A7 Logic Model Nursing in the Community
From the suggested reading materials, select a home visiting or case management program and summarize in 250 words or less the program goals and objectives and what interventions are provided. Focus on nursing activities when possible. Develop a logic model that would reflect that program. Ensure the critical elements of inputs, outputs, outcomes or impacts are included. There will be aspects of the logic model that will require research so references are required using APA style. Place the detail references on a separate page with the logic model.Click here for a guide to developing and using logic models (https://www.cdc.gov/dhdsp/docs/logic_model.pdf). Click here for an example of logic model (https://www.cdc.gov/prc/pdf/prc-logic-model.pdf).
The assignment should be presented in logic model format with APA formatted citations and references. At least two scholarly sources, other than the textbook and provided materials are required.
JOGNN I N F O C U S
Effects of Home Visiting and Maternal
Mental Health on Use of the Emergency
Department among Late Preterm Infants
Neera K. Goyal, Alonzo T. Folger, Eric S. Hall, Robert T. Ammerman, Judith B. Van Ginkel, and Rita S. Pickler
Correspondence
Neera K. Goyal, MD
3333 Burnet Ave. ML 7009
Cincinnati, OH 45229.
[emailprotected]
Keywords
emergency department
home visit
late preterm
maternal mental health
ABSTRACT
Objective: To describe use of the emergency department (ED) among late preterm versus term infants enrolled in a
home visiting program and to determine whether home visiting frequency was associated with outcome differences.
Design: Retrospective, cohort study.
Setting: Regional home visiting program in southwest Ohio from 20072010.
Participants: Late preterm and term infants born to mothers enrolled in home visiting. Program eligibility requires
one of four characteristics: unmarried, low income, < 18 years, or suboptimal prenatal care.
Methods: Data were derived from vital statistics, hospital discharges, and home visiting records. Negative binomial
regression was used to determine association of ED visits in the first year with late preterm birth and home visit
frequency, adjusting for maternal and infant characteristics.
Results: Of 1,804 infants, 9.2% were born during the late preterm period. Thirty-eight percent of all infants had at least
one ED visit, 15.6% had three or more. No significant difference was found between the number of ED visits for late
preterm and term infants (39.4% vs. 37.8% with at least one ED visit, p = .69). In multivariable analysis, late preterm
birth combined with a maternal mental health diagnosis was associated with an ED incident rate ratio (IRR) of 1.26,
p = .03; high frequency of home visits was not significant (IRR = .92, p = .42).
Conclusions: Frequency of home visiting service over the first year of life is not significantly associated with reduced
ED visits for infants with at-risk attributes and born during the late preterm period. Research on how home visiting can
address ED use, particularly for those with prematurity and maternal mental health conditions, may strengthen program
impact and cost benefits.
JOGNN, 44, 135-144; 2015. DOI: 10.1111/1552-6909.12538
Accepted July 2014
Neera K. Goyal, MD, is an
assistant professor in the
Department of Pediatrics,
Cincinnati Childrens
Hospital Medical Center,
Cincinnati, OH.
Alonzo T. Folger, PhD, is a
senior epidemiologist in the
Department of Pediatrics,
Cincinnati Childrens
Hospital Medical Center,
Cincinnati, OH.
