Kinder Ready Clinics: A Collaborative Model for Creating Equitable and Engaged Early Learning Environments for Low-income Families.

Disparities in children's school readiness (SR) in the U.S. are well-documented and have detrimental long-term consequences. Clinic-based early education interventions are limited. This report summarizes collaborative efforts of pediatricians and community stakeholders to develop and implement clinic-based interventions to promote early learning and SR among low-income children.

Anti-Poverty Medicine Through Medical-Financial Partnerships: A New Approach to Child Poverty.

Poverty threatens child health. In the United States, financial strain, which encompasses income and asset poverty, is common with many complex etiologies. Even relatively successful antipoverty programs and policies fall short of serving all families in need, endangering health. We describe a new approach to address this pervasive health problem: antipoverty medicine. Historically, medicine has viewed poverty as a social problem outside of its scope. Increasingly, health care has addressed poverty's downstream effects, such as food and housing insecurity. However, strong evidence now shows that poverty affects biology, and thus, merits treatment as a medical problem. A new approach uses Medical-Financial Partnerships (MFPs), in which healthcare systems and financial service organizations collaborate to improve health by reducing family financial strain. MFPs help families grow assets by increasing savings, decreasing debt, and improving credit and economic opportunity while building a solid foundation for lifelong financial, physical, and mental health. We review evidence-based approaches to poverty alleviation, including conditional and unconditional cash transfers, savings vehicles, debt relief, credit repair, financial coaching, and employment assistance. We describe current national MFPs and highlight different applications of these evidence-based clinical financial interventions. Current MFP models reveal implementation opportunities and challenges, including time and space constraints, time-sensitive processes, lack of familiarity among patients and communities served, and sustainability in traditional medical settings. We conclude that pediatric health care practices can intervene upon poverty and should consider embracing antipoverty medicine as an essential part of the future of pediatric care.

A Text-Based Intervention to Promote Literacy: An RCT.

BACKGROUND AND OBJECTIVES: Children entering kindergarten ready to learn are more likely to thrive. Inequitable access to high-quality, early educational settings creates early educational disparities. TipsByText, a text-message-based program for caregivers of young children, improves literacy of children in preschool, but efficacy for families without access to early childhood education was unknown. METHODS: We conducted a randomized controlled trial with caregivers of 3- and 4-year-olds in 2 public pediatric clinics. Intervention caregivers received TipsByText 3 times a week for 7 months. At pre- and postintervention, we measured child literacy using the Phonological Awareness Literacy Screening Tool (PALS-PreK) and caregiver involvement using the Parent Child Interactivity Scale (PCI). We estimated effects on PALS-PreK and PCI using multivariable linear regression. RESULTS: We enrolled 644 families, excluding 263 because of preschool participation. Compared with excluded children, those included in the study had parents with lower income and educational attainment and who were more likely to be Spanish speaking. Three-quarters of enrollees completed pre- and postintervention assessments. Postintervention PALS-PreK scores revealed an unadjusted treatment effect of 0.260 (P = .040); adjusting for preintervention score, child age, and caregiver language, treatment effect was 0.209 (P = .016), equating to ∼3 months of literacy gains. Effects were greater for firstborn children (0.282 vs 0.178), children in 2-parent families (0.262 vs 0.063), and 4-year-olds (0.436 vs 0.107). The overall effect on PCI was not significant (1.221, P = .124). CONCLUSIONS: The health sector has unique access to difficult-to-reach young children. With this clinic-based texting intervention, we reached underresourced families and increased child literacy levels.

Policy in pediatric nephrology: successes, failures, and the impact on disparities.

