Pediatric caregiver attitudes toward email communication: survey in an urban primary care setting.

BACKGROUND: Overall usage of email communication between patients and physicians continues to increase, due in part to expanding the adoption of electronic health records and patient portals. Unequal access and acceptance of these technologies has the potential to exacerbate disparities in care. Little is known about the attitudes of pediatric caregivers with regard to their acceptance of email as a means to communicate with their health care providers. OBJECTIVE: We conducted a survey to assess pediatric caregiver access to and attitudes toward the use of electronic communication modalities to communicate with health care providers in an urban pediatric primary care clinic. METHODS: Participants were pediatric caregivers recruited from an urban pediatric primary care clinic in Baltimore, Maryland, who completed a 35-item questionnaire in this cross-sectional study. RESULTS: Of the 229 caregivers who completed the survey (91.2% response rate), 171 (74.6%) reported that they use email to communicate with others. Of the email users, 145 respondents (86.3%) stated that they would like to email doctors, although only 18 (10.7%) actually do so. Among email users, African-American caregivers were much less likely to support the expanded use of email communication with health care providers (adjusted OR 0.34, 95% CI 0.14-0.82) as were those with annual incomes less than US $30,000 (adjusted OR 0.26, 95% CI 0.09-0.74). CONCLUSIONS: Caregivers of children have access to email and many would be interested in communicating with health care providers. However, African-Americans and those in lower socioeconomic groups were much less likely to have positive attitudes toward email.

Pediatric caregiver attitudes and technologic readiness toward electronic follow-up communication in an urban community emergency department.

OBJECTIVE: Follow-up of pediatric patients after an emergency department (ED) visit is important for monitoring changes in patient health and informing patients of test results conducted during the visit. The telephone has been the standard method of communication, but contact rates are poor. We conducted a survey to assess pediatric caregiver attitudes toward and access to alternate electronic communication modalities after a pediatric ED encounter. SUBJECTS AND METHODS: Participants (n=102) were recruited from an urban community ED and completed a 35-item questionnaire in this cross-sectional study. RESULTS: The majority of pediatric caregivers have Internet access in their home (72%), although less than half check e-mail daily (46%). A larger percentage owns a cell phone (90%) and checks text messages daily (87%). The majority agree that more doctors should communicate by e-mail (70%), and nearly half (45%) would like to receive test results by text message. CONCLUSIONS: Caregivers of children have access to the Internet and mobile phone technologies, and many would be interested in communicating with healthcare providers following an ED visit. Cell phone and text-messaging technologies appear to be more available than e-mail and may serve as an underutilized contact method. A combination of modalities directed by caregiver preferences may improve ED follow-up contact rates.

Characteristics of children eligible for public health insurance but uninsured: data from the 2007 National Survey of Children's Health.

To describe the state variation, demographic and family characteristics of children eligible for public health insurance but uninsured. Using data from the National Survey of Children's Health we selected a subset of children living in households with incomes <200 % of the federal poverty level, who are generally eligible for Medicaid or CHIP. We used multiple logistic regression to examine associations between insurance status among this group of eligible children and certain demographic factors, family characteristics, and state of residence. In adjusted models children aged 6-11 and 12-17 years were more likely to be eligible but uninsured compared to those aged 0-5 years (AOR 1.57; 95 % CI 1.15-2.16 and AOR 1.93; 95 % CI 1.41-2.64). Children who received school lunch (AOR 0.67; 95 % CI 0.52-0.86) and SNAP (AOR 0.33; 95 % CI 0.24-0.46) were less likely to be eligible but uninsured compared to those children not receiving those needs based services; however, a majority (58.7 %) of eligible uninsured children were enrolled in the school lunch program. Five states (Texas, California, Florida, Georgia, New York) accounted for 46 % of the eligible uninsured children. Vermont had the lowest adjusted estimate of eligible uninsured children (3.6 %) and Nevada had the highest adjusted estimate (35.5 %). Using nationally representative data we have identified specific state differences, demographic and household characteristics that could help guide federal and local initiatives to improve public health insurance enrollment for children who are eligible but uninsured.

Characteristics of Children Diagnosed With SARS-CoV-2 in the Ambulatory Setting.

