PEDIATRICS Vol. 120 No. 2 August 2007, pp. e391-e400 (doi:10.1542/peds.2006-3389)
ARTICLE |
Decision-Making for Postpartum Discharge of 4300 Mothers and Their Healthy Infants: The Life Around Newborn Discharge Study
a Department of Pediatrics, Dartmouth Medical School, Children's Hospital at Dartmouth, Lebanon, New Hampshire
b Ann Arbor, Michigan
c Pediatric Research in Office Settings, Department of Research, American Academy of Pediatrics, Elk Grove Village, Illinois
d Department of Pediatrics, Vermont College of Medicine, Burlington, Vermont
e Departments of Biostatistics
h Maternal and Child Health, Harvard School of Public Health, Harvard University, Boston, Massachusetts
f School of Medicine, Indiana University, Bloomington, Indiana
g Delaware Valley Pediatric Associates, Lawrenceville, New Jersey
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ABSTRACT |
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 TOP ABSTRACT PATIENTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVES. Postpartum discharge of mothers and infants who are not medically or psychosocially ready may place the family at risk. Most studies of postpartum length of stay, however, do not reflect the necessary complexity of decision-making. With this study we aimed to characterize decision-making on the day of postpartum discharge from the perspective of multiple key informants and identify correlates of maternal and newborn unreadiness for discharge.
PATIENTS AND METHODS. This was a prospective observational cohort study of healthy term infants with mothers, pediatric providers, and obstetricians as key informants to assess the decision-making process regarding mother-infant dyad unreadiness for discharge. A mother-infant dyad was defined as unready for postpartum hospital discharge if 
1 of 3 informants perceived that either the mother or infant should stay longer at time of nursery discharge. Data were collected through self-administered questionnaires on the day of discharge.
RESULTS. Of 4300 mother-infant dyads, unreadiness was identified in 17% as determined by the mother (11%), pediatrician (5%), obstetrician (1%), and 2 informants (<1%). Significant correlates of unreadiness were as follows: black non-Hispanic maternal race/ethnicity, maternal history of chronic disease, primigravid status, inadequate prenatal care as determined by the Kotelchuck Adequacy of Prenatal Care Utilization Index, delivering during nonroutine hours, in-hospital neonatal problems, receiving a limited number of in-hospital classes, and intent to breastfeed.
CONCLUSIONS. Mothers, pediatricians, and obstetricians must make decisions about postpartum discharge jointly, because perceptions of unreadiness often differ. Sensitivity toward specific maternal vulnerabilities and an emphasis on perinatal education to insure individualized discharge plans may increase readiness and determine optimal timing for discharge and follow-up care.
Key Words: newborn readiness • postpartum discharge • decision-making
Abbreviations: LOS—length of stay • LAND—Life Around Newborn Discharge • PROS—Pediatric Research in Office Settings • AAP—American Academy of Pediatrics • OR—odds ratio • CI—confidence interval
The immediate postpartum period includes major biological and social transitions for the mothers and families of the >4 million infants born in the United States each year. This critical period provides the health care system opportunities to identify and respond to acute and chronic health and social problems facing families.1,2 By the early 1990s, lengths of hospital stay and services were so reduced because of cost-containment measures implemented by managed care companies and hospitals operating under capitation that mothers were commonly discharged the day after a normal vaginal delivery. These cost reduction efforts raised questions about medical, behavioral, and emotional consequences for mothers and their infants.3–9 Debate among medical professionals, legislators, and families was fueled by concerns about potentially adverse outcomes of early postpartum discharge. In response, the Newborns' and Mothers' Health Protection Act of 1996 established federal requirements for minimum hospital length of stay (LOS) postpartum as 48 hours after vaginal deliveries and 96 hours after cesarean deliveries.10–12
Typically, research on the postpartum period has focused on LOS, its impact on infrequent medical events (eg, infant readmission to the hospital, infant mortality after discharge, and maternal and neonatal complications), and well-defined programs of follow-up care in special populations. Much of this research involves self-selected and small samples that may not pertain to the broader, childbearing population.3–9,13–17 Information is lacking regarding the postpartum decision-making process and the consequences of shorter postpartum hospital stays for the mother and infant, rendering additional research necessary to inform policy and practice about LOS and key outcomes.18–20
The decision-making process for postpartum discharge is complex. Discharge before a family is medically or psychologically ready places the new family at greater risk of poor maternal or infant health status, increased use of health services, or adoption of behaviors disadvantageous to maternal and infant health during the immediate postpartum period.18 Infants and families are best served when the services they receive are matched to their needs. The Life Around Newborn Discharge (LAND) study was designed to address gaps in knowledge around postpartum discharge decision-making, overcome flaws of previous studies, and inform reimbursement and clinical care policies. Specifically, the LAND study sought to characterize decision-making around postpartum discharge from the perspective of multiple informants and identify factors correlated with maternal and newborn unreadiness for discharge.