Pediatric nephrology has a history rooted in pediatric advocacy and has made numerous contributions to child health policy affecting pediatric kidney diseases. Despite this progress, profound social disparities remain for marginalized and socially vulnerable children with kidney disease. Different risk factors, such as genetic predisposition, environmental factors, social risk factors, or health care access influence the emergence and progression of pediatric kidney disease, as well as access to life-saving interventions, leading to disparate outcomes. This review will summarize the breadth of literature on social determinants of health in children with kidney disease worldwide and highlight policy-based initiatives that mitigate the adverse social factors to generate greater equity in pediatric kidney disease.

A Clinic-Based School Readiness Coaching Intervention for Low-Income Latino Children: An Intervention Study.

This intervention study assessed school readiness (SR)-related parent behaviors and perceived barriers for Latino parent-child pairs (N = 149, Mage = 4.5) after a clinic-based SR intervention (n = 74) or standard well-child care (n = 75). Intervention was a 1-hour visit with a community health worker (CHW) to assess child SR, model SR interactions, and provide SR tools and resources. Primary outcomes were parent behaviors and barriers collected by phone questionnaire. Regression analyses revealed that parents in the intervention were more likely to tell their child a story and visit the library in the last week and less likely to report barriers of limited SR knowledge. A brief, SR coaching intervention with a CHW increased SR-related parent behaviors and reduced barriers to SR. Evaluation with school entry data is underway.

Meeting the Needs of Postpartum Women With and Without a Recent Preterm Birth: Perceptions of Maternal Family Planning in Pediatrics.

OBJECTIVES: Women face distinct barriers to meeting their reproductive health needs postpartum, especially women who deliver preterm. Pediatric encounters present unique opportunities to address women's family planning, particularly within 18 months of a prior pregnancy, when pregnancy has an elevated risk of an adverse outcome, such as preterm birth. To ensure maternal family planning initiatives are designed in a patient-centered manner, we explored perspectives on addressing reproductive health in a pediatric setting among women with and without a recent preterm delivery. METHODS: We conducted semi-structured, qualitative interviews with 41 women (66% delivered preterm). Women who delivered at any gestational age were interviewed at a pediatric primary care clinic. We also interviewed women whose infants were either in a level II intensive care nursery or attending a high-risk infant follow-up clinic, all of whom had delivered preterm. Data were analyzed using team-based coding and theme analysis. RESULTS: While women's preferred timing and setting for addressing peripartum contraception varied, they largely considered pediatric settings to be an acceptable place to discuss family planning. A few women felt family planning fell outside of the pediatric scope or distracted from the child focus. Women discussed various barriers to accessing family planning care postpartum, including circumstances unique to women who delivered preterm. CONCLUSIONS FOR PRACTICE: Family planning interventions in pediatric settings were overall an acceptable approach to reducing barriers to care among our sample of women who predominantly delivered preterm. These exploratory findings justify further investigation to assess their generalizability and to develop maternal family planning interventions for pediatric settings.

Disparities in Inpatient Intensity of End-of-Life Care for Complex Chronic Conditions.

BACKGROUND: Children with complex chronic conditions (CCCs) require a disproportionate share of health care services and have high mortality rates, but little is known about their end-of-life care. METHODS: We performed a retrospective population-based analysis using a California State administrative database of children aged 1 to 21 years with a CCC who died of disease-related causes between 2000 and 2013. Rates of and sociodemographic and clinical factors associated with previously defined inpatient end-of-life intensity indicators were determined. The intensity indicators included: (1) hospital death, (2) receipt of a medically intense intervention within 30 days of death (ICU admission, cardiopulmonary resuscitation, hemodialysis, and/or intubation), and (3) having ≥2 intensity markers (including hospital death). RESULTS: There were 8654 children in the study population with a mean death age of 11.8 years (SD 6.8). The 3 most common CCC categories were neuromuscular (47%), malignancy (43%), and cardiovascular (42%). Sixty-six percent of the children died in the hospital, 36% had a medically intense intervention in the last 30 days of life, and 35% had ≥2 intensity markers. Living in a low-income neighborhood was associated with increased odds of hospital death, a medically intense intervention, and ≥2 intensity markers. Hispanic and "other" race and/or ethnicity were associated with hospital death and ≥2 intensity markers. Age 15 to 21 years was associated with hospital death, a medically intense intervention, and ≥2 intensity markers. CONCLUSIONS: Sociodemographic disparities in the intensity of end-of-life care for children with CCCs raise concerns about whether all children are receiving high-quality and goal-concordant end-of-life care.

