Authors:Susan E. Levy; Alexander G. Fiks Pages: 364 - 365 Abstract: Publication date: May–June 2018 Source:Academic Pediatrics, Volume 18, Issue 4 Author(s): Susan E. Levy, Alexander G. Fiks
Authors:Alan R. Tait; Michael E. Geisser; Lamira Ray; Raymond J. Hutchinson; Terri Voepel-Lewis Pages: 370 - 375 Abstract: Publication date: May–June 2018 Source:Academic Pediatrics, Volume 18, Issue 4 Author(s): Alan R. Tait, Michael E. Geisser, Lamira Ray, Raymond J. Hutchinson, Terri Voepel-Lewis Objective Despite the importance of child assent, there is little consensus on what information should be disclosed and what information is most important to children for decision-making. This study was designed to compare children's/adolescents' priorities for research information with the information parents believe is most important to their children. Methods Child-parent dyads completed separate and independent surveys regarding information (risks, benefits, etc) that they perceived to be most important to the child to make decisions about participating in a hypothetical randomized controlled trial. Parents responded in the context of what information they believed their child (not themselves) would think important. Results Fifty-five parent-child dyads completed surveys. Although all information was deemed important, children/adolescents put greater emphasis on privacy and less on knowing the purpose of the study and the benefits compared with what their parents believed was important to their child. Adolescents (13–17 years old) placed greater importance on knowing the procedures, direct benefits, and the voluntary nature of participation compared with younger children (8–12 years old). Parents of older girls in particular placed greater emphasis on their daughter's need to know the purpose of the study, the procedures, benefits, and voluntary nature, compared with parents of boys. Conclusions Results show that the information priorities of children/adolescents considering participation in a randomized controlled trial differ from that which their parents think is important to them. Pediatric researchers can use this knowledge to ensure that parents do not conflate their own expectations/priorities with those of their child and that children receive the information they need.
Authors:Brooke E. Lifland; Rita Mangione-Smith; Tonya M. Palermo; Jennifer A. Rabbitts Pages: 376 - 383 Abstract: Publication date: May–June 2018 Source:Academic Pediatrics, Volume 18, Issue 4 Author(s): Brooke E. Lifland, Rita Mangione-Smith, Tonya M. Palermo, Jennifer A. Rabbitts Objectives Monitoring patient-centered health outcomes after hospital discharge is important for identifying patients experiencing poor recovery after surgery. Utilizing parent reports may improve the feasibility of monitoring recovery when children are not available to provide self-report. We therefore aimed to examine agreement between parent and child reports of child pain and health-related quality of life (HRQOL) in children after hospital discharge from inpatient surgery. Methods A total of 295 children aged 8 to 18 years and their parents reported on child pain intensity using an 11-point numerical rating scale and on HRQOL using the 0- to 100-point Pediatric Quality of Life Inventory Version 4.0 Generic Core Scales by phone or online, 4 to 8 weeks after surgery. Agreement between parent and child ratings was assessed by absolute discrepancy scores, Pearson product-moment correlations, 2-way mixed effects intraclass correlation coefficient models, and linear regression models. Results We found good to excellent agreement between child and parent reports of pain intensity and HRQOL. Average absolute discrepancy scores of pain intensity and HRQOL were 0.6 and 7.8 points, respectively. Pearson product-moment correlation coefficients were 0.74 and 0.80, and intraclass correlation coefficients were 0.72 and 0.79, for pain intensity and HRQOL, respectively. Regression coefficients for models examining pain intensity and HRQOL were 0.93 to 0.98 and 1.0, respectively. Conclusions Although child and parent reports may both contribute important information, parent report is a valid proxy for child self-reported pain intensity and HRQOL after discharge from inpatient pediatric surgery, which may prove important for better understanding pain experiences and intervention needs.
Authors:Gary L. Freed; Matthew M. Davis; Dianne C. Singer; Acham Gebremariam; Sara L. Schultz; Amilcar Matos-Moreno; Mark Wietecha Pages: 384 - 389 Abstract: Publication date: May–June 2018 Source:Academic Pediatrics, Volume 18, Issue 4 Author(s): Gary L. Freed, Matthew M. Davis, Dianne C. Singer, Acham Gebremariam, Sara L. Schultz, Amilcar Matos-Moreno, Mark Wietecha Objective To assess adults' perceptions regarding the health and well-being of children today relative to their own health and well-being as youth and the potential for intergenerational differences in those perceptions. Methods A cross-sectional, Internet-based survey of a nationally representative household sample was conducted using GfK Custom Research's Web-enabled KnowledgePanel, a probability-based panel representative of the US population. We assessed perceptions of children's health and well-being today compared to when respondents were growing up, including physical and mental health; and children's education, exercise, diet, health care, safety of communities, and emotional support from families, groups, and organizations. Results Overall, 1330 (65%) of 2047 adult respondents completed the survey. Only 26% of respondents believed that the current physical health of children, and 14% that the current mental health of children, is better today than when they were growing up. There was a significant trend among generations, with a greater proportion of older generations perceiving the physical health of children to be better today. Only 15% of respondents reported the chances for a child to grow up with good mental health in the future are “better” now than when they were growing up. Conclusions Adults across all generations in the United States today view children's health as unlikely to meet the goals of the American Dream of continuous improvement. Although demographic changes require continued focus on our aging population, we must equally recognize the importance of advancing a healthy future for our nation's children, who will assume the mantle of our future.
