Equity and Inclusion in Pediatric Gastroenterology Telehealth: A Study of Demographic, Socioeconomic, and Digital Disparities.

OBJECTIVES: The purpose of our study is to compare in-person and telehealth pediatric care ambulatory visits for gastroenterology (GI) at the Nemours Children's Health System in the Delaware Valley (NCH-DV) based on geospatial, demographic, socioeconomic, and digital disparities. METHODS: Characteristics of 26,565 patient encounters from January 2019 to December 2020 were analyzed. U.S. Census Bureau geographic identifiers were assigned to each participant and aligned with the American Community Survey (2015-2019) socioeconomic and digital outcomes. Reported odds ratios (OR) are telehealth encounter/in-person encounter. RESULTS: GI telehealth usage increased 145-fold in 2020 compared to 2019 for NCH-DV. Comparing telehealth to in-person usage in 2020 revealed that GI patients who required a language translator were 2.2-fold less likely to choose telehealth [individual level adjusted OR (I-OR a ) [95% confidence interval, CI], 0.45 [0.30-0.66], P < 0.001]. Individuals of Hispanic ethnicity or non-Hispanic Black or African American race are 1.3-1.4-fold less likely to utilize telehealth than non-Hispanic Whites (I-OR a [95% CI], 0.73 [0.59-0.89], P = 0.002 and 0.76 [0.60-0.95], P = 0.02, respectively). Households in census block groups (BG) that are more likely to utilize telehealth: have broadband access (BG-OR = 2.51 [1.22-5.31], P = 0.014); are above the poverty level (BG-OR = 4.44 [2.00-10.24], P < 0.001); own their own home (BG-OR = 1.79 [1.25-2.60], P = 0.002); and have a bachelor's degree or higher (BG-OR = 6.55 [3.25-13.80], P < 0.001). CONCLUSIONS: Our study is the largest reported pediatric GI telehealth experience in North America that describes racial, ethnic, socioeconomic, and digital inequities. Advocacy and research for pediatric GI focused on telehealth equity and inclusion is urgently needed.

A comprehensive scoring system to measure healthy community design in land use plans and regulations.

Comprehensive land use plans and their corresponding regulations play a role in determining the nature of the built environment and community design, which are factors that influence population health and health disparities. To determine the level in which a plan addresses healthy living and active design, there is a need for a systematic, reliable and valid method of analyzing and scoring health-related content in plans and regulations. This paper describes the development and validation of a scoring tool designed to measure the strength and comprehensiveness of health-related content found in land use plans and the corresponding regulations. The measures are scored based on the presence of a specific item and the specificity and action-orientation of language. To establish reliability and validity, 42 land use plans and regulations from across the United States were scored January-April 2016. Results of the psychometric analysis indicate the scorecard is a reliable scoring tool for land use plans and regulations related to healthy living and active design. Intraclass correlation coefficients (ICC) scores showed strong inter-rater reliability for total strength and comprehensiveness. ICC scores for total implementation scores showed acceptable consistency among scorers. Cronbach's alpha values for all focus areas were acceptable. Strong content validity was measured through a committee vetting process. The development of this tool has far-reaching implications, bringing standardization of measurement to the field of land use plan assessment, and paving the way for systematic inclusion of health-related design principles, policies, and requirements in land use plans and their corresponding regulations.

Surveillance of ventricular septal defects in Delaware.

BACKGROUND: The prevalence of ventricular septal defects (VSDs), a birth defect in which there is an opening in the wall that separates the left and right ventricles of the heart, seemed to be substantially higher in Delaware compared with the National Birth Defects Prevention Network (NBDPN). The Delaware Birth Defects Registry (BDR) noted their high prevalence of VSDs in comparison with other states. METHODS: A subset of children with a VSD born in 2007 through 2010 was identified from the complete reportable statewide defect list that the BDR creates each year. VSDs were categorized by type of VSD (muscular, perimembranous, conotruncal, or atrioventricular septal defect), by either isolated or complex, and then by spontaneously closed, surgically closed, open but clinically insignificant, lost to follow-up, fetal or neonatal death. RESULTS: The BDR team found a prevalence of VSD of 83.4 per 10,000 including fetal/neonatal deaths. Excluding fetal and neonatal deaths the prevalence was 78.7 per 10,000 live births. Excluding small muscular VSDs, the prevalence in Delaware falls to 25.7 per 10,000. CONCLUSION: The BDR team chose to include all babies with all types of VSDs. Using these criteria Delaware's prevalence of 78.7 was higher than that reported by other states (whose prevalence ranges from 1.6 to 70.0 per 10,000 live births) (National Birth Defects Prevention Network, ). Delaware's prevalence is similar to other states when small muscular VSDs are excluded. Birth Defects Research (Part A) 106:888-893, 2016. © 2016 Wiley Periodicals, Inc.

