRICS Beck, A. F., Tschudy, M. M., Coker, T. R., Mistry, K. B., Cox, J. E., Gitterman, B. A., Chamberlain, L. J., Grace, A. M., Hole, M. K., Klass, P. E., Lobach, K. S., Ma, C. T., Navsaria, D., Northrip, K. D., Sadof, M. D., Shah, A. N., Fierman, A. H. 2016; 137 (3)


    More than 20% of children nationally live in poverty. Pediatric primary care practices are critical points-of-contact for these patients and their families. Practices must consider risks that are rooted in poverty as they determine how to best deliver family-centered care and move toward action on the social determinants of health. The Practice-Level Care Delivery Subgroup of the Academic Pediatric Association's Task Force on Poverty has developed a roadmap for pediatric providers and practices to use as they adopt clinical practice redesign strategies aimed at mitigating poverty's negative impact on child health and well-being. The present article describes how care structures and processes can be altered in ways that align with the needs of families living in poverty. Attention is paid to both facilitators of and barriers to successful redesign strategies. We also illustrate how such a roadmap can be adapted by practices depending on the degree of patient need and the availability of practice resources devoted to intervening on the social determinants of health. In addition, ways in which practices can advocate for families in their communities and nationally are identified. Finally, given the relative dearth of evidence for many poverty-focused interventions in primary care, areas that would benefit from more in-depth study are considered. Such a focus is especially relevant as practices consider how they can best help families mitigate the impact of poverty-related risks in ways that promote long-term health and well-being for children.

    View details for DOI 10.1542/peds.2015-3673

    View details for Web of Science ID 000371395800056

    View details for PubMedID 26933205

  • Pharmacy Expenditures for Children With Serious Chronic Illness Reply JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Chamberlain, L. J., Swenson, S. M., Wise, P. H. 2016; 315 (7): 706?7

    View details for PubMedID 26881379

  • In Their Own Voices: The Reproductive Health Care Experiences of Detained Adolescent Girls WOMENS HEALTH ISSUES Johnston, E. E., Argueza, B. R., Graham, C., Bruce, J. S., Chamberlain, L. J., Anoshiravani, A. 2016; 26 (1): 48-54


    Adolescent girls involved with the juvenile justice system have higher rates of sexually transmitted infections and pregnancy than their nondetained peers. Although they may receive reproductive health care while detained, following clinician recommendations and accessing services in the community can be challenging.This study aimed to determine the barriers this population faces 1) accessing reproductive health care and 2)following the recommendations they receive when they are in the community.Adolescent girls at a juvenile detention facility completed online surveys about their demographics and sexual health behaviors. A subsequent semistructured interview assessed their experiences with reproductive health care services.Twenty-seven girls aged 14 to 19 were interviewed. The majority (86%) self-reported as Latina or Hispanic. The average age of sexual debut was 13.8 years. The major interview themes were 1) personal priorities and motivations affect decision making, 2) powerful external voices influence reproductive health choices, 3) accessing services ?on the run? is particularly challenging, and 4) detention represents an opportunity for intervention and change.Adolescent girls who are detained within the juvenile justice system face reproductive health challenges that vary with their life circumstances. They frequently have priorities, external voices, and situations that influence their decisions. Clinicians who care for these young women are in a unique position to address their health needs. Eliciting girls? goals, beliefs, and influences through motivational interviewing, as well as developing targeted interventions based on their unique experiences, may be particularly helpful for this population.

    View details for DOI 10.1016/j.whi.2015.09.009

    View details for Web of Science ID 000368262500011

  • Attitudes Toward Smoking Cessation Among Sheltered Homeless Parents JOURNAL OF COMMUNITY HEALTH Stewart, H. C., Stevenson, T. N., Bruce, J. S., Greenberg, B., Chamberlain, L. J. 2015; 40 (6): 1140-1148


    The prevalence of smoking among homeless adults is approximately 70 %. Cessation programs designed for family shelters should be a high priority given the dangers cigarette smoke poses to children. However, the unique nature of smoking in the family shelter setting remains unstudied. We aimed to assess attitudes toward smoking cessation, and unique barriers and motivators among homeless parents living in family shelters in Northern California. Six focus groups and one interview were conducted (N = 33, ages 23-54). The focus groups and interviews were audiorecorded, transcribed verbatim, and a representative team performed qualitative theme analysis. Eight males and 25 females participated. The following major themes emerged: (1) Most participants intended to quit eventually, citing concern for their children as their primary motivation. (2) Significant barriers to quitting included the ubiquity of cigarette smoking, its central role in social interactions in the family shelter setting, and its importance as a coping mechanism. (3) Participants expressed interest in quitting "cold turkey" and in e-cigarettes, but were skeptical of the patch and pharmacotherapy. (4) Feelings were mixed regarding whether individual, group or family counseling would be most effective. Homeless parents may be uniquely motivated to quit because of their children, but still face significant shelter-based social and environmental barriers to quitting. Successful cessation programs in family shelters must be designed with the unique motivations and barriers of this population in mind.