Authors:Neal A. deJong; Troy Richardson; Nicole Chandler; Michael J. Steiner; Matt Hall; Jay Berry Pages: 390 - 396 Abstract: Publication date: May–June 2018 Source:Academic Pediatrics, Volume 18, Issue 4 Author(s): Neal A. deJong, Troy Richardson, Nicole Chandler, Michael J. Steiner, Matt Hall, Jay Berry Objectives Hospitalizations for ambulatory care–sensitive conditions (ACSC) are measured to indicate health care system quality, with the premise that fewer hospitalizations would occur with better preceding outpatient care. Our objectives were to identify outpatient care received in the 7 days preceding acute pediatric hospitalizations and to compare receipt of outpatient care by hospitalization type (ACSC vs non-ACSC). Methods This retrospective observational study used a 10-state database of Medicaid claims to identify outpatient visits within 7 days before acute unplanned hospitalization for children aged 0 to 17 years. We used logistic regression to assess the relationship between hospitalization type and occurrence of a preceding outpatient clinic visit, controlling for patient age, race/ethnicity, type of Medicaid, and complex chronic conditions. Results Of 254,902 hospitalizations, 28.6% had a preceding outpatient visit. Thirty-five percent of hospitalizations were for ACSC. A greater percentage of ACSC versus non-ACSC hospitalizations had a preceding outpatient visit (31.1% vs 27.3%, P < .001). In multivariable analysis, characteristics associated with a preceding outpatient visit were age <1 versus 13 to 17 years (adjusted odds ratio [aOR] 2.4; 95% confidence interval [CI] 2.3–2.5), ≥2 vs 0 complex chronic conditions (aOR 1.9; 95% CI 1.8–2.0), Medicaid managed care versus fee for service (aOR 1.2; 95% CI 1.2–1.3), and ACSC versus non-ACSC hospitalization (aOR 1.2; 95% CI 1.1–1.2). Conclusions Although receipt of outpatient care was modestly higher in children hospitalized with an ACSC, most hospitalized children did not receive preceding outpatient care. Further investigation is needed to assess why such a large proportion of children do not receive outpatient care before acute unplanned hospitalization, especially for ACSC.
Authors:Melissa A. Bright; Lawrence Kleinman; Bruce Vogel; Elizabeth Shenkman Pages: 397 - 404 Abstract: Publication date: May–June 2018 Source:Academic Pediatrics, Volume 18, Issue 4 Author(s): Melissa A. Bright, Lawrence Kleinman, Bruce Vogel, Elizabeth Shenkman Objective To examine the rate of access to primary and preventive care and emergency department (ED) reliance for foster youth as well as the impact of a transition from fee-for-service (FFS) Medicaid to managed care (MC) on this access. Methods Secondary administrative data were obtained from Medicaid programs in one state that transitioned foster youth from an FFS to an MC (Texas) and another state, comparable in population size and racial/ethnic diversity, which continuously enrolled foster youth in an FFS system (Florida). Eligible participants were foster youth (aged 0–18 years) enrolled in these states between 2006 and 2010 (n = 126,714). A Puhani approach to difference-in-difference was used to identify the effect of transition after adjusting for race/ethnicity, gender, and health status. Data were used to calculate access to primary and preventive care as well as ED reliance. ED reliance was operationalized as the number of ED visits relative to the number of total ambulatory visits; high ED reliance was defined as ≥33%. Results The transition to MC was associated with a 6% to 13% increase in access to primary care. Preventive care visits were 10% to 13% higher among foster youth in MC compared to those in FFS. ED reliance declined for the intervention group but to a lesser extent than did the control group, yielding a positive mean percentage change. Conclusions Foster youth access to care may benefit from a Medicaid MC delivery system, particularly as the plans used are designed with the unique needs of this vulnerable population.
Authors:Sarah Morsbach Honaker; Tamara Dugan; Ameet Daftary; Stephanie Davis; Chandan Saha; Fitsum Baye; Emily Freeman; Stephen M. Downs Pages: 418 - 424 Abstract: Publication date: May–June 2018 Source:Academic Pediatrics, Volume 18, Issue 4 Author(s): Sarah Morsbach Honaker, Tamara Dugan, Ameet Daftary, Stephanie Davis, Chandan Saha, Fitsum Baye, Emily Freeman, Stephen M. Downs Objective To examine primary care provider (PCP) screening practice for obstructive sleep apnea (OSA) and predictive factors for screening habits. A secondary objective was to describe the polysomnography completion proportion and outcome. We hypothesized that both provider and child health factors would predict PCP suspicion of OSA. Methods A computer decision support system that automated screening for snoring was implemented in 5 urban primary care clinics in Indianapolis, Indiana. We studied 1086 snoring children aged 1 to 11 years seen by 26 PCPs. We used logistic regression to examine the association between PCP suspicion of OSA and child demographics, child health characteristics, provider characteristics, and clinic site. Results PCPs suspected OSA in 20% of snoring children. Factors predicting PCP concern for OSA included clinic site (P < .01; odds ratio [OR] = 0.13), Spanish language (P < .01; OR = 0.53), provider training (P = .01; OR = 10.19), number of training years (P = .01; OR = 4.26) and child age (P < .01), with the youngest children least likely to elicit PCP concern for OSA (OR = 0.20). No patient health factors (eg, obesity) were significantly predictive. Proportions of OSA suspicion were variable between clinic sites (range, 6–28%) and between specific providers (range, 0–63%). Of children referred for polysomnography (n = 100), 61% completed the study. Of these, 67% had OSA. Conclusions Results suggest unexplained small area practice variation in PCP concern for OSA among snoring children. It is likely that many children at risk for OSA remain unidentified. An important next step is to evaluate interventions to support PCPs in evidence-based OSA identification.
Authors:Douglas J. Opel; Chuan Zhou; Jeffrey D. Robinson; Nora Henrikson; Katherine Lepere; Rita Mangione-Smith; James A. Taylor Pages: 430 - 436 Abstract: Publication date: May–June 2018 Source:Academic Pediatrics, Volume 18, Issue 4 Author(s): Douglas J. Opel, Chuan Zhou, Jeffrey D. Robinson, Nora Henrikson, Katherine Lepere, Rita Mangione-Smith, James A. Taylor Objective Presumptive formats to initiate childhood vaccine discussions (eg, “Well, we have to do some shots”) have been associated with increased vaccine acceptance after one visit compared to participatory formats (eg, “How do you feel about vaccines'”). We characterize discussion format patterns over time and the impact of their repeated use on vaccine acceptance. Methods We conducted a longitudinal prospective cohort study of children of vaccine-hesitant parents enrolled in a Seattle-based integrated health system. After the child's 2-, 4-, and 6-month visits, parents reported the format their child's provider used to begin the vaccine discussion (presumptive, participatory, or other). Our outcome was the percentage of days underimmunized of the child at 8 months old for 6 recommended vaccines. We used linear regression and generalized estimating equations to test the association of discussion format and immunization status. Results We enrolled 73 parent–child dyads and obtained data from 82%, 73%, and 53% after the 2-, 4-, and 6-month visits, respectively. Overall, 65% of parents received presumptive formats at ≥1 visit and 42% received participatory formats at ≥1 visit. Parental receipt of presumptive formats at 1 and ≥2 visits (vs no receipt) was associated with significantly less underimmunization of the child, while receipt of participatory formats at ≥2 visits was associated with significantly more underimmunization. Visit-specific use of participatory (vs presumptive) formats was associated with a child being 10.1% (95% confidence interval, 0.3, 19.8; P = .04) more days underimmunized (amounting to, on average, 98 more days underimmunized for all 6 vaccines combined). Conclusions Presumptive (vs participatory) discussion formats are associated with increased immunization.
