Academic Pediatrics最新文献

Objective: To understand the association between food insecurity (FI) and housing insecurity (HI) risk, the effects of the COVID-19 pandemic on health-related activities among children with overweight or obesity, and caregivers' and clinicians' challenges and priorities related to pediatric weight management.

Methods: We conducted surveys with caregivers of children with overweight and obesity and pediatric clinicians at two academic medical centers in the Greater Boston area. We used multivariable logistic regression models to examine associations between FI and HI risk and the effects of the COVID-19 pandemic on health-related activities and descriptive statistics to summarize caregivers' and clinicians' challenges and priorities related to pediatric weight management.

Results: We analyzed data from surveys with 344 caregivers and 100 pediatric clinicians. Overall, 37% of caregivers endorsed both FI+HI, 18% FI alone, 10% HI alone, and 35% neither FI/HI. In the adjusted logistic regression models, combined FI+HI (reference: neither FI/HI) was significantly associated with higher odds of sleeping less (aOR 2.96 [95% confidence interval (CI): 1.46, 6.01]) and higher odds of spending less time outside (aOR 2.10 [95% CI: 1.06, 4.16]). Top priorities for pediatric weight management identified by both caregivers and clinicians were related to physical activity and availability of outdoor spaces.

Conclusions: Endorsement of both FI+HI was associated with children getting less sleep and spending less time outside during the COVID-19 pandemic. Future innovations in care plans for children with overweight and obesity should be adapted to a family's social context and should incorporate caregivers' and clinicians' challenges and priorities.

What's new: This qualitative analysis offers an actionable, stepwise approach to remediation.

Introduction: The goal of graduate medical education is for trainees to develop the competence needed to practice independently; however, some residents struggle to achieve competency and require remediation. Evidence around how to best facilitate remediation is lacking. The objective of this study was to understand best practices for remediation in pediatrics.

Method: A national web-based survey of pediatric residency program directors (PDs) on remediation practices was performed. The survey included 3 open-ended questions about PDs' experiences with remediation. Self-reported barriers to and strategies for remediation were systematically analyzed using inductive thematic analysis to develop a theory of effective remediation in pediatric residency training.

Results: A total of 99 out of 195 (50.8%) program directors responded. Two main themes emerged: developing a personalized plan that ensures competency attainment and fostering psychological safety. Twelve categories outline actionable steps that PDs can take to make the remediation process successful.

Discussion: Built from insight from pediatric PDs, we propose a conceptual model for effective remediation that accounts for competency attainment while safeguarding the emotional health of the resident. The conceptual model breaks the remediation process down into four phases: identification of the learner who struggles, planning the remediation process, implementation of the plan, and assessing the outcome of the process.

Objective: Selective serotonin reuptake inhibitor (SSRI) prescribing is increasingly being integrated into primary care but few data are available about prescribing patterns by pediatric primary care clinicians (PCCs) following implementation of integrated behavioral health (BH) care.

Methods: Using administrative claims data, we performed a cross-sectional analysis of SSRI prescribing within a statewide pediatric primary care network over 10 years after initiation of an integrated BH program, calculating the rate of PCC and specialist SSRI prescribing. Using electronic health record data, we analyzed a proposed set of quality metrics for SSRI initiation.

Results: Over 10 years, SSRI prescribing by PCCs increased from 56 fills/1000 patient-years to 446; over the same time period, prescribing by specialists for the network's patients rose from 233 fills/1000 patient-years to 380. In 2013, PCCs prescribed 19% of all SSRIs while by 2022 they prescribed 54% of the total (P<0.001 for change for PCCs compared to specialists). Among 16272 initial SSRI prescribing events by PCCs, 99.6% prescribed a recommended SSRI; 97.5% used an appropriate starting dose; 55.2% documented a validated symptom rating scale at initiation; 53.4% had a contact within 14 days; 67.8% had a follow-up visit within 60 days; and 37.4% documented a symptom rating scale within 60 days.

