Principles for Primary Care Screening in the Context of Population Health.

A key component of primary care pediatrics is health promotion through screening: applying a test or procedure to detect a previously unrecognized disease or disease risk. How do we decide whether to screen? In 1965, Wilson and Jungner published an influential set of screening principles focused on the health problem's importance, the screening tool's performance, and the evidence for treatment efficacy. However, if we want realistic estimates of the population effects of routine screening, we must also account for the health care system's real-world functioning and disparities in care. We offer revised principles to guide discussions about routine screening in the primary care setting. We add to Wilson and Jungner's principles: 1. A focus on life course epidemiology and its consequences for population health, 2. A need to screen for the early stages of chronic health problems, 3. A concern for screening's acceptability to providers and the community, 4. A recommendation for estimating the uncertainty in benefits and harms in evaluating screening, 5. Inclusion of systematic plans for population data collection and monitoring, and 6. Recognition that achieving population health improvement requires a high-performing system with sufficient throughput and monitoring to deliver accessible, affordable, and effective care, especially for the groups experiencing the greatest inequities in access. Above all, instead of assuming best practices in treatment delivery and monitoring after screening, we argue for realism about the health care system functioning in routine practice.

Learning competing risks across multiple hospitals: one-shot distributed algorithms.

OBJECTIVES: To characterize the complex interplay between multiple clinical conditions in a time-to-event analysis framework using data from multiple hospitals, we developed two novel one-shot distributed algorithms for competing risk models (ODACoR). By applying our algorithms to the EHR data from eight national children's hospitals, we quantified the impacts of a wide range of risk factors on the risk of post-acute sequelae of SARS-COV-2 (PASC) among children and adolescents. MATERIALS AND METHODS: Our ODACoR algorithms are effectively executed due to their devised simplicity and communication efficiency. We evaluated our algorithms via extensive simulation studies as applications to quantification of the impacts of risk factors for PASC among children and adolescents using data from eight children's hospitals including the Children's Hospital of Philadelphia, Cincinnati Children's Hospital Medical Center, Children's Hospital of Colorado covering over 6.5 million pediatric patients. The accuracy of the estimation was assessed by comparing the results from our ODACoR algorithms with the estimators derived from the meta-analysis and the pooled data. RESULTS: The meta-analysis estimator showed a high relative bias (∼40%) when the clinical condition is relatively rare (∼0.5%), whereas ODACoR algorithms exhibited a substantially lower relative bias (∼0.2%). The estimated effects from our ODACoR algorithms were identical on par with the estimates from the pooled data, suggesting the high reliability of our federated learning algorithms. In contrast, the meta-analysis estimate failed to identify risk factors such as age, gender, chronic conditions history, and obesity, compared to the pooled data. DISCUSSION: Our proposed ODACoR algorithms are communication-efficient, highly accurate, and suitable to characterize the complex interplay between multiple clinical conditions. CONCLUSION: Our study demonstrates that our ODACoR algorithms are communication-efficient and can be widely applicable for analyzing multiple clinical conditions in a time-to-event analysis framework.

Rural-urban differences in social and emotional protective factors and their association with child health and flourishing.

BACKGROUND: Children in rural communities experience higher mortality rates and less access to health care services than those in urban communities. Protective factors like social support also vary by geography, but their contribution to differences in child health is understudied. Understanding geographic variation in protective health factors could provide insight into their impact on health and guide future intervention strategies. RESEARCH OBJECTIVE: To examine protective factors' association with child flourishing and child health status in rural and urban communities. METHODS: Publicly available data from the National Survey of Children's Health, 2018-2021, with nonmissing geographic data (N = 150,493) were used to assess the relationship between protective factors and child flourishing and health by rurality. Multivariate survey-weighted probit models examined these relationships, adjusting for child and caregiver characteristics. FINDINGS: More than a third of children were not flourishing, according to parental report. An estimated 62% of rural children were flourishing compared to 66% of urban children (P<0.001). Urban caregivers also were more likely to report better adult mental and physical health status. Nevertheless, rural children were reported to receive more social support than urban children, while their caregivers reported more emotional support and living in supportive and safe neighborhoods (P<0.001). Rural caregivers reported more support from places of worship and less from counselors/other mental health care providers than urban caregivers. CONCLUSIONS: Despite higher reported caregiver emotional support and child social support, fewer rural children are flourishing. Health systems and community organizations able to leverage these existing social and emotional protective factors in rural communities could help close this gap.