The Intersection of Health and Education to Address School Readiness of All Children.

Children who enter kindergarten healthy and ready to learn are more likely to succeed academically. Children at the highest risk for not being ready for school live in poverty and/or with chronic health conditions. High-quality early childhood education (ECE) programs can be used to help kids be ready for school; however, the United States lacks a comprehensive ECE system, with only half of 3- and 4-year-olds being enrolled in preschool, lagging behind 28 high-income countries. As addressing social determinants of health gains prominence in pediatric training and practice, there is increasing interest in addressing ECE disparities. Unfortunately, evidence is lacking for clinically based, early educational interventions. New interventions are being developed asynchronously in pediatrics and education, often without knowledge of the evidence base in the other's literature. In this State-of-the-Art Review, we synthesize the relevant work from the field of education (searchable through the Education Resources Information Center, also known as the "PubMed" of education), combining it with relevant literature in PubMed, to align the fields of pediatrics and education to promote this timely transdisciplinary work. First, we review the education literature to understand the current US achievement gap. Next, we provide an update on the impact of child health on school readiness and explore emerging solutions in education and pediatrics. Finally, we discuss next steps for future transdisciplinary work between the fields of education and pediatrics to improve the health and school readiness of young children.

Inpatient utilization and disparities: The last year of life of adolescent and young adult oncology patients in California.

BACKGROUND: Studies of adolescent and young adult (AYA) oncology end-of-life care utilization are critical because cancer is the leading cause of nonaccidental AYA death and end-of-life care contributes significantly to health care expenditures. This study was designed to determine the quantity of and disparities in inpatient utilization in the last year of life of AYAs with cancer. METHODS: The California Office of Statewide Health Planning and Development administrative discharge database, linked to death certificates, was used to perform a population-based analysis of cancer patients aged 15 to 39 years who died in 2000-2011. The number of hospital days and the inpatient costs were determined for each patient in the last year of his or her life, as were clinical and sociodemographic factors associated with high inpatient utilization. Admission patterns as death approached were also evaluated. RESULTS: The 12,883 patients were admitted for 40 days on average in the last year of life, and this cost $151,072 per patient in inpatient costs. As death approached, the admission rates and the percentage of all admissions occurring at nonspecialty centers increased. Five percent of patients used 20% of bed days in the last year (high utilizers). Factors associated with high utilization included younger age (15-30 years), Hispanic ethnicity, non-health maintenance organization insurance, and hematologic malignancies. CONCLUSIONS: AYA oncology decedents were admitted for 40 days in their last year of life. Subgroups with high utilization had distinct sociodemographic and clinical characteristics, and nonspecialty center admissions increased as death approached. This demonstrates the need for palliative care at nonspecialty centers. Future studies need to determine whether these patterns are goal-concurrent, include high utilizers, and monitor the effects of health care reform. Cancer 2018;124:1819-27. © 2018 American Cancer Society.

The Patient Protection and Affordable Care Act dependent coverage expansion: Disparities in impact among young adult oncology patients.

