Authors:Carlos F. Lerner; Thomas S. Klitzner Pages: 581 - 588 Abstract: Publication date: August 2017 Source:Academic Pediatrics, Volume 17, Issue 6 Author(s): Carlos F. Lerner, Thomas S. Klitzner The medical home has been widely promoted as a model of primary care with the potential to transform the health care delivery system. Although this model was initially focused on children with chronic conditions, the American Academy of Pediatrics has endorsed a generalization of the model, promoting the statement, “Every child deserves a medical home.” Recently, other major professional and governmental organizations have embraced this more inclusive vision, and the medical home concept has been promoted in provisions of the Affordable Care Act. Yet, rigorous evaluations of the value of the medical home, within pediatrics and beyond, have been limited, and the results have been mixed. Early results from large demonstration projects in adults have generally noted modest improvements in quality without accompanying reductions in cost. At this critical period in health care, with widespread interest in health care delivery and payment reform, these results present a potential threat to the medical home. Understanding possible reasons for these early findings is crucial to sustaining the spread of the medical home beyond its first 50 years. With this aim, we review the history of the medical home and trends in child health, and we explore the concepts of value and complexity as they pertain to pediatric health care delivery. We propose that, because of the demographic characteristics and economics of child health and current policy imperatives with regard to health care, a strong value proposition for the medical home in pediatrics involves children with medical complexity.
Authors:Ross Mangum; John Lazar; Melissa J. Rose; John D. Mahan; Suzanne Reed Pages: 589 - 592 Abstract: Publication date: August 2017 Source:Academic Pediatrics, Volume 17, Issue 6 Author(s): Ross Mangum, John Lazar, Melissa J. Rose, John D. Mahan, Suzanne Reed
Authors:James M. Perrin; Ellen C. Perrin Pages: 593 - 594 Abstract: Publication date: August 2017 Source:Academic Pediatrics, Volume 17, Issue 6 Author(s): James M. Perrin, Ellen C. Perrin
Authors:Jill S. Halterman; Reynaldo Tajon; Paul Tremblay; Maria Fagnano; Arlene Butz; Tamara T. Perry; Kenneth M. McConnochie Pages: 595 - 599 Abstract: Publication date: August 2017 Source:Academic Pediatrics, Volume 17, Issue 6 Author(s): Jill S. Halterman, Reynaldo Tajon, Paul Tremblay, Maria Fagnano, Arlene Butz, Tamara T. Perry, Kenneth M. McConnochie In the spirit of Dr. Haggerty's teachings, we present an overview of our work to improve care for children with asthma in the context of 3 lessons learned: 1) the importance of providing integrated services across disciplinary boundaries for children with chronic illness, 2) the need to move from a care model focused only on the individual child to a model focused on the child, family, and community, and 3) the need to expand beyond the local community and take a broad perspective on improving health on a national level. The goal of our program is to develop sustainable models to overcome the multiple obstacles to effective preventive care for urban children with asthma. The primary intervention for our original School-Based Asthma Therapy program was directly observed administration of preventive asthma medications in school (with dose adjustments on the basis of National Heart, Lung, and Blood Institute guidelines). We found that children who received preventive medications in school through directly observed therapy had improved outcomes across multiple outcome measures. Our subsequent asthma programs have focused on dissemination and sustainability, with the incorporation of communication technology to enhance the system of care. We are currently testing the ‘School-Based Telemedicine Enhanced Asthma Management’ program, including 400 children with persistent asthma from the Rochester City School District. This program includes directly observed administration of preventive asthma medication at school, and school-based telemedicine to assure appropriate evaluation, preventive medication prescription, and follow-up care. It is designed to implement and sustain guideline-based asthma care through existing community infrastructure, and could serve as a model for the integration of services in rural as well as urban communities.
Authors:W. Thomas Boyce Pages: 600 - 606 Abstract: Publication date: August 2017 Source:Academic Pediatrics, Volume 17, Issue 6 Author(s): W. Thomas Boyce This article—presented on the celebratory occasion of Dr Robert Haggerty's 91st birthday—describes how a 1962 article by Dr Haggerty and his colleague Dr Roger Meyer launched a previously unexplored, pediatric research enterprise by asserting that: “There are little precise data to explain why one person becomes ill with an infecting agent and another not.” Noting a prospective association between family stressors and the acquisition of β-hemolytic streptococcal infections, the article introduced a generation of young academic pediatricians—the author of the present article among them—to the possibility of causal linkages among children's adversity exposures, compromised immunological processes, and the development of immune-mediated, acute or chronic diseases of childhood. That research agenda has led, over the past 40 years, to the advent of psychoneuroimmunology as a field of study, to the recognition of childhood stress and adversity as potential etiologic agents among childhood morbidities, and to the discovery of differential susceptibility to social adversities within populations of children.
Authors:Robert S. Kahn; Srikant B. Iyer; Uma R. Kotagal Pages: 607 - 613 Abstract: Publication date: August 2017 Source:Academic Pediatrics, Volume 17, Issue 6 Author(s): Robert S. Kahn, Srikant B. Iyer, Uma R. Kotagal
Authors:Tristram Smith; Suzannah Iadarola; David S. Mandell; Robin Harwood; Connie Kasari Pages: 614 - 619 Abstract: Publication date: August 2017 Source:Academic Pediatrics, Volume 17, Issue 6 Author(s): Tristram Smith, Suzannah Iadarola, David S. Mandell, Robin Harwood, Connie Kasari Objective To illustrate the process of community-partnered participatory research to develop and evaluate interventions for children with autism in urban school districts. Methods We formed partnerships of school personnel, parents, and researchers to guide the project. We then conducted focus groups, key informant interviews, and town halls to explore how public schools currently serve students with autism. We used findings from these activities to adapt interventions for public schools. We then tested interventions in randomized clinical trials (RCTs). Results Community input indicated a particular need for interventions to improve children's social interaction and instructional supports to promote their success throughout the day. On the basis of this input, we adapted 2 interventions: Remaking Recess for improving peer engagement during social times; and Schedules, Tools, and Activities for Transition (STAT) for facilitating successful transitions between activities throughout the daily routine. Results of the RCT of Remaking Recess are not yet available. The RCT of STAT involved 150 children and 56 teachers. Teachers reported high buy-in and increased their proficiency at implementing STAT; children with ASD reduced their disruptive behavior and made progress toward teacher-nominated goals. However, teachers' implementation remained inconsistent, and children did not reliably improve in academic engagement or independence. Conclusions The findings suggest that although community-partnered participatory research has limitations, it can assist in selecting interventions to address community priorities and produce some favorable outcomes for children with autism in public schools. An important next step is to evaluate the sustainability of the interventions introduced in this project.
Authors:Lisa K. Mundy; Louise Canterford; Timothy Olds; Nicholas B. Allen; George C. Patton Pages: 620 - 624 Abstract: Publication date: August 2017 Source:Academic Pediatrics, Volume 17, Issue 6 Author(s): Lisa K. Mundy, Louise Canterford, Timothy Olds, Nicholas B. Allen, George C. Patton Objective There is growing concern that rising rates of electronic media use might be harmful. However, the extent to which different types of electronic media use might be associated with emotional and behavioral problems is unclear. In this study we examined associations between emotional and behavioral problems and electronic media use during late childhood, in a large community sample. Methods Participants were 876 8- to 9-year-old children taking part in the Childhood to Adolescence Transition Study in Australia. Parents reported on their child's emotional and behavioral problems using the Strengths and Difficulties Questionnaire and on their child's duration of electronic media use (in hours: television, video games, general computer use). Results Logistic regression analyses were conducted with adjustments for age, socioeconomic status, and body mass index z score, separately for male and female participants. Boys who played more video games had significantly greater odds of scoring borderline/abnormal on conduct (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.02–1.12) and emotional problems (OR, 1.07; 95% CI, 1.04–1.11) for each additional hour of weekly use. This equates to 2.58-fold greater odds for a boy who plays on average 2 hours per day per week. Television viewing was associated with greater odds of hyperactivity/inattention in boys (OR, 1.04; 95% CI, 1.00–1.07). There were no significant relationships for girls. Conclusions Because of the increasing rates of electronic media use in children, these results might have important implications for child mental health. Future interventions might be more effective if they are targeted at specific types of electronic media use.
