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Provider Use of Corrected Age During Health Supervision Visits for Premature Infants
ARTICLE
Provider Use of Corrected Age During Health Supervision Visits for Premature Infants Jo Ann DÕAgostino, DNP, RN, CPNP, Marsha Gerdes, PhD, Casey Hoffman, PhD, Mary Lou Manning, PhD, RN, CPNP, Ann Phalen, PhD, APRN, NNP-BC, & Judy Bernbaum, MD ABSTRACT Introduction: Correcting age for prematurity is recommended by the American Academy of Pediatrics and the Centers for Disease Control and Prevention. The use of chronological age instead of corrected age for infants born prematurely may result in incorrect interpretations regarding the adequacy of a childÕs growth or developmental progress and has the potential to negatively affect care. This study examined the frequency and impact of the use of corrected age by primary care providers. Method: A retrospective cross-sectional electronic health record review was performed for all infants < 32 weeksÕ gestation who were seen for a health supervision visit in a 31-site pediatric network during a 1-year period. Primary care providers used an electronic health record that defaulted to chronological age information. Results: Primary care providers used corrected age for developmental surveillance for 24% of visits, they used chronologJo Ann DÕAgostino, Nurse Practitioner, Neonatal Follow-up Program, Department of Pediatrics and Division of General Pediatrics, The ChildrenÕs Hospital of Philadelphia, Philadelphia, PA. Marsha Gerdes, Psychologist, Department of Child and Adolescent Psychiatry and Behavioral Sciences, The ChildrenÕs Hospital of Philadelphia, Philadelphia, PA. Casey Hoffman, Psychologist, Department of Child and Adolescent Psychiatry and Behavioral Sciences, The ChildrenÕs Hospital of Philadelphia, Philadelphia, PA. Mary Lou Manning, Associate Professor, Director, Doctor of Nursing Practice Program, School of Nursing, Thomas Jefferson University, Philadelphia, PA. Ann Phalen, Assistant Professor, School of Nursing, Thomas Jefferson University, Philadelphia, PA. Judy Bernbaum, Director, Neonatal Follow-up Program, Department of Pediatrics and Division of General
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ical age for 71% of visits, and the age used was unclear in 5% of visits. The lower a childÕs gestational age and the more that chronological age was used, the more concerns were identified by primary care providers. Dietary changes that included the introduction of solid foods, the start of fluoride, and the introduction of milk typically were recommended on the basis of chronological age. Discussion: Primary care providers used chronological age more than corrected age, which influenced assessment and recommendations for care. This study illustrates the impact of not using corrected age, the importance of ensuring that care aligns with guidelines, and the possible influence of the design of the electronic health record on patient care. Because families of premature infants rely on primary care providers to accurately identify sequelae associated with prematurity, and to provide reassurance when it is warranted, these findings have implications for all health care providers who treat premature infants. J Pediatr Health Care. (2013) 27, 172-179. Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA. This research was funded in part by the Pennsylvania Delaware Valley Chapter of the National Association of Pediatric Nurse Practitioners. Conflicts of interest: None to report. Correspondence: Jo Ann DÕAgostino, DNP, RN, CPNP, Neonatal Follow-up Program, Room 12NW93, The ChildrenÕs Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA 191044399; e-mail: [email protected]. 0891-5245/$36.00 Copyright Q 2013 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. Published online October 28, 2011. http://dx.doi.org/10.1016/j.pedhc.2011.09.001
Journal of Pediatric Health Care
KEY WORDS Premature infants, health supervision visits, corrected age, chronological age, electronic health record
Correcting age for prematurity is recommended by the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC; AAP/ American Congress of Obstetricians and Gynecologists [ACOG], 2007; Bernbaum, Campbell, & Imaizumi, 2009; CDC, 2007). A review of the literature supports the use of age correction for prematurity (DÕAgostino, 2010). Corrected age also commonly is referred The use of to as adjusted age. The chronological age use of chronological age instead of corinstead of rected age may result corrected age may in incorrect interpretaresult in incorrect tions regarding the adequacy of a childÕs interpretations growth or developregarding the mental progress and adequacy of has the potential to negatively affect care. a childÕs growth or Infants who are born developmental prematurely are at inprogress and has creased risk for numerous medical and the potential to neurodevelopmental negatively affect sequelae including care. growth failure, cerebral palsy, developmental delay, and intellectual disability (Saigal & Doyle, 2008). Increased utilization of primary care services by premature infants has been well documented (Bird et al., 2010; Doyle, Ford, & Davis, 2003; Goldfeld, Wright, & Oberklaid, 2003; Jackson, Schollin, Bodin, & Ternestedt, 2001; Spicer et al., 2008; Wade et al., 2008). As a result, the primary care provider plays a vital role in the assessment and care of premature infants. Guidelines and recommendations regarding the care of premature infants by primary care providers have been published by the AAP (AAP/ACOG, 2007; Bernbaum et al., 2009). These guidelines include monitoring a childÕs growth and development with use of correction of age for the degree of prematurity until at least 24 monthsÕ corrected age. The CDC concurs with the use of corrected age when monitoring the growth of a premature infant (CDC, 2007). However, preventive health supervision visits and immunizations are based on a childÕs chronological age. As such, the primary care provider needs to remember to correct for prematurity to accurately assess a premature infant. We did not find any reports that explored the actual clinical usage of age correction by health care providers www.jpedhc.org
during provision of care for premature infants. The objectives of this study were to determine if the recommendation to use corrected age for premature infants was being followed in a primary care setting and to describe how the use of corrected age affected primary care providersÕ assessments and recommendations for care. METHODS Study Population This study used a retrospective cross-sectional design. All children born at < 32 weeksÕ gestation who were seen for a routine child care visit between 2 to 12 months chronological age in the primary care network at a large urban pediatric center during the 1-year period of October 1, 2008 to September 30, 2009, were eligible for inclusion. The network included 31 sites; four were large urban primary care centers and 27 were small urban and suburban practices that extended throughout the Philadelphia region, southern New Jersey, and Delaware. Health care providers consisted of attending pediatricians, resident physicians, and nurse practitioners. After institutional review board approval, subjects were identified through an electronic database search and data were retrieved through a medical record review by the principle investigator. Information was collected from the EPIC Hyperspace Spring 2008 electronic health record system (EPIC, 2011). All health supervision visits during the aforementioned study period were reviewed for each subject. Organization of the Electronic Health Record At the time of the study, the electronic health record in the network provided a template for health supervision visits that defaulted to the childÕs chronological age. Primary care providers were presented with a standard growth chart with measurements plotted for chronological age. A primary care provider could correct the measurements for a childÕs degree of prematurity by clicking a checkbox during the visit. The template also provided a nonstandardized developmental checklist that defaulted to items corresponding to the childÕs chronological age. The developmental checklist used in the network was derived from common early childhood screening and assessment measures, with items set at an approximate 25% delay level so that failure of any item should trigger referral. Milestones in social, adaptive/fine motor, language, and gross motor skills were assessed. The primary care provider was prompted by the electronic health record to select if the child was delayed or age appropriate in each area and to provide a summary of developmental progress at the end of the checklist. A different set of questions was provided for 2, 4, 6, 9, and 12 months. Although the checklist defaulted to the childÕs chronological age, for a child born prematurely, the primary care May/June 2013
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provider could access a set of questions that corresponded to the childÕs corrected age. Procedures Use of corrected or chronological age was determined by noting which set of questions a health care provider selected for developmental surveillance. The problem list and visit assessment for each child were reviewed for health care provider concerns related to developmental progress and concerns about growth. The visit record also was reviewed for evidence of a health care providerÕs recommendation to initiate early intervention services. To determine if corrected or chronological age was used for dietary assessment and recommendations, the ages at initiation of three common dietary changes were assessed. The first dietary change was the childÕs chronological age at the start of solid foods, which, according to AAP guidelines, are to begin between 4 and 6 months chronological age (Hagan, Shaw, & Duncan, 2008). The second dietary change was fluoride supplementation, which, as recommended by the CDC, is to start at 6 months chronological age if the water supply is deficient (CDC, 2001). The third dietary change was the introduction of milk, which included toddler formulas. According to AAP guidelines, it is recommended that children not be transitioned to milk until they are 12 months chronological age (Hagan et al., 2008; Wagner, Greer, & AAP Section on Breastfeeding and Committee on Nutrition, 2008). Because correction of age for prematurity is recommended for dietary changes (Bernbaum et al., 2009), the age of introduction of these three dietary changes would indicate if corrected or chronological age was used. Provider use of corrected or chronological age for the assessment of the growth chart could not be evaluated. The checkbox that corrected measurements in the electronic health record was designed to automatically reset after the visit record was closed, thereby negating retrieval of this information. Information regarding the primary care site, provider type (attending pediatrician, resident physician, or nurse practitioner), birth weight, and gestational age was collected to assess the impact of these variables on the use of corrected or chronological age.