BACKGROUND: Private health insurance is associated with improved outcomes in patients with cancer. However, to the authors' knowledge, little is known regarding the impact of the Patient Protection and Affordable Care Act Dependent Coverage Expansion (ACA-DCE), which extended private insurance to young adults (to age 26 years) beginning in 2010, on the insurance status of young adults with cancer. METHODS: The current study was a retrospective, population-based analysis of hospitalized young adult oncology patients (aged 22-30 years) in California during 2006 through 2014 (11,062 patients). Multivariable regression analyses examined factors associated with having private insurance. Results were presented as adjusted odds ratios and 95% confidence intervals. A difference-in-difference analysis examined the influence of the ACA-DCE on insurance coverage by race/ethnicity and federal poverty level. RESULTS: Multivariable regression demonstrated that patients of black and Hispanic race/ethnicity were less likely to have private insurance before and after the ACA-DCE, compared with white patients. Younger age (22-25 years) was associated with having private insurance after implementation of the ACA-DCE (odds ratio, 1.20; 95% confidence interval, 1.06-1.35). In the difference-in-difference analysis, private insurance increased among white patients aged 22 to 25 years who were living in medium-income (2006-2009: 64.6% vs 2011-2014: 69.1%; P = .003) and high-income (80.4% vs 82%; P = .043) zip codes and among Asians aged 22 to 25 years living in high-income zip codes (73.2 vs 85.7%; P = .022). Private insurance decreased for all Hispanic patients aged 22 to 25 years between the 2 time periods. CONCLUSIONS: The ACA-DCE provision increased insurance coverage, but not among all patients. Private insurance increased for white and Asian patients in higher income neighborhoods, potentially widening social disparities in private insurance coverage among young adults with cancer. Cancer 2018;124:110-7. © 2017 American Cancer Society.

High-Expenditure Pharmaceutical Use Among Children in Medicaid.

BACKGROUND AND OBJECTIVES: Medication use may be a target for quality improvement, cost containment, and research. We aimed to identify medication classes associated with the highest expenditures among pediatric Medicaid enrollees and to characterize the demographic, clinical, and health service use of children prescribed these medications. METHODS: Retrospective, cross-sectional study of 3 271 081 Medicaid-enrolled children. Outpatient medication spending among high-expenditure medication classes, defined as the 10 most expensive among 261 mutually exclusive medication classes, was determined by using transaction prices paid to pharmacies by Medicaid agencies and managed care plans among prescriptions filled and dispensed in 2013. RESULTS: Outpatient medications accounted for 16.6% of all Medicaid expenditures. The 10 most expensive medication classes accounted for 63.9% of all medication expenditures. Stimulants (amphetamine-type) accounted for both the highest proportion of expenditures (20.6%) and days of medication use (14.0%) among medication classes. Users of medications in the 10 highest-expenditure classes were more likely to have a chronic condition of any complexity (77.9% vs 41.6%), a mental health condition (35.7% vs 11.9%), or a complex chronic condition (9.8% vs 4.3%) than other Medicaid enrollees (all P < .001). The 4 medications with the highest spending were all psychotropic medications. Polypharmacy was common across all high-expenditure classes. CONCLUSIONS: Medicaid expenditure on pediatric medicines is concentrated among a relatively small number of medication classes most commonly used in children with chronic conditions. Interventions to improve medication safety and effectiveness and contain costs may benefit from better delineation of the appropriate prescription of these medications.

Lunch at the library: examination of a community-based approach to addressing summer food insecurity.

OBJECTIVE: To examine a library-based approach to addressing food insecurity through a child and adult summer meal programme. The study examines: (i) risk of household food insecurity among participants; (ii) perspectives on the library meal programme; and (iii) barriers to utilizing other community food resources. DESIGN: Quantitative surveys with adult participants and qualitative semi-structured interviews with a sub-sample of adult participants. SETTING: Ten libraries using public and private funding to serve meals to children and adults for six to eight weeks in low-income Silicon Valley communities (California, USA) during summer 2015. SUBJECTS: Adult survey participants (≥18 years) were recruited to obtain maximum capture, while a sub-sample of interview participants was recruited through maximum variation purposeful sampling. RESULTS: Survey participants (n 161) were largely Latino (71 %) and Asian (23 %). Forty-one per cent of participants screened positive for risk of food insecurity in the past 12 months. A sub-sample of programme participants engaged in qualitative interviews (n 67). Interviewees reported appreciating the library's child enrichment programmes, resources, and open and welcoming atmosphere. Provision of adult meals was described as building community among library patrons, neighbours and staff. Participants emphasized lack of awareness, misinformation about programmes, structural barriers (i.e. transportation), immigration fears and stigma as barriers to utilizing community food resources. CONCLUSIONS: Food insecurity remains high in our study population. Public libraries are ideal locations for community-based meal programmes due to their welcoming and stigma-free environment. Libraries are well positioned to link individuals to other social services given their reputation as trusted community organizations.

