Point-of-Care Testing Improves Lead Screening Rates at 1- and 2-Year Well Visits.

OBJECTIVE: To increase blood lead level screening rates in children at 12- and 24-month well visits through provider education and the implementation of a point-of-care (POC) lead screening program in 4 primary care practice offices located in and neighbored by counties with ≥5% prevalence of blood lead levels ≥5 µg/dL. STUDY DESIGN: Baseline data were collected July 2017 to June 2018. All providers received education on screening recommendations and local prevalence of elevated blood lead levels in July 2018. POC testing began June 2019 at 1 of the 4 practice sites. Screening rates were measured by electronic medical record abstraction. Rates were plotted monthly on statistical process control charts during implementation and analyzed using logistic regression under an interrupted time series approach for program evaluation. RESULTS: There was a small but significant increase in screening following provider education (OR 1.04 per month, 95% CI 1.02-1.07). POC testing was associated with a substantial immediate increase (OR 4.17, 95% CI 2.45-7.09) and a substantial continued increase (OR 1.34 per month, 95% CI 1.17-1.54) in screening at the site that implemented POC. CONCLUSIONS: POC testing substantially increases blood lead level screening rates at 12- and 24-month well visits and may be beneficial in other primary care settings.

Improving infant sleep safety via electronic health record communication: a randomized controlled trial.

BACKGROUND: With increased use of telehealth, interventions to improve infant sleep environments have not been explored. This study sought to assess the feasibility and efficacy of using electronic health record patient portals to transmit photographs of infant sleep between mothers and healthcare professionals as part of an intervention to promote sleep environments consistent with AAP guidelines. METHODS: One hundred eighty-four mother-newborn dyads consented to participate in a randomized trial requiring patient portal registration within 1 month of delivery. We first assessed feasibility as measured by a) the proportion of consented mothers enrolling in the portal and b) maternal adherence to prompts to submit photographs of their infant sleeping to the research team through the patient portal. Intervention group mothers were prompted at 1 and 2 months; controls were prompted only at 2 months. Efficacy was determined via research assistant review of submitted photographs. These assistants were trained to detect sudden unexplained infant death risk factors utilizing AAP guidelines. Standardized feedback was returned to mothers through the patient portal. We used Fisher's Exact test to assess group differences in guideline adherence at 2 months. RESULTS: One hundred nine mothers (59%) enrolled in the patient portal and were randomized to intervention (N = 55) and control (N = 54) groups. 21 (38, 95% CI 25-52%) intervention group participants sent photographs at 1 month and received personalized feedback. Across both groups at 2 months, 40 (37, 95% CI 28-46%) sent photographs; 56% of intervention group participants who submitted photographs met all safe sleep criteria compared with 46% of controls (difference 0.10, 95% CI - 0.26 to 0.46, p = .75). Common reasons for guideline non-adherence were sleeping in a room without a caregiver (43%), loose bedding (15%) and objects (8%) on the sleep surface. CONCLUSIONS: Utilizing the patient portal to individualize safe infant sleep is possible, however, we encountered numerous barriers in this trial to assess its effects on promoting safe infant sleep. Photographs of infants sleeping showed substantial non-adherence to AAP guidelines, suggesting further needs for improvement to promote safe infant sleep practices. TRIAL REGISTRATION: Name: Improving Infant Sleep Safety With the Electronic Health Record; Clinicaltrials.gov: NCT03662048 ; Date of Registration: September 7, 2018; Data Sharing Statement: None.

Correction to: Improving infant sleep safety via electronic health record communication: a randomized controlled trial.

An amendment to this paper has been published and can be accessed via the original article.

Variability in State-Based Recommendations for Management of Alpha Thalassemia Trait and Silent Carrier Detected on the Newborn Screen.

We conducted an inventory of state-based recommendations for follow-up of alpha thalassemia silent carrier and trait identified on newborn screen. We found wide variability in the nature and timing of these recommendations. We recommend a standardized recommendation to guide pediatricians in evidenced-based care for this population.