Authors:Elsie M. Taveras; Sheryl L. Rifas-Shiman; Kristen L. Bub; Matthew W. Gillman; Emily Oken Pages: 625 - 632 Abstract: Publication date: August 2017 Source:Academic Pediatrics, Volume 17, Issue 6 Author(s): Elsie M. Taveras, Sheryl L. Rifas-Shiman, Kristen L. Bub, Matthew W. Gillman, Emily Oken Objective To examine associations between insufficient sleep and neurobehavioral functioning in childhood as reported by mothers and teachers. Methods Participants were 1046 children in a prebirth cohort study. Main exposures were insufficient sleep durations at 3 time points: 6 months to 2 years, defined as sleep <11 h/d, 11 to <12 h/d (vs ≥12); 3 to 4 years, defined as sleep <10 h/d, 10 to <11 h/d (vs ≥11); and 5 to 7 years, sleep <9 h/d, 9 to <10 h/d (vs ≥10). Outcomes at age 7 years were executive function, behavior, and social-emotional functioning, assessed using the Behavioral Rating Inventory of Executive Function (BRIEF) and the Strengths and Difficulties Questionnaire (SDQ). Higher scores indicate poorer functioning. Mothers and teachers completed both instruments independently. Results At age 7 years, mean (SD) mother and teacher report of the BRIEF global executive composite scale were 48.3 (7.9) and 50.7 (9.4) points, respectively, and of the SDQ total difficulties score was 6.5 (4.7) and 6.2 (5.7). In multivariable models, children who slept <10 h/d at 3 to 4 years had worse maternal-reported scores for the BRIEF (2.11 points; 95% confidence interval, 0.17–4.05) and SDQ (1.91 points; 95% confidence interval, 0.78–3.05) than those with age-appropriate sleep. Children who slept <9 h/d at 5 to 7 years also had worse scores. At both ages, associations with teacher-reported results were consistent with those of mothers. Infants who slept 11 to <12 h/d had higher teacher- but not mother-reported scores. Conclusions Insufficient sleep in the preschool and early school years is associated with poorer mother- and teacher-reported neurobehavioral processes in midchildhood.
Authors:Mitchell D. Wong; Danielle Strom; Lourdes R. Guerrero; Paul J. Chung; Desiree Lopez; Katherine Arellano; Rebecca N. Dudovitz Pages: 633 - 641 Abstract: Publication date: August 2017 Source:Academic Pediatrics, Volume 17, Issue 6 Author(s): Mitchell D. Wong, Danielle Strom, Lourdes R. Guerrero, Paul J. Chung, Desiree Lopez, Katherine Arellano, Rebecca N. Dudovitz Background We examined whether standardized test scores and grades are related to risky behaviors among low-income minority adolescents and whether social networks and social-emotional factors explained those relationships. Methods We analyzed data from 929 high school students exposed by natural experiment to high- or low-performing academic environments in Los Angeles. We collected information on grade point average (GPA), substance use, sexual behaviors, participation in fights, and carrying a weapon from face-to-face interviews and obtained California math and English standardized test results. Logistic regression and mediation analyses were used to examine the relationship between achievement and risky behaviors. Results Better GPA and California standardized test scores were strongly associated with lower rates of substance use, high-risk sexual behaviors, and fighting. The unadjusted relative odds of monthly binge drinking was 0.72 (95% confidence interval, 0.56–0.93) for 1 SD increase in standardized test scores and 0.46 (95% confidence interval, 0.29–0.74) for GPA of B− or higher compared with C+ or lower. Most associations disappeared after controlling for social-emotional and social network factors. Averaged across the risky behaviors, mediation analysis revealed social-emotional factors accounted for 33% of the relationship between test scores and risky behaviors and 43% of the relationship between GPA with risky behaviors. Social network characteristics accounted for 31% and 38% of the relationship between behaviors with test scores and GPA, respectively. Demographic factors, parenting, and school characteristics were less important explanatory factors. Conclusions Social-emotional factors and social network characteristics were the strongest explanatory factors of the achievement-risky behavior relationship and might be important to understanding the relationship between academic achievement and risky behaviors.
Authors:Wanda M. Tempelaar; Nelleke de Vos; Carolien M. Plevier; Willemijn A. van Gastel; Fabian Termorshuizen; James H. MacCabe; Marco P.M. Boks Pages: 642 - 648 Abstract: Publication date: August 2017 Source:Academic Pediatrics, Volume 17, Issue 6 Author(s): Wanda M. Tempelaar, Nelleke de Vos, Carolien M. Plevier, Willemijn A. van Gastel, Fabian Termorshuizen, James H. MacCabe, Marco P.M. Boks Objective Previous research suggests that cognitive functioning is associated with the risk of several adult psychiatric disorders. In this study we investigated whether adolescents who perform worse than expected at secondary school are at a higher risk for general mental health problems. Methods In a cross-sectional survey comprising 10,866 Dutch adolescents aged 13 to 16 years, underachievement at secondary school was defined as the discrepancy between predicted school grade and actual grade 1 or 3 years later. Mental health problems were assessed using the Strengths and Difficulties Questionnaire. We investigated the association of underachievement with mental health problems using logistic regression, adjusting for potential confounders. Results Underachievement was associated with general psychopathology in pupils aged 13 to 14 years (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.47–2.37) and in pupils aged 15 to 16 years (OR, 2.05; 95% CI, 1.67–2.52) in a multivariate analysis including sociodemographic factors. The association between underachievement and mental health problems was attenuated when school factors such as teacher advice and interaction between underachievement and teacher advice were added, but underachievement remained significantly associated with mental health problems in adolescents in the higher educational tracks (pupils aged 13–14 years: OR, 2.22; 95% CI, 1.07–4.60 and OR, 2.41; 95% CI, 1.10–5.30, age 15–16 years: OR, 2.63; 95% CI, 1.38–5.03). In the multivariate analysis including the interaction between underachievement and teacher advice, a significant interaction effect occurs between underachievement and teacher advice in the higher tracks. Values of OR and CI are given for each significant interaction term. In the younger age group (pupils aged 13-14 years) this results in 2 sets of OR and CI. This association was most pronounced for the hyperactivity subscale of the Strengths and Difficulties Questionnaire. Conclusions Underachievement at secondary school is associated with general mental health problems, especially with hyperactivity symptoms, in pupils who started at high educational tracks.
Authors:LaRita C. Jones; Sylvie Mrug; Marc N. Elliott; Sara L. Toomey; Susan Tortolero; Mark A. Schuster Pages: 649 - 655 Abstract: Publication date: August 2017 Source:Academic Pediatrics, Volume 17, Issue 6 Author(s): LaRita C. Jones, Sylvie Mrug, Marc N. Elliott, Sara L. Toomey, Susan Tortolero, Mark A. Schuster Objective Chronic physical health conditions are highly prevalent in youth, frequently persisting into adulthood and contributing to the current and future health care burden in the United States. Our study evaluated associations of chronic physical health conditions with depressive and physiological anxiety symptoms in a community sample of youth and examined how those associations changed from early to midadolescence. Methods In this longitudinal study of 5147 youth, students and their caregivers were interviewed when youth were in grades 5 (mean age = 11), 7 (mean age = 13), and 10 (mean age = 16). Caregivers reported family sociodemographics, youth race/ethnicity, and youth chronic physical health history at baseline. Youth reported their depressive symptoms at each time point and their physiological anxiety symptoms at grades 7 and 10. Results At age 11, 28.5% had experienced a chronic physical health condition. Having any chronic physical health condition was related to elevated depressive symptoms at age 11 (2.05 ± 0.05 vs 1.89 ± 0.03; mean ± standard error; P < .01) and anxiety symptoms at age 16 (2.72 ± 0.06 vs 2.55 ± 0.04; P < .05). Experiencing multiple conditions was also related to experiencing more depressive symptoms (b = 0.13; P < .01) and physiological anxiety symptoms (b = 0.13; P < .05). After adjusting for previous mental health symptoms, having any condition still predicted anxiety at age 16. Conclusions Children with chronic physical health conditions have an increased risk of depressive symptoms and physiological anxiety symptoms, especially in early and midadolescence. Repeated screening for these symptoms may help identify children in need of interventions.