Adolescent and young adult oncology patients: Disparities in access to specialized cancer centers.

BACKGROUND: Adolescents and young adults (AYAs) ages 15 to 39 years with cancer continue to experience disparate survival outcomes compared with their younger and older counterparts. This may be caused in part by differential access to specialized cancer centers (SCCs), because treatment at SCCs has been associated with improved overall survival. The authors examined social and clinical factors associated with AYA use of SCCs (defined as Children's Oncology Group-designated or National Cancer Institute-designated centers). METHODS: A retrospective, population-based analysis was performed on all hospital admissions of AYA oncology patients in California during 1991 through 2014 (n = 127,250) using the Office of Statewide Health Planning and Development database. Multivariable logistic regression analyses examined the contribution of social and clinical factors on always receiving care from an SCC (vs sometimes or never). Results are presented as adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Over the past 20 years, the percentage of patients always receiving inpatient care at an SCC increased over time (from 27% in 1991 to 43% in 2014). In multivariable regression analyses, AYA patients were less likely to always receive care from an SCC if they had public insurance (OR, 0.64; 95% CI, 0.62-0.66), were uninsured (OR, 0.51; 95% CI, 0.46-0.56), were Hispanic (OR, 0.88; 95% CI, 0.85-0.91), lived > 5 miles from an SCC, or had a diagnosis other than leukemia and central nervous system tumors. CONCLUSIONS: Receiving care at an SCC was influenced by insurance, race/ethnicity, geography, and tumor type. Identifying the barriers associated with decreased SCC use is an important first step toward improving outcomes in AYA oncology patients. Cancer 2017;123:2516-23. © 2017 American Cancer Society.

Pediatric Oncology Discharges With Febrile Neutropenia: Variation in Location of Care.

We examined the use of Pediatric Cancer Specialty Centers (PCSCs) over time and the length of stay (LOS) in pediatric oncology patients with a diagnosis of febrile neutropenia. PCSCs were defined as Children's Oncology Group and California Children's Services designated centers. We performed a retrospective analysis on all discharges of pediatric (0 to 18) oncology patients with febrile neutropenia in California (1983 to 2011) using the private Office of Statewide Health Planning and Development database. We examined influence of age, sex, race/ethnicity, payer, income, distance, tumor type, and complications on utilization of PCSCs and LOS (SAS 9.2). Analysis of 24,559 pediatric oncology febrile neutropenia discharges showed hospitalizations in PCSCs increasing from 48% in 1983 to 94% in 2011. The adjusted regression analysis showed decreased PCSC utilization for ages 15 to 18, Hispanic patients, and those living >40 miles away. The median PCSC LOS was 9 days compared with 7 days at a non-PCSC (P<0.0001). Discharge from a PCSC was associated with a LOS >8 days after controlling for complications. Inpatient PCSC care for febrile neutropenia in California has increased since 1983. Receiving care at a PCSC is influenced by age, tumor type, ethnicity, geography, and complications.

Redesigning Health Care Practices to Address Childhood Poverty.

Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

Childhood Poverty and Its Effect on Health and Well-being: Enhancing Training for Learners Across the Medical Education Continuum.

