JAMA Pediatrics最新文献

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Implementation of a Secure Firearm Storage Program in Pediatric Primary Care: A Cluster Randomized Trial. 在儿科初级保健中实施枪支安全存放计划：分组随机试验

IF 24.7 1区医学 Q1 PEDIATRICS

JAMA Pediatrics

Pub Date : 2024-11-01 DOI: 10.1001/jamapediatrics.2024.3274

Rinad S Beidas, Kristin A Linn, Jennifer M Boggs, Steven C Marcus, Katelin Hoskins, Shari Jager-Hyman, Christina Johnson, Melissa Maye, LeeAnn Quintana, Courtney Benjamin Wolk, Leslie Wright, Celeste Pappas, Arne Beck, Katy Bedjeti, Alison M Buttenheim, Matthew F Daley, Marisa Elias, Jason Lyons, Melissa Lynne Martin, Bridget McArdle, Debra P Ritzwoller, Dylan S Small, Nathaniel J Williams, Shiling Zhang, Brian K Ahmedani

Importance: Increased secure firearm storage can reduce youth firearm injury and mortality, a leading cause of death for children and adolescents in the US. Despite the availability of evidence-based secure firearm storage programs and recommendations from the American Academy of Pediatrics, few pediatric clinicians report routinely implementing these programs.

Objective: To compare the effectiveness of an electronic health record (EHR) documentation template (nudge) and the nudge plus facilitation (ie, clinic support to implement the program; nudge+) at promoting delivery of a brief evidence-based secure firearm storage program (SAFE Firearm) that includes counseling about secure firearm storage and free cable locks during all pediatric well visits.

Design, setting, and participants: The Adolescent and Child Suicide Prevention in Routine Clinical Encounters (ASPIRE) unblinded parallel cluster randomized effectiveness-implementation trial was conducted from March 14, 2022, to March 20, 2023, to test the hypothesis that, relative to nudge, nudge+ would result in delivery of the firearm storage program to an additional 10% or more of the eligible population, and that this difference would be statistically significant. Thirty pediatric primary care clinics in 2 US health care systems (in Michigan and Colorado) were included, excluding clinics that were not the primary site for participating health care professionals and a subset selected at random due to resource limitations. All pediatric well visits at participating clinics for youth ages 5 to 17 years were analyzed.

Interventions: Clinics were randomly assigned in a 1:1 ratio to receive either the nudge or nudge+.

Main outcomes and measures: Patient-level outcomes were modeled to estimate the primary outcome, reach, which is a visit-level binary indicator of whether the parent received both components of the firearm storage program (counseling and lock), as documented by the clinician in the EHR. Secondary outcomes explored individual program component delivery.

Results: A total of 47 307 well-child visits (median [IQR] age, 11.3 [8.1-14.4] years; 24 210 [51.2%] male and 23 091 [48.8%] female) among 46 597 children and 368 clinicians were eligible to receive the firearm storage program during the trial and were included in analyses. Using the intention-to-treat principle, a higher percentage of well-child visits received the firearm storage program in the nudge+ condition (49%; 95% CI, 37-61) compared to nudge (22%; 95% CI, 13-31).

Conclusions and relevance: In this study, the EHR strategy combined with facilitation (nudge+) was more effective at increasing delivery of an evidence-based secure firearm storage program compared to nudge alone.

Trial registration: ClinicalTrials.gov Identifier: NCT04844021.