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PATIENTS AND METHODS |
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TOPABSTRACTPATIENTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Conceptualization
LAND-study investigators sought to examine decision-making by mothers, pediatricians, and obstetricians about postpartum discharge. The decision-making process among these 3 informants was characterized by obtaining their respective perceptions of unreadiness for the mother-infant dyad on the actual discharge day. Hypothesized correlates of unreadiness for postpartum discharge incorporated prenatal, perinatal, and postpartum factors and included sociodemographic and provider characteristics.
Definition of Unreadiness for Discharge
A mother-infant dyad was defined as unready for postpartum hospital discharge if 1 of 3 informants perceived that either the mother or infant should stay longer at time of nursery discharge (Table 1). All 3 of the informants must have considered both mother and infant to be ready for discharge for the dyad to be identified as ready.
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Study Design
A prospective observational cohort study of mothers and infants was conducted by Pediatric Research in Office Settings (PROS), the practice-based research network of the American Academy of Pediatrics (AAP).21,22 Practices across 49 states, the District of Columbia, Puerto Rico, and Canada enrolled subjects between September 1999 and August 2002. Approval was obtained from the institutional review boards at participating hospitals and practices, as well as the AAP Institutional Review Board. The methodologic barriers and selected strategies and approaches developed and implemented in the successful conduct of this study are detailed elsewhere.23
Study Population
Mothers, pediatric providers, and obstetricians were selected as key informants to assess the decision-making process regarding mother-infant dyad unreadiness for discharge. To avoid additional complexity, fathers and nurses were not included. To prevent significant imposition on obstetric practitioners' clinical time, their individual demographic information was not collected. Eligible newborns from participating PROS practices seen consecutively in a hospital nursery were enrolled prospectively during a period of 8 weeks. Eighteen percent of participating sites completed a second enrollment period, with each site enrolling no more than a total of 120 dyads.
Enrollment was limited to healthy term infants, with special efforts made to enroll minority populations sufficient to approximate the national annual birth cohort. Eligible infants included the following: those without a major congenital disorder; those who were single gestations of 37 weeks (by obstetric dates); those with a birth weight of 5 lb; those who spent <8 hours in a special care nursery; and those who were not scheduled for adoption. Eligible mothers included those without severe, active chronic illness at the time of delivery as judged by the obstetrician that would adversely affect their ability to care for their newborn; those who had telephone access; those who had chosen the participating PROS practice for postdischarge pediatric care; and those who felt able to complete study materials in English or Spanish. Practitioners recorded the birth date, discharge date, and gender of eligible newborns not enrolled to assess selection bias.