Authors:Olivia J. Lindly; G. John Geldhof; Alan C. Acock; Kari-Lyn K. Sakuma; Katharine E. Zuckerman; Sheryl Thorburn Pages: 656 - 664 Abstract: Publication date: August 2017 Source:Academic Pediatrics, Volume 17, Issue 6 Author(s): Olivia J. Lindly, G. John Geldhof, Alan C. Acock, Kari-Lyn K. Sakuma, Katharine E. Zuckerman, Sheryl Thorburn Objective Family-centered care (FCC), including shared decision making (SDM), has become increasingly emphasized in pediatric health care delivery. Past studies using national surveys have used different FCC measurement approaches without determining their validity. We, therefore, sought to develop an FCC measurement model with Medical Expenditure Panel Survey (MEPS) items previously used to assess FCC or SDM; and to determine temporal associations of FCC with unmet health care need. Methods Four longitudinal MEPS data files (2007–2011) were combined. The study sample included 15,764 US children aged 0 to 17 years. Eight items assessed FCC, and 5 items assessed unmet health care need. We performed exploratory factor analyses to develop an FCC measurement model and fit a cross-lagged structural equation model to determine temporal associations between FCC and unmet health care need. Results Results supported a 2-factor FCC model including family–provider communication and SDM. The family–provider communication factor was indicated by items reflecting general communication between the child's doctor and family. The SDM factor was indicated by items reflecting decision-making about the child's health care. Adjusted cross-lagged structural equation model results showed family–provider communication and SDM were associated with a reduced likelihood of unmet health care need the following year. Unmet health care need was not significantly associated with family–provider communication or SDM the subsequent year. Conclusions Study results support differentiating between family–provider communication and SDM as interrelated aspects of FCC in future pediatric health care quality measurement and improvement. Family–provider communication and SDM may reduce the likelihood of unmet health care need the following year among US children.
Authors:Savithri Nageswaran; Shannon L. Golden Pages: 665 - 671 Abstract: Publication date: August 2017 Source:Academic Pediatrics, Volume 17, Issue 6 Author(s): Savithri Nageswaran, Shannon L. Golden Objective The objectives of this study are to describe the quality of home health care services for children with medical complexity, identify barriers to delivering optimal home health care, and discuss potential solutions to improve home health care delivery. Methods In this qualitative study, we conducted 20 semistructured in-depth interviews with primary caregivers of children with medical complexity, and 4 focus groups with 18 home health nurses. During an iterative analysis process, we identified themes related to quality of home health care. Results There is substantial variability between home health nurses in the delivery of home health care to children. Lack of skills in nurses is common and has serious negative health consequences for children with medical complexity, including hospitalizations, emergency room visits, and need for medical procedures. Inadequate home health care also contributes to caregiver burden. A major barrier to delivering optimal home health care is the lack of training of home health nurses in pediatric care and technology use. Potential solutions for improving care include home health agencies training nurses in the care of children with medical complexity, support for nurses in clinical problem solving, and reimbursement for training nurses in pediatric home care. Caregiver-level interventions includes preparation of caregivers about: providing medical care for their children at home and addressing problems with home health care services. Conclusions There are problems in the quality of home health care delivered to children with medical complexity. Training nurses in the care of children with medical complexity and preparing caregivers about home care could improve home health care quality.
Authors:Elizabeth S. Barnert; Ryan J. Coller; Bergen B. Nelson; Lindsey R. Thompson; Vincent Chan; Cesar Padilla; Thomas S. Klitzner; Moira Szilagyi; Paul J. Chung Pages: 672 - 677 Abstract: Publication date: August 2017 Source:Academic Pediatrics, Volume 17, Issue 6 Author(s): Elizabeth S. Barnert, Ryan J. Coller, Bergen B. Nelson, Lindsey R. Thompson, Vincent Chan, Cesar Padilla, Thomas S. Klitzner, Moira Szilagyi, Paul J. Chung Objective Because children with medical complexity (CMC) display very different health trajectories, needs, and resource utilization than other children, it is unclear how well traditional conceptions of population health apply to CMC. We sought to identify key health outcome domains for CMC as a step toward determining core health metrics for this distinct population of children. Methods We conducted and analyzed interviews with 23 diverse national experts on CMC to better understand population health for CMC. Interviewees included child and family advocates, health and social service providers, and research, health systems, and policy leaders. We performed thematic content analyses to identify emergent themes regarding population health for CMC. Results Overall, interviewees conveyed that defining and measuring population health for CMC is an achievable, worthwhile goal. Qualitative themes from interviews included: 1) CMC share unifying characteristics that could serve as the basis for population health outcomes; 2) optimal health for CMC is child specific and dynamic; 3) health of CMC is intertwined with health of families; 4) social determinants of health are especially important for CMC; and 5) measuring population health for CMC faces serious conceptual and logistical challenges. Conclusions Experts have taken initial steps in defining the population health of CMC. Population health for CMC involves a dynamic concept of health that is attuned to individual, health-related goals for each child. We propose a framework that can guide the identification and development of population health metrics for CMC.
Authors:Megumi J. Okumura; Heather A. Knauer; Kris E. Calvin; John I. Takayama Pages: 678 - 686 Abstract: Publication date: August 2017 Source:Academic Pediatrics, Volume 17, Issue 6 Author(s): Megumi J. Okumura, Heather A. Knauer, Kris E. Calvin, John I. Takayama Background Few studies have investigated pediatrician attitudes about providing primary medical care for children with special health care needs. The objective of this study was to determine pediatrician perspectives on their comfort level in providing care and on where the medical home should be for children with chronic medical and developmental conditions. Methods Survey of pediatricians in California in 2014. Pediatricians were randomized to receive surveys featuring either a case of a child with a chronic medical (neurofibromatosis) or a developmental condition (autism). They were then asked about their comfort level in providing primary care for the child. We developed logistic regression models to adjust for practice and provider factors, and availability of family social resources. Results The survey response rate was 50.2%. Primary care pediatricians expressed more comfort than nonprimary care pediatricians in providing a medical home for a child with chronic medical or developmental condition (range, 84%–92% comfortable vs 58%–79% comfortable), respectively. All pediatricians expressed more comfort providing care for a child with autism than neurofibromatosis. Nearly all primary care pediatricians (90%) believed that the medical home should be in pediatric primary care practice. Pediatrician comfort in becoming a medical home was higher when the family had more social resources. Conclusions Most pediatricians endorse that the medical home for children with special health care needs be in the primary care setting. Improving access to subspecialty care and providing resources, such as case management, to address family social complexity might raise pediatrician comfort in providing primary care to children with medical and developmental conditions.
Authors:Meredith O'Connor; Stefanie Rosema; Jon Quach; Amanda Kvalsvig; Sharon Goldfeld Pages: 687 - 693 Abstract: Publication date: August 2017 Source:Academic Pediatrics, Volume 17, Issue 6 Author(s): Meredith O'Connor, Stefanie Rosema, Jon Quach, Amanda Kvalsvig, Sharon Goldfeld Objective A fifth of children enter school with special health care needs (SHCN), many of whom have difficulties that are milder or not yet formally diagnosed (emerging SHCN). This study aimed to investigate how differing perceptions of children's emerging SHCN across the family and school contexts relates to service utilization. Methods Sample: The nationally representative birth cohort of the Longitudinal Study of Australian Children, which includes parent reports on the abbreviated Children with Special Health Care Needs Screener. For a subsample of 2459 children teachers also completed the Australian Early Development Census, a measure of early childhood development at school entry that includes SHCN. Analysis: Logistic regression analyses were conducted adjusting for severity of condition, gender, language background, and disadvantage. Results Overall 24.1% of children were identified by their parent and/or teacher as experiencing emerging SHCN. Compared with those with consistent reports, children with parent-only identified needs had lower odds of accessing school services (odds ratio [OR], 0.29; 95% confidence interval [CI], 0.10–0.81). Similarly, children with parent-only (OR, 0.39; 95% CI, 0.20–0.75) and teacher-only (OR, 0.25; 95% CI, 0.14–0.46) identified needs had significantly lower odds of accessing services in the community. Conclusions When parent and teacher perceptions of children's emerging SHCN were inconsistent, service use was lower at school and in the community. Further efforts are needed by health and education providers to ensure that common understandings about a child's needs at school are established early in children's educational careers.
