Pediatric primary care provider and staff perspectives on the implementation of electronic health record-based social needs interventions: A mixed-methods study.

Introduction: Interventions to address social needs in clinical settings can improve child and family health outcomes. Electronic health record (EHR) tools are available to support these interventions but are infrequently used. This mixed-methods study sought to identify approaches for implementing social needs interventions using an existing EHR module in pediatric primary care. Methods: We conducted focus groups and interviews with providers and staff (n = 30) and workflow assessments (n = 48) at four pediatric clinics. Providers and staff completed measures assessing the acceptability, appropriateness, and feasibility of social needs interventions. The Consolidated Framework for Implementation Research guided the study. A hybrid deductive-inductive approach was used to analyze qualitative data. Results: Median scores (range 1-5) for acceptability (4.9) and appropriateness (5.0) were higher than feasibility (3.9). Perceived barriers to implementation related to duplicative processes, parent disclosure, and staffing limitations. Facilitators included the relative advantage of the EHR module compared to existing documentation practices, importance of addressing social needs, and compatibility with clinic culture and workflow. Self-administered screening was seen as inappropriate for sensitive topics. Strategies identified included providing resource lists, integrating social needs assessments with existing screening questionnaires, and reducing duplicative documentation. Conclusions: This study offers insight into the implementation of EHR-based social needs interventions and identifies strategies to promote intervention uptake. Findings highlight the need to design interventions that are feasible to implement in real-world settings. Future work should focus on integrating multiple stakeholder perspectives to inform the development of EHR tools and clinical workflows to support social needs interventions.

Parent Perspectives on Electronic Health Record-Based Social Needs Screening and Documentation: A Qualitative Study.

OBJECTIVE: Social needs interventions in clinical settings can improve child health outcomes; however, they are not routinely delivered in routine pediatric care. The electronic health record (EHR) can support these interventions, but parent engagement in the development of EHR-based social needs interventions is lacking. The aim of this study was to assess parent perspectives on EHR-based social needs screening and documentation and identify family-centered approaches for screening design and implementation. METHODS: We enrolled 20 parents from four pediatric primary care clinics. Parents completed a social risk questionnaire from an existing EHR module and participated in qualitative interviews. Parents were asked about the acceptability of EHR-based social needs screening and documentation and preferences for screening administration. A hybrid deductive-inductive approach was used to analyze qualitative data. RESULTS: Parents identified the benefits of social needs screening and documentation but expressed concerns related to privacy, fear of negative outcomes, and use of outdated documentation. Some felt self-administered electronic questionnaires would mitigate parent discomfort and encourage disclosure of social needs, while others felt face-to-face screening would be more effective. Parents stressed the importance of transparency on the purpose of social needs screening and the use of data. CONCLUSIONS: This work can inform the design and implementation of EHR-based social needs interventions that are acceptable and feasible for parents. Findings suggest strategies such as clear communication and multi-modal delivery methods may enhance intervention uptake. Future work should integrate feedback from multiple stakeholders to design and evaluate interventions that are family-centered and feasible to implement in clinical settings.

The Association of Socioeconomic Vulnerability and Race and Ethnicity With Disease Burden Among Children in a Statewide Medicaid Population.

OBJECTIVE: Individuals enrolled in Medicaid have disproportionately worse health outcomes due to challenges related to Social Determinants of Health. We aim to examine the prevalence of 3 childhood conditions (asthma, type 2 diabetes, and attention deficit hyperactivity disorder [ADHD]) in children within the Texas Medicaid system. In order to recognize the layers of vulnerability, we examine prevalence at the intersection of socioeconomic status with race and ethnicity within this economically challenged population. METHODS: Children ages 0 to 17 were identified from claims and encounter data for all children enrolled in Texas Medicaid in 2017 for at least 6 months. All children were placed into one of 5 quintiles based on their census tract socioeconomic vulnerability. The Rate Ratio statistical test was employed to identify the statistical significance of the disparity in health outcomes related to higher neighborhood vulnerability within each racial or ethnic group. RESULTS: Asthma for each race and ethnicity group was significantly more prevalent in the higher vulnerability census tracts. Increased vulnerability related to significant increase in type 2 diabetes for Hispanic children, but not for other groups. Diagnosed ADHD prevalence was significantly higher in less vulnerable non-Hispanic white children compared to more vulnerable. CONCLUSIONS: This study found that even among children who receive Medicaid and are thus economically disadvantaged, socioeconomic vulnerability applies an additional burden within racial and ethnic groups to produce disparities in health-related burden. However, the trend of the relationship varied by race and ethnicity group and health condition.