    View details for DOI 10.1007/s10900-015-0040-2

    View details for Web of Science ID 000363978000012

    View details for PubMedID 25980523

  • Mental Illness Drives Hospitalizations for Detained California Youth. journal of adolescent health Anoshiravani, A., Saynina, O., Chamberlain, L., Goldstein, B. A., Huffman, L. C., Wang, N. E., Wise, P. H. 2015; 57 (5): 455-461


    The purpose of the study was to describe inpatient hospitalization patterns among detained and nondetained youth in a large, total population of hospitalized adolescents in California.We examined the unmasked California Office of Statewide Health Planning and Development Patient Discharge Dataset from 1997 to 2011. We considered hospitalized youth aged 11-18 years "detained" if admitted to California hospitals from detention, transferred from hospital to detention, or both. We compared discharge diagnoses and length of stay between detained youth and their nondetained counterparts in the general population.There were 11,367 hospitalizations for detained youth. Hospitalizations differed for detained versus nondetained youth: 63% of all detained youth had a primary diagnosis of mental health disorder (compared with 19.8% of nondetained youth). Detained girls were disproportionately affected, with 74% hospitalized for a primary mental health diagnosis. Detained youth hospitalized for mental health disorder had an increased median length of stay compared with nondetained inpatient youth with mental illness (? 6 days vs. 5 days, respectively). This group difference was heightened in the presence of minority status, public insurance, and concurrent substance abuse. Hospitalized detained youth discharged to chemical dependency treatment facilities had the longest hospital stays (? 43 days).Detained juvenile offenders are hospitalized for very different reasons than the general adolescent population. Mental illness, often with comorbid substance abuse, requiring long inpatient stays, represents the major cause for hospitalization. These findings underscore the urgent need for effective, well-coordinated mental health services for youth before, during, and after detention.

    View details for DOI 10.1016/j.jadohealth.2015.05.006

    View details for PubMedID 26208862

  • 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


    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


    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

  • Child Advocacy in the Twenty-first Century. Advances in pediatrics Chamberlain, L. J., Kelly, N. 2015; 62 (1): 91-103

    View details for DOI 10.1016/j.yapd.2015.04.010

    View details for PubMedID 26205110

  • 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


    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

  • Lesbian, Gay, Bisexual, and Transgender Patient Care: Medical Students' Preparedness and Comfort. Teaching and learning in medicine White, W., Brenman, S., Paradis, E., Goldsmith, E. S., Lunn, M. R., Obedin-Maliver, J., Stewart, L., Tran, E., Wells, M., Chamberlain, L. J., Fetterman, D. M., Garcia, G. 2015; 27 (3): 254-263


    Phenomenon: Lesbian, gay, bisexual, and transgender (LGBT) individuals face significant barriers in accessing appropriate and comprehensive medical care. Medical students' level of preparedness and comfort caring for LGBT patients is unknown.An online questionnaire (2009-2010) was distributed to students (n = 9,522) at 176 allopathic and osteopathic medical schools in Canada and the United States, followed by focus groups (2010) with students (n = 35) at five medical schools. The objective of this study was to characterize LGBT-related medical curricula, to determine medical students' assessments of their institutions' LGBT-related curricular content, and to evaluate their comfort and preparedness in caring for LGBT patients.Of 9,522 survey respondents, 4,262 from 170 schools were included in the final analysis. Most medical students (2,866/4,262; 67.3%) evaluated their LGBT-related curriculum as "fair" or worse. Students most often felt prepared addressing human immunodeficiency virus (HIV; 3,254/4,147; 78.5%) and non-HIV sexually transmitted infections (2,851/4,136; 68.9%). They felt least prepared discussing sex reassignment surgery (1,061/4,070; 26.1%) and gender transitioning (1,141/4,068; 28.0%). Medical education helped 62.6% (2,669/4,262) of students feel "more prepared" and 46.3% (1,972/4,262) of students feel "more comfortable" to care for LGBT patients. Four focus group sessions with 29 students were transcribed and analyzed. Qualitative analysis suggested students have significant concerns in addressing certain aspects of LGBT health, specifically with transgender patients. Insights: Medical students thought LGBT-specific curricula could be improved, consistent with the findings from a survey of deans of medical education. They felt comfortable, but not fully prepared, to care for LGBT patients. Increasing curricular coverage of LGBT-related topics is indicated with emphasis on exposing students to LGBT patients in clinical settings.

    View details for DOI 10.1080/10401334.2015.1044656

    View details for PubMedID 26158327

  • 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


    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

  • More hippocrates, less hypocrisy: eliminate sugar-sweetened beverages from residency lunches. Academic medicine Nagata, J. M., Chamberlain, L. J., Robinson, T. N. 2015; 90 (2): 127-128

    View details for DOI 10.1097/ACM.0000000000000601

    View details for PubMedID 25628132

  • Educating Health Care Professionals on Human Trafficking PEDIATRIC EMERGENCY CARE Grace, A. M., Lippert, S., Collins, K., Pineda, N., Tolani, A., Walker, R., Jeong, M., Trounce, M. B., Graham-Lamberts, C., Bersamin, M., Martinez, J., Dotzler, J., Vanek, J., Storfer-Isser, A., Chamberlain, L. J., Horwitz, S. M. 2014; 30 (12): 856-861


    The US Department of State estimates that there are between 4 and 27 million individuals worldwide in some form of modern slavery. Recent studies have demonstrated that 28% to 50% of trafficking victims in the United States encountered health care professionals while in captivity, but were not identified and recognized. This study aimed to determine whether an educational presentation increased emergency department (ED) providers' recognition of human trafficking (HT) victims and knowledge of resources to manage cases of HT.The 20 largest San Francisco Bay Area EDs were randomized into intervention (10 EDs) or delayed intervention comparison groups (10 EDs) to receive a standardized educational presentation containing the following: background about HT, relevance of HT to health care, clinical signs in potential victims, and referral options for potential victims. Participants in the delayed intervention group completed a pretest in the period the immediate intervention group received the educational presentation, and all participants were assessed immediately before (pretest) and after (posttest) the intervention. The intervention effect was tested by comparing the pre-post change in the intervention group to the change in 2 pretests in the delayed intervention group adjusted for the effect of clustering within EDs. The 4 primary outcomes were importance of knowledge of HT to the participant's profession (5-point Likert scale), self-rated knowledge of HT (5-point Likert scale), knowledge of who to call for potential HT victims (yes/no), and suspecting that a patient was a victim of HT (yes/no).There were 258 study participants from 14 EDs; 141 from 8 EDs in the intervention group and 117 from 7 EDs in the delayed intervention comparison group, of which 20 served as the delayed intervention comparison group. Participants in the intervention group reported greater increases in their level of knowledge about HT versus those in the delayed intervention comparison group (1.42 vs -0.15; adjusted difference = 1.57 [95% confidence interval, 1.02-2.12]; P < 0.001). Pretest ratings of the importance of knowledge about HT to the participant's profession were high in both groups and there was no intervention effect (0.31 vs 0.55; -0.24 [-0.90-0.42], P = 0.49). Knowing who to call for potential HT victims increased from 7.2% to 59% in the intervention group and was unchanged (15%) in the delayed intervention comparison group (61.4% [28.5%-94.4%]; P < 0.01). The proportion of participants who suspected their patient was a victim of HT increased from 17% to 38% in the intervention group and remained unchanged (10%) in the delayed intervention comparison group (20.9 [8.6%-33.1%]; P < 0.01).A brief educational intervention increased ED provider knowledge and self-reported recognition of HT victims.

