Electronic Health RecordBased Decision Support to Improve Asthma Care: A Cluster-Randomized Trial Louis M.

Bell, Robert Grundmeier, Russell Localio, Joseph Zorc, Alexander G. Fiks, Xuemei Zhang, Tyra Bryant Stephens, Marguerite Swietlik and James P. Guevara Pediatrics 2010;125;e770; originally published online March 15, 2010; DOI: 10.1542/peds.2009-1385

The online version of this article, along with updated information and services, is located on the World Wide Web at:
http://pediatrics.aappublications.org/content/125/4/e770.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2010 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Electronic Health RecordBased Decision Support to Improve Asthma Care: A Cluster-Randomized Trial
WHATS KNOWN ON THIS SUBJECT: The science and understanding of how to design and implement effective CDS is evolving. Embedding CDS within the EHR, if done effectively, has the potential to improve quality of care. WHAT THIS STUDY ADDS: This study uses an EHR as a platform on which a CDS tool is built. This design allowed the CDS to be smoothly integrated into the clinicians work ow, improving clinician compliance with asthma care guidelines.
AUTHORS: Louis M. Bell, MD,a,b,c Robert Grundmeier, MD,a,c Russell Localio, PhD,d Joseph Zorc, MD,b,e Alexander G. Fiks, MD, MSCE,a,b,c Xuemei Zhang, MS,f Tyra Bryant Stephens, MD,c Marguerite Swietlik, CRNP,a and James P. Guevara, MD, MPHb,c
Pediatric Research Consortium; bPediatric Generalist Research Group; Divisions of cGeneral Pediatrics and eEmergency Medicine, Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania; fDepartment of Pediatrics, Childrens Hospital of Philadelphia-Westat Biostatistics and Data Management Core, Philadelphia, Pennsylvania; and dDepartment of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania KEY WORDS clinical decision support, electronic health record, asthma, pediatrics, asthma-control tool ABBREVIATIONS NAEPPNational Asthma Education and Prevention Program ACPasthma action/care plan CDS clinical decision support EHR electronic health record CHOPChildrens Hospital of Philadelphia UP urban practice SPsuburban practice PACTpediatric asthma-control tool This trial has been registered at www.clinicaltrials.gov (identier NCT00918944). www.pediatrics.org/cgi/doi/10.1542/peds.2009-1385 doi:10.1542/peds.2009-1385 Accepted for publication Nov 16, 2009 Address correspondence to Louis M. Bell, MD, Division of General Pediatrics, 12th Floor Northwest Tower, Childrens Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104. E-mail: belll@email.chop.edu PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright 2010 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no nancial relationships relevant to this article to disclose.
a

abstract
OBJECTIVE: Asthma continues to be 1 of the most common chronic diseases of childhood and affects 6 million US children. Although National Asthma Education Prevention Program guidelines exist and are widely accepted, previous studies have demonstrated poor clinician adherence across a variety of populations. We sought to determine if clinical decision support (CDS) embedded in an electronic health record (EHR) would improve clinician adherence to national asthma guidelines in the primary care setting. METHODS: We conducted a prospective cluster-randomized trial in 12 primary care sites over a 1-year period. Practices were stratied for analysis according to whether the site was urban or suburban. Children aged 0 to 18 years with persistent asthma were identied by International Classication of Diseases, Ninth Revision codes for asthma. The 6 intervention-practice sites had CDS alerts imbedded in the EHR. Outcomes of interest were the proportion of children with at least 1 prescription for controller medication, an up-to-date asthma care plan, and the performance of ofce-based spirometry. RESULTS: Increases in the number of prescriptions for controller medications, over time, was 6% greater (P .006) and 3% greater for spirometry (P .04) in the intervention urban practices. Filing an up-todate asthma care plan improved 14% (P .03) and spirometry improved 6% (P .003) in the suburban practices with the intervention. CONCLUSION: In our study, using a cluster-randomized trial design, CDS in the EHR, at the point of care, improved clinician compliance with National Asthma Education Prevention Program guidelines. Pediatrics 2010;125:e770e777