Data Collection
Data were collected through self-administered questionnaires on the day of discharge. Maternal judgments about herself and her infant were obtained using an instrument set at a fourth- to sixth-grade reading level; this was also translated into universal-dialect Spanish and back translated. Data on unreadiness were also collected from the pediatrician (who rendered judgments for both mother and infant) and obstetrician (judgment rendered for mother only). All 3 of the informants were asked to respond to the question(s) in Table 1. If any respondent considered the discharge day "not right," the reasons were ascertained. Information on the demographic characteristics of the respondents, prepartum and postpartum maternal health, and neonatal health were obtained from the appropriate respondent. A pilot study to refine procedures and instruments was first conducted in 13 PROS practices.18
Statistical Analysis
A sample size of 4000 dyads was set prospectively to detect differences in health measures and judgment of unreadiness. Bivariate and multivariate relationships between unreadiness and correlates of unreadiness from the conceptual model were investigated using logistic regression. The generalized estimating equation approach for binary data24 was initially considered to adjust for clustering within practice; however, results were comparable to simpler logistic approaches. Multiple imputation was used to derive values for missing data.25,26 All of the analyses were conducted using SAS 9.0 (SAS Institute, Inc, Cary, NC).27
Bivariate relationships between unreadiness and correlates were explored. Subsequently, multivariate models were examined using the following model-building strategy: all of the maternal sociodemographic and pediatric practitioner characteristics were included, and domains of prenatal, perinatal, and postpartum variables that were statistically significant at the .10 level in bivariate analyses were entered sequentially (considering the continuum from pregnancy through delivery and nursery stay); only variables statistically significant at the .05 level in multivariate analyses were kept in the model for assessment of subsequent domains. Unadjusted and adjusted odds ratios (ORs) with corresponding 95% confidence intervals (CIs) and P values are provided for bivariate and multivariate analyses.
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RESULTS |
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TOPABSTRACTPATIENTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Study Population
Hospital affiliates and offices of 451 practitioners from 112 PROS practices participated. Of 4974 dyads approached for recruitment, 4300 (86%) were enrolled. Reported reasons for maternal nonparticipation included maternal refusal (n = 333), provider's inability to approach the mother (n = 126), and miscellaneous/other (n = 215). The median number of dyads enrolled per PROS practice was 34 (interquartile range: 20–50). Women who participated in the LAND study were comparable to the general population of women who gave birth in the year 2000 with respect to Medicaid coverage28 and smoking cigarettes during pregnancy but tended to be more educated, more likely to breastfeed, and to have received more medical care during pregnancy.29
Study questionnaires were returned at high rates from the mothers (83%) and pediatricians (95%) but at notably lower rates (65%) from the obstetricians. Forty-six percent of dyads had complete data to assess unreadiness from all 3 of the informants.
Mother-infant demographic information is presented in Table 2. Thirty-six percent of mothers were minorities (nonwhite and/or Hispanic). Participating PROS practices were geographically distributed nationally. Mean practitioner age was 42.9 years, and the sample included 51% men. Years of experience ranged from 0 to 49 (mean: 12.8 years); 84% were board certified, and 77% were parents themselves. There was modest racial/ethnic diversity among practitioners, with a majority (78%) self-identifying as white, non-Hispanic.
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Unreadiness for Discharge
At time of discharge,
16% to 17% of dyads met the definition of unready (Table 3). The assessment of unready was unanimous in <1% of all of the cases; most were defined as unready because of maternal perception alone (11%–12%). Nearly two thirds of mothers who perceived themselves as unready for discharge reported needing longer hospital stays for their own physical concerns. Pediatricians and obstetricians reported that, for mothers who they perceived as unready, LOS should be longer to address maternal education and comfort needs. For newborns perceived as unready, mothers reported a need to address feeding issues and for further newborn medical care, whereas pediatricians reported a need for longer LOS because of feeding issues and the mothers' need for further parenting education.
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Bivariate Correlates of Unreadiness
Table 4 provides maternal sociodemographic and pediatric practitioner characteristics, along with prenatal, perinatal, and postpartum correlates of unreadiness.
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Maternal Sociodemographics
Significant sociodemographic correlates of unreadiness reflected a relative lack of resources. Unreadiness was higher among younger mothers, those with incomes below the federal poverty threshold, minorities, and those uninsured or on public insurance. First-time mothers and those with a history of chronic disease, as judged by their obstetrician, were also more likely to be considered unready. Maternal education was not associated with unreadiness.
Pediatric Practitioner Characteristics
Self-reported characteristics of pediatric practitioners associated with higher levels of unreadiness reflected less experience. Pediatricians who were younger, less experienced, not parents themselves, and not board certified were more likely to deem dyads unready for discharge.
