Academic Pediatrics最新文献

Background: Examination maneuvers used to diagnose developmental hip dysplasia (DDH) translate poorly to video and written curricula. This poses a challenge to teaching the infant hip exam to orthopedic, family medicine, and pediatric trainees. This work investigated the impact of the MiHip simulation-based training program on residents' knowledge, confidence, and exam skills in the simulated setting, and translation of these skills to the clinical setting.

Methods: Fifty-four pediatric (n=39) and family medicine (n=15) residents participated in a non-randomized, stepped-wedge study during 2-4 week newborn rotations. Residents participated in simulation-based training facilitated by a pediatric orthopedic surgeon. Prior to and following training, residents completed a 10-item quiz and reported their confidence toward their DDH skills. Residents' and attendings' hip exam diagnoses were captured on 1,063 newborns. Residents' knowledge, confidence, and DDH diagnosis sensitivity were compared pre- and post-training. Chart analysis of 21 newborns that underwent a hip ultrasound compared residents' and practicing physicians' diagnoses' agreement with ultrasound findings.

Results: Following training, residents' knowledge, confidence and diagnosis skills improved modestly, P<0.001. In the clinical setting, residents' confidence (P<0.001) and skill improved for residents with (sensitivity Δ=.29) and without (Δ =.18) previous simulation-based training experience. Resident diagnoses demonstrated higher agreement with hip ultrasounds than practicing primary care physicians, (M_trainee=88.9%, M_PCP=25.0%, P = 0.003, φ=.63).

Conclusion: The hands-on training with the MiHip simulator improved resident knowledge and DDH examination confidence, and ultimately, improved diagnostic accuracy in the clinical setting. Further work is required to assess the larger clinical impact on orthopedic referral rates.

Objective: To improve pediatric residents' skills in the diagnosis and treatment of children with ADHD by giving real-time feedback utilizing Bug-in-the-Ear technology (BIE).

Methods: This prospective, controlled study had 2 treatment groups and 3 standardized patient (SP) sessions. Session-1 was baseline. In Session-2, the intervention group (IG) received feedback via BIE and the control group (CG) received traditional feedback. Session-3 (3 months later) assessed maintenance of skills, and neither group used BIE. Sessions were recorded and scored by research assistants trained with a novel scoring system called the Clinical Practice Index (CPI). The CPI is an observational instrument based on current AAP ADHD guidelines and DSM-5 criteria for ADHD and was reviewed by content experts in ADHD. CPI scores were analyzed using Repeated Measures ANOVA.

Results: Twenty-five pediatric residents participated; 13 in the CG and 12 in the IG. Maximum obtainable CPI score was 44 points. The IG showed a significant increase in their CPI score from Session-1 to Session-3 (8.27, p<0.001). The CG's CPI scores from Session-1 to Session-3 did not change significantly (2.85, p=0.536). The IG and CG CPI scores were significantly different at Session-2 (11.7, p<0.001), but not Session-3 (5.03, p=0.1407).

Conclusion: Immediate feedback via BIE showed significant improvement in the IG's skills in Session-2 and the IG's mean difference between Session-1 and Session-3. One exposure of BIE was not sufficient for the IG to maintain their skills, and further research is warranted to determine the number of BIE exposures needed for greater maintenance of skills.

Background and objectives: Human trafficking (HT) is a public health issue, with adolescents disproportionately at risk for reasons spanning multiple biopsychosocial domains. We explored youth HT survivors' healthcare barriers, experiences, and needs.

Methods: In this qualitative multi-methods study, 24 participants (≤26 years old) with HT experience receiving services from non-profit organizations in San Diego, California completed an electronic survey and were invited to participate in online interviews. Thematic analysis for interview responses was performed using constant comparative methodology. Authors created codes and connections between codes, and refined findings by discussion.

Results: All participants endorsed labor trafficking, 96% endorsed sex trafficking and 46% reported seeing a health care professional (HCP) while exploited. Nine survey respondents completed follow-up interviews: 100% endorsed labor and sex trafficking and 44% seeing a HCP. Interview participants' barriers to presenting to healthcare and receiving needed help were categorized into patient-focused - lack of awareness of exploitation and medical needs, emotional bonds to the trafficker, and misperceptions about their ability to obtain care); vs healthcare system-focused - negative experiences and need for consistency with HCPs, and desire for targeted resources and effective care.

Conclusions: Barriers to healthcare for trafficked youth included factors the healthcare system could change versus those that could be reduced with universal patient education. Participants named lack of legal guardian support and proof of insurance as barriers to healthcare access while being exploited. Participants noted conventional mental health interventions for recovery are not appropriate and lack survivor-led guidance; participants offered alternatives about how they would receive effective care.

Objectives: Children with medical complexity (CMC) have disproportionately high healthcare utilization and mortality. Goals of care (GOC) discussions improve goal-concordance and subjective outcomes for CMC and their caregivers; however, little is known about the frequency or characteristics of GOC discussions in CMC. We sought to define GOC discussion frequency and attributes in CMC and identify patient characteristics that may influence GOC discussion occurrence.

