Implementation and evaluation of an electronic consult program at a large academic health system.

BACKGROUND: Although the benefits of eConsults in increasing access and lowering unnecessary utilization have been well described, the development of a successful program can be challenging. OBJECTIVE: We sought to share the experiences of a large academic health system in implementing and evaluating a high-volume electronic consultation (eConsult) program across 34 adult and pediatric medical and surgical specialties. METHODS: Using a multi-method approach, we collected qualitative and quantitative data on operational and process outcomes to describe adoption of eConsults, and survey data to capture satisfaction and experience among referring and specialist clinicians. RESULTS AND CONCLUSIONS: Data evaluating this eConsult program demonstrated robust uptake of the eConsult workflow as well as high satisfaction amongst primary care and specialty clinicians. Effective implementation strategies included engaging leadership, building a dedicated team, and developing quality assurance mechanisms. These experiences and findings may inform implementation at health systems interested in eConsult programs.

External Validation of an Electronic Phenotyping Algorithm Detecting Attention to High Body Mass Index in Pediatric Primary Care.

OBJECTIVES: The lack of feasible and meaningful measures of clinicians' behavior hinders efforts to assess and improve obesity management in pediatric primary care. In this study, we examined the external validity of a novel algorithm, previously validated in a single geographic region, using structured electronic health record (EHR) data to identify phenotypes of clinicians' attention to elevated body mass index (BMI) and weight-related comorbidities. METHODS: We extracted structured EHR data for 300 randomly selected 6- to 12-year-old children with elevated BMI seen for well-child visits from June 2018 to May 2019 at pediatric primary care practices affiliated with Yale. Using diagnosis codes, laboratory orders, referrals, and medications adapted from the original algorithm, we categorized encounters as having evidence of attention to BMI only, weight-related comorbidities only, or both BMI and comorbidities. We evaluated the algorithm's sensitivity and specificity for detecting any attention to BMI and/or comorbidities using chart review as the reference standard. RESULTS: The adapted algorithm yielded a sensitivity of 79.2% and specificity of 94.0% for identifying any attention to high BMI/comorbidities in clinical documentation. Of 86 encounters labeled as "no attention" by the algorithm, 83% had evidence of attention in free-text components of the progress note. The likelihood of classification as "any attention" by both chart review and the algorithm varied by BMI category and by clinician type (p < 0.001). CONCLUSION: The electronic phenotyping algorithm had high specificity for detecting attention to high BMI and/or comorbidities in structured EHR inputs. The algorithm's performance may be improved by incorporating unstructured data from clinical notes.

Improving access to first-line treatment for pediatric obesity: Lessons from the dissemination of SmartMoves.

OBJECTIVE: The increasing prevalence of and inequities in childhood obesity demand improved access to effective treatment. The SmartMoves curriculum used in Bright Bodies, a proven-effective, intensive health behavior and lifestyle treatment (IHBLT), was disseminated to ≥30 US sites from 2003 to 2018. We aimed to identify barriers to and facilitators of IHBLT implementation/sustainment. METHODS: We surveyed and interviewed key informants about experiences acquiring/implementing SmartMoves. In parallel, we analyzed and then integrated survey findings and themes from interviews using the constant comparative method. RESULTS: Participants from 16 sites (53%) completed surveys, and 12 participants at 10 sites completed interviews. The 11 sites (63%) that implemented SmartMoves varied in both use of training opportunities/materials and fidelity to program components. In interviews, demand for obesity programming, organizational priorities, and partnerships facilitated implementation. Seven sites discontinued SmartMoves prior to the COVID-19 pandemic. Funding insecurity and insufficient staffing emerged as dominant barriers to implementation/sustainment discussed by all interviewees, and some also noted participants' competing demands and the program's fit with population as challenges. CONCLUSIONS: System- and organizational-level barriers impeded sustainment of an evidence-based IHBLT program. Adequate funding could enable sufficient staffing and training to promote fidelity to the intervention's core functions and adaptation to fit local populations/context.

Barriers to and facilitators of improving physical activity and nutrition behaviors during chemotherapy for breast cancer: a sequential mixed methods study.

