Accelerating Innovation in Primary Care to Support Adolescent Health Discussions.

BACKGROUND AND OBJECTIVES: Adolescent strengths and risks are not routinely captured in systematized and actionable ways in pediatric primary care. To address this problem, we developed a comprehensive adolescent health questionnaire (AHQ) integrated within the electronic health record and evaluated the AHQ's impact on collection of information on prioritized health-related domains. METHODS: We developed and pilot tested the AHQ. We then scaled and assessed the AHQ's impact on data collection. AHQ development used innovation methods and measured feasibility and acceptability outcomes. Scaling and postscaling outcomes included Reach, Effectiveness, Adoption, Implementation, Maintenance and Sustainability measures: Reach (total questionnaires completed), Effectiveness (capture of key information across health domains pre- vs post-AHQ scaling), Adoption (proportion of practices that adopted the AHQ), Implementation (proportion of eligible adolescents who completed the AHQ), and Maintenance (monthly completion rates). RESULTS: AHQ development led to a tool that was feasible and acceptable for use. During scaling (October 2020-December 2021), 22 147 questionnaires were completed by 20 749 unique adolescents aged 13 to 21 years at their preventive visit. Comparing pre- versus post-AHQ scaling data, use of the AHQ increased collection of information across domains, especially for strengths, gun safety, substance use, sexual activity, sexual orientation, and gender identity, from ranges of 0%-25% to 92%-95%. All 31 practices adopted the AHQ with completion at 88.7% of visits (n = 24 968). Two years postscaling, completion rates were >91% per month. CONCLUSIONS: We successfully developed, scaled, and maintained an AHQ in a widely-used electronic health record system, a model for improving adolescent care and foundation for developing future interventions.

The Role of Family Support in Moderating Mental Health Outcomes for LGBTQ+ Youth in Primary Care.

Importance: Lesbian, gay, bisexual, transgender, queer, and/or questioning (LGBTQ+) youth face worse mental health outcomes than non-LGBTQ+ peers. Family support may mitigate this, but sparse evidence demonstrates this in clinical settings. Objectives: To compare depression and suicide risk between LGBTQ+ and non-LGBTQ+ youth in primary care settings and to investigate whether family support mitigates these negative mental health outcomes. Design, Setting, and Participants: This cross-sectional study uses data from well care visits completed by adolescents aged 13 to 19 years from February 2022 through May 2023, including the Patient Health Questionnaire-9 Modified for Teens (PHQ-9-M) and the Adolescent Health Questionnaire (AHQ; an electronic screener assessing identity, behaviors, and guardian support), at 32 urban or suburban care clinics in Pennsylvania and New Jersey. Exposures: The primary exposure was self-reported LGBTQ+ status. Family support moderators included parental discussion of adolescent strengths and listening to feelings. Race and ethnicity (determined via parent or guardian report at visit check-in), sex, payer, language, age, and geography were covariates. Main Outcomes and Measures: PHQ-9-M-derived mental health outcomes, including total score, recent suicidal ideation, and past suicide attempt. Results: The sample included 60 626 adolescents; among them, 9936 (16.4%) were LGBTQ+, 15 387 (25.5%) were Black, and 30 296 (50.0%) were assigned female sex at birth. LGBTQ+ youth, compared with non-LGBTQ+ youth, had significantly higher median (IQR) PHQ-9-M scores (5 [2-9] vs 1 [0-3]; P < .001) and prevalence of suicidal ideation (1568 [15.8%] vs 1723 [3.4%]; P < .001). Fewer LGBTQ+ youth endorsed parental support than non-LGBTQ+ youth (discussion of strengths, 8535 [85.9%] vs 47 003 [92.7%]; P < .001; and listening to feelings, 7930 [79.8%] vs 47 177 [93.1%]; P < .001). In linear regression adjusted for demographic characteristics and parental discussion of strengths, LGBTQ+ status was associated with a higher PHQ-9-M score (mean difference, 3.3 points; 95% CI, 3.2-3.3 points). In logistic regression, LGBTQ+ youth had increased adjusted odds of suicidal ideation (adjusted odds ratio, 4.3; 95% CI, 4.0-4.7) and prior suicide attempt (adjusted odds ratio, 4.4; 95% CI, 4.0-4.7). Parental support significantly moderated the association of LGBTQ+ status with PHQ-9-M score and suicidal ideation, with greater protection against these outcomes for LGBTQ+ vs non-LGBTQ+ youth. Conclusions and Relevance: Compared with non-LGBTQ+ youth, LGBTQ+ youth at primary care visits had more depressive symptoms and higher odds of suicidal ideation and prior suicide attempt. Youth-reported parental support was protective against these outcomes, suggesting potential benefits of family support-focused interventions to mitigate mental health inequities for LGBTQ+ youth.