ing the study period. Manual examination of the electronic health record revealed that six children had birth weights and neonatal histories inconsistent with a gestational age < 32 weeks, and one child who fit the study criteria registered for a health supervision visit but left before being seen. These seven children were excluded from the study. The remaining 432 children were included in the analysis. The children were 51% female, 43% Black or African American, 41% White, 2% Asian, 2% Hispanic or Latino Black, and 12% other. The mean gestational age was 28.4 2.3 weeks (range, 22–31 weeks), and the mean birth weight was 1200 394 g (range, 374–2359 g). The children had 1032 health supervision visits during the study period, with an average of two visits per child (range, 1–7 visits). Visits were categorized into 2-, 4-, 6-, 9-, and 12-month chronological age cohorts corresponding to the AAP schedule for health supervision visits (Hagan et al., 2008). Fifty-nine additional or off-schedule visits were excluded. The final analysis included 973 visits (N = 973). These visits represented 94% of all the health supervision visits for the sample. Attending physicians were providers for 85% (826) of the visits, resident physicians were providers for 9% (88) of the visits, and nurse practitioners were providers for 6% (59) of the visits. Primary care providers used age correction for developmental surveillance for 24% (234) of the health supervision visits. Chronological age was used for 71% (695) of the visits, and the use of chronological or corrected age was unable to be determined for 5% (44) of the visits (Figure 1). Although the use of age correction for a child’s degree of prematurity was documented at 24% of the visits, providers used the appropriate surveillance checklist which corresponded to the child’s corrected age at only 8% (75) of the total visits. At 16% (159) of the total visits, providers documented an adaptation in order to correct for prematurity instead of using the appropriate checklist (Figure 2). These provider adaptations will be referred to as ‘‘adapted corrected age.’’ The adaptations FIGURE 1. Use of chronological age and corrected age for developmental surveillance for all health supervision visits (N = 973).
Statistical Analysis Data were analyzed with use of SPSS version 18 statistical software (IBM Corporation, Armonk, New York) and included descriptive statistics, PearsonÕs v2, and logistic regression. RESULTS An electronic record search revealed that 439 children met the study criteria. These children represented 1.8% of all children of the same age seen in the entire primary care network for health supervision visits dur174
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FIGURE 2. Use of chronological, corrected, and adapted corrected age for developmental surveillance for all health supervision visits (N = 973).
included comments on progress with regard to corrected age after either the use of a chronological age surveillance checklist (14%; 133) or after no documentation of the use of a formal surveillance checklist (2%; 26). For the 929 visits for which the use of chronological or corrected age could be determined, providers gradually tapered the use of corrected age toward the end of the first year of life (v2 = 16.77, p < .01; Figure 3). Predictors for the use of chronological or corrected age included gestational age (p < .001) and the childÕs chronological age at visit (p < .01). The lower the gestational age (odds ratio [OR], 1.25 [95% confidence interval (CI), 1.13–1.38]) and the younger the chronological age of the child (OR, 1.1 [95% CI, 1.03–1.18]), the more likely it was that corrected age was used. Birth weight, primary care site, and type of provider (attending, resident, or nurse practitioner) were not predictive for the use of corrected or chronological age. Developmental Surveillance To assess the impact of the use of chronological or corrected age on the identification of developmental delays with use of the surveillance checklist, the following visits were excluded (N = 70): visits for which corrected or chronological age could not be determined and visits for which the formal surveillance
checklist was not used. The remaining 903 health supervision visits were assessed. Children who were evaluated with use of the surveillance checklist that corresponded to corrected age were less likely to have identified delays (v2 = 10.6, p < .01; Figure 4). Predictors for the identification of delays in one or more area included gestational age (p < .001), use of corrected age compared with adapted corrected age (p < .01), and use of corrected age compared with chronological age (p < .05). The lower the gestational age, the more likely delays were identified (OR, 1.23 [95% CI, 1.11–1.36]). A child who was assessed with use of adapted corrected age was 4.7 times more likely to be identified as having delays compared with a child who was assessed with use of corrected age (OR, 4.7 [95% CI, 1.75–12.62]). For a child assessed using chronological age, the odds were 2.6 times greater that delays would be found compared with a child assessed with corrected age (OR, 2.6 [95% CI, 1.15–6.10]). Concerns About Growth and Development Concerns about growth were documented in the final summary or visit diagnoses for 4.2% of the visits. The use of chronological or corrected age, the childÕs gestational age, and birth weight were not predictors for concerns about growth. Concerns about development were documented at 11.5% of visits. Predictors for concerns about development included gestational age (p < .01) and the use of corrected or chronological age (p < .05). Primary care providers were more likely to have concerns the lower the gestational age (OR, 1.25 [95% CI, 1.10–1.43]) and the more chronological age was used for developmental surveillance (OR, 2.57 [95% CI, 1.12–5.87]). Initiation of Early Intervention Referral Primary care providers documented referral for early intervention services for 24% (104) of the children; 42% (182) had documentation of already being involved in services, and no documentation was found regarding early intervention for 34% (146). Predictors for referral to early intervention included delays in one or more area (p < .001) and gestational
FIGURE 3. Use of chronological age and corrected age for developmental surveillance for all health supervision visits (N = 929).
