Academic Pediatrics最新文献

Objective: To assess the impact of preference signals (PS) and geographic signals (GS) on pediatric interview and match results in the 2023-2024 application cycle.

Methods: Residency programs provided de-identified application data (number of applicants, interview invitations, and applicants interviewed, ranked, and matched). Applicants were subdivided by degree type (MD/DO/IMG), underrepresented in medicine (URiM) status, and couples match/local student status. The proportion of applicants in each category who did/did not utilize PS/GS was compared using chi-square and Fisher's tests with OR and 95% CI reported.

Results: Ten participating programs received 11,194 applications (64.6 +/- 47.5 per available position); 10.4% included PS and 57.5% used GS. Applicants using PS had higher odds of receiving interview invitations (OR: 7.15, p < 0.001), interviewing (OR 5.41, p < 0.001), and matching (OR: 17.12, p < 0.001) than those without PS. Applicants using GS had higher odds of receiving invitations, interviewing, and matching, but this was not true across all sub-categories. PS was associated with increased odds of interviewing once invited (OR 4.82, p = 0.004), and of matching once interviewed (OR 5.80, p < 0.001). Candidates in a "matchable" rank position with PS had 8.75x higher odds of matching at a program vs. those without PS (95% CI: 5.86-13.20, p < 0.001).

Conclusions: In this cohort, applicants using PS and GS were more likely to receive interview invitations, complete an interview, and match with programs than those without PS or GS, with PS a stronger influence than GS.

Objective: Palliative care (PC) communication skills are essential to patient care, yet many pediatric fellows do not receive formal PC education. Where it exists, current training often relies on lecture and observation. Simulation-based training is an effective, experiential education tool that allows pediatric fellows to safely practice and debrief difficult conversations to improve their PC communication skills.

Methods: Pediatric fellows in hematology/oncology, critical care medicine, and neonatology completed annual or biannual half-day simulation sessions practicing PC communication skills throughout their three-year fellowship. Each session included three scenes with standardized patients (SPs) followed by debriefing with PC faculty, discipline-specific physicians, and the SP. Fellows completed validated surveys evaluating their own "Self-Efficacy" and "Adequacy of their Medical Education" at four time points: baseline and the end of each fellowship year. Faculty evaluators rated each participant in nine communication domains.

Results: Participants reported self-perceived improvements in their Self-Efficacy with PC communication (p<0.001) and in the Adequacy of their PC Medical Education (p<0.001) throughout the 3-year intervention. As rated by external evaluators, communication scores in all nine domains improved throughout the intervention (p<0.001). Participants found the simulation-based trainings highly realistic (95%), useful (97%), and preferable to lecture-based education (87%).

Conclusions: Simulation-based PC communication training is an effective strategy to bolster self-efficacy and skills in pediatric fellows. This method enables fellows to safely practice navigating complex clinical situations as they prepare to become attending physicians. Expanding simulation to other disciplines and pediatric training programs can bolster PC education opportunities and improve patient care.

Objective: Five residency training programs studied the implementation of a new X+Y scheduling model. Utilizing qualitative thematic analysis, we aim to understand why X+Y scheduling impacts faculty and resident perceptions of the residency experience.

Methods: Residents and faculty completed a multiple-choice question and free text response asking which scheduling system, X+Y versus traditional block schedule, was preferred and why yearly during three years of study. Using a constructivist paradigm, thematic analysis was utilized to analyze free text responses to identify themes.

Results: Five common themes emerged among faculty and residents: continuity, patient safety, focus, wellness, and education. Although most themes and subthemes reflected the positive effects of X+Y scheduling, some negative elements were uncovered, including how continuity of scheduling is viewed by faculty.

Conclusions: Residents and faculty shared common themes in their preference for X+Y scheduling, and these themes were consistent whether they viewed X+Y as a positive or negative change. As pediatric programs adjust schedules to align with accreditation requirements, understanding why X+Y scheduling impacts faculty and residents can assist with implementation.

Objective: Social determinants of health (SDOH) are nonmedical factors that impact health and well-being. Primary care clinics have implemented screening for SDOH, but system-wide programs that reach multiple clinics remain limited in pediatric settings. This study evaluates the system-wide implementation of a SDOH screening and resource referral program at 8 community-based pediatric primary care clinics.

Methods: The SDOH program, which is built into the electronic health record (EHR), was piloted at a large, academic-based clinic. Implementation strategies from the pilot were used in this study. Implementation was evaluated with the RE-AIM framework. Data was collected from the EHR and surveys of the clinic practice managers.

