Accuracy and Performance of Triage Blood Pressure Measurements in A Real-World Clinic Setting.

OBJECTIVES: To investigate the agreement and accuracy of triage blood pressure (BP) in a real-world clinic setting, compared with the reference standard. STUDY DESIGN: Paired triage and standardized BP measurements from patients 4 through 21 years old evaluated in an obesity-related hypertension clinic were obtained via chart-review. Triage BPs were measured by a medical assistant or nurse, often by automated device. Triplicate manual BPs were obtained by the clinic physician. Bland-Altman analyses determined mean differences between paired triage and mean standardized BPs. GEE-based multivariable relative risk (RR) regression determined the RR of triage BP overestimation by ≥ 5 mmHg. Overall agreement, sensitivity, specificity, positive predictive value, and negative predictive value of triage BP measurements identifying hypertensive BP were determined. RESULTS: One hundred thirty participants with 347 clinic encounters were included. Mean age was 13.3 years (SD 3.94), 76% were Black, and 58% were male. Overall mean systolic and diastolic BP difference was 8.7 mmHg (95% limits on agreement: -16.66, 34.07) and 4.1 mmHg (95% limits on agreement: -18.56, 26.68), respectively. Triage systolic BP was more likely overestimated by ≥ 5 mmHg when a large adult (RR = 1.49; 95% CI: 1.00, 2.21) or thigh cuff (RR = 1.94; 95% CI: 1.08, 3.51) was required compared with when a child/adult cuff was required. Overall agreement in identifying hypertensive BP was 57.6%. Sensitivity (52.6%), specificity (63.4%), positive predictive value (60.8%), and negative predictive value (55.3%) were low across all cuffs. CONCLUSIONS: There was poor agreement between usual triage and standardized BP measurements, with potential for significant clinical implications. CLINICAL TRIAL REGISTRATION: ReNEW Clinic Cohort Study (ReNEW), NCT03816462, https://clinicaltrials.gov/ct2/show/NCT03816462.

Pediatric advocacy: Advancement in academic institutions.

IMPACT: Children are facing many threats to their health today that require system change at a sweeping level to have real-world impact. Pediatricians are positioned as natural leaders to advocate for these critical community and policy changes. Academic medical center (AMC) leaders recognize the importance of this advocacy and clear steps can be taken to improve the structure to support pediatricians in their advocacy careers through faculty development and promotion, including standardized scholarly measurement of the outcomes.

Medication Safety Counseling Practices of Pediatric Primary Care Clinicians.

Medication exposures and poisonings are a major cause of pediatric morbidity and mortality. Unsafe patient practices are well documented despite the American Academy of Pediatrics recommending that pediatric primary care clinicians discuss medication safety with patients. Current clinician counseling practices for pediatric patients are unknown. Studies of adult patients suggest that physician counseling practices often focus on administration but not storage or disposal. To address this gap, we administered a web-based survey to clinically active pediatric primary care clinicians in two mid-Atlantic health care systems. Survey content focused on characteristics of medication safety counseling practices by age group, including safe medication storage, administration, and disposal. Of 151 clinicians emailed, 40 (26.5%) responded. The majority were physicians (93.5%), female (87.1%), and completed residency/clinical training in pediatrics >15 years ago (58.1%). Most (82.5%) reported having >1 pediatric patient (aged < 19 years) in their practice who experienced an unintentional or intentional medication exposure or poisoning event. Reported practices for medication safety counseling often varied by patient age but safe disposal was rarely addressed for any age group. Respondents generally felt less knowledgeable and less comfortable with providing counseling on safe disposal in comparison to safe storage and safe administration. Nearly all respondents (97%) would like to provide more counseling about medication safety, and the majority (81.3%) wanted additional educational resources. In this survey, we identified several modifiable deficits in pediatric medical counseling practices and a need for additional clinician training and resources, most notably in the content area of safe disposal.

Understanding caregiver acceptance of screening for family substance use in pediatric clinics serving economically disadvantaged children.