重要性：加强枪支的安全存放可以减少青少年枪支伤害和死亡率，这是美国儿童和青少年死亡的主要原因。尽管有循证的枪支安全存放计划和美国儿科学会的建议，但很少有儿科临床医生表示会常规实施这些计划：目的：比较电子健康记录（EHR）文档模板（"推动"）和 "推动+促进"（即诊所支持实施该计划；"推动+"）在促进实施简短的循证枪支安全存放计划（SAFE Firearm）方面的效果：在 2022 年 3 月 14 日至 2023 年 3 月 20 日期间，开展了 "常规临床就诊中的青少年和儿童自杀预防"（ASPIRE）非盲平行群组随机有效性实施试验，以检验以下假设：相对于 "推力"，"推力+"将使符合条件的人群中多 10%或更多的人受益于枪支储存计划，并且这种差异具有显著的统计学意义。研究对象包括美国密歇根州和科罗拉多州两个医疗保健系统中的 30 家儿科初级保健诊所，其中不包括非参与研究的医疗保健专业人员主要就诊地点的诊所，也不包括因资源限制而随机选择的子集。研究分析了参与研究的诊所为5至17岁青少年进行的所有儿科健康检查：干预措施：以 1:1 的比例随机分配诊所接受 nudge 或 nudge+：对患者层面的结果进行建模，以估算主要结果 "到达率"。"到达率 "是一个就诊层面的二进制指标，表示家长是否接受了枪支储存计划的两个组成部分（咨询和上锁），临床医生在电子病历中对此进行了记录。次要结果探讨了各个项目组成部分的实施情况：共有 46 597 名儿童和 368 名临床医生中的 47 307 名儿童（中位数 [IQR] 年龄为 11.3 [8.1-14.4] 岁；24 210 [51.2%] 名男性和 23 091 [48.8%] 名女性）有资格在试验期间接受枪支保管计划，并纳入分析。根据意向治疗原则，与 "劝导"（22%；95% CI，13-31）相比，"劝导+"条件下（49%；95% CI，37-61）接受枪支储存计划的儿童健康访视比例更高：在这项研究中，电子病历策略与鼓励相结合（"鼓励+"）与单纯的鼓励相比，能更有效地提高循证安全枪支储存计划的实施率：试验注册：ClinicalTrials.gov Identifier：NCT04844021.

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引用次数: 0

Medicaid Accountable Care Organizations and Disparities in Pediatric Asthma Care. 医疗补助责任护理组织与小儿哮喘护理中的差异。

IF 24.7 1区医学 Q1 PEDIATRICS

JAMA Pediatrics

Pub Date : 2024-11-01 DOI: 10.1001/jamapediatrics.2024.3935

Kimberley H Geissler, Meng-Shiou Shieh, Arlene S Ash, Peter K Lindenauer, Jerry A Krishnan, Sarah L Goff

Importance: Nearly 6 million children in the US have asthma, and over one-third of US children are insured by Medicaid. Although 23 state Medicaid programs have experimented with accountable care organizations (ACOs), little is known about ACOs' effects on longstanding insurance-based disparities in pediatric asthma care and outcomes.Objective: To determine associations between Massachusetts Medicaid ACO implementation in March 2018 and changes in care quality and use for children with asthma.Design, setting, and participants: Using data from the Massachusetts All Payer Claims Database from January 1, 2014, to December 31, 2020, we determined child-years with asthma and used difference-in-differences (DiD) estimates to compare asthma quality of care and emergency department (ED) or hospital use for child-years with Medicaid vs private insurance for 3 year periods before and after ACO implementation for children aged 2 to 17 years. Regression models accounted for demographic and community characteristics and health status. Data analysis was conducted between January 2022 and June 2024.Exposure: Massachusetts Medicaid ACO implementation.Main outcomes and measures: Primary outcomes were binary measures in a calendar year of (1) any routine outpatient asthma visit, (2) asthma medication ratio (AMR) greater than 0.5, and (3) any ED or hospital use with asthma. To determine the statistical significance of differences in descriptive statistics between groups, χ2 and t tests were used.Results: Among 376 509 child-year observations, 268 338 (71.27%) were insured by Medicaid and 73 633 (19.56%) had persistent asthma. There was no significant change in rates of routine asthma visits for Medicaid-insured child-years vs privately insured child-years post-ACO implementation (DiD, -0.4 percentage points [pp]; 95% CI, -1.4 to 0.6 pp). There was an increase in the proportion with AMR greater than 0.5 for Medicaid-insured child-years vs privately insured in the postimplementation period (DiD, 3.7 pp; 95% CI, 2.0-5.4 pp), with absolute declines in both groups postimplementation. There was an increase in any ED or hospital use for Medicaid-insured child-years vs privately insured postimplementation (DiD, 2.1 pp; 95% CI, 1.2-3.0 pp), an 8% increase from the preperiod Medicaid use rate.Conclusions and relevance: Introduction of Massachusetts Medicaid ACOs was associated with persistent insurance-based disparities in routine asthma visit rates; a narrowing in disparities in appropriate AMR rates due to reductions in appropriate rates among those with private insurance; and worsening disparities in any ED or hospital use for Medicaid-insured children with asthma compared to children with private insurance. Continued study of changes in pediatric asthma care delivery is warranted in relation to major Medicaid