PURPOSE: Use qualitative and quantitative methods to explore factors influencing the adoption of guideline-based physical activity (PA) and dietary recommendations among participants enrolled in a lifestyle intervention during and after chemotherapy for breast cancer. METHODS: Among women with stage I-III breast cancer who participated in the intervention arm of the Lifestyle, Exercise, and Nutrition early after diagnosis (LEANer) trial, we used stratified, purposeful sampling to interview women who met both, one, or neither intervention goal after the 1-year intervention: (1) 150 min/week moderate-to-vigorous intensity exercise via a self-reported PA questionnaire and (2) improved self-reported diet quality measured by the Healthy Eating Index-2015. Semi-structured interviews were audio-recorded, transcribed verbatim, and analyzed using thematic content analysis. RESULTS: The 29 women interviewed were 52 ± 11 years old on average, with a mean body mass index of 29.6 ± 7.7 kg/m2. Three themes emerged regarding aspects of the LEANer intervention that facilitated behavior change: (1) providing a conduit of trustworthy, timely, and personalized support and education; (2) shifting mindsets and enhanced understanding of the benefits of PA and nutrition during chemotherapy; and (3) fostering a sense of control and alternative focus. Factors described as hindering adoption of goals included: (1) adverse effects of chemotherapy and (2) competing priorities. CONCLUSIONS: Women reported the external support, tailored education, and experiencing the physical and mental benefits of the LEANer intervention facilitated the adoption of the interventions' behavioral goals. Addressing chemotherapy-related symptoms and competing priorities may facilitate adherence to lifestyle interventions during chemotherapy for breast cancer.

Cost-effectiveness of a primary care-based Healthy Weight Clinic compared with usual care.

OBJECTIVE: The objective of this study was to project the cost-effectiveness of implementing the Healthy Weight Clinic (HWC), a primary care-based intervention for 6- to 12-year-old children with overweight or obesity, at federally qualified health centers (FQHCs) nationally. METHODS: We estimated intervention costs from a health care sector and societal perspective and used BMI change estimates from the HWC trial. Our microsimulation of national HWC implementation among all FQHCs from 2023 to 2032 estimated cost per child and per quality-adjusted life year (QALY) gained and projected impact on obesity prevalence by race and ethnicity. Probabilistic sensitivity analyses assessed uncertainty around estimates. RESULTS: National implementation is projected to reach 888,000 children over 10 years, with a mean intervention cost of $456 (95% uncertainty interval [UI]: $409-$506) per child to the health care sector and $211 (95% UI: $175-$251) to families (e.g., time participating). Assuming effect maintenance, national implementation could result in 2070 (95% UI: 859-3220) QALYs gained and save $14.6 million (95% UI: $5.6-$23.5 million) in health care costs over 10 years, yielding a net cost of $278,000 (95% CI: $177,000-$679,000) per QALY gained. We project greater reductions in obesity prevalence among Hispanic/Latino and Black versus White populations. CONCLUSIONS: The HWC is relatively low-cost per child and projected to reduce obesity disparities if implemented nationally in FQHCs.

Quantifying the Association between Pump Use and Breastfeeding Duration.

OBJECTIVE: To quantify the extent to which pump use is associated with breastfeeding duration. STUDY DESIGN: We conducted a cross-sectional analysis of weighted data from the Centers for Disease Control and Prevention Pregnancy Risk Assessment Monitoring System from Maine, Michigan, New Mexico, and Utah between 2016 and 2021. Included respondents had a live-born infant at survey completion, initiated breastfeeding, and had nonmissing data for reported pump use and breastfeeding duration. Using Cox proportional hazard regression, we quantified the hazard of breastfeeding cessation and median duration (weeks) of breastfeeding by pump use. Pump use was suspected to be differentially impacted by race and ethnicity; an interaction was tested in our regression model. RESULTS: Our sample included 19 719 mothers (weighted n = 723 808) with mean age (SD) 29.5 years (5.6). Mothers with age <18 years, Medicaid enrollment, race, and ethnicity other than non-Hispanic White, lower income or education, and unmarried status demonstrated lower pump use (P < .001). Pump use was associated with 37% lower hazard of breastfeeding cessation (adjusted hazard ratio 0.63; 95% CI: 0.56-0.70) and 21 additional weeks of breastfeeding on average. The association varied by race and ethnicity (significant interaction observed between pump use and non-Hispanic Black mothers, P = .013); stratified analysis demonstrated the lowest hazard of breastfeeding cessation among non-Hispanic Black and Native American pump users (adjusted hazard ratio 0.47 [0.40-0.54] and 0.51 [0.37-0.70], respectively). CONCLUSIONS: Pump use was associated with longer breastfeeding duration; the greatest magnitudes of association were found among non-Hispanic Black and Native American participants, groups disproportionately affected by breastfeeding inequities. Future research examining the context around and causal impact of pump use on breastfeeding outcomes is needed.