Authors:Olivier Drouin; Jonathan P. Winickoff Pages: 460 - 467 Abstract: Publication date: May–June 2018 Source:Academic Pediatrics, Volume 18, Issue 4 Author(s): Olivier Drouin, Jonathan P. Winickoff Objective Unhealthy behaviors are a major cause of chronic disease. Preappointment screening has been suggested as one way to improve preventive care delivery related to these behaviors by specifying risks to be addressed. We aimed to determine whether screening for health-related behaviors before the clinical encounter will lead to higher counseling rate and service delivery by clinicians. Methods We used a pre/post design in one practice with a control practice to evaluate the effects of preappointment screening for 3 behavioral risk factors (tobacco smoke exposure, no recent dental care visit, and consumption of sugar-sweetened beverages). After their clinic visit, we asked English-speaking parents whose child had one or more risk factor whether they had received counseling or services from their pediatrician to address them. Results We recruited 264 parents in the pre phase and 242 in the post phase. Among 215 parents whose child had one or more risk factors, parents in the post phase were as likely to report receiving counseling than parents in the pre phase for each of the risk factors: smoking odds ratio 6.75 (95% confidence interval, 0.51, 88.88), dental health odds ratio 1.44 (95% confidence interval, 0.47, 4.41), and sugar-sweetened beverage consumption odds ratio 0.34 (95% confidence interval, 0.23, 5.18). Service delivery and reported behavior change were also similar in both phases. Conclusions Counseling rates for tobacco, dental health, or sugar-sweetened beverage consumption were low in pediatric primary care, and preappointment screening did not significantly affect clinician counseling. Future efforts will require a more robust approach to effect change in counseling, provision of service, and family behavior.
Authors:Jonathan S. Litt; M. Maria Glymour; Penny Hauser-Cram; Thomas Hehir; Marie C. McCormick Pages: 468 - 474 Abstract: Publication date: May–June 2018 Source:Academic Pediatrics, Volume 18, Issue 4 Author(s): Jonathan S. Litt, M. Maria Glymour, Penny Hauser-Cram, Thomas Hehir, Marie C. McCormick Objective To evaluate the effect of community-based early intervention (EI) services the on functional outcomes of high-risk infants at school age. Methods This was a retrospective cohort study using data from the US Department of Education's National Early Intervention Longitudinal Study. Participants were enrolled in 1997 to 1998 with follow-up through 5 years and had a neonatal intensive care unit (NICU) admission, birth weight >400 g, and gestational age >23 weeks. Kindergarten outcomes were teacher assessments of academic and physical skills compared with classmates. Because treatment assignment is determined according to 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 (adjusted odds ratio [aOR], 0.65; 95% confidence interval [CI], 0.43–0.99) and trending, although not significantly, higher for those with greater service duration (aOR, 1.47; 95% CI, 0.98–2.22) and breadth (odds ratio, 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 intensity (aOR, 1.06; 95% CI, 1.00–1.13) and breadth (aOR, 1.86; 95% CI, 1.03–3.35), approaching significance for those with greater service duration (aOR, 1.41; 95% CI, 0.96–2.09). 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:Ariel S. Winn; S. Jean Emans; Lori R. Newman; Thomas J. Sandora Pages: 477 - 479 Abstract: Publication date: May–June 2018 Source:Academic Pediatrics, Volume 18, Issue 4 Author(s): Ariel S. Winn, S. Jean Emans, Lori R. Newman, Thomas J. Sandora Promoting professional development is a challenging but vital component of residency training. We created resident academies (scholarly homes) that aimed to develop academic skills, enhance mentorship, and create a sense of community based on scholarly interest.
Abstract: Publication date: Available online 21 June 2018 Source:Academic Pediatrics Author(s): Elizabeth S Barnert, Laura S. Abrams, Rebecca Dudovitz, Tumaini R. Coker, Eraka Bath, Lello Tesema, Bergen B. Nelson, Christopher Biely, Paul J Chung Objective We sought to quantify the association between child incarceration in the U.S. and subsequent adult health outcomes. Methods We analyzed National Longitudinal Study of Adolescent to Adult Health data from 1,727 adult (Wave IV) participants first incarcerated at age <25. Using Chi-squared tests and multivariate logistic regression models, we compare adult health outcomes (mobility limitations, depressive symptoms, suicidal thoughts) among those first incarcerated at age ≤14, 15-17, and 18-20, with 21-24 as the reference group. Results Of the 1,727 participants, 105 (6.7%) were first incarcerated at age ≤14 (“child incarceration category”), 315 (19.3%) at age 15-17, 696 (38.5%) at age 18-20, and 611 (35.6%) at age 21-24. Those incarcerated as children (age ≤14) were disproportionately black or Hispanic compared to those incarcerated at age 15-24. Compared with first incarceration at age 21-24, child incarceration independently predicted adult mobility limitations (adjusted odds ratio [OR]=3.74; p=0.001), adult depression (OR=1.98; p=0.034), and adult suicidal thoughts (OR= 4.47; p=0.005). Conclusions Child incarceration displays even wider sociodemographic disparities than incarceration generally and is associated with even worse adult physical and mental health outcomes.
