Change in Site of Children's Primary Care: A Longitudinal Population-Based Analysis.

PURPOSE: Evidence that fewer children are being seen at family physician (FP) practices has not been confirmed using population-level data. This study examines the proportion of children seen at FP and pediatrician practices over time and the influence of patient demographics and rurality on this trend. METHODS: We conducted a retrospective longitudinal analysis of Vermont all-payer claims (2009-2016) for children aged 0 to 21 years. The sample included 184,794 children with 2 or more claims over 8 years. Generalized estimating equations modeled the outcome of child attribution to a FP practice annually, with covariates for calendar year, child age, sex, insurance, and child Rural Urban Commuting Area (RUCA) category. RESULTS: Over time, controlling for other covariates, children were 5% less likely to be attributed to a FP practice (P <.001). Children had greater odds of attribution to a FP practice as they aged (odds ratio (OR) = 1.11, 95% CI, 1.10-1.11), if they were female (OR = 1.05, 95% CI, 1.03-1.07) or had Medicaid (OR = 1.09, 95% CI, 1.07-1.10). Compared with urban children, those from large rural cities (OR = 1.54, 95% CI, 1.51-1.57), small rural towns (OR = 1.45, 95% CI, 1.42-1.48), or isolated/small rural towns (OR = 1.96, 95% CI, 1.93-2.00) had greater odds of FP attribution. When stratified by RUCA, however, children had 3% lower odds of attending a FP practice in urban areas and 8% lower odds in isolated/small rural towns. CONCLUSIONS: The declining proportion of children attending FP practices, confirmed in this population-based analysis and more pronounced in rural areas, represents a continuing challenge.

Electronic health record (EHR) based postmarketing surveillance of adverse events associated with pediatric off-label medication use: A case study of short-acting beta-2 agonists and arrhythmias.

PURPOSE: Use electronic health record (EHR) data to (1) estimate the risk of arrhythmia associated with inhaled short-acting beta-2 agonists (SABA) in pediatric patients and (2) determine whether risk varied by on-label versus off-label prescribing. METHODS: Retrospective cohort study of 335 041 children ≤18 years using EHR primary care data from 2 pediatric health systems (2011-2013). A series of monthly pseudotrials were created, using propensity score methodology to balance baseline characteristics between SABA-exposed (identified by prescription) and SABA-unexposed children. Association between SABA and subsequent arrhythmia for each health system was estimated through pooled logistic regression with separate estimates for children initiating under and over 4 years old (off-label and on-label, respectively). RESULTS: Eleven percent of the cohort received a SABA prescription, 57% occurred under the age of 4 years (off-label). During the follow-up period, there were 283 first arrhythmia events, most commonly atrial tachyarrhythmias and premature ventricular/atrial contractions. In 1 health system, adjusted risk for arrhythmia was increased among exposed children (OR 1.89, 95% CI 1.31-2.73) without evidence of interaction between label status and risk. The absolute adjusted rate difference was 3.6/10 000 person-years of SABA exposure. The association between SABA exposure and arrhythmias was less strong in the second system (OR 1.26, 95% CI 0.30-5.33). CONCLUSION: Using EHR data, we could estimate the risk of a rare event associated with medication use and determine difference in risk related to on-label versus off-label status. These findings support the value of EHR-based data for postmarketing drug studies in the pediatric population.

Outcome of BMI2+: Motivational Interviewing to Reduce BMI Through Primary Care AAP PROS Practices.

BACKGROUND: Pediatric obesity rates in the United States remain at an all-time high. Pediatric primary care clinicians and registered dietitians can help treat childhood obesity, and motivational interviewing (MI) has shown promising effects in prior trials. METHODS: We randomized 18 pediatric primary care practices to receive the Brief Motivational Interviewing to Reduce BMI or BMI2+ intervention or continue with usual care (UC). Practices were recruited through the American Academy of Pediatrics Pediatric Research in Office Settings network. The intervention comprised 4 components1: in-person and telehealth MI counseling by pediatric clinicians; 4 recommended sessions,2 6 telephone MI counseling sessions from a registered dietitian,3 text message reminders and tailored motivational messages, and4 parent educational materials. The main outcome was the change in the percentage of the 95th percentile of BMI. The study was conducted 2017 through 2021. RESULTS: There was a significant treatment x time interaction (b = 0.017, 95% confidence interval: [0.0066-0.027]) for the main outcome, favoring the UC group, with youth in the intervention arm showing a greater relative increase in their percent of the 95th percentile. CONCLUSIONS: There was no overall benefit of the intervention and, contrary to expectations, youth in the intervention arm gained more weight, based on percent of the distance from the 95th percentile than matched youth from UC practices. The absolute excess weight gain among intervention relative to UC youth was small, approximately 0.5 BMI units and 1 kg over 2 years. We offer several potential explanations for these unexpected findings.

Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial.

IMPORTANCE: Antimicrobial stewardship programs have been effective for inpatients, often through prescribing audit and feedback. However, most antimicrobial use occurs in outpatients with acute respiratory tract infections (ARTIs). OBJECTIVE: To evaluate the effect of an antimicrobial stewardship intervention on antibiotic prescribing for pediatric outpatients. DESIGN: Cluster randomized trial of outpatient antimicrobial stewardship comparing prescribing between intervention and control practices using a common electronic health record. After excluding children with chronic medical conditions, antibiotic allergies, and prior antibiotic use, we estimated prescribing rates for targeted ARTIs standardized for age, sex, race, and insurance from 20 months before the intervention to 12 months afterward (October 2008-June 2011). SETTING AND PARTICIPANTS: A network of 25 pediatric primary care practices in Pennsylvania and New Jersey; 18 practices (162 clinicians) participated. INTERVENTIONS: One 1-hour on-site clinician education session (June 2010) followed by 1 year of personalized, quarterly audit and feedback of prescribing for bacterial and viral ARTIs or usual practice. MAIN OUTCOMES AND MEASURES: Rates of broad-spectrum (off-guideline) antibiotic prescribing for bacterial ARTIs and antibiotics for viral ARTIs for 1 year after the intervention. RESULTS: Broad-spectrum antibiotic prescribing decreased from 26.8% to 14.3% (absolute difference, 12.5%) among intervention practices vs from 28.4% to 22.6% (absolute difference, 5.8%) in controls (difference of differences [DOD], 6.7%; P = .01 for differences in trajectories). Off-guideline prescribing for children with pneumonia decreased from 15.7% to 4.2% among intervention practices compared with 17.1% to 16.3% in controls (DOD, 10.7%; P < .001) and for acute sinusitis from 38.9% to 18.8% in intervention practices and from 40.0% to 33.9% in controls (DOD, 14.0%; P = .12). Off-guideline prescribing was uncommon at baseline and changed little for streptococcal pharyngitis (intervention, from 4.4% to 3.4%; control, from 5.6% to 3.5%; DOD, -1.1%; P = .82) and for viral infections (intervention, from 7.9% to 7.7%; control, from 6.4% to 4.5%; DOD, -1.7%; P = .93). CONCLUSIONS AND RELEVANCE: In this large pediatric primary care network, clinician education coupled with audit and feedback, compared with usual practice, improved adherence to prescribing guidelines for common bacterial ARTIs, and the intervention did not affect antibiotic prescribing for viral infections. Future studies should examine the drivers of these effects, as well as the generalizability, sustainability, and clinical outcomes of outpatient antimicrobial stewardship. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01806103.

The patient record and the rise of the pediatric EHR.

Medical documentation arose as individual case reports written for teaching purposes. Documentation for patient care later occurred in physicians' personal daybooks and only evolved into the individual patient record in the early 20th century. Dr. Lawrence Weed improved the utility of the patient record by introducing a problem-oriented/subject-object-assessment-plan structure and he and other innovators transformed the patient record into electronic form. Pediatricians built on these innovations to create a child health electronic health record (EHR) for primary care. An American Academy of Pediatrics task force formally specified the child-specific needs of the EHR, but much work remains to integrate the EHR into the pediatric primary care of the future.

Cost-effectiveness of a motivational interviewing obesity intervention versus usual care in pediatric primary care offices.

OBJECTIVE: This study aimed to assess the incremental cost-effectiveness ratio (ICER) of a 2-year motivational interviewing (MI) intervention versus usual primary care. METHODS: A national trial was implemented in the Pediatric Research in Office Settings (PROS) network of the American Academy of Pediatrics to evaluate MI versus usual care for children (2-8 years old; baseline BMI 85th-97th percentiles). Health care use, food costs, provider fees, and training costs were assessed, and sensitivity analyses were conducted. Primary outcome was the ICER, calculated as cost per unit change in BMI percentile for intervention versus usual care. RESULTS: At 2 years, 72% of enrolled parent/child dyads were retained; 312 children were included in the analysis. Mean BMI percentile point change was -4.9 and -1.8 for the intervention and control, respectively, yielding an incremental reduction of 3.1 BMI percentile points (95% CI: 1.2-5.0). The intervention cost $1051 per dyad ($658 for training DVD development). Incorporating health care and non-health care costs, the intervention ICER was $363 (range from sensitivity analyses: cost saving, $3159) per BMI percentile point decrease per participant over 2 years. CONCLUSIONS: Training pediatricians, nurse practitioners, and registered dietitians to deliver MI-based interventions for childhood obesity in primary care is clinically effective and acceptably cost-effective. Future work should explore this approach in broader dissemination.