    View details for PubMedID 25407038

  • Neonatal intensive care unit to home: the transition from parent and pediatrician perspectives, a prospective cohort study JOURNAL OF PERINATOLOGY Enlow, E., Herbert, S. L., Jovei, I. J., Lorch, S. A., Anderson, C., Chamberlain, L. J. 2014; 34 (10): 761-766

    View details for DOI 10.1038/jp.2014.75

    View details for Web of Science ID 000342717100009

  • Neonatal intensive care unit to home: the transition from parent and pediatrician perspectives, a prospective cohort study. Journal of perinatology Enlow, E., Herbert, S. L., Jovel, I. J., Lorch, S. A., Anderson, C., Chamberlain, L. J. 2014; 34 (10): 761-766


    To describe the experience of a low-income population during the transition from the neonatal intensive care unit (NICU) to home and to compare these experiences with pediatrician perspectives.A prospective cohort study in a Level III, 40-bed NICU at a county hospital in Northern California affiliated with seven outpatient pediatric clinics. We surveyed parents in English or Spanish at discharge (n=79) and two weeks after discharge (n=49), along with outpatient pediatricians (n=17). Parents assessed experiences with discharge and the frequency with which barriers were encountered after discharge. We compared parent experiences with pediatrician estimates on four of these barriers.Spanish survey participants had more difficulty finding a NICU doctor (P=0.05) or nurse (P=0.001) to answer their questions. After discharge, 16% of families experienced significant challenges with two or more barriers. In contrast, the majority of pediatricians estimated that 50% or more families had significant challenges with all four barriers.Communication difficulties were the most commonly reported barriers during the NICU stay and physicians overestimated the frequency that families experienced challenges after discharge. Parent input is important to create effective interventions aimed at improving care and limiting disparities.

    View details for DOI 10.1038/jp.2014.75

    View details for PubMedID 24831523

  • "You get what you pay for": resources for training and practice in community pediatrics matter. Pediatrics Chamberlain, L. J., Kaczorowski, J. M. 2014; 134 (1): 173-175

    View details for DOI 10.1542/peds.2014-1130

    View details for PubMedID 24982107

  • Children and the Patient Protection and Affordable Care Act: Opportunities and Challenges in an Evolving System ACADEMIC PEDIATRICS Keller, D., Chamberlain, L. J. 2014; 14 (3): 225-233


    The Patient Protection and Affordable Care Act (ACA), passed in 2010, focused primarily on the problems of adults, but the changes in payment for and delivery of care it fosters will likely impact the health care of children. The evolving epidemiology of pediatric illness in the United States has resulted in a relatively small population of medically fragile children dispersed through the country and a large population of children with developmental and behavioral health issues who experience wide degrees of health disparities. Review of previous efforts to change the health care system reveals specific innovations in child health delivery that have been designed to address issues of child health. The ACA is complex and contains some language that improves access to care, quality of care, and the particular needs of the pediatric workforce. Most of the payment models and delivery systems proposed in the ACA, however, were not designed with the needs of children in mind and will need to be adapted to address their needs. To assure that the needs of children are met as systems evolve, child health professionals within and outside academe will need to focus their efforts in clinical care, research, education, and advocacy to incorporate child health programs into changing systems and to prevent unintended harm to systems designed to care for children.

    View details for Web of Science ID 000335368000003

  • Children and the Patient Protection and Affordable Care Act: opportunities and challenges in an evolving system. Academic pediatrics Keller, D., Chamberlain, L. J. 2014; 14 (3): 225-233


    The Patient Protection and Affordable Care Act (ACA), passed in 2010, focused primarily on the problems of adults, but the changes in payment for and delivery of care it fosters will likely impact the health care of children. The evolving epidemiology of pediatric illness in the United States has resulted in a relatively small population of medically fragile children dispersed through the country and a large population of children with developmental and behavioral health issues who experience wide degrees of health disparities. Review of previous efforts to change the health care system reveals specific innovations in child health delivery that have been designed to address issues of child health. The ACA is complex and contains some language that improves access to care, quality of care, and the particular needs of the pediatric workforce. Most of the payment models and delivery systems proposed in the ACA, however, were not designed with the needs of children in mind and will need to be adapted to address their needs. To assure that the needs of children are met as systems evolve, child health professionals within and outside academe will need to focus their efforts in clinical care, research, education, and advocacy to incorporate child health programs into changing systems and to prevent unintended harm to systems designed to care for children.