Authors:R. Christopher Sheldrick; Daryl Garfinkel Pages: 464 - 470 Abstract: Publication date: July 2017 Source:Academic Pediatrics, Volume 17, Issue 5 Author(s): R. Christopher Sheldrick, Daryl Garfinkel In their recommendations on screening for autism and developmental disabilities, the American Academy of Pediatrics recommends referral subsequent to a positive screening result. In this article, we argue that positive screening results are not always sufficient to justify a referral. We show that although positive predictive values are often low, they actually overstate the probability of having a disorder for many children who screen positive. Moreover, recommended screening thresholds are seldom set to ensure that the benefits of referral will equal or exceed the costs and risk of harm, which is a necessary condition for an optimal threshold in decision analysis. Drawing on recent recommendations for the Institute of Medicine/National Academy of Medicine, we discuss the implications of this argument for pediatric policy, education, and practice. In particular, we recommend that screening policies be revised to ensure that the costs and benefits of actions recommended in the event of a positive screen are appropriate to the screening threshold. We recommend greater focus on clinical decision-making in the education of physicians, including shared decision-making with patients and their families. Finally, we recommend broadening the scope of screening research to encompass not only the accuracy of specific screening instruments, but also their ability to improve decision-making in the context of systems of care.
Authors:Maya Venkataramani; Tina L. Cheng; Barry S. Solomon; Craig Evan Pollack Pages: 476 - 478 Abstract: Publication date: July 2017 Source:Academic Pediatrics, Volume 17, Issue 5 Author(s): Maya Venkataramani, Tina L. Cheng, Barry S. Solomon, Craig Evan Pollack Objective Maternal family planning plays an important role in child, maternal, and family health; children's health care providers are in a unique position to counsel adult caregivers regarding contraception and appropriate birth spacing. We sought to determine the prevalence of caregiver family planning counseling by children's health care providers during preventive care visits for infants and young children. Methods Data from the National Ambulatory Medical Care Survey from 2009 to 2012 as well as National Hospital Ambulatory Medical Care Survey from 2009 to 2011 were analyzed to determine the weighted frequency of family planning/contraception counseling provided during preventive, primary care visits for children younger than the age of 2 years. Results Family planning/contraception counseling or education was documented in only 16 of 4261 preventive care visits in primary care settings for children younger than the age of 2 years, corresponding to 0.30% (95% confidence interval, −0.08% to 0.68%) of visits nationally. Similar frequencies were calculated for preventive visits with children younger than 1 year and with infants younger than 60 days of age. Conclusions Despite Bright Futures' recommendations for children's health care providers to address caregiver family planning during well infant visits, documented counseling is rare. The results indicate that there are missed opportunities to promote family health in the pediatric setting.
Authors:Cori Green; Amy Storfer-Isser; Ruth E.K. Stein; Andrew S. Garner; Bonnie D. Kerker; Moira Szilagyi; Karen G. O'Connor; Kimberly E. Hoagwood; Sarah M. Horwitz Pages: 479 - 486 Abstract: Publication date: July 2017 Source:Academic Pediatrics, Volume 17, Issue 5 Author(s): Cori Green, Amy Storfer-Isser, Ruth E.K. Stein, Andrew S. Garner, Bonnie D. Kerker, Moira Szilagyi, Karen G. O'Connor, Kimberly E. Hoagwood, Sarah M. Horwitz Objective Given the prevalence of mental health (MH) conditions (MHC) in children, pediatricians should initiate treatment alone or in collaboration with a specialist for children with MHC. However, the majority of pediatricians do not manage or comanage common MHC even with an on-site MH provider. We examined which physician, practice, and training characteristics are associated with pediatricians' comanaging at least half of their patients with MHC. Methods We analyzed responses of general pediatricians (n = 305) from the American Academy of Pediatrics 2013 Periodic Survey. Practice characteristics include presence of an on-site MH provider and perceived access to services. Independent variables included sociodemographics, training experiences, and interest in further training. The outcome was comanagement of ≥50% of patients with MHC. Weighted univariate, bivariate, and multivariable analyses were performed. Results Of the pediatricians who reported comanaging ≥50% of their patients with MHC, logistic regression analysis showed that pediatricians who completed ≥4 weeks of developmental behavioral pediatrics training had 1.8 increased odds (95% confidence interval 1.06, 3.08, P = .03) of comanagement, those very interested in further education in managing/treating MHC had 2.75 increased odds (95% confidence interval 1.63, 3.08, P < .001), and those with more training in MH treatment with medications had 1.4 increased odds (95% confidence interval 1.12, 1.75, P = .004) of comanaging children with MHC. Conclusions Specific educational experiences and interest in further education in managing or treating MHC were significantly associated with comanaging ≥50% of patients, suggesting that enhanced MH training among pediatricians could increase the comanagement of children with MHC.
Authors:Bobbi J. Byrne; Mary Pat Frintner; Heather N. Abraham; Amy J. Starmer Pages: 487 - 496 Abstract: Publication date: July 2017 Source:Academic Pediatrics, Volume 17, Issue 5 Author(s): Bobbi J. Byrne, Mary Pat Frintner, Heather N. Abraham, Amy J. Starmer Objective Maintenance of certification (MOC) value and relevance have been recent topics of controversy and discussion in medicine. Systematically assessing pediatrician's attitudes and experiences to encourage and inform future modifications is important. Methods We surveyed 866 pediatricians in 2014 who graduated from residency 10 to 12 years ago and are part of a larger longitudinal study. Cross-sectional quantitative and qualitative data on understanding, attitudes, barriers, and needs specific to MOC part 2 (self-assessment/continued learning activities) and part 4 (quality improvement projects) were analyzed. McNemar tests compared responses on questions specific to part 2 with those specific to part 4. Multivariable logistic regression considered differences in participants who did and did not have positive part 4 attitudes. Results A total of 77.8% completed the survey. Comparing part 4 to part 2, there was less understanding of requirements (59.9%, 72.9%, P < .001), more agreement that relevant available activities is a barrier (67.6%, 44.0%, P < .001), stronger agreement that more choices would be helpful (72.8%, 53.8%, P < .001), and less perceived impact on patient care or lifelong learning (12.5%, 47.2%, P < .001). Participants reporting that part 4 improves care were less likely to agree that time to fulfill requirements (adjusted odds ratio = 0.30, 95% confidence interval 0.18–0.51) and relevant available activities (adjusted odds ratio = 0.22, 95% confidence interval 0.13–0.39) were barriers. Qualitative analysis revealed themes including time, cost, and relevance. Conclusions Pediatricians expressed significant frustration with the MOC process, poor understanding of requirements, and barriers with the process, especially for part 4. Increasing diplomate education on the process and increasing available and relevant activities may be important to optimize physician's continuous learning.
Authors:Clement J. Bottino; Erinn T. Rhodes; Catherine Kreatsoulas; Joanne E. Cox; Eric W. Fleegler Pages: 497 - 503 Abstract: Publication date: July 2017 Source:Academic Pediatrics, Volume 17, Issue 5 Author(s): Clement J. Bottino, Erinn T. Rhodes, Catherine Kreatsoulas, Joanne E. Cox, Eric W. Fleegler Objective To describe a clinical approach for food insecurity screening incorporating a menu offering food-assistance referrals, and to examine relationships between food insecurity and referral selection. Methods Caregivers of 3- to 10-year-old children presenting for well-child care completed a self-administered questionnaire on a laptop computer. Items included the US Household Food Security Survey Module: 6-Item Short Form (food insecurity screen) and a referral menu offering assistance with: 1) finding a food pantry, 2) getting hot meals, 3) applying for Supplemental Nutrition Assistance Program (SNAP), and 4) applying for Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Referrals were offered independent of food insecurity status or eligibility. We examined associations between food insecurity and referral selection using multiple logistic regression while adjusting for covariates. Results A total of 340 caregivers participated; 106 (31.2%) reported food insecurity, and 107 (31.5%) selected one or more referrals. Forty-nine caregivers (14.4%) reported food insecurity but selected no referrals; 50 caregivers (14.7%) selected one or more referrals but did not report food insecurity; and 57 caregivers (16.8%) both reported food insecurity and selected one or more referrals. After adjustment, caregivers who selected one or more referrals had greater odds of food insecurity compared to caregivers who selected no referrals (adjusted odds ratio 4.0; 95% confidence interval 2.4–7.0). Conclusions In this sample, there was incomplete overlap between food insecurity and referral selection. Offering referrals may be a helpful adjunct to standard screening for eliciting family preferences and identifying unmet social needs.