Social Needs as a Risk Factor for Positive Postpartum Depression Screens in Pediatric Primary Care.

OBJECTIVE: The goal of this study was to examine the association between self-reported social needs and postpartum depression (PPD) symptoms of mothers screened in pediatric primary care clinics. METHODS: This retrospective cohort study used electronic health record data from 3616 pediatric patients (age 0-6 months), whose mothers completed the Edinburgh Postpartum Depression Scale (EPDS) and a social needs screening in a large pediatric primary care network between April 2021 and February 2022. Mothers were screened for four self-reported social needs (food, housing, transportation, and utilities). Logistic regression evaluated the association between the report of any social need and a positive EPDS screen (≥ 10), adjusting for demographic and clinical characteristics and ZIP code-level poverty. RESULTS: Overall, 8.6% of mothers screened positive for PPD and 10.0% reported any social needs. The odds of a positive depression screen were significantly higher among mothers who reported any social need compared to those not reporting a social need (OR 4.18, 95% CI 3.11-5.61). The prevalence of all depressive symptoms on the EPDS was significantly higher among those who reported any social need, relative to those reporting no needs. Mothers reporting any social needs were significantly more likely to report thoughts of self-harm (6.9% vs 1.5%, P < .005). CONCLUSIONS: Self-report of social need was significantly associated with positive PPD screens during infant well-child visits. Social needs may be a target of future interventions addressing PPD in pediatric settings. Improving care for social needs may have added benefit of alleviating the risk of PPD.

Collection of biospecimens from parent-child dyads in a community garden-based nutrition intervention: protocol and feasibility.

BACKGROUND: Non-invasive human biospecimens, including stool, urine, and hair, are important in understanding the relationship between diet and changes in human physiologic processes that affect chronic disease outcomes. However, biospecimen collection can be difficult when collecting samples for research studies that occur away from a centralized location. We describe the protocol and feasibility in collecting stool, urine, and hair biospecimens from parents and their children at a remote location as a part of a summer community garden-based intervention. METHODS: Stool, urine, and hair were collected as a part of the Summer Harvest Adventure (SHA) study, a randomized controlled, community garden-based intervention targeting children (ages 8-11 years) and their parents from low-resource neighborhoods. Biospecimens were collected from willing children and/or their parent/adult caregivers at baseline and post-intervention for evaluation of microbiome, metabolomics, and hair analyses among both intervention and control groups at a location distant from the academic laboratories conducting the analysis. The protocol used to assemble, deliver, collect, and process biospecimens are presented along with the frequencies with which specimens were successfully obtained. RESULTS: One hundred forty six participants (73 parent-child dyads) were part of the larger SHA study and thus eligible to provide a biospecimen. A total of 126 participants, 115 participants, and 127 participants consented to provide their hair, stool and urine samples, respectively. Of the participants that consented to provide a sample, 44 children (69.8%) and 38 parents (60.3%) provided at least one hair sample, 27 children (48.2%) and 37 parents (62.7%) provided at least one stool sample, and 36 children (57.1%) and 42 parents (65.6%) provided at least one urine sample. Sample collection at the offsite location, transport, and handling at the academic center were successful and all biospecimens were deemed adequate for analyses. DNA and metabolomics yield on a subset of stool samples obtained provided excellent results in terms of an abundance of species and metabolities, as would be predicted. Urine and hair analyses are underway. CONCLUSION: Our work is one of the first to describe the feasibility of collecting human biospecimens, specifically stool, urine, and hair, from both parents and their children from low-resourced neighborhoods in a non-traditional garden research setting. Future work will report findings related to mechanisms between diet, microbiome, metabolites, and clinical outcomes.

Caring for Children of Incarcerated Parents.