Conclusions: In the first 10 years of a pediatric integrated BH program, SSRI prescribing by PCCs increased over seven-fold and surpassed specialist prescribing for the patient population. PCCs chose medications and starting doses appropriately but could improve their use of validated symptom rating scales and consistent follow-up.

Objectives: (1) To quantify hospital-level variation in use of neuroimaging to screen for intracranial injury (ICI) among infants without overt signs or symptoms of head trauma undergoing subspecialty evaluations for physical abuse; (2) to assess for disproportionality in neuroimaging based on race/ethnicity and insurance type.

Methods: This was a cross-sectional study of infants age <12 months receiving subspecialty child abuse evaluations from 02/2021 - 12/2022 at 10 sites in CAPNET, a multicenter child abuse research network. Infants were included if they underwent a skeletal survey and lacked overt signs of possible ICI or blunt head injury. Outcome was completion of neuroimaging (computed tomography [CT] or magnetic resonance imaging [MRI]). Multivariable logistic regression was used to assess associations between demographic, clinical, and hospital factors with neuroimaging use.

Results: Of 1,114 infants, 746 (67%) underwent neuroimaging ranging from 51% to 80% across CAPNET hospitals. In multivariable analysis, young age, presence of rib fracture(s), and site had significant associations with neuroimaging. Insurance type and race/ethnicity did not contribute significantly to the model. After adjustment for case-mix, there was significant variation across hospitals, with neuroimaging use ranging from 51% (95% CI: 43%, 59%) to 79% (95% CI 71%, 88%) CONCLUSION: We identified significant variation in neuroimaging use across CAPNET hospitals, highlighting the need for guideline development and care standardization during the care of infants undergoing abuse evaluations.

Objectives: Police violence is a public health crisis that disproportionately impacts youth of color, particularly Black youth. These disparities may also compel Black youth to engage in police avoidance (i.e., efforts to circumvent police contact and surveillance). Even so, research on Black youths' engagement in police avoidance is lacking. The present study is the first to investigate factors that may underpin police avoidance among Black youth.

Methods: Data come from the Survey of Police-Adolescent Contact Experiences (SPACE), a recent, cross-sectional, non-probability survey of Black youth (~52% male) aged 12-21 in Baltimore City (n = 345).

Results: Findings indicate that youth 1) identifying as bisexual or queer, 2) perceiving lower safety at home and in their neighborhoods, 3) reporting more negative attitudes about police, and 4) engaging in delinquent behaviors reported significantly greater police avoidance. Furthermore, youth who reported a greater number of known persons stopped by the police (e.g., family members, friends, neighbors) and had personally experienced officer intrusion during direct or witnessed stops (e.g., harsh language, threats of force, use of force) also exhibited greater police avoidance.

Conclusions: LGBQ identity, reduced perceptions of environmental safety, negative attitudes about police, delinquent behaviors, and multiple types of police exposure may shape police avoidance among Black youth. Findings have the potential to inform targeted strategies to mitigate racial and LGBQ disparities in adolescent well-being.

Clinical trial registration: None.

Objectives: Children who experience socioeconomic adversity often have worse health; however, less is known about their quality of care. We sought to evaluate the association between parent/caregiver-reported socioeconomic adversity and quality of pediatric primary, acute, and chronic ambulatory care on a national level.

Methods: This was a retrospective cohort study of 5368 representative US children (1-17 years) in the 2021 Medical Expenditure Panel Survey. Socioeconomic adversity was defined as parent/caregiver-reported food, housing, transportation, or utility insecurity in the past 12 months. Outcomes included 10 quality measures of primary, acute, and chronic care, and experience of care measured through parent/caregiver survey. We described variation in socioeconomic adversity and used multivariable regression to examine associations with quality outcomes.

