Implementation of the adverse childhood experiences conversation in primary care.

BACKGROUND: Research has focused on screening for adverse childhood experiences, rather than provision of education as a part of routine anticipatory guidance. An adverse childhood experiences 'conversation' is one method that has not been studied empirically but represents a complimentary or alternative approach to screening which could overcome many existing barriers. OBJECTIVES: This study aims to examine parent/guardian and provider acceptability/feasibility of the adverse childhood experiences conversation during well-child visits in primary care. METHODS: Providers engaged in a conversation with parents/guardians of patients during well-child visits in a family medicine residency clinic. Parents/guardians and providers were surveyed following the visit to examine acceptability and feasibility. Quarterly assessments to further examine provider perspectives were completed. Data were collected for 1 year. RESULTS: In total, 238 parent/guardian and 231 provider surveys were completed. Most parents/guardians felt positively (76%) about and comfortable (81%) with the information discussed and 97% felt that the conversation should be had with their primary care provider specifically. Most providers (71%) indicated that parents/guardians were receptive to the conversation, that the conversations took 1-2 minutes (60%) and that there were few disclosures of adversity (9%), none of which required mandatory reporting. CONCLUSIONS: Results suggest that the adverse childhood experiences conversation is well received by parents/guardians and providers and is feasible to implement into primary care. The conversation could be used as a complimentary or alternative method to screening to further spread knowledge of toxic stress and health, provide resources for families and promote resilience.

The impact of adverse childhood experiences on healthcare utilization in children.

BACKGROUND: Adverse childhood experiences (ACEs) are related to long-term negative outcomes. The impact of these experiences on healthcare utilization in children has been understudied. OBJECTIVE: To examine the impact of ACEs on children's healthcare utilization, medical diagnoses, and pharmacological treatment. PARTICIPANTS AND SETTING: Children aged 6 months to 17 years who were screened for ACEs in the Behavioral Health Department or in primary care locations as part of an initial consultation visit and who had at least one subsequent healthcare visit during the study period were included in the study. METHODS: Adverse childhood experiences were measured using the ACE screening questionnaire designed by Felitti et al. (1998). Data from the year following administration of the ACE screening tool were retrospectively extracted from the electronic health record. RESULTS: Overall, 1,183 children met study inclusion criteria. Children with any reported ACEs were more likely to no show appointments (1-3 ACEs incidence rate ratio (IRR) [95 % confidence interval (CI)]: 1.40 [1.11-1.77]; 4+ ACEs IRR [95 % CI]: 1.41 [1.08-1.84]) and to use emergency services (1-3 ACEs IRR [95 % CI]: 1.24 [1.00-1.53]; 4+ ACEs: IRR [95 % CI]: 1.42 [1.11-1.81) than children with no ACEs. Those with 4+ ACEs used the telephone nurse advisor less frequently (1-3 ACEs IRR [95 % CI]: 0.67 [0.53-0.84]; 4+ ACEs IRR [95 % CI]: 0.69 [0.53-0.90]). Although ACE scores were associated with healthcare utilization, insurance status was more robustly associated with healthcare utilization than ACE score. CONCLUSIONS: Healthcare systems may employ results from this study to adopt trauma-informed care initiatives. Ensuring that all patients have insurance may be a first step toward improving healthcare utilization.

The relationship between adverse childhood experiences, healthcare utilization, cost of care and medical comorbidities.

BACKGROUND: Prior research suggests that those experiencing adverse childhood experiences (ACEs) may be higher utilizers of the healthcare system. The frequency and financial impact of kept, cancelled and no-showed visits is largely unknown. OBJECTIVE: To examine the impact of adverse childhood experiences (ACEs) on healthcare utilization in a sample of US adults. PARTICIPANTS AND SETTING: Two thousand thirty-eight adult patients who completed an ACE screening within the behavioral health department of a medium sized, Midwestern healthcare system during 2015-2017 were included. METHODS: Data was extracted retrospectively from 1-year post ACE screen. RESULTS: Individuals with high ACEs (4+) made more but kept fewer appointments than those with no or moderate (1-3) ACEs (p < 0.0001). Individuals with high ACES had more late-cancelled and no-showed appointments compared to those with no ACEs (p's < .0001). Relationships were significant even after controlling for age, gender, and insurance type. Those with high ACEs had the greatest impact on potential lost revenue given that they late-cancelled and no-showed more appointments. Those with high ACEs also had more medical comorbidities, medications, and needed care coordinator than those with moderate or no ACEs (p's < .05) CONCLUSIONS: Results from this study should be used to inform providers and health care systems on the effects of adversity on patterns of utilization of health care and encourage innovative strategies to better address the needs of these patients.

Pediatric advance care planning.

OBJECTIVE: This study describes the process and population involved in pediatric advance care planning at one Midwest medical center. The outcomes and the parents' perceptions of this planning are also discussed. METHODS: Pediatric patients with advance directives were identified from ethics consultations records. Information about the type of advance directive, the patient's medical condition and care received was obtained from the medical records. Parents of the children were then contacted and interviewed in regard to the advance care planning process done for their child. The interviews were audiotaped and transcribed. Transcribed interviews were reviewed and themes were identified. RESULTS: Seventeen children from 16 families were included in the study. Almost all of the patients had progressive disorders other than cancer. Of the 17 children, 9 are deceased, 7 died at home and 2 died at a hospital. Eight of the children's advance directives were followed during the dying process, while 1 was not. Thirteen parents were interviewed. Twelve stated that the process of advance care planning benefited their children and their family. Rarely, individuals in the community raised concerns about the child's advance directive. CONCLUSIONS: Even though the topic of their child's death is difficult, the majority of the interviewed parents found the advance care planning process for the child helpful because it assured the best care for the child, including preserving their child's quality of life and avoiding unnecessary suffering.