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FIGURE 4. Determination of delays in surveillance areas based on use of corrected age, adapted corrected age, and chronological age (N = 903).
age (p < .001). For a child with delays identified in one or more areas, the odds of being referred to early intervention were 3.7 times more likely than for a child when no delays were found (OR, 3.7 [95% CI, 1.89–7.15]). A decrease in gestational age also increased the likelihood of a child being referred (OR, 1.37 [95% CI, 1.18–1.60]). The type of age used for the assessment— corrected compared with chronological and corrected compared with corrected adapted—was not predictive for referral to early intervention. Interestingly, despite the increased likelihood of delays being identified if adapted corrected or chronological age was used for surveillance and the increased likelihood of referral for intervention services if delays were noted, use of corrected age or chronological age surveillance did not predict referral for early intervention. Referral to early intervention was comparable for children in the corrected, adapted corrected, and chronological age groups. Of those assessed with corrected age, 25% were referred for service; 24% of those assessed with chronological age were referred for service, and 21% of those assessed with adapted corrected age were referred for service. Typically, infants were referred for intervention services early in the first year of life. The mean chronological age at time of referral was 5.2 2.7 months. Initiation of Dietary Changes The recommendation to start solid foods was documented for 43 patients. For the majority of those
patients, 91% (39), it was recommended that solid foods be started at either the 4-month or 6-month chronological age visit. The recommendation to start administering fluoride or the first notation of the presence of fluoride in a childÕs water supply was documented for 165 patients. This recommendation or notation occurred most frequently (56%; 92) at the 6-month chronological age visit. The recommendation to start giving the child milk was documented for 45 patients. This recommendation occurred for the majority (91%; 41) at the 12-month chronological age visit. The mean chronological ages at which providers recommended that these three dietary changes be started are shown in Table. When correction for prematurity was applied, the mean starts for all three changes were earlier than those recommended by the AAP/CDC. Gestational age and the use of corrected age or chronological age by primary care providers for developmental surveillance were not predictors for the start of solid foods, fluoride supplementation, or the introduction of milk to the diet. Patterns to the Use of Chronological and Corrected Age In this study, the number of children who were seen for more than one health supervision visit and for whom the use of chronological or corrected age could be determined totaled 271. A difference in the exclusive use of chronological or corrected age for all of a childÕs visits was found. Corrected age was used exclusively at 34%
TABLE. Dietary changes: mean chronological age when recommended to start Dietary change
Actual chronological age (mean mo SD)
When age correction applied (mean mo SD)
Recommended age to start (mo)
Solid foods (N = 43) Fluoride (N = 165) Milk (N = 45)
5.5 1 (range, 3.75–9) 7.9 2.5 (range, 2–12.75) 12.2 0.5 (range, 10.25–12.75)
2.7 1 (range, 1–6.25) 5.1 2.6 (range, –0.5–10.5) 9.4 0.7 (range, 7.75–10.50)
4–6a 6b 12a
a
Hagan, Shaw, & Duncan (Eds.) (2008). Centers for Disease Control and Prevention (2001).
b
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of repeat visits (28/82) compared with chronological age, which was used exclusively at 79% of the repeat visits (149/189; v2 = 50.4, p < .001). Primary care site and provider type were not predictive of the exclusive use of chronological or corrected age. Gestational age approached significance; the higher the gestational age, the more likely the exclusive use of chronological age occurred (p = .06). The use of chronological and corrected age at individual primary care sites was assessed. Of the 31 sites in the network, a combination of chronological and corrected age was used for assessment at 25 sites; chronological age was used exclusively at six sites; and at no sites was corrected age used exclusively for assessment. DISCUSSION The findings from this study demonstrate that contrary to AAP recommendations, primary care providers documented use of chronological age more frequently than corrected age. Failure to use corrected age for premature infants had implications for developmental surveillance and dietary recommendations. The use of chronological age or the attempt to correct for a childÕs prematurity without using a corrected age surveillance checklist increased the likelihood that primary care providers identified a child as having developmental delays. This finding supports the research that indicated that premature infants more closely reflected the developmental profiles of chronological age-matched full-term infants and more accurately reflected normative references when assessed with use of corrected age rather than chronological age (Allen & Alexander, 1992; Allen & Alexander, 1990; Den Ouden, Rijken, Brand, Verloove-Vanhorick, & Ruys, 1991; Lems, Hopkins, & Samson, 1993; Piper, Pinnell, Darrah, Byrne, & Watt, 1992; Restiffe & Gherpelli, 2006; Stjernqvist & Svenningsen, 1995; Sugita, Iai, Inoue, & Ohta, 1990). An interesting observation from this study is the finding that only 8% of the providers who corrected for prematurity for developmental surveillance used the corrected age surveillance checklist. This finding may be related to how the electronic health record presented information to the provider. Because the default surveillance checklist coincided with the childÕs chronological age, the provider needed to know how to access the surveillance checklist that coincided with the childÕs corrected age. From dialogues with providers at various sites, it was discovered that it was not universally known how to access the corrected age surveillance checklist. Considering the fact that premature infants are at increased risk for developmental issues, it is a cause for concern that providers who used the chronological age surveillance checklist, as well as those who attempted to correct for prematurity without using the corrected age surveillance checklist, did not have an age-appropriate tool for surveillance. www.jpedhc.org
Compounding this issue is that infants < 32 weeksÕ gestation, as represented in this study, composed a small percentage of the infants who were seen for health supervision in the network. In the flow of a busy practice, the need to correct an infantÕs age may be inadvertently overlooked. The finding that the type of age used for surveillance did not appear to predict a referral to early intervention may reflect other reasons for referral in addition to delays on developmental surveillance. Although this information was not systematically collected, observation of the documentation of other reasons for referral included the need for monitoring because of premature birth, tonal abnormalities, and social concerns. None of these reasons would be affected by whether or not a childÕs age was corrected. Although limited documentation was available regarding provider recommendations to start feeding solid foods or milk, when documented, the recommendations usually were made according to chronological age guidelines. This situation not only resulted in earlier mean starting ages when age correction was applied but, as shown, for some infants these changes were initiated at very early corrected ages. Because the nutritional needs of premature infants may be greater than those of healthy full-term infants, this earlier start may not provide premature infants with maximum nutritional benefits during the first year of life. Inconsistency in the approach of providers to the care of premature infants was another finding of this study. Because these children were all < 32 weeksÕ gestation, age correction should have been universal. For children for whom age correction was applied, and who were seen for more than one visit during the study period, inconsistency was reflected in that only one third had exclusive use of age correction for all visits. It also appeared that some primary care providers used age correction for developmental surveillance but not for the start of dietary changes, because the use of corrected age for surveillance was not a predictor for when dietary changes were initiated. An implication of the findings in this study that warrants further investigation is the impact of the providerÕs assessment and recommendations on familiesÕ perceptions and expectations of their children. Providers were more likely to be concerned about delays if they were not using corrected age. This concern may have been communicated to families and unnecessarily resulted in alarming parents who were already concerned about their childrenÕs developmental outcomes. Families of premature infants have been through unexpected and, in many cases, stressful neonatal courses, which commonly include counseling about the potential long-term sequelae of prematurity. Parental perception of a childÕs vulnerability has been associated with increased utilization of health care (Levy, 1980; May/June 2013