重要性：美国有近 600 万儿童患有哮喘，超过三分之一的美国儿童参加了医疗补助计划。尽管已有 23 个州的医疗补助计划尝试采用责任医疗组织（ACO），但人们对 ACO 对长期以来基于保险的儿科哮喘护理和结果差异的影响知之甚少：确定 2018 年 3 月马萨诸塞州医疗补助 ACO 的实施与哮喘儿童护理质量和使用变化之间的关联：利用马萨诸塞州所有支付方索赔数据库中 2014 年 1 月 1 日至 2020 年 12 月 31 日的数据，我们确定了患有哮喘的儿童年数，并使用差异估计值（DiD）比较了 ACO 实施前后 3 年期间，医疗补助与私人保险对 2 至 17 岁儿童的哮喘护理质量和急诊科（ED）或医院使用情况。回归模型考虑了人口和社区特征以及健康状况。数据分析在 2022 年 1 月至 2024 年 6 月期间进行。暴露：马萨诸塞州医疗补助 ACO 实施情况：主要结果为一个日历年中的二元测量值：（1）任何哮喘常规门诊就诊；（2）哮喘用药比（AMR）大于 0.5；（3）任何哮喘急诊室或医院就诊。为确定组间描述性统计差异的统计学意义，采用了χ2和t检验：在 376 509 个儿童年观察对象中，268 338 人（71.27%）参加了医疗补助计划，73 633 人（19.56%）患有持续性哮喘。在实施 ACO 后，医疗补助保险儿童年与私人保险儿童年的哮喘常规就诊率没有明显变化（DiD，-0.4 个百分点 [pp]；95% CI，-1.4 至 0.6 个百分点）。在 ACO 实施后，医疗补助参保儿童年的 AMR 大于 0.5 的比例比私人参保儿童年的 AMR 大于 0.5 的比例有所增加（DiD，3.7 个百分点；95% CI，2.0-5.4 个百分点），实施后两组的绝对值均有所下降。医疗补助计划实施后，医疗补助计划参保儿童与私人参保儿童的任何急诊室或医院使用率均有所上升（DiD，2.1pp；95% CI，1.2-3.0pp），比医疗补助计划实施前的使用率上升了 8%：马萨诸塞州医疗补助 ACO 的引入与以下因素有关：基于保险的常规哮喘就诊率差异持续存在；由于私人保险儿童的适当就诊率降低，适当 AMR 率的差异缩小；与私人保险儿童相比，医疗补助保险儿童哮喘患者在任何急诊室或医院就诊的差异加剧。有必要继续研究儿科哮喘护理服务的变化与重大医疗补助计划融资和服务系统改革的关系。

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引用次数: 0

Prevalence of Obesity Is Higher Than Published Estimates Suggest-Reply. 肥胖症患病率高于已公布的估计值--回复。

IF 24.7 1区医学 Q1 PEDIATRICS

JAMA Pediatrics

Pub Date : 2024-11-01 DOI: 10.1001/jamapediatrics.2024.3621

Xinyue Zhang, Peng Li, Zhihui Li

引用次数: 0

Further Considerations on Adverse Childhood Experiences and Neurocognitive Development. 对童年不良经历和神经认知发展的进一步思考。