Results: One-third of parent/caregivers reported socioeconomic adversity. Food insecurity (23.6%) was most common followed by utility (19.5%), housing (15.0%), and transportation (4.7%) insecurity. Black (53.2%) and Hispanic (46.9%) parent/caregivers experienced the highest rates of socioeconomic adversity. Children with socioeconomic adversity received lower quality of care for four quality measures, including more frequent Emergency Department visits (Odds Ratio (OR)= 1.69 [95% Confidence Interval (CI): 1.28-2.23]), less favorable asthma medication ratio (OR=0.04 [95% CI: 0.01-0.31]), and less frequent well child (OR=0.73 [95% CI: 0.59-0.90]) and dental care (OR=0.76 [95% CI: 0.63-0.94], P < .05 for all). There were no statistically significant differences in experience of care.

Conclusions: Socioeconomic adversity is common among US children with disproportionate impact on Black and Hispanic families. There are significant disparities in pediatric primary, acute, and chronic care quality, based on parent/caregiver-reported socioeconomic adversity, highlighting the need for systems-level interventions.

Objective: Human papillomavirus (HPV) vaccine uptake remains suboptimal among US adolescents. A cluster randomized trial was conducted at six primary care practices in southeast Minnesota to assess the impact of parent reminder-recall letters and provider audit-feedback reports on 11-12-year-old HPV vaccine uptake. Audit-feedback reports included access to a web toolkit with instruction on two communication approaches. We evaluated the process of the audit-feedback report intervention to inform future adaptations.

Methods: We sent a survey to providers assigned to the intervention and asked about their use and perceptions of the reports, web toolkit, the communication approaches, and HPV vaccine recommendation.

Results: Surveys from 95 providers were analyzed. Most (97.9%) recalled receiving audit-feedback reports, with 92.4% finding them somewhat to very easy to understand, 86% somewhat to very familiar with their content and objectives, and 69.9% using them five or more times in the past year. Few respondents (11.6%) recalled receiving access to the web toolkit. Web analytics showed that the toolkit was rarely used. Most reported familiarity with communication approaches but less than half reported that these positively impacted the tone of the clinical encounter. Higher familiarity with audit-feedback reports (OR=2.58) and perceived peer approval about using presumptive language (the first of two communication approaches) to recommend HPV vaccination (OR=2.16) correlated with higher frequency of vaccine recommendation.

Conclusions: Implementation of the audit-feedback reports showed good acceptability. Low utilization of the web toolkit suggests a need to further examine provider preferences on delivery and usability of training materials.

Objective: Measures of neighborhood disadvantage demonstrate correlations to health outcomes in children. We compared differing indices of neighborhood disadvantage with emergency medical services (EMS) interventions in children.

Methods: We performed a retrospective study of EMS encounters for children (<18 years) from approximately 2000 US EMS agencies between 2021 and 2022. Our exposures were the Child Opportunity Index (COI; v2.0), 2021 Area Deprivation Index (ADI), and 2018 Social Vulnerability Index (SVI). We evaluated the agreement in how children were classified with each index using the intraclass correlation coefficient. We used logistic regression to evaluate the association of each index with transport status, presence of cardiac arrest, and condition-specific interventions and assessments.

Results: We included 738,892 encounters. The correlation between the indices indicated good agreement (intraclass correlation coefficient=0.75). There was overlap in relationships between the COI, ADI, and SVI for each of the study outcomes, both when visualized as a splined predictor and when using representative odds ratios (OR) comparing the third quartile of each index to the lower quartile (most disadvantaged). For example, the OR of non-transport was 1.12 (95% confidence interval [CI]: 1.10-1.14) for COI, 1.18 (95% CI: 1.16-1.20) for ADI, and 1.22 (95% CI: 1.20-1.23) for SVI.

Conclusion: The COI, ADI, and SVI had good correlation and demonstrated similar effect size estimates for a variety of clinical outcomes. While investigators should consider potential causal pathways for outcomes when selecting an index for neighborhood disadvantage, the relative strength of association between each index and all outcomes was similar.