Abstract: Publication date: Available online 19 June 2018 Source:Academic Pediatrics Author(s): Alyna T. Chien, Sara L. Toomey, Dennis Z. Kuo, Jeanne Van Cleave, Amy J. Houtrow, Megumi J. Okumura, Matthew Y. Westfall, Carter R. Petty, Jessica A. Quinn, Karen A. Kuhlthau, Mark A. Schuster Objective To identify opportunities to improve care value for children with disabilities (CWD), we examined CWD prevalence within a commercially insured population and compared outpatient care quality and annual health plan spending levels for CWD relative to children with complex medical conditions without disabilities, children with chronic conditions that are not complex, and children without disabling, complex, or chronic conditions. Methods Cross-sectional study of 1,118,081 person-years of Blue Cross Blue Shield Massachusetts data for beneficiaries aged 1-19 years old during 2008-2012. We combined the newly developed and validated Children with Disabilities Algorithm with the Pediatric Medical Complexity Algorithm to identify CWD and non-CWD sub-groups. We used 14 validated and/or National Quality Forum-endorsed measures to assess outpatient care quality and paid claims to examine annual plan spending levels and components. Results CWD constituted 4.5% of all enrollees. Care quality for CWD was between 11-59% for 8 of 14 quality measures and >80% for the 6 remaining measures, and generally comparable to that for non-CWD sub-groups. Annual plan spending among CWD had a median and mean 23% and 53% higher than that for children with complex medical conditions without disabilities, respectively; CWD mean/median values were higher than for all other groups as well. Conclusions CWD were prevalent in our commercially insured population. CWD experienced sub-optimal levels of care, but those levels were comparable to non-CWD groups. Improving the care value for CWD involves a deeper understanding of what higher spending delivers and additional aspects of care quality.
Abstract: Publication date: Available online 18 June 2018 Source:Academic Pediatrics Author(s): Dina H. Griauzde, Julie C. Lumeng, Prachi E. Shah, Niko Kaciroti Objectives To examine differences in body mass index z-score (BMIz) trajectory during early childhood among children with a younger sibling compared to those without and to test potential mediators. Methods Longitudinal cohort study of 6050 participants of the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B). Focal children's weight, height, sibship status, screen time, active play time, family dinner frequency, and diet quality were assessed at 9 months, 24 months, preschool and kindergarten when available. A piecewise linear regression model was used to examine the association between sibling birth and focal child's subsequent BMIz trajectory to kindergarten. Mediation by screen time, active play time, family dinner frequency, and diet quality was tested. Results BMIz trajectory was lower among children who had a new sibling join the family before kindergarten compared to children who did not have a new sibling join the family by kindergarten. The association was strongest when new sibship occurred when then the focal child was 48 to 66 months (b=-0.026, p=0.044). The association was not mediated by screen time, active play time, family dinner frequency, or diet quality. Conclusion Among a nationally representative cohort of US children, new sibship before kindergarten was associated with a lower BMIz trajectory. Several common obesogenic risk factors did not explain the association.
Authors:Kai A. Jones; Stephanie Do; Lorena Porras-Javier; Sandra Contreras; Paul J. Chung; Tumaini R. Coker Abstract: Publication date: Available online 9 June 2018 Source:Academic Pediatrics Author(s): Kai A. Jones, Stephanie Do, Lorena Porras-Javier, Sandra Contreras, Paul J. Chung, Tumaini R. Coker Background In a community-academic partnership, we implemented a group-based model for well-child care (CenteringParenting) and conducted a pilot test for feasibility and acceptability among families at a federally-qualified health center (FQHC). Methods The FQHC implemented CenteringParenting for all well-child care (WCC) visits in the first year of life, starting at the 2-week visit. Over a 14-month time period, parents from each new CenteringParenting group were enrolled into the study. Baseline data were collected at enrollment (infant age <31 days), and again at a 6-month follow-up survey. Main outcomes were feasibility and acceptability of CenteringParenting; we also collected exploratory measures (parent experiences of care, utilization, self-efficacy and social support). Results Forty parent-infant dyads were enrolled in the pilot; 28 CenteringParenting participants completed the 6-month follow-up assessment. The majority of infants were Latino, black, or “other” race/ethnicity; over 90% were Medicaid insured. Of 28 CenteringParenting participants who completed the 6-month follow-up, 25 completed all visits between ages 2 weeks through 6 months in the CenteringParenting group. 97%-100% of CenteringParenting participants reported having adequate time with their provider, patient education, and having their needs met at visits; the majority reported feeling comfortable at the group visit, and all reported wanting to continue CenteringParenting for their WCC. CenteringParenting participants’ mean scores on exploratory measures demonstrated positive experiences of care, overall satisfaction of care, confidence in parenting, and parental social support. Conclusion A community-academic partnership implemented CenteringParenting; the intervention was acceptable and feasible for a minority, low-income population. We highlight key challenges of implementation.
Authors:Laura Boland; Margaret L. Lawson; Ian D. Graham; France Légaré; Kristin Dorrance; Allyson Shephard; Dawn Stacey Abstract: Publication date: Available online 1 June 2018 Source:Academic Pediatrics Author(s): Laura Boland, Margaret L. Lawson, Ian D. Graham, France Légaré, Kristin Dorrance, Allyson Shephard, Dawn Stacey Objective To assess barriers and facilitators of shared decision-making (SDM) for pediatric healthcare providers (HCP) after they have been trained in SDM. Methods A mixed methods study using triangulation of data sources. Pediatric HCPs with SDM training who worked at a Canadian tertiary care pediatric hospital were eligible. Participants completed a validated SDM barriers survey (n=60) and a semi-structured interview (n=11). We calculated descriptive statistics. Univariate and multivariable ordinary least squares linear regression models determined predictors of HCPs’ intention to use SDM. Interviews were audiotaped and transcribed verbatim. We analyzed qualitative data using deductive and inductive content analyses and organized categories according to the Ottawa Model of Research Use. Results Intention to use SDM was high (mean score = 5.6/7, SD=0.78) and positively correlated with SDM use (RR=1.46, 95% CI 1.18-1.81). However, 52% of survey respondents reported not using SDM after training. HCPs identified factors influencing SDM at the levels of innovation, adopter, environment, and training. Insufficient time (barrier) and buy-in and agreement with SDM (facilitators) were most commonly cited. To improve SDM use, HCPs want a more team-based approach to SDM training, continuing education, and implementation. Conclusion Despite training and positive intentions, many HCPs report not subsequently using SDM and identified numerous post-training barriers to its use. To overcome SDM barriers and improve uptake, HCPs recommend creating a socially supportive environment through a team-based approach to SDM training and implementation. These findings can inform SDM training and implementation interventions at pediatric health care centers.