Better Guidelines and Policies: AAP's Partnership for Policy Implementation.

OBJECTIVES: In 2005, the American Academy of Pediatrics founded the Partnership for Policy Implementation (PPI). The PPI has collaborated with authors to improve the quality of clinical guidelines, technical reports, and policies that standardize care delivery, improve care quality and patient outcomes, and reduce variation and costs. METHODS: In this article, we describe how the PPI trained informaticians apply a variety of tools and techniques to these guidance documents, eliminating ambiguity in clinical recommendations and allowing guideline recommendations to be implemented by practicing clinicians and electronic health record (EHR) developers more easily. RESULTS: Since its inception, the PPI has participated in the development of 45 published and 27 in-progress clinical practice guidelines, policy statements, technical and clinical reports, and other projects endorsed by the American Academy of Pediatrics. The partnership has trained informaticians to apply a variety of tools and techniques to eliminate ambiguity or lack of decidability and can be implemented by practicing clinicians and EHR developers. CONCLUSIONS: With the increasing use of EHRs in pediatrics, the need for medical societies to improve the clarity, decidability, and actionability of their guidelines has become more important than ever.

User-Centered Framework for Implementation of Technology (UFIT): Development of an Integrated Framework for Designing Clinical Decision Support Tools Packaged With Tailored Implementation Strategies.

BACKGROUND: Electronic health record-based clinical decision support (CDS) tools can facilitate the adoption of evidence into practice. Yet, the impact of CDS beyond single-site implementation is often limited by dissemination and implementation barriers related to site- and user-specific variation in workflows and behaviors. The translation of evidence-based CDS from initial development to implementation in heterogeneous environments requires a framework that assures careful balancing of fidelity to core functional elements with adaptations to ensure compatibility with new contexts. OBJECTIVE: This study aims to develop and apply a framework to guide tailoring and implementing CDS across diverse clinical settings. METHODS: In preparation for a multisite trial implementing CDS for pediatric overweight or obesity in primary care, we developed the User-Centered Framework for Implementation of Technology (UFIT), a framework that integrates principles from user-centered design (UCD), human factors/ergonomics theories, and implementation science to guide both CDS adaptation and tailoring of related implementation strategies. Our transdisciplinary study team conducted semistructured interviews with pediatric primary care clinicians and a diverse group of stakeholders from 3 health systems in the northeastern, midwestern, and southeastern United States to inform and apply the framework for our formative evaluation. RESULTS: We conducted 41 qualitative interviews with primary care clinicians (n=21) and other stakeholders (n=20). Our workflow analysis found 3 primary ways in which clinicians interact with the electronic health record during primary care well-child visits identifying opportunities for decision support. Additionally, we identified differences in practice patterns across contexts necessitating a multiprong design approach to support a variety of workflows, user needs, preferences, and implementation strategies. CONCLUSIONS: UFIT integrates theories and guidance from UCD, human factors/ergonomics, and implementation science to promote fit with local contexts for optimal outcomes. The components of UFIT were used to guide the development of Improving Pediatric Obesity Practice Using Prompts, an integrated package comprising CDS for obesity or overweight treatment with tailored implementation strategies. TRIAL REGISTRATION: ClinicalTrials.gov NCT05627011; https://clinicaltrials.gov/study/NCT05627011.