The effects of experimentally manipulated social status and subjective social status on physical activity among Hispanic adolescents: An RCT.

BACKGROUND: Low objective socioeconomic status (SES) and subjective social status (SSS), one's perceived social rank, are associated with obesity. This association may be due, in part, to social status-related differences in energy expenditure. Experimental studies are needed to assess the extent to which SES and SSS relate to energy expenditure. OBJECTIVE: Assess the effects of experimentally manipulated social status and SSS on moderate-to-vigorous physical activity (MVPA) and sedentary behaviour. METHODS: One hundred thirty-three Hispanic adolescents aged 15-21 were randomized to a high or low social status position, facilitated through a rigged game of Monopoly™. SSS was assessed with MacArthur Scales. Post-manipulation 24-h MVPA and sedentary behaviour were assessed via accelerometry. Analyses were conducted with general linear regression models. RESULTS: Experimentally manipulated social status did not significantly affect the total time spent in MVPA or sedentary behaviour; however, identifying as low SSS was significantly associated with less MVPA (p = 0.0060; 18.76 min less). CONCLUSIONS: Tewnty-four-hour MVPA and sedentary behaviour are not affected by an acute experimental manipulation of social status. However, low SSS, independent of SES, was associated with clinically significant differences in MVPA. SSS may be a better predictor of MVPA than SES among Hispanic adolescents, potentially influencing obesity, and other health-related outcomes.

Telemedicine in Pediatric Training: A National Needs Assessment of the Current State of Telemedicine Education in Pediatric Training.

PURPOSE: To describe the current state of telemedicine within pediatric training programs to inform development of a national telemedicine training curriculum for pediatric trainees. METHODS: We conducted an anonymous cross-sectional survey of pediatric residency (Fall 2020) and fellowship program directors (Spring 2021) on their current telemedicine practices in pediatric post-graduate training. RESULTS: Forty-eight US pediatric residency programs (n = 48/198, 24%) and 422 fellowship programs completed the survey (n = 422/872, 48%); combined response rate 44% (n = 470/1070). Pre-COVID-19, 12% (n = 57/470) of programs surveyed reported using telemedicine in their training program, but during the pandemic 71% (n = 334/470) reported telemedicine use with trainees. Over 71% (n = 334/470) agreed that a formalized curriculum is important, yet 69% (n = 262/380) of programs reporting telemedicine use either did not have a curriculum or were unsure if one existed at their program. Respondents who were unsure/not likely to add a telemedicine curriculum and/or indicated that a telemedicine curriculum would not be important (52% n = 243/470), cited "time" (55%, n = 136/243) most frequently as a barrier. CONCLUSIONS: Our needs assessment indicates marked increase in use of telemedicine with trainees by respondent pediatric training programs, with fewer than 50% reporting a formalized training curriculum and most agreeing that a curriculum is important.

Disparities in Pediatric Patient Portal Activation and Feature Use.

OBJECTIVE: Disparities in adult patient portal adoption are well-documented; however, less is known about disparities in portal adoption in pediatrics. This study examines the prevalence and factors associated with patient portal activation and the use of specific portal features in general pediatrics. MATERIALS AND METHODS: We analyzed electronic health record data from 2012 to 2020 in a large academic medical center that offers both parent and adolescent portals. We summarized portal activation and use of select portal features (messaging, records access and management, appointment management, visit/admissions summaries, and interactive feature use). We used logistic regression to model factors associated with patient portal activation among all patients along with feature use and frequent feature use among ever users (ie, ≥1 portal use). RESULTS: Among 52 713 unique patients, 39% had activated the patient portal, including 36% of patients aged 0-11, 41% of patients aged 12-17, and 62% of patients aged 18-21 years. Among activated accounts, ever use of specific features ranged from 28% for visit/admission summaries to 92% for records access and management. Adjusted analyses showed patients with activated accounts were more likely to be adolescents or young adults, white, female, privately insured, and less socioeconomically vulnerable. Individual feature use among ever users generally followed the same pattern. CONCLUSIONS: Our findings demonstrate that important disparities persist in portal adoption in pediatric populations, highlighting the need for strategies to promote equitable access to patient portals.