The objective of this study was to characterize the clinical presentation and outcomes of children and adolescents testing positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the ambulatory setting. We found that about 8% of children tested positive for SARS-CoV-2, with the large majority being symptomatic (80%). The average age of our population was 12.5 years, and females and males were affected equally. However, African American patients (62%) were substantially more likely to test positive compared with other races. Children in this study tended to have a mild course, mostly presenting with respiratory symptoms, and very few required hospitalization. As the epidemiology of the pandemic evolves, it will be important to monitor the effects that changing variants have on infected children and the impact that vaccination programs have on mitigating infection risk.

Patient Centered Medical Home Cooking: Community Culinary Workshops for Multidisciplinary Teams.

Ideal management of chronic disease includes team based primary care, however primary care medical staff face a lack of training when addressing nutritional counseling and lifestyle prevention. Interactive culinary medicine education has shown to improve knowledge and confidence among medical students. The aim of this study was to determine whether a culinary medicine curriculum delivered to a multidisciplinary team of primary care medical staff and medical students in a community setting would improve self-reported efficacy in nutritional counseling and whether efficacy differed between participant roles. A 4-h interactive workshop that took place within the neighborhood of a primary care medical home was delivered to medical staff and students. Participants completed a voluntary questionnaire before and after the workshop that addressed participants' attitudes and confidence in providing nutritional counseling to patients. Chi-square tests were run to determine statistically significant associations between role of participant and survey question responses. Sign Rank tests were run to determine if pre-workshop responses differed significantly from post-workshop responses. Thirteen of seventeen responses related to attitudes and efficacy demonstrated significant improvement after the workshop compared with prior to the workshop. Significant differences noted between roles prior to the workshop disappear when asking the same questions after the workshop. Delivery of culinary medicine curricula to a primary care medical home team in a community setting is an innovative opportunity to collaboratively improve nutritional education and counseling in chronic disease prevention.

Knowledge and management of fever among Latino parents.

Fever is a common childhood condition that is often misunderstood and incorrectly managed by parents. This study uses a questionnaire about fever administered to a convenience sample of Spanish-speaking-only parents bringing their child to a hospital-based urban pediatric clinic. The questionnaire elicits information about definition and cause of fever, concerns about fever, methods of temperature measurement, and treatment modalities used by the parents. Latino parents have numerous misconceptions about fever and its role in illness. Educational interventions should target fever definition, clarification of cause and potential harm of elevated temperatures, temperature monitoring, and safe treatment modalities. Owning a thermometer is strongly associated with correct knowledge of temperature values. Providing parents with a thermometer and educating them about its proper use may lead to an increase in appropriate monitoring and medical treatment of the febrile child.

Promoting reading in children: do reading practices differ in children with developmental problems?

OBJECTIVE: The objective of this study was to describe and compare reading practices in caregivers of children with developmental/behavioral problems (DEV) to caregivers of children without developmental problems attending a general pediatric clinic (GEN). METHOD: Cross-sectional, convenience samples of 321 caregivers of DEV and GEN children self-report reading practices including amount of daytime and nighttime reading, TV viewing, and number of books in the house. Reading 4 or more days per week is the primary outcome. Multivariate logistic regression analysis was used to compare reading 4 or more days per week with specific predictors. Odds ratios and 95% confidence intervals were reported. RESULTS: Three hundred and twenty-one caregivers participated in the study (DEV 204, GEN 117). Mean number of books in home (51.1+/-49.9), TV viewing hours per day (2.6+/-2.0), and days or nights read per week (days, 4.9+/-2.1; nights, 4.0+/-2.4) did not differ by group. Caregivers reporting incomes at 200% above the federal poverty level (FPL) were more likely to engage in reading more than 4 days per week (odds ratio 5.32; 95% confidence intervals, 1.19, 23.81) after controlling for developmental status, caregiver education and age, and frequency of television viewing. CONCLUSION: Positive home reading practices were predicted by FPL in children with and without developmental or behavioral problems and while controlling for child group status (DEV or GEN), caregiver education and age, and amount of TV viewing. Reading promotion programs should focus on children from low socioeconomic environments regardless of disability risk status.

Coaching Primary Care Clinicians in the Ambulatory Setting: Direct Observation and Deliberate Practice.