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Asthma is the most common chronic disease of childhood and affects more than 6 million children in the United States. Rising asthma prevalence, hospitalizations, and costs over recent decades have led to efforts to improve asthma care, such as the National Asthma Education and Prevention Program (NAEPP) guidelines published by the National Heart, Lung, and Blood Institute.1,2 The NAEPP guidelines emphasize the importance of preventive care on the basis of evidence-based principles, including (1) appropriate classication of asthma severity to initiate controller medications for persistent asthma symptoms,3 (2) monitoring asthma control through repeated symptom assessments,47 (3) education in conjunction with a written home asthma action/care plan (ACP) that guides self-management for asthma ares,810 and (4) the use of primary care ofce spirometry as a tool for both diagnosis and monitoring asthma control.1114 We used a site-randomized trial design to determine if clinical decision support (CDS) embedded in an electronic health record (EHR) would improve clinician adherence to the NAEPP guidelines in the primary care setting. We hypothesized that this tool would help clinicians increase how often they prescribe controller medications for persistent asthma. The CDS was also designed to encourage clinicians use of home ACPs and primary care ofce based spirometry.

with experience using an ambulatory EHR (EpicCare [Verona, WI]). The Pediatric Research Consortium is a multistate, hospital-owned, primary care practice based research network that includes 235 000 children and adolescents. Study practices included 4 urban teaching practices (UPs) in which fewer than 35% of the patients have private insurance and 8 suburban practices (SPs) not involved in resident reaching and in which more than 80% of the children are privately insured. One practice located in Philadelphia, Pennsylvania, was grouped with the SPs because of its lack of resident teaching. Study Design and Patient Population We conducted a prospective clusterrandomized trial of decision support in 12 primary care sites over a 1-year period beginning in April 2007. Children aged 2 to 18 years with asthma were identied by the presence of International Classication of Diseases, Ninth Revision (ICD-9) codes for asthma (493.00 493.92) in their chronicproblem lists or visit diagnoses. These ICD-9 codes were modied in 2001 by our institution to permit description of the patients asthma severity (eg, mild-persistent, moderate-persistent, or severe-persistent asthma). Preintervention Educational Program and Spirometry Training In the 6 months before the intervention, all 12 practices participated in an educational program designed to improve asthma knowledge and communication between clinicians and patients by using a modied version of Physician Asthma Care Education (PACE), a validated program.12 Training was conducted by experienced pediatricians and occurred in 2 blocks, each lasting 2 hours. Before the start of the intervention, a pediatric asthma-control tool (PACT)

was introduced in the EHR to all 12 practice locations. The PACT was developed and validated by a multidisciplinary team at CHOP.13 An abbreviated subscale of the PACT designed for the ofce setting showed good internal consistency, good correlation with a gold standard of a subspecialist assessment of control, and excellent correlation with a previously validated asthma-related quality-of-life measure.15 All practices were prompted in the EHR to complete the PACT if one had not been led in the EHR in the last 3 months for a patient with asthma. In the intervention practices, the PACT information was used to personalize the CDS for each individual patient during all visits to the practice. Before the start of the intervention, nurses were trained to perform spirometry and provide education for ACPs and asthma devices. Physicians were trained on spirometry use and interpretation, including ongoing monthly case discussions in person or by telephone to review the spirometry tracings and regular quality assessments by a pediatric pulmonologist. Intervention and Randomization All practices had the same asthma management tools available in the EHR either passively (the control group) or actively via decision-support alerts and reminders (the intervention group). The asthma management tools available to all practices and available in the EHR consisted of: 1. the PACT data-entry tool for capturing asthma symptom frequency; 2. standardized documentation templates to facilitate severity classication; 3. order sets to facilitate ordering controller medications and spirometry; and 4. an ACP that can be supplied to families.
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METHODS
Setting This study was conducted in 12 practices within the Childrens Hospital of Philadelphia (CHOP) Pediatric Research Consortium. Before the study, approval was obtained from the CHOP institutional review board. All practices we approached agreed to participate in the study. We chose practices
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The intervention-practice sites had CDS alerts and reminders activated to guide clinicians to these tools. The recommendations were personalized for each patient on the basis of information captured in the PACT and diagnosis and medication history. These alerts were dened by using the NAEPP guidelines, created by a panel of institutional experts and implemented in the EHR by using an existing decisionsupport framework.16 This framework presents decision-support tools prominently in the clinical workow, but without disruptive pop-ups (Fig 1). To balance practices with previous asthma education or involvement in resident teaching and patient characteristics, the practices were stratied according to site (UP or SP) in blocks of 2. Therefore, 4 clusters of practices were compared in the analysis: 2 control UPs, 2 intervention UPs, 4 control SPs, and 4 intervention SPs. Outcome Measures Outcomes were measured for all children younger than 18 years who received asthma care at 1 of the study locations. We calculated the proportion of children:

1. with persistent asthma with at least 1 prescription for a controller medication in each time period; 2. with persistent asthma with an upto-date ACP led in the previous year; 3. aged 6 to 18 years with persistent asthma with documentation of spirometry performed. Persistent asthma was dened as mild, moderate, or severe on the basis of the NAEPP guidelines. Asthma classication was determined by the clinicians judgment. The clinicians in the intervention practices were alerted by the CDS tool to a suggested asthmaseverity classication (see Fig 2) and prompted to enter it if no classication was on le. For each site, the proportions of children with the outcomes of interest were compared with those in the time periods before introduction of the intervention CDS. The time periods used in the analysis were: 1. The preeducation period: from December 1, 2005, to May 30, 2006. 2. The education period: from October 13, 2006, to April 15, 2007. All prac-

tices participated in the same asthma care curriculum. 3. The rst intervention period (intervention 1): from April 16, 2007, to October 15, 2007. 4. The second intervention period (intervention 2): from October 16, 2007, to April 15, 2008. To determine differences, the intervention and control practices performances were compared in the intervention 2 and education time periods. Both periods spanned winter months. Finally, unless otherwise noted, the analysis included all visits to the practices, including both health maintenance and sick visits. Covariates Patient-level factors collected included age, gender, race and ethnicity, asthma severity, and insurance type (Table 1). Statistical Analysis Statistical analyses followed the demands of a cluster-randomized repeated cross-sectional design in which the contrasts of interest were the relative improvement over time periods between the intervention and control sites.17,18 These contrasts were tested by means of generalized linear models that produce robust variances and P values that account for clustering of patients within sites or, conversely, the variation across the study sites in the measures of interest. Analyses of the proportions of patients as a fraction of all patients were implemented via models with logit links and binomial error structure. Contrasts of interests were tested by time-byintervention interactions. These models were tted with and without patient-level factors as potential confounders. We compared intervention and control practices across these patient characteristics by means of 2 statistics and simple regressions

FIGURE 1
Example of the CDS tool as it appeared in the EHR for the intervention group. Note that the CDS tool includes 2 categories: the asthma assistant and asthma resources. The asthma-assistant lettering is color coded in green and red. The red lettering prompts and alerts the provider that action is needed. The asthma-resources section (in blue lettering) provides, in this instance, a link to education materials for the family.

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A
Percent change

30 20

B
Percent change

30 20 10 0 -10 -20 -30 -40

10 0 -10 -20 -30 -40

S1

U1

S2

U2

S3

S4

S5

U3

S6

U4

S7

S8

S1

S3

S4

S2

U2

U1

S8

S5

S6

U3

U4

S7

Control practices

P = .15

Intervention practices
30 20 10 0 -10 -20 -30 -40

Control practices

P = .22

Intervention practices

C
Percent change

S2

U1

S1

U2

S4

S3

U3

U4

S7

S6

S5

S8

Control practices

P = .23

Intervention practices

FIGURE 2
Percentage change between intervention 2 and education time period for the outcomes of interest (all visits included). A, Prescription for controller medication; B, spirometry performed; C, ACP. The education time period was October 13, 2006, to April 15, 2007, and the intervention 2 time period was October 16, 2007, to April 15, 2008. Site-specic changes in percentages of children were documented as having received the above-listed outcomes. P values reect the difference between all control and intervention sites according to the t test. S indicates SP; U, UP.