IF 24.7 1区医学 Q1 PEDIATRICS

JAMA Pediatrics

Pub Date : 2024-11-01 DOI: 10.1001/jamapediatrics.2024.3414

Habib Bhurawala, Alison Poulton

引用次数: 0

Integrating Diet and Health Care in Child Health Research-Reply. 儿童健康研究中的饮食与保健相结合--回复。

IF 24.7 1区医学 Q1 PEDIATRICS

JAMA Pediatrics

Pub Date : 2024-11-01 DOI: 10.1001/jamapediatrics.2024.3578

Zhaolong Adrian Li, Mary Katherine Ray, Tamara Hershey

引用次数: 0

Tribal Identity, Pain Interference, and Substance Use Among American Indian and Alaska Native Adolescents. 美国印第安人和阿拉斯加原住民青少年的部落认同、疼痛干扰和药物使用。

IF 24.7 1区医学 Q1 PEDIATRICS

JAMA Pediatrics

Pub Date : 2024-11-01 DOI: 10.1001/jamapediatrics.2024.3284

Ashna Jagtiani, Melvin D Livingston, Caroline M Barry, Sierra Talavera-Brown, Hannah LaBounty, Juli R Skinner, Bethany J Livingston, Ashley N Lincoln, Kelli A Komro

Importance: Substance use is high among American Indian/Alaska Native adolescents. Pain interference is a risk factor for substance use, and identifying potential protective factors, such as Tribal identity, is important to help inform culturally grounded substance use prevention strategies.Objective: To examine the protective potential of Tribal identity as a moderator in the association between pain interference and substance use in American Indian/Alaska Native adolescents.Design, setting, and participants: This cross-sectional study of 10th-grade students self-identifying as American Indian/Alaska Native was conducted among students enrolled at 20 high schools on or near the Cherokee Nation Reservation. Data for this study were collected from the baseline assessments of a cluster randomized trial to prevent substance use among adolescents living on or near the Cherokee Nation Reservation. Inclusion criteria for high schools' participation included being located within counties that partially or fully fall within the Cherokee Nation reservation, a town population of 3000 individuals or fewer, and class sizes between 30 and 100 students. Exclusion criteria included high schools within metropolitan and micropolitan cores (per the US Census Bureau's Rural-Urban Commuting Area codes) and the existence of an established community drug prevention coalition. Student surveys were conducted from September 2021 to May 2024.Exposure: Pain interference in the 7 days prior to baseline assessment.Main outcomes and measures: The primary outcomes were past 30-day alcohol use, marijuana use, and prescription opioid misuse. Generalized estimating equations Poisson models were used, with an exchangeable correlation structure clustered on the school level using baseline data from a cluster randomized trial to prevent alcohol and substance use among adolescents. For each substance, a separate multivariable model was fit, which included pain interference, Tribal identity, an interaction term between pain interference and Tribal identity, age, gender, food insecurity, anxiety symptoms, and depressive symptoms.Results: Among 514 self-identified American Indian/Alaska Native students at 20 high schools on or near the Cherokee Nation Reservation, mean (SD) participant age was 15.59 (0.62) years, and 252 participants (49.0%) self-identified as female. Pain interference was associated with alcohol use and prescription opioid misuse in American Indian/Alaska Native adolescents, controlling for age, gender, food insecurity, anxiety symptoms, and depressive symptoms. Tribal identity significantly moderated the association between pain interference and alcohol use (coefficient, -0.13; 95% CI, -0.23 to -0.02).Conclusions and relevance: When Tribal identity was high, the adverse association of pain interference with