High Blood Pressure in Children Aged 3 to 12 Years Old With Overweight or Obesity.

Objective: (1) To describe the prevalence of high blood pressure (BP) and the association with BMI in young children with overweight/obesity; (2) to evaluate the accuracy of a single high BP to diagnose sustained hypertension over three visits. Methods: We used pre-intervention data from the Improving Pediatric Obesity Practice Using Prompts (iPOP-UP) trial. We included children aged 3-12 years with BMI ≥85th percentile at well-visits in 2019-2021 at 84 primary care practices in 3 US health systems in the Northeast, Midwest, and South. BP percentiles were calculated from the first visit with BP recorded during the study period. Hypertensive-range BP was defined by the 2017 American Academy of Pediatrics guideline. We tested the association between BMI classification and hypertensive BP using multivariable logistic regression. Results: Of 78,280 children with BMI ≥85th percentile, 76,214 (97%) had BP recorded during the study period (mean 7.4 years, 48% female, 53% with overweight, and 13% with severe obesity). The prevalence of elevated or hypertensive BP was 31%, including 27% in children with overweight and 33%, 39%, and 49% with class I, II, and III obesity, respectively. Higher obesity severity was associated with higher odds of hypertensive BP in the multivariable model. Stage 2 hypertensive BP at the initial visit had specificity of 99.1% (95% confidence interval 98.9-99.3) for detecting sustained hypertension over ≥3 visits. Conclusions: High BP is common in 3- to 12-year-olds with overweight/obesity, with higher obesity severity associated with greater hypertension. Children with overweight/obesity and stage 2 BP are likely to have sustained hypertension and should be prioritized for evaluation. Trial Registration: ClinicalTrials.gov Identifier: NCT05627011.

Dispensing of Glucagon-Like Peptide-1 Receptor Agonists to Adolescents and Young Adults, 2020-2023.

This study uses data from US retail pharmacies to assess national GLP-1RA dispensing to adolescents and young adults from 2020-2023.

Sources of Contraception Among Adolescents and Young Adults.

This cross-sectional study describes the nationwide pattern of contraception access by sociodemographic characteristics and health care settings among US youth aged 15 to 24 years.

Improving lifestyle behaviors during chemotherapy for breast cancer: The Lifestyle, Exercise, and Nutrition Early After Diagnosis (LEANer) Trial.

BACKGROUND: Little is known about improving physical activity (PA) and diet during and after chemotherapy for breast cancer. This secondary analysis examines changes in PA and diet quality during a yearlong intervention for patients with breast cancer undergoing chemotherapy and evaluates factors associated with these changes. METHODS: Newly diagnosed patients with breast cancer (N = 173) undergoing chemotherapy were randomized to a year-long nutrition and exercise intervention (n = 87) or usual care (UC, n = 86). Mixed models compared 1-year changes in PA and diet quality via the Healthy Eating Index (HEI)-2015 by study arm. Among the intervention group, baseline factors associated with change in PA and diet were assessed with multivariable linear and logistic regression. RESULTS: At 1 year, compared with UC, the intervention arm increased PA more (mean difference = 136.1 minutes/week; 95% CI, 90.2-182.0), participated in more strength training (56% vs. 15%; p < .001), and had suggestive improvements in HEI-2015 (mean difference = 2.5; 95% CI, -0.3 to 5.3; p = .08). In the intervention arm, lower fatigue was associated with improved PA (p = .04) and higher education was associated with improved HEI-2015 (p = .001) at 1 year. Higher HEI-2015 (p = .04) and married/living with someone (p = .05) were associated with higher odds of participating in strength training at 1 year. CONCLUSIONS: This year-long lifestyle intervention for patients with breast cancer undergoing chemotherapy resulted in increases in PA and suggestive improvements in diet quality. Behavior change was associated with baseline fatigue, diet quality, education, and married/living with someone. Addressing these factors in interventions may improve uptake of lifestyle behaviors in trials during and after chemotherapy.

The Role of the Pediatrician in the Promotion of Healthy, Active Living.