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Spurrier et al., 2000) and in one study was associated with worse developmental outcome at 1 year corrected age (Allen et al., 2004). As such, a primary care provider plays an important role not only in the accurate identification of sequelae but also in providing parental reassurance that developmental progress is appropriate when applicable. Although the use of age correction for plotting growth could not be assessed in this study, this area warrants further investigation. The potential exists for providers to misinterpret the adequacy of an infantÕs growth if measurements are not corrected. Concerns about growth inadequacy based on uncorrected measurements could result in unnecessary alarm, dietary changes that may promote unhealthy weight gain, or needless referral for further evaluation. A concerning implication of this study is that the electronic health record did not facilitate the choice of corrected age by the provider and may have contributed to the providerÕs use of chronological age because of automatic defaults to chronological age. As the transition to the electronic health record becomes increasingly more common, it will be crucial to monitor how the design of the system may affect patient safety and quality of care. The potential for silent errors exists. Computerized support systems ‘‘must present the right information, in the right format, at the right time, without requiring special effort’’ (James, 2001, p. 992). As was demonstrated in this study, this was not the case for premature infants. How primary care providers are systematically alerted to the need for age correction, when appropriate, is an issue that ambulatory practices need to address. For practices How primary care that use manual records, the approach providers are will vary depending systematically on the method used alerted to the need for record keeping and would be best adfor age correction, dressed by persons when appropriate, most familiar with is an issue that those methods. For practices that use an ambulatory electronic health repractices need to cord, age correction address. could be facilitated automatically by the system. Automatic defaults to corrected age developmental surveillance tools, growth charts, and anticipatory guidance, as well as automatic calculation of both the childÕs current chronological and corrected age, are ways to address this issue. These measures could facilitate more accurate developmental assessments and dietary recommendations and increase the standardization of care for preterm infants. A project currently under investigation in this ambulatory network is the development of a clinical decision 178
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support tool that facilitates automatic age correction and assists providers in the management of the care of preterm infants. Limitations of this study included the inability to assess provider use of the growth chart because this information could not be collected and the need to rely on provider documentation of what occurred during the visit. It is possible there may have been cases in which primary care providers considered a childÕs prematurity in counseling and verbal recommendations given to parents without documenting this information in the electronic health record. CONCLUSIONS The findings of this study regarding the use of chronological and corrected age during the primary care of premature infants in a large university network have implications for all providers who care for premature infants. Despite guideline recommendations to correct age for prematurity, the majority of providers documented use of chronological age instead of a corrected age for premature infants. The use of chronological age instead of corrected age resulted in possible overidentification of developmental delays and dietary changes before the ages recommended for premature infants. This study illustrates the importance of monitoring care to ensure alignment with practice guidelines. As exemplified by this study, the electronic health record may have contributed to the primary care providerÕs inappropriate use of chronological age by providing this as a default feature, resulting in the need for a provider to take additional steps to correct for prematurity. As the transition to the electronic health record becomes more common, it is important for providers to be aware of how the design of the system can influence patient safety and quality of care. REFERENCES American Academy of Pediatrics & American Congress of Obstetricians and Gynecologists. (2007). Guidelines for perinatal care (6th ed.). Elk Grove Village, IL: American Academy of Pediatrics. Allen, E. C., Manuel, J. C., Legault, C., Naughton, M. J., Pivor, C., & OÕShea, T. M. (2004). Perception of child vulnerability among mothers of former premature infants. Pediatrics, 113(2), 267-273. Allen, M. C., & Alexander, G. R. (1990). Gross motor milestones in preterm infants: Correction for degree of prematurity. Journal of Pediatrics, 116(6), 955-959. Allen, M. C., & Alexander, G. R. (1992). Using gross motor milestones to identify very preterm infants at risk for cerebral palsy. Developmental Medicine & Child Neurology, 34(3), 226-232. Bernbaum, J. C., Campbell, D. E., & Imaizumi, S. O. (2009). Followup care of the graduate from the neonatal intensive care unit. In T. McInerny (Ed.), American Academy of Pediatrics textbook of pediatric care. Elk Grove Village, IL: American Academy of Pediatrics. Bird, T. M., Bronstein, J. M., Hall, R. W., Lowery, C. L., Nugent, R., & Mays, G. P. (2010). Late preterm infants: Birth outcomes and health care utilization in the first year. Pediatrics, 126(2), e311-e319.
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Centers for Disease Control and Prevention. (2001). Recommendations for using fluoride to prevent and control dental caries in the United States. Morbidity and Mortality Weekly Report, 50, 1-42. Centers for Disease Control and Prevention. (2007). VLBW infantsÕ growth patterns. Retrieved from http://www.cdc.gov/nccdphp/ dnpa/growthcharts/training/modules/module2/text/page5a.htm DÕAgostino, J. A. (2010). An evidentiary review regarding the use of chronological and adjusted age in the assessment of preterm infants. Journal for Specialists in Pediatric Nursing, 15(1), 26-32. Den Ouden, L., Rijken, M., Brand, R., Verloove-Vanhorick, S. P., & Ruys, J. H. (1991). Is it correct to correct? Developmental milestones in 555 ‘‘normal’’ preterm infants compared with term infants. Journal of Pediatrics, 118(3), 399-404. Doyle, L. W., Ford, G., & Davis, N. (2003). Health and hospitalistions after discharge in extremely low birth weight infants. Seminars in Neonatology, 8(2), 137-145. EPIC. (2011). Choosing what fits or have it all. Retrieved from http:// www.epic.com/software-index.php Goldfeld, S. R., Wright, M., & Oberklaid, F. (2003). Parents, infants and health care: Utilization of health services in the first 12 months of life. Journal of Paediatrics and Child Health, 39(4), 249-253. Hagan, J., Shaw, J., & Duncan, P. (Eds.). (2008). Bright futures: Guidelines for health supervision of infants, children and adolescents (3rd ed.). Elk Grove, IL: American Academy of Pediatrics. Jackson, K., Schollin, J., Bodin, L., & Ternestedt, B. M. (2001). Utilization of healthcare by very-low-birthweight infants during their first year of life. Acta Paediatrica, 90(2), 213-217. James, B. C. (2001). Making it easy to do it right. New England Journal of Medicine, 345(13), 991-993. Lems, W., Hopkins, B., & Samson, J. F. (1993). Mental and motor development in preterm infants: The issue of corrected age. Early Human Development, 34(1-2), 113-123. Levy, J. C. (1980). Vulnerable children: ParentsÕ perspectives and the use of medical care. Pediatrics, 65(5), 956-963.
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Piper, M. C., Pinnell, L. E., Darrah, J., Byrne, P. J., & Watt, M. J. (1992). Early developmental screening: Sensitivity and specificity of chronological and adjusted scores. Developmental Medicine & Behavioral Pediatrics, 13(2), 95-101. Restiffe, A. P., & Gherpelli, J. L. (2006). Comparison of chronological and corrected ages in the gross motor assessment of low-risk preterm infants during the first year of life. Arquivos De NeuroPsiquiatria, 64(2B), 418-425. Saigal, S., & Doyle, L. W. (2008). An overview of mortality and sequelae of preterm birth from infancy to adulthood. Lancet, 371(9608), 261-269. Spicer, A., Pinelli, J., Saigal, S., Wu, Y. W., Cunningham, C., & DiCenso, A. (2008). Health status and health service utilization of infants and mothers during the first year after neonatal intensive care. Advances in Neonatal Care, 8(1), 33-41. Spurrier, N. J., Sawyer, M. G., Staugas, R., Martin, A. J., Kennedy, D., & Streiner, D. L. (2000). Association between parental perception of childrenÔs vulnerability to illness and management of childrenÕs asthma. Pediatric Pulmonology, 29(2), 88-93. Stjernqvist, K., & Svenningsen, N. W. (1995). Extremely low-birthweight infants less than 901 g: Development and behaviour after 4 years of life. Acta Paediatrica, 84(5), 500-506. Sugita, K., Iai, M., Inoue, T., & Ohta, R. (1990). Normative data and the effect of correction for prematurity on test scores in the psychomotor development of extremely low birthweight infants. Brain Development, 12(3), 334-338. Wade, K. C., Lorch, S. A., Bakewell-Sachs, S., Medoff-Cooper, B., Silber, J. H., & Escobar, G. J. (2008). Pediatric care for preterm infants after NICU discharge: High number of office visits and prescription medications. Journal of Perinatology, 28(10), 696-701. Wagner, C. L., Greer, F. R., and the AAP Section on Breastfeeding and Committee on Nutrition. (2008). Prevention of rickets and vitamin D deficiency in infants, children and adolescents. Pediatrics, 122(5), 1142-1152.
