Academic Pediatrics最新文献

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.

Background: Primary care physicians (PCPs) may rely upon factors other than screening test scores in making referral decisions to developmental services. This study investigated which patient, provider, and screening test factors predict a PCP's IDEA Part C Early Intervention (EI) referral after a positive screening test result.

Methods: Child demographics, developmental screening test results and EI referral decisions were collected via medical record review of 2756 15-, 18-, 24- and 30-month well-child checks conducted at seven community primary care clinics in four Oregon counties, in 2020-2021. A provider survey collected PCP demographic and professional characteristics. We tested the association of receipt of EI referral with screening test (Ages & Stages-3 [ASQ-3] and Modified Checklist for Autism in Toddlers - Revised [MCHAT-R]) scores, provider demographic information, child demographic data (sex, language, race and ethnicity), using multivariable logistic regression.

Results: Around 54% of children with positive MCHAT-R screens, and 42% of children with positive ASQ-3 screens received EI referrals. Multivariable analyses showed that MCHAT-R score, ASQ-3 Communication and Gross Motor scores were associated with referral after a positive screen. Child sex, race, ethnicity, and language, and provider demographics had no multivariable association with referral. Referral rates varied substantially by site and individual provider.

Conclusions: The majority of toddlers with positive developmental screens were not receiving EI referrals from their PCP during the COVID-19 pandemic. Screening test thresholds and clinical thresholds for EI referral differ substantially, and some portions of the ASQ-3 do not seem to impact provider referral decisions. These findings may help inform physician training on developmental screening in primary care, specifically during times of unprecedented health care challenges.

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.

Background: Children and youth with special health care needs (CYSHCN) may be at greater risk for accidental physical trauma. Interventions should be informed by the literature indicating incident characteristics and at-risk subpopulations.

Objective: To conduct a scoping review of accidental physical trauma in CYSHCN to characterize published literature and identify gaps.

Data sources: Peer-reviewed literature within CINAHL, Embase, and PubMed, 1998 to February 2021.

Study eligibility criteria: Studies that included individuals younger than 19 with special health care need(s) with accidental injuries classified as trauma.

Study appraisal and synthesis methods: The study team extracted: research method, author field, special health care needs, geographic scope, author country, demographics, incident characteristics, and injury characteristics.

Results: We included 85 articles from an initial yield of 10,481. Pediatrics (32%) was the most-represented field among authors published on this topic. Publications most often considered developmental conditions (77.7%), including Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder (ADD/ADHD). Studies differed in how often they reported demographic characteristics: gender (96.5%); social determinants of health/socioeconomic status (41.2%) or race and ethnicity (25.9%). Few articles included injury time of day (10.6%) and day of week (2.4%); 40% did not include information about the place of injury.

Limitations: Our search term development focused on diagnosis rather than need; we did not search reference lists or grey literature.

Conclusions and implications of key findings: This review reveals key gaps in the literature pertaining to incident characteristics and place of injury for CYSHCN. Those advising families and/or planning interventions focused on mitigating risk for CYSHCN have limited evidence upon which to rely for certain conditions.

Systematic review registration number: PROSPERO registration is not applicable to scoping reviews.

Objective: To examine associations between cognitive stimulation in the home at 6 months and maternal feeding styles at 24 months, direct intervention effects of Smart Beginnings (SB) on feeding styles, and potential indirect effects of SB on feeding styles via earlier intervention effects on cognitive stimulation.

Methods: Single-blind, two-site randomized clinical trial (RCT) of the SB intervention. SB integrates PlayReadVIP, a universal, pediatric primary care-based program, and Family Check-Up (FCU), a targeted secondary home-based parenting intervention. Mother-infant dyads (N = 327) were randomized at birth to standard pediatric care or the SB intervention. Linear regression analyses determined associations between cognitive stimulation at 6 months and maternal feeding styles at 24 months, a secondary data analysis. Direct intervention impacts on feeding styles, a secondary RCT outcome, were also assessed and mediation analyses explored intervention effects on feeding styles via earlier intervention impacts on cognitive stimulation.

Results: Cognitive stimulation was significantly associated with higher responsive and lower indulgent feeding styles. SB mothers were less likely to exhibit pressuring styles compared with controls (Effect Size [ES]=-0.12, P = 0.02). Although no direct intervention effects were found on responsive or indulgent feeding styles, indirect effects of SB were evident on these feeding styles through intervention-induced increases in cognitive stimulation in the SB group.