OBJECTIVE: Childhood poverty is unacceptably common in the US and threatens the health, development, and lifelong well-being of millions of children. Health care providers should be prepared through medical curricula to directly address the health harms of poverty. In this article, authors from The Child Poverty Education Subcommittee (CPES) of the Academic Pediatric Association Task Force on Child Poverty describe the development of the first such child poverty curriculum for teachers and learners across the medical education continuum. METHODS: Educators, physicians, trainees, and public health professionals from 25 institutions across the United States and Canada were convened over a 2-year period and addressed 3 goals: 1) define the core competencies of child poverty education, 2) delineate the scope and aims of a child poverty curriculum, and 3) create a child poverty curriculum ready to implement in undergraduate and graduate medical education settings. RESULTS: The CPES identified 4 core domains for the curriculum including the epidemiology of child poverty, poverty-related social determinants of health, pathophysiology of the health effects of poverty, and leadership and action to reduce and prevent poverty's health effects. Workgroups, focused on each domain, developed learning goals and objectives, built interactive learning modules to meet them, and created evaluation and faculty development materials to supplement the core curriculum. An editorial team with representatives from each workgroup coordinated activities and are preparing the final curriculum for national implementation. CONCLUSIONS: This comprehensive, standardized child poverty curriculum developed by an international group of educators in pediatrics and experts in the health effects of poverty should prepare medical trainees to address child poverty and improve the health of poor children.

Determinants of Health and Pediatric Primary Care Practices.

More than 20% of children nationally live in poverty. Pediatric primary care practices are critical points-of-contact for these patients and their families. Practices must consider risks that are rooted in poverty as they determine how to best deliver family-centered care and move toward action on the social determinants of health. The Practice-Level Care Delivery Subgroup of the Academic Pediatric Association's Task Force on Poverty has developed a roadmap for pediatric providers and practices to use as they adopt clinical practice redesign strategies aimed at mitigating poverty's negative impact on child health and well-being. The present article describes how care structures and processes can be altered in ways that align with the needs of families living in poverty. Attention is paid to both facilitators of and barriers to successful redesign strategies. We also illustrate how such a roadmap can be adapted by practices depending on the degree of patient need and the availability of practice resources devoted to intervening on the social determinants of health. In addition, ways in which practices can advocate for families in their communities and nationally are identified. Finally, given the relative dearth of evidence for many poverty-focused interventions in primary care, areas that would benefit from more in-depth study are considered. Such a focus is especially relevant as practices consider how they can best help families mitigate the impact of poverty-related risks in ways that promote long-term health and well-being for children.

In Their Own Voices: The Reproductive Health Care Experiences of Detained Adolescent Girls.

BACKGROUND: Adolescent girls involved with the juvenile justice system have higher rates of sexually transmitted infections and pregnancy than their nondetained peers. Although they may receive reproductive health care while detained, following clinician recommendations and accessing services in the community can be challenging. OBJECTIVES: This study aimed to determine the barriers this population faces 1) accessing reproductive health care and 2)following the recommendations they receive when they are in the community. METHODS: Adolescent girls at a juvenile detention facility completed online surveys about their demographics and sexual health behaviors. A subsequent semistructured interview assessed their experiences with reproductive health care services. RESULTS: Twenty-seven girls aged 14 to 19 were interviewed. The majority (86%) self-reported as Latina or Hispanic. The average age of sexual debut was 13.8 years. The major interview themes were 1) personal priorities and motivations affect decision making, 2) powerful external voices influence reproductive health choices, 3) accessing services "on the run" is particularly challenging, and 4) detention represents an opportunity for intervention and change. CONCLUSION: Adolescent girls who are detained within the juvenile justice system face reproductive health challenges that vary with their life circumstances. They frequently have priorities, external voices, and situations that influence their decisions. Clinicians who care for these young women are in a unique position to address their health needs. Eliciting girls' goals, beliefs, and influences through motivational interviewing, as well as developing targeted interventions based on their unique experiences, may be particularly helpful for this population.