The Impact of COVID-19 on Infant Maltreatment Emergency Department and Inpatient Medical Encounters.

OBJECTIVE: To assess the counts of infant maltreatment-related medical encounters at a large medical system during a 21-month span of the COVID-19 pandemic. METHODS: Retrospective data for this study came from all inpatient and emergency department medical encounters for infants from January 1, 2016, through November 30, 2021, at a single children's hospital system in California. Distributions of medical encounters were tabulated and plotted over time. Interrupted time series models were used to evaluate changes in child maltreatment medical encounters. RESULTS: Medical encounters for infants with child maltreatment diagnoses increased following the onset of COVID-19. Monthly counts of encounters with indicated maltreatment trended upward following the start of the pandemic. Interrupted time series models showed that the count of maltreatment encounters increased 64% with the onset of COVID-19. CONCLUSIONS: We found an increase in infant maltreatment medical encounters during a 21-month period following the onset of COVID-19. These findings suggest that the pandemic may have adversely affected the safety of infants and ongoing work is needed to understand better the pandemic impacts on child maltreatment.

Evaluating Transition Readiness: Is Self-Report Valid as the Gold Standard?

OBJECTIVE: Determination of transitional readiness is an essential component of delivery of transition services to adolescents and young adults with chronic diseases, including those with inflammatory bowel disease (IBD). To date, this has been performed using the transition checklist (TC). However, clinical experience suggests the validity of the checklist may not be ideal. We sought to evaluate the validity of the TC among adolescents and young adults with IBD (AYA IBD). METHODS: We evaluated the validity of the TC compared with a skills-based practicum (TKSP) in a cross-sectional study using a real-world clinical cohort of AYA IBD. Extent of concordance between TC and TKSP was assessed using confusion matrices and calculation of Matthews correlation coefficients. RESULTS: Concordance between self-reported TC answers and TKSP performance varied based on skill/knowledge base assessed, ranging from 81.3% for mastery of knowing one's medical condition to 39.2% for mastery of knowing one's medication schedule and 29.3% for mastery of knowing how to refill medications. Matthews correlation coefficients were closer to random prediction than perfect correlation for all skills/knowledge tested. CONCLUSIONS: Self-reported TC answers lack sufficient concordance with TKSP performance. Our findings suggest that a TKSP should be performed to assess for transition readiness and to identify individual AYA IBD patient needs during the transition process.

Improving Hepatitis B Screening at Family Health Centers Using Quality Improvement and Electronic Medical Record Tools.

Chronic hepatitis B viral (HBV) infection is associated with significant morbidity and mortality with endemic areas carrying most of the global burden of HBV disease. Current HBV screening rates in the United States are suboptimal. We aimed to improve HBV screening rates at regional family health centers serving high-risk refugee populations by 20% over 2 years. We used quality improvement (QI) methodology and implemented interventions providing electronic medical record (EMR)-enabled HBV screening tools within known clinical workflows. EMR tools captured country-of-origin data to identify persons from HBV-endemic regions with provision of a laboratory order set to ensure performance of appropriate HBV screening tests. The project was initiated prior to the COVID pandemic but continued during the pandemic with imposed social isolation measures. We nevertheless demonstrated 4 statistical process control chart shifts and achieved our QI smart aim. Further, we demonstrated a high HBV detection rate (8.2%-12.8%) among persons identified for screening.

Harnessing Electronic Medical Record Tools to Provide Proceduralist Feedback on Pediatric Endoscopy Quality Metrics.

In 2022, the Pediatric Endoscopy Quality Improvement Network published quality metrics related to pediatric endoscopy. We utilized electronic medical record (EMR) tools to collect pediatric endoscopy quality metrics (PEQM) and to standardize proceduralist feedback. EMR tools were created to capture and display PEQM: (1) an endoscopy documentation template, (2) nursing documentation of events during endoscopy for timed calculations, and (3) a data dashboard. Dashboard metrics provided individualized PEQM feedback relative to group performance and ideals where available. Utilization of the endoscopy documentation tools and data dashboard was measured. Utility was assessed using a survey based on the Technology Adoption Model. Adoption of documentation tools has been nearly universal with positive survey outcomes. Robust dashboard visualization has been demonstrated. Use of EMR documentation tools standardized PEQM collection. Future capture and sharing of common PEQM data across institutions could help determine PEQM benchmarks.

