Implicit Bias in Pediatric Academic Medicine.

OBJECTIVE: Despite known benefits of diversity, certain racial/ethnic groups remain underrepresented in academic pediatrics. Little research exists regarding unconscious racial attitudes among pediatric faculty responsible for decisions on workforce recruitment and retention in academia. This study sought to describe levels of unconscious racial bias and perceived barriers to minority recruitment and retention among academic pediatric faculty leaders. METHODS: Authors measured unconscious racial bias in a sample of pediatric faculty attending diversity workshops conducted at local and national meetings in 2015. A paper version of the validated Implicit Association Test (IAT) measured unconscious racial bias. Subjects also reported perceptions about minority recruitment and retention. RESULTS: Of 68 eligible subjects approached, 58 (85%) consented and completed the survey with IAT. Of participants, 83% had leadership roles and 93% were involved in recruitment. Participants had slight pro-white/anti-black bias on the IAT (M = 0.28, SD = 0.49). There were similar IAT scores among participants in leadership roles (M = 0.33, SD = 0.47) and involved in recruitment (M = 0.28, SD = 0.43). Results did not differ when comparing participants in local workshops to the national workshop (n = 36, M = 0.29, SD = 0.40 and n = 22, M = 0.27, SD = 0.49 respectively; p = 0.88). Perceived barriers to minority recruitment and retention included lack of minority mentors, poor recruitment efforts, and lack of qualified candidates. CONCLUSIONS: Unconscious pro-white/anti-black racial bias was identified in this sample of academic pediatric faculty and leaders. Further research is needed to examine how unconscious bias impacts decisions in academic pediatric workforce recruitment. Addressing unconscious bias and perceived barriers to minority recruitment and retention represent opportunities to improve diversity efforts.

A high throughput embryonic stem cell screen identifies Oct-2 as a bifunctional regulator of neuronal differentiation.

Neuronal differentiation is a complex process that involves a plethora of regulatory steps. To identify transcription factors that influence neuronal differentiation we developed a high throughput screen using embryonic stem (ES) cells. Seven-hundred human transcription factor clones were stably introduced into mouse ES (mES) cells and screened for their ability to induce neuronal differentiation of mES cells. Twenty-four factors that are capable of inducing neuronal differentiation were identified, including four known effectors of neuronal differentiation, 11 factors with limited evidence of involvement in regulating neuronal differentiation, and nine novel factors. One transcription factor, Oct-2, was studied in detail and found to be a bifunctional regulator: It can either repress or induce neuronal differentiation, depending on the particular isoform. Ectopic expression experiments demonstrate that isoform Oct-2.4 represses neuronal differentiation, whereas Oct-2.2 activates neuron formation. Consistent with a role in neuronal differentiation, Oct-2.2 expression is induced during differentiation, and cells depleted of Oct-2 and its homolog Oct-1 have a reduced capacity to differentiate into neurons. Our results reveal a number of transcription factors potentially important for mammalian neuronal differentiation, and indicate that Oct-2 may serve as a binary switch to repress differentiation in precursor cells and induce neuronal differentiation later during neuronal development.

Financial support policies as a mechanism to reduce child welfare involvement.

None.

Low-Income Caregiver Perspectives on a State Education Savings Program and Receptivity to Clinic-Based Financial Counseling.

BACKGROUND AND OBJECTIVE: In 2019, Pennsylvania launched a Children's Development Account (CDA) program that invests $100 in an education savings account for every child born in the state. However, as of 2021, only 10.6% of families claimed the investment. Low-income communities may stand to benefit most from educational investments, but few studies have assessed barriers and facilitators of uptake in these communities. We sought to examine low-income caregivers' perceptions of and barriers and facilitators to participation in a statewide CDA program and their receptivity to clinic-based financial counseling through a medical financial partnership. METHODS: We surveyed 100 caregivers of Medicaid-insured children from 2 primary care practices serving a predominantly low-income community. From these 100, we purposively sampled 30 caregivers for follow-up interviews. RESULTS: The 100 survey participants were predominantly female (83%), Black or African American (92%), and non-Hispanic or Latino (93%). Twenty-nine percent of survey participants were aware of the CDA program, 4% had enrolled, and 64% were interested in clinic-based financial counseling. In interviews, caregivers identified several barriers to and facilitators of engagement in the CDA program. They also identified several strategies to boost engagement, including simplifying registration, providing additional and personalized program information, expanding the investment amount, and providing clinic- and community-based outreach. CONCLUSIONS: Low-income caregivers identified several barriers to enrollment in a statewide CDA program and strategies to boost enrollment, including clinic-based financial counseling. Future research should examine the effectiveness, cost-effectiveness, and long-term financial and health consequences of clinic-based financial services for low-income families.