Authors:M. Katherine Henry; Joanne N. Wood Abstract: Publication date: Available online 30 May 2018 Source:Academic Pediatrics Author(s): M. Katherine Henry, Joanne N. Wood
Authors:Katherine A. Moreau; Kaylee Eady Abstract: Publication date: Available online 30 May 2018 Source:Academic Pediatrics Author(s): Katherine A. Moreau, Kaylee Eady Objective To explore the potential benefits and challenges of involving adolescents in the education of medical students and residents from the perspectives of adolescents who are hospitalized with chronic health conditions. Methods We conducted qualitative interviews with adolescents at a Canadian pediatric hospital. Eligible participants were those between 13-18 years of age, with chronic health conditions lasting more than three months who were feeling well enough to participate in an interview. We used conventional content analysis to analyze the data. Results Sixteen adolescents participated in the study. In terms of benefits, the participants described how involving adolescents in the education of medical students and residents would improve patient-physician interactions, increase patients’ confidence and self-worth, encourage patients to self-reflect and gain knowledge about their health conditions and themselves, as well as enable patients to socialize with other patients. When asked about the challenges, the participants discussed how it might be difficult to include diverse patient perspectives, manage adolescents’ negativity, and ensure that learners are non-judgmental towards adolescents and take them seriously. Conclusions While many of the reported benefits and challenges correspond with those featured in the literature on adult patient involvement in medical education, our findings underscore the distinctive benefits and challenges that medical educators may experience in designing and implementing educational initiatives that involve adolescents. Through the future design and implementation of educational initiatives, it is important to further explore the benefits and challenges of such adolescent involvement, as we know that adolescents can be valuable contributors to medical education.
Authors:Callie L. Brown; Eliana M. Perrin Abstract: Publication date: Available online 29 May 2018 Source:Academic Pediatrics Author(s): Callie L. Brown, Eliana M. Perrin Despite many public health and clinical interventions, obesity rates remain high and evidence-based preventive strategies are elusive. Many consensus guidelines suggest providers should screen all children after age 2 for obesity by measuring height and weight, calculating body mass index (BMI), and sensitively communicating weight status in the context of health to the family at each visit. However, preventive counseling should begin in infancy and focus on healthy feeding, activity, and family lifestyle behaviors. For children with overweight or obesity, the American Academy of Pediatrics outlined four stages of treatment. 1) Primary care providers should offer “Prevention Plus,” the use of motivational interviewing to achieve healthy lifestyle modifications in family behaviors or environments. 2) Children requiring the next level of obesity treatment, “structured weight management,” require additional support beyond the primary care provider (such as a dietitian, physical therapist, or mental health counselor) and more structured goal setting with the team including providers adept at weight management counseling. 3) Children with severe obesity and motivated families may benefit from a referral to a “comprehensive multidisciplinary intervention,” such as an obesity treatment clinic. 4) “Tertiary care interventions” occur in a multidisciplinary pediatric obesity treatment clinic with standard clinical protocols for evaluation of interventions, including medications and surgery. While it is certainly a challenge for providers to fit all the desired prevention and treatment counseling during preventive health visits, by beginning to provide anticipatory guidance at birth, providers can respond to parental questions, add to parents’ knowledge base, and partner with parents and children and adolescents to help them grow up healthy. This is especially important in an increasingly toxic food environment with many incentives and messages to eat unhealthfully, barriers to appropriate physical activity, and concomitant stigma about obesity. Focusing on key nutrition and physical activity habits, and establishing these healthy behaviors at an early age, will allow children to develop a healthy growth trajectory. Much more work is required, however, to determine the best evidence-based practices for providers to counsel families on improving target behaviors, environmental modifications, and parenting skills and to decrease abundant disparities in obesity prevalence and treatment.
Authors:Anna D. Johnson; Christina M. Padilla Abstract: Publication date: Available online 29 May 2018 Source:Academic Pediatrics Author(s): Anna D. Johnson, Christina M. Padilla Objectives We investigate links between child-care experiences – specifically care instability and mother's perceptions of care access – and maternal depressive symptoms, in an effort to illuminate policy-amenable mechanisms through which child-care experiences can support maternal mental health. Methods Data come from the nationally representative Early Childhood Longitudinal Study – Birth Cohort (ECLS-B). We use regression models with lagged dependent variables to estimate associations between aspects of child-care instability and perceptions of care availability, and maternal depressive symptoms. We do so on the full sample and then on subgroups of mothers for whom child-care instability may be especially distressing: mothers who are low-income, working, single, or non-native speakers of English. Results Child-care instability – length in months in the longest arrangement, and number of arrangements – was not associated with maternal depressive symptoms. However, mothers’ perception of having good choices for care was associated with a reduced likelihood of clinical depressive symptomology, even after controlling for prior depressive symptoms and concurrent parenting stress; this latter association was observed both in the full sample (Adjusted Odds Ratio [AOR]=0.77; 95% Confidence Interval [CI]=0.63-0.96) and among subgroups of employed mothers (AOR=0.71; CI=0.57-0.87) and single mothers (AOR=0.72; CI=0.52-0.99). Conclusions Although dimensions of care instability did not associate with maternal depressive symptoms, mothers’ perceptions of available care options, did. If replicated, findings would highlight a previously unconsidered avenue – increasing care accessibility and awareness of available options – for promoting maternal mental health in a population likely to experience depression but unlikely to be treated.
Authors:Brandi Freeman; Tumaini Coker Abstract: Publication date: Available online 29 May 2018 Source:Academic Pediatrics Author(s): Brandi K. Freeman, Tumaini R. Coker In the United States, well-child care has the goal of providing comprehensive care to children by addressing developmental, behavioral, psychosocial, and health issues through visits at recommended intervals. The preventive care needs of families can outpace the capacity of clinics and practices to provide it, thus necessitating a redesign of our well-child care system that aligns the structure of preventive care delivery with the needs of families. In this Perspectives article, we focus on six questions (the what, when, who, why, how, and where) for well-child care redesign for infants and young children; by addressing these key questions and providing recommendations for advancing well-child care redesign in the clinical and research arenas, we hope to accelerate the process of well-child care redesign. In the current political and socio-economic environment, continuing with well-child care “as usual” will mean that many families will find that their well-child care visits do not fully address the most pressing needs impacting child health and well-being. It's time to stop tinkering around the edges, and implement and sustain real change in our system for preventive care.