The Future(s) of Pediatric Primary Care.

Pediatric primary care (PPC) arose in the early 20th century as the fusion of acute and chronic pediatric illness care with preventive elements borrowed from public and maternal and child health. Well-established and thriving by the 1930s, PPC saw major changes in childhood morbidity and mortality in the latter half of the 20th century with the recognition of the "new morbidity" of school, behavior, and social problems. At the same time, PPC experienced changes in its workforce, which became increasingly female and added nurse practitioners and physician assistants as practitioners. Independent practice, previously the dominant business model, decreased in prominence at the end of the 20th century as health systems bought practices and other sites morphed into federally qualified health centers. In the present century, electronic health records (EHRs) have brought profound changes in PPC workflows and practitioner experience. In addition, disruptive market competition such as retail clinics and corporate telemedicine providers coupled with changes in health insurance from fee-for-service to value-based payment further challenge the care model and economics of PPC. Finally, recognition of family social circumstances as major determinants of children's health presents another challenge to the status quo. As such, although one PPC future may resemble its present state, a more innovative future is likely to include clinics and practices more oriented toward and linked to communities and directed at the social determinants of health. In addition, the rise in physical, behavioral, and social problems in practice call for a growing focus on wellness, including sleep, nutrition, and activity, that promises to reorient the PPC future in productive new directions. The half-way technology of current EHR systems will ideally be spun into electronic hubs that facilitate teamwork between PPC, specialists, and community groups. Research and practice improvement strategies including involvement in "learning health systems" will be critical to making PPC effective in an evolving society. Although threatened by 21st century forces and hard-to-anticipate change, PPC is ideally positioned to build upon its core functions to create multidisciplinary teams that reach into the community, promoting a holistic wellness for children consistent with the broadest definition of health.

Addressing silent hypoxemia with COVID-19: Implementation of an outpatient pulse oximetry program in Vermont.

OBJECTIVES: We initiated an outpatient pulse oximetry program to facilitate more rapid detection of clinical deterioration of persons with COVID-19. METHODS: Vermont residents in non-congregate settings with laboratory-confirmed SARS-CoV-2 infection were eligible for inclusion. RESULTS: Acceptance of pulse oximetry occurred more frequently among those who were older or symptomatic, spoke English, or who had underlying medical conditions. CONCLUSIONS: We provide the first description of an outpatient pulse oximetry program for COVID-19 by a state health department in the U.S.

Persistent Hypertension in Children and Adolescents: A 6-Year Cohort Study.

OBJECTIVES: To determine the natural history of pediatric hypertension. METHODS: We conducted a 72-month retrospective cohort study among 165 primary care sites. Blood pressure measurements from two consecutive 36 month periods were compared. RESULTS: Among 398 079 primary care pediatric patients ages 3 to 18, 89 347 had ≥3 blood pressure levels recorded during a 36-month period, and 43 825 children had ≥3 blood pressure levels for 2 consecutive 36-month periods. Among these 43 825 children, 4.3% (1881) met criteria for hypertension (3.5% [1515] stage 1, 0.8% [366] stage 2) and 4.9% (2144) met criteria for elevated blood pressure in the first 36 months. During the second 36 months, 50% (933) of hypertensive patients had no abnormal blood pressure levels, 22% (406) had elevated blood pressure levels or <3 hypertensive blood pressure levels, and 29% (542) had ≥3 hypertensive blood pressure levels. Of 2144 patients with elevated blood pressure in the first 36 months, 70% (1492) had no abnormal blood pressure levels, 18% (378) had persistent elevated blood pressure levels, and 13% (274) developed hypertension in the second 36-months. Among the 7775 patients with abnormal blood pressure levels in the first 36-months, only 52% (4025) had ≥3 blood pressure levels recorded during the second 36-months. CONCLUSIONS: In a primary care cohort, most children initially meeting criteria for hypertension or elevated blood pressure had subsequent normal blood pressure levels or did not receive recommended follow-up measurements. These results highlight the need for more nuanced initial blood pressure assessment and systems to promote follow-up of abnormal results.

