Promoting Pediatric Preventive Visits Through Quality Improvement Initiatives in the Primary Care Setting.

OBJECTIVE: To evaluate whether quality improvement (QI) capacity-building in affiliated primary care practices could increase well care visit uptake. STUDY DESIGN: Partners For Kids (PFK) is an accountable care organization caring for pediatric Medicaid beneficiaries in Ohio. PFK QI specialists recruited practices to develop QI projects around increasing well care visit rates (proportion of eligible children with well care visits during calendar year) for children aged 3-6 years and adolescents. The QI specialists supported practice teams in implementing interventions and collecting data through monthly or bimonthly practice visits. RESULTS: Ten practices, serving more than 26 000 children, participated in QI projects for a median of 8.5 months (IQR 5.3-17.6). Well care visit rates in the QI-engaged practices significantly improved from 2016 to 2018 (P < .001 for both age groups). Over time, well care visit rates for 3- to 6-year-old children increased by 11.8% (95% CI 5.4%-18.2%) in QI-engaged practices, compared with 4.1% (95% CI 0.1%-7.4%) in non-engaged practices (P = .233). For adolescents, well care visit rates increased 14.3% (95% CI -2.6% to 31.2%) compared with 5.4% (95% CI 1.8%-9.0%) in QI-engaged vs non-engaged practices over the same period (P = .215). Although not statistically significant, QI-engaged practices had greater magnitudes of rate increases for both age groups. CONCLUSIONS: Through practice facilitation, PFK helped a diverse group of community practices substantially improve preventive visit uptake over time. QI programs in primary care can reach patients early to promote preventive services that potentially avoid costly downstream care.

Parental Adverse Childhood Experiences and Pediatric Healthcare Use by 2 Years of Age.

OBJECTIVE: To determine whether maternal and paternal exposure to adverse childhood experiences (ACEs) has an association with offspring healthcare use by 2 years of age. STUDY DESIGN: A retrospective cohort study was performed on 454 patients at a large suburban pediatric primary care practice whose mother (n = 374) or father (n = 156) or both (n = 123) completed an ACE survey between October 2012 and June 2014. The association between self-reported parental ACEs and healthcare use by 2 years of age, including number of missed well-child visits, sick visits, and delayed or missed immunizations, was modeled using multivariable negative binomial regression. All analyses adjusted for child sex, payer source, and preterm birth. RESULTS: Maternal, but not paternal, ACE exposure was significantly associated with missed well-child visits by 2 years of age. For each additional maternal ACE, there was a significant 12% increase in the incidence rate of missed well-child visits (relative risk, 1.12; 95% CI, 1.03-1.22; P = .010). Maternal and paternal ACE scores were not significantly associated with increased sick visits or delayed or missed immunizations. CONCLUSIONS: The ACE exposure of mothers is negatively associated with adherence to preventive healthcare visits among their children early in life. Future research is needed to elucidate the mechanisms of this association and to develop and implement family-based intervention strategies.

Adolescent Health Promotion Interventions Using Well-Care Visits and a Smartphone Cognitive Behavioral Therapy App: Randomized Controlled Trial.

BACKGROUND: Adolescent health promotion is important in preventing risk behaviors and improving mental health. Health promotion during adolescence has been shown to contribute to the prevention of late onset of the mental health disease. However, scalable interventions have not been established yet. OBJECTIVE: This study was designed to test the efficacy of two adolescent health promotion interventions: a well-care visit (WCV) with a risk assessment interview and counseling and self-monitoring with a smartphone cognitive behavioral therapy (CBT) app. Our hypothesis was that participants who had received both WCV and the CBT app would have better outcomes than those who had received only WCV or those who had not received any intervention. We conducted a prospective multi-institutional randomized controlled trial. METHODS: Participants were 217 adolescents aged 13-18 years. They were randomly divided into two intervention groups (WCV group and WCV with CBT app group) and a nonintervention group. WCV comprised a standardized physical examination along with a structured interview and counseling for youth risk assessment, which was designed with reference to the Guideline for Health Supervision of Adolescents of Bright Futures. A smartphone-based CBT program was developed based on the CBT approach. The CBT app comprised a 1-week psychoeducation component and a 1-week self-monitoring component. During the CBT program, participants created several self-monitoring sheets based on the CBT model with five window panels: event, thoughts, feelings, body response, and actions. The primary outcome was the change in scores for depressive symptoms. Secondary outcomes included changes in scores for self-esteem, quality of life, self-monitoring, and an adolescent health promotion scale. These outcomes were evaluated at baseline and at 1, 2, and 4 months after baseline. The exploratory outcome was the presence of suicidal ideation during the observation period. Intervention effects were estimated using mixed effect models. RESULTS: In total, 94% (204/217) of the participants completed the 4-month evaluation. Both intervention groups showed a significant effect in the form of reduced scores for depressive symptoms at 1 month in high school students; however, these effects were not observed at 2 and 4 months. The intervention effect was significantly more predominant in those scoring above cutoff for depressive symptoms. There was significantly less suicidal ideation in the intervention groups. As for secondary outcomes, there was significant increase in health promotion scale scores at the 4-month follow-up among junior high school students in the WCV group. Moreover, the CBT app was significantly effective in terms of obtaining self-monitoring skills and reducing depressive symptoms. CONCLUSIONS: Although adolescent health promotion interventions may have short-term benefits, the frequency of WCV and further revision of the CBT app should be considered to evaluate long-term effectiveness. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry UMIN 000036343; https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000041246.