Authors:Julia Sharp; Jonathon Maguire Sarah Carsley Kawsari Abdullah Yang Chen Abstract: Publication date: May–June 2018 Source:Academic Pediatrics, Volume 18, Issue 4 Author(s): Julia R. Sharp, Jonathon L. Maguire, Sarah Carsley, Kawsari Abdullah, Yang Chen, Eliana M. Perrin, Patricia C. Parkin, Catherine S. Birken Objective Outdoor free play is important for preschoolers' physical activity, health, and development. Certain temperamental characteristics are associated with obesity, nutrition, and sedentary behaviors in preschoolers, but the relationship between temperament and outdoor play has not been examined. This study examined whether there is an association between temperament and outdoor play in young children. Methods Healthy children aged 1 to 5 years recruited to The Applied Research Group for Kids (TARGet Kids!), a community-based primary care research network, from July 2008 to September 2013 were included. Parent-reported child temperament was assessed using the Childhood Behavior Questionnaire. Outdoor free play and other potential confounding variables were assessed through validated questionnaires. Multivariable linear regression was used to determine the association between temperament and outdoor play, adjusted for potential confounders. Results There were 3393 children with data on outdoor play. The association between negative affectivity and outdoor play was moderated by sex; in boys, for every 1-point increase in negative affectivity score, mean outdoor play decreased by 4.7 minutes per day. There was no significant association in girls. Surgency was associated with outdoor play; for every 1-point increase in surgency/extraversion, outdoor play increased by 4.6 minutes per day. Conclusions Young children's temperamental characteristics were associated with their participation in outdoor free play. Consideration of temperament could enhance interventions and strategies to increase outdoor play in young children. Longitudinal studies are needed to elucidate the relationship between children's early temperament and physical activity.
Authors:Claire A. MacGeorge; Kit N. Simpson; William T. Basco; David G. Bundy Abstract: Publication date: Available online 16 April 2018 Source:Academic Pediatrics Author(s): Claire A. MacGeorge, Kit N. Simpson, William T. Basco, David G. Bundy Objective Pediatric constipation is common, costly and often managed in the Emergency Department (ED). The objectives of this study were to determine the frequency of constipation-related ED visits in a large commercially insured population, the frequency of an office visit in the month before and after these visits, demographics associated with these office visits and the ED-associated payments. Methods Data were extracted from the Truven MarketScan® database for commercially insured children from 2012-2013. The presence and timing of clinic visits within 30 days before and after an ED constipation visit and demographic variables were extracted. Logistic regression was used to predict an outcome of presence of a visit with independent variables of age, sex and region of the country. Results In a population of 17 million children aged 0 to 17 years, 448,440 (2.6%) were identified with constipation in at least one setting, with 65,163 (14.5%) having an ED visit for constipation. 45% of all children with a constipation-related ED visit had no office visit in the 30 days before or after the ED visit. Increasing age was associated with absence of an office visit. The median payment by insurance for an ED constipation visit was $523, the median out-of-pocket payment was $100, for a total of $623 per visit. Conclusion One in 7 children with constipation in this commercially insured population received ED care for constipation, many without an outpatient visit in the month before or after. Efforts to improve primary care utilization for this condition should be encouraged.
Authors:Martha Goleman; Millie Dolce Jennifer Morack Abstract: Publication date: Available online 26 May 2018 Source:Academic Pediatrics Author(s): Martha J. Goleman, Millie Dolce, Jennifer Morack Objective Adolescent human papillomavirus (HPV) vaccine rates remain low. Early vaccination may improve the efficacy of the vaccine and immunization rates. However, clinicians have not routinely made a strong recommendation to younger adolescents. This study assessed the feasibility of routine vaccination at nine years of age. Methods Three sequential quality improvement (QI) interventions were implemented to shift the initiation of the HPV vaccine to nine years of age in a primary care network in low-income neighborhoods in Columbus, Ohio. The first intervention changed the electronic medical record (EMR) alert for the HPV vaccine from eleven to nine years of age and focused on cancer prevention when discussing the vaccine with families. The second intervention was formation of an HPV QI team. The third intervention was a clinic incentive for HPV captured opportunity rates. Immunization rates were monitored using statistical process control charts to compare the HPV immunization rate in a sample of nine and ten-year-old children with a sample of 11 and 12-year-old children. Results The percentage of patients receiving an HPV vaccine before 11 years increased from 4.6% to 35.7% during the six months after the QI initiative began and to 60.8% 18 months after the project began. In comparison, the HPV vaccination rate in the sample of 11 and 12 year-olds increased from 78.7% to 82.8% 18 months later. Conclusion This QI project used multiple interventions to increase HPV vaccination at nine years of age in a large primary care network serving a diverse low-income population.
Authors:Darcy A. Thompson; Sarah J. Schmiege; Susan L. Johnson; Elizabeth A. Vandewater; Richard E. Boles; Ruth E. Zambrana; Jerusha Lev; Jeanne M. Tschann Abstract: Publication date: Available online 17 May 2018 Source:Academic Pediatrics Author(s): Darcy A. Thompson, Sarah J. Schmiege, Susan L. Johnson, Elizabeth A. Vandewater, Richard E. Boles, Ruth E. Zambrana, Jerusha Lev, Jeanne M. Tschann Objectives To (1) examine whether the Information, Motivation, and Behavioral Skills Model predicts maternal screen-related parenting practices and (2) evaluate the relationship of American Academy of Pediatrics(AAP)-recommended parenting practices with child television (TV) use behaviors. Methods In this cross-sectional study, 312 Spanish- and/or English-speaking female primary caregivers of Mexican descent with a child 3-5 years of age were recruited from safety-net pediatric clinics. Participants completed a phone interview and screen media diary. Measures included maternal screen-related beliefs, self-efficacy, and parenting practices (time restriction, TV in the child's bedroom, allowing viewing while eating meals and while eating snacks) and child viewing behaviors (amount of TV viewing, frequency of eating while viewing). Two path analytic models were estimated. Results Positive general beliefs about TV viewing and positive functional beliefs were negatively associated with maternal self-efficacy to restrict TV time (β=-0.14, p<.05; β=-0.27, p<.001). Greater self-efficacy to restrict time was associated with more maternal restriction of time (β=0.29, p<.001). Greater positive functional beliefs was associated with less self-efficacy to restrict TV viewing with snacks (OR=0.56, 95% CIs 0.38-0.81). High self-efficacy to restrict viewing with snacks was associated with less allowing of viewing while snacking (β=-0.16, p<.01). Time restriction, TV in the child's bedroom, and allowing viewing while snacking were associated with child TV viewing behaviors. Conclusions Providers should consider maternal beliefs, including beliefs regarding the functional use of screens, and self-efficacy to engage in AAP-recommended parenting practices, when counseling on screen use in this population.