Accelerating Innovation in Primary Care to Support Adolescent Health Discussions.

BACKGROUND AND OBJECTIVES: Adolescent strengths and risks are not routinely captured in systematized and actionable ways in pediatric primary care. To address this problem, we developed a comprehensive adolescent health questionnaire (AHQ) integrated within the electronic health record and evaluated the AHQ's impact on collection of information on prioritized health-related domains. METHODS: We developed and pilot tested the AHQ. We then scaled and assessed the AHQ's impact on data collection. AHQ development used innovation methods and measured feasibility and acceptability outcomes. Scaling and postscaling outcomes included Reach, Effectiveness, Adoption, Implementation, Maintenance and Sustainability measures: Reach (total questionnaires completed), Effectiveness (capture of key information across health domains pre- vs post-AHQ scaling), Adoption (proportion of practices that adopted the AHQ), Implementation (proportion of eligible adolescents who completed the AHQ), and Maintenance (monthly completion rates). RESULTS: AHQ development led to a tool that was feasible and acceptable for use. During scaling (October 2020-December 2021), 22 147 questionnaires were completed by 20 749 unique adolescents aged 13 to 21 years at their preventive visit. Comparing pre- versus post-AHQ scaling data, use of the AHQ increased collection of information across domains, especially for strengths, gun safety, substance use, sexual activity, sexual orientation, and gender identity, from ranges of 0%-25% to 92%-95%. All 31 practices adopted the AHQ with completion at 88.7% of visits (n = 24 968). Two years postscaling, completion rates were >91% per month. CONCLUSIONS: We successfully developed, scaled, and maintained an AHQ in a widely-used electronic health record system, a model for improving adolescent care and foundation for developing future interventions.

Neighborhood Greenspace and Changes in Pediatric Obesity During COVID-19.

INTRODUCTION: Pediatric obesity rates increased during the COVID-19 pandemic. This study examined the associations of neighborhood greenspace with changes in pediatric obesity during the pandemic. METHODS: Electronic health record data from a large pediatric primary care network were extracted to create a retrospective cohort of patients aged 2-17 years with a visit in each of 2 periods: June 2019-December 2019 (before pandemic) and June 2020-December 2020 (pandemic). Multivariable longitudinal generalized estimating equations Poisson regression estimated the associations of census tract‒level Normalized Difference Vegetation Index with (1) changes in obesity risk during the pandemic and (2) risk of new-onset obesity among children who were not obese prepandemic. Analyses were conducted between November 2021 and May 2022. RESULTS: Among 81,418 children (mean age: 8.4 years, 18% Black), the percentage of children who were obese increased by 3.2% during the pandemic. Children in Normalized Difference Vegetation Index Quartiles 2-4 had smaller increases in obesity risk during the pandemic than those in Quartile 1 (risk ratio=0.96, 95% CI=0.93, 0.99; Quartile 3 risk ratio=0.95; 95% CI=0.91, 0.98; Quartile 4 risk ratio=0.95, 95% CI=0.92, 0.99). Among the subset who were not obese before the pandemic, children in Normalized Difference Vegetation Index quartiles 3-4 had a lower risk of new-onset obesity during the pandemic (Quartile 3 risk ratio=0.82, 95% CI=0.71, 0.95; Quartile 4 risk ratio=0.73, 95% CI=0.62, 0.85). Higher Normalized Difference Vegetation Index was associated with smaller increases in obesity risk and lower risk of new-onset obesity among children in urban and suburban areas, but results were in the opposite direction for children in rural areas. CONCLUSIONS: Children living in greener neighborhoods experienced smaller increases in obesity during the pandemic than children in less green neighborhoods, although findings differed by urbanicity.