Variation in Tdap and Influenza Vaccination Coverage Among Pregnant Women by Insurance Type - Florida, 2016-2018.

Infants are at increased risk for pertussis-associated morbidity and mortality, and pregnant women and their infants are more likely than other patient populations to experience severe influenza-related illness (1,2). The Advisory Committee on Immunization Practices (ACIP) recommends that all women receive the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine during each pregnancy, preferably during the early part of gestational weeks 27-36 (3). ACIP also recommends that women who are or might be pregnant during the influenza season receive the inactivated influenza vaccine at any time during pregnancy (4). Despite these recommendations, coverage with Tdap and influenza vaccines during pregnancy has been low, with approximately one half of women receiving each vaccine and only one third receiving both, based on a survey during March-April 2019 (5). Data obtained through a retrospective chart review of randomly selected pregnant women who delivered at the University of Florida Health Shands Hospital in Gainesville, Florida, from January 1, 2016, to December 31, 2018, were analyzed to assess vaccination coverage by insurance type. Because the Florida Medicaid policy at that time did not cover these vaccines during pregnancy, the hospital system offered Tdap and influenza vaccines at no additional cost to mothers during the immediate postpartum hospital stay. Among 341 women, 68.6% of privately insured and 13.4% with Medicaid received Tdap during pregnancy, and among 316 women, 70.4% of privately insured and 35.6% with Medicaid received influenza vaccine during pregnancy. Many women, especially those with Medicaid, were vaccinated in the immediate postpartum period, when vaccination was available at no cost, increasing Tdap vaccination rates to 79.3% for privately insured and 51.7% for women with Medicaid; influenza vaccination rates rose to 72.0% for privately insured and 43.5% for women with Medicaid. These data suggest that the state Medicaid policy to not cover these vaccines during pregnancy might have significantly reduced coverage among its enrollees.

Longitudinal Effect of Ambient Air Pollution and Pollen Exposure on Asthma Control: The Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Asthma Study.

OBJECTIVE: Although exposure to air pollution and pollen is associated with asthma exacerbation and increased health care use, longitudinal effects of fine particulate matter 2.5 (PM2.5), ozone (O3), and pollen exposure on asthma control status in pediatric patients are understudied. This study investigated effects of exposure to PM2.5, O3, and pollen on asthma control status among pediatric patients with asthma. METHODS: A total of 229 dyads of pediatric patients with asthma and their parents were followed for 15 months. The Asthma Control and Communication Instrument was used to measure asthma control, which was reported weekly by parents during a 26-week period. PM2.5 and O3 data were collected from the US Environmental Protection Agency Air Quality System. Pollen data were obtained from Intercontinental Marketing Services Health. Mean air pollutant and pollen exposures within 7 days before the reporting of asthma control were used to estimate weekly exposures for each participant. Linear mixed-effects models were performed to test associations of PM2.5, O3, and pollen exposure with asthma control status. Sensitivity analyses were performed to evaluate the robustness of findings by different exposure monitoring days per week and distances between monitoring sites and participants' residences. RESULTS: Elevated PM2.5 concentration and pollen severity were associated with poorer asthma control status (P < .05), yet elevated O3 concentration was marginally associated with better asthma control (P < .1). CONCLUSIONS: Poorer asthma control status was associated with elevated PM2.5 and pollen severity. Reducing harmful outdoor environmental ambient exposure may improve asthma outcomes in children and adolescents.

Improving Adolescent Health Risk Assessment: A Multi-method Pilot Study.