Methods: This was a single-institution retrospective cohort study including CMC with at least one complex, chronic condition (CCC) and one hospitalization in 2021. GOC discussion documentation prior to or during 2021 was identified by structured chart review. GOC discussion frequency and attributes were compared by category of patient medical complexity. Patient characteristics were analyzed as predictors of GOC discussion occurrence.

Results: Out of 1235 CMC, documented GOC discussions were uncommon (22%) and 70% occurred in the intensive care unit. In patients who died, 78% of GOC discussions occurred within 6 months of death. In multivariable regression analysis, increased odds of GOC discussion occurrence was observed in CMC who died (p<0.001), spent fewer days at home (p<0.001), had ≥4 CCCs or technology dependence (p<0.001), were uninsured (p=0.008), or identified as Black (p<0.001), Hispanic (p=0.02), or non-Hispanic Other race (p=0.001).

Conclusions: GOC discussions in CMC were infrequent and typically occurred around critical illness or death. Increased GOC discussion occurrence in racial and ethnic minority CMC may be a proxy for disparate morbidity and mortality and indicates racial and ethnic differences in communication regularity and intensity that warrant further investigation.

Objectives: To characterize the 1) types of material goods (non-medical items) offered in pediatric residency continuity clinics, 2) consistency of good availability, 3) funding sources used to support supply, 4) whether goods are provided in response to social needs screening, and 5) common challenges with provision. To assess the extent to which provision of goods varied by clinic size and proportion of publicly insured patients.

Methods: Faculty and staff members from clinics in the Academic Pediatric Association's Continuity Research Network (APA CORNET) completed an online survey about material goods provided in their clinic in the preceding 12 months. Descriptive analyses were performed; Chi square tests were used to assess differences by clinic size and proportion of publicly insured patients.

Results: 51 of 113 eligible programs completed the survey (45%), representing varying clinic sizes and all regions in the United States. All clinics provided books, but reports varied regarding provision of other goods (49% provided food), as did the availability, funding sources, and screening processes for each good. Commonly reported challenges were funding (82%), storage (65%), and sustainability (53%). The types of material goods provided did not vary by clinic size or proportion of publicly insured patients.

Conclusion: This report highlights the range of material goods provided in pediatric continuity clinics and the variability in their availability, funding sources, and screening processes and can serve as the basis for future research to evaluate the impact of material goods provision.

Background: The goal of graduate medical education is for residents to achieve the skills and knowledge to practice medicine independently. While remediation is not uncommon in residency training, evidence is lacking to guide best practices.

Methods: We conducted a national survey of pediatric residency programs regarding their remediation experiences identifying struggling residents, documentating the process, and monitoring progress during remediation.

Results: A total of 50.8% (99/195) programs responded. Approximately 4.7% of residents underwent remediation, and 91% (262/288) of residents successfully completed remediation. Programs used data from the Clinical Competency Committee (CCC; 100%), rotation evaluations (98.9%) and direct observation (96.6%) to identify residents who need remediation. Most programs used an improvement plan to document resident progress (88.8%) and assigned a mentor or coach to support the resident (88.8%). Nearly all programs used rotation evaluations (93.3%) to monitor progress towards achieving the goals of remediation. Two-thirds (66.3%) felt their remediation process was either very effective or effective, and about half (56.2%) were very satisfied or satisfied with their remediation process. Programs with more residents who successfully completed remediation were more likely to feel satisfied with their program's remediation processess and effectiveness.

Conclusions: Nearly 5% of pediatrics residents undergo remediation, with 91% successfully remediating. Two-thirds of program leaders feel their remediation practices are effective, and only half are satisfied with remediation processes in their program. Opportunities exist to improve remediation processes for pediatric residents and for programs to ensure graduation of competent pediatricians.

The state of pediatric mental health in the United States remains an ongoing challenge. Contributing to this challenge is the biopsychosocial nature of mental health - an interconnected system of biological, psychological, social, and legal factors. Consequently, addressing pediatric mental health requires interdisciplinary collaboration. Medical-legal partnerships (MLPs) integrate legal assistance into traditional health care. Though MLPs have gained momentum in general pediatric health care delivery, they are surprisingly underutilized in the pediatric mental health landscape. This current work highlights the Yale Child Study Center Medical-Legal Partnership Project (YCSC-MLPP), which is to our knowledge, the first MLP in a children's behavioral health setting in the country. The YCSC-MLPP emerged as an interdisciplinary collaboration between the Yale Schools of Medicine and Law as well as the Center for Children's Advocacy. Between November 2021 to October 2022, the YCSC-MLPP received 150 referrals regarding patients whose care was complicated by health-harming legal needs. Of these referrals, 70% were non-client consultations, 26% were direct consultation with families, and 4% were full legal representation. The most pertinent topics addressed included education, health, housing, individual rights, and immigration. The creation of the YCSC-MLPP sets an example for what a reimagined, interdisciplinary approach to pediatric mental health can look like.