The 21st Century CURES Act in Pediatric Gastroenterology: Problems, Solutions, and Preliminary Guidance.

ABSTRACT: The information blocking (IB) prohibition component of the 21st Century CURES Act (21CCA) comes into effect April 5, 2021, which gives patients and their families near-instant access to almost all clinical notes, lab results, and health data. Exceptions to IB prohibition include risk of harm and patient privacy, but violations can be punished by a fine of up to $1,000,000.00. A committee of pediatric gastroenterologists reviewed the 21CCA regulation and compared local practice policies. Pediatric practitioners need to understand how age will affect local information release policies and to know which note types are released, paying special consideration to trainee notes and confidential information. Extraneous detail should be removed from notes, emotional labeling be avoided, and objective statements be made when referring to the care of other providers. Awareness of the 21CCA provides pediatric gastroenterologists with the opportunity to adapt their medical documentation practices to accommodate the new law.

Harnessing the Electronic Health Record to Distribute Transition Services to Adolescents With Inflammatory Bowel Disease.

OBJECTIVES: The aim of the study was to evaluate feasibility and utility of an electronic health record (EHR) activity to assess transitional readiness, deliver services to meet individual needs, and to track patient progress. METHODS: We developed a Transition EHR activity (TEA) to track patients through a standardized process where transition readiness is annually assessed and services distributed based on need. The process assesses transition skills starting at age 12 years and sets goals through shared decision-making, delivers resources according to need, reviews patients' personal medical histories, and documents healthcare transfer to adult gastroenterology. We piloted TEA among patients with inflammatory bowel disease (IBD) ages ≥12 years. Distribution to patients was measured and tolerability assessed via patient self-report evaluations. RESULTS: Since launch, TEA has been distributed to all eligible patients (N = 53) with a median age of 16 (14,18) years (median [IQR]), 62% male, 58% white, 26% Hispanic at our weekly dedicated IBD clinic. All have performed the transition skills' self-assessment and practicum, and set transition goals with their healthcare provider. Of these individuals, 41 (77%) participated in survey feedback. On a utility rating scale of 0 (not helpful at all) to 10 (very helpful), patients reported median (IQR) utility scores of 8 (7,10) for the transition readiness assessment, 9 (7,10) for transition resources provided, and 9 (7,10) for the medical history summary. Most (91%) would recommend TEA to other patients. CONCLUSIONS: TEA standardized delivery of resources among pediatric IBD patients and was well received and friendly to clinical workflow.

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on Entrustable Professional Activities: Development of Pediatric Gastroenterology, Hepatology, and Nutrition Entrustable Professional Activities.

Quality training in pediatric gastroenterology, hepatology, and nutrition is essential for the future of our specialty from advancing the science through research to providing clinical care for children with gastrointestinal, hepatic and nutritional disorders. As educational theory has developed, both the American Board of Pediatrics (ABP) and the Accreditation Council for Graduate Medical Education (ACGME) have commissioned projects to better define training including core competencies, and milestones with the goal of competency-based assessment. Seeking to provide a clinical context for these competencies and milestones, the ABP commissioned a project for each pediatric subspecialty to develop entrustable professional activities (EPA) while at the same time developing EPAs that are common to all pediatric subspecialties. North American Society for Pediatric Gastroenterology, Hepatology, Nutrition (NASPGHAN) commissioned an EPA Task Force to develop the pediatric gastroenterology, hepatology and nutrition EPAs. This document serves as an introduction to EPAs, including their historical background, underlying educational theory, and the process used to develop the pediatric gastroenterology, hepatology and nutrition EPAs in the United States of America.

Pediatric Gastroenterology, Hepatology, and Nutrition Entrustable Professional Activities: Development of an Assessment Tool and Curricular Resources.