Effects of COVID-19 pandemic on pediatric weight: A retrospective chart review.

The COVID-19 pandemic forced United States school closures in March 2020. Students moved to online learning, fostering a sedentary lifestyle. As the pandemic heightened population disparities, the impact on weight gain may also be unequally distributed. This study aimed to evaluate changes in body mass index (BMI) z-scores and weight percentiles of pediatric patients during the pandemic and associated demographics to identify those at risk for weight gain. Methods included a retrospective chart review of patients 5-18 years-old with a well-visit in the three years 2018, 2019 and 2020; first identified with a well-visit in August-September of 2020. BMI z-scores and weight percentiles were analyzed using a correlated errors regression model appropriate for longitudinal data. This longitudinal approach was used to model outcomes by patient demographics. Interaction terms with time were evaluated for each variable. Of 728 patients, mean age was 9.7 years (2018); 47 % female, 70 % white, and 23 % publicly insured. BMI z-score did not increase significantly from 2018-2019 versus 2019-2020. Weight percentile demonstrated a slight trajectory increase over these same time points. Publicly insured patients demonstrated significantly greater increase in BMI z-score versus privately insured patients (p = 0.009). Mean differences between groups increased from 0.26 in 2018 (95 % CI [0.07, 0.45]) to 0.42 in 2020 (95 % CI [0.23, 0.61]). Results were similar for weight percentile. Publicly insured pediatric patients experienced significant increase in BMI-z score and weight percentile, but over time this trajectory remained constant. The results support targeting at risk subgroups in addressing long-term impacts of the pandemic.

Increasing the adoption of evidence-based communication practices for HPV vaccination in primary care clinics: The HPV ECHO study protocol for a cluster randomized controlled trial.

BACKGROUND: The safe, highly-effective human papillomavirus (HPV) vaccine remains underused in the US. The Announcement Approach Training (AAT) has been shown to effectively increase HPV vaccine uptake by training providers to make strong vaccine recommendations and answer parents' common questions. Systems communications, like recall notices, can further improve HPV vaccination by reducing missed clinical opportunities for vaccination. Never tested in supporting HPV vaccination, the ECHO (Extension for Community Healthcare Outcomes) model is a proven implementation strategy to increase best practices among healthcare providers. This trial uses a hybrid effectiveness-implementation design (type II) to evaluate two ECHO-delivered interventions intended to increase HPV vaccination rates. METHODS: This 3-arm cluster randomized controlled trial will be conducted in 36 primary care clinics in Pennsylvania. Aim 1 evaluates the impact of HPV ECHO (AAT to providers) and HPV ECHO+ (AAT to providers plus recall notices to vaccine-declining parents) versus control on HPV vaccination (≥1 dose) among adolescents, ages 11-14, between baseline and 12-month follow-up (primary outcome). Using a convergent mixed-methods approach, Aim 2 evaluates the implementation of the HPV ECHO and HPV ECHO+ interventions. Aim 3 explores exposure to and impact of vaccine information from providers and other sources (e.g., social media) on secondary acceptance among 200 HPV vaccine-declining parents within 12 months. DISCUSSION: We expect to demonstrate the effectiveness and evaluate the implementation of two highly scalable interventions to increase HPV vaccination in primary care clinics. Our study seeks to address the communication needs of both providers and parents, increase HPV vaccination, and, eventually, prevent HPV-related cancers. TRIAL REGISTRATION: ClinicalTrials.govNCT04587167. Registered on October 14, 2020.

Treatment Engagement Following a Positive Mental Health Screening Questionnaire.