TABLE 1 Comparison of Characteristics of Patients With Asthma Between the Intervention and
Control Groups (Urban and Suburban) for the 4 Time Periods Together
Control SP No. of patients with asthma (aged 18 y) Race, % Black Other White Missing Hispanic or Latino Asthma severity-unclassied, % Asthma severity, % Mild intermittent Mild persistent Moderate persistent Severe persistent Insurance, % Commercial Medicaid Self-pay Unknown 3843 UP 5192 Intervention SP 5375 UP 5040 Intervention vs Control, P

5 15 80 0 5 55 59 33 9 0 89 9 1 1

96 3 1 0 1 16 46 37 15 1 29 70 1 1

50 10 40 0 3 26 57 32 10 1 86 12 1 1

80 8 13 0 3 15 50 35 13 2 27 72 1 1

.001

factors to assess whether patient demographics remained the same during the education and intervention 2 periods. All analyses were performed by using proc genmod in SAS 9.1 to account for the clustering within practices (SAS Institute, Inc, Cary, NC).

RESULTS
.001 .002

Patient and Clinician Characteristics A total of 19 450 children with asthma were included in the analysis over the course of the 4 consecutive time periods of the study: preeducation, education, intervention 1, and intervention 2. The patient characteristics did not differ between the intervention and control practices in any of the time periods except for race and percentage of children with an asthma-severity classication documented (Table 1). The control SPs had signicantly fewer black children and were less likely to have classied their patients asthma than the other groups. These differe773

.001

The 4 time periods were preeducation (December 1, 2005, to May 30, 2006), education (October 13, 2006, to April 15, 2007), intervention 1 (April 16, 2007, to October 15, 2007), and intervention 2 (October 16, 2007, to April 15, 2008).

stratied according to site and separately for the education and intervention 2 periods. These comparisons determined whether the cluster ranPEDIATRICS Volume 125, Number 4, April 2010

domizations created comparable groups of children during the key periods for evaluation. In addition, we contrasted the practices over time by the same

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ences remained static in the population over time; however, we found no confounding by patient-level covariates for differences within practices over time. Other differences between the SPs and UPs were expected (ie, commercial insurance). The characteristics of the clinicians in each of the practices were comparable between the intervention cluster and the control cluster with respect to years in clinical practice and gender. Visit-Level Characteristics There were a total of 49 059 visits for asthma over the 4 time periods. There were no important differences in the average number of asthma visits per child between the control and intervention groups for any of the time periods studied (Table 2).

Use of the Appropriate PACT Overall use of the PACT at the start of intervention 1 was 48% of visits; use at the start of intervention 2 was 66%. There was no signicant difference between the groups in the rate at which the PACT was used. Both the intervention and control groups used the PACT as required 69% of the time, on average, during the intervention periods, which lasted from April 16, 2007, to April 15, 2008. Visit-Level Outcomes The average site-level effect of the CDS system over time is shown in Table 3. The P values are the comparison of intervention 2 versus the education period. There was a statistically signicant increase in controller-medication prescriptions in the intervention UPs

compared with control UPs (7% vs 1%, respectively; P .006). Conversely, there was an increase in ACP use in the intervention SPs compared with control SPs (14% vs 11%; P .03). The proportion of patients with persistent asthma who had spirometry performed was low but increased over time in both the UPs and SPs. The intervention UP group increased the use of spirometry for its patients from 15% (87 of 586) to 24% (147 of 604) (P .04). Among the SP groups in the intervention sites, spirometry increased from 8% to 14%, whereas in the control SP group it decreased from 8% to 1% over time (P .003). It should be noted that for every population and metric in Table 3, the UPs had a higher proportion of compliance than the SPs. Figure 2 shows changes at the site level for the outcomes of interest. All statistical tests used t tests that considered only the number of sites (12) and ignored the large number of subjects per site. The SPs and UPs were analyzed together. The intervention practices were always superior in their performance, although the difference in performance failed to reach statistical signicance. However, the position (above or below 0) and size of

TABLE 2 Average Number of Visits for Patients With Asthma During the 4 Time Periods Studied
Control SP Total No. of visits Average No. of visits per mo Average No. of visits per patient Total No. of well-child visits Average No. of well-child visits per mo Average No. of maintenance visits per patient 8939 372 2.3 6131 255 1.6 UP 13186 549 2.5 10865 453 2.1 SP 13104 546 2.4 9745 406 1.8 Intervention UP 13830 576 2.7 11887 495 2.4

The 4 time periods were preeducation (December 1, 2005, to May 30, 2006), education (October 13, 2006, to April 15, 2007), intervention 1 (April 16, 2007, to October 15, 2007), and intervention 2 (October 16, 2007, to April 15, 2008).