(Continued)
The elevated risk of mortality and morbidity for late
preterm infants (LPIs) born at 34 weeks 0 days to
36 weeks 6 days gestation, who represent more
than 70% of all preterm infants, has been increas-
ingly well described (Bird et al., 2010; Engle,
Tomashek, & Wallman, 2007; Martin, Kirmeyer,
Osterman, & Shepherd, 2009; Raju, Higgins,
Stark, & Leveno, 2006). Compared with infants
born full term ( 37 weeks), LPIs have higher
rates of hospitalization and emergency depart-
ment (ED) use in the neonatal period and through
the first year of life (Escobar et al., 2005; Jain &
Cheng, 2006; McLaurin, Hall, Jackson, Owens, &
Mahadevia, 2009). Importantly, for certain condi-
tions like neonatal jaundice, risk of hospitalization
for LPIs is higher compared with full-term infants
as well as infants born at earlier gestational ages
(Ray & Lorch, 2013), suggesting an interplay of
immature physiology and current systems of care
for this population. In contrast to very preterm
infants, LPIs are often discharged home from the
hospital without a prolonged period of observation
(Goyal, Fager, & Lorch, 2011), and many are not
seen by any health care professional during the
first week home (Hwang et al., 2013). Moreover,
the majority of these infants are not enrolled in
systematic, high-risk infant follow-up programs,
which generally focus on very early preterm in-
fants (Walker, Holland, Halliday, & Badawi, 2012).
For LPIs, therefore, further research is needed to
develop models of follow up care that can improve
outcomes (National Perinatal Association, 2012;
Premji, Young, Rogers, & Reilly, 2012).
One potential strategy to address these concerns
is home visiting, a voluntary service delivered
The authors report no con-
flict of interest or relevant
financial relationships.
http://jognn.awhonn.org C 2014 AWHONN, the Association of Womens Health, Obstetric and Neonatal Nurses 135
I N F O C U S Effects of Home Visiting and Maternal Mental Health on Use of the Emergency Department Among Late Preterm Infants
Given the late preterm birth rate among at-risk infants, practices
and policies related to their care have the potential for a large
public health impact.
in a familys home to provide care coordination,
parenting education, and social support for
at-risk child-bearing women and their children
(American Academy of Pediatrics Council on
Child and Adolescent Health, 1998; Kitzman
et al., 1997; Sweet & Appelbaum, 2004). Several
national models of home visiting, including Nurse
Family Partnership and Healthy Families America,
have developed specific program curricula and
protocols; qualifications of home visitors range
from nurses to social workers to paraprofessionals
(U.S. Department of Health and Human Services,
2013). Currently, an estimated 400 publicly and
privately funded home visiting programs serve at
least 500,000 families in the United States, and
an additional $1.5 billion was allocated through
the Patient Protection and Affordable Care Act
to expand these services (Astuto & Allen, 2009;
Health Resources and Services Administration,
2010). Despite significant public investment in this
intervention, to date, a paucity of literature on out-
comes such as ED use for preterm infants enrolled
in such programs (Goyal, Teeters, & Ammerman,
2013).
Eric S. Hall, PhD, is an
assistant professor in the
Department of Pediatrics,
Cincinnati Childrens
Hospital Medical Center,
Cincinnati, OH.
Robert T. Ammerman,
PhD, is a professor in the
Department of Pediatrics,
Cincinnati Childrens
Hospital Medical Center,
Cincinnati, OH.
Judith B. Van Ginkel, PhD,
is a professor in the
Department of Pediatrics,
Cincinnati Childrens
Hospital Medical Center,
Cincinnati, OH.
Rita S. Pickler, RN, PhD, is
a professor of nursing in the
Department of Pediatrics,
Cincinnati Childrens
Hospital Medical Center,
Cincinnati, OH.
The study objectives were to characterize ED
use over the first year of life among late preterm
and full-term infants enrolled in home visiting
and to determine whether increased frequency
of home visiting participation is associated with
improvement in this outcome. Our logic model
for this study was based on the social-ecological
model of child health that underpins the role of
home visiting for at-risk families. A strong body
of literature has linked social and environmental
risk factors with adverse child health outcomes,
including avoidable hospitalizations and ED
visits, that may be mitigated through early detec-
tion, parental education, and care coordination
(McLaren & Hawe, 2005; Paul, Phillips, Widome, &
Hollenbeak, 2004; Shanley, Mittal, & Flores, 2013;
Shonkoff & Garner, 2012). Given the known con-
tribution of LPIs to pediatric morbidity and health
care costs and the fact that preterm birth is likely
to disproportionately affect at-risk mothers eligible
for home visiting, a more detailed understanding
of program effectiveness for LPIs may be critical
to addressing gaps in care for this important
population.