Assessing inter-rater reliability (IRR) of Tanner staging and orchidometer use with boys: a study from PROS.

BACKGROUND: Few studies have systematically assessed the reliability of pubertal markers; most are flawed by limited numbers of markers and ages studied. AIM: To conduct a comprehensive examination of inter-rater reliability in the assessment of boys' sexual maturity. SUBJECTS: Eight pairs of practitioners independently rated 79 consecutive boys aged 8-14 years. METHODS: Two raters in each of eight practices independently rated boys aged 8-14 years, presenting for physical examinations, on key pubertal markers: pubic hair and genitalia (both on 5-point Tanner scales), testicular size (via palpation and comparison with a four-bead Prader orchidometer), and axillary hair (via a three-point scale). RESULTS: Intraclass correlations assessing degree of inter-rater reliability for pubertal markers ranged from 0.61 to 0.94 (all significant at p < 0.001). Rater Kappas for signs of pubertal initiation ranged from 0.49 to 0.79. CONCLUSIONS: Practitioners are able to reliably stage key markers of male puberty and identify signs of pubertal initiation.

Routine Cholesterol Tests and Subsequent Change in BMI Among Overweight and Obese Children.

INTRODUCTION: In 2011, the National Heart, Lung and Blood Institute and American Academy of Pediatrics concluded that both familial and obesity-associated dyslipidemias increase cardiovascular risk and recommended universal cholesterol testing at ages 9 to 11. It remains unknown whether testing influences body mass index (BMI) trajectory, a key modifiable cardiovascular outcome. METHODS: This quasi-experimental-matched cohort includes children aged 9 to 11 years completing well visits in a diverse primary care network from 2012 to 2014. Participants had baseline BMI ≥85th% and no prior cholesterol testing. Propensity score matching identified untested children similar to tested children on weight measures, practice site, sex, age, race, ethnicity, insurance, and well visit frequency. Change in BMI z-score was assessed over 18 months. Regression adjusted for residual confounding following matching. Data were analyzed in 2018. RESULTS: Matching improved balance between tested and untested children for all characteristics. The matched cohort of 1808 children was predominantly non-Latino black (48%) or non-Latino white (33%), and Medicaid insured (39%). Baseline BMI z-score was 1.88 for tested and 1.84 for untested children. Of tested children, 25% had cholesterol levels above the 2011 guideline's "acceptable" range. Two children received cholesterol lowering medications. Adjusted analysis found no difference in change in BMI z-score between tested and untested children (0.02, 95% confidence interval -0.01, 0.04). CONCLUSIONS: Individual risk assessment in the form of cholesterol testing is not associated with change in BMI trajectory among overweight and obese children. Though testing may identify familial hypercholesterolemia, results suggest testing does not change BMI trajectory, a key strategy to reduce cardiovascular risk.

Improving pediatric practice immunization rates through distance-based quality improvement: a feasibility trial from PROS.

The feasibility and effectiveness of a distance-based quality improvement model were examined in a cohort of Pediatric Research in Office Settings (PROS) practices, with the goal of improving immunization rates and practitioner behaviors and attitudes. Of an initially assessed 82 practices, 29 with baseline rates of < or =88% for children 8 to 15 months of age were randomized into year-long paper-based education or distance-based quality improvement intervention groups. Outcomes were utility/helpfulness of quality improvement modalities, immunization rate change, and behavior/attitude change. Quality improvement participants attended approximately 75% of monthly conference calls but used the quality improvement Listserv and Web site infrequently (mean 1.09 and 0.92 uses, respectively). Helpfulness ratings of quality improvement modalities mirrored usage. Analyses revealed a 4.9% increase in quality improvement group immunization rates (P = .061), a 0.8% education group increase (P = .752), and a 4.1% difference between groups (P = .261). More quality improvement practices adopted systems identifying children behind in immunizations. A distance-based quality improvement model is feasible and may improve immunization rates.

Office-based motivational interviewing to prevent childhood obesity: a feasibility study.