Provider Adherence to Preventative Health Care Guidelines in Adolescent Girls Presenting for Well Visit.

A dearth of research exists examining provider adherence to preventative health care guidelines at adolescent well-care visits. We examined adherence in 3 domains: documentation of sexual activity, documentation of menstrual characteristics, and administration of the human papillomavirus vaccine. We identified electronic health records of a random sample of 124 adolescent girls seen within the hospital-affiliated pediatric primary care clinics from July 1, 2014, to June 30, 2015. Approximately one quarter of the records examined had no documentation of sexual activity. Documentation occurred more frequently in English speakers (P = .003). Asian girls had the least documentation of sexual activity (P = .003). Clinicians documented menses characteristics in only 27% of adolescent girls with no documentation noted for Asian adolescents. Over 40% of eligible adolescents did not receive the human papillomavirus vaccine. Only 19.4% of adolescents received all the 3 recommended services. This study demonstrates that adolescent girls are not receiving recommended assessments or care to protect their reproductive health.

Using computer-extracted data from electronic health records to measure the quality of adolescent well-care.

OBJECTIVE: To determine whether quality measures based on computer-extracted EHR data can reproduce findings based on data manually extracted by reviewers. DATA SOURCES: We studied 12 measures of care indicated for adolescent well-care visits for 597 patients in three pediatric health systems. STUDY DESIGN: Observational study. DATA COLLECTION/EXTRACTION METHODS: Manual reviewers collected quality data from the EHR. Site personnel programmed their EHR systems to extract the same data from structured fields in the EHR according to national health IT standards. PRINCIPAL FINDINGS: Overall performance measured via computer-extracted data was 21.9 percent, compared with 53.2 percent for manual data. Agreement measures were high for immunizations. Otherwise, agreement between computer extraction and manual review was modest (Kappa = 0.36) because computer-extracted data frequently missed care events (sensitivity = 39.5 percent). Measure validity varied by health care domain and setting. A limitation of our findings is that we studied only three domains and three sites. CONCLUSIONS: The accuracy of computer-extracted EHR quality reporting depends on the use of structured data fields, with the highest agreement found for measures and in the setting that had the greatest concentration of structured fields. We need to improve documentation of care, data extraction, and adaptation of EHR systems to practice workflow.

Buen trato a la infancia: deriva semántica en la producción científica publicada en Latinoamérica

La deriva semántica de los conceptos en la producción científica muchas veces significa una puerta de entrada para las diversas representaciones colectivas y su praxis consecuente. Anterior a la difusión de las palabras mismas y su asimilación en el imaginario colectivo en la vida cotidiana, cada una de ellas muestra un curso de validación dentro de la comunidad científica. El buen trato a la infancia es un concepto emergente que comienza a ser nombrado en 1997, frecuentemente asociado a prácticas de cuidado en salud o protección social, creado por oposición y en prevención al maltrato infantil. Mayormente presente en el mundo francés e hispano, esta noción logra un importante impacto en la comunidad científica latinoamericana. El propósito de este estudio es mostrar el comportamiento que presenta el despliegue del concepto en las principales revistas indexadas en la red de Redalyc durante los últimos quince años. Desde un análisis de orientación bibliométrica del término se compara la participación de países latinoamericanos de habla hispana en la publicación de artículos que usan el término en referencia al mismo como fenómeno presente en diversos campos y disciplinas. A partir del reconocimiento de esta distribución en el tiempo, se develan los principales significados y referencias del concepto. Se espera, a partir de este mapeo, contribuir a la dilucidación y delimitación del mismo, para aportar a su validación dentro y fuera de la comunidad científica.