Measures of Neighborhood Opportunity and Adherence to Recommended Pediatric Primary Care.

Importance: Neighborhood conditions are known to broadly impact child health. Research to date has not examined the association of the Childhood Opportunity Index (COI), a multidimensional indicator of neighborhood environment conditions, specifically with pediatric primary care outcomes. Objective: To determine the association of neighborhood opportunity measured by the COI with health metrics commonly captured clinically in pediatric primary care, reflecting both access to preventive care and child well-being. Design, Setting, and Participants: This cross-sectional observational study used electronic health record data from a large pediatric primary care network in the northeastern US. Participants included patients aged 0 to 19 years who were active in the primary care network between November 2020 and November 2022. Data were analyzed in December 2022. Exposure: Census tract-level COI overall score (in quintiles). Main Outcomes and Measures: Outcomes included up-to-date preventive care and immunization status and presence of obesity, adolescent depression and suicidality, and maternal depression and suicidality. Multivariable mixed-effects logistic regressions estimated associations of these outcomes with COI quintiles, adjusted for age, sex, race and ethnicity, and insurance type. Results: Among 338 277 patients (mean [SD] age, 9.8 [5.9] years; 165 223 female [48.8%]; 158 054 [46.7%] non-Hispanic White, 209 482 [61.9%] commercially insured), 81 739 (24.2%) and 130 361 (38.5%) lived in neighborhoods of very low and very high COI, respectively. Living in very high COI neighborhoods (vs very low COI) was associated with higher odds of being up-to-date on preventive visits (odds ratio [OR], 1.40; 95% CI, 1.32-1.48) and immunizations (OR, 1.77; 95% CI, 1.58-2.00), and with lower odds of obesity (OR, 0.55; 95% CI, 0.52-0.58), adolescent depression (OR, 0.78; 95% CI, 0.72-0.84) and suicidality (OR, 0.79; 95% CI, 0.73-0.85), and maternal depression (OR, 0.78; 95% CI, 0.72-0.86) and suicidality (OR, 0.71; 95% CI, 0.61-0.83). Conclusions and Relevance: This cross-sectional study of electronic health record data found that neighborhood opportunity was associated with multiple pediatric primary care outcomes. Understanding these associations can help health systems identify neighborhoods that need additional support and advocate for and develop partnerships with community groups to promote child well-being. The findings underscore the importance of improving access to preventive care in low COI communities.

Trends and Persistent Disparities in Child Obesity During the COVID-19 Pandemic.

The COVID-19 pandemic has been associated with increases in pediatric obesity and widening pre-existing disparities. To better understand the pandemic's long-term impacts, we evaluated trends in obesity across different demographic groups during the pandemic through December 2022. Using a retrospective cohort design, we analyzed electronic health record data from a large pediatric primary care network. Logistic regression models fit using generalized estimating equations estimated odds ratios (ORs) for changes in the level and trajectory of obesity across 2-year month-matched periods: prepandemic (June 2017 to December 2019) and pandemic (June 2020 to December 2022). Among a cohort of 153,667 patients with visits in each period, there was a significant increase in the level of obesity at the pandemic onset [OR: 1.229, 95% confidence interval (CI): 1.211-1.247] followed by a significant decrease in the trend for obesity (OR: 0.993, 95% CI: 0.992-0.993). By December 2022, obesity had returned to prepandemic levels. However, persistent sociodemographic disparities remain.

Trends in Positive Depression and Suicide Risk Screens in Pediatric Primary Care During COVID-19.