BACKGROUND AND OBJECTIVES: Clinical coaching programs can improve clinician performance through feedback following direct observation and the promotion of reflection. This study assessed the feasibility and acceptability of a primary care coaching program applied in community-based practices. METHODS: Using a 31-item behavioral checklist that was iteratively revised, four faculty observed 18 community-based primary care clinicians (15 of whom were physicians) across 36 patient encounters. Each behavior was scored as a binary variable (observed or not observed). After watching them care for patients, each clinician participated in a focused feedback session to discuss strengths and areas for improvement. RESULTS: Behaviors observed with the highest frequency were: reflects compassion (100%), appears to enjoy caring for the patient (100%), leads and follows with open-ended questions (97%), and asks thoughtful and smart questions (95%). Areas for improvement were those behaviors done less commonly: apologizes for running behind schedule (18%), acknowledges computer and/or explains role in patient care (14%), and assesses understanding (teachback; 7%). Most clinicians agreed or strongly agreed that they would like to be coached again in the future (81%), and that the coaching feedback would help them become more effective in primary care practice (94%). Nearly all patients surveyed substantiated that it did not bother them to have another doctor in the room and that it is a good idea to offer coaching to clinicians to help them improve. CONCLUSIONS: Coaching busy primary care clinicians is feasible and a valued experience. Focusing on specific observable behaviors can identify clinicians' strengths and opportunities for improvement. Patients are pleased to learn that their clinicians are receiving coaching as part of their professional development.

Variability in the evaluation and management of opiate-exposed newborns in Maryland.

During 2003 and 2004 an estimated 2000 pregnant women and 31 000 nonpregnant women aged 15 to 44 reported using heroin. The majority of those newborns exposed in utero to opioids will develop symptoms of neonatal abstinence syndrome (NAS). Standardized guidelines for the evaluation and management of opiate-exposed newborns are lacking. The objective of this study was to document variations in the evaluation and management of opiate-exposed newborns among Maryland hospitals using a 13-item phone survey. Twenty-seven (82%) of the hospitals completed the survey. Staff at every hospital reported that they delivered opiate-exposed infants, however only 52% reported using a standardized evaluation and treatment protocol for this population consisting of guidelines for maternal toxicology screening, length-of-stay criteria and a monitoring tool for drug-exposed infants, infant supportive care techniques, and pharmacologic treatment guidelines. Significant variability exists in the evaluation and management of opiate-exposed newborns in Maryland. Validated, evidence-based guidelines are needed to standardize the care of these vulnerable newborns across all hospital settings.

Buprenorphine versus methadone in the treatment of pregnant opioid-dependent patients: effects on the neonatal abstinence syndrome.

This study was designed to compare the neonatal abstinence syndrome (NAS) in neonates of methadone and buprenorphine maintained pregnant opioid-dependent women and to provide preliminary safety and efficacy data for a larger multi-center trial. This randomized, double-blind, double-dummy, flexible dosing, parallel-group controlled trial was conducted in a comprehensive drug-treatment facility that included residential and ambulatory care. Participants were opioid-dependent pregnant women and their neonates. Treatment involved daily administration of either sublingual buprenorphine or oral methadone using flexible dosing of 4-24 mg or 20-100 mg, respectively. Primary a priori outcome measures were: (1) number of neonates treated for NAS; (2) amount of opioid agonist medication used to treat NAS; (3) length of neonatal hospitalization; and (4) peak NAS score. Two of 10 (20%) buprenorphine-exposed and 5 of 11 (45.5%) methadone-exposed neonates were treated for NAS (p=.23). Total amount of opioid-agonist medication administered to treat NAS in methadone-exposed neonates was three times greater than for buprenorphine-exposed neonates (93.1 versus 23.6; p=.13). Length of hospitalization was shorter for buprenorphine-exposed than for methadone-exposed neonates (p=.021). Peak NAS total scores did not significantly differ between groups (p=.25). Results suggest that buprenorphine is not inferior to methadone on outcome measures assessing NAS and maternal and neonatal safety when administered starting in the second trimester of pregnancy.

Parental beliefs and practices regarding early introduction of solid foods to their children.

This study was a cross-sectional survey of primary female caregivers during their child's 4-month well-child visit. Our objectives were to document current caregiver awareness of infant feeding guidelines, and calculate the frequency of and reasons for early introduction of solid foods. Questionnaires were completed for 102 children. Forty-five respondents (44%) introduced solids at less than 4 months of age. Hispanic caregivers, OR 0.2 (0.07-0.9), and those who breastfed (partial or exclusive), OR 0.4 (0.2-0.9), were less likely to introduce cereal at less than 4 months of age. Among caregivers who introduced solids at less than 4 months, 36 (80%) stated that the child was not satisfied with formula or breast milk alone and 24 (53%) stated that solids helped the child sleep better at night. Thirty-four caregivers (76%) who started solids at less than 4 months were aware of guidelines regarding proper infant feeding practices. Despite knowledge of infant feeding guidelines, female caregivers frequently introduce solids at less than 4 months of age. Early targeted anticipatory guidance is needed to address the most common reasons caregivers begin solid foods before the recommended age.