    View details for DOI 10.1016/j.acap.2014.02.004

    View details for PubMedID 24767775

  • Increased utilization of pediatric specialty care: a population study of pediatric oncology inpatients in california. Journal of pediatric hematology/oncology Chamberlain, L. J., Pineda, N., Winestone, L., Saynina, O., Rangaswami, A., Link, M., Wise, P. H. 2014; 36 (2): 99-107


    To examine inpatient utilization of pediatric cancer specialty centers (PCSCs) by pediatric oncology patients.We performed a retrospective (1999 to 2010) population-based analysis of oncology hospitalizations for pediatric patients aged 0 through 18 years using the California Office of Statewide Health Planning and Development database. Logistic regression examined hospitalization at 29 PCSCs and variables of age, sex, tumor type, payer, race, income, and distance to admission site.Analysis of 103,961 pediatric oncology discharges revealed that 93% occurred at PCSCs. These sites experienced a 20% increase in pediatric oncology discharges, conversely non-PCSCs exhibited a 70% decrease (P<0.0001). Multivariate analyses revealed increased utilization with young age (odds ratio [OR], 4.58; 95% CI, 3.88-5.42), African American (OR, 1.26; 95% CI, 1.11-1.43), and middle income (OR, 1.36; 95% CI, 1.29-1.45). Decreased utilization was seen for females (OR, 0.88; 95% CI, 0.84-0.93) and Hispanics (OR, 0.72; 95% CI, 0.68-0.77). Payer and proximity were not significantly associated with change in utilization. Tumor types less likely to utilize a PCSC included germ cell, solid, and central nervous system tumors. Adolescents were >3 times less likely to be treated at a PCSC.Inpatient pediatric oncology care in California has become increasingly regionalized with the vast majority of patients accessing PCSCs. However, variability in hospitalizations of adolescent patients and children not treated in PCSCs deserve further evaluation.

    View details for DOI 10.1097/01.mph.0000438027.07467.f1

    View details for PubMedID 24517965

  • Legislative advocacy: evaluation of a grand rounds intervention for pediatricians. Academic pediatrics Bensen, R., Roman, H., Bersamin, M., Lu, Y., Horwitz, S., Chamberlain, L. J. 2014; 14 (2): 181-185

    View details for DOI 10.1016/j.acap.2013.08.004

    View details for PubMedID 24126045

  • Legislative advocacy: evaluation of a grand rounds intervention for pediatricians. Academic pediatrics Bensen, R., Roman, H., Bersamin, M., Lu, Y., Horwitz, S., Chamberlain, L. J. 2014; 14 (2): 181-185


    To evaluate the impact of a Grand Rounds Action Alert (GRAA) intervention on the behaviors, knowledge, and attitudes of pediatric grand rounds (GR) attendees; and to assess its acceptability.A cross-sectional, quasi-experimental study was performed at a freestanding children's hospital. GRAA on child health legislative topics were presented in the first 2 minutes of the pediatric GR session as well as posted outside. Each session included an action item, such as writing/signing letters to elected officials or informational sheets with legislator contact information. Main outcome measures included self-reported behavior, advocacy knowledge, attitudes, and acceptability.One year after GRAA implementation, GR attendees with high exposure to the intervention were more likely to have written/signed a letter to a legislator compared to those with low/no exposure (60% vs 35%, P = .016). Those with high exposure were also more knowledgeable regarding financing of health care for low-income children (20% vs 5%, P = .027). Attitudes toward advocacy at baseline were positive: respondents agreed it is important to remain informed about (98%) and advocate for (94%) legislation favorable to children's health. Implementing this program was challenging, but the intervention was accepted favorably: 93% of respondents agreed that GRAA should continue.GRAA facilitated participation in legislative advocacy behaviors while improving self-perceived knowledge of legislative issues relating to children's health. They were well received in a large tertiary children's hospital.

    View details for DOI 10.1016/j.acap.2013.08.004

    View details for PubMedID 24126045

  • Asthma, tobacco smoke and the indoor environment: a qualitative study of sheltered homeless families JOURNAL OF ASTHMA Buu, M. C., Carter, L., Bruce, J. S., Baca, E. A., Greenberg, B., Chamberlain, L. J. 2014; 51 (2): 142-148


    Asthma is common in homeless children with an incidence of 28-40%. There are few published studies investigating asthma in homeless children. This study examines the perspectives of both caregivers and shelter staff regarding challenges and opportunities of caring for children with asthma.A focus group of sheltered parents (n?=?10) with children who have asthma was conducted to identify barriers to optimal asthma management. Key informant interviews (n?=?6) were conducted with shelter staff to discuss the shelter systems and policies to address childhood asthma. Data were audio-recorded and transcribed. A representative analysis team performed qualitative theme analysis.Key themes across 5 domains were identified: asthma education, access to asthma medication and equipment, asthma action plans, structural barriers to asthma management and environmental triggers. Parents identified multiple asthma triggers present in the shelter environment but cited lack of control as a barrier to remediation. Shelter staff desired elimination of asthma triggers but refer to the lack of resources as the primary barrier. Shelter staff favored a smoking ban on shelter property but named challenges to policy implementation. Both parents and staff identified asthma education and increased access to medications would be helpful.Policies to reduce environmental exposures, such as a smoking ban, to asthma triggers has the potential to improve the health of sheltered children with asthma.

    View details for DOI 10.3109/02770903.2013.857682

    View details for Web of Science ID 000331908900005

    View details for PubMedID 24147583

  • Innovations in Practice: Exploring an intensive meditation intervention for incarcerated youth CHILD AND ADOLESCENT MENTAL HEALTH Barnert, E. S., Himelstein, S., Herbert, S., Garcia-Romeu, A., Chamberlain, L. J. 2014; 19 (1): 69-73

    View details for DOI 10.1111/camh.12019

    View details for Web of Science ID 000330639100012

  • Utilization of subspecialty care by Hispanic pediatric oncology patients, California 1983-2010. Alvarez, E., Chamberlain, L. J., Marina, N., Saynina, O., Wise, P. AMER SOC CLINICAL ONCOLOGY. 2013
  • 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
  • A Multi-Institutional Medical Educational Collaborative: Advocacy Training in California Pediatric Residency Programs ACADEMIC MEDICINE Chamberlain, L. J., Wu, S., Lewis, G., Graff, N., Javier, J. R., Park, J. S., Johnson, C. L., Woods, S. D., Patel, M., Wong, D., Blaschke, G. S., Lerner, M., Kuo, A. K. 2013; 88 (3): 314-321