By age 18, one in fourteen American children has had a parent incarcerated. Although children from all backgrounds experience parental incarceration, racial and ethnic minority groups and those living in poverty are disproportionately affected. Parental incarceration is an adverse childhood experience that can negatively affect health and well-being over the life course. However, resilient children of incarcerated parents can flourish despite profound adversity. Pediatric providers should create safe, inclusive medical homes that foster sensitive disclosures and discussions about parental incarceration. If pediatric providers identify parental incarceration, they should promote foundational relationships and family resilience (including relationships with incarcerated parents when appropriate) and consider referrals to mental health specialists and specialized programs for children of incarcerated parents. Pediatric providers are also uniquely positioned to advocate for partnerships and policies that support children of incarcerated parents.

Mental Health-related Utilization of Emergency Departments During Pregnancy in the U.S., 2016-2019.

INTRODUCTION: Mental health conditions are a leading comorbidity of pregnancy, but little is known about the use of emergency departments (EDs) for mental health-related care during pregnancy. This study aims to describe both the characteristics of pregnant women who receive mental health-related care in hospital EDs in the United States and the most common mental health diagnoses, types of medications, and mental health services that these women receive. METHODS: Pooled, cross-sectional data from the National Hospital Ambulatory Medical Care Survey (2016-2019) were used. Pregnant patients were identified based on diagnosis and reason for visit codes. Weighted descriptive analyses were performed to describe characteristics of pregnant women, services offered, and medications received for mental health-related visits. RESULTS: Mental health-related visits comprised 6.2% of all ED visits during pregnancy. History of depression was significantly higher in pregnant patients with mental health-related visits compared to those pregnant patients presenting for other reasons. The most common diagnoses for pregnant patients with mental health-related visits were substance use disorders (30.7%), anxiety-related disorders (19.1%), and depressive disorders (14.6%). Anxiolytics and antidepressants were the most common pharmacotherapies given. Few women saw a mental health provider during their visit (6.7%), while most were referred to an outside clinic for follow-up (55.0%). DISCUSSION: Many pregnant women seek care from EDs for mental health-related reasons. It remains important to train health care professionals who treat pregnant women in EDs how to deliver effective treatments, particularly for substance use disorders and anxiety. SIGNIFICANCE: Many pregnant patients receive care in emergency departments during pregnancy. Despite mental health conditions being a leading comorbidity of pregnancy, little is known about the use of emergency departments for mental health-related reasons during pregnancy. This study is the first to analyze a representative sample of emergency department visits by pregnant women in the United States between 2016 and 2019 and report on mental health-related visits. Among pregnant women seen in the ED for mental health-related reasons, the most common diagnoses were substance use disorders, anxiety-related disorders, and depressive disorders, but few saw a mental health provider during their visit.

Valuing the cross-sector benefits from improving youth health to drive investment in place-based preventive interventions in the US: A simulation modeling study.

Healthcare payment reform has not produced incentives for investing in place-based, or population-level, upstream preventive interventions. This article uses economic modeling to estimate the long-term benefits to different sectors associated with improvements in population health indicators in childhood. This information can motivate policymakers to invest in prevention and provide guidance for cross-sector contracting to align incentives for implementing place-based preventive interventions. A benefit-cost model developed by the Washington State Institute for Public Policy was used to estimate total and sector-specific benefits expected from improvements to nine different population health indicators at ages 17 and 18. The magnitudes of improvement used in the model were comparable to those that could be achieved by high-quality implementation of evidence-based population-level preventive interventions. Benefits accruing throughout the lifecycle and over a ten-year time horizon were modelled. Intervention effect sizes of 0.10 and 0.20 demonstrated substantial long-term benefits for eight of the nine outcomes measured. At an effect size of 0.10, the median lifecycle benefit per participant across the ten indicators was $3080 (ranged: $93 to $14,220). The median over a 10-year time horizon was $242 (range: $14 to $1357). Benefits at effect sizes of 0.20 were approximately double. Policymakers may be able to build will for additional investment based on these cross-sector returns and communities may be able to capture these cross-sector benefits through contracting to better align incentives for implementing and sustaining place-based preventive interventions.