Prenatal Factors
A relative lack of prenatal services (except for education) or more prenatal complications were factors correlated with greater degrees of unreadiness. Pregnant women who did not meet with a pediatric provider or who had inadequate prenatal care as determined by the Kotelchuck Adequacy of Prenatal Care Utilization Index30 were more likely to be unready for discharge, as were those having prenatal problems and multiple prenatal complications. The exception was prenatal education: those who attended prenatal classes were more likely to be unready, as were those who reported a greater number of topics covered in prenatal classes.
Perinatal Factors
Statistically significant perinatal correlates of unreadiness again suggest that complicated pregnancy and delivery influence the perceptions of unreadiness. Women with a duration of labor >12 hours (maternal report), prolonged labor (obstetrician report), delivery during nonroutine hours (defined as 7:00 PM to 7:00 AM), and characteristics reflecting biological vulnerability (eg, lower birth weight, prenatal problems, cesarean section, or in-hospital neonatal problems) were more likely to be unready for discharge. Although mothers with cesarean sections were more likely to be unready than those with vaginal deliveries, this association was not statistically significant.
Postpartum Factors
Fewer postpartum services were associated with a greater degree of unreadiness. Dyads having no hospital visit from the pediatrician, receiving a limited number of in-hospital classes or not receiving any classes, and not being asked to schedule their first infant office visit while in the hospital were more likely to be deemed unready for discharge. Maternal plans to breastfeed, concerns about lack of support at home (either self-reports that the father will not help with the infant at home or not living with the father), and maternal perception of a lack of parenting ability were additional postpartum factors associated with greater unreadiness for discharge. LOS was not correlated with perception of unreadiness for discharge. The proportions of dyads with shorter lengths of stay classified as unready or ready were comparable, independent of mode of delivery: vaginal LOS <48 hours (53% vs 54%, respectively) or cesarean section LOS <72 hours (46% vs 41%, respectively).
Multivariate Correlates of Unreadiness
After controlling for maternal sociodemographic and pediatric practitioner factors, 8 factors remained statistically significant in the multivariate model (see Table 5). These factors of unreadiness included the mother being black and non-Hispanic, having received "inadequate" prenatal care (ie, ranked by the Kotelchuck Adequacy of Prenatal Care Utilization Index), having a known chronic disease, delivering during nonroutine hours (ie, 7:00 PM to 7:00 AM), being primigravid, receiving at best only a modest amount of in-hospital education, intending to breastfeed, and having a newborn with neonatal problems in the nursery.
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DISCUSSION |
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TOPABSTRACTPATIENTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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A small body of research has examined readiness for hospital discharge in other contexts, defining discharge readiness as "a multifaceted, multistage concept that provides an estimate of a patient's ability to leave an acute care facility,"31 and, alternatively, as "patients' and families' perception of being prepared or not prepared for hospital discharge."32 The LAND study examined a previously unexplored concept, perceptions of unreadiness for postpartum discharge by mothers and the health professionals responsible for their and their infants' care. A literature review yielded only 1 study, which retrospectively reviewed maternal perceptions of readiness for discharge. This study found that mothers who were discharged early were more likely to be multiparous, less educated, of low socioeconomic status, and without privately funded health insurance,33 consistent with LOS literature. A perception of not being ready was associated with early discharge; the authors postulated that early discharge may have precipitated feelings of not being ready to go home.33
Clinical standards for a given condition and key decision-makers' perceptions contribute to the decision of whether a patient is ready for hospital discharge.34–36 The LAND-study finding that <1% of dyads were perceived as unready by all 3 of the informants at the time of discharge illustrates the degree to which perceptions of readiness or unreadiness may differ and attests to the complexity of making an appropriate discharge decision for each new mother and infant. In a survey of spouses' perceptions of readiness for discharge after cardiac surgery, perceptions of discharge readiness were positively influenced by the availability of social support, use of coping strategies, personal resources, and knowing what to expect. However, perceptions of readiness in this study were not assessed contemporaneously and, therefore, did not assess mutual agreement.37,38
Past and current debate among medical professionals, legislators, and families about postpartum hospital stays has been fueled by concerns about adverse outcomes associated with shortened LOS. In our study, LOS and perceptions of unreadiness for discharge were not correlated. Instead, 8 factors were identified as correlates of perceptions of maternal and newborn unreadiness: (1) maternal race/ethnicity; (2) maternal history of chronic disease; (3) primigravid status; (4) level of/access to prenatal care; (5) neonatal problems whereas in the hospital; (6) time of delivery; (7) number of topics covered in the hospital; and (8) plans to engage in breastfeeding. These findings suggest that LOS is not the actual determinant of outcome and that the chronological clock is not necessarily what is important. The debate regarding postpartum hospital stays must be refocused toward a broadened scope of policy and clinical care considerations.