    Educational collaboratives offer a promising approach to disseminate educational resources and provide faculty development to advance residents' training, especially in areas of novel curricular content; however, their impact has not been clearly described. Advocacy training is a recently mandated requirement of the Accreditation Council for Graduate Medical Education that many programs struggle to meet.The authors describe the formation (in 2007) and impact (from 2008 to 2010) of 13 California pediatric residency programs working in an educational collaboration ("the Collaborative") to improve advocacy training. The Collaborative defined an overarching mission, assessed the needs of the programs, and mapped their strengths. The infrastructure required to build the collaboration among programs included a social networking site, frequent conference calls, and face-to-face semiannual meetings. An evaluation of the Collaborative's activities showed that programs demonstrated increased uptake of curricular components and an increase in advocacy activities. The themes extracted from semistructured interviews of lead faculty at each program revealed that the Collaborative (1) reduced faculty isolation, increased motivation, and strengthened faculty academic development, (2) enhanced identification of curricular areas of weakness and provided curricular development from new resources, (3) helped to address barriers of limited resident time and program resources, and (4) sustained the Collaborative's impact even after formal funding of the program had ceased through curricular enhancement, the need for further resources, and a shared desire to expand the collaborative network.

    View details for DOI 10.1097/ACM.0b013e3182806291

    View details for PubMedID 23348081

  • Global Health Training in Pediatric Residency: A Qualitative Analysis of Faculty Director Insights ACADEMIC PEDIATRICS Eneriz-Wiemer, M., Nelson, B. D., Bruce, J., Chamberlain, L. J. 2012; 12 (3): 238-244


    Interest and participation in global health (GH) has been growing rapidly among pediatric residents. Residency programs are responding by establishing formal GH programs. We sought to define key insights in GH education from pediatric residency programs with formal GH tracks.Seven model pediatric residency programs with formal GH training were identified in 2007. Faculty directors representing 6 of these programs participated in expert interviews assessing 6 categories of questions about GH tracks: understanding how GH tracks establish partnerships with global sites; defining organizational and financing structure of GH tracks; describing resident curriculum and pre-trip preparation; describing clinical experiences of residents in GH tracks; defining evaluation of residents and GH tracks; and defining factors that affect development and ongoing implementation of GH tracks. Data were analyzed using qualitative methodology.All programs relied on faculty relationships to establish dynamic partnerships with global sites. All programs acknowledged resident burden on GH partners. Strategies to alleviate burden included improving resident supervision and providing varying models of GH curricula and pre-trip preparation, generally based on core residency training competencies. Support and funding for GH programs are minimal and variable. Resident experiences included volunteer patient care, teaching, and research. Commitment of experienced faculty and support from institutional leadership facilitated implementation of GH programs.Directors of 6 model GH programs within pediatric residencies provided insights that inform others who want to establish successful GH partnerships and resident training that will prepare trainees to meet global child health needs.

    View details for Web of Science ID 000304212400014

    View details for PubMedID 22503444

  • A neonatal resuscitation curriculum in Malawi, Africa: did it change in-hospital mortality? International journal of pediatrics Hole, M. K., Olmsted, K., Kiromera, A., Chamberlain, L. 2012; 2012: 408689-?


    Objective. The WHO estimates that 99% of the 3.8 million neonatal deaths occur in developing countries. Neonatal resuscitation training was implemented in Namitete, Malawi. The study's objective was to evaluate the training's impact on hospital staff and neonatal mortality rates. Study Design. Pre-/postcurricular surveys of trainee attitude, knowledge, and skills were analyzed. An observational, longitudinal study of secondary data assessed neonatal mortality. Result. All trainees' (n = 18) outcomes improved, (P = 0.02). Neonatal mortality did not change. There were 3449 births preintervention, 3515 postintervention. Neonatal mortality was 20.9 deaths per 1000 live births preintervention and 21.9/1000 postintervention, (P = 0.86). Conclusion. Short-term pre-/postintervention evaluations frequently reveal positive results, as ours did. Short-term pre- and postintervention evaluations should be interpreted cautiously. Whenever possible, clinical outcomes such as in-hospital mortality should be additionally assessed. More rigorous evaluation strategies should be applied to training programs requiring longitudinal relationships with international community partners.

    View details for DOI 10.1155/2012/408689

    View details for PubMedID 22164184

    View details for PubMedCentralID PMC3228395

  • Do Medical Professionalism and Medical Education Involve Commitments to Political Advocacy? ACADEMIC MEDICINE Palfrey, J. S., Chamberlain, L. J. 2011; 86 (9): 1062-1063

    View details for DOI 10.1097/ACM.0b013e3182267696

    View details for Web of Science ID 000294254300005

    View details for PubMedID 21865894

  • Access to Pediatric Subspecialty Care: A Population Study of Pediatric Rheumatology Inpatients in California ARTHRITIS CARE & RESEARCH Pineda, N., Chamberlain, L. J., Chan, J., Cidon, M. J., Wise, P. H. 2011; 63 (7): 998-1005