Development of a Symptom-Focused Model to Guide the Prescribing of Antipsychotics in Children and Adolescents: Results of the First Phase of the Safer Use of Antipsychotics in Youth (SUAY) Clinical Trial.

OBJECTIVE: To develop a new approach to prescribing guidelines as part of a pragmatic trial, Safer Use of Antipsychotics in Youth (SUAY; ClinicalTrials.gov Identifier: NCT03448575), which supports prescribers in delivering high-quality mental health care to youths. METHOD: A nominal group technique was used to identify first- to nth-line treatments for target symptoms and potential diagnoses. The panel included US pediatricians, child and adolescent psychiatrists, and psychopharmacology experts. Meeting materials included information about Medicaid review programs, systematic reviews, prescribing guidelines, and a description of the pragmatic trial. Afterward, a series of 4 webinar discussions were held to achieve consensus on recommendations. RESULTS: The panel unanimously agreed that the guideline should focus on target symptoms rather than diagnoses. Guidance included recommendations for first- to nth-line treatment of target mental health symptoms, environmental factors to be addressed, possible underlying diagnoses that should first be considered and ruled out, and general considerations for pharmacological and therapeutic treatments. CONCLUSION: Prescribing guidelines are often ignored because they do not incorporate the real-world availability of first-line psychosocial treatments, comorbid conditions, and clinical complexity. Our approach addresses some of these concerns. If the approach proves successful in our ongoing pragmatic trial, Safer Use of Antipsychotics in Youth (SUAY), it may serve as a model to state Medicaid programs and health systems to support clinicians in delivering high-quality mental health care to youths. CLINICAL TRIAL REGISTRATION INFORMATION: Safer Use of Antipsychotics in Youth; http://clinicaltrials.gov/; NCT03448575.

Left behind again: Rural home health services in a Medicaid pediatric accountable care organization.

PURPOSE: To contrast trends in rural and urban pediatric home health care use among Medicaid enrollees. METHODS: Medicaid administrative claims data were used to assess differences in home health care use for child members in a large pediatric accountable care organization (ACO) in Ohio. Descriptive statistics assessed rural and urban differences in health care use over a 10-year period between 2010 and 2019. FINDINGS: Pediatric home health care use increased markedly in the low-income (CFC) and disabled (ABD) Medicaid categories. Over the past 10 years, CFC-enrolled children from urban communities have seen more home health visits, fewer emergency department (ED) visits, and more well child visits compared to rural CFC-enrolled children. Children enrolled due to disabilities in urban communities have also seen more home health visit use but fewer preventive care visits than their rural counterparts. CONCLUSIONS: Within a pediatric ACO, rural home health care use has remained relatively stagnant over a 10-year period, a stark contrast to increases in home health care use among comparable urban populations. There are likely multiple explanations for these differences, including overuse in urban communities, lack of access in rural communities, and changes to home health reimbursement. More can be done to improve rural home health access. Such improvement will likely necessitate large-scale changes to home health care delivery, workforce, and financing. Improvements should be evaluated for return-on-investment not only in terms of direct costs, that is, reduced inpatient or ED costs, but also in terms of patient and family quality-of-life or key indicators of child well-being such as educational attainment.

"Prevention of opioid use disorder: the HOME (housing, opportunities, motivation and engagement) feasibility study".