Background: Children of parents with substance use disorders are at greater risk for mental and physical health co-morbidities. Despite guidelines, pediatricians rarely screen for substance use in the family/household, citing fear of offending parents. The objectives of this study were to examine (1) caregiver acceptance of pediatricians screening for family/household substance use during well-child visits, (2) prevalence of family/household substance use, and (3) the association between family/household substance use and trust in their child's pediatrician. Methods: This cross-sectional study surveyed adult caregivers presenting a child for medical care at two urban pediatric outpatient clinics using a brief anonymous computer-based survey. The primary outcome measured the acceptability of pediatrician screening for family/household substance use. Substance use and concerns about use in the family/household were also assessed. Results: Adult caregivers (n = 271) surveyed were mean age 35 years, 73% mothers, 90% African American, and 85% on Medicaid. Over half (51%) of caregivers reported substance use by someone in the family/household, most commonly cigarettes (38%), followed by alcohol (19%) and marijuana (10%). Sixty-one percent of caregivers who reported family substance use expressed concern about the use of this substance. The majority (87%) agreed it is appropriate for pediatricians to ask caregivers about family/household substance use. No differences were found between caregivers who did and did not report substance use in their family/household. Caregivers with concerning substance use in their family/household were less likely to trust their pediatrician [OR = 0.21, 95%CI: 0.05, 0.85] Conclusions: Caregivers endorsed acceptance of universal screening for substance use, including illicit substances, and substance use disorders in the family/household during well-child visits. Pediatricians are trusted professionals with expertise in communicating with parents to maximize the health of their patients; assessing family history of substance use and substance use disorders is a natural extension of their role.

Evaluation of digital otoscopy in pediatric patients: A prospective randomized controlled clinical trial.

BACKGROUND: Acute otitis media is often misdiagnosed. Pediatric trainees learn otoscopy from supervisors who cannot concurrently view the eardrum. Digital, smartphone otoscopes show promise to improve the visibility and learning due to a concurrent view by trainees and supervisors. We aimed to determine whether use of digital otoscopes improved accuracy of the ear exams between medical trainees and their supervisors, compared to using traditional otoscopes. Secondarily, we evaluated whether the use of digital otoscopes reduced the number of repeat ear examinations by supervisors, changed the trainee's confidence in their exam findings, and led to differences in the rate of antibiotics prescribed. METHODS: This study was a randomized controlled trial comparing use of a digital otoscope to a traditional otoscope, in a pediatric emergency department and primary care clinic in an academic tertiary care children's center. We used a modified validated image-based grading scale to compare accuracy of the ear exam between trainees and supervisors. Surveys documented modified OMgrade scores, frequency of supervisor exams, trainee confidence on a 5-point Likert scale, and antibiotic prescriptions. Inter-rater agreement of trainees and supervisors, the number of supervisor confirmatory examinations performed, trainee confidence, and antibiotic prescription rates were evaluated. RESULTS: Amongst 188 children, 375 ears were examined by 85 trainees and 22 supervisors. The digital otoscope was utilized in 92 (48.9%) exams and 96 (51.1%) used the traditional otoscope. Accuracy of ear exam findings between trainees and supervisors improved by 11.2% (95% CI: 1.5, 21.8%, p = 0.033) using the Cellscope Oto (74.8%, 95% CI: 67.3, 82.1%) compared to the traditional otoscope (63.5%, 95% CI: 56.7, 70.4%). Fewer repeat supervisor exams were performed in the digital otoscope group (27.2%) vs. the traditional otoscope group (97.9%) (p < 0.001). There was no difference in mean trainee confidence in their examination (p = 0.955) or antibiotic prescription rates when using digital versus traditional otoscopes (p = 0.071). CONCLUSIONS: Utilization of a digital otoscope resulted in increased accuracy of the ear exam between trainees and supervisors, and fewer total number of examinations performed on a given child. Compared to a traditional otoscope, a digital otoscope may be a more efficient and effective diagnostic tool.

Evaluation of a Culturally Tailored Educational Video Intervention to Promote Bike Helmet Safety for Urban Children: A Pilot Study.