Semantic drift of concepts in scientific production often means a gate for several collective representations and their application in the praxis consequent with it. Before diffusion of the words and their assimilation in the imaginary of people in the daily world, each one of them shows a course of validation into the scientific community. Well care in childhood is an emergent concept which begins to be named in 1997, frequently associated to practices of health or social care and it's created by opposition and for preventing child maltreatment. More present in French and Spanish world, this notion have gotten an important impact inside of Latin-American scientific community. The purpose of this study is to show the conduct of deployment of the concept in leading journals indexed in Redalyc network over the past fifteen years. From a bibliometric analysis of the term, the participation of Spanish speaking Latin American countries are compared in base of publications of articles that use the term in reference of a related phenomena in various fields and disciplines. Upon recognition of their distribution over time, the main concept meanings and references are revealed. Is expected from this mapping, contribute to clarify and to delimit the concept, to contribute to its validation inside and outside the scientific community.

A deriva semântica dos conceitos na produção científica muitas vezes significa uma porta de entrada para as diversas representações coletivas e sua prática consecutiva. Anterior a uma difusão das mesmas palavras e sua assimilação no imaginário coletivo na vida cotidiana, cada uma delas indica um curso de validação dentro da comunidade científica. El buen trato a la infancia es un concepto emergente que comenzó a ser nombrado en 1997, freqüentemente associado a prácticas de cuidado em saúde e proteção social, criado por oposição e em prevenção ao maltrato infantil. Destaque para o mundo francês e hispano, esta noção é importante para a comunidade científica latinoamericana. O objetivo deste estudo é mostrar o comportamento que apresenta o despliegue do conceito nas principais revistas indexadas no vermelho de Redalyc durante os últimos anos do quince. Desde um estudo de orientação bibliométrica do termo comparado a participação de países latinoamericanos de fala hispana na publicação de artigos que usan o termo em referência ao mesmo como um fenómeno presente em diversos campos e disciplinas. A partir do reconhecimento de sua distribuição no tempo, se develan os principais significados e referências do conceito. Se espera, a partir de este mapeo, contribuir para a diluição e delimitação do mesmo, para a validação de um dentro e fora da comunidade científica.

Vivenciando o cuidado perioperatório de Enfermagem / Experiencing perioperative nursing care

Trata-se de estudo qualitativo, tendo como objeto as vivências de cuidar/cuidado perioperatório de pacientes de cirurgias gerais eletivas. Objetivou compreender como os pacientes no perioperatório de cirurgias gerais eletivas vivenciam o cuidar/cuidado de enfermagem. Os sujeitos foram 12 colaboradores em 04 unidades cirúrgicas de um hospital público de Salvador-Bahia em 2005. As informações foram levantadas usando-se a técnica da história oral de vida, seguindo-se um roteiro de entrevista semi-estruturada. O processo de análise utilizado, tendo por referencial o cuidar e o cuidado de enfermagem, foi a análise temática de Minayo. Emergiram duas categorias temáticas: Vivências perioperatórias de cuidados de enfermagem por pacientes submetidos a cirurgias gerais eletivas constituída das seguintes subcategorias: a) Externando sentimentos negativos na experiência cirúrgica geral eletiva; b) Externando o cuidado sistematizado na experiência cirúrgica geral eletiva; Significados de cuidar e de cuidados de enfermagem por pacientes que vivenciaram o perioperatório de cirurgias gerais eletivas com as subcategorias: a) Cuidado é implementação de procedimentos pré-operatórios e cuidados pós-operatórios; b) O cuidar e o cuidado se estabelecem nas relações entre paciente e equipe de enfermagem; c) O cuidar e o cuidado significam comunicar-se; e d) Reconhecendo aspectos éticos do cuidar e do cuidado perioperatório. Os resultados apontam para o reconhecimento de que o processo de cuidar envolve a soma de cuidados técnicos bio-psico-afetivos. Conclui-se que, em relação à SAEP, a admissão está implantada no Centro Cirúrgico; a enfermagem está preocupada com a redefinição de seus papéis no cuidar/cuidado; os colaboradores reconhecem que há necessidade de se perceberem prioridades diante de aspectos negativos do cuidar/cuidado. Para o paciente, estar na condição de perioperatório significa vivenciar sentimentos de medo, apreensão e incertezas. Há valorização da comunicação, relação cuidativa e presença dos componentes da equipe de enfermagem nesse processo. Os princípios de responsabilidade, beneficência, não maleficência, autonomia e liberdade permeiam a vivência do cuidar/cuidado no perioperatório.(AU)