Objectives Given poor compliance by providers with adolescent health risk assessment (HRA) in primary care, we describe the development and feasibility of using a health information technology (HIT)-enhanced HRA to improve the frequency of HRAs in diverse clinical settings, asking adolescents' recall of quality of care as a primary outcome. Methods We conducted focus groups and surveys with key stakeholders (Phase I) , including adolescents, clinic staff and providers to design and implement an intervention in a practice-based research network delivering private, comprehensive HRAs via tablet (Phase II). Providers and adolescents received geo-coded community resources according to individualized risks. Following the point-of-care implementation , we collected patient-reported outcomes using post-visit quality surveys (Phase III). Patient-reported outcomes from intervention and comparison clinics were analyzed using a mixed-model, fitted separately for each survey domain. Results Stakeholders agreed upon an HIT-enhanced HRA (Phase I). Twenty-two academic and community practices in north-central Florida then recruited 609 diverse adolescents (14-18 years) during primary care visits over 6 months; (mean patients enrolled = 28; median = 20; range 1-116; Phase II). Adolescents receiving the intervention later reported higher receipt of confidential/private care and counseling related to emotions and relationships (adjusted scores 0.42 vs 0.08 out of 1.0, p < .01; 0.85 vs 0.57, p < .001, respectively, Phase III) than those receiving usual care. Both are important quality indicators for adolescent well-child visits. Conclusions Stakeholder input was critical to the acceptability of the HIT-enhanced HRA. Patient recruitment data indicate that the intervention was feasible in a variety of clinical settings and the pilot evaluation data indicate that the intervention may improve adolescents' perceptions of high quality care.

Responsiveness to Change in PROMIS(®) Measures among Children with Asthma: A Report from the PROMIS(®) Pediatric Asthma Study.

OBJECTIVE: To compare the responsiveness to change of the Patient-Reported Outcomes Measurement Information System (PROMIS(®)) asthma impact, pain interference, fatigue, depressive symptoms, mobility, and peer relationship scales to a legacy scale, the Paediatric Asthma Quality of Life Questionnaire (PAQLQ). METHODS: Two hundred and twenty-nine child-parent dyads from public insurance programs were enrolled. PROMIS pediatric short forms (SFs) and the PAQLQ were used to measure health-related quality of life across four time points (T1-T4) over 2 years. The Asthma Control and Communication Instrument was used to measure the change in asthma control, and the Global Rating of Change (GRC) Index for breathing problems and overall health was used to measure the change in health status. Responsiveness was tested by comparing the changes in health-related quality of life with the changes in asthma control and health status over time using t tests, generalized estimating equations, and relative validity approaches. Magnitudes of the responsiveness between the Pediatric PROMIS and PAQLQ were assessed through statistical significance, Cohen's d effect size (ES), and standardized response mean (SRM). RESULTS: The PROMIS asthma impact scale and all PAQLQ scales exhibited significant responsiveness (p's<0.05) and small to medium ES/SRM when anchored to asthma control, GRC breathing problems, and overall health. Relative validity, especially related to change in asthma control status and GRC breathing problems, was equivalent. PROMIS pain interference, fatigue, and mobility SFs also indicated adequate responsiveness. CONCLUSIONS: The PROMIS asthma impact SF indicated similar responsiveness to the PAQLQ scales. Due to its brevity and responsiveness, the PROMIS asthma impact SF is useful for clinical practice or research.

Increasing human papillomavirus vaccine initiation among publicly insured Florida adolescents.