Addressing these factors to decrease unreadiness may take a 2-pronged approach: awareness of predetermined factors (race/ethnicity, primigravid status, and maternal health history/chronic disease) accompanied by enhanced provision of services to mitigate their impact and identification of nonpredetermined situations affecting unreadiness along with strategies for addressing them. Practitioners, particularly obstetricians, should consider maternal health history and the resources available during certain times of the day, because hospitals are generally less well staffed between the nonroutine hours of 7:00 PM to 7:00 AM. In-hospital stays are an opportune time to address infant-related maternal concerns, such as breastfeeding or infant's health problems, and protocols for systematically tackling maternal concerns should be integrated into best practices guidelines for postpartum clinical care of both mother and infant.
Interestingly, bivariate analyses revealed that those mothers who took prenatal classes that covered a moderate number of topics were more likely to be unready compared with those who did not take prenatal classes and those women whose prenatal classes covered either a few or many topics. We can speculate that the more information brought to a mother's attention, the more she had to bear in mind and potentially worry about, or perhaps this illuminates an evolving integration of information that provides answers rather than just prompts more questions. Either way, unlike the number of topics covered in the hospital, the number of topics covered in prenatal classes was not identified in our multivariate model as a correlate of unreadiness.
The LAND study incurred certain limitations. One concern is the generalizability of results obtained from clinicians in a practice-based research network. Past analyses have demonstrated that PROS practitioners are similar to random samples of AAP practitioners.39–41 With respect to practitioner volunteer bias, LAND-study practitioners were comparable on most demographic variables to a random and contemporaneous sample of AAP members who saw newborns as part of their practice. Although similar in gender, PROS practitioners were older and less likely to be parents, practice in a suburban area, or work in a self-employed solo practice. Although one might speculate that PROS practitioners have a heightened concern about quality-of-care issues, it should not confound the central question of the study.
Volunteer bias of participating mothers is difficult to assess, because the study protocol did not allow for collection of demographic data on nonparticipating mothers. Mothers who felt unready for discharge might have been more likely to enroll to express their concerns or possibly less likely to enroll because they were feeling ill or overwhelmed. Given the differences cited above between the LAND-study population (more educated, more likely to breastfeed, and with more medical care received during pregnancy) and the general US birthing population, it seems likely that LAND-study estimates of unreadiness for discharge represent a lower bound and that unreadiness in the general population could actually be higher.
Finally, a notable fraction of obstetric assessment data reflects imputation. Whereas analyses using only cases with completed data provide similar results to those reported here, the results might be different if the obstetricians for whom there were no assessments differed systematically from those who did.
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CONCLUSIONS |
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TOPABSTRACTPATIENTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The LAND-study results suggest that the mother and the clinicians caring for her and her infant must make the postpartum discharge decision jointly, because perceptions of readiness or unreadiness at the time of discharge often differ. Clinical decision-making regarding maternal and infant discharge is a subjective and contextual process that must take into account the perspectives of each person involved in the mothers' and infants' health care experience. This joint decision-making process is especially critical when there are heightened risks for problems in the mother (eg, postpartum depression) and infant (eg, jaundice or infection) during this transitional time. The newly augmented family unit may not be medically or psychologically prepared to deal with the challenges posed by discharge.