    To examine trends in the specialty care hospitalization of pediatric rheumatology patients and determine how nonclinical factors influence access.This study used California's Office of Statewide Health Planning and Development discharge database to perform a retrospective population analysis of pediatric rheumatology hospitalizations in California between 1999 and 2007. We used logistic regression to examine the relationship between hospitalization in specialty care centers with a pediatric rheumatologist and nonclinical patient characteristics.A total of 18,641 pediatric discharges revealed that 57% were discharged from a specialty care center with a pediatric rheumatologist. Multivariate analysis showed that the factors associated with increased utilization of specialty care centers with a pediatric rheumatologist were public insurance (odds ratio [OR] 1.62, 95% confidence interval [95% CI] 1.51-1.74; P < 0.0001), being Hispanic (OR 1.29, 95% CI 1.19-1.40; P < 0.0001) or Asian non-Hispanic (OR 1.39, 95% CI 1.26-1.54; P < 0.0001), and high pediatric rheumatology specialty care bed supply (OR 2.79, 95% CI 2.49-3.14; P < 0.0001). A decreased utilization of specialty care centers with a pediatric rheumatologist was seen for patients ages <1 year (OR 0.45, 95% CI 0.40-0.52; P < 0.0001), ages 1-4 years (OR 0.50, 95% CI 0.46-0.55; P < 0.0001), ages 5-9 years (OR 0.68, 95% CI 0.62-0.75; P < 0.0001), ages 15-18 years (OR 0.51, 95% CI 0.47-0.56; P < 0.0001), males (OR 0.75, 95% CI 0.70-0.80; P < 0.0001), and patients residing farther away from a specialty care center with a pediatric rheumatologist (OR 0.57, 95% CI 0.51-0.63; P < 0.0001).Nonclinical factors play an increasingly important role in the hospitalization patterns of pediatric rheumatology patients in California. Understanding these factors is crucial if we are to ensure that the variation in access to care reflects clinical need.

    View details for DOI 10.1002/acr.20458

    View details for Web of Science ID 000292809200011

    View details for PubMedID 21360697

  • Health, Occupational and Environmental Risks of Emancipated Migrant Farmworker Youth JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Peoples, J. D., Bishop, J., Barrera, B., Lamas, O., Dunlap, J. L., Gonzalez, P. A., Horwitz, S. M., Chamberlain, L. J. 2010; 21 (4): 1215-1226


    This study examines the perceptions of health, health seeking behavior, access to information and resources, work related hazards, substance abuse, and social support of emancipated migrant youth (EMY) who come to the United States without their families to work.Semi-structured interviews were performed with EMY living without their families in Santa Clara County, California. Interviews were digitally recorded in Spanish, transcribed, translated into English, and analyzed by a five-person analysis team.Eleven interviews were conducted with 29 participants. Work was identified as the overarching priority of the EMY Their greatest concern was becoming sick and unable to work. They described their work environment as demanding and stressful, but felt obliged to work regardless of conditions. Alcohol and drug abuse were reported as prevalent problems.Emancipated migrant youth are a vulnerable population who have significant occupational stress, hazardous environmental exposures, social isolation, and drug/alcohol abuse.

    View details for Web of Science ID 000283622700012

    View details for PubMedID 21099073

  • Variation in Specialty Care Hospitalization for Children With Chronic Conditions in California PEDIATRICS Chamberlain, L. J., Chan, J., Mahlow, P., Huffman, L. C., Chan, K., Wise, P. H. 2010; 125 (6): 1190-1199


    Despite the documented utility of regionalized systems of pediatric specialty care, little is known about the actual use of such systems in total populations of chronically ill children. The objective of this study was to evaluate variations and trends in regional patterns of specialty care hospitalization for children with chronic illness in California.Using California's Office of Statewide Health Planning and Development unmasked discharge data set between 1999 and 2007, we performed a retrospective, total-population analysis of variations in specialty care hospitalization for children with chronic illness in California. The main outcome measure was the use of pediatric specialty care centers for hospitalization of children with a chronic condition in California.Analysis of 2 170 102 pediatric discharges revealed that 41% had a chronic condition, and 44% of these were discharged from specialty care centers. Specialty care hospitalization varied by county and type of condition. Multivariate analyses associated increased specialty care center use with public insurance and high pediatric specialty care bed supply. Decreased use of regionalized care was seen for adolescent patients, black, non-Hispanic children, and children who resided in zip codes of low income or were located farther from a regional center of care.Significant variation exists in specialty care hospitalization among chronically ill children in California. These findings suggest a need for greater scrutiny of clinical practices and child health policies that shape patterns of hospitalization of children with serious chronic disease.

    View details for DOI 10.1542/peds.2009-1109

    View details for PubMedID 20439593

  • Impact of Managed Care on Publicly Insured Children with Special Health Care Needs ACADEMIC PEDIATRICS Huffman, L. C., Brat, G. A., Chamberlain, L. J., Wise, P. H. 2010; 10 (1): 48-55


    The aim of this review was to evaluate the impact of managed care on publicly insured children with special health care needs (CSHCN).We conducted a review of the extant literature. Using a formal computerized search, with search terms reflecting 7 specific outcome categories, we summarized study findings and study quality.We identified 13 peer-reviewed articles that evaluated the impact of Medicaid and State Children's Health Insurance program (SCHIP) Managed Care (MSMC) on health services delivery to populations of CSHCN, with all studies observational in design. Considered in total, the available scientific evidence is varied. Findings concerning care access demonstrate a positive effect of MSMC; findings concerning care utilization were mixed. Little information was identified concerning health care quality, satisfaction, costs, or health status, whereas no study yielded evidence on family impact.The available studies suggest that the evaluated record of MSMC for CSHCN has been mixed, with considerable heterogeneity in the definition of CSHCN, program design, and measured outcomes. These findings suggest caution should be exercised in implementing MSMC for CSHCN and that greater emphasis on health outcomes and cost evaluations is warranted.