PURPOSE: We evaluated the feasibility of a multilevel intervention to increase the human papillomavirus (HPV) vaccine initiation among adolescents. METHODS: We used a four-arm factorial, quasi-experimental trial to assess feasibility and short-term, preliminary effectiveness of a health system-level, gender-specific postcard campaign and an in-clinic health information technology (HIT) system. Between August and November 2013, we tested the intervention among 11- to 17-year-olds without prior HPV vaccine claims in the Florida Medicaid or Children's Health Insurance Program encounters (2,773 girls and 3,350 boys) who attended or were assigned to primary care clinics in North Central Florida. RESULTS: At least one postcard was deliverable to 95% of the parents. Most parents (91% boys' and 80% girls') who participated in the process evaluation survey (n = 162) reported seeking additional information about the vaccine after receiving the postcard. Only 8% (57 of 1,062) of the adolescents assigned to a HIT provider with an office visit during the study used the HIT system. When compared with arms not containing that component, HPV vaccine initiation increased with the postcard campaign (girls, odds ratio [OR] = 1.6; 95% confidence interval [CI] = 1.1-2.3 and boys, not significant), the HIT system (girls, OR = 1.5; 95% CI = 1.0-2.3 and boys, OR = 1.4; 95% CI = 1.0-2.0), and the combined HIT and postcard intervention (girls, OR = 2.4; 95% CI = 1.4-4.3 and boys, OR = 1.6; 95% CI = 1.0-2.5). CONCLUSIONS: A system-level postcard campaign was feasible. Despite low recruitment to the in-clinic HIT system, the intervention demonstrated short-term, preliminary effectiveness similar to prior HPV vaccine interventions.

Developing item banks for measuring pediatric generic health-related quality of life: an application of the International Classification of Functioning, Disability and Health for Children and Youth and item response theory.

The purpose of this study was to develop item banks by linking items from three pediatric health-related quality of life (HRQoL) instruments using a mixed methodology. Secondary data were collected from 469 parents of children aged 8-16 years. The International Classification of Functioning, Disability and Health-Children and Youth (ICF-CY) served as a framework to compare the concepts of items from three HRQoL instruments. The structural validity of the individual domains was examined using confirmatory factor analyses. Samejima's Graded Response Model was used to calibrate items from different instruments. The known-groups validity of each domain was examined using the status of children with special health care needs (CSHCN). Concepts represented by the items in the three instruments were linked to 24 different second-level categories of the ICF-CY. Eight item banks representing eight unidimensional domains were created based on the linkage of the concepts measured by the items of the three instruments to the ICF-CY. The HRQoL results of CSHCN in seven out of eight domains (except personality) were significantly lower compared with children without special health care needs (p<0.05). This study demonstrates a useful approach to compare the item concepts from the three instruments and to generate item banks for a pediatric population.

Recruiting low income and racially/ethnically diverse adolescents for focus groups.

Recruiting and enrolling low income, racially and ethnically diverse adolescents into research studies can be a challenge. This paper details our research team's methodology in the recruitment and enrollment of low income and racially/ethnically diverse adolescents in three cities as part of a broader study to understand adolescent perceptions of a health risks. Our team used Florida's Medicaid and Children's Health Insurance Plan administrative databases to identify a sample of adolescents for focus group participation. Utilizing geographic information systems software we generated maps of racial and ethnic group clusters in three cities and identified community centers within each cluster to hold the focus groups. We mailed initial focus group introduction letters, conducted follow-up phone calls for recruitment and further implemented techniques to optimize participant confidentiality and comfort. We enrolled 35 participants for eight focus groups in three cities at a total cost of $264 per participant, including personnel, materials, travel, and incentives costs. As a result of our efforts, groups were fairly evenly distributed by both race and gender. Administrative databases provide opportunities to identify and recruit low income and racially/ethnically diverse adolescents for focus groups that might not otherwise have the opportunity to participate in research studies. It is important that researchers ensure these populations are represented when conducting health assessment tool evaluations.

Racial and ethnic variation in ADHD, comorbid illnesses, and parental strain.

Our objective was to understand the racial and ethnic variation in parental strain for non-Latino White, African American, and Latino parents of children with ADHD and other comorbid diagnoses. We selected 5,397 children with a current diagnosis of ADHD from the 2007 National Survey of Child Health (NSCH) and identified comorbid conditions that could cause additional parental strain. Multivariate regression analyses of parental strain, from ADHD plus comorbid physical and mental health conditions, varied by race and ethnicity in our sample. Additionally we found variables such as mother's mental health, family structure and social support to play significant roles in parental strain. These findings indicate a need for greater understanding of the family mechanisms in place that affect parental strain for these varying populations of families. Interventions to reduce parental strain also need to be tailored to the specific needs of racially and ethnically diverse parents of children with ADHD.

Online schools and children with special health and educational needs: comparison with performance in traditional schools.

