Academic Pediatrics最新文献

Pediatric clinician educators face the challenge of juggling clinical practice with teaching responsibilities. The balancing act is even more challenging when one considers the need to stay current with evidence from clinical and medical education literature. In this narrative review of 2023 medical education literature, the Academic Pediatric Association Education Committee's Top Articles team summarizes high-yield articles that possess the potential to significantly influence pediatric clinician educator teaching and practice. A standardized blinded rubric was applied to identify the most impactful articles from 19 medical education and specialty journals. Final selections were categorized into six domains: artificial intelligence and technology, belonging in the learning environment, bias in the workplace, clinical learning, curriculum and assessment, and family and community partnerships. The reviewers summarize key findings from the top articles and describe implications for pediatric clinician educator practice.

Objective: HPV infection is associated with a large burden of disease prevalence, morbidity, and known disparities. HPV vaccination rates remain lower than other childhood immunizations, despite vaccine safety and effectiveness. The objective of this QI intervention was to improve HPV vaccination rate by 15% over 3-years through early initiation and analyze trends across health disparities.

Methods: QI study in ages 9 to 13 at Nemours Primary Care from 2019 to 2022, which includes rural and urban regions and diverse populations. Interventions included updating EHR to begin at age 9, practice-level feedback, and updated education. Primary outcome measure was the HEDIS rate for HPV vaccination (proportion completed by age 13). Process measure was early HPV vaccine initiation rate (proportion aged 9-10 with at least one dose). Year-end early HPV vaccine initiation rates were analyzed to assess trends by race and ethnicity, geography, insurance, and Child Opportunity Index (COI).

Results: The number of eligible 9 and 10 year olds ranged from 16,466 to 17,925 annually. HEDIS rates improved over three years from 49.2% to 59.5% (p < 0.0001). Early initiation increased from 13.2% in 2019 to 42.2% in 2022 (p < 0.0001) and improved significantly across demographic variables (p < 0.0001). Groups with the lowest baseline early vaccination rates increased significantly.

Conclusion: HPV vaccine completion by 13 increased significantly with QI supporting early initiation. Demographic analyses showed the highest degree of improvement in populations with the lowest baseline rates. This supports altering CDC recommendation for HPV vaccination initiation at ages 9-12.

Objective: To understand the feelings of pediatrics residents early in the COVID-19 pandemic and to offer insights still relevant today.

Methods: We performed a thematic analysis exploring resident feelings early in the pandemic using free-text responses on a national survey distributed between May and June 2020. We analyzed responses from the following multi-part free text question embedded in the larger survey, "Which of the following feelings have you experienced in your role as a pediatric resident during the COVID-19 pandemic" with response prompts including relief, guilt, pride, sadness, worry, fear, and other.

Results: While many feelings that respondents shared were common to society at large, some were specific to their intersecting roles as healthcare workers, pediatricians, and trainees. Some issues uncovered have continued relevance today including varied interactions with program and institutional leadership, training away from established support networks and during an important life stage, and societal concerns.

Conclusions: This study uncovered vulnerabilities inherent to being a trainee such as limited control over one's own schedule or institutional policies and training away from established supports. Their feelings shine light on the moral distress experienced in residency and the role program and institutional leadership can play in the experiences of residents.

Objective: Mandatory enrollment into Medicaid-contracted Health Maintenance Organizations (HMOs) is the most common form of Medicaid managed care (MMC), but the effects of this enrollment on children are unclear. We leveraged variation in MMC implementation within and across states over time to examine the effect of mandatory Medicaid HMO enrollment on children's access, utilization, and health outcomes.

Methods: Using Medical Expenditure Panel Survey data from 2000 to 2018 and multivariable regression models, we estimated the effects of living in a county with mandatory Medicaid HMO enrollment only, compared to other MMC types and FFS combined in one comparison group, on outcomes for children under 18 years. We also evaluated potential effect heterogeneity across age, race/ ethnicity, and for children with special healthcare needs (CSHCNs).

Results: There were small and non-significant associations between mandatory HMO enrollment and most outcome measures. However, mandatory HMO enrollment was associated with a 1.8 percentage-point decline in the likelihood of having a usual source of care,95% CI[-0.035,-0.001], a 4.2 percentage-point increase in the likelihood of delayed access to care,95% CI[0.012,0.072], and a 2.2 percentage-point reduction in the likelihood of having any outpatient physician visits, 95% CI[-0.043,-0.0004], compared to other MMC and FFS combined in one group. Mandatory HMO enrollment was associated with more difficulty seeing a specialist for CSHCNs.

Conclusions: Overall, there is little evidence that mandatory Medicaid HMO enrollment has discernable and consistent effects across a broad range of outcomes. Evaluating how mandatory Medicaid HMOs affect more nuanced healthcare measures especially for children with greater healthcare needs remains an important future research question.

Background: The pediatric emergency department is a high-value site for screening and resource referral for health-related social needs. However, best practices for this unique environment remain unclear. This study's objective was to introduce a consensus-based social care training toolkit for the pediatric emergency medicine (PEM) setting.

Methods: We conducted a modified Delphi study to establish consensus on social care practice and develop a user-friendly toolkit. Initially, five priority areas (sections) were identified. Participants reviewed literature and shared their expertise to draft preliminary sections of the toolkit. Two rounds of the modified Delphi process were conducted, involving a ranking system, significant qualitative feedback, and a final approval stage, resulting in the finalized toolkit.