OBJECTIVE: Adolescent mental health concerns increased during COVID-19, but it is unknown whether early increases in depression and suicide risk have been sustained. We examined changes in positive screens for depression and suicide risk in a large pediatric primary care network through May 2022. METHODS: Using an observational repeated cross-sectional design, we examined changes in depression and suicide risk during the pandemic using electronic health record data from adolescents. Segmented logistic regression was used to estimate risk differences (RD) for positive depression and suicide risk screens during the early pandemic (June 2020-May 2021) and late pandemic (June 2021-May 2022) relative to before the pandemic (March 2018-February 2020). Models adjusted for seasonality and standard errors accounted for clustering by practice. RESULTS: Among 222,668 visits for 115,627 adolescents (mean age 15.7, 50% female), the risk of positive depression and suicide risk screens increased during the early pandemic period relative to the prepandemic period (RD, 3.8%; 95% CI, 2.9, 4.8; RD, 2.8%; 95% CI, 1.7, 3.8). Risk of depression returned to baseline during the late pandemic period, while suicide risk remained slightly elevated (RD, 0.7%; 95% CI, -0.4, 1.7; RD, 1.8%; 95% CI, 0.9%, 2.7%). CONCLUSIONS: During the early months of the pandemic, there was an increase in positive depression and suicide risk screens, which later returned to prepandemic levels for depression but not suicide risk. Results suggest that pediatricians should continue to prioritize screening adolescents for depressive symptoms and suicide risk and connect them to treatment.

Health information technology and equity: Applying history's lessons to tomorrow's innovations.

Health and health care disparities are widespread with major impacts on outcomes for children and families. Inequitable care is poor quality care. Though health IT has the potential to improve disparities, health IT implementation can have unintended consequences of widening, maintaining, or creating disparities by disproportionately benefiting advantaged children, adolescents, and their caregivers. Narrowing disparities can be achieved by embracing an approach that places marginalized patients at the center of health IT design and implementation. Health care systems can leverage the disparity-reducing potential of health information technologies by housing innovation within an equity framework. Initial steps include evaluating for disparities exacerbated by health IT, implementing universal precautions to prevent health IT intervention-generated inequalities, and co-designing future innovations with marginalized communities. By directly addressing community needs, health IT systems designed to effectively benefit underserved children, adolescents, and their caregivers have the potential to yield more equitable health care IT, and better outcomes for our young patients.

Perspectives of Urban Adolescent Black Males and Their Parents on Well Care.

OBJECTIVE: Adolescents have fewer well-care visits than all other age groups. Males and ethnic minorities are seen least often. We elicited from Black adolescent males and their parents key drivers of teen well-care seeking. METHODS: We conducted separate semistructured interviews with Black adolescent males and their parents. We recruited parent-teen dyads from West Philadelphia. Eligible teens were age 13 to 18, with no complex chronic health conditions. We purposively sampled teens who had not received preventive care in at least 2 years, some of whom had since returned to care and some not. Interviews were recorded, transcribed, and coded by 2 coders using the constant comparative method, resolving discrepancies by consensus. Interviews continued until thematic saturation. RESULTS: We interviewed 23 Black adolescent males (mean age 15) and 22 parents (20 mothers). Participants understood that teens should routinely receive preventive care. Four themes emerged: receiving preventive care is important to knowing teens are mentally and physically well; remembering to schedule/attend visits is challenging - participants find appointment reminders helpful; mothers noted that males of all ages are generally disengaged from health care; teens and parents felt that a "good" parent ensures teens receive preventive care. CONCLUSIONS: Black adolescent males and their parents value regular preventive care as an opportunity to ensure the teen is physically and mentally well, but competing priorities interfere with care receipt. Results support testing the impact of reminders on receipt of care in this population. These reminders may be most effective if directed at mothers and focused on "good parenting."

COVID-19 and Adolescent Depression and Suicide Risk Screening Outcomes.