    View details for PubMedID 20129481

  • Lessons learned from a community-academic partnership addressing adolescent pregnancy prevention in Filipino American families. Progress in community health partnerships : research, education, and action Javier, J. R., Chamberlain, L. J., Rivera, K. K., Gonzalez, S. E., Mendoza, F. S., Huffman, L. C. 2010; 4 (4): 305-313


    Filipino Americans have more adolescent pregnancies than other Asian-Pacific Islanders (APIs). Few community-academic collaborations have addressed adolescent pregnancy prevention in this community.We sought to describe the lessons learned from and impact of a community-based teen pregnancy prevention program for Filipino Americans implemented by a Filipina pediatrics resident.We formed a community-academic partnership between the Filipino Youth Coalition, a community-based organization (CBO) in San Jose, California, and the Stanford School of Medicine's Pediatric Advocacy Program. We developed a culturally tailored parent-teen conference addressing adolescent pregnancy prevention in Filipino Americans. We qualitatively and quantitatively evaluated this intervention by collecting both pre- and post-conference data using a convenience sample design.Engaging particular aspects of Filipino culture (i.e., religion and intergenerational differences) helped to make this community-academic partnership successful. For physicians-in-training who are conducting community-based participatory research (CBPR), project challenges may include difficulties in building and maintaining academic- community relationships, struggles to promote sustainability, and conflicting goals of "community insiders" and "academic outsiders." Authors offer insights and implications for residents interested in practicing CBPR.CBPR is a key tool for exploring health issues in understudied populations. CBPR experiences can provide meaningful educational opportunities for physicians-in-training and can build sustained capacity in CBOs. They can also help residents to develop analytic skills, directly affect the health of the communities they serve, and, for minority physicians, give back to the communities they call home.

    View details for DOI 10.1353/cpr.2010.0023

    View details for PubMedID 21169708

  • Integrating Collaborative Population Health Projects into a Medical Student Curriculum at Stanford ACADEMIC MEDICINE Chamberlain, L. J., Wang, N. E., Ho, E. T., Banchoff, A. W., Braddock, C. H., Gesundheit, N. 2008; 83 (4): 338-344


    The authors describe the population health curriculum at the Stanford University School of Medicine from 2003 to 2007 that includes a requirement for first-year medical students to engage in community-based population health projects. The new curriculum in population health comprises classroom and experiential teaching methods. Population health projects, a key component of the curriculum, are described and classified by topic and topic area (e.g., health education; health services) and the intended outcome of the intervention (e.g., establishing new policies; advocacy). During the past four years, 344 students have entered the curriculum and have participated in 68 population health projects. The projects were determined both by students' interests and community needs, and they represented diverse topics: 51% of the 68 projects addressed topics in the area of disease prevention and health promotion; 28% addressed health care access; 15% addressed health services; 4% addressed emergency preparedness; and 1% addressed ethical issues in health. Each project had one of three targets for intervention: community capacity building, establishing policies and engaging in advocacy, and bringing about change or improvement in an aspect of the health care system. Projects represented diverse stages in the evolution of a community-campus partnership, from needs assessment to planning, implementation, and evaluation of project outcomes. Experience to date shows that classroom-based sessions and experiential learning in the area of population health can be successfully integrated in a medical school curriculum. When contextualized in a population health curriculum, population health projects can provide future physicians with an experiential counterpart to their classroom learning.

    View details for Web of Science ID 000267654000005

    View details for PubMedID 18367891

  • Introduction of a Pediatric Palliative Care Curriculum for pediatric residents JOURNAL OF PALLIATIVE MEDICINE Schiffman, J. D., Chamberlain, L. J., Palmer, L., Contro, N., Sourkes, B., Sectish, T. C. 2008; 11 (2): 164-170


    The Pediatric Palliative Care Curriculum (PPCC) was introduced as a pilot study in response to the published need for increased pediatric education in end-of-life (EOL) care. The PPCC was designed to better train residents in EOL issues so they could become more comfortable and knowledgeable in caring for children and adolescents with life-threatening illnesses.The PPCC consisted of six hour-long sessions run by a clinical psychologist, a licensed social worker, and faculty with experience in EOL care. The curriculum repeated every 6 weeks for 1 year. Residents in the training program at Stanford University rotating through oncology, pulmonology, and pediatric intensive care unit (PICU) were invited to attend. Session topics included: (1) personal coping skills, (2) being a caring professional, (3) recognizing cultural and familial differences, (4) pain management, (5) practical issues, and (6) meeting a bereaved parent. Pretest and posttest surveys with five-point Likert scale questions were used to measure curricular impact.Statistically significant improvement was found in resident self-report of: feeling prepared to initiate do-not-resuscitate discussions (p

    View details for DOI 10.1089/jpm.2007.0194

    View details for Web of Science ID 000254651600010

    View details for PubMedID 18333729

  • Making pediatrics residency programs family friendly: Views along the professional educational continuum JOURNAL OF PEDIATRICS Sectish, T. C., Rosenberg, A. R., Pageler, N. M., Chamberlain, L. J., Burgos, A., Stuart, E. 2006; 149 (1): 1-2

    View details for DOI 10.1016/j.jpeds.2006.06.006

    View details for Web of Science ID 000239352000001

    View details for PubMedID 16860111

  • 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

  • Does children's screen time predict requests for advertised products? Cross-sectional and prospective analyses ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Chamberlain, L. J., Wang, Y., Robinson, T. N. 2006; 160 (4): 363-368


    To examine children's screen media exposure and requests for advertised toys and food/drinks.Prospective cohort study.Twelve elementary schools in northern California.Eight hundred twenty-seven third grade children participated at baseline; 386 students in 6 schools were followed up for 20 months.None.Child self-reported requests for advertised toys and foods/drinks.At baseline, children's screen media time was significantly associated with concurrent requests for advertised toys (Spearman r = 0.15 [TV viewing] and r = 0.20 [total screen time]; both P<.001) and foods/drinks (Spearman r = 0.16 [TV viewing] and r = 0.18 [total screen time]; both P<.001). In prospective analysis, children's screen media time at baseline was significantly associated with their mean number of toy requests 7 to 20 months later (Spearman r = 0.21 [TV viewing] and r = 0.24 [total screen time]; both P<.001) and foods/drinks requests (Spearman r = 0.14 [TV viewing] and r = 0.16 [total screen time]; both P<.01). After adjusting for baseline requests and sociodemographic variables, the relationship between screen media exposure and future requests for advertised foods/drinks remained significant for total TV viewing and total screen media exposure. The relationship with future requests for toys remained significant for total screen media exposure.Screen media exposure is a prospective risk factor for children's requests for advertised products. Future experimental studies on children's health- and consumer-related outcomes are warranted.