Authors:Carole H. Stipelman; Brad Poss; Laura Anne Stetson; Luca Boi; Michael Rogers; Caleb Puzey; Sri Koduri; Robert Kaplan; Vivian S. Lee; Edward B Clark Abstract: Publication date: Available online 17 May 2018 Source:Academic Pediatrics Author(s): Carole H. Stipelman, Brad Poss, Laura Anne Stetson, Luca Boi, Michael Rogers, Caleb Puzey, Sri Koduri, Robert Kaplan, Vivian S. Lee, Edward B Clark Purpose To determine whether residency training represents a net positive or negative cost to academic medical centers, we analyzed the cost of a residency program and clinical productivity of residents and faculty in outpatient primary care practice with or without residents. Method Patient volume and revenue data (Current Procedural Terminology codes) from an academic primary care general pediatric clinic were evaluated for faculty clinics (faculty only) and resident teaching clinics (Longitudinal Outpatient Experience [LOE]) with 1-4 residents/faculty. Detailed cost per resident was determined using a departmental financial model that included salary, benefits, faculty and administrative staff effort, non-personnel costs, and institutional GME support. Results The LOE clinics had greater mean number of patient visits (11.6 vs 6.8) than faculty clinics per faculty member. In the LOE clinic, the number of patient visits per clinic was directly proportional to the number of residents per faculty. The cost for each resident was $250 per clinic ($112 per resident, $88 per medical assistant per resident, and $50 per room per resident). When factoring in clinic costs and faculty supervision time, the LOE clinic (average 3.5 residents with one supervising faculty) had greater average cost (+$687.00) and revenue (+$319.45) and lower operating margin (revenue minus cost, −$367.55) than faculty clinic (one faculty member). Conclusions Pediatric resident LOE clinic had a greater average number of patient visits and revenue per faculty member but higher costs and lower operating margin than faculty clinic.
Authors:S. Christy Sadreameli; Kristin A. Riekert; Elizabeth C. Matsui; Cynthia S. Rand; Michelle N. Eakin Abstract: Publication date: Available online 3 May 2018 Source:Academic Pediatrics Author(s): S. Christy Sadreameli, Kristin A. Riekert, Elizabeth C. Matsui, Cynthia S. Rand, Michelle N. Eakin Background Urban minority children are at risk for poor asthma outcomes and may not receive appropriate primary or subspecialty care. Objective We hypothesized that preschool children with asthma whose caregivers reported more barriers to care would be less likely to have seen their primary care provider (PCP) or an asthma subspecialist and more likely to have had a recent emergency department (ED) visit for asthma. Methods The Barriers to Care Questionnaire (BCQ) measures expectations, knowledge, marginalization, pragmatics, and skills. We assessed asthma control via TRACK and these outcomes: PCP visits for asthma in past six months, subspecialty care (allergist or pulmonologist) in past two years, and ED visits in past three months. Results 395 caregivers (96% African-American, 82% low-income, 96% Medicaid) completed the BCQ. Sixty percent(N=236) of children had uncontrolled asthma, 86% had seen a PCP, 23% had seen a subspecialist, and 29% had an ED visit. Barriers related to marginalization were associated with decreased likelihood of PCP (OR 0.95, p=0.014) and subspecialty visits (OR 0.92, p=0.019). Overall BCQ score was associated with decreased likelihood of subspecialty care (OR 0.98, p=0.027). Barriers related to expectations, knowledge, pragmatics, and skills were not associated with any of the care outcomes. Conclusions Among low-income, predominantly African-American preschool children with asthma, primary and subspecialty care were less likely if caregivers reported past negative experiences with the healthcare system (marginalization). Clinicians who serve at-risk populations should be sensitive to families' past experiences and should consider designing interventions to target the most commonly reported barriers.
Authors:Anne Fuller; Mary Jo Messito; Alan L. Mendelsohn; Suzette O. Oyeku; Rachel S. Gross Abstract: Publication date: Available online 2 May 2018 Source:Academic Pediatrics Author(s): Anne Fuller, Mary Jo Messito, Alan L. Mendelsohn, Suzette O. Oyeku, Rachel S. Gross Objective Prenatal maternal stresses have been associated with infant temperament patterns linked to later behavioral difficulties. Material hardships, defined as inability to meet basic needs, are important prenatal stressors. Our objective was to determine the associations between prenatal material hardships and infant temperament at 10 months. Methods This was a longitudinal study of mother-infant pairs in a randomized controlled trial of a primary care-based early obesity prevention program (Starting Early). Independent variables representing material hardship were: housing disrepair, food insecurity, difficulty paying bills and neighborhood stress (neighborhood safety). Dependent variables representing infant temperament were assessed using questions from three subscales of the Infant Behavior Questionnaire: orienting/regulatory capacity, negative affect, and surgency/extraversion. We used linear regression to investigate associations between individual and cumulative hardships and each temperament domain, adjusting for confounders, and testing for depression as a moderator. Results 412 mother-infant pairs completed 10 month assessments. 32% reported food insecurity, 26% difficulty paying bills, 35% housing disrepair and 9% neighborhood stress. In adjusted analyses, food insecurity was associated with lower orienting/regulatory capacity scores (B=-0.25, 95% CI -0.47, -0.04), as were neighborhood stress (B=-0.50, 95% CI -0.83, -0.16) and experiencing 3-4 hardships (compared with none) (B=-0.54, 95% CI -0.83, -0.21). For neighborhood stress, the association was stronger among infants of mothers with prenatal depressive symptoms (interaction term p=0.06). Conclusion Prenatal material hardships were associated with lower orienting/regulatory capacity. These findings support the need for further research exploring how temperament relates to child behavior, and for policies to reduce prenatal material hardships.