When considering postpartum discharge, there is no "one-size-fits-all" answer to readiness; a customized reflection of both the mother's and her infant's needs and concerns is required. Assessment of and consideration for fixed maternal vulnerabilities, coupled with enhanced health care and educational support, should be conducted in day-to-day practice and be incorporated into clinical guidelines and policy relevant to postpartum discharge and follow-up care. Knowing the characteristics and requirements of each mother and infant allows for postpartum discharge plans to be tailored and individualized to that of the dyad's needs. However, when perceptions of maternal or infant readiness do not coincide, whose perspective takes precedence? Should a clinician's experience supersede the mother's perception of unreadiness or does the mother's feeling of unreadiness warrant specific postpartum supports and services be put in place to address maternal concerns?
Although this joint decision-making process helps to ensure a more comprehensive evaluation of mother-infant readiness in hopes of improving maternal and infant postpartum outcomes, the impact of the Newborns' and Mothers' Health Protection Act of 1996 remains largely unexamined. The health outcomes that are susceptible to unreadiness for postpartum discharge require further exploration to fully assess the impact of the policy initiative.
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ACKNOWLEDGMENTS |
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This study was supported by Health Resources and Services Administration Maternal and Child Health Bureau grants 5 R40 MC00117 and 2R60 MC 00107–09, with additional support from the AAP Friends of Children and Research in Pediatric Practice Funds.
The superb administrative assistance of Rebecca Stoltz, Sarah Isbey, and Amilyn Taplin in preparing this article for submission is much appreciated. We especially appreciate the efforts of the PROS practices and practitioners. The pediatric practices or individual practitioners who enrolled mother-infant dyads in this study are listed here by AAP chapter. Alabama: University of South Alabama (Mobile); Alaska: Anchorage Pediatric Group, LLC (Anchorage); Arizona: Orange Grove Pediatrics (Tucson); California-1: Castro Valley Pediatrics (Castro Valley), Razia Sheikh, MD (Fresno), Pediatric and Adolescent Medical Associates of the Pacific Coast, Inc (Salinas), University of California (San Francisco); California-2: University of California West Los Angeles Office (Los Angeles); California-3: Pediatric Medical Associates of Tri-City, Inc (Vista); Colorado: Rocky Mountain Youth Clinics (Thornton); Connecticut: Healthwide Medical Associates (Vernon Rockville); East Military: National Naval Medical Center (Bethesda); Florida: Family Health Center East and Oviedo Children's Health Center (Orlando), Nemours Clinical Management Program (Orlando), Sacred Heart Pediatric Care Center (Pensacola), Kenneth S Cohen, MD (Pembroke Pines); Georgia: Decatur Pediatric Group (Clarkston), Snapfinger Woods Pediatric Associates, PC (Decatur), The Pediatric Center (Stone Mountain), Swainsboro Pediatrics and Adolescent Center, LLC (Swainsboro); Hawaii: Island Youth Heart and Health Center (Hilo), University of Hawaii (Honolulu); Illinois: ACCESS Hawthorne Family Health Center–Sinai Health Care System (Cicero), Kidz Health (Chicago), Kedzie Plaza Sinai Medical Group (Chicago), ACCESS Community Health Centro Medico San Rafael–Sinai Health Care System (Chicago), Sinai Health System–Centro Medico SMG (Chicago), Sinai Health System–Kling Pediatrics (Chicago), ACCESS Plaza Medical Center–Sinai Health Care System (Chicago); Indiana: Southern Indiana Pediatrics (Bedford), Southern Indiana Pediatrics, LLC (Bloomington), IU Medical Group (Indianapolis), Saint Vincent Pediatric Clinic (Indianapolis), Witham Pediatrics (Lebanon); Iowa: Genesis Health Group (Bettendorf), University of Iowa (Iowa City); Kansas: Ashley Clinic (Chanute), Bethel Pediatrics (Newton); Maine: Kennebec Pediatrics (Augusta); Maryland: Shore Pediatrics (Easton), Main Street Pediatrics, LLC (Towson), Shady Side Medical Associates (Shady Side); Massachusetts: Alewife Brook Community Pediatrics (Arlington), Burlington Pediatrics (Burlington), Mystic Valley Pediatrics (Medford), Mary Lane Pediatric Associates (Ware), University of Massachusetts Memorial Pediatric Primary Care (Worcester); Michigan: Pediatric and Adolescent Medicine (Bay City); Minnesota: Kundel Pediatrics Associates (Duluth); Missouri: Tenney Pediatric and Adolescent LLC (Kansas City), Priority Care Pediatrics, LLC (Kansas City), Timothy Reed, MD (Saint Peters); New Jersey: Delaware Valley Pediatric Associates, PA (Lawrenceville), Chestnut Ridge Pediatric Associates (Woodcliff Lake); New Mexico: Albuquerque Pediatric Associates, Ltd (Albuquerque), Presbyterian Family Healthcare–Rio Bravo (Albuquerque), University of New Mexico Hospital (Albuquerque), First Step Pediatrics (Las Cruces); New York-1: Elmwood Pediatric Group (Rochester), Lewis Pediatrics (Rochester), Parkway Pediatrics and Adolescent Medicine (Rochester), Parkway Primary Care Clinic (Salamanca); New York-2: One Hanson Place Pediatrics, PC (Brooklyn); North Carolina: Carolinas Medical Center (Charlotte), Elizabeth Pediatrics (Charlotte), Eastover Pediatrics (Charlotte), Randolph Pediatrics Associates (Charlotte), Matthews Children's Clinic, PA (Matthews); North Dakota: Altru Clinic (Grand Forks); Ohio: Bryan Medical Group (Bryan), Oxford Pediatrics and Adolescents (Oxford), Galion Pediatrics (Galion); Pennsylvania: Coudersport Pediatrics (Coudersport), Pennridge Pediatric Associates (Sellersville), Laurel Health Center (Wellsboro); South Carolina: Palmetto Pediatrics and Adolescent Clinic, PA (Columbia); Texas: Sarah L Helfand, MD (Dallas), Su Clinica Familiar (Harlingen), PediMed Center (Midland), Rainbow Pediatric Clinic (Weslaco); Utah: Alpine Pediatrics (Pleasant Grove), John Weipert, MD (American Fork), Utah Valley Pediatrics, LC (American Fork), Michael Whiting, MD (American Fork), David Nuttall, MD (American Fork), Utah Valley Pediatrics, LC–Cherry Tree Office (Orem), Utah Valley Pediatrics, LC–Physician Plaza (Provo), Utah Valley Pediatrics, LC–Provo North University Office (Provo), Pediatric Care, Inc (Provo), Uintah Basin Medical Center (Roosevelt), University South Main Public Health Center (Salt Lake City); Vermont: Green Mountain Pediatrics, PC (Bennington), University Pediatrics, University Health Center Campus (Burlington), Rebecca Collman, MD (Colchester), Essex Pediatrics (Essex Junction), Shelburne Pediatrics, Inc (Shelburne), Hagan and Rinehart Pediatricians (South Burlington), Pediatric Medicine (South Burlington), Timber Lane Pediatrics (South Burlington), University Pediatrics (Williston); Virginia: Stonewall Pediatrics (Lexington); Washington: Northwest Pediatric Center (Centralia), Oakland Bay Pediatrics (Shelton), Yakima Neighborhood Health Services, Inc (Yakima); West Military: Naval Medical Center San Diego (San Diego); West Virginia: Marshall University Medical Center (Huntington), Grant Memorial Pediatrics (Petersburg); Wisconsin: Beloit Clinic SC (Beloit), Prohealth Care Medical Centers–Muskego (Muskego), Waukesha Pediatric Associates (Waukesha); and Wyoming: Jackson Pediatrics, PC (Jackson).
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FOOTNOTES |
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Accepted Apr 2, 2007.
Address correspondence to Henry H. Bernstein, DO, General Academic Pediatrics, Children's Hospital at Dartmouth, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756-0001. E-mail: henry.bernstein{at}hitchcock.org
The authors have indicated they have no financial relationships relevant to this article to disclose.
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