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Provider Use of Corrected Age During Health Supervision Visits for Premature Infants Jo Ann DÕAgostino, DNP, RN, CPNP, Marsha Gerdes, PhD, Casey Hoffman, PhD, Mary Lou Manning, PhD, RN, CPNP, Ann Phalen, PhD, APRN, NNP-BC, & Judy Bernbaum, MD ABSTRACT Introduction: Correcting age for prematurity is recommended by the American Academy of Pediatrics and the Centers for Disease Control and Prevention. The use of chronological age instead of corrected age for infants born prematurely may result in incorrect interpretations regarding the adequacy of a childÕs growth or developmental progress and has the potential to negatively affect care. This study examined the frequency and impact of the use of corrected age by primary care providers. Method: A retrospective cross-sectional electronic health record review was performed for all infants < 32 weeksÕ gestation who were seen for a health supervision visit in a 31-site pediatric network during a 1-year period. Primary care providers used an electronic health record that defaulted to chronological age information. Results: Primary care providers used corrected age for developmental surveillance for 24% of visits, they used chronologJo Ann DÕAgostino, Nurse Practitioner, Neonatal Follow-up Program, Department of Pediatrics and Division of General Pediatrics, The ChildrenÕs Hospital of Philadelphia, Philadelphia, PA. Marsha Gerdes, Psychologist, Department of Child and Adolescent Psychiatry and Behavioral Sciences, The ChildrenÕs Hospital of Philadelphia, Philadelphia, PA. Casey Hoffman, Psychologist, Department of Child and Adolescent Psychiatry and Behavioral Sciences, The ChildrenÕs Hospital of Philadelphia, Philadelphia, PA. Mary Lou Manning, Associate Professor, Director, Doctor of Nursing Practice Program, School of Nursing, Thomas Jefferson University, Philadelphia, PA. Ann Phalen, Assistant Professor, School of Nursing, Thomas Jefferson University, Philadelphia, PA. Judy Bernbaum, Director, Neonatal Follow-up Program, Department of Pediatrics and Division of General
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ical age for 71% of visits, and the age used was unclear in 5% of visits. The lower a childÕs gestational age and the more that chronological age was used, the more concerns were identified by primary care providers. Dietary changes that included the introduction of solid foods, the start of fluoride, and the introduction of milk typically were recommended on the basis of chronological age. Discussion: Primary care providers used chronological age more than corrected age, which influenced assessment and recommendations for care. This study illustrates the impact of not using corrected age, the importance of ensuring that care aligns with guidelines, and the possible influence of the design of the electronic health record on patient care. Because families of premature infants rely on primary care providers to accurately identify sequelae associated with prematurity, and to provide reassurance when it is warranted, these findings have implications for all health care providers who treat premature infants. J Pediatr Health Care. (2013) 27, 172-179. Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA. This research was funded in part by the Pennsylvania Delaware Valley Chapter of the National Association of Pediatric Nurse Practitioners. Conflicts of interest: None to report. Correspondence: Jo Ann DÕAgostino, DNP, RN, CPNP, Neonatal Follow-up Program, Room 12NW93, The ChildrenÕs Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA 191044399; e-mail: [email protected]. 0891-5245/$36.00 Copyright Q 2013 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. Published online October 28, 2011. http://dx.doi.org/10.1016/j.pedhc.2011.09.001
Journal of Pediatric Health Care
KEY WORDS Premature infants, health supervision visits, corrected age, chronological age, electronic health record
Correcting age for prematurity is recommended by the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC; AAP/ American Congress of Obstetricians and Gynecologists [ACOG], 2007; Bernbaum, Campbell, & Imaizumi, 2009; CDC, 2007). A review of the literature supports the use of age correction for prematurity (DÕAgostino, 2010). Corrected age also commonly is referred The use of to as adjusted age. The chronological age use of chronological age instead of corinstead of rected age may result corrected age may in incorrect interpretaresult in incorrect tions regarding the adequacy of a childÕs interpretations growth or developregarding the mental progress and adequacy of has the potential to negatively affect care. a childÕs growth or Infants who are born developmental prematurely are at inprogress and has creased risk for numerous medical and the potential to neurodevelopmental negatively affect sequelae including care. growth failure, cerebral palsy, developmental delay, and intellectual disability (Saigal & Doyle, 2008). Increased utilization of primary care services by premature infants has been well documented (Bird et al., 2010; Doyle, Ford, & Davis, 2003; Goldfeld, Wright, & Oberklaid, 2003; Jackson, Schollin, Bodin, & Ternestedt, 2001; Spicer et al., 2008; Wade et al., 2008). As a result, the primary care provider plays a vital role in the assessment and care of premature infants. Guidelines and recommendations regarding the care of premature infants by primary care providers have been published by the AAP (AAP/ACOG, 2007; Bernbaum et al., 2009). These guidelines include monitoring a childÕs growth and development with use of correction of age for the degree of prematurity until at least 24 monthsÕ corrected age. The CDC concurs with the use of corrected age when monitoring the growth of a premature infant (CDC, 2007). However, preventive health supervision visits and immunizations are based on a childÕs chronological age. As such, the primary care provider needs to remember to correct for prematurity to accurately assess a premature infant. We did not find any reports that explored the actual clinical usage of age correction by health care providers www.jpedhc.org
during provision of care for premature infants. The objectives of this study were to determine if the recommendation to use corrected age for premature infants was being followed in a primary care setting and to describe how the use of corrected age affected primary care providersÕ assessments and recommendations for care. METHODS Study Population This study used a retrospective cross-sectional design. All children born at < 32 weeksÕ gestation who were seen for a routine child care visit between 2 to 12 months chronological age in the primary care network at a large urban pediatric center during the 1-year period of October 1, 2008 to September 30, 2009, were eligible for inclusion. The network included 31 sites; four were large urban primary care centers and 27 were small urban and suburban practices that extended throughout the Philadelphia region, southern New Jersey, and Delaware. Health care providers consisted of attending pediatricians, resident physicians, and nurse practitioners. After institutional review board approval, subjects were identified through an electronic database search and data were retrieved through a medical record review by the principle investigator. Information was collected from the EPIC Hyperspace Spring 2008 electronic health record system (EPIC, 2011). All health supervision visits during the aforementioned study period were reviewed for each subject. Organization of the Electronic Health Record At the time of the study, the electronic health record in the network provided a template for health supervision visits that defaulted to the childÕs chronological age. Primary care providers were presented with a standard growth chart with measurements plotted for chronological age. A primary care provider could correct the measurements for a childÕs degree of prematurity by clicking a checkbox during the visit. The template also provided a nonstandardized developmental checklist that defaulted to items corresponding to the childÕs chronological age. The developmental checklist used in the network was derived from common early childhood screening and assessment measures, with items set at an approximate 25% delay level so that failure of any item should trigger referral. Milestones in social, adaptive/fine motor, language, and gross motor skills were assessed. The primary care provider was prompted by the electronic health record to select if the child was delayed or age appropriate in each area and to provide a summary of developmental progress at the end of the checklist. A different set of questions was provided for 2, 4, 6, 9, and 12 months. Although the checklist defaulted to the childÕs chronological age, for a child born prematurely, the primary care May/June 2013
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provider could access a set of questions that corresponded to the childÕs corrected age. Procedures Use of corrected or chronological age was determined by noting which set of questions a health care provider selected for developmental surveillance. The problem list and visit assessment for each child were reviewed for health care provider concerns related to developmental progress and concerns about growth. The visit record also was reviewed for evidence of a health care providerÕs recommendation to initiate early intervention services. To determine if corrected or chronological age was used for dietary assessment and recommendations, the ages at initiation of three common dietary changes were assessed. The first dietary change was the childÕs chronological age at the start of solid foods, which, according to AAP guidelines, are to begin between 4 and 6 months chronological age (Hagan, Shaw, & Duncan, 2008). The second dietary change was fluoride supplementation, which, as recommended by the CDC, is to start at 6 months chronological age if the water supply is deficient (CDC, 2001). The third dietary change was the introduction of milk, which included toddler formulas. According to AAP guidelines, it is recommended that children not be transitioned to milk until they are 12 months chronological age (Hagan et al., 2008; Wagner, Greer, & AAP Section on Breastfeeding and Committee on Nutrition, 2008). Because correction of age for prematurity is recommended for dietary changes (Bernbaum et al., 2009), the age of introduction of these three dietary changes would indicate if corrected or chronological age was used. Provider use of corrected or chronological age for the assessment of the growth chart could not be evaluated. The checkbox that corrected measurements in the electronic health record was designed to automatically reset after the visit record was closed, thereby negating retrieval of this information. Information regarding the primary care site, provider type (attending pediatrician, resident physician, or nurse practitioner), birth weight, and gestational age was collected to assess the impact of these variables on the use of corrected or chronological age.