Results: Seventeen participants were included in the Delphi process, including pediatric and general EM faculty and trainees, as well as a social worker and public health professor. Forty-two content items were ranked in the first Delphi round. Based on a combination of score cut-off and extensiveness of qualitative comments, items were either minorly edited and kept (29%) or sent back to their section for review (71%). The second Delphi round integrated further suggested edits, and all participants in this final round approved the publicly available version of the toolkit.

Conclusion: By utilizing diverse sources of information and a consensus-driven process of the modified Delphi, we generated best practice recommendations for the design, implementation, and training of social care programs in the PEM setting.

Objective: To examine the experience of Medicaid Accountable Care Organizations (ACOs) that include pediatric practices, including their motivations and experiences working together.

Methods: This mixed methods study is set within the first two years of the Massachusetts Medicaid ACO Program, which created 17 Medicaid ACOs across the Commonwealth in 2018. It combines qualitative interviews from organizational leaders across three Medicaid ACOs with pediatric representation (N=28; purposive sample; 2018) with a 44-item primary care practice leader survey (N=225 after 64% response rate; statewide stratified random sample of primary care practices; 2019). Interviews gathered information about organizational motivations and experiences with becoming a Medicaid ACO; the survey asked five domains of questions describing the experience of pediatric- and adult-focused primary care practices in joining Medicaid ACOs (e.g., how much practices solved problems jointly with the ACO). We used ordinary least squares regression to describe differences in experiences across pediatric vs. non-pediatric practices.

Results: Leaders of Medicaid ACO with pediatric representation expressed a desire to voice pediatric concerns regarding state Medicaid payment policy and to integrate social services as part of routine medical care. Relative to the experience of adult-focused primary care practice leaders, pediatric-focused practices reported less collaboration within the Medicaid ACO (95% confidence interval 0.81 to 0.05; p = 0.03) and less change toward standardization of policies such as physician compensation (95% confidence interval 0.61 to 0.02; p = 0.04).

Conclusions: Initial Medicaid ACO experiences can differ based on the degree to which organizations joining Medicaid ACO programs serve pediatric populations.

Article summary: Early in Massachusetts' implementation of Medicaid Accountable Care Organizations (ACO), pediatric-focused practices reported less collaboration and standardization within their Medicaid ACOs than adult-focused practices.

Objectives: To examine associations between preschooler screen time trajectories and executive functions and effortful control at age 5.

Methods: Prospective, community-based convenience sample of 315 parents of preschoolers (54% male), studied at the ages of 3.5 (2020), 4.5 (2021), and 5.5 (2022). Parent-reported screen use at the ages of 3.5, 4.5, and 5.5 was used to estimate preschooler screen use trajectories. Using latent growth modeling, we identified low (mean=.9 hrs/day, 23%), medium (mean=3.0 hrs/day, 56%), and high (mean=6.38 hrs/day, 21%) screen time groups. Children completed assessments of inhibitory control and cognitive flexibility at age 5.5. Both tasks are from the NIH Toolbox. Parents reported child effortful control at the age of 3.5 and 5.5 using the Children's Behavior Questionnaire, educational attainment, and parenting stress.

Results: Children in the average (b =-5.24) and high (b=.9.30) screen time trajectories scored significantly lower on inhibitory control than those in the low screen time group. Children in the average and high screen time groups also scored higher than children in the low screen time group on cognitive flexibility (b =-4.50) and (b=-10.12), respectively. Finally, children in the average and high screen time groups scored lower than children in the low screen time groups on effortful control (b =-.41) and (b=-.61), respectively.

Conclusions: The present study shows that stability in high levels of screen use is common among preschoolers and may forecast higher risk of cognitive difficulty and lower levels of cognitive control by the time of school entry.

Summary: High levels of preschooler screen use were associated with lower scores on assessments of inhibitory control, cognitive flexibility, and effortful control.

Objective: Clinical reasoning (CR) includes numerous essential skills for clinicians, but how these skills are assessed in pediatric residency training is not well described. This study aimed to explore pediatric residency program leader perspectives on clinical reasoning assessment and identification of trainee deficiencies in this area.

Methods: Taking a social constructionist worldview, we conducted a thematic analysis of 20 semi-structured interviews with pediatric residency program leaders. Interviews explored how pediatric residency programs assess CR and how deficiencies are identified. Recruitment and analysis continued iteratively until thematic sufficiency was reached. Member checking enhanced trustworthiness of the results.

Results: Participants noted a perceived lack of a shared mental model for CR assessment between program leaders and clinical supervisors. Four themes were generated to highlight CR assessment in pediatric residency programs: 1) Clinical supervisors escalate concerns about behaviors representing symptoms of CR deficits rather than diagnosing CR competency deficiencies and that CR assessment requires: 2) an outward display of autonomous decision-making, 3) psychologically safe environments for inquiry, and 4) longitudinal, individualized observation. Elements of pediatric residency programs that impede CR assessment were identified, including family-centered rounds and team-based clinical care.

Conclusions: This study identified key components necessary for CR assessment and barriers that may lead to missed identification of deficiencies. While no single solution can create an ideal environment for CR assessment, this study identifies elements for enhancing assessment opportunities for early identification of deficiencies.