Teen mothers, unintended pregnancies, and costs across Delaware.

The present study used data from several sources to 1) present information on mothers and births in a single state (Delaware); 2) present cost data to estimate health-related birth real costs; and 3) use the data to estimate the costs and impact on mothers, health care providers, and taxpayers. In addition, this study explicitly examined costs of births through the lens of unplanned/unintended teen and young adult births. Concomitantly, the medical cost of these pregnancies for most of these young mothers who had not wanted to be pregnant at the time, was paid for through the state's Medicaid program. The percentage of Medicaid funded births was much higher for young mothers than for older mothers. Ultimately, it was estimated that young teen (age 17 and under) births cost about $4.0 million each year, older teens (18-20) births $14.0 million, and young adults (21-24) over $26 million. The State funded almost 75 percent of the health care costs of young teen pregnancy prenatal care, deliveries, and newborn care, through Medicaid. And over 75 percent of these Medicaid costs are for births that were unintended at the time. The cost of unintended teen and young adult births funded through Medicaid in Delaware was approximately $25 million annually.

Awareness of the 5 A's and motivational interviewing among community primary care providers.

BACKGROUND: The United States Preventive Services Task Force and numerous other organizations recommend the use of brief motivational interventions as evidence-based approaches to achieve effective behavior change. The extent to which community primary care providers are familiar or trained in these methods is not known. CONTEXT AND PURPOSE: To assess awareness and training in the use of brief motivational interventions among primary care providers. METHODS: Cross-sectional assessment of primary care providers' familiarity and training in the use of the 5A's and Motivational Interviewing (MI). Participants include physicians, nurse practitioners, and nurses attending professional education events focused on women and heart disease across a single state. Familiarity with the 5 A's and MI, assessed using a five-point Likert scale, and prior training in MI were measured using cross tabulations and chi-square testing. RESULTS: Of the 186 providers, only 32.1 percent were generally or very familiar with the 5A's and only 17.7 percent were generally or very familiar with MI. Although there were no statistically significant differences by provider types, family physicians may have been more familiar with the 5 A's while family physicians and general internists were significantly more familiar with MI than all provider types (p = .012). There was a significant association between recency of medical training and experience with MI training. CONCLUSIONS: There is a low level of familiarity with brief motivational interventions among primary care providers. Increasing post-graduate training in the 5 A's and MI can be an important strategy to increasing the effectiveness of the primary care provider in helping their patients achieve lasting behavior change.

Integrating an HIV/HCV brief intervention in prisoner reentry: results of a multisite prospective study.

Brief interventions to reduce harmful or problem behaviors have become increasingly popular in a variety of health fields, including HIV and hepatitis risk reduction. A central issue in intervention research involves the evaluation of what constitutes an effective "dose" of an intervention. This research examines the relative effectiveness of three alternative brief interventions of varying intensity designed to change the risk behaviors of inmates who are reentering society: a DVD-based, peer delivered intervention; the NIDA Standard HIV Intervention; and a standard practice condition (HIV educational video). All participants randomly received one of the interventions and were tested for HIV and HCV prior to release from custody. Thirty and ninety-day follow-ups examined changes in high-risk behaviors. Results reported here for 343 subjects who have completed the 90-day follow up indicate significant reductions in reported sexual risk behaviors for those participating the DVD intervention, compared to the other two brief interventions. This study is among the first to report any positive impacts on sexual behaviors among a population of inmates returning to the community.

Navigating the Health Care System: An Adolescent Health Literacy Unit for High Schools.