Measures of Neighborhood Opportunity and Adherence to Recommended Pediatric Primary Care.

Importance: Neighborhood conditions are known to broadly impact child health. Research to date has not examined the association of the Childhood Opportunity Index (COI), a multidimensional indicator of neighborhood environment conditions, specifically with pediatric primary care outcomes. Objective: To determine the association of neighborhood opportunity measured by the COI with health metrics commonly captured clinically in pediatric primary care, reflecting both access to preventive care and child well-being. Design, Setting, and Participants: This cross-sectional observational study used electronic health record data from a large pediatric primary care network in the northeastern US. Participants included patients aged 0 to 19 years who were active in the primary care network between November 2020 and November 2022. Data were analyzed in December 2022. Exposure: Census tract-level COI overall score (in quintiles). Main Outcomes and Measures: Outcomes included up-to-date preventive care and immunization status and presence of obesity, adolescent depression and suicidality, and maternal depression and suicidality. Multivariable mixed-effects logistic regressions estimated associations of these outcomes with COI quintiles, adjusted for age, sex, race and ethnicity, and insurance type. Results: Among 338 277 patients (mean [SD] age, 9.8 [5.9] years; 165 223 female [48.8%]; 158 054 [46.7%] non-Hispanic White, 209 482 [61.9%] commercially insured), 81 739 (24.2%) and 130 361 (38.5%) lived in neighborhoods of very low and very high COI, respectively. Living in very high COI neighborhoods (vs very low COI) was associated with higher odds of being up-to-date on preventive visits (odds ratio [OR], 1.40; 95% CI, 1.32-1.48) and immunizations (OR, 1.77; 95% CI, 1.58-2.00), and with lower odds of obesity (OR, 0.55; 95% CI, 0.52-0.58), adolescent depression (OR, 0.78; 95% CI, 0.72-0.84) and suicidality (OR, 0.79; 95% CI, 0.73-0.85), and maternal depression (OR, 0.78; 95% CI, 0.72-0.86) and suicidality (OR, 0.71; 95% CI, 0.61-0.83). Conclusions and Relevance: This cross-sectional study of electronic health record data found that neighborhood opportunity was associated with multiple pediatric primary care outcomes. Understanding these associations can help health systems identify neighborhoods that need additional support and advocate for and develop partnerships with community groups to promote child well-being. The findings underscore the importance of improving access to preventive care in low COI communities.

Neighborhood Greenspace and Changes in Pediatric Obesity During COVID-19.

INTRODUCTION: Pediatric obesity rates increased during the COVID-19 pandemic. This study examined the associations of neighborhood greenspace with changes in pediatric obesity during the pandemic. METHODS: Electronic health record data from a large pediatric primary care network were extracted to create a retrospective cohort of patients aged 2-17 years with a visit in each of 2 periods: June 2019-December 2019 (before pandemic) and June 2020-December 2020 (pandemic). Multivariable longitudinal generalized estimating equations Poisson regression estimated the associations of census tract‒level Normalized Difference Vegetation Index with (1) changes in obesity risk during the pandemic and (2) risk of new-onset obesity among children who were not obese prepandemic. Analyses were conducted between November 2021 and May 2022. RESULTS: Among 81,418 children (mean age: 8.4 years, 18% Black), the percentage of children who were obese increased by 3.2% during the pandemic. Children in Normalized Difference Vegetation Index Quartiles 2-4 had smaller increases in obesity risk during the pandemic than those in Quartile 1 (risk ratio=0.96, 95% CI=0.93, 0.99; Quartile 3 risk ratio=0.95; 95% CI=0.91, 0.98; Quartile 4 risk ratio=0.95, 95% CI=0.92, 0.99). Among the subset who were not obese before the pandemic, children in Normalized Difference Vegetation Index quartiles 3-4 had a lower risk of new-onset obesity during the pandemic (Quartile 3 risk ratio=0.82, 95% CI=0.71, 0.95; Quartile 4 risk ratio=0.73, 95% CI=0.62, 0.85). Higher Normalized Difference Vegetation Index was associated with smaller increases in obesity risk and lower risk of new-onset obesity among children in urban and suburban areas, but results were in the opposite direction for children in rural areas. CONCLUSIONS: Children living in greener neighborhoods experienced smaller increases in obesity during the pandemic than children in less green neighborhoods, although findings differed by urbanicity.