TABLE 3 The Proportion of Children With Persistent Asthma Who Were Prescribed a Controller Medication or Received an ACP or Spirometry During Any
Visit
Population Metric Practice Group Proportion With Metric During Study Period, % (n/N)a Education Persistent asthma Controller medication prescribed UP SP Persistent asthma ACP led UP SP Persistent asthma (6 y old) Spirometry performed UP SP
a

Change, %b

Pc

Intervention 2 80 (1068/1328) 78 (943/1205) 51 (209/409) 74 (682/926) 68 (903/1328) 63 (763/1205) 36 (148/409) 53 (491/926) 22 (150/690) 24 (147/604) 1 (2/185) 14 (67/464) 1 7 3 7 4 3 11 14 6 9 7 6 .006 NS NS .03 .04 .003

Control Intervention Control Intervention Control Intervention Control Intervention Control Intervention Control Intervention

79 (947/1193) 71 (798/1123) 48 (168/347) 67 (527/782) 72 (858/1193) 66 (746/1123) 47 (163/347) 39 (305/782) 16 (101/647) 15 (87/586) 8 (10/129) 8 (30/387)

The education period was from October 13, 2006, to April 15, 2007, and the intervention 2 period was from October 16, 2007, to April 15, 2008. Change in proportion of children with documentation of spirometry performed over time among the intervention and control practice sites: UPs and SPs. c The P value was determined by comparing the performance in the intervention 2 and education time periods.
b

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the bars show that, in all cases, both the number of sites with improvement and the site-specic levels of improvement favored the intervention sites.

DISCUSSION
Practicing high-quality medical care requires incorporating guidelines, once they exist, into routine care. The adoption of practice guidelines is often a slow process taking 5 years or more from the time guidelines are agreed on to when they are incorporated into practice.19 Even when guidelines are broadly accepted they are often not followed.2022 To improve adherence, researchers have assessed various interventions including clinician education, quality-improvement programs, and incentives.2326 Information systems that provide support to users at the time they make decisions may enable health clinicians to accelerate adoption of guidelines and eventually close the gap between optimal and actual practice.19,28 There have been other studies that have evaluated CDS designed to improve the management of asthma.2931 In 2 of the reports, researchers developed stand-alone decision-support software that required clinicians to activate the system to receive the decision support for their adult patients with asthma.29,30 There was no signicant impact on process-of-care measures (including prescriptions for controller medication) or patient outcomes (eg, emergency department visits). In a third, randomized study, using a handheld computer-based decisionsupport program at the point of care did improve clinician adherence to guidelines but was associated with longer visits and higher fees. There was no improvement in patient outcomes.31 The science and understanding of how to design and implement effective CDS is still in its infancy.19,3234 Using the EHR as a platform allows for a design
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that adheres to the concepts that seem most important for decision support to be effective, such as automatic prompting, speedily delivered when needed (ie, during the patient visit), smooth integration into the clinicians workow, and trust that the recommendations are accurate and specic for the individual patient.19,32,35,36 With attention to the concepts above, CDS has had success in improving practitioner performance in adherence to disease-management guidelines, reducing medication errors, and improving immunization rates in children.16,37,38 The EHR allows for CDS at the point of care. In this case, the CDS was designed to compare a patients characteristics with a knowledge base, thereby guiding the clinician with patient-specic and situation-specied advice. In our study, the CDS showed mixed results, improving clinician compliance with NAEPP guidelines in the UPs with improved prescription rates for controller medications and use of spirometry, and in the SPs with improved rates for lling out an ACP for families and use of spirometry. It is important to note that the effects of the CDS were sustained over the entire year of the intervention (April 16, 2007, to April 15, 2008) without a signicant decline in clinician compliance over that time. The mixed performance of the CDS may be because of the differences between the UPs and SPs, as anticipated in the project design. The UPs were complying with the NAEPP guidelines at a higher rate than the SPs before the project started. The highperformance UPs improved their rates of prescriptions for inhaled corticosteroids, whereas the lowerperforming SPs improved in both the control and intervention practices, resulting in no signicant relative impact of the CDS. The opposite was true for the rates of providing an ACP to the families. The UPs were performing at

