Inclusionary zoning-requiring and encouraging developers to build some affordable housing in market-rate projects-is a growing but deeply contested practice. We evaluate the experience of inclusionary zoning programs in Los Angeles and Orange Counties, including their structure and elements, effectiveness in delivering affordable housing, and effect on housing markets and supply, to address the debate. We find that the programs vary but are not heavily demanding and include cost offsets. Low in-lieu fees, however, can be the weak link. Many of the mandatory programs are effective, if effectiveness is measured by comparing the affordable housing productivity of inclusionary zoning with other affordable housing programs. We found no statistically significant evidence of inclusionary zoning's adverse effect on housing supply in cities with inclusionary mandates. We conclude that critics underestimate the affordable housing productivity of inclusionary zoning, and overestimate its adverse effects on housing supply. Nonetheless, inclusionary zoning is no panacea and needs to be part of a comprehensive housing strategy. Improving access to affordable housing is always a key challenge for local governments. With regular cutbacks in both federal and state support for housing programs, the task keeps becoming more difficult. One local government-based response to the persistent affordable housing shortage in the context of declining funds is the policy of inclusionary zoning. Inclusionary zoning requires and encourages private housing developers to build a specified proportion-often ranging from 10% to 15% -of affordable housing units in market-rate projects. Although some scholars and Direct correcpondence to: Vinit Mukhija,

Objective: Previous research has suggested an association between plagiocephaly and developmental delay. However, study samples drawn from children seen in subspecialty clinics increase the potential for selection and referral bias. Our study evaluates the association between plagiocephaly and developmental delay and the timing of these diagnoses in a primary care setting, where plagiocephaly is commonly diagnosed and managed. Methods: Our retrospective analysis used electronic medical record data from 45 primary care sites within a children's health system from 1999 to 2017, including children aged 0 to 5 years with diagnoses determined by physician diagnosis codes at primary care visits. Children were classified in the plagiocephaly group if diagnosis occurred by 12 months of age. Primary outcome was any developmental delay. Pearson χ2 test, Fisher exact test, and logistic regression analyses were conducted, with multivariable models adjusted for sex, race, ethnicity, insurance, prematurity status (22–36 weeks' gestation), primary care sites, birth year, and diagnoses of abnormal tone and torticollis. Results: Of 77,108 patients seen by 12 months, 2315 (3.0%) were diagnosed with plagiocephaly, with an increase in diagnosis prevalence over the study time frame. Plagiocephaly was independently associated with an increased odds of any developmental delay diagnosis (adjusted odds ratio 1.50, 95% confidence interval 1.32–1.70). The diagnosis of plagiocephaly was recorded before the diagnosis of developmental delay in most cases when both diagnoses were present (374 of 404, 92.6%). Conclusion: Data from a large primary care cohort demonstrate an association between plagiocephaly and developmental delay, affirming findings in previous subspecialty literature.

The medical education community's conversations about residents' duty hours have long focused solely on the number of those hours. In July 2011, the Accreditation Council for Graduate Medical Education (ACGME) enacted its most recent iteration of standards regarding duty hours. Those standards, as well as a 2008 Institute of Medicine report, look beyond the quantity of duty hours to address their quality as well. Indeed, the majority of the 2011 ACGME standards specify requirements for the qualitative components of residents' working and learning environments, including supervision of residents; professionalism, personal responsibility, and patient safety; transitions of care; and clinical responsibilities (including workload). The authors believe that focusing on these qualitative (rather than quantitative) components of the resident's working and learning environment provides the greatest promise for balancing patient care with resident education, thus optimizing the safety and effectiveness of both. For each of the four qualitative components that the authors discuss (enhancing supervision, nurturing professionalism and personal responsibility, ensuring safe transitions of care, and optimizing workloads and cognitive loads), they offer agendas for faculty development, educational program planning, and research. Thus, the authors call on the medical education community to expand its discussion beyond counting duty hours to focus on these critical issues that ensure quality resident education and patient care and to implement necessary strategies to address them.

BackgroundChild maltreatment is a significant public health issue in the United States. Yet, fewer than half of pediatricians discuss behavioral, developmental, or parenting issues with parents.ObjectiveThis paper describes the testing of bundles of tools and processes, part of a larger intervention, Practicing Safety, targeted at changing physician and staff behavior to identify families at risk for child maltreatment, provide anticipatory guidance, refer to community resources, and follow-up and track at-risk families. The intervention was implemented with 14 pediatric primary care practices throughout the United States; the study was completed in 2011.MethodsA within-subjects repeated measures pre-post follow-up design was used to evaluate the intervention. Baseline and repeated measurements of pediatric practices’ processes were collected using qualitative and quantitative methods. In total, 14 core improvement teams from across the country tested three bundles of tools (maternal, infant, toddler) within a quality improvement framework over seven months.ResultsQuantitative results showed statistically significant adoption of tools and processes and enhancement of practice behaviors and office environmental supports. The increase in tool use was immediate and was sustained for six months after implementation. Qualitative data provided insight as to how meaningful the intervention was to the core improvement teams, especially with more complicated behaviors (eg, engaging social workers or community agencies for referrals). Barriers included lack of community resources. Findings showed unanticipated outcomes such as helping practices to become medical homes.ConclusionLessons learned included that practices appreciate and can adopt brief interventions that have meaningful and useful tools and process to enhance psychosocial care for children 0–3 and that do not place a burden on pediatric practice. An innovative, quality improvement strategy, intuitive to pediatricians, with a brief intervention may help prevent child maltreatment.

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