Authors:Robert McMillen; Karen G. O'Connor; Judith Groner; Susanne Tanski; Elyse R. Park; Jonathan D. Klein Pages: 504 - 514 Abstract: Publication date: July 2017 Source:Academic Pediatrics, Volume 17, Issue 5 Author(s): Robert McMillen, Karen G. O'Connor, Judith Groner, Susanne Tanski, Elyse R. Park, Jonathan D. Klein Introduction The American Academy of Pediatrics (AAP) advises pediatricians to counsel parents and patients who use tobacco to quit. This study assesses changes in counseling between 2004 and 2010, and factors associated with counseling in 2010. Methods In 2004 and 2010, the Periodic Survey, a national survey of AAP members, inquired about tobacco counseling. Chi-square tests were performed to compare responses by survey year. Bivariate and multivariable analyses examined factors associated with counseling. Results Similar proportions of pediatricians in both years (N2004 = 535 and N2010 = 549) advised adolescents who smoke to quit (85% vs 81%), discussed quitting techniques (34% vs 32%), and recommended nicotine replacement medications (17% vs 18%). More pediatricians in 2010 reported helping patients assess reasons for and against continuing to smoke (56% vs 48%), providing quitting materials (20% vs 15%), and referring patients to cessation programs (18% vs 13%). More pediatricians in 2010 reported providing quitting materials to parents who smoke (14% vs 10%) and referring to smoking cessation programs (16% vs 11%) (all P < .05). Pediatricians' confidence in their ability to counsel, with more tobacco prevention training, and routine documentation of patients' tobacco smoke exposure were associated with counseling about cessation. Conclusions Most pediatricians advised patients and parents who smoke to quit, and these percentages did not change from 2004 to 2010. Although percentages for assisting with cessation did increase for several activities, most pediatricians still do not do so. Opportunities exist to improve clinicians' protection of children from tobacco and tobacco smoke through quit-line referrals, motivational interviewing, and offering medications.
Authors:Nina R. Joyce; Justin P. Zachariah; Charles B. Eaton; Amal N. Trivedi; Gregory A. Wellenius Pages: 515 - 522 Abstract: Publication date: July 2017 Source:Academic Pediatrics, Volume 17, Issue 5 Author(s): Nina R. Joyce, Justin P. Zachariah, Charles B. Eaton, Amal N. Trivedi, Gregory A. Wellenius Objective There is increasing evidence of an association between statin use and type 2 diabetes mellitus (T2DM) in adults, yet this relationship has never been studied in children or adolescents and may have important implications for assessing risks and benefits of treatment in this population. We estimated the association between statin use and the risk of T2DM in children with and without a dyslipidemia diagnosis. Methods Propensity scores were used to match new users of statins with a minimum 50 percent of days covered (PDC) in the first year of use to up to 10 nonusers. Analyses were stratified by a dyslipidemia diagnosis based on recent evidence suggesting a potentially protective effect of familial hypercholesterolemia on T2DM. In sensitivity analyses, we varied this period of exclusion and PDC. Cox proportional hazard models compared the hazard of the outcome between the exposed and unexposed patients. Results A total of 21,243,305 patients met the eligibility criteria, 2085 (0.01%) of whom met the exposure definition and 1046 (50%) of whom had a dyslipidemia diagnosis. Statin use was associated with an increased risk of T2DM in children without dyslipidemia (hazard ratio 1.96, 95% confidence interval 1.20–3.22), but not in children with dyslipidemia (hazard ratio 1.11, 95% confidence interval 0.65–1.90). The results were consistent across variations in the exclusion period and PDC. Conclusions Statin use was associated with an increased likelihood of developing T2DM in children without dyslipidemia. Physicians and patients need to weigh the possible risk of T2DM against the long-term benefits of statin therapy at a young age.
Authors:Elizabeth Peacock-Chambers; Jenny S. Radesky; Samantha E. Parker; Barry Zuckerman; Julie C. Lumeng; Michael Silverstein Pages: 523 - 528 Abstract: Publication date: July 2017 Source:Academic Pediatrics, Volume 17, Issue 5 Author(s): Elizabeth Peacock-Chambers, Jenny S. Radesky, Samantha E. Parker, Barry Zuckerman, Julie C. Lumeng, Michael Silverstein Objective Difficult infant temperament is associated with higher weight status in infancy. However, the association of infant temperament, including regulatory capacities, has not been well studied as a possible predictor of future weight status in early childhood. We examined prospective associations of infant regulatory difficulties with obesity in early childhood in a large, diverse cohort. Methods We used data from 5750 children in the Early Childhood Longitudinal Study—Birth Cohort, excluding preterm infants and infants small or large for gestational age. Infant regulatory ability was measured at age 9 months by the Infant Toddler Symptom Checklist (ITSC). We created a multivariable logistic regression model comparing risk of obesity at preschool age in infants with ITSC scores ≥6 to infants with scores <6. We further examined the association when stratified by a measure of maternal sensitivity. Results The cohort of children was 48% non-Hispanic white, and 51% were boys. Twenty-one percent of children with ITSC scores ≥6 were obese at preschool age. Infants with ITSC scores ≥6 had 32% increased odds of being obese at preschool age (adjusted odds ratio 1.32 [95% confidence interval 1.03, 1.70]). The strongest association existed among children described as demanding attention constantly. There was no difference in the association when comparing mothers with high or low maternal sensitivity. Conclusions Infant regulatory difficulties are associated with a higher risk of obesity at preschool age. Helping parents manage and respond to difficult infant behaviors before preschool may serve as a focal point for future interventions.
Authors:Michael L. Rinke; Hardeep Singh; Moonseong Heo; Jason S. Adelman; Heather C. O’Donnell; Steven J. Choi; Amanda Norton; Ruth E.K. Stein; Tammy M. Brady; Christoph U. Lehmann; Steven W. Kairys; Elizabeth Rice-Conboy; Keri Thiessen; David G. Bundy Abstract: Publication date: Available online 10 August 2017 Source:Academic Pediatrics Author(s): Michael L. Rinke, Hardeep Singh, Moonseong Heo, Jason S. Adelman, Heather C. O’Donnell, Steven J. Choi, Amanda Norton, Ruth E.K. Stein, Tammy M. Brady, Christoph U. Lehmann, Steven W. Kairys, Elizabeth Rice-Conboy, Keri Thiessen, David G. Bundy Objective Diagnostic errors (DEs), “the failure to establish an accurate and timely explanation of the patient’s health problem(s) or communicate that explanation,” cause appreciable morbidity, but are understudied in pediatrics. Pediatricians have expressed interest in reducing high-frequency/sub-acute DEs, but their epidemiology remains unknown. The objective of this study was to investigate the frequency of two high-frequency/sub-acute DEs and one missed opportunity for diagnosis (MOD) in primary care pediatrics. Methods As part of a national quality improvement collaborative, 25 primary care pediatric practices were randomized to collect five months of retrospective data on one DE or MOD: elevated blood pressure(BP) and abnormal laboratory values(DEs), or adolescent depression evaluation(MOD). Relationships between DE or MOD proportions and patient age, gender, and insurance status were explored with mixed-effects logistic regression models. Results DE or MOD rates in pediatric primary care were found to be 54% for patients with elevated BP(N=389), 11% for patients with abnormal laboratory values(N=381) and 62% for adolescents with an opportunity to evaluate for depression(N=400). When examining the number of times a pediatrician may have recognized an abnormal condition, but either knowingly or unknowingly did not act according to recommended guidelines: providers did not document recognition of an elevated BP in 51% of patients with elevated BP, and did not document recognition of an abnormal laboratory value without a delay in 9% of patients with abnormal laboratory values. Conclusion DEs and MODs occur at an appreciable frequency in pediatric primary care. These errors may contribute to care delays and patient harm.