Methods
Setting and Par ticipants
In this retrospective, cohort study we examined
ED use among late preterm and term infants born
to at-risk, first-time mothers enrolled in a well-
established, regional home visiting program serv-
ing southwest Ohio. This community-based home
visiting program, which has to date served more
than 19,000 families, comprises 11 local home vis-
iting agencies which adhere to program, training,
and evaluation standards established by a cen-
tral office at Cincinnati Childrens Hospital Medi-
cal Center (CCHMC). To track and document pro-
cess and outcome measures within and across
agencies, the program uses rigorous continuous
quality improvement procedures under the super-
vision of CCHMC quality improvement staff and
is facilitated by a web-based data entry system
(Ammerman et al., 2007).
In addition to being first- time mothers, women
eligible for this program must have at least one
of four risk characteristics: unmarried, low income
(up to 300% of poverty level, receipt of Medicaid,
or reported concerns about finances), < 18 years
of age, or suboptimal prenatal care. Participants
may be enrolled during pregnancy or postde-
livery, before their child reaches age 3 months.
Referrals to the program may be self-initiated or
come from clinics, hospitals, and other commu-
nity sources. Home visits are provided by social
workers, child development specialists, or other
professionals who employ a core program curricu-
lum that is based on the Healthy Families America
model of home visiting. The overall goals of the
program are to (a) provide nutrition education and
substance use reduction during pregnancy; (b)
support parents in providing children with a safe,
nurturing, and stimulating home environment; (c)
optimize child health and development; (d) link
families to health care and other services; and
(e) promote economic self-sufficiency. To achieve
these goals as outlined within the curriculum, the
home provider offers printed materials for fami-
lies but primarily focuses on interactive sessions
with parents that may address curriculum content
as well other issues or concerns specific to the
family. Screening inventories for home safety, par-
enting stress, substance use, and other items are
also performed at scheduled intervals to identify
and address risks and to generate appropriate
service referrals. Expected visit frequency consis-
tent with the curriculum is weekly through the first
3 months of infancy, tapering to biweekly through
the remainder of the first year.
136 JOGNN, 44, 135-144; 2015. DOI: 10.1111/1552-6909.12538 http://jognn.awhonn.org
Goyal, N. K. et al. I N F O C U S
For this analysis, infants born prior to 34 weeks
gestation were excluded, resulting in 1,852 late
preterm and term infants born during the years
2007 to 2010 whose mothers enrolled in home
visiting either prenatally or within 3 months af-
ter delivery. Of these infants, 43 additional infants
were excluded from analysis due to major congen-
ital anomalies, as their patterns of health care use
were expected to vary significantly from otherwise
healthy infants. For similar reasons, six infants who
died of any cause before their first birthdays were
also excluded from analysis.
Data Sources
Home visiting data were abstracted from the pro-
grams web-based data entry system described
above. This system contains detailed information
on each participant including enrollment timing,
home visit history, and maternal demographic and
psychosocial screening information. Enrolled par-
ticipants consented to data being used for the
purpose of quality improvement benchmarking
and research. These data were linked to Ohio vi-
tal statistics, available from the Ohio Department
of Health, and birth-related hospital discharge
records of mother and infant, available from the
Ohio Hospital Association. Because no common
unique identifier across data sources was avail-
able, record linkage was accomplished using
LINKS (University of Manitoba), a SAS-based
probabilistic and deterministic matching program.
Selected variables used for linking included ma-
ternal and infant dates of birth, hospital of birth, de-
livery method, sex, and maternal address. Further
details of linkage for these data sources has been
previously described (Hall et al., 2014). The result-
ing data set contained information regarding ma-
ternal/child health including demographics, social
factors, pregnancy-related conditions, and infant
characteristics. Lastly, this data core was linked
to electronic health record data at CCHMC for
outcome measures of hospital service use. The
Ohio Department of Health and CCHMC Institu-
tional Review Boards approved this study.