Bicycle-related falls are a significant cause of mortality and morbidity. Use of bicycle helmets substantially reduces risk of severe traumatic brain injury but compliance with this safety practice is particularly low in urban children. Given the lack of educational interventions for urban youth, our research team created a youth-informed, culturally relevant educational video on bike helmet safety, which was informed by focus groups with Baltimore City youth. This video, You Make the Call, linked the concept of use of cases to protect phones to use of helmets to protect heads and can be viewed at http://bit.ly/2Kr7UCN. The impact of the video as part of an intervention (coupled with a free helmet, fit instructions, and a parent guidance document) was tested with 20 parent-child dyads. The majority (80%) of youth (mean age 9.9 ± 1.8 years) reported not owning or wearing a helmet. At 1-month follow-up (n = 12, 60% response rate), helmet use was higher in the five youth reporting bike-riding after the intervention; 100% "always" used helmets compared to 0% preintervention. There were increases in youth reporting that parents required helmet use (35% pre vs. 67% post) and that is was possible to fall when bike-riding (60% pre vs. 92% post). These pilot results support the use of this video and educational intervention along with further evaluation in a larger sample size. This youth-informed and culturally tailored approach could be explored as a strategy to address other pediatric injury topics.

Health education intervention promoting infant safe sleep in paediatric primary care: randomised controlled trial.

BACKGROUND: Few randomised controlled trials (RCTs) have been conducted to improve infant sleep practices. There is limited research on how best to integrate safe sleep information into routine paediatric anticipatory guidance delivered at well child visits (WCVs). This protocol paper describes the design of the Safe Start Study, which aims to evaluate the impact of safe sleep interventions on parents' knowledge, beliefs and behaviours related to creating and maintaining a safe sleep environment for their infants. METHODS: Safe Start is a three-group RCT comparing a safe sleep health education intervention delivered as part of the 2-week WCV, an attention-matched control group that receives a scald burn prevention intervention, and a standard of care group. A baseline survey is completed at the 2-week WCV; follow-up surveys and observations are completed in the home at 2-4 weeks and 2-3 months. Participants include mother-baby dyads attending a large urban paediatric primary care practice and their paediatricians. Primary outcomes are self-reported behaviours (baby sleeps alone, on back, in crib and in a smoke-free environment), observations of the sleep environment, paediatricians' anticipatory guidance counselling about safe sleep and participants' reported exposure to an existing city-wide safe sleep campaign. DISCUSSION: Providing a theory-driven and evidenced-based safe sleep intervention is both a research and a clinical practice priority. This study will advance the application of educational and environmental interventions in the primary care setting to improve the safety of infant sleep environments in high-risk families. TRIAL REGISTRATION NUMBER: NCT03070639; Pre-results.

Promoting Bike Helmet Safety for Urban Children Through a Culturally Tailored Educational Video Intervention.

Bicycle-related falls are a significant cause of mortality and morbidity. Use of bicycle helmets substantially reduces risk of severe traumatic brain injury but compliance with this safety practice is particularly low in urban children. We recruited eleven 8- to 15-year-old youth to participate in focus groups to inform the creation of a video promoting helmet use. Key emerging themes included that youth were responsible for keeping themselves safe and that most youth had cell phones with cases to protect them. A video was created that linked the concept of use of cases to protect phones to use of helmets to protect heads. Soliciting information from urban youth was helpful for developing this educational video.

Desirability of Clinic-Based Financial Services in Urban Pediatric Primary Care.

OBJECTIVES: To determine the desirability of integrating financial services in pediatric primary care among caregivers and older adolescents. STUDY DESIGN: We conducted a cross-sectional study among caregivers and late adolescents 18 years and older attending an urban, pediatric primary care clinic. RESULTS: The 221 participants had a mean age of 32.1 years, with 28% of the sample aged 18-25 years. The majority were African American (90.1%), female (83.3%), and single parents (55.1%). More than one-third of the participants (35.8%) reported no household earned income, and 26.7% had a yearly household total income of <$12,000. More than one-half (61.5%) reported financial stress in general, and 67.9% believed that the clinic should provide financial services, including financial education and job workshops. A greater proportion of those who desired clinic-based services were African American (94.7% vs 75%; P < .001) and had a low or middle subjective social status (95.7% vs 83.7%; P = .01). CONCLUSIONS: Clinic-based financial services are desired by caregivers and late adolescents in an urban pediatric primary care practice. Prospective studies are needed to assess the long-term impact of integrated services on childhood poverty and family well-being.

Caregiver Health Promotion in Pediatric Primary Care Settings: Results of a National Survey.