Few children and adolescents meet federal nutrition or physical activity recommendations, and many experience poor or inadequate sleep and negative health effects from screen use and social media. These lifestyle factors exacerbate physical and mental health risks for children and adolescents. This clinical report provides guidance to help pediatricians address the nutritional, physical activity, sleep, media and screen use, and social-emotional factors that affect child and adolescent health and wellness. The recommendations in this clinical report aim to promote health and wellness practices for infants, children, and adolescents across several domains of influence, including the individual, interpersonal, institutional, community, and public policy levels.

A Narrative Review of Public Health Interventions for Childhood Obesity.

PURPOSE OF REVIEW: Public health interventions that intervene on macrolevel systems hold the promise of reducing childhood obesity at the population level through prevention. The purpose of this review is to highlight some of the recent and best scientific evidence related to public health interventions for the prevention of childhood obesity. We provide a narrative review of scientific evidence for six categories of public health interventions and their impact on childhood obesity: federal nutrition assistance programs, programs implemented in early care and education centers, interventions to support healthy nutrition and physical activity in schools, community-based programs and policies, labeling policies and marketing to children, and taxes on sugar sweetened beverages (SSB). RECENT FINDINGS: Federal nutrition assistance programs have the strongest evidence to support reduction in childhood obesity and serve populations with the highest prevalence of childhood obesity. Other interventions including SSB taxes, community-wide interventions, and interventions at schools and early care and education centers also show significant improvements in child weight status. Overall public health interventions have strong evidence to support widespread implementation in service of reducing childhood obesity rates at the population level. To effectively address the recalcitrant childhood obesity epidemic, multi-pronged solutions are needed. The current evidence for public health obesity interventions is consistent with the paradigm that recognizes the importance of macrolevel systems influences on childhood obesity: interventions that are most effective intervene at macrolevels.

Exploring the determinants of successful implementation of a preventive mental health and wellness intervention for Afghan refugee families: a qualitative analysis.

Many refugee children experience trauma in early childhood. Effective, tailored interventions are needed to improve refugee children's access to preventive mental health. We interviewed refugee-serving stakeholders and parents participating in an evidence-based preventive mental health and wellness intervention adapted for Afghan refugee children and families who may have experienced trauma. Interview guide development was informed by two implementation science frameworks: the Consolidated Framework for Implementation Research and the Model for Adaptation Design and Impact. A three-person team coded transcripts via rapid qualitative analysis, and the study team reached consensus on themes. Six refugee-serving facilitators and five refugee parents discussed key determinants of successful implementation. Themes included: (i) modeling cultural humility to promote communication about emotions; (ii) needed linguistic support and referral networks to avoid miscommunications and missed communications; (iii) bridging connections between children, families and schools; (iv) different takeaways, or differing goals and expectations between facilitators and participants; and (v) timely, specific cultural considerations to overcome participation barriers. Overall, we found key determinants of successful implementation of a preventive mental health and wellness intervention for refugee children and families included adaptations to enhance cultural humility and sensitivity to cultural context while strengthening communication among facilitators, children and families.

Post-diagnosis weight trajectories and mortality among women with breast cancer.