    View details for Web of Science ID 000236516500004

    View details for PubMedID 16585480

  • Universal health care coverage for children: Impact on pediatric health care providers JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Chamberlain, L. J., Hughes, D. C., Bishop, J. S., Matsuda, D. H., Sassoubre, L. 2005; 16 (4): 622-633


    A Northern California county expanded health coverage to cover nearly all children in the state through a new insurance program. In two years, 75,500 children entered a health care system near capacity. We hypothesized that the influx of thousands of previously uninsured children into the health system would affect providers in many ways. This cross-sectional study sought to investigate how this influx affected provider practices, job satisfaction, access to specialists, and overarching views about the program. Qualitative analyses of expert interviews were performed. Providers reported improved access to health care, specialists, and medications for patients. They cited increased job satisfaction for providers due to fewer limits on care, improved referral process, and decreased patient family financial stress. Providers noted the persistence of long appointment wait times for specialist care. After moving to near universal coverage, safety net providers described increased job satisfaction. Because this study examined safety-net providers, future research requires a more representative sample of providers.

    View details for Web of Science ID 000233779500005

    View details for PubMedID 16311488

  • 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


    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

  • Creating an analytic voice in the policy storm AMBULATORY PEDIATRICS Wise, P. H., Chamberlain, L. 2005; 5 (1): 45-46

    View details for Web of Science ID 000226460500004

    View details for PubMedID 15656704

  • Lead paint dangers and physician advocacy. The virtual mentor : VM Chamberlain, L. J., Hoff, T. 2005; 7 (12)
  • The crucial role of the vanishing school nurse ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Chamberlain, L. J., Bauer, L. 2004; 158 (11): 1091-1091

    View details for Web of Science ID 000224837700016

    View details for PubMedID 15520352

  • Children's advocacy: Past, present, and future Panicker, N., Chamberlain, L. J., Sectish, T. C. INT PEDIATRIC RESEARCH FOUNDATION, INC. 2004: 259A
  • Child advocacy training for pediatric residents: A multi-site educational intervention Chamberlain, L. J., Sanders, L., Takayama, J. INT PEDIATRIC RESEARCH FOUNDATION, INC. 2003: 84A
  • Impact of child advocacy training on pediatric residents Chamberlain, L. J., Huffman, L. C., Shocket, S., Sanders, L. M., Sectish, T. C., Mendoza, F. S., Takayama, J. I. INT PEDIATRIC RESEARCH FOUNDATION, INC. 2002: 77A
  • Wernicke encephalopathy and Beriberi during total parenteral nutrition attributable to multivitamin infusion shortage PEDIATRICS Hahn, J. S., Berquist, W., Alcorn, D. M., Chamberlain, L., Bass, D. 1998; 101 (1)


    Wernicke encephalopathy (WE) is an acute neurologic disorder characterized by a triad of ophthalmoplegia, ataxia, and mental confusion. WE is attributable to thiamine (vitamin B1) deficiency. Beriberi is the systemic counterpart of thiamine deficiency and often manifests in cardiovascular collapse. WE is usually associated with alcoholism and malnutrition. It has also been seen in people with gastrointestinal diseases with malabsorption. Patients who have received total parenteral nutrition (TPN) without proper replacement of thiamine have also developed WE. Since November 1996, there has been a shortage of multivitamin infusion (MVI). Many patients who were on chronic TPN with MVI ceased to receive the MVI and were converted to an oral form of the multivitamin. As a result, there have been several reports of children and adults on TPN who have developed WE as a result of thiamine deficiency. With this case report, we bring to attention the association of the MVI shortage and WE. Early diagnosis of WE is important, because if it is treated with thiamine in the acute stages, the neurologic and cardiovascular abnormalities can be reversed.We report a 20-year-old female patient with Crohn's disease who developed WE as a result of thiamine deficiency. She had Crohn's disease since age 9 years and was on chronic TPN. Two months before admission, MVI was discontinued in the TPN because of the shortage of its supply. An oral multivitamin tablet was substituted instead. She was admitted to the hospital for persistent vomiting. In the hospital, she continued to receive TPN without MVI, but continued taking an oral multivitamin preparation. Two weeks after admission, she developed signs of WE including diplopia, ophthalmoplegia, nystagmus, and memory disturbance. She also developed hypotension that was thought to be caused by beriberi. She was treated with 50 mg of intravenous thiamine. Within hours of the intravenous thiamine, her hypotension resolved. The day after the infusion, she no longer complained of diplopia, and her ophthalmoplegia had improved dramatically. Magnetic resonance imaging showed several areas of abnormally high signal on T2-weighted images in the brainstem, thalamus, and mamillary bodies. The topographic distribution of these changes was typical of WE. After 2 months, her mental status and neurologic status had recovered completely.WE and thiamine deficiency should be considered in all patients with malabsorption, malnutrition, and malignancies. WE from thiamine deficiency can occur as a result of cessation of MVI in the TPN infusion. Even if an oral multivitamin preparation is given instead of MVI, patients with malabsorption may not absorb thiamine adequately. Prompt diagnosis of WE is important because it is potentially fatal and readily treatable with thiamine supplementation. Early recognition of WE may be more difficult in children, because the classic triad of symptoms may not develop fully. Magnetic resonance imaging may be useful in these cases to confirm the diagnosis of WE. Because the shortage of MVI is expected to be a long-term, there are likely to be more cases of WE in the pediatric population of TPN-dependent children. Because there is no shortage of intravenous thiamine, it should be administered with TPN even if MVI is not available.

    View details for Web of Science ID 000071331400026

    View details for PubMedID 9417174

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