Authors:Daniel J. Schumacher; Mary Pat Frintner; William Cull Abstract: Publication date: Available online 4 August 2017 Source:Academic Pediatrics Author(s): Daniel J. Schumacher, Mary Pat Frintner, William Cull Objective Determine pediatric resident training and preparation for 14 ACGME-required procedures. Methods National, random sample of 1000 graduating pediatric residents in 2015. For each of the ACGME-required procedures, residents were asked if they received training, successfully completed the procedure at least once, were comfortable performing the procedure unsupervised, and desired more training. To examine relationships among these 4 measures of training, we conducted logistic regression models and receiver operating characteristics (ROC) curves. Chi-square examined whether desiring more training varied by program size and career goal. Results Response rate was 55% (550/1000). More than half of residents received training in each procedure (56.4-99.3% across procedures) and had successfully completed them at least once (59.8-99.6%). However, 91.3% desired more training in at least one procedure, and 30.0% would like more training in over half of the procedures (8 or more). Relationships were found between the four training measures, with some relationships stronger than others. Residents with primary care goals were more likely than those with subspecialty or hospital practice goals to desire more training in abscess incision and drainage and temporary splinting of fractures, p<.05. Residents in large programs were more likely than those in smaller programs to desire more training in bladder catheterization, peripheral intravenous catheter placement, and venipuncture, p<.05. Conclusions While pediatric residents are overall well-prepared to perform ACGME-required procedures, exceptions exist. Considering the role of program size and resident career goal may help when optimizing and individualizing resident procedural training and preparation.
Authors:Rachel M. Cunningham; Charles G. Minard; Danielle Guffey; Laurie S. Swaim; Douglas J. Opel; Julie A. Boom Abstract: Publication date: Available online 4 August 2017 Source:Academic Pediatrics Author(s): Rachel M. Cunningham, Charles G. Minard, Danielle Guffey, Laurie S. Swaim, Douglas J. Opel, Julie A. Boom Objective Non-medical exemptions continue to rise due to increasing proportions of vaccine-hesitant parents. The proportion of expectant parents who are vaccine-hesitant is currently unknown. We assessed the prevalence of vaccine hesitancy among expectant parents receiving care at an obstetrics clinic in Houston, Texas. Methods We conducted a cross-sectional survey of expectant parents between 12 and 31 weeks gestation who received care at Texas Children’s Pavilion for Women between July 2014 – September 2015. Using convenience sampling, participants completed a questionnaire that included demographic items, self-assessed pregnancy risk, receipt of annual influenza vaccine and the 15-item Parents Attitudes about Childhood Vaccines (PACV) survey, a validated tool to identify vaccine-hesitant parents. We used multivariable logistic regression to determine the association of demographics, pregnancy risk, and influenza vaccine receipt with vaccine hesitancy after controlling for variables significant in univariable analyses. Results 610 expectant mothers and 38 expectant fathers completed the PACV. Overall, 50 of 610 expectant mothers (8.2%, 95% CI: 6.1%, 10.7%) were vaccine-hesitant. Expectant mothers were primarily non-Hispanic White, ≥30 years old, and married. The odds of being vaccine hesitant were 2.2 times greater (95% CI: 1.2, 4.1) among expectant mothers with a college level of education or less compared with those with more than a 4-year degree. The odds of being vaccine-hesitant were 7.4 times greater (95% CI: 3.9, 14.0) among expectant mothers who do not receive an annual influenza vaccine compared with those who did. Conclusion Our findings suggest the need to identify and address vaccine hesitancy prior to birth.
Authors:Conor M. Jones; Darren A. DeWalt; I-Chan Huang Abstract: Publication date: Available online 2 August 2017 Source:Academic Pediatrics Author(s): Conor M. Jones, Darren A. DeWalt, I-Chan Huang Objectives Poor asthma control in children is related to impaired patient-reported outcomes (PROs; e.g., fatigue, depressive symptoms, anxiety), but less well studied is the impact of PROs on children's school performance and sleep outcomes. This study investigated whether the consistency status of PROs over time impacted school functioning and daytime sleepiness in children with asthma. Methods Of the 238 children with asthma enrolled in the Patient-Reported Outcomes Measurement Information System® (PROMIS®) Pediatric Asthma Study, 169 children who provided survey data for all four time points were used in analysis. The child’s PROs, school functioning, and daytime sleepiness were measured four times within a 15-months period. PROs domains included asthma impact, pain interference, fatigue, depressive symptoms, anxiety, and mobility. Each child was classified as having poor/fair vs. good PROs per meaningful cut-points. The consistency status of each domain was classified as consistently poor/fair if poor/fair status was present for at least three time points; otherwise, the status was classified as consistently good. Seemingly unrelated regression was performed to test if consistently poor/fair PROs predict impaired school functioning and daytime sleepiness at the fourth time point. Results Consistently poor/fair in all PROs domains was significantly associated with impaired school functioning and excessive daytime sleepiness (p’s <0.01) after controlling for the influence of the child’s age, sex, and race/ethnicity. Conclusions Children with asthma with consistently poor/fair PROs are at risk of poor school functioning and daytime sleepiness. Developing child-friendly PROs assessment systems to track PROs can inform potential problems in the school setting.
Authors:Jonathan S. Litt; M. Maria Glymour; Penny Hauser-Cram; Thomas Hehir; Marie C. McCormick Abstract: Publication date: Available online 2 August 2017 Source:Academic Pediatrics Author(s): Jonathan S. Litt, M. Maria Glymour, Penny Hauser-Cram, Thomas Hehir, Marie C. McCormick Objective To evaluate the effect of community-based (EI) services the on functional outcomes of high-risk infants at school age. Design Retrospective cohort study using data from the US Department of Education’s National Early Intervention Longitudinal Study. Participants were enrolled in 1997-1998 with follow-up through 5 years and had a NICU admission, birth weight >400 grams, and gestational age >23 weeks. Kindergarten outcomes were teacher assessments of academic and physical skills compared to classmates. Because treatment assignment is determined by level of clinical need, we used repeated measures, marginal structural models with inverse probability of treatment weighting to account for confounding by indication. Results Of 405 participants, 47% had academic ratings average/above average and 71% had physical skills ratings average/above average. Odds of average/above average academic skills were lower for those with delayed EI enrollment (aOR 0.65, 95% CI 0.43, 0.99) and higher for those with greater service duration (aOR 1.47, 95% CI 0.98, 2.22) and breadth (OR 1.74, 95% CI 0.95, 3.20). Odds of average/above average physical skills were lower for those with delayed EI enrollment (aOR 0.61, 95% CI 0.40, 0.93) and higher for those with greater service duration (aOR 1.41, 95% CI 0.96, 2.09), intensity (aOR 1.06, 95% CI 1.00, 1.13), and breadth (aOR 1.86, 95% CI 1.03, 3.35). Conclusions Longer, more intense services were associated with higher kindergarten skills ratings in children at risk for disabilities. Our novel findings support the effectiveness of large-scale EI programs and reinforce the importance of referral after NICU discharge.
Authors:Keely Dwyer-Matzky; Amy Blatt; Barbara L. Asselin; David L. Wood Abstract: Publication date: Available online 1 August 2017 Source:Academic Pediatrics Author(s): Keely Dwyer-Matzky, Amy Blatt, Barbara L. Asselin, David L. Wood Objective We examined the self-reported preparedness of hospitalized adolescent and young adults (AYA) for transition from pediatric to adult-oriented health care in regards to; (1) previous health care transition (HCT) preparation; (2) Self-Determination Theory (SDT) constructs of health self-management autonomy and competence and (3) their perception of medical knowledge, attitudes and concerns. Methods From 2013-2015, 139 hospitalized patients aged 15-21 years completed a 40-item survey evaluating HCT preparation, attitudes, concerns and perception of knowledge adapted in part from validated questionnaires of the DHHS, MCHB and SDT Treatment Self-Regulation Study. Results Fewer than 40% of all respondents endorsed prior HCT preparation such as providers discussing taking responsibility for their health, transitioning to adult providers and only 20% had discussed future health insurance needs. Of our AYA population, 84% had one or more special health care needs. Older patients, females and those with increased HCT preparation scores had increased autonomous motivation, positive attitudes towards transition, yet also increased transition concerns. Higher autonomous motivation and perceived competence correlated with increased perception of knowledge and more positive attitudes towards transition planning (p=.002, <.001 and p<.001, .054). Multivariate regression analysis revealed those with increased HCT preparation and those with increased perceived competence had increased perception of knowledge (β=.25, p=.005 and β=.35, p<.001). Conclusions Our findings suggest that hospitalized AYA received limited education and preparation regarding key elements of HCT to adult-oriented healthcare. Moreover, those previously exposed to transition preparation efforts were more likely to have motivation and a sense of competence in HCT skills.