ing the study period. Manual examination of the electronic health record revealed that six children had birth weights and neonatal histories inconsistent with a gestational age < 32 weeks, and one child who fit the study criteria registered for a health supervision visit but left before being seen. These seven children were excluded from the study. The remaining 432 children were included in the analysis. The children were 51% female, 43% Black or African American, 41% White, 2% Asian, 2% Hispanic or Latino Black, and 12% other. The mean gestational age was 28.4 2.3 weeks (range, 22–31 weeks), and the mean birth weight was 1200 394 g (range, 374–2359 g). The children had 1032 health supervision visits during the study period, with an average of two visits per child (range, 1–7 visits). Visits were categorized into 2-, 4-, 6-, 9-, and 12-month chronological age cohorts corresponding to the AAP schedule for health supervision visits (Hagan et al., 2008). Fifty-nine additional or off-schedule visits were excluded. The final analysis included 973 visits (N = 973). These visits represented 94% of all the health supervision visits for the sample. Attending physicians were providers for 85% (826) of the visits, resident physicians were providers for 9% (88) of the visits, and nurse practitioners were providers for 6% (59) of the visits. Primary care providers used age correction for developmental surveillance for 24% (234) of the health supervision visits. Chronological age was used for 71% (695) of the visits, and the use of chronological or corrected age was unable to be determined for 5% (44) of the visits (Figure 1). Although the use of age correction for a child’s degree of prematurity was documented at 24% of the visits, providers used the appropriate surveillance checklist which corresponded to the child’s corrected age at only 8% (75) of the total visits. At 16% (159) of the total visits, providers documented an adaptation in order to correct for prematurity instead of using the appropriate checklist (Figure 2). These provider adaptations will be referred to as ‘‘adapted corrected age.’’ The adaptations FIGURE 1. Use of chronological age and corrected age for developmental surveillance for all health supervision visits (N = 973).
Statistical Analysis Data were analyzed with use of SPSS version 18 statistical software (IBM Corporation, Armonk, New York) and included descriptive statistics, PearsonÕs v2, and logistic regression. RESULTS An electronic record search revealed that 439 children met the study criteria. These children represented 1.8% of all children of the same age seen in the entire primary care network for health supervision visits dur174
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FIGURE 2. Use of chronological, corrected, and adapted corrected age for developmental surveillance for all health supervision visits (N = 973).
included comments on progress with regard to corrected age after either the use of a chronological age surveillance checklist (14%; 133) or after no documentation of the use of a formal surveillance checklist (2%; 26). For the 929 visits for which the use of chronological or corrected age could be determined, providers gradually tapered the use of corrected age toward the end of the first year of life (v2 = 16.77, p < .01; Figure 3). Predictors for the use of chronological or corrected age included gestational age (p < .001) and the childÕs chronological age at visit (p < .01). The lower the gestational age (odds ratio [OR], 1.25 [95% confidence interval (CI), 1.13–1.38]) and the younger the chronological age of the child (OR, 1.1 [95% CI, 1.03–1.18]), the more likely it was that corrected age was used. Birth weight, primary care site, and type of provider (attending, resident, or nurse practitioner) were not predictive for the use of corrected or chronological age. Developmental Surveillance To assess the impact of the use of chronological or corrected age on the identification of developmental delays with use of the surveillance checklist, the following visits were excluded (N = 70): visits for which corrected or chronological age could not be determined and visits for which the formal surveillance
checklist was not used. The remaining 903 health supervision visits were assessed. Children who were evaluated with use of the surveillance checklist that corresponded to corrected age were less likely to have identified delays (v2 = 10.6, p < .01; Figure 4). Predictors for the identification of delays in one or more area included gestational age (p < .001), use of corrected age compared with adapted corrected age (p < .01), and use of corrected age compared with chronological age (p < .05). The lower the gestational age, the more likely delays were identified (OR, 1.23 [95% CI, 1.11–1.36]). A child who was assessed with use of adapted corrected age was 4.7 times more likely to be identified as having delays compared with a child who was assessed with use of corrected age (OR, 4.7 [95% CI, 1.75–12.62]). For a child assessed using chronological age, the odds were 2.6 times greater that delays would be found compared with a child assessed with corrected age (OR, 2.6 [95% CI, 1.15–6.10]). Concerns About Growth and Development Concerns about growth were documented in the final summary or visit diagnoses for 4.2% of the visits. The use of chronological or corrected age, the childÕs gestational age, and birth weight were not predictors for concerns about growth. Concerns about development were documented at 11.5% of visits. Predictors for concerns about development included gestational age (p < .01) and the use of corrected or chronological age (p < .05). Primary care providers were more likely to have concerns the lower the gestational age (OR, 1.25 [95% CI, 1.10–1.43]) and the more chronological age was used for developmental surveillance (OR, 2.57 [95% CI, 1.12–5.87]). Initiation of Early Intervention Referral Primary care providers documented referral for early intervention services for 24% (104) of the children; 42% (182) had documentation of already being involved in services, and no documentation was found regarding early intervention for 34% (146). Predictors for referral to early intervention included delays in one or more area (p < .001) and gestational
FIGURE 3. Use of chronological age and corrected age for developmental surveillance for all health supervision visits (N = 929).