Results: During the implementation phase (07/01/23-12/31/23), all 8 community-based clinics supported adoption of the program. Five clinics identified champions, and 4 completed training and adopted quality assurance processes. During the maintenance phase (01/01/24-09/30/24), there were 14590 well child visits across all clinics, and 9818 (67.3%) completed screening. SDOH screening rates varied between clinics (21.6% - 95.9%). Clinics tended to maintain their screening rates over time. 2542 patient caregivers (25.9%) who completed screening were positive for at least one SDOH domain. Most clinics reported using a combination of resource lists (78%) or referrals (89%) to address positive screens. 67% of clinics reported the screening took less than 5 minutes per patient and addressing positive screens took 5 minutes or less.

Conclusions: The EHR-based SDOH screening and resource referral program was effectively expanded to multiple community-based pediatric primary care clinics, and screening rates were maintained over time.

Objective: Many young children with isolated skull fractures are referred to child protective services (CPS) despite being assessed to have a low likelihood of abuse. We sought to identify factors associated with CPS referrals in this population and to quantify hospital-level variation.

Methods: We performed a multicenter retrospective cross-sectional study of children <2 years with skull fractures with or without a small underlying intracranial hemorrhage (ICH) and no additional injuries undergoing a child abuse pediatrics (CAP) subspecialty evaluation. We explored associations between demographic factors, clinical characteristics, psychosocial risk factors, and hospital site with CPS referral status. We performed multivariable logistic regression, adjusting for transfer status and all significant covariates from unadjusted analyses. We utilized marginal standardization to calculate the estimated probability of CPS referrals at each site, adjusting for all factors in the final model.

Results: Of 528 children, 303 (57.4%) were referred to CPS, with 86.5% referred prior to CAP consultation. In multivariable logistic regression, presence of psychosocial risk factors (OR 4.00; 95% CI 2.25, 7.11), in-person CAP consult (OR 3.93; 1.61, 9.62), inflicted or no trauma history provided (OR 6.15; 3.30, 11.45), absence of ICH (OR 2.03; 1.26, 3.27), and site were significantly associated with CPS referral. After adjustment for case-mix, the percentage of children referred to CPS ranged from 34.6% to 76.4% across sites.

Conclusions: We found a two-fold variation in CPS referrals based on site. Most referrals occurred prior to CAP involvement. These findings support the need for increased guidance regarding indications for referral.

Background: Effective communication between providers and patients/families is essential for optimal health outcomes, especially for children with medical complexity (CMC). Pediatric residents' perspectives on facilitators of and barriers to communication with families of CMC could help inform targeted approaches to training and skill development.

Objective: To explore pediatric residents' reflections on facilitators and barriers of effective communication with families of CMC during clinical encounters.

Methods: We conducted a thematic analysis of semi-structured interviews with senior pediatric residents. The interview guide was informed by literature review and consensus of experts including family partners. Data collection and analysis continued iteratively until thematic sufficiency was reached. We obtained participant demographic data at the time of enrollment.

Results: Eleven senior pediatric residents participated in this study, most of whom had previous experience on inpatient and/or outpatient complex care clinical rotations. Themes included factors affecting communication related to families of CMC (health literacy, expertise, teaching), residents (bias, emotion, experience), and context (distractions and time constraints in acute settings, continuity), as well as communication strategies that enable clinical partnership (humanizing, exploring incongruence, active listening, collaboration, systematic approach). Themes aligned with constructs related to shared decision-making models.

Conclusions: Our findings highlight important factors that residents perceive as affecting meaningful communication with families of CMC during clinical encounters. Residents' reflections centered around opportunities to engage in shared decision-making with families as members of the care team. Communication strategies that were noted to be effective may inform future curricula to support patient/family-centered care for CMC.

Objective: The study investigated the effects of an early childhood caries (ECC) intervention on the need for dental treatment in Indigenous Australian Children. We hypothesized that exposure to an early intervention program would reduce the need for dental treatment among Indigenous children.

Methods: This randomized controlled trial allocated 448 pregnant women with an Aboriginal child to either an immediate (II) or delayed (DI) intervention group between January 2011 and May 2012. There were four components to the ECC intervention: 1) Dental care during pregnancy, 2) Anticipatory Guidance and 3) Motivational interviewing for mothers, and 4) Fluoride Varnish Application for children. The outcome was having dental treatment over five years. Bivariate log-Poisson regression models were used to estimate prevalence ratios (PRs) and 95% confidence intervalence (CI). Sensitivity analyses were performed to assess the strength of the ECC intervention in reducing dental treatment by using imputed data.

Results: Data were available for 181 in II and 186 in DI children aged 5 years. Children in the DI group had twice the prevalence (PR=2.00; 95% CI: 1.13-3.51) of having dental treatment compared to the II group. A higher prevalence of having dental treatment was positively associated with families residing in non-metropolitan areas, children with higher sweet food consumption and mothers with lower oral health literacy.

Conclusion: The study suggests that early intervention in infancy can decrease the need for dental treatment by age 5 years, potentially reducing the burden for children, families and Aboriginal communities.