Authors:Kelly Donahue; Kristin Hendrix; Lynne Sturm; Gregory Zimet Abstract: Publication date: Available online 25 July 2017 Source:Academic Pediatrics Author(s): Kelly Donahue, Kristin Hendrix, Lynne Sturm, Gregory Zimet Objective Understand the effect of a health messaging intervention focused on provider communication about vaccination on mothers’ willingness to vaccinate children against HPV and seasonal influenza. Methods 2,476 mothers of 9-13-year-olds in the U.S. completed a Web-based survey in August 2014. Mothers were randomized to one of two groups targeting HPV or influenza vaccine. Mothers whose child had not received the target vaccine (i.e., zero doses of HPV vaccine/no prior-year administration of influenza vaccine) were randomized to the intervention. The study used a 3x2 between-subjects design; illustrated vignettes depicted one of three levels of provider recommendation strength (brief mention of vaccination, strong recommendation of vaccination, or personal disclosure of vaccination of own children), and presence or absence of information comparing safety of vaccination to the safety of a common daily activity. Outcome was mothers’ willingness to have their child receive the target vaccine (0-100.) Perceived benefits of vaccination were assessed prior to viewing the intervention and included as a covariate in analyses, along with child gender. Results For HPV vaccine, there was a main effect of safety information, F(1,684)=7.99, p=.005, and perceived benefits of vaccination, F(1,684)=221.64, p<.001) on mothers’ willingness to vaccinate. For influenza, perceived benefits of vaccination significantly related to willingness, F(1,462)=105.78, p<.001). Child gender was not associated with willingness. Conclusions Provider communication about vaccination may need to be tailored to the vaccine in question. A next step to increasing coverage for both HPV and influenza vaccines may be an intervention aimed at increasing mothers’ perceived benefits of vaccination.
Authors:JoAnna K. Leyenaar; Paul A. Rizzo; Dmitry Khodyakov; Laurel K. Leslie; Peter K. Lindenauer; Rita Mangione-Smith Abstract: Publication date: Available online 21 July 2017 Source:Academic Pediatrics Author(s): JoAnna K. Leyenaar, Paul A. Rizzo, Dmitry Khodyakov, Laurel K. Leslie, Peter K. Lindenauer, Rita Mangione-Smith Background Children with medical complexity (CMC) account for disproportionate hospital utilization and adverse outcomes following discharge, and several gaps exist regarding the quality of hospital-to-home transitional care for this population. We conducted an expert elicitation process to identify important and feasible hospital-to-home transitional care interventions for CMC from the perspectives of parents and healthcare professionals. Methods We conducted a two-round electronic Delphi process to identify important and feasible transitional care interventions. Panelists included parents of CMC and multidisciplinary healthcare professionals. In the first round, panelists rated the importance and feasibility of 39 transitional care interventions on a 9-point Likert scale; agreement between panelists was defined according to RAND/UCLA Appropriateness Methods. The second round of data collection evaluated 16 interventions that panelists did not agree on in the first round and 8 new or revised interventions, accompanied by quantitative and qualitative data summaries. Results A total of 29 parents of CMC and 37 healthcare professionals participated in the Delphi process (response rate 75%). Both stakeholder panels endorsed the majority of interventions as important; healthcare professionals were less likely to rate several interventions as feasible compared with the parent panel. Over two rounds of data collection, the two stakeholder panels endorsed 25 interventions as both important and feasible. These interventions related to family engagement during the hospitalization, care coordination and social support assessment, pre-discharge education, and written materials. Conclusions Parents and healthcare professionals considered several transitional care interventions both important and feasible. This research may inform hospitals’ transitional care programs and policies.
Authors:Alexander N. Ortega; Ryan M. McKenna; Jie Chen; Héctor E. Alcalá; Brent A. Langellier; Dylan H. Roby Abstract: Publication date: Available online 21 July 2017 Source:Academic Pediatrics Author(s): Alexander N. Ortega, Ryan M. McKenna, Jie Chen, Héctor E. Alcalá, Brent A. Langellier, Dylan H. Roby Objective To examine whether there have been changes in insurance coverage and health care utilization for youth before and after the national implementation of the Patient Protection and Affordable Care Act (ACA) and to assess whether racial and ethnic inequities have improved. Methods Data are from 64,565 youth (ages 0-17) participants in the 2011-2015 National Health Interview Survey (NHIS). We conducted multivariate logistic regression analyses to determine how the period after national implementation of the ACA (years 2011-2013 versus years 2014-2015) was associated with health insurance coverage and utilization of health care services (well-child visits, having visited an emergency department, and having visited a physician, all in the past 12 months), and whether changes over the pre- and post-ACA periods varied by race and Latino ethnicity. Results The post-ACA period was associated with improvements in insurance coverage and well-child visits for all youth. Latino youth had the largest absolute gain in insurance coverage; however, they continued to have the highest proportion of uninsurance post national ACA implementation. With regards to health care equity, non-Latino black youth were less likely to be uninsured and Latino youth had no significant improvements in insurance coverage relative to non-Latino white youth after national ACA implementation. Inequities in health care utilization for non-Latino black and Latino youth relative to non-Latino white youth did not improve. Conclusions Insurance coverage and well-child visits have significantly improved for all youth since passage of the ACA, but inequities persist, especially for Latino youth.
Authors:Margaret G.K. Parker; Eve R. Colson; Lauren Provini; Denis V. Rybin; Stephen M. Kerr; Timothy Heeren; Michael J. Corwin Abstract: Publication date: Available online 17 July 2017 Source:Academic Pediatrics Author(s): Margaret G.K. Parker, Eve R. Colson, Lauren Provini, Denis V. Rybin, Stephen M. Kerr, Timothy Heeren, Michael J. Corwin Objective To examine variation in safe sleep and breastfeeding practices among US non-Hispanic black (NHB) mothers according to birth country Methods We analyzed NHB mothers that were surveyed regarding safe sleep and breastfeeding practices when their infants were 2-6 months of age in 2011-14, as part of a larger national study. We examined prevalences of safe sleep and breastfeeding practices according to birth country and examined odds of adherence to American Academy of Pediatrics recommended safe sleep and breastfeeding practices in foreign born NHBs, compared to US born NHBs. Our multivariate models included adjustment for maternal age, education, income, and US geographic region, and infant age at the time of the survey. Results Among 828 NHB mothers, 690 (83%) were US born, 42 (5%) were African born, 47 (6%) were Haitian born, 24 (3%) were Jamaican born, and 25 (3%) were born elsewhere. In the analysis of 803 US, African, Haitian, and Jamaican born mothers, we found that Jamaican born mothers had a lower rate of supine sleep compared to US born mothers (40% vs. 66%, aOR 0.34 [95%CI 0.18, 0.63]). African born mothers had lower rates of bedsharing compared to US born mothers (25% vs. 11%, aOR 0.22 [95% CI 0.11, 0.46]). Foreign-born mothers had higher rates of any and exclusive breastfeeding, compared to US born mothers (40% and 85% vs. 13% and 23%, respectively). Conclusion Safe sleep and breastfeeding practices vary among US NHB mothers according to birth country. These data illustrate the importance of recognizing heterogeneity of safe sleep and breastfeeding practices within racial/ethnic groups.