重要性：美国印第安人/阿拉斯加原住民青少年使用药物的比例很高。疼痛干扰是药物使用的一个风险因素，确定潜在的保护因素（如部落身份）对于帮助制定基于文化的药物使用预防策略非常重要：目的：研究部落身份作为美国印第安人/阿拉斯加原住民青少年疼痛干扰与药物使用之间关联的调节因素的保护潜力：这项横断面研究的对象是自我认同为美国印第安人/阿拉斯加原住民的 10 年级学生，研究对象是切诺基部落保留地或附近 20 所高中的在校学生。本研究的数据是从一项群集随机试验的基线评估中收集的，该试验旨在防止生活在切诺基部落保留地或附近的青少年使用药物。高中的加入标准包括：位于部分或全部属于切罗基部落保留地的县内，城镇人口不超过 3000 人，班级规模在 30 到 100 人之间。排除标准包括位于大都市和微型城市核心地区（根据美国人口普查局的农村-城市通勤区代码）的高中，以及是否存在已成立的社区毒品预防联盟。学生调查于 2021 年 9 月至 2024 年 5 月进行：基线评估前 7 天内的疼痛干扰：主要结果是过去 30 天内饮酒、吸食大麻和滥用处方阿片类药物的情况。采用了广义估计方程泊松模型，并利用一项旨在预防青少年酗酒和滥用药物的分组随机试验的基线数据，在学校层面聚类了可交换的相关结构。对于每种药物，都拟合了一个单独的多变量模型，其中包括疼痛干扰、部落身份、疼痛干扰与部落身份之间的交互项、年龄、性别、食物不安全、焦虑症状和抑郁症状：在切诺基部落保留地或附近 20 所高中的 514 名自我认同为美国印第安人/阿拉斯加原住民的学生中，平均（标清）年龄为 15.59（0.62）岁，252 名学生（49.0%）自我认同为女性。在控制年龄、性别、食物不安全、焦虑症状和抑郁症状的情况下，美国印第安人/阿拉斯加原住民青少年的疼痛干扰与酒精使用和处方阿片类药物滥用有关。部落身份明显缓和了疼痛干扰与饮酒之间的关联（系数为-0.13；95% CI为-0.23至-0.02）：当部落认同度较高时，疼痛干扰与酗酒之间的不良关联会明显减弱。这表明部落身份对酒精使用具有保护作用，可为今后在美国印第安人/阿拉斯加原住民青少年中开展药物使用预防工作提供参考：试验注册：ClinicalTrials.gov Identifier：NCT04839978.

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引用次数: 0

The Exposome as a Key to Understanding Pediatric Health Disparities. 暴露组是了解儿科健康差异的关键。

IF 24.7 1区医学 Q1 PEDIATRICS

JAMA Pediatrics

Pub Date : 2024-11-01 DOI: 10.1001/jamapediatrics.2024.3448

Martinš M Gatavinš, Ashley M Cooper, Ran Barzilay

引用次数: 0

Low-Dose Iron and Early Development in Breastfed Infants-Reply. 低剂量铁与母乳喂养婴儿的早期发育--回复。

IF 24.7 1区医学 Q1 PEDIATRICS

JAMA Pediatrics

Pub Date : 2024-11-01 DOI: 10.1001/jamapediatrics.2024.3303

Anna Chmielewska, Magnus Domellöf

引用次数: 0

What I Have Learned in the Last 24 Years Being Editor-in-Chief. 担任主编 24 年来的心得体会。

IF 24.7 1区医学 Q1 PEDIATRICS

JAMA Pediatrics

Pub Date : 2024-11-01 DOI: 10.1001/jamapediatrics.2024.3288

Frederick P Rivara

引用次数: 0

Efficacy of Gamified Digital Mental Health Interventions for Pediatric Mental Health Conditions: A Systematic Review and Meta-Analysis. 游戏化数字心理健康干预对儿科心理健康问题的疗效：系统回顾与元分析》。

IF 24.7 1区医学 Q1 PEDIATRICS

JAMA Pediatrics

Pub Date : 2024-11-01 DOI: 10.1001/jamapediatrics.2024.3139

Barry R Bryant, Morgan R Sisk, Joseph F McGuire

Importance: Anxiety, depression, and attention-deficit/hyperactivity disorder (ADHD) affect up to 20% of children and adolescents. Despite demonstrated efficacy, evidence-based treatments for these conditions are often inaccessible; innovative solutions are essential to meet the demand for pediatric mental health care.