Conclusions: This study found positive linkages between cognitive stimulation in the home and later feeding styles. Additionally, the SB intervention was associated with less pressured feeding and indirect pathways mediated by intervention effects on cognitive stimulation. Implications for early childhood parenting interventions are discussed.

Background: A significant proportion of US families are affected by substance use disorders. Both child- and adult- serving systems are called upon to care for families, yet the disciplines involved inherently have different priorities, preventing a true family-centered care model.

Objectives: The purpose of the scoping review was to explore the alignment of current national guidance related to the medical care of families affected by substance use disorders (SUD). In the review, we examined 1) the quality of the documents, 2) the documents' positions within the continuum of family-centered care and the promotion of multidisciplinary collaboration, and 3) potential gaps in the promotion of services for families.

Methods: We chose a priori to manually examine the websites of national medical and public health associations for clinical practice and policy recommendations. We included documents published between 2016 and 2023 with selected keywords, totaling seven documents for review. We operationalized and rated each document's recommendations based on their promotion of "family-centered care" and "multidisciplinary collaboration."

Results: The quality of each document varied, with an average score of 5.2 out of 7. The average family-centeredness rating was 3.0 out of 7; five of the seven documents prioritized the parent's care over the child's. The average multidisciplinary collaboration rating was 2.8 out of 7.

Conclusions: Overall, we found low to moderate family-centered and multidisciplinary collaboration scores. Collectively, these findings suggest that despite these practices emerging as optimal for the care of families affected by SUD, the promotion of these practices has yet to be fully adopted in guidance statements by national medical disciplines.

Objective: Organization-sponsored interventions have the potential to promote, and destigmatize seeking help for, wellbeing. Our study objective was to explore the acceptability and feasibility of a coaching intervention to improve wellbeing among faculty.

Methods: We conducted a pilot, pre/post design, study in a convenience sample of pediatric faculty at an academic medical center. Participants were offered ≤6 live virtual coaching sessions at the participant's discretion. In addition, a novel wellbeing individual development plan (WB-IDP) was distributed to participants. Primary outcomes were feasibility of the intervention, defined as completing ≥1 coaching session and acceptability measured by anonymous feedback and use of the WB-IDP. Secondary outcomes were wellbeing (WHO Wellbeing Index (WHO-5)), stress (Perceived Stress Scale (PSS)), and work engagement (Utrecht Work Engagement Scale (UWES)), at baseline, 3, and 6 months.

Results: All enrollees (N = 28) completed at least one, 18/28 (64%) completed at least four, and 9/28 (32%) completed six coaching sessions. Of 28 participants, 11 (39%) started a WB-IDP and 5/28 (18%) completed and implemented the plan. The aggregate WHO-5 score showed a statistically significant change from baseline (53.3) to month 6 (64.3) (P < .01). Fourteen 14/27 (52%) participants had an improvement of ≥10 points in WHO-5 score between baseline and month 6. No other significant changes were observed.

Conclusions: Individualized certified coaching for wellbeing was successfully implemented and associated with a significant increase in wellbeing. We speculate that wellbeing coaching can be promoted by faculty development programs in university and health care settings and has potential to improve organizational outcomes.

Clinical trial registration: Pediatrician Wellbeing Program, NCT04805294, https://clinicaltrials.gov/ct2/show/NCT04805294?term=pediatrician&cond=wellbeing&cntry=US&state=US%3ANC&draw=2&rank=1.

Objective: This study estimates and compares variation in the probability of child unmet need for mental health care and difficulties accessing care for each state in the United States. Estimates are also generated and compared for three socioeconomic and demographic subgroups nationwide: racial and ethnic group, household income, and insurance type.

Methods: Using a retrospective, cross-sectional design, this study pooled 2016-2019 National Survey of Children's Health data. National, state, and subgroup adjusted probabilities of caregiver-reported child unmet need for mental health care and ease of access to mental health care were generated from logistic regression models with marginal post-estimation.

Results: Adjusted national probabilities of caregiver-reported child unmet mental health need and difficulty in accessing care were 0.21 and 0.46, respectively. State probabilities of unmet need ranged from 0.08 to 0.32. One state was significantly above the national estimate; nine states were below it. State probabilities of difficulty accessing mental health care ranged from 0.28 to 0.57; nine states' probabilities were significantly below the national estimate and two states were significantly above it. Estimates of unmet mental health need and difficulty accessing care varied more widely across states than across racial or ethnic groups, income groups, insurance groups.

Conclusions: Geographic inequities in children's mental health care access persist; in some cases, they are larger than sociodemographic inequities.