Covariates and Key Predictors
As described previously, data for maternal co-
variates were obtained through a combination of
linked vital statistics, hospital discharge records,
and home visiting data (Hall et al., 2014). These
variables included race, ethnicity, payer source,
maternal age, education level, marital status,
substance use, household membership, and
paternal involvement. Indicator variables for
relevant clinical factors were constructed using
International Classification of Diseases, 9th Revi-
sion, Clinical Modification (ICD-9-CM) codes and
vital statistics data (Centers for Disease Control
and Prevention, 2014). The ICD-9-CM codes used
to derive a composite maternal mental health
diagnosis were obtained from the maternal birth
hospitalization record.
Late preterm birth was defined as infant birth from
34 weeks 0 days to 36 weeks 6 days gestation;
gestational age measures were obtained from vi-
tal statistics and represented the best clinical es-
timates. Additionally, as a sensitivity analysis we
repeated analyses using a combined gestational
age estimate from vital statistics rather than the
clinical gestational age estimate, as prior studies
have demonstrated discordance between these
measures (Wingate, Alexander, Buekens, & Vahra-
tian, 2007). To measure home visiting service in-
tensity, we adapted a prior approach from Duggan
et al. (2004), counting the number of home visits
conducted over the first year of life and then di-
viding this by the number of expected home visits
over the infants first year per the program cur-
riculum to calculate a percentage of expected vis-
its. Mother/infant pairs were classified as receiving
a high dose of service if they received 75% of
expected visits, a commonly used cutoff for ser-
vice evaluation in home visiting programs (Healthy
Families New York, 2014). Timing of program en-
rollment was dichotomized as enrollment prena-
tally or after birth of the infant.
Analysis
Bivariate analyses using chi-squared or t tests
were used to identify covariates associated with
any ED use and number of unique ED visits over
the first year after birth. Factors deemed to be
empirically or statistically important (p values less
than 0.25) were considered and tested using
step-wise multivariable modeling to derive parsi-
monious models. To account for overdispersion
of the ED visit data due to excess zeros, we used
a random-effects negative binomial regression
model as an alternative to standard Poisson
regression, adjusting for clustering by individual
home visiting agency. Models were tested for
goodness of fit using Akaike Information Criterion
values and link tests for model specification.
Multicollinearity was also assessed, with variance
inflation factors for all retained variables < 10
(Obrien, 2007).
The final multivariable model included the follow-
ing variables: infant sex, maternal race, ethnicity,
JOGNN 2015; Vol. 44, Issue 1 137
I N F O C U S Effects of Home Visiting and Maternal Mental Health on Use of the Emergency Department Among Late Preterm Infants
Home visiting for at-risk families may reduce unnecessary
emergency department use through care coordination,
education, and social support.
insurance status, maternal age, paternal living ar-
rangement, smoking status, and mental health di-
agnosis. To prevent individual patients from bias-
ing rates and to reduce measurement error, a small
number of infants with >8 ED visits in the first year
(1% of the sample) were deemed to be outliers
based on visual assessment of the data and were
omitted from the final analysis. Interaction terms
between late preterm status with number of home
visits, maternal age, smoking status, and mental
health diagnosis were added and tested for sta-
tistical significance using likelihood ratio tests and
only an interaction term with mental health diag-
nosis was retained. All statistical tests were two
sided, and type I error was controlled at 0.05. Anal-
yses were performed using STATA 11.0.
Results
Of the 1,804 infants meeting study inclusion cri-
teria, 9.2% were born late preterm. No significant
differences in maternal characteristics were ob-
served among late preterm versus full term in-
fants (56% vs. 52% with maternal age <20 years,
p = .34), 96% versus 95% with single marital status
(p = .56), and 81% versus 80% insured by Med-
icaid (p = .96). Forty-eight percent of the sample
enrolled in the home visiting program prenatally.