BACKGROUND: In the United States, primary and secondary online schools are institutions that deliver online curricula for children enrolled in kindergarten through 12th grade (K-12). These institutions commonly provide opportunities for online instruction in conjunction with local schools for students who may need remediation, have advanced needs, encounter unqualified local instructors, or experience scheduling conflicts. Internet-based online schooling may potentially help children from populations known to have educational and health disadvantages, such as those from certain racial or ethnic backgrounds, those of low socioeconomic status, and children with special health care needs (CSHCN). OBJECTIVE: To describe the basic and applied demographics of US online-school users and to compare student achievement in traditional versus online schooling environments. METHODS: We performed a brief parental survey in three states examining basic demographics and educational history of the child and parents, the child's health status as measured by the CSHCN Screener, and their experiences and educational achievement with online schools and class(es). Results were compared with state public-school demographics and statistical analyses controlled for state-specific independence. RESULTS: We analyzed responses from 1971 parents with a response rate of 14.7% (1971/13,384). Parents of online-school participants were more likely to report having a bachelor's degree or higher than were parents of students statewide in traditional schools, and more of their children were white and female. Most notably, the prevalence of CSHCN was high (476/1971, 24.6%) in online schooling. Children who were male, black, or had special health care needs reported significantly lower grades in both traditional and online schools. However, when we controlled for age, gender, race, and parental education, parents of CSHCN or black children reported significantly lower grades in online than in traditional schooling (adjusted odds ratio [aOR] 1.45, 95% confidence interval [CI] 1.29-1.62 for CSHCN, P < .001; aOR 2.73, 95% CI 2.11-3.53 for black children, P < .001.) In contrast, parents with a bachelor's degree or higher reported significantly higher online-school grades than traditional-school grades for their children (aOR 1.45, 95% CI 1.15-1.82, P < .001). CONCLUSIONS: The demographics of children attending online schools do not mirror those of the state-specific school populations. CSHCN seem to opt into online schools at a higher rate. While parents report equivalent educational achievement in online and traditional classrooms, controlling for known achievement risks suggests that CSHCN and black children have lower performance in online than in traditional schools. Given the millions of students now in online schools, future studies must test whether direct assistance in online schools, such as taking individualized education plans into consideration, will narrow known disparities in educational success. Only then can online schools emerge as a true educational alternative for at-risk populations.

The impact of insurance on satisfaction and family-centered care for CSHCN.

BACKGROUND: Children with special health care needs (CSHCN) have worse health outcomes and satisfaction compared with children with typical needs. Although individual characteristics influence satisfaction and family-centered care, additional effects of health insurance and state child health policies are unknown. OBJECTIVES: To determine if satisfaction and family-centered care varied among CSHCN, after adjusting for individual characteristics, according to insurance type and state child health policies. METHODS: We performed descriptive and multivariate analyses by using demographic, insurance, and satisfaction data from the 2006 National Survey of Children With Special Health Care Needs (N = 40723). Additional state data included Medicaid and State Children's Health Insurance Program (SCHIP) characteristics and the supply of pediatricians. We supplemented the national findings with survey data from Florida's SCHIP comprehensive care program (CMS-Duval ["Ped-I-Care"]) for CSHCN (N = 300). RESULTS: Nationally, 59.8% of parents were satisfied with their child's health services, and two thirds (65.7%) received family-centered care. Adjusting for individual predictors, those uninsured and those with public insurance were less satisfied (odds ratios [ORs]: 0.45 and 0.83, respectively) and received less family-centered care (ORs: 0.43 and 0.80, respectively) than privately insured children. Of note, satisfaction increased with state Medicaid spending. Survey data from Ped-I-Care yielded significantly higher satisfaction (91.7%) compared with national levels of satisfaction in the SCHIP (54.2%) and similar rates of family-centered care (65.6%). These results suggest that satisfaction is based more on experiences with health systems, whereas family-centered care reflects more on provider encounters. CONCLUSIONS: Insurance type affects both satisfaction and family-centered care for CSHCN, and certain state-level health care characteristics affect satisfaction. Future studies should focus on interventions in the health care system to improve satisfaction and patient encounters for family-centered care.