Authors:Paul L. Aronson; Eugene D. Shapiro; Linda M. Niccolai; Liana Fraenkel Abstract: Publication date: Available online 16 July 2017 Source:Academic Pediatrics Author(s): Paul L. Aronson, Eugene D. Shapiro, Linda M. Niccolai, Liana Fraenkel Background Shared decision-making (SDM) has mostly been used with adults and parents in the primary care setting, and there is limited knowledge on the use of SDM with parents of acutely ill children. Objective To review the literature on SDM with parents in the management of acutely ill children. Data Sources We searched MEDLINE, SCOPUS, PsycINFO, the Cochrane Library, and ClinicalTrials.gov for English language studies published from the time of database inception to February, 2017. Study Eligibility Criteria Use of SDM with parents for children age ≤18 years with an acute medical problem. Results We identified 2 ongoing clinical trials and 10 published studies meeting inclusion criteria: 2 using hypothetical SDM scenarios, 1 mixed-methods study, and 7 intervention studies. Only 1 study compared an SDM intervention to usual care in a randomized controlled trial. The limited literature demonstrates that parents of acutely ill children have differing preferences for testing and/or treatment, and that they generally want the opportunity to express those preferences through an SDM process. Use of SDM often results in acutely ill children undergoing fewer and/or less intensive testing or treatment, though the effect on outcomes is unclear. Conclusions and Implications Parents welcome participation in SDM for management decisions with their acutely ill child. Further investigation is needed to determine how best to implement SDM with parents of acutely ill children and to assess the impact of SDM on outcomes.
Authors:Elyse Olshen Kharbanda; Stephen E. Asche; Alan Sinaiko; James D. Nordin; Heidi L. Ekstrom; Patricia Fontaine; Steven P. Dehmer; Nancy E. Sherwood; Patrick J. O’Connor Abstract: Publication date: Available online 16 July 2017 Source:Academic Pediatrics Author(s): Elyse Olshen Kharbanda, Stephen E. Asche, Alan Sinaiko, James D. Nordin, Heidi L. Ekstrom, Patricia Fontaine, Steven P. Dehmer, Nancy E. Sherwood, Patrick J. O’Connor Objective To evaluate, among adolescents 10-17 years with an incident hypertensive BP (≥95th percentile) at a primary care visit, whether TeenBP, a novel electronic health record (EHR) linked clinical decision support tool (CDS), improved recognition of elevated BP and return for follow-up BP evaluation. Methods We conducted a pragmatic cluster randomized trial in 20 primary care clinics in a large Midwestern medical group. Ten clinics received the TeenBP CDS, including an alert to remeasure a hypertensive BP at that visit, an alert that a hypertensive BP should be repeated in 1-3 weeks and patient-specific order sets. In the 10 usual care (UC) clinics, elevated BPs were displayed in red font in the EHR. Comparisons between CDS and UC used generalized linear mixed models. Results The study population included 607 CDS patients and 607 UC patients with an incident hypertensive BP. In adjusted analyses, at the index visit, CDS patients were more likely to have their hypertensive BP based on two or more BPs (47.1% versus 27.6%, p=0.007) and to have elevated BP (ICD-9 796.2) diagnosed (28.2% versus 4.2%, p<0.001). In a multivariate model adjusting for age, sex, SBP percentile, and visit type, rates for repeat BP measurement within 30 days were 14.3% at TeenBP CDS clinics versus 10.6% at UC clinics (p=0.07). Conclusions The TeenBP CDS intervention significantly increased repeat BP measurement at the index visit and recognition of a hypertensive BP. Rates for follow-up BP measurement at 30 days were low and did not differ between TeenBP and UC subjects.
Authors:Christopher E. Gaw; Thitphalak Chounthirath; Jonathan Midgett; Kyran Quinlan; Gary A. Smith Abstract: Publication date: Available online 16 July 2017 Source:Academic Pediatrics Author(s): Christopher E. Gaw, Thitphalak Chounthirath, Jonathan Midgett, Kyran Quinlan, Gary A. Smith Objective To investigate the circumstances of death and types and roles of objects present in the sleep environment at the time of death for infants who died from suffocation or strangulation during sleep. Methods This study analyzed 1,736 reported incidents of accidental suffocation and strangulation in bed (ASSB) of infants younger than one year of age. These fatalities occurred from 2000 through 2012 and were reported to the United States Consumer Product Safety Commission. Results The mean age of ASSB death was 3.76 months (SD: 2.51). Infants younger than five months accounted for 67.3% (1,168/1,736) of all reported fatalities and 58.3% (1,009/1,731) were male. Deceased infants were often found in a crib or bassinet (30.6%; 383/1,253) or in the prone orientation (84.9%; 595/701). The most common objects associated with infant ASSB were pillows (24.5%; 425/1,736), mattresses (21.0%; 364/1,736), blankets (13.1%; 228/1,736), and walls (11.5%; 199/1,736). Wedged (43.3%; 616/1,424) or positioned on top of an object (25.9%; 369/1,424) were the most common positions associated with death. Infants were often found wedged between a mattress and wall (30.2%; 181/599) or oriented face-down or prone on top of a pillow (52.2%; 187/358). Sleep surface sharing was associated with 6.5% (112/1,736) of ASSB deaths. Conclusions Pillows and blankets are objects in sleep environments frequently associated with unintentional suffocation and strangulation of infants. Increased efforts should be made to remove these and other objects from sleep environments of infants.
Authors:Sandra H. Jee; Constance Baldwin; Rita Dadiz; Marybeth Jones; Linda Alpert-Gillis Abstract: Publication date: Available online 15 July 2017 Source:Academic Pediatrics Author(s): Sandra H. Jee, Constance Baldwin, Rita Dadiz, Marybeth Jones, Linda Alpert-Gillis Teaser Primary care pediatricians and psychology practitioners who co-manage mental health problems can develop interdisciplinary communication and collaborative skills from joint standardized patient encounters and debriefings, combined with brief didactics. Learners demonstrated increased confidence in shared management of behavior health problems.
Authors:Rita Mangione-Smith; Chuan Zhou; Michael J. Corwin; James A. Taylor; Fiona Rice; James W. Stout Abstract: Publication date: Available online 8 July 2017 Source:Academic Pediatrics Author(s): Rita Mangione-Smith, Chuan Zhou, Michael J. Corwin, James A. Taylor, Fiona Rice, James W. Stout Objective To determine the effectiveness of the Spirometry 360™ distance learning quality improvement (QI) program for enhancing the processes and outcomes of care for children with asthma. Methods Cluster randomized controlled trial involving 25 matched pairs of pediatric primary care practices. Practices were recruited from two practice-based research networks: the Slone Center Office-based Research Network at Boston University, Boston, MA and the Puget Sound Pediatric Research Network in Seattle, WA. Study participants included providers from one of the 50 enrolled pediatric practices and 626 of their patients with asthma. Process measures assessed included: spirometry test quality and appropriate prescription of asthma controller medications. Outcome measures included: asthma-specific health-related quality of life, and outpatient, emergency department and inpatient utilization for asthma. Results At baseline, 25.4% of spirometry tests performed in control practices and 50.4% of tests performed in intervention practices were of high quality. During the six month post-intervention period, 28.7% of spirometry tests performed in control practices and 49.9% of tests performed in intervention practices were of high quality. The adjusted difference-of-differences analysis revealed no intervention effect on spirometry test quality. Adjusted differences-of-differences analysis also revealed no intervention effect on appropriate use of controller medications or any of the parent/patient-reported outcomes examined. Conclusion In this study, the Spirometry 360™ distance learning QI program was ineffective in improving spirometry test quality or parent/patient-reported outcomes. QI programs like the one assessed here may need to focus on practices with lower baseline performance levels or be tailored for those with higher baseline performance.
Authors:Peter G. Szilagyi; Benard P. Dreyer; Elena Fuentes-Afflick; Tamera Coyne-Beasley; Lewis First Abstract: Publication date: Available online 3 May 2017 Source:Academic Pediatrics Author(s): Peter G. Szilagyi, Benard P. Dreyer, Elena Fuentes-Afflick, Tamera Coyne-Beasley, Lewis First
Authors:Carolyn S. Avery; Jimmy Beck; Ryan Padrez; Lauren LaRue Walker; Lisa E. Herrmann; Suzanne Woods; Alan R. Schroeder; Adam Schickedanz Abstract: Publication date: Available online 18 April 2017 Source:Academic Pediatrics Author(s): Carolyn S. Avery, Jimmy Beck, Ryan Padrez, Lauren LaRue Walker, Lisa E. Herrmann, Suzanne Woods, Alan R. Schroeder, Adam Schickedanz
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