Approximately 17.5% of infants were classified as
receiving a high dose of home visiting, with no
significant difference between late preterm com-
pared with term infants (18% vs. 17%, p = .82).
The number of ED visits in the first year of life for
all infants ranged from 0 to 17, with 38% of infants
having at least one ED visit and more than 15% of
infants having three or more ED visits. As shown
in Figure 1, the distributions of primary diagnoses
accounting for more than 80% of ED visits were
similar, although late preterm compared with term
infants had a higher incidence of visits for feeding
difficulty (3.3% vs. 0.7%) and asthma/wheezing
not otherwise specified (2.2% vs. 0.8%).
Unadjusted Analysis
As shown in Table 1, bivariate comparisons
demonstrated no significant difference in any ED
use by gestational age category (term vs. late
preterm birth). In univariable analysis, late preterm
birth was also not associated with a significantly
Table 1: Bivariate Comparisons of Predic-
tors with any Emergency Department (ED)
use in the First Year of Life
No ED use Any ED use p value
Gestational age, % (n)
Late preterm 60.6 (100) 39.4 (65) 0.70
Full term 62.2 (1019) 37.8 (619)
Home visiting service, % (n)
<75% expected 60.7 (903) 39.3 (585) 0.01
visits
75% expected 68.4 (216) 31.7 (100)
visits
Timing of enrollment, % (n)
Prenatal 59.2 (514) 40.8 (354) 0.02
Postnatal 64.6 (605) 35.4 (331)
Infant gender, % (n)
Female 64.1 (579) 35.9 (324) 0.07
Male 59.9 (540) 40.1 (361)
Race, % (n)
White 65.8 (379) 34.2 (197) 0.60
Black 59.5 (672) 40.5 (458)
Asian/Pacific 66.7 (10) 33.3 (5)
Islander
Multirace 67.3 (37) 32.7 (18)
Other 74.1 (20) 25.9 (7)
Ethnicity, % (n)
Hispanic 82.8 (135) 17.2 (28) <.001
Non-Hispanic 60.0 (984) 40.0 (657)
Insurance, % (n)
Medicaid 60.0 (861) 40.0 (573) 0.002
Private 67.5 (187) 32.5 (90)
Self-pay 76.3 (58) 23.7 (18)
Other 81.8 (9) 18.2 (2)
Maternal age, % (n)
<20 years 61.4 (578) 38.6 (364) 0.02
2030 years 62.5 (530) 37.5 (318)
>30 years 78.6 (11) 21.4 (3)
Mental health diagnosis, % (n)
Yes 53.4 (95) 46.6 (83) 0.01
No 63.0 (1024) 37.0 (602)
(Continued)
138 JOGNN, 44, 135-144; 2015. DOI: 10.1111/1552-6909.12538 http://jognn.awhonn.org
Goyal, N. K. et al. I N F O C U S
Table 1: Continued
No ED use Any ED use p value
Smoking status, % (n)
Yes 56.5 (309) 43.5 (238) 0.001
No 64.4 (810) 35.6 (447)
Lives with infants father, % (n)
Yes 68.3 (198) 31.7 (92) .05
No 60.4 (836) 39.6 (549)
increased number of ED visits (incident rate ra-
tio (IRR) 1.06, 95% confidence interval (CI) [0.91,
1.24]). High intensity of home visits over the first
year of life was associated with a reduced inci-
dence of any ED visit (31.7% vs. 39.3% among
the low-intensity home visiting group); however,
as shown in Table 2 this association was not ob-
served for multiple ED visits, with an IRR = .88,
95% CI [0.72, 1.08]. The association of prenatal
versus postnatal enrollment was significant in uni-
variable analysis, both when modelled as any ED
use (Table 1) and as a count of ED visits, IRR =
1.18, 95% CI [1.02, 1.36].