such a high level for the ACP end point that the CDS alerts had no effect, whereas the CDS reminder to ll out the ACP signicantly improved performance for the SPs. Another factor, outside of the project, likely affected the performance of the UPs. Beginning on July 1, 2005, before we started this project, discussions had begun about instituting asthma carerelated pay-for-performance clinician incentives in the UPs only. Note that the incentives were introduced to both the intervention and control UPs. The rst evaluation period for asthma managementspecic metrics (such as use of the ACP and prescriptions for inhaled corticosteroids) in the UPs was begun on October 1, 2006, which was just before the beginning of this projects education period, which was from October 13, 2006, to April 15, 2007. Given the randomized design, we are condent that despite this contemporaneous development, the CDS was responsible for signicantly improving the UPs performances in both prescriptions for controller medications and use of spirometry. Pay for performance was not introduced in the SPs during the study.

LIMITATIONS
This study had limitations. More practices in the randomization would have improved our ability to evaluate the impact of the CDS in terms of assessing the variability of the effect of the intervention over time across practices and in being able to generalize from the sampled sites to primary care practices in general. We found differences in patient characteristics according to intervention group, largely because of demographic and related clinical differences across practices and the inherent difculty in balancing by patient-level factors when randomization is by cluster. Also, with only 12 practices, our power to detect differe775

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ences by using summary measures at the practice level for comparisons would be limited. This weakness was somewhat offset by the number of patients evaluated across the practices. In addition, other changes were inuencing performance contemporaneously with the intervention (eg, payfor-performance incentives discussed above). Any randomization-concomitant exposures, such as performance incentives, most likely had the effect of improving the control practices results and perhaps blunting the additional effect of the CDS. Despite this, some signicant differences were found. Finally, in this project we studied clinician reREFERENCES
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sponse to a CDS tool. The next step will be to determine if patient outcomes are improved as a result.

CONCLUSIONS AND SPECULATION In our study, using a clusterrandomized trial design, CDS in the EHR was effective at improving clinician compliance with NAEPP guidelines. The effectiveness of the CDS, however, seemed to depend on both the specic outcome being measured and the level of practice compliance with the guidelines before the introduction of the CDS. These results suggest that, if thoughtfully introduced, CDS embedded in the EHR might shorten the interval from guideline ac-

ceptance to actual use in practice, for low-compliance practices, or might help to optimize performance in highly compliant practices.

ACKNOWLEDGMENTS We thank the Agency for Healthcare Research and Quality for its support (R21HS014873-01A1). We thank the network of primary care physicians and their patients and families for their contributions to clinical research through the Pediatric Research Consortium at CHOP. In addition, we thank Valerie Kanak and James Massey for their work on this project.

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Electronic Health RecordBased Decision Support to Improve Asthma Care: A Cluster-Randomized Trial Louis M. Bell, Robert Grundmeier, Russell Localio, Joseph Zorc, Alexander G. Fiks, Xuemei Zhang, Tyra Bryant Stephens, Marguerite Swietlik and James P. Guevara Pediatrics 2010;125;e770; originally published online March 15, 2010; DOI: 10.1542/peds.2009-1385
Updated Information & Services References including high resolution figures, can be found at: http://pediatrics.aappublications.org/content/125/4/e770.full.h tml This article cites 32 articles, 14 of which can be accessed free at: http://pediatrics.aappublications.org/content/125/4/e770.full.h tml#ref-list-1 This article has been cited by 9 HighWire-hosted articles: http://pediatrics.aappublications.org/content/125/4/e770.full.h tml#related-urls Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pediatrics.aappublications.org/site/misc/Permissions.xht ml Information about ordering reprints can be found online: http://pediatrics.aappublications.org/site/misc/reprints.xhtml

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