OBJECTIVE: To assess practice patterns, barriers, and facilitators related to caregiver health promotion in pediatric primary care settings. STUDY DESIGN: We conducted a mail-based survey of a nationally representative sample of 1000 children's primary care physicians (trained in pediatrics, family medicine, or medicine-pediatrics). We assessed engagement in 6 caregiver health issues (maternal depression, tobacco use, intimate partner violence, family planning, health insurance, and tetanus, diphtheria, and acellular pertussis immunization status) along with barriers and facilitators related to engagement. We used multivariable logistic regression to identify physician and practice correlates of engagement. RESULTS: The response rate was 30%. The majority of respondents (79.3%) regularly addressed at least 3 caregiver health issues during well infant/child visits, most commonly maternal depression, tobacco use, and tetanus, diphtheria, and acellular pertussis immunization immunization status. Screening was the most common activity. In adjusted analyses, pediatricians were less likely to screen for intimate partner violence and family planning compared with other providers. There were no other differences in engagement by physician specialty. Lack of time was the most commonly endorsed barrier (by 85.2% of respondents). Co-location of auxiliary services was the most frequently cited facilitator for the majority of issues. CONCLUSIONS: Children's primary care physicians and their care teams routinely engage in a variety of activities promoting caregiver health, largely independent of training background and despite multiple practice-related barriers. Co-location of auxiliary services could support the efforts of pediatric care teams. Future efforts that investigate care models which address these barriers and facilitators will help to realize the potential of pediatric settings to impact adult health.

Beyond screening: a review of pediatric primary care models to address maternal depression.

Depression is one of the most debilitating chronic disorders in the United States, affecting 15 million children in homes with depressed mothers, many of whom endure household chaos, inconsistent nurturing, inadequate safety practices, and harsh discipline. Depressed mothers are under diagnosed and undertreated, yet there is broad consensus about the importance of identifying and managing maternal depression, as reflected in recommendations by pediatric and obstetric professional organizations to routinely screen for perinatal depression. Screening was shown to be acceptable to women and most pediatric providers, and adding a screening component need not impair clinic efficiency. Screening, however, is not sufficient, and there are few models in the literature to guide medical practices in implementing successful interventions to identify, treat, and prevent maternal depression, particularly in the pediatric setting. We reviewed the literature and identified six studies that evaluated models for screening and managing mothers' depression in pediatric primary care settings. Some of these interventions have promise, but no studies characterized health outcomes of the depressed mothers and children. We discuss the components of these models, their implementation, and the practice and research needed to create effective pediatrics-based systems to reduce the negative effects of maternal depression on mothers, children, and families.

Translating Life Course Theory to clinical practice to address health disparities.

Life Course Theory (LCT) is a framework that explains health and disease across populations and over time and in a powerful way, conceptualizes health and health disparities to guide improvements. It suggests a need to change priorities and paradigms in our healthcare delivery system. In "Rethinking Maternal and Child Health: The Life Course Model as an Organizing Framework," Fine and Kotelchuck identify three areas of rethinking that have relevance to clinical care: (1) recognition of context and the "whole-person, whole-family, whole-community systems approach;" (2) longitudinal approach with "greater emphasis on early ("upstream") determinants of health"; and (3) need for integration and "developing integrated, multi-sector service systems that become lifelong "pipelines" for healthy development". This paper discusses promising clinical practice innovations in these three areas: addressing social influences on health in clinical practice, longitudinal and vertical integration of clinical services and horizontal integration with community services and resources. In addition, barriers and facilitators to implementation are reviewed.

Addressing Social Determinants of Health in Practice.

This review summarizes the current pediatric literature related to social determinants of health, including strengths and weaknesses of screening practices and intervention strategies, common concerns and potential unintended consequences, opportunities for further research, and provides evidence-informed practical strategies for clinicians.

Resident Perceptions of Continuity Clinic Patient Metrics Differ From EHR Data: Pilot Use of Population Health Dashboards.