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FIGURE 4. Determination of delays in surveillance areas based on use of corrected age, adapted corrected age, and chronological age (N = 903).
age (p < .001). For a child with delays identified in one or more areas, the odds of being referred to early intervention were 3.7 times more likely than for a child when no delays were found (OR, 3.7 [95% CI, 1.89–7.15]). A decrease in gestational age also increased the likelihood of a child being referred (OR, 1.37 [95% CI, 1.18–1.60]). The type of age used for the assessment— corrected compared with chronological and corrected compared with corrected adapted—was not predictive for referral to early intervention. Interestingly, despite the increased likelihood of delays being identified if adapted corrected or chronological age was used for surveillance and the increased likelihood of referral for intervention services if delays were noted, use of corrected age or chronological age surveillance did not predict referral for early intervention. Referral to early intervention was comparable for children in the corrected, adapted corrected, and chronological age groups. Of those assessed with corrected age, 25% were referred for service; 24% of those assessed with chronological age were referred for service, and 21% of those assessed with adapted corrected age were referred for service. Typically, infants were referred for intervention services early in the first year of life. The mean chronological age at time of referral was 5.2 2.7 months. Initiation of Dietary Changes The recommendation to start solid foods was documented for 43 patients. For the majority of those
patients, 91% (39), it was recommended that solid foods be started at either the 4-month or 6-month chronological age visit. The recommendation to start administering fluoride or the first notation of the presence of fluoride in a childÕs water supply was documented for 165 patients. This recommendation or notation occurred most frequently (56%; 92) at the 6-month chronological age visit. The recommendation to start giving the child milk was documented for 45 patients. This recommendation occurred for the majority (91%; 41) at the 12-month chronological age visit. The mean chronological ages at which providers recommended that these three dietary changes be started are shown in Table. When correction for prematurity was applied, the mean starts for all three changes were earlier than those recommended by the AAP/CDC. Gestational age and the use of corrected age or chronological age by primary care providers for developmental surveillance were not predictors for the start of solid foods, fluoride supplementation, or the introduction of milk to the diet. Patterns to the Use of Chronological and Corrected Age In this study, the number of children who were seen for more than one health supervision visit and for whom the use of chronological or corrected age could be determined totaled 271. A difference in the exclusive use of chronological or corrected age for all of a childÕs visits was found. Corrected age was used exclusively at 34%
TABLE. Dietary changes: mean chronological age when recommended to start Dietary change
Actual chronological age (mean mo SD)
When age correction applied (mean mo SD)
Recommended age to start (mo)
Solid foods (N = 43) Fluoride (N = 165) Milk (N = 45)
5.5 1 (range, 3.75–9) 7.9 2.5 (range, 2–12.75) 12.2 0.5 (range, 10.25–12.75)
2.7 1 (range, 1–6.25) 5.1 2.6 (range, –0.5–10.5) 9.4 0.7 (range, 7.75–10.50)
4–6a 6b 12a
a
Hagan, Shaw, & Duncan (Eds.) (2008). Centers for Disease Control and Prevention (2001).
b
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of repeat visits (28/82) compared with chronological age, which was used exclusively at 79% of the repeat visits (149/189; v2 = 50.4, p < .001). Primary care site and provider type were not predictive of the exclusive use of chronological or corrected age. Gestational age approached significance; the higher the gestational age, the more likely the exclusive use of chronological age occurred (p = .06). The use of chronological and corrected age at individual primary care sites was assessed. Of the 31 sites in the network, a combination of chronological and corrected age was used for assessment at 25 sites; chronological age was used exclusively at six sites; and at no sites was corrected age used exclusively for assessment. DISCUSSION The findings from this study demonstrate that contrary to AAP recommendations, primary care providers documented use of chronological age more frequently than corrected age. Failure to use corrected age for premature infants had implications for developmental surveillance and dietary recommendations. The use of chronological age or the attempt to correct for a childÕs prematurity without using a corrected age surveillance checklist increased the likelihood that primary care providers identified a child as having developmental delays. This finding supports the research that indicated that premature infants more closely reflected the developmental profiles of chronological age-matched full-term infants and more accurately reflected normative references when assessed with use of corrected age rather than chronological age (Allen & Alexander, 1992; Allen & Alexander, 1990; Den Ouden, Rijken, Brand, Verloove-Vanhorick, & Ruys, 1991; Lems, Hopkins, & Samson, 1993; Piper, Pinnell, Darrah, Byrne, & Watt, 1992; Restiffe & Gherpelli, 2006; Stjernqvist & Svenningsen, 1995; Sugita, Iai, Inoue, & Ohta, 1990). An interesting observation from this study is the finding that only 8% of the providers who corrected for prematurity for developmental surveillance used the corrected age surveillance checklist. This finding may be related to how the electronic health record presented information to the provider. Because the default surveillance checklist coincided with the childÕs chronological age, the provider needed to know how to access the surveillance checklist that coincided with the childÕs corrected age. From dialogues with providers at various sites, it was discovered that it was not universally known how to access the corrected age surveillance checklist. Considering the fact that premature infants are at increased risk for developmental issues, it is a cause for concern that providers who used the chronological age surveillance checklist, as well as those who attempted to correct for prematurity without using the corrected age surveillance checklist, did not have an age-appropriate tool for surveillance. www.jpedhc.org
Compounding this issue is that infants < 32 weeksÕ gestation, as represented in this study, composed a small percentage of the infants who were seen for health supervision in the network. In the flow of a busy practice, the need to correct an infantÕs age may be inadvertently overlooked. The finding that the type of age used for surveillance did not appear to predict a referral to early intervention may reflect other reasons for referral in addition to delays on developmental surveillance. Although this information was not systematically collected, observation of the documentation of other reasons for referral included the need for monitoring because of premature birth, tonal abnormalities, and social concerns. None of these reasons would be affected by whether or not a childÕs age was corrected. Although limited documentation was available regarding provider recommendations to start feeding solid foods or milk, when documented, the recommendations usually were made according to chronological age guidelines. This situation not only resulted in earlier mean starting ages when age correction was applied but, as shown, for some infants these changes were initiated at very early corrected ages. Because the nutritional needs of premature infants may be greater than those of healthy full-term infants, this earlier start may not provide premature infants with maximum nutritional benefits during the first year of life. Inconsistency in the approach of providers to the care of premature infants was another finding of this study. Because these children were all < 32 weeksÕ gestation, age correction should have been universal. For children for whom age correction was applied, and who were seen for more than one visit during the study period, inconsistency was reflected in that only one third had exclusive use of age correction for all visits. It also appeared that some primary care providers used age correction for developmental surveillance but not for the start of dietary changes, because the use of corrected age for surveillance was not a predictor for when dietary changes were initiated. An implication of the findings in this study that warrants further investigation is the impact of the providerÕs assessment and recommendations on familiesÕ perceptions and expectations of their children. Providers were more likely to be concerned about delays if they were not using corrected age. This concern may have been communicated to families and unnecessarily resulted in alarming parents who were already concerned about their childrenÕs developmental outcomes. Families of premature infants have been through unexpected and, in many cases, stressful neonatal courses, which commonly include counseling about the potential long-term sequelae of prematurity. Parental perception of a childÕs vulnerability has been associated with increased utilization of health care (Levy, 1980; May/June 2013