BACKGROUND: Mental health concerns increased during the coronavirus disease 2019 pandemic, but previous studies have not examined depression screening in pediatric primary care. We aimed to describe changes in screening, depressive symptoms, and suicide risk among adolescents during the coronavirus disease 2019 pandemic. METHODS: In a repeat cross-sectional analysis of electronic health record data from a large pediatric primary care network, we compared the percentage of primary care visits where adolescents aged 12 to 21 were screened for depression, screened positive for depressive symptoms, or screened positive for suicide risk between June and December 2019 (prepandemic) and June and December 2020 (pandemic). Changes were examined overall, by month, and by sex, race and ethnicity, insurance type, and income. Modified Poisson regression was used to calculate prevalence ratios (PRs) for the prepandemic to pandemic changes. RESULTS: Depression screening at primary care visits declined from 77.6% to 75.8% during the pandemic period (PR: 0.98, 95% confidence interval [CI]: 0.90-1.06). The percentage of adolescents screening positive for depressive symptoms increased from 5.0% to 6.2% (PR: 1.24, 95% CI: 1.15-1.34), with greater increases among female, non-Hispanic Black, and non-Hispanic white adolescents. Positive suicide risk screens increased from 6.1% to 7.1% (PR: 1.16, 95% CI: 1.08-1.26), with a 34% relative increase in reporting recent suicidal thoughts among female adolescents (PR: 1.34, 95% CI: 1.18-1.52). CONCLUSIONS: Results suggest that depression and suicide concerns have increased during the pandemic, especially among female adolescents. Results underscore the importance of consistent depression and suicidality screening.

Academic careers and the COVID-19 pandemic: Reversing the tide.

The COVID-19 pandemic halted research operations at academic medical centers. This shutdown has adversely affected research infrastructure, the current research workforce, and the research pipeline. We discuss the impact of the pandemic on overall research operations, examine its disproportionate effect on underrepresented minority researchers, and provide concrete strategies to reverse these losses.

Implementing Resident Team Assistant Programs at Academic Medical Centers: Lessons Learned.

BACKGROUND: Excessive inpatient administrative tasks can lead to adverse consequences for residents and their patients. Furthermore, this burden has been linked to depersonalization, a major component of physician burnout. OBJECTIVE: To describe the development, implementation, feasibility, acceptability, and early outcomes of Resident Team Assistant (RTA) programs. METHODS: Three large academic medical centers created RTA programs in which administrative assistants are incorporated into inpatient medical teams. First steps included a needs assessment and driver diagram creation to identify key issues and to solidify goals. Program directors were assigned, and RTAs were hired, trained, and incorporated into inpatient teams at each institution (2003, 2016, 2018). Program leadership and institutional stakeholders met regularly to discuss development and quality assurance. Surveys and direct interviews were performed to evaluate impact and acceptability. Institutional goals in accordance to RTAs tasks were also investigated. RESULTS: Resident surveys and interviews have shown acceptability with RTAs completing a large percentage of resident administrative tasks while promoting time spent in direct clinical care and job satisfaction. Hospital-specific improvements have included increase in referring physician communication rate and decrease in work hour violations. The programs have maintained high feasibility and sustainability with a relatively low time commitment from leadership and cost for the institutions. CONCLUSIONS: The RTA programs at the 3 institutions have continued to be sustained over time with perceived improvements in administrative task burden and job satisfaction for the residents. They have maintained high acceptability and feasibility in terms of effort and costs for the hospitals.

Do politics affect prevalence? An overview and the case of cerebral palsy.

Many factors must be considered when assessing estimates of prevalence, including research methods and quality of the work by the research team. Broad social and political forces also influence estimates of prevalence, as seen in the case of autism and intellectual disability. Indeed, researchers themselves may be influenced by broader sociopolitical factors in ways that they do not recognize. To further explore the relationship of prevalence to sociopolitical factors, we reviewed the historical prevalence of cerebral palsy (CP) (as a proxy for physical disability) in the late 20th century. We hypothesized that increased awareness of physical impairments associated with the disability rights movement of the 1970s would increase the prevalence of CP, primarily because of changes in case definition. Although prevalence of CP did rise slightly in the 1980s, we conclude that this change is better explained by increased survival of low birth weight infants, which is only indirectly related to the disability rights movement.