Multivariable Analysis
Table 3 depicts results of negative binomial re-
gression analysis adjusting for clustering by home
visiting agency as well as covariates. Although
the incidence of mental health diagnosis in this
sample was not significantly different between late
preterm and term infants (7% vs. 10%, p = .15),
we observed a significant modifying effect of men-
tal health diagnosis on the association between
late preterm birth and ED visits. Compared with
term infants of mothers without a diagnosis, LPIs
of mothers with a mental health diagnosis had a
2.26 IRR for ED visits in the first year, 95% CI [1.10,
4.67]. Maternal mental health was also a statisti-
cally significant predictor for term infants; how-
ever, the effect size was smaller (IRR = 1.27, 95%
CI [1.01, 1.60]). In this multivariable model, neither
timing of enrollment nor frequency of home visiting
service during the first year was significantly asso-
ciated with a reduced rate of ED use. Other covari-
ates in the model that were statistically significant
included Hispanic ethnicity (adjusted odds ratio
[AOR] = .52, 95% CI [0.34, 0.80]), maternal smok-
ing (AOR = 1.26, 95% CI [1.07, 1.49]), Black race
(AOR = 1.23, 95% CI [1.01, 1.49]), and maternal
age >30 years (AOR = .41, 95% CI [0.20, 0.81]).
Results of a sensitivity analysis using multivariable
logistic regression were similar and therefore not
depicted.
Discussion
The vulnerability of LPIs in terms of mortality,
morbidity, and increased health care use in the
neonatal period and later in infancy and early
0
5
10
15
20
25
P
er
ce
nt
o
f E
m
er
ge
nc
y
V
is
its
Late preterm
0
5
10
15
20
25
P
er
ce
nt
o
f E
m
er
ge
nc
y
V
is
its
Full term
Figure 1. Primary diagnoses accounting for >80% of emergency department visits in the first year among term and late
preterm infants.
JOGNN 2015; Vol. 44, Issue 1 139
I N F O C U S Effects of Home Visiting and Maternal Mental Health on Use of the Emergency Department Among Late Preterm Infants
Table 2: Bivariate Comparisons of Predic-
tors with 3 Emergency Department (ED)
Visits in the First Year of Life
<3 ED visits 3 ED visits p-value Gestational age, % (n) Late preterm 84.2 (139) 15.8 (26) 0.88 Full term 84.7 (1387) 15.3 (251) Home visiting service, % (n) <75% expected 84.5 (1257) 15.5 (231) 0.77 visits 75% expected 85.1 (269) 14.9 (47) visits Timing of enrollment, % (n) Prenatal 83.1 (721) 16.9 (147) 0.08 Postnatal 86.0 (805) 14.0 (131) Infant gender, % (n) Female 86.5 (781) 13.5 (122) 0.03 Male 82.7 (745) 17.3 (156) Race, % (n) White 89.2 (514) 10.8 (62) 0.001 Black 81.9 (926) 18.1 (204) Asian/Pacific 100.0 (15) 0.0 (0) Islander Multi-Race 83.6 (46) 16.4 (9) Other 88.9 (24) 11.1 (3) Ethnicity, % (n) Hispanic 92.6 (151) 7.4 (12) 0.003 Non-Hispanic 83.8 (1375) 16.2 (266) Insurance, % (n) Medicaid 83.7 (1200) 16.3 (234) 0.09 Private 87.0 (241) 13.0 (36) Self-pay 90.8 (69) 9.2 (7) Other 100.0 (11) 0.0 (0) Maternal age, % (n) <20 years 85.7 (806) 14.3 (135) 0.02 2030 years 82.7 (672) 17.3 (141) >30 years 95.9 (47) 4.1 (2)
Mental health diagnosis, % (n)
Yes 78.1 (139) 21.9 (39) 0.01
No 85.3 (1387) 14.7 (239)
(Continued)
Table 2: Continued