Young adults experiencing homelessness are at high risk of opioid and other substance use, poor mental health outcomes, exposure to trauma, and other risks. Providing access to stable housing has the potential to act as a powerful preventive intervention, but supportive housing programs have been studied most often among chronically homeless adults or adults with serious mental illness. The Housing First model, which does not precondition supportive housing on sobriety, may reduce drug use in homeless adults. In the present study, we piloted an adapted model of Housing First plus prevention services that was tailored to the needs of young adults (18-24 years) experiencing homelessness in the USA. Preventive services were added to the Housing First model and included youth-centered advocacy services, motivational interviewing, and HIV risk prevention services. This model was piloted in a single-arm study (n = 21) to assess the feasibility, acceptability, and initial efficacy of a Housing First model over a 6-month period in preparation for a larger randomized trial. We use repeated measures ANOVA to test for changes in alcohol and drug use (percent days of use; alcohol or drug use consequences), housing stability, social network support, and cognitive distortions over 6 months of follow-up. A total of 17 youth completed the study (85% retention), and a high proportion of youth were stably housed at 6-month follow-up. Participation in intervention services was high with an average of 13.57 sessions for advocacy, 1.33 for MI, and 0.76 for HIV prevention. Alcohol use did not change significantly over time. However, drug use, drug use consequences, and cognitive distortions, and the size of youths' social networks that were drug using individuals decreased significantly. The Housing First model appeared to be feasible to deliver, and youth engaged in the supportive intervention services. The study demonstrates the potential for an adapted Housing First model to be delivered to youth experiencing homelessness and may improve outcomes, opening the way for larger randomized trials of the intervention.

The Potential for Improving the Population Health Effectiveness of Screening: A Simulation Study.

BACKGROUND AND OBJECTIVES: Screening interventions in pediatric primary care often have limited effects on patients' health. Using simulation, we examined what conditions must hold for screening to improve population health outcomes, using screening for depression in adolescence as an example. METHODS: Through simulation, we varied parameters describing the working recognition and treatment of depression in primary care. The outcome measure was the effect of universal screening on adolescent population mental health, expressed as a percentage of the maximum possible effect. Through simulations, we randomly selected parameter values from the ranges of possible values identified from studies of care delivery in real-world pediatric settings. RESULTS: We examined the comparative effectiveness of universal screening over assessment as usual in 10 000 simulations. Screening achieved a median of 4.2% of the possible improvement in population mental health (average: 4.8%). Screening had more impact on population health with a higher sensitivity of the screen, lower false-positive rate, higher percentage screened, and higher probability of treatment, given the recognition of depression. However, even at the best levels of each of these parameters, screening usually achieved <10% of the possible effect. CONCLUSIONS: The many points at which the mental health care delivery process breaks down limit the population health effects of universal screening in primary care. Screening should be evaluated in the context of a realistic model of health care system functioning. We need to identify health care system structures and processes that strengthen the population effectiveness of screening or consider alternate solutions outside of primary care.

Trends Over Time in Antipsychotic Initiation at a Large Children's Health Care System.

Objectives: Antipsychotic prescribing in children and adolescents increased sharply beginning in the 1990s, but recent reports among Medicaid enrollees suggest declining trends. However, few studies have included both commercially and publicly insured patients or focused on trends in new antipsychotic medications in children without documented psychotic disorders or other indicated conditions. The objective of the study was to report trends in new antipsychotic prescribing for pediatric patients (age 3-17 years) in a large children's health care system. Methods: Data were abstracted from electronic medical records (January 1, 2013 to December 31, 2017). New antipsychotic medication orders were defined as antipsychotic orders for patients without an order in the 180 days prior. Patients were excluded if the order was initiated in an emergency department or inpatient setting; they were diagnosed with psychotic disorder, mania, autism spectrum disorder, or intellectual disability; or the order was for prochlorperazine. The crude rate of new antipsychotic prescribing is reported quarterly with Poisson 95% confidence intervals in the total sample and by demographic subgroups (child vs. adolescent, female vs. male, public vs. private insurance, and white vs. nonwhite). Results: Antipsychotic orders decreased from 54.9 prescriptions per 10,000 person months in the first quarter of 2013 to 34.1 per 10,000 person months in the last quarter of 2017. Rates of antipsychotic prescribing were significantly higher for adolescents compared with children, patients who were commercially insured compared with Medicaid insured, and at most time points for white compared with non-white patients. However, prescribing rates did not differ significantly based on gender. Conclusions: Antipsychotic prescribing declined for both commercially and Medicaid-insured children in a pediatric hospital-based system, although white and commercially insured patients were more likely to be prescribed antipsychotics. More attention may be needed for reducing potentially avoidable prescribing of antipsychotics in previously understudied subgroups, such as commercially insured patients. Clinical Trial Registration Number: NCT03448575.