Pediatric observation status beds on an inpatient unit: an integrated care model.

OBJECTIVES: Describe the usage of observation status (OS) beds on a pediatric inpatient unit and identify diagnoses likely to be successfully discharged compared to those requiring formal inpatient admission. METHODS: Retrospective chart review of all patients (0-18 years) transferred to pediatric OS beds from the emergency department (ED) between April 1, 1997 and April 30, 1999. Outcome measures consisted of time interval between ED triage and arrival to an OS bed, total hours in observation, and need for admission or transfer. Using relative risk (RR), we compared admission rates for the 4 most common diagnoses. RESULTS: We studied 800 transfers to pediatric OS beds. Asthma (27%), gastroenteritis/dehydration (16%), infectious disease (12%), and bronchiolitis (9%) were the 4 most common diagnoses. There were 597 patients (75%) successfully discharged from observation and 174 (22%) required inpatient admission. Seventeen patients (2%) were transferred to a psychiatric facility and 12 patients (1%) were transferred to a tertiary care center for further evaluation and treatment. Compared to gastroenteritis/dehydration, patients with asthma were just as likely to be admitted/transferred (RR 1.05, 95% CI, 0.87-1.27), those with an infectious disease were 1.3 times more likely to be admitted/transferred (RR 1.35, 95% CI, 1.0-1.83), and those with bronchiolitis were 2 times more likely to be admitted/transferred (RR 1.92, 95% CI, 1.34-2.74). CONCLUSIONS: We describe the usage of OS beds in a community hospital that we believe can be a successful model for the care of pediatric patients. Future studies are needed to delineate the clinical characteristics of patients that would benefit from this care delivery model.

Clinical excellence in pediatrics.

The 7 core domains of clinical excellence in academic medicine, as defined by the Miller-Coulson Academy of Clinical Excellence at Johns Hopkins, are applicable to the field of pediatrics. The authors use published case reports and teaching models from the pediatric literature to illustrate how thoughtful clinicians have realized distinction in each of the 7 clinical excellence domains, recognizing excellent pediatric patient care serves to strengthen all 3 arms of the tripartite academic mission. Clinicians who feel valued by their institution may be more likely to remain in an academic clinical setting, where they promote the health and well-being of their patients, provide support to families and caregivers, serve as role models for pediatric trainees, and integrate research into their practice with the overall aim of improving patient outcomes.

Electrocardiogram interpretation skills in pediatric residents.

OBJECTIVE: The primary objective of this study was to evaluate pediatric residents' ability to correctly identify electrocardiogram (ECG) findings and pair them to a corresponding cardiac diagnosis. METHODS: Forty-six pediatric residents from the Johns Hopkins Children's Center were surveyed to evaluate their ability to interpret ECGs and factors affecting that ability. Included in the survey was a packet of 10 patient vignettes each accompanied by a 12-lead ECG. The primary outcome variable was the resident's score of correctly paired ECG findings with the appropriate cardiac diagnosis. One point was given for each pair correctly identified for a maximum of 10 points. Simple and multiple linear regression was used to estimate the magnitude and significance of any association between score of correct responses and resident year, completion of a pediatric cardiology rotation, self-rated ability to read ECGs, and training received in reading ECGs. RESULTS: The mean number of correct ECG findings and cardiac diagnosis pairings out of 10 for the PGY 1 group was 4.1 +/- 3, PGY 2 group 4.9 +/- 2.9, PGY 3 group 6.6 +/- 2, and the PGY 4 group 6.8 +/- 1.7. In the unadjusted linear regression model, the PGY 3 group correctly identified 2.4 more pairings compared to the PGY 1 group (P =0.02). Those who completed a pediatric cardiology rotation correctly identified 2.5 more pairings compared to those who did not complete a rotation (P=0.001). CONCLUSIONS: ECG interpretation significantly improved from PGY 1 to PGY 3. Educational programs involving ECG interpretation should target those diagnoses with high clinical severity and average to poor resident knowledge.

Assessment of risk of bias among pediatric randomized controlled trials.

