Academic Pediatrics最新文献

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.

Objective: 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=.9h/d, 23%), medium (mean=3.0h/d, 56%), and high (mean=6.38h/d, 21%) screen time groups. Children completed assessments of inhibitory control and cognitive flexibility at age 5.5. Both tasks are from the National Institute of Health 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 CR assessment and identification of trainee deficiencies in this area.

Methods: Taking a social constructionist worldview, we conducted a thematic analysis of 20 semistructured 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 the 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.