Weight gain after breast cancer diagnosis is associated with adverse health outcomes. Yet, few studies have characterized post-diagnosis weight change in the modern treatment era or populations most at risk for weight changes. Among women diagnosed with stages I-III breast cancer in the Smilow Care Network (2013-2019; N = 5441), we abstracted demographic and clinical characteristics from electronic health records and survival data from tumor registries. We assessed if baseline characteristics modified weight trajectories with nonlinear multilevel mixed-effect models. We evaluated body mass index (BMI) at diagnosis and weight change 1-year post-diagnosis in relation to all-cause and breast cancer-specific mortality with Cox proportional hazard models. Women had 34.4 ± 25.5 weight measurements over 3.2 ± 1.8 years of follow-up. Weight gain was associated with ER/PR-, HER2+ tumors, BMI ≤ 18.5 kg/m2, and age ≤ 45 years (+4.90 kg (standard error [SE] = 0.59), +3.24 kg (SE = 0.34), and +1.75 kg (SE = 0.10), respectively). Weight loss was associated with BMI ≥ 35 kg/m2 and age ≥ 70 years (-4.50 kg (SE = 0.08) and -4.34 kg (SE = 0.08), respectively). Large weight loss (≥10%), moderate weight loss (5-10%), and moderate weight gain (5-10%) 1-year after diagnosis were associated with higher all-cause mortality (hazard ratio [HR] = 2.93, 95% confidence interval [CI] = 2.28-3.75, HR = 1.32, 95% CI = 1.02-1.70 and HR = 1.39, 95% CI = 1.04-1.85, respectively). BMI ≥ 35 kg/m2 or BMI ≤ 18.5 kg/m2 at diagnosis were also associated with higher all-cause mortality. Weight change after a breast cancer diagnosis differed by demographic and clinical characteristics highlighting subgroups at-risk for weight change during a 5-year period post-diagnosis. Monitoring and interventions for weight management early in clinical care are important.

Randomized Trial Evaluating a Self-Guided Lifestyle Intervention Delivered via Evidence-Based Materials versus a Waitlist Group on Changes in Body Weight, Diet Quality, Physical Activity, and Quality of Life among Breast Cancer Survivors.

Background: Lifestyle interventions for breast cancer survivors have proved effective at stimulating positive behavior change and promoting healthy weight loss, although integrating these programs into clinical practice is challenging. We evaluated the effect of a 6-month, unsupervised, self-guided, lifestyle intervention using printed materials and online videos vs. waitlist group on body weight for breast cancer survivors. Methods: The Lifestyle, Exercise and Nutrition (LEAN) Self-Guided trial randomized breast cancer survivors with a body mass index ≥25 kg/m2 to a 6-month lifestyle intervention (N = 102) or waitlist group (N = 103). Effects of the intervention on self-reported body weight, physical activity (PA), diet quality (via Health Eating Index-2010 (HEI-2010)), and quality of life were assessed using mixed model repeated measures analysis. Results: At 6 months, the intervention arm had significantly greater weight loss compared with the waitlist group (mean difference = -1.3 kg, 95% confidence interval [CI] = -2.5, -0.13). We observed suggestive improvements in PA (mean difference = 18.7 min/week, 95% CI = -24.2, 61.6), diet quality (mean difference in HEI = 3.2 points, 95% CI = -0.20, 6.5), and fatigue (mean difference in Functional Assessment of Chronic Illness Therapy-Fatigue scale = 1.4 points, 95% CI = -1.1, 3.9). Conclusions: The LEAN Self-Guided intervention led to favorable weight changes over 6 months. Low-resource-intensive programs have the potential to be delivered in diverse healthcare settings and may support breast cancer survivors in achieving a healthy body weight.

Clinicians' Perspectives on Equitable Health Care Delivery in Group Well-Child Care.

OBJECTIVE: To explore clinicians' perspectives about the impact of group well-child care (GWCC) on equitable health care delivery. METHODS: In this qualitative study, we conducted semistructured interviews with clinicians engaged in GWCC recruited via purposive and snowball sampling. We first conducted a deductive content analysis using constructs from Donabedian's framework for health care quality (structure, process, and outcomes) followed by inductive thematic analysis within these constructs. RESULTS: We completed 20 interviews with clinicians who deliver or research GWCC in 11 institutions across the United States. Four major themes around equitable health care delivery in GWCC emerged from clinicians' perspectives: 1) shifts in power dynamics (process); 2) enabling relational care, social support, and a sense of community (process, outcome); 3) centering multidisciplinary care delivery around patient and family needs (structure, process, and outcomes); and 4) unaddressed social and structural barriers limit patient and family participation. CONCLUSIONS: Clinicians perceived that GWCC enhances equity in health care delivery by shifting hierarchies in clinical visits and promoting relational, patient, and family-centered care. However, potential opportunities exist to further address provider implicit bias in group care delivery and structural inequities at the level of the health care institution. Clinicians underscored the need to address barriers to participation so that GWCC can more fully enhance equitable health care delivery.