Pediatrician Adherence to Guidelines for Diagnosis and Management of High Blood Pressure.

OBJECTIVES: To assess pediatrician adherence to the 2017 American Academy of Pediatrics' clinical practice guideline for high blood pressure (BP). STUDY DESIGN: Pediatric primary care practices (n = 59) participating in a quality improvement collaborative submitted data for patients with high BP measured between November 2018 and January 2019. Baseline data included patient demographics, BP, body mass index (BMI), and actions taken. Logistic regression was used to test associations between patient BP level and BMI with provider adherence to guidelines (BP measurement, counseling, follow-up, evaluation). RESULTS: A total of 2677 patient charts were entered for analysis. Only 2% of patients had all BP measurement steps completed correctly, with fewer undergoing 3-limb and ambulatory BP measurement. Overall, 46% of patients received appropriate weight, nutrition, and lifestyle counseling. Follow-up for high BP was recommended or scheduled in 10% of encounters, and scheduled at the appropriate interval in 5%. For patients presenting with their third high BP measurement, 10% had an appropriate diagnosis documented, 2% had appropriate screening laboratory tests conducted, and none had a renal ultrasound performed. BMI was independently associated with increased odds of counseling, but higher BP was associated with lower odds of counseling. Higher BP was independently associated with an increased likelihood of documentation of hypertension. CONCLUSIONS: In this multisite study, adherence to the 2017 American Academy of Pediatrics' guideline for high BP was low. Given the long-term health implications of high BP in childhood, it is important to improve primary care provider recognition and management. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03783650.

Time to Stable Dose of Psychostimulants in Pediatric Patients With ADHD.

OBJECTIVES: The prevalence of attention-deficit/hyperactivity disorder (ADHD) is increasing and psychostimulants are the pharmacological standard of care. Patients benefit most when there is efficient titration to a stable dose of medication as defined by maintaining that same dose for 6 months. The aims of this study were to describe time to stable dose in a cohort of children with ADHD and examine the impact of demographic factors. METHODS: A list of pediatric patients with a diagnosis of ADHD in the electronic health record was generated, and a retrospective chart review of stimulant use was conducted on 500 patients randomly selected from 2010 to 2015 who met inclusion criteria. Time to stable dosing and its association with demographic characteristics were assessed. RESULTS: Patients were predominantly male (72%), white (81%), and privately insured (67%). Fifty-five percent of patients achieved a stable dose of medication on first attempt; therefore, the median time to stable dosing for the cohort was 0 days with the interquartile range being 0 to 133.8 days. There was significant increase in time to stable dose for patients younger than 10 years compared with those ≥10 years of age (p = 0.01). Time to stable dose was not significantly associated with race (p = 0.13), sex (p = 0.72), type of insurance (p = 0.56), or formulation being immediate or extended release (p = 0.56). CONCLUSIONS: Many patients had long titration periods when trying to reach a stable dose. Given that medication switching can be challenging for patients and families, more frequent contact with providers during titration may be necessary.

Home monitoring for COVID-19.

Cleveland Clinic recognized the importance of mitigating community transmission of COVID-19 by keeping people at home. Patient-care activities quickly pivoted to remote touches, preserving continuity through a variety of digital and telephonic modalities. As the number of confirmed cases grew, standardizing home-based care became critical to managing high-risk patients, moderating the risk of exposure for healthcare workers, and reducing the amount of community spread through appropriate education on home-based care for exposed or infected individuals. This novel, team-based approach to caring for patients with COVID-19 incorporates a self-monitoring app for patient engagement, monitors symptoms for early intervention, and promotes a holistic view of care.

Trends, Distribution, and Impact of Pediatric Messages in a Large Health System From 2019 to 2021.

This cohort study assesses changes in the volume of medical advice messages between 2019 and 2021, variation among pediatricians, and the association of volume with time spent working on the electronic health record outside clinical hours.

ADHD: Overdiagnosed and overtreated, or misdiagnosed and mistreated?

In today's changing medical climate, physicians need to treat attention-deficit/hyperactivity disorder (ADHD) better and more cost-effectively. The authors review recommendations supported by recent research and offer simple practices that integrate medicine and behavioral health for patients with ADHD.