Authors:Rebecca Rebbe; Paula S. Nurius; Mark E. Courtney; Kym R. Ahrens Abstract: Publication date: Available online 27 April 2018 Source:Academic Pediatrics Author(s): Rebecca Rebbe, Paula S. Nurius, Mark E. Courtney, Kym R. Ahrens Objective Former youth in foster care (YFC) are at greater risk of chronic health conditions than their peers. Although research in general population samples has demonstrated a dose-response relationship between adverse childhood experiences (ACEs) and adult health outcomes, few studies have conducted similar analyses in highly stress-exposed populations such as YFC. This paper uses person-centered latent class analysis (LCA) methods to examine the relationship between different profiles of ACE exposures and divergent health trajectories amongst this high-risk population. Methods Data are from longitudinal research that followed transition-age YFC from age 17-26 (N =732). Using three subgroups previously identified by their ACEs histories, Complex, Environmental, and Lower Adversity groups, we applied group mean statistics to test for differences between the groups for physical and sexual health outcomes in young adulthood. Results In contrast to prior research demonstrating that the Environmental group was at the highest risk of criminal behavior outcomes, for most of the physical and sexual health risk outcomes evaluated in this paper, the Complex Adversity group had the highest risk. Conclusions This study demonstrates that there are subgroups of YFC which each have a distinct profile of risk in young adulthood, with the Complex group being at highest risk of the physical and sexual health risk outcomes evaluated. Findings strongly suggest the need for targeted strategies to promote screening for ACEs and chronic health conditions, linkage to adult healthcare, and continuity of care for adolescents and young adults in foster care to offset these trajectories.
Authors:Mary E. Rimsza; Holly S. Ruch-Ross; Conrad J. Clemens; William B. Moskowitz; Holly J. Mulvey Abstract: Publication date: Available online 27 April 2018 Source:Academic Pediatrics Author(s): Mary E. Rimsza, Holly S. Ruch-Ross, Conrad J. Clemens, William B. Moskowitz, Holly J. Mulvey Objective To update pediatric subspecialty workforce data to support evidence-based legislation and public policy decisions by replicating the American Academy of Pediatrics' 1998 Future of Pediatric Education (FOPE II) workforce survey. Study Design A descriptive and comparative analysis of survey responses from 9,950 US pediatric subspecialists who completed an electronic survey. Results Pediatric subspecialists are working fewer hours and spending less of their time in direct patient care than they did in 1998 but the mean hours worked differs significantly by subspecialty. The majority of subspecialists continues to be board-certified, white, non-Hispanic men although the percentage who are women and from minority groups has increased. The proportion of subspecialists practicing in an academic medical center has increased since 1998. Thirty percent of pediatric subspecialists reported appointment wait times of >2 weeks and pediatric subspecialists in developmental pediatrics, endocrinology, and neurology identified much longer wait times than other subspecialists. . Conclusion The demographic and practice characteristics of pediatric subspecialists have changed since the FOPE II survey and access to subspecialty care in a family's community remains a challenge. However, pediatric subspecialties are not monolithic and solutions to workforce shortages will need to take into account these differences in order to improve access to subspecialty care.
Authors:Dylan P. Cliff; Steven J. Howard; Jenny S. Radesky; Jade McNeill; Stewart A. Vella Abstract: Publication date: Available online 26 April 2018 Source:Academic Pediatrics Author(s): Dylan P. Cliff, Steven J. Howard, Jenny S. Radesky, Jade McNeill, Stewart A. Vella Objective To investigate: i) prospective associations between media exposure (television viewing, computers, and electronic games) at 2 years and self-regulation at 4 and 6 years, and ii) bi-directional associations between media exposure and self-regulation at 4 and 6 years. We hypothesized that media exposure and self-regulation would display a negative prospective association and subsequent bi-directional inverse associations. Methods Data from the nationally-representative Longitudinal Study of Australian Children (LSAC) when children were aged 2 (n=2786) and 4/6 years (n=3527) were used. Primary caregivers reported children's weekly electronic media exposure. A composite measure of self-regulation was computed from caregivers-, teacher-, and observer-report data. Associations were examined using linear regression and cross-lagged panel models, accounting for covariates. Results Lower television viewing and total media exposure at 2 years were associated with higher self-regulation at 4 years (both β -0.02; 95% confidence interval [CI] -0.03, -0.01). Lower self-regulation at 4 years was also significantly associated with higher television viewing (β -0.15; 95% CI -0.21, -0.08), electronic game use (β -0.05; 95% CI -0.09, -0.01), and total media exposure (β -0.19; 95% CI -0.29, -0.09) at 6 years. However, media exposure at 4 years was not associated with self-regulation at 6 years. Conclusions Although media exposure duration at 2 years was associated with later self-regulation, and self-regulation at 4 years was associated with later media exposure, associations were of small magnitude. More research is needed examining content quality, social context, and mobile media use and child self-regulation.
Authors:Su-Ting T. Li; Daniel J. Tancredi; Alan Schwartz; Ann Guillot; Ann E. Burke; R. Franklin Trimm; Susan Guralnick; John D. Mahan; Kimberly Gifford Abstract: Publication date: Available online 25 April 2018 Source:Academic Pediatrics Author(s): Su-Ting T. Li, Daniel J. Tancredi, Alan Schwartz, Ann Guillot, Ann E. Burke, R. Franklin Trimm, Susan Guralnick, John D. Mahan, Kimberly Gifford Background The Accreditation Council for Graduate Medical Education requires semiannual Milestone reporting on all residents. Milestone expectations of performance are unknown. Objective Determine pediatric program director (PD) minimum Milestone expectations for residents prior to being ready to supervise and prior to being ready to graduate. Methods Mixed methods survey of pediatric PDs on their programs' Milestone expectations before residents are ready to supervise and before they are ready to graduate, and in what ways PDs use Milestones to make supervision and graduation decisions. If programs had no established Milestone expectations, PDs indicated expectations they considered for use in their program. Mean minimum Milestone level expectations adjusted for program size, region, and clustering of Milestone expectations by program were calculated for prior to supervise and prior to graduate. Free-text questions were analyzed using thematic analysis. Results The response rate was 56.8% (113/199). Most programs had no required minimum Milestone level before residents are ready to supervise (80%; 76/95) or ready to graduate (84%; 80/95). For readiness to supervise, minimum Milestone expectations PDs considered establishing for their program were highest for humanism (2.46, 95% CI: 2.21-2.71) and professionalization (2.37, 2.15-2.60). Minimum Milestone expectations for graduates were highest for help-seeking (3.14, 2.83-3.46). Main themes included the use of Milestones in combination with other information to assess learner performance and Milestones are not equally weighted when making advancement decisions. Conclusions Most PDs have not established program minimum Milestones, but would vary such expectations by competency.
Authors:Margot A. Lazow; Francis J. Real; Nicholas J. Ollberding; David Davis; Bradley Cruse; Melissa D. Klein Abstract: Publication date: Available online 20 April 2018 Source:Academic Pediatrics Author(s): Margot A. Lazow, Francis J. Real, Nicholas J. Ollberding, David Davis, Bradley Cruse, Melissa D. Klein
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