<3 ED visits 3 ED visits p-value Smoking status, % (n) Yes 81.7 (447) 18.3 (100) 0.03 No 85.8 (1079) 14.2 (178) Lives with infants father, % (n) Yes 87.9 (247) 12.1 (34) 0.80 No 83.8 (1160) 16.3 (225) childhood, has been established in previous liter- ature (Bird et al., 2010; Engle et al., 2007; Martin et al., 2009; Medoff-Cooper et al., 2012; Raju et al., 2006). However, a gap remains in the evidence to support models of postdischarge care that may improve outcomes for this population (Premji et al., 2012). The majority of LPIs are not enrolled in high-risk infant follow-up programs that generally focus on very preterm infants (Walker et al., 2012). Additionally, recent evidence suggests that many families of LPIs do not access timely primary care follow-up (Hwang et al., 2013). Moreover, given known social and environmental risks associated with preterm birth, LPIs compared with term in- fants may be more likely to be affected by poverty, social isolation, and other factors that place them at further risk for adverse health and developmen- tal outcomes (Eunice Kennedy Shriver National Institute of Child Health and Human Development, 2014). We evaluated ED visit outcomes in a cohort of late preterm and term infants enrolled in a home visiting program, an intervention aimed at addressing social determinants of health for disadvantaged families through parent education, social support, and care coordination. Prior litera- ture on at least one national model of home visiting (Nurse Family Partnership) suggests that infants receiving home visits may incur fewer hospital- izations for injuries and ingestions compared with those not receiving home visits (Kitzman et al., 1997). Our results demonstrate an association between intensity and timing of home visits and ED use in the first year; however, this relationship does not persist after adjusting for other clinical and social factors. We did not find evidence to support that LPIs benefit differently from this inter- vention than do other at-risk infants born full term. We did not detect an independent association be- tween late preterm birth and ED use, perhaps due to relatively small sample size as well as the over- all high level of use across the cohort regardless of gestational age. Importantly, we did find that within this at-risk cohort, maternal mental health 140 JOGNN, 44, 135-144; 2015. DOI: 10.1111/1552-6909.12538 http://jognn.awhonn.org Goyal, N. K. et al. I N F O C U S Table 3: Random Effects Negative Binomial Regression Analysisa of Emergency Depart- ment Visits in the First Year of Life Incident 95% confidence rate ratio interval Late preterm 0.97 0.74, 1.27 Maternal mental health diagnosis 1.27 1.01, 1.60 Late preterm 2.26 1.10, 4.67 mental health diagnosis 75% expected visits 0.92 0.74, 1.13 Prenatal enrollment 1.05 0.91, 1.22 Female 0.79 0.69, 0.92 Race White reference Black 1.23 1.01, 1.49 Asian/Pacific 1.42 0.57, 3.52 Islander Multi-Race 1.15 0.71, 1.85 Other 0.71 0.29, 1.71 Hispanic 0.52 0.34, 0.80 Insurance Medicaid reference Private 0.85 0.68, 1.06 Self-pay 0.63 0.39, 1.02 Other 0.72 0.18, 2.81 Maternal age, % (n) <20 years 1.00 0.86, 1.16 2030 years reference >30 years 0.41 0.20, 0.81
Smoking 1.26 1.07, 1.49
Lives with infants
father
0.84 0.68, 1.05
Note. a Adjusts for clustering by home visiting agency with
an exchangeable correlation structure; 11 outlier observations
(>8 ED visits in the first year) were omitted from analysis.
conditions were a significant modifier on the as-
sociation between late preterm birth and ED use
in infancy. That is, LPIs whose mothers had di-
agnosed mental health conditions had more than
double the rate of ED visits in the first year of life
than full-term infants of mothers without diagnosed
mental health conditions. Prior work on maternal
mental health has demonstrated a link between
maternal depression and anxiety with increased
infant acute and emergency visits (Chung, Mc-
Collum, Elo, Lee, & Culhane, 2004; Mandl, Tronick,
Brennan, Alpert, & Homer, 1999; Minkovitz et al.,
2005; Sills, Shetterly, Xu, Magid, & Kempe, 2007).