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Spurrier et al., 2000) and in one study was associated with worse developmental outcome at 1 year corrected age (Allen et al., 2004). As such, a primary care provider plays an important role not only in the accurate identification of sequelae but also in providing parental reassurance that developmental progress is appropriate when applicable. Although the use of age correction for plotting growth could not be assessed in this study, this area warrants further investigation. The potential exists for providers to misinterpret the adequacy of an infantÕs growth if measurements are not corrected. Concerns about growth inadequacy based on uncorrected measurements could result in unnecessary alarm, dietary changes that may promote unhealthy weight gain, or needless referral for further evaluation. A concerning implication of this study is that the electronic health record did not facilitate the choice of corrected age by the provider and may have contributed to the providerÕs use of chronological age because of automatic defaults to chronological age. As the transition to the electronic health record becomes increasingly more common, it will be crucial to monitor how the design of the system may affect patient safety and quality of care. The potential for silent errors exists. Computerized support systems ‘‘must present the right information, in the right format, at the right time, without requiring special effort’’ (James, 2001, p. 992). As was demonstrated in this study, this was not the case for premature infants. How primary care providers are systematically alerted to the need for age correction, when appropriate, is an issue that ambulatory practices need to address. For practices How primary care that use manual records, the approach providers are will vary depending systematically on the method used alerted to the need for record keeping and would be best adfor age correction, dressed by persons when appropriate, most familiar with is an issue that those methods. For practices that use an ambulatory electronic health repractices need to cord, age correction address. could be facilitated automatically by the system. Automatic defaults to corrected age developmental surveillance tools, growth charts, and anticipatory guidance, as well as automatic calculation of both the childÕs current chronological and corrected age, are ways to address this issue. These measures could facilitate more accurate developmental assessments and dietary recommendations and increase the standardization of care for preterm infants. A project currently under investigation in this ambulatory network is the development of a clinical decision 178
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support tool that facilitates automatic age correction and assists providers in the management of the care of preterm infants. Limitations of this study included the inability to assess provider use of the growth chart because this information could not be collected and the need to rely on provider documentation of what occurred during the visit. It is possible there may have been cases in which primary care providers considered a childÕs prematurity in counseling and verbal recommendations given to parents without documenting this information in the electronic health record. CONCLUSIONS The findings of this study regarding the use of chronological and corrected age during the primary care of premature infants in a large university network have implications for all providers who care for premature infants. Despite guideline recommendations to correct age for prematurity, the majority of providers documented use of chronological age instead of a corrected age for premature infants. The use of chronological age instead of corrected age resulted in possible overidentification of developmental delays and dietary changes before the ages recommended for premature infants. This study illustrates the importance of monitoring care to ensure alignment with practice guidelines. As exemplified by this study, the electronic health record may have contributed to the primary care providerÕs inappropriate use of chronological age by providing this as a default feature, resulting in the need for a provider to take additional steps to correct for prematurity. As the transition to the electronic health record becomes more common, it is important for providers to be aware of how the design of the system can influence patient safety and quality of care. REFERENCES American Academy of Pediatrics & American Congress of Obstetricians and Gynecologists. (2007). Guidelines for perinatal care (6th ed.). Elk Grove Village, IL: American Academy of Pediatrics. Allen, E. C., Manuel, J. C., Legault, C., Naughton, M. J., Pivor, C., & OÕShea, T. M. (2004). Perception of child vulnerability among mothers of former premature infants. Pediatrics, 113(2), 267-273. Allen, M. C., & Alexander, G. R. (1990). Gross motor milestones in preterm infants: Correction for degree of prematurity. Journal of Pediatrics, 116(6), 955-959. Allen, M. C., & Alexander, G. R. (1992). Using gross motor milestones to identify very preterm infants at risk for cerebral palsy. Developmental Medicine & Child Neurology, 34(3), 226-232. Bernbaum, J. C., Campbell, D. E., & Imaizumi, S. O. (2009). Followup care of the graduate from the neonatal intensive care unit. In T. McInerny (Ed.), American Academy of Pediatrics textbook of pediatric care. Elk Grove Village, IL: American Academy of Pediatrics. Bird, T. M., Bronstein, J. M., Hall, R. W., Lowery, C. L., Nugent, R., & Mays, G. P. (2010). Late preterm infants: Birth outcomes and health care utilization in the first year. Pediatrics, 126(2), e311-e319.
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Centers for Disease Control and Prevention. (2001). Recommendations for using fluoride to prevent and control dental caries in the United States. Morbidity and Mortality Weekly Report, 50, 1-42. Centers for Disease Control and Prevention. (2007). VLBW infantsÕ growth patterns. Retrieved from http://www.cdc.gov/nccdphp/ dnpa/growthcharts/training/modules/module2/text/page5a.htm DÕAgostino, J. A. (2010). An evidentiary review regarding the use of chronological and adjusted age in the assessment of preterm infants. Journal for Specialists in Pediatric Nursing, 15(1), 26-32. Den Ouden, L., Rijken, M., Brand, R., Verloove-Vanhorick, S. P., & Ruys, J. H. (1991). Is it correct to correct? Developmental milestones in 555 ‘‘normal’’ preterm infants compared with term infants. Journal of Pediatrics, 118(3), 399-404. Doyle, L. W., Ford, G., & Davis, N. (2003). Health and hospitalistions after discharge in extremely low birth weight infants. Seminars in Neonatology, 8(2), 137-145. EPIC. (2011). Choosing what fits or have it all. Retrieved from http:// www.epic.com/software-index.php Goldfeld, S. R., Wright, M., & Oberklaid, F. (2003). Parents, infants and health care: Utilization of health services in the first 12 months of life. Journal of Paediatrics and Child Health, 39(4), 249-253. Hagan, J., Shaw, J., & Duncan, P. (Eds.). (2008). Bright futures: Guidelines for health supervision of infants, children and adolescents (3rd ed.). Elk Grove, IL: American Academy of Pediatrics. Jackson, K., Schollin, J., Bodin, L., & Ternestedt, B. M. (2001). Utilization of healthcare by very-low-birthweight infants during their first year of life. Acta Paediatrica, 90(2), 213-217. James, B. C. (2001). Making it easy to do it right. New England Journal of Medicine, 345(13), 991-993. Lems, W., Hopkins, B., & Samson, J. F. (1993). Mental and motor development in preterm infants: The issue of corrected age. Early Human Development, 34(1-2), 113-123. Levy, J. C. (1980). Vulnerable children: ParentsÕ perspectives and the use of medical care. Pediatrics, 65(5), 956-963.
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Piper, M. C., Pinnell, L. E., Darrah, J., Byrne, P. J., & Watt, M. J. (1992). Early developmental screening: Sensitivity and specificity of chronological and adjusted scores. Developmental Medicine & Behavioral Pediatrics, 13(2), 95-101. Restiffe, A. P., & Gherpelli, J. L. (2006). Comparison of chronological and corrected ages in the gross motor assessment of low-risk preterm infants during the first year of life. Arquivos De NeuroPsiquiatria, 64(2B), 418-425. Saigal, S., & Doyle, L. W. (2008). An overview of mortality and sequelae of preterm birth from infancy to adulthood. Lancet, 371(9608), 261-269. Spicer, A., Pinelli, J., Saigal, S., Wu, Y. W., Cunningham, C., & DiCenso, A. (2008). Health status and health service utilization of infants and mothers during the first year after neonatal intensive care. Advances in Neonatal Care, 8(1), 33-41. Spurrier, N. J., Sawyer, M. G., Staugas, R., Martin, A. J., Kennedy, D., & Streiner, D. L. (2000). Association between parental perception of childrenÔs vulnerability to illness and management of childrenÕs asthma. Pediatric Pulmonology, 29(2), 88-93. Stjernqvist, K., & Svenningsen, N. W. (1995). Extremely low-birthweight infants less than 901 g: Development and behaviour after 4 years of life. Acta Paediatrica, 84(5), 500-506. Sugita, K., Iai, M., Inoue, T., & Ohta, R. (1990). Normative data and the effect of correction for prematurity on test scores in the psychomotor development of extremely low birthweight infants. Brain Development, 12(3), 334-338. Wade, K. C., Lorch, S. A., Bakewell-Sachs, S., Medoff-Cooper, B., Silber, J. H., & Escobar, G. J. (2008). Pediatric care for preterm infants after NICU discharge: High number of office visits and prescription medications. Journal of Perinatology, 28(10), 696-701. Wagner, C. L., Greer, F. R., and the AAP Section on Breastfeeding and Committee on Nutrition. (2008). Prevention of rickets and vitamin D deficiency in infants, children and adolescents. Pediatrics, 122(5), 1142-1152.
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