BACKGROUND AND OBJECTIVES: Population health management (PHM) dashboards using electronic health record (EHR) data can teach trainees about the population they serve while also delivering data on their clinical practice. Yet, few studies have demonstrated their use. In this pilot study, we assessed baseline resident perceptions of population health metrics for continuity clinic panels by comparing resident estimates with EHR-reported values delivered by individualized PHM dashboards. METHODS: A descriptive, comparative study was conducted at a primary continuity clinic site for pediatric residents in January 2018. Residents were surveyed about population health metrics for their patient panels, including demographics, utilization, and medical diagnoses. We compared resident estimates to corresponding EHR-reported values using 2-tailed paired t tests. RESULTS: A total of 42 out of 55 eligible residents (76%) completed the survey. Compared with EHR-reported values, residents estimated higher percentages of emergency department utilization (22.1% vs 10.3%, P < .01) and morbidity, including medical complexity (15.6% vs 5.9%, P < .01), overweight (38.1% vs 11.7%, P < .01), obesity (20.5% vs 15.8%, P = .02), and asthma (34.6% vs 21.4%, P < .01). CONCLUSIONS: In this pilot study of PHM dashboards, resident perceptions of continuity clinic population health metrics did not align with EHR data. Estimates were higher for measures of utilization and morbidity. PHM dashboards may help trainees better understand their patient populations and serve as a consistent source of objective practice data. However, further research and investment is needed to evaluate dashboard implementation and impact on trainee and patient outcomes.

"Before I Could Get Him, He Fell": Experiences, Concerns, and Fall Prevention Strategies of Parents With Young Children.

Little is known about parents' perceptions and prevention strategies regarding childhood falls. In this qualitative study using semi-structured interviews, we sought to describe parental reports of child fall experiences, concerns, and prevention strategies in the home. Sixteen parents with at least one child younger than 18 months were asked about their awareness of fall risks, falls experienced by the child, fall concerns, prevention strategies, and where in the home the child spends time throughout the day. Seven themes emerged: (1) "falls are unexpected," (2) "role of the physical environment," (3) "children's temperament and developmental stage," (4) "physical barriers and baby products," (5) "addressing walking surfaces," (6) "modifying the height of a fall," and (7) "supervision." Parents are aware of in-home fall hazards and actively use strategies to lessen fall risk. Anticipatory guidance should promote evidence-based and evidence-informed prevention strategies and augment effective strategies some parents use to lower fall risk.

Postpartum depression and intimate partner violence in urban mothers: co-occurrence and child healthcare utilization.

OBJECTIVE: To assess the prevalence, timing, and co-occurrence of positive screens for maternal postpartum depression and intimate partner violence and examine their relationships with children's healthcare utilization from birth to 2 years. STUDY DESIGN: Between February and March 2008, mothers bringing newborn, 2-, 4-, or 6-month-old children to an urban primary care clinic were screened for postpartum depression and intimate partner violence. A retrospective chart review abstracted demographic data, maternal responses on the postpartum depression/intimate partner violence screen at the initial and subsequent visits, and, from the child's birth to second birthday, adherence with well-child care and use of pediatric acute care and emergency department visits. Descriptive, bivariate, and multivariate analyses were conducted. RESULTS: A total of 173 mothers completed at least one postpartum depression/intimate partner violence screening survey. Overall, 26% screened positive for postpartum depression and 7% screened positive for intimate partner violence; most positive screens occurred at the initial visit. About 60% of mothers with a positive intimate partner violence screen also had a positive postpartum depression screen. Well-child care adherence and acute care visit utilization were not associated with maternal postpartum depression/intimate partner violence screening. Children of women with a positive screen for postpartum depression had greater emergency department utilization. CONCLUSION: The co-occurrence of postpartum depression and intimate partner violence is high in urban mothers. Primary care providers should routinely screen for both problems in this population and recognize the importance of screening for one problem if the other problem is identified.

Engagement in a Social Needs Navigation Program and Health Care Utilization in Pediatric Primary Care.