OBJECTIVE: To determine whether pediatricians and dietitians can implement an office-based obesity prevention program using motivational interviewing as the primary intervention. DESIGN: Nonrandomized clinical trial. Fifteen pediatricians belonging to Pediatric Research in Office Settings, a national practice-based research network, and 5 registered dietitians were assigned to 1 of 3 groups: (1) control; (2) minimal intervention (pediatrician only); or (3) intensive intervention (pediatrician and registered dietitian). SETTING: Primary care pediatric offices. PARTICIPANTS: Ninety-one children presenting for well-child care visits met eligibility criteria of being aged 3 to 7 years and having a body mass index (calculated as the weight in kilograms divided by the height in meters squared) at the 85th percentile or greater but lower than the 95th percentile for the age or having a normal weight and a parent with a body mass index of 30 or greater. INTERVENTIONS: Pediatricians and registered dietitians in the intervention groups received motivational interviewing training. Parents of children in the minimal intervention group received 1 motivational interviewing session from the physician, and parents of children in the intensive intervention group received 2 motivational interviewing sessions each from the pediatrician and the registered dietitian. MAIN OUTCOME MEASURE: Change in the body mass index-for-age percentile. RESULTS: At 6 months' follow-up, there was a decrease of 0.6, 1.9, and 2.6 body mass index percentiles in the control, minimal, and intensive groups, respectively. The differences in body mass index percentile change between the 3 groups were nonsignificant (P=.85). The patient dropout rates were 2 (10%), 13 (32%), and 15 (50%) for the control, minimal, and intensive groups, respectively. Fifteen (94%) of the parents reported that the intervention helped them think about changing their family's eating habits. CONCLUSIONS: Motivational interviewing by pediatricians and dietitians is a promising office-based strategy for preventing childhood obesity. However, additional studies are needed to demonstrate the efficacy of this intervention in practice settings.

Automated identification of implausible values in growth data from pediatric electronic health records.

OBJECTIVE: Large electronic health record (EHR) datasets are increasingly used to facilitate research on growth, but measurement and recording errors can lead to biased results. We developed and tested an automated method for identifying implausible values in pediatric EHR growth data. MATERIALS AND METHODS: Using deidentified data from 46 primary care sites, we developed an algorithm to identify weight and height values that should be excluded from analysis, including implausible values and values that were recorded repeatedly without remeasurement. The foundation of the algorithm is a comparison of each measurement, expressed as a standard deviation score, with a weighted moving average of a child's other measurements. We evaluated the performance of the algorithm by (1) comparing its results with the judgment of physician reviewers for a stratified random selection of 400 measurements and (2) evaluating its accuracy in a dataset with simulated errors. RESULTS: Of 2 000 595 growth measurements from 280 610 patients 1 to 21 years old, 3.8% of weight and 4.5% of height values were identified as implausible or excluded for other reasons. The proportion excluded varied widely by primary care site. The automated method had a sensitivity of 97% (95% confidence interval [CI], 94-99%) and a specificity of 90% (95% CI, 85-94%) for identifying implausible values compared to physician judgment, and identified 95% (weight) and 98% (height) of simulated errors. DISCUSSION AND CONCLUSION: This automated, flexible, and validated method for preparing large datasets will facilitate the use of pediatric EHR growth datasets for research.

Effects of Patient-centered Medical Home Transformation on Child Patient Experience.

INTRODUCTION: Patient experience, 1 of 3 aims for improving health care, is rarely included in studies of patient-centered medical home (PCMH) transformation. This study examines the association between patient experience and National Committee on Quality Assurance (NCQA) PCMH transformation. METHODS: This was a cross-sectional study of parent-reported child patient experience from PCMH and non-PCMH practices. It used randomly sampled experience surveys completed by 2599 patients at 29 pediatric and family medicine PCMH (n = 21) and non-PCMH (n = 8) practices in Vermont from 2011 to 2013. Patient experiences related to child development and prevention were assessed using the Consumer Assessment of Health care Providers and Systems (CAHPS). RESULTS: A 10-point increase in NCQA score at PCMH practices is associated with a 3.1% higher CAHPS child prevention score (P = .004). Among pediatric practices, PCMH recognition is associated with 7.7% (P < .0005) and 7.2% (P < .0005) higher CAHPS child development and prevention composite scores, respectively. Among family medicine practices, PCMH recognition is associated with 7.4% (P = .001) and 11.0% (P < .0005) lower CAHPS child development and prevention composite scores, respectively. CONCLUSIONS: Our results suggest that PCMH recognition may improve child patient experience at pediatric practices and worsen experience at family medicine practices. These findings warrant further investigation into the differential influence of NCQA PCMH transformation on family medicine and pediatric practices.