BACKGROUND: Entrustable professional activities (EPAs) are critical activities performed by medical professionals, which can be observed and assessed. Adding on to common EPAs for all pediatric subspecialty trainees, specialty-specific EPAs for pediatric gastroenterology, hepatology, and nutritional fellowship were developed by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) EPA Task Force. METHODS: Having developed specialty-specific EPAs, building EPA assessments is the next logical step, as EPAs are included under a larger umbrella of competency-based assessment. Thus, the NASPGHAN EPA Task Force and Training Committee collaborated on an assessment tool and associated curricular resources to aid in tracking trainees' progression to entrustment within individual EPAs and readiness for independent practice. RESULTS: This manuscript reports the development of an EPA assessment tool, including guiding principles and the theory behind the assessment tool, with a focus on simple, meaningful assessments that can provide crucial performance feedback to trainees. In addition, curricular resources were developed, based on the assessment tool, to support training. Ultimately, it is the hope of the NASPGHAN EPA Task Force and Training Committee that this tool can aid training programs in providing formative feedback for trainees, and can be used by training programs and clinical competency committees for summative evaluation.

Adolescents' and Young Adults' Satisfaction with and Understanding of Medical Notes from a Pediatric Gastroenterology Practice: A Cross-Sectional Cohort Study.

Medical note sharing enhances patient-physician relationships, increases medication adherence, and improves self-care. However, many institutions do not release medical notes to adolescents, citing poor understanding and patient harm concerns. We evaluated the results of medical note sharing among adolescents with chronic disease and found high satisfaction and adequate comprehension.

Outcomes From Pediatric Gastroenterology Maintenance of Certification Using Web-based Modules.

OBJECTIVES: Beginning in 2013, the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) sponsored and developed subspecialty field-specific quality improvement (QI) activities to provide Part 4 Maintenance of Certification (MOC) credit for ongoing certification of pediatric gastroenterologists by the American Board of Pediatrics. Each activity was a Web-based module that measured clinical practice data repeatedly over at least 3 months as participants implemented rapid cycle change. Here, we examine existing variations in clinical practice among participating pediatric gastroenterologists and determine whether completion of Web-based MOC activities improves patient care processes and outcomes. METHODS: We performed a cross-sectional and prospective analysis of physician and parent-reported clinical practice data abstracted from Web-based MOC modules on the topics of upper endoscopy, colonoscopy, and informed consent collected from pediatric gastroenterologists from North America from 2013 to 2016. RESULTS: Among 134 participating pediatric gastroenterologists, 56% practitioners practiced at an academic institution and most (94%) were NASPGHAN members. Participating physicians reported data from 6300 procedures. At baseline, notable practice variation across measured activities was demonstrated. Much of the rapid cycle changes implemented by participants involved individual behaviors, rather than system/team-based improvement activities. Participants demonstrated significant improvements on most targeted process and quality care outcomes. CONCLUSIONS: Pediatric gastroenterologists and parents reported baseline practice variation, and improvement in care processes and outcomes measured during NASPGHAN-sponsored Web-based MOC QI activities. Subspecialty-oriented Web-based MOC QI activities can reveal targets for reducing unwarranted variation in clinical pediatric practice, and can effectively improve care and patient outcomes.

Pilot Study of Functional Magnetic Resonance Imaging Responses to Somatic Pain Stimuli in Youth With Functional and Inflammatory Gastrointestinal Disease.