OBJECTIVE: Evidence for social needs interventions on resource linkage has grown over the past decade. Though social and economic needs predict health care utilization, few studies have assessed social needs interventions on these outcomes. The objective of this study was to examine the association between enrollment in a clinic-based social needs program on subsequent well-child visit (WCV) attendance and emergency department (ED) use in 2 primary care clinics. METHODS: A retrospective cohort study was conducted of patients in 2 clinics referred to a social risk screening and navigation program between June and August 2018. We compared health care utilization over the subsequent 12 months for those who completed a full intake and received resource navigation (enrolled) to those referred (not enrolled). Logistic regression was used to assess the association between enrollment with WCV attendance and ED visits. RESULTS: During the study period, of the 969 patients referred to the program, 761 were enrolled across the 2 clinics. At both sites, the majority of enrolled patients had high WCV attendance postintervention (Site A: 81.6%, Site B: 71.4%). High WCV attendance for nonenrolled but referred patients was significantly lower (Site A: 52.7%, Site B: 35.0%). Enrolled participants were significantly more likely to have high WCV attendance than nonenrolled patients, adjusting for preintervention utilization (Site A adjusted odds ratio [aOR]: 5.83, Site B aOR : 4.20). There were no significant differences in ED use at either clinic. CONCLUSIONS: Addressing families' social needs through resource linkage and navigation can improve WCV attendance.

Addressing Trauma and Building Resilience in Children and Families: Standardized Patient Cases for Pediatric Residents.

INTRODUCTION: Adverse childhood experiences (ACEs) and trauma are common and can negatively impact children's health. Standardized patient (SP) learning may provide trainees with knowledge and skills to screen for and manage ACEs, apply trauma-informed care approaches, and teach resilience strategies. METHODS: With content experts, we developed three SP cases based on common clinical encounters, as well as didactic and debriefing materials. Case 1 focused on somatic symptoms in an adolescent with ACEs, case 2 focused on an ACE disclosure by a parent, and case 3 focused on de-escalation. The workshop required facilitators, SPs, simulation exam room and meeting space, and audiovisual equipment. It lasted 4 hours and included an orientation (1 hour), the three SP cases (totaling 2 hours), and group debriefing (1 hour). RESULTS: We conducted five identical workshops with 22 pediatric residents. Participants responded favorably to case fidelity and applicability to their clinical work. Resident mean self-assessment scores improved significantly from baseline. Specifically, we assessed comfort with inquiring about and discussing ACEs, explaining the health impacts of trauma, identifying protective factors, resilience counseling, and de-escalation. Over 90% of responses indicated that residents were likely to apply what they had learned to their clinical practice. DISCUSSION: These findings demonstrate that our SP cases were well received and suggest that such curricula can help pediatric residents feel more prepared to address trauma and promote resilience. Future work will assess these outcomes, as well as behavior change, in a larger sample to further substantiate these promising findings.

The Distinguished Teaching Society at the Johns Hopkins University School of Medicine: A Student-Led Initiative to Recognize Clinical Educators.

PROBLEM: Some focus on recognizing excellence in clinical teaching has been lost with the increasing emphasis placed on clinical efficiency and value. Clinical teaching awards and academies of educators aim to address this problem. In 2015, medical student leaders at the Johns Hopkins University School of Medicine created the Distinguished Teaching Society (DTS), a student-driven program to recognize the best clinical educators. APPROACH: Medical students designed a comprehensive scoring rubric focusing on 3 domains: feedback and evaluation, role model behavior, and teaching process. A student committee solicits student nominations providing narratives endorsing faculty or house staff for potential inclusion in the DTS. Using the rubric, student judges score each deidentified narrative nomination, as well as an application from finalists and comments about finalists submitted by the student body. Inductees are recognized at an annual ceremony. OUTCOMES: From academic years 2015-2016 to 2018-2019, students nominated 254 unique candidates, and 82 nominees (32%) were inducted into the DTS. The majority of inductees were faculty and male. In 2017-2018 and 2018-2019, nearly half of inductees were female, and less than 10% of inductees self-reported as underrepresented in medicine and/or LGBTQ+. The Department of Internal Medicine had the greatest departmental representation. There were no statistically significant differences in the proportional representation within the nomination and inductee cohorts by gender, rank, and department. Several process changes were made in response to student feedback and to increase nominee and inductee diversity. NEXT STEPS: Next steps include adding a diversity and inclusion chair to the student committee and collecting survey data on student and DTS inductee opinions on how to improve learner-teacher engagement and the clinical learning environment. Future activities may include educational workshops, panel discussions, mentorship programs, and networking events. Other medical schools may find value in considering similar structures.