Trends and Persistent Disparities in Child Obesity During the COVID-19 Pandemic.

The COVID-19 pandemic has been associated with increases in pediatric obesity and widening pre-existing disparities. To better understand the pandemic's long-term impacts, we evaluated trends in obesity across different demographic groups during the pandemic through December 2022. Using a retrospective cohort design, we analyzed electronic health record data from a large pediatric primary care network. Logistic regression models fit using generalized estimating equations estimated odds ratios (ORs) for changes in the level and trajectory of obesity across 2-year month-matched periods: prepandemic (June 2017 to December 2019) and pandemic (June 2020 to December 2022). Among a cohort of 153,667 patients with visits in each period, there was a significant increase in the level of obesity at the pandemic onset [OR: 1.229, 95% confidence interval (CI): 1.211-1.247] followed by a significant decrease in the trend for obesity (OR: 0.993, 95% CI: 0.992-0.993). By December 2022, obesity had returned to prepandemic levels. However, persistent sociodemographic disparities remain.

Trends in Positive Depression and Suicide Risk Screens in Pediatric Primary Care During COVID-19.

OBJECTIVE: Adolescent mental health concerns increased during COVID-19, but it is unknown whether early increases in depression and suicide risk have been sustained. We examined changes in positive screens for depression and suicide risk in a large pediatric primary care network through May 2022. METHODS: Using an observational repeated cross-sectional design, we examined changes in depression and suicide risk during the pandemic using electronic health record data from adolescents. Segmented logistic regression was used to estimate risk differences (RD) for positive depression and suicide risk screens during the early pandemic (June 2020-May 2021) and late pandemic (June 2021-May 2022) relative to before the pandemic (March 2018-February 2020). Models adjusted for seasonality and standard errors accounted for clustering by practice. RESULTS: Among 222,668 visits for 115,627 adolescents (mean age 15.7, 50% female), the risk of positive depression and suicide risk screens increased during the early pandemic period relative to the prepandemic period (RD, 3.8%; 95% CI, 2.9, 4.8; RD, 2.8%; 95% CI, 1.7, 3.8). Risk of depression returned to baseline during the late pandemic period, while suicide risk remained slightly elevated (RD, 0.7%; 95% CI, -0.4, 1.7; RD, 1.8%; 95% CI, 0.9%, 2.7%). CONCLUSIONS: During the early months of the pandemic, there was an increase in positive depression and suicide risk screens, which later returned to prepandemic levels for depression but not suicide risk. Results suggest that pediatricians should continue to prioritize screening adolescents for depressive symptoms and suicide risk and connect them to treatment.

Improving WeeFIM score completion rates: An interdisciplinary inpatient rehabilitation unit quality improvement project.

PURPOSE: The WeeFIM is a tool commonly used in pediatric rehabilitation settings to measure objective patient progress while receiving comprehensive therapy services on inpatient rehabilitation units. This Quality Improvement (QI) project aimed for 95% of inpatients to have complete, on-time documented and displayed WeeFIM scores upon admission and discharge by 12/2017. METHODS: An interdisciplinary team examined historic WeeFIM completion rates. Using Plan-Do-Study-Act cycles, a unified flowsheet was developed in the electronic health record (EHR) to revamp workflow and identify opportunities for improvement, data accuracy, and finally sustainability. Progress was monitored in real time via an automated data visualization tool which monitored score timeliness and completeness. RESULTS: On-time admission completion rates increased from 0% to 95% during the intervention period. On-time discharge completion rates increased from 0% to 89% during the intervention period. This change has been sustained over two years with on-time admission and discharge scores averaging 79.4% and 77.9% respectively, and 96.4% of scores completed. CONCLUSION: Changes in the completion rate of WeeFIMs are sustainable, evidenced by ongoing maintenance of our initial gains over the course of multiple months. The incorporation of WeeFIM documentation into the workflow increased on-time and overall completion rates. The success of this project shows that integrating new tasks into provider workflows helps drive completion.