Objective: To examine the efficacy and moderators of gamified DMHIs for anxiety, depression, and ADHD in randomized clinical trials (RCTs) for children and adolescents.

Data sources: A systematic search of PubMed, PsycInfo, and Web of Science was conducted for RCTs published before March 20, 2024.

Study selection: RCTs that evaluated the efficacy of gamified DMHIs for treating pediatric ADHD, depression, or anxiety were included. Studies were excluded if they did not use a gamified DMHI, provide sufficient data for effect sizes, or were unavailable in English.

Data extraction and synthesis: Efficacy data were extracted from rating scales for ADHD, depression, and anxiety. Extracted moderator variables included participant characteristics (eg, age and sex), intervention characteristics (eg, delivery modality and time limit), and trial design characteristics (eg, outcome measure and risk of bias).

Main outcomes and measures: The primary outcome was change in ADHD, depression, or anxiety severity in the treatment group compared to the control group. Hedges g quantified treatment effects.

Results: The search strategy identified 27 RCTs that included 2911 participants across ADHD, depression, and anxiety disorders. There were modest significant effects of gamified DMHIs on ADHD (g, 0.28; 95% CI, 0.09 to 0.48) and depression (g, 0.28; 95% CI, 0.08 to 0.47) but small, nonsignificant effects for anxiety disorders (g, 0.07; 95% CI, -0.02 to 0.17). Moderator analyses revealed that DMHIs for ADHD delivered on a computer and those RCTs that had a greater preponderance of male participants produced larger treatment effects. DMHIs for depressive disorders that used preset time limits for gamified DMHIs also exhibited larger treatment effects.

Conclusions and relevance: The findings suggest a benefit of gamified DMHIs for youth with ADHD or depressive disorder. Pediatricians and other health care professionals have new information about novel, accessible, and efficacious options for pediatric mental health care.

重要性：多达 20% 的儿童和青少年患有焦虑症、抑郁症和注意力缺陷/多动障碍 (ADHD)。尽管疗效已得到证实，但这些疾病的循证治疗往往难以获得；要满足儿科心理保健的需求，创新的解决方案至关重要：在针对儿童和青少年的随机临床试验（RCT）中，研究游戏化 DMHIs 对焦虑症、抑郁症和多动症的疗效和调节因素：在PubMed、PsycInfo和Web of Science上对2024年3月20日之前发表的RCT进行了系统检索：纳入了评估游戏化 DMHIs 治疗小儿多动症、抑郁症或焦虑症疗效的 RCT。如果研究未使用游戏化DMHI、未提供足够的效应大小数据或未提供英文版，则排除这些研究：从多动症、抑郁症和焦虑症的评分量表中提取疗效数据。提取的调节变量包括参与者特征（如年龄和性别）、干预特征（如实施方式和时间限制）和试验设计特征（如结果测量和偏倚风险）：主要结果是治疗组与对照组相比，ADHD、抑郁或焦虑严重程度的变化。Hedges g量化了治疗效果：搜索策略确定了 27 项 RCT，共纳入 2911 名参与者，涉及多动症、抑郁症和焦虑症。游戏化 DMHI 对多动症（g, 0.28; 95% CI, 0.09 to 0.48）和抑郁症（g, 0.28; 95% CI, 0.08 to 0.47）有适度的显着效果，但对焦虑症（g, 0.07; 95% CI, -0.02 to 0.17）的效果较小且不显着。调节因子分析显示，通过计算机进行的针对多动症的 DMHIs 和男性参与者较多的 RCTs 产生的治疗效果较大。针对抑郁障碍的 DMHIs，如果使用了游戏化 DMHIs 的预设时间限制，也会产生较大的治疗效果：研究结果表明，游戏化 DMHI 对患有多动症或抑郁障碍的青少年有益。儿科医生和其他医疗保健专业人员获得了有关儿科心理健康护理的新颖、便捷和有效选择的新信息。

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