In a recent study of term infants, the authors noted
that the degree of association with infant ED visits
differed by timing of maternal depression and anx-
iety with even higher use for those infants whose
mothers mental health conditions began during
the postpartum period (Farr et al., 2013). To our
knowledge, the differential effect of maternal men-
tal health on ED visits for late preterm versus term
infants has not been previously evaluated. How-
ever, prior researchers have described the rela-
tionship between late preterm birth and maternal
anxiety, particularly relating to feeding difficulty
(DeMauro, Patel, Medoff-Cooper, Posencheg, &
Abbasi, 2011; McDonald et al., 2013). Combined
with the fact that LPIs have rates and patterns of
feeding dysfunction in the first year of life that are
similar to those of very preterm infants, this result
likely contributes to our finding of higher incidence
of ED visits for feeding problems compared with
term infants.
Finally, our current findings with this cohort
enrolled in a home visiting program are generally
consistent with previously reported data on in-
creased risk of ED use among late preterm versus
term infants (Jain & Cheng, 2006). However,
overall rates of ED visits in this sample are high
compared with national data on ED use (published
estimates for young children age 04 years are
17% with at least one ED visit, and 11% with two or
more visits). This finding likely reflects the higher
risk level of families eligible for and receiving home
visiting services, as many sociodemographic fac-
tors including poverty, single-parent status, Black
race, and Medicaid coverage are associated
with more frequent ED use (Bloom, Cohen, &
Freeman, 2011; Halfon, Newacheck, Wood, & St
Peter, 1996). Maternal smoking status was also
a significant factor in our analysis, consistent
with prior literature demonstrating its association
with respiratory and gastrointestinal disorders in
infancy (Carroll et al., 2007; Shenassa & Brown,
2004). Given that more than 30% of mothers
in this sample were classified as smokers, this
behavior may be a critical point of targeted inter-
vention within home visiting prenatally and during
infancy.
JOGNN 2015; Vol. 44, Issue 1 141
I N F O C U S Effects of Home Visiting and Maternal Mental Health on Use of the Emergency Department Among Late Preterm Infants
Further efforts to develop and refine community-based
programs serving late preterm infants and their families may
need to address maternal mental health conditions.
Limitations
Several limitations related to use of adminis-
trative data in this retrospective analysis are
acknowledged. Complications and comorbidities
identified using vital statistics and hospital dis-
charge data may result in a misclassification bias
(Hsia, Krushat, Fagan, Tebbutt, & Kusserow, 1988;
Iezzoni et al., 1992; Romano & Mark, 1994). In par-
ticular, the mental health diagnosis variable, which
was based on the list of discharge diagnoses from
the birth hospital, has high specificity but lower
sensitivity in that there are likely women in the
sample with uncoded or undiagnosed conditions,
which could drive risk estimates towards the null
(Yasmeen, Romano, Schembri, Keyzer, & Gilbert,
2006). Moreover, this measure would not include
new mental health conditions that emerged after
the birth hospitalization period. However, to further
assess the validity of this variable, we compared
it to maternal scores on the Interpersonal Support
Evaluation List (ISEL), a validated screening tool
collected by home visitors at enrollment that mea-
sures perceived social support and correlates
with stress and negative effect (Merz et al., 2014);
as expected, the mental health variable was
significantly associated with lower (worse) ISEL
scores in our bivariate assessments, p = .001. An-
other potential limitation is that outcome measures
were reliant on data captured through the CCHMC
system, the regions only pediatric ED services
provider. This system sees nearly 90% of pedi-
atric admissions within its eight- county primary
catchment zone, with that percentage increas-
ing for the youngest patients. These data may
underestimate rates of ED visits and introduce
selection bias, though our findings are robust
to adjustment for geographic clustering by zip
code. Another limitation may be generalizability
due to the regional population represented in the
study. Finally, though home visitors place a strong
emphasis