BACKGROUND: Brain-gut axis signaling modifies gastrointestinal symptomatology. Altered neural processing of intestinal pain signals involves interoceptive brain regions in adults with functional and inflammatory gastrointestinal disorders. Although these disorders frequently present in childhood, there are no published studies in youth. We determined whether neural processing of somatic pain stimuli differs in adolescents and young adults (AYA) with irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD), as compared to healthy controls (HC). METHODS: IBS and IBD AYA (16-20 years) underwent anticipated and thermal pain stimuli of low and high intensity on their forearm and simultaneous blood oxygen level-dependent functional magnetic resonance imaging. Data from adult HC were used for comparison. Subjects answered surveys evaluating alexithymia, anxiety, depression, and pain catastrophizing. Group data were compared using linear mixed effects and analysis of variance. RESULTS: Study groups were similar by sex but not age. Significant group by pain condition interactions were observed in interoceptive brain regions during pain anticipation, and within perceptual brain regions during perceived pain. Higher activation within interoceptive brain regions during anticipated pain was observed in IBS compared with IBD and HC subjects. IBD patients demonstrated increased activation in perceptual brain regions during experienced pain as compared to IBS and HC. CONCLUSIONS: IBS and IBD AYA demonstrate altered neural processing of somatic pain compared with each other and with HC. Our results suggest that neuromodulatory interventions targeting interoceptive brain circuits in IBS and perceptual brain regions in IBD may be effective.

Parental and youth understanding of the informed consent process for pediatric endoscopy.

OBJECTIVES: Informed consent (IC) is an essential communication between patient/representative and physician that acknowledges patient autonomy; assent is the equivalent process performed between youth and physician. For clinical procedures involving youth, only the IC process between guardian/parent and physician is required to be performed. Nevertheless, experts recommend that youth undergo assent whenever possible. In the present study, we explored both parental and youth understanding of required IC elements in IC discussions before pediatric endoscopy. METHODS: Following signing of IC documents on the day of endoscopy at a tertiary care academic medical center, youth and their parents underwent structured interviews to assess comprehension of key elements of the IC process. RESULTS: A total of 88 children and adolescents and their parents were evaluated. Two youth and 12 parents demonstrated comprehensive understanding of key IC elements for pediatric endoscopy. Suboptimal youth understanding was demonstrated for nature of the procedure (25% with adequate understanding) and related risks (17%), and alternatives (14%) to the procedure. Suboptimal parental understanding was demonstrated for procedure alternatives (24%). Youth overall understanding of IC varied by age, whereas parental global understanding of IC varied by physician. CONCLUSIONS: Understanding of IC performed for pediatric endoscopy could be improved in both parents and youth. Our findings suggest that interventions targeting parents, youth, and physicians may be helpful. Further study is needed to determine whether our findings are representative of IC understanding at other pediatric endoscopy centers.

Influence of specific individual and environmental variables on the relationship between body mass index and health-related quality of life in overweight and obese adolescents.

PURPOSE: Overweight and obese adolescents are at risk for low health-related quality of life (HRQOL). We examined the role of individual- and environmental-level variables on the relationship between body mass index (BMI kg/m(2)) and HRQOL in adolescents. METHODS: Linear regressions were performed to conduct mediation and moderation analyses on the relationship between BMI and HRQOL in overweight and obese adolescents (N = 205). HRQOL was measured by the Pediatric Quality of Life Inventory. Hypothesized mediators included depression, measured by the Center for Epidemiologic Studies Depression Scale; body image, measured by the gender-specific body dissatisfaction subscale of the Eating Disorder Inventory; and self-esteem, measured by the Rosenberg Self-Esteem Scale. Mediation was assessed using Baron and Kenny's approach and Sobel's test of indirect effects. Anglo-acculturation, measured by the Short Acculturation Scale for Hispanics-Youth, and environmental perception, measured by parent-proxy report of the Neighborhood Environment Walkability Scale, were hypothesized moderators. RESULTS: Body image mediated the relationship between BMI and HRQOL (b = -0.34, SE = 0.17, adj R (2) = 0.19, p = .051), and self-esteem was a partial mediator (b = -0.37, SE = 0.17, adj R (2) = 0.24, p = .027). Sobel's test confirmed these results (p < .05). No significant moderation effects were found. CONCLUSIONS: The finding that individual-level factors, such as body image and self-esteem, influence the relationship between BMI and HRQOL while environmental factors, such as neighborhood environment and acculturation, do not extends previous research. The finding that body image and self-esteem partially mediate this relationship presents new areas to investigate in interventions that address BMI in youth.