Improving Asthma Care by Building Statewide Quality Improvement Infrastructure.

BACKGROUND AND OBJECTIVES: Pediatric medical professionals have an increasing desire for quality improvement (QI) methods that produce sustainable changes in health care delivery. Previous reports have described QI in single settings or single coordinating entities that work with multiple sites. The objectives of this project are (1) to improve care for children with asthma across multiple practice settings and (2) to develop state-level expertise to support QI projects across entities in multiple states. METHODS: Using a multiwave approach, the Chapter Quality Network of the American Academy of Pediatrics implemented statewide learning collaboratives in several states. For each cycle, a national leadership team coached multiple American Academy of Pediatrics chapter leadership teams, which, in turn, coached individual pediatric practices through 2 nested learning collaboratives. State chapters received data and reporting tools and a curriculum fostering QI learning and support change at the practice level. Practices implemented an asthma assessment tool and registry, analyzed work flows, and implemented self-management tools in plan-do-study-act cycles. Sixteen process and outcome measures, including optimal asthma care, were collected and analyzed by using run charts on a monthly dashboard. Chapter leaders provided feedback on sustainable QI change through surveys and interviews. RESULTS: Optimal asthma care improved from 42% to 81% across the 4 waves. The percentage of patients rated by physicians as well controlled rose from 59% to 74%. CONCLUSIONS: Asthma care can be improved by supporting practice change through statewide QI learning collaboratives.

Development of an Objective Autism Risk Index Using Remote Eye Tracking.

OBJECTIVE: Abnormal eye gaze is a hallmark characteristic of autism spectrum disorder (ASD), and numerous studies have identified abnormal attention patterns in ASD. The primary aim of the present study was to create an objective, eye tracking-based autism risk index. METHOD: In initial and replication studies, children were recruited after referral for comprehensive multidisciplinary evaluation of ASD and subsequently grouped by clinical consensus diagnosis (ASD n = 25/15, non-ASD n = 20/19 for initial/replication samples). Remote eye tracking was blinded to diagnosis and included multiple stimuli. Dwell times were recorded to each a priori-defined region of interest (ROI) and averaged across ROIs to create an autism risk index. Receiver operating characteristic curve analyses examined classification accuracy. Correlations with clinical measures evaluated whether the autism risk index was associated with autism symptom severity independent of language ability. RESULTS: In both samples, the autism risk index had high diagnostic accuracy (area under the curve [AUC] = 0.91 and 0.85, 95% CIs = 0.81-0.98 and 0.71-0.96), was strongly associated with Autism Diagnostic Observation Schedule-Second Edition (ADOS-2) severity scores (r = 0.58 and 0.59, p < .001), and not significantly correlated with language ability (r ≤| -0.28|, p > .095). CONCLUSION: The autism risk index may be a useful quantitative and objective measure of risk for autism in at-risk settings. Future research in larger samples is needed to cross-validate these findings. If validated and scaled for clinical use, this measure could inform clinical judgment regarding ASD diagnosis and track symptom improvements.

Evaluation of the Duration of Action and Comparative Effectiveness of Lisdexamfetamine Dimesylate and Behavioral Treatment in Youth With ADHD in a Quasi-Naturalistic Setting.

OBJECTIVE: This study compared the relative effects of three treatment conditions: long-acting stimulant medication (MED), behavior modification, and medication/behavioral treatments combined (COM) in children with ADHD. METHOD: A total of 25 children, aged 6 to 12 years, received the three treatment conditions during a 7-week Summer Treatment Program in an alternating treatments design. Counselors completed behavioral ratings from 0.5 to 12.5 hr post dose, and parents completed nighttime ratings. RESULTS: Ratings for SKAMP (Swanson, Kotkin, Agler, M-Flynn, and Pelham) and for following instructions indicated COM and MED improved symptoms over BEH treatment beginning 3 hr post dose (p = .008), with ratings maintained 12.5 hr post dose (p = .001 and .006). Results for frustration tolerance indicated significant improvement in all three conditions until 9 hr post dose. CONCLUSION: MED and COM separated from BEH at 3 hr post dose, and sustained benefit was observed across the day for two of three measures. BEH appears to have an additive effect, extending the duration of frustration tolerance.