Talking trash: Perspectives on community environmental health in the Dominican Republic.

A safe and healthy natural and built environment is fundamental to children's health and represents a significant determinant of community well-being. We aimed to identify and prioritize environmental health concerns within resource-poor neighborhoods in the Dominican Republic using free-listing and semi-structured focus groups composed of parents and caregivers in the perirural community of Consuelo, Dominican Republic. Transcripts were coded and relevant themes identified using qualitative content analysis. Demographic data and information regarding trash disposal practices were also collected. Participants described common health concerns, including respiratory infections, asthma, vector-borne illnesses, and diarrheal diseases and linked them to environmental hazards in their communities, such as air quality and sanitation. Interventional priorities that emerged included reduction of trash accumulation and trash burning as well as improvement of sanitation facilities.

COVID-19 and Adolescent Depression and Suicide Risk Screening Outcomes.

BACKGROUND: Mental health concerns increased during the coronavirus disease 2019 pandemic, but previous studies have not examined depression screening in pediatric primary care. We aimed to describe changes in screening, depressive symptoms, and suicide risk among adolescents during the coronavirus disease 2019 pandemic. METHODS: In a repeat cross-sectional analysis of electronic health record data from a large pediatric primary care network, we compared the percentage of primary care visits where adolescents aged 12 to 21 were screened for depression, screened positive for depressive symptoms, or screened positive for suicide risk between June and December 2019 (prepandemic) and June and December 2020 (pandemic). Changes were examined overall, by month, and by sex, race and ethnicity, insurance type, and income. Modified Poisson regression was used to calculate prevalence ratios (PRs) for the prepandemic to pandemic changes. RESULTS: Depression screening at primary care visits declined from 77.6% to 75.8% during the pandemic period (PR: 0.98, 95% confidence interval [CI]: 0.90-1.06). The percentage of adolescents screening positive for depressive symptoms increased from 5.0% to 6.2% (PR: 1.24, 95% CI: 1.15-1.34), with greater increases among female, non-Hispanic Black, and non-Hispanic white adolescents. Positive suicide risk screens increased from 6.1% to 7.1% (PR: 1.16, 95% CI: 1.08-1.26), with a 34% relative increase in reporting recent suicidal thoughts among female adolescents (PR: 1.34, 95% CI: 1.18-1.52). CONCLUSIONS: Results suggest that depression and suicide concerns have increased during the pandemic, especially among female adolescents. Results underscore the importance of consistent depression and suicidality screening.

The impact of access to immunization information on vaccine acceptance in three countries.

INTRODUCTION: Vaccine acceptance is a critical component of sustainable immunization programs, yet rates of vaccine hesitancy are rising. Increased access to misinformation through media and anti-vaccine advocacy is an important contributor to hesitancy in the United States and other high-income nations with robust immunization programs. Little is known about the content and effect of information sources on attitudes toward vaccination in settings with rapidly changing or unstable immunization programs. OBJECTIVE: The objective of this study was to explore knowledge and attitudes regarding vaccines and vaccine-preventable diseases among caregivers and immunization providers in Botswana, the Dominican Republic, and Greece and examine how access to information impacts reported vaccine acceptance. METHODS: We conducted 37 focus groups and 14 semi-structured interviews with 96 providers and 153 caregivers in Botswana, the Dominican Republic, and Greece. Focus groups were conducted in Setswana, English, Spanish, or Greek; digitally recorded; and transcribed. Transcripts were translated into English, coded in qualitative data analysis software (NVivo 10, QSR International, Melbourne, Australia), and analyzed for common themes. RESULTS: Dominant themes in all three countries included identification of health care providers or medical literature as the primary source of vaccine information, yet participants reported insufficient communication about vaccines was available. Comments about level of trust in the health care system and government contrasted between sites, with the highest level of trust reported in Botswana but lower levels of trust in Greece. CONCLUSIONS: In Botswana, the Dominican Republic, and Greece, participants expressed reliance on health care providers for information and demonstrated a need for more communication about vaccines. Trust in the government and health care system influenced vaccine acceptance differently in each country, demonstrating the need for country-specific data that focus on vaccine acceptance to fully understand which drivers can be leveraged to improve implementation of immunization programs.