OBJECTIVE: The goal was to assess the risk of bias among pediatric, randomized, controlled trials (RCTs) reported in 8 high-impact journals. METHODS: We searched PubMed for all pediatric RCTs reported between July 1, 2007, and June 30, 2008, in 8 journals with high impact factors. Using Cochrane Collaboration methods for risk assessment, we evaluated all reports for risk of bias according to domain (ie, randomized sequence generation, allocation concealment, masking, incomplete outcome data, selective outcome reporting, and other). We used multiple logistic regression to test for associations between the presence of a high risk of bias according to domain and funding source, intervention type, trial registration, and multicenter status. RESULTS: Industry-funded RCTs were more likely to show a high risk of bias for sequence generation, compared with government-funded RCTs (adjusted odds ratio [aOR]: 6.1 [95% confidence interval [CI]: 1.70- 21.89]), and behavioral/educational trials were more likely to show a high risk of bias for sequence generation (aOR: 2.8 [95% CI: 1.06-7.36]) and allocation concealment (aOR: 4.09 [95% CI: 1.69-9.90]), compared with drug trials. Registered trials were less likely to have a high risk of bias for sequence generation, compared with nonregistered trials (aOR: 0.33 [95% CI: 0.15-0.71]). CONCLUSIONS: Overall, we found a large proportion of pediatric RCT reports with a high risk of bias for sequence generation and allocation concealment. Factors associated with a high risk of bias included industry funding and assessment of behavioral/educational interventions, whereas trial registration was associated with a lower risk of bias.

Neonatal abstinence scores in opioid-exposed and nonexposed neonates: a blinded comparison.

Twenty-nine opioid-exposed and 26 nonopioid-exposed neonates received neonatal abstinence syndrome (NAS) assessment by an examiner blinded to group status twice daily over the first two postnatal days. The opioid-exposed group had higher mean NAS scores than the nonopioid-exposed group. A 3-sign index, consisting of hyperactive moro reflex, mild tremors when undisturbed, and increased muscle tone, showed excellent discrimination between groups. The use of a 3-sign screening index in the days immediately after birth may provide a cost-effective mechanism for the identification of opioid-exposed infants, particularly in infants of women for whom identification of status as a substance user may not be immediately evident. Although a potentially useful screening tool, the 3-sign screening tool should not replace the full assessment of the opioid-exposed infant after birth.

Ethnic differences in parental perceptions and management of childhood fever.

To explore knowledge and management of childhood fever among ethnically diverse parents and identify opportunities for educational intervention, we administered a cross-sectional survey to a convenience sample of 487 parents of children enrolled in 2 urban hospital-based pediatric clinics. Outcomes included parental definition of fever, level of concern, and management of fever. Latino parents were least likely to identify a temperature as nonfebrile from 97-100.3 degrees F (adjusted odds ratios [AOR] 0.06) or identify a fever as a temperature from 100.4-107 degrees F (AOR 0.52). African Americans were least likely to believe that fever can cause death or brain damage (AOR 0.4). African Americans were more likely to dose ibuprofen more frequently than recommended (AOR 1.97). All ethnicities are equally likely to treat normal temperatures and dose acetaminophen too frequently.Therefore continued education of all families about fever is necessary, and there are opportunities to develop ethnically sensitive strategies to target educational interventions.

Association of bicycling and childhood overweight status.

OBJECTIVES: Obesity is the most common chronic disease of childhood. Although it is accepted that diet and exercise practices are important, there is little data to discern the contributions of specific activities toward a healthy body weight. We sought to identify associations between bicycling and overweight status and to compare this with other physical activities and dietary practices thought to be protective against overweight status. METHODS: We constructed a survey to gather dietary and activity practices in a cross-sectional, convenience sample of 100 children presenting to an urban hospital setting in Baltimore, Maryland. We chose to emphasize bicycling because it is a widely available activity that requires a sustained level of moderate energy expenditure, yet little is known about the relationship of this particular activity with childhood overweight status. RESULTS: The mean age of our population was 11.8 years and 56% were overweight (body mass index>85 percentile). Most (96%) knew how to ride a bike and 80% reported owning a bike. Children who rode a bike just once a week or less were the most likely to be overweight (multivariate-adjusted odds ratio 6.6, 95% confidence interval, 2.1-21). This association was stronger than for all other dietary and activity practices. We found that approximately half of our participants do not eat breakfast, fruits, or vegetables regularly. More than half never ride a bike to school, walk to school, or participate in any organized sport. CONCLUSIONS: Riding a bicycle at least 2 or more days during the week is associated with a decreased likelihood of being overweight during childhood.