BACKGROUND: Currently, no intervention concerning transition of health care responsibilities from parents to teens exists for adolescents in the general population. The purpose of this intervention was to evaluate teacher satisfaction and student knowledge gain of a health unit developed for adolescents on becoming their own health care advocates. METHODS: Throughout the 2014-2015 school year, 13 health and career technical education teachers in 11 Delaware high schools taught the unit to 948 students in 2 90-minute classes in 35 classrooms. Assessments included teacher reflections and student pre- and posttests to measure knowledge transfer and gain and gather feedback. RESULTS: Teacher and student feedback indicated the materials were appropriate and useful in teaching students to navigate the health care system. Student knowledge increased from pretest (64%) to posttest (82%), (p < .001). The educational background of the teacher did not influence this outcome. Students reported they will know what to do better at their next doctor's appointment because of this unit and indicated support for peers to learn this information. CONCLUSIONS: The unit resulted in content knowledge increase for students. It was consistently effective throughout all schools regardless of social and demographic characteristics, teacher type, or experience teaching the unit.

Postpartum healthcare after gestational diabetes and hypertension.

BACKGROUND: Gestational diabetes and hypertensive disorders of pregnancy identify women with an elevated lifetime risk of diabetes and cardiovascular disease. METHODS: Prospective cohort of women recruited from the postpartum service of a large community-based academic obstetrical hospital after delivery of a pregnancy complicated by gestational diabetes (GDM) or a hypertensive disorder of pregnancy (HDP). Interviews were conducted, and validated surveys completed, before hospital discharge and again 3 months postpartum. RESULTS: The study sample included 249 women: 111 with GDM, 127 with HDP, and 11 with both. Most, 230 (92.4%) had a PCP prior to pregnancy and 97 (39.0%) reported an office visit with their PCP during the prenatal period. Of the 176 (70.7%) participants who attended the 3-month study visit, 169 (96.0%) women with either diagnosis reported they had attended their 6-week postpartum visit. By the 3-month study visit, 51 (57.9%) women with GDM had completed follow-up glucose testing; 93 (97.9%) with HDP had follow-up blood pressure testing; and 101 (57.4%) with either diagnosis recalled ever having completed lipid screening. Women least likely to complete screening tests were those who had no college education, less than a high school level of health literacy, and who were not privately insured. CONCLUSION: There are important opportunities to improve postpartum testing for diabetes and CVD risk factor assessment. Most women were connected to primary care suggesting a "hand-off" to a primary care physician after pregnancy is feasible. More robust strategies may be needed to improve follow-up care for women with less education, lower health literacy, and those without private health insurance.

Independent relation of maternal prenatal factors to early childhood obesity in the offspring.

OBJECTIVE: To examine the independent contribution of risk factors developing during pregnancy to subsequent risk of obesity in young children. METHODS: We conducted a historical cohort study using data from electronic medical records of mothers and their 3,302 singleton offspring born between 2004 and 2007 at a community-based obstetric facility who attended a 4-year well visit at a pediatric practice network. The child's body mass index (BMI) z score at age 4 years was studied in relation to the mother's gestational weight gain, gestational diabetes mellitus, gestational hypertension or preeclampsia, and prenatal tobacco use. Institute of Medicine categories defined excess and inadequate gestational weight gain at term. Analysis of variance and multiple linear regression were used to test their independent relation to BMI. RESULTS: Mothers were white (39%), African American (46%), and of Hispanic ethnicity (11%); 46% were privately insured. The association of net gestational weight gain with the child's BMI z score was significant after adjustment for prepregnancy maternal factors (P<.001); gestational diabetes mellitus, gestational hypertension, and tobacco use were not significant in adjusted models. Children of mothers with excess gestational weight gain had a higher mean BMI z score (P<.001) but a significant association was observed only for inadequate gestational weight gain after adjusting for prepregnancy BMI and other covariates. Prepregnancy BMI (P<.001), Hispanic ethnicity (P<.001), and being married (P<.05) were independently associated with increasing BMI z score of the offspring. CONCLUSIONS: Preconception maternal factors had a greater influence on child obesity than prenatal factors. The gestational weight gain category was independently related to BMI z score of 4 year olds, but this association was significant only for mothers with inadequate gestational weight gain. LEVEL OF EVIDENCE: II.