INTRODUCTION: Less than half of U.S. adolescents with major depressive disorder receive treatment. Despite the U.S. Preventive Services Task Force 2016 statement supporting primary care major depressive disorder screening, there is limited data examining whether positive screens prompt treatment engagement. This study evaluated treatment engagement following a positive Patient Health Questionnaire-Adolescent Version screen and assessed the impact of demographics, clinical variables, and provider recommendations on treatment engagement. METHODS: This was a retrospective cohort study (analysis November 2021) of adolescents aged 11-18 years seen at a primary care clinic of an academic medical center from July 2017 to December 2018 and identified with a positive Patient Health Questionnaire-Adolescent Version (broadest definition score ≥10; ≥1 for Item 9 regarding suicidal thoughts; yes for unscored Items 1, 3, or 4; or very or extremely difficult for unscored Item 2). Positive screen by score ≥10 alone was also considered. The primary outcome was treatment engagement, defined as initiation of a psychotropic medication, or a behavioral health treatment session within 1 year of symptom identification. RESULTS: Of the 1,315 eligible adolescents, 23.0% had a positive Patient Health Questionnaire-Adolescent Version (n=302) by the broadest criteria; 92/302 (30.5%) engaged in treatment. Patients whose providers recommended treatment had 7.32 times the odds (95% CI=3.76, 14.2, p<0.001) of treatment engagement. For those positive by Patient Health Questionnaire-Adolescent Version ≥10 (85/302, 28.1%), 37/85 (43.5%) engaged in treatment. The influence of provider recommendations was comparable (OR=6.96, 95% CI=3.56, 13.6, p<0.001). CONCLUSIONS: Less than half of adolescents with a positive Patient Health Questionnaire-Adolescent Version at an academic primary care clinic engaged with treatment. Provider recommendation was an impactful intervention to improve mental healthcare treatment engagement.

The Impact of Medical Scribes on Relative Value Units in a Pediatric Primary Care Practice.

OBJECTIVE: Our study assessed the impact of adding medical scribes to an academic pediatric primary practice by measuring the relationship between work relative value units (wRVUs) and use of the medical scribe. METHODS: This is a retrospective comparative study on the effect of medical scribes on average wRVUs per patient encounter. wRVUs were abstracted from procedure codes in the billing system. RESULTS: Six clinicians performed 2277 patient visits included in the study over 2 different time periods during 2017 and 2018. The first period was without the use of medical scribes and the second period included scribes. Average clinician wRVU production per visit increased by 7.68% (P < .001) with medical scribes over the previous period without them. CONCLUSIONS: This study shows that scribes contribute to improving the wRVU per visit in a primary pediatric practice. This finding is consistent with other research showing that scribes help increase volume and improve wRVUs for specialists who perform complex procedures.

Improving Hospital Infant Safe Sleep Compliance by Using Safety Prevention Bundle Methodology.

BACKGROUND AND OBJECTIVES: Sudden unexpected infant death often results from unsafe sleep environments and is the leading cause of postneonatal mortality in the United States. Standardization of infant sleep environment education has been revealed to impact such deaths. This standardized approach is similar to safety prevention bundles typically used to monitor and improve health outcomes, such as those related to hospital-acquired conditions (HACs). We sought to use the HAC model to measure and improve adherence to safe sleep guidelines in an entire children's hospital. METHODS: A hospital-wide safe sleep bundle was implemented on September 15, 2017. A safe sleep performance improvement team met monthly to review data and discuss ideas for improvement through the use of iterative plan-do-study-act cycles. Audits were performed monthly from March 2017 to October 2019 and monitored safe sleep parameters. Adherence was measured and reviewed through the use of statistical process control charts (p-charts). RESULTS: Overall compliance improved from 9% to 72%. Head of bed flat increased from 62% to 93%, sleep space free of extra items increased from 52% to 81%, and caregiver education completed increased from 10% to 84%. The centerline for infant in supine position remained stable at 81%. CONCLUSIONS: Using an HAC bundle safety prevention model to improve adherence to infant safe sleep guidelines is a feasible and effective method to improve the sleep environment for infants in all areas of a children's hospital.

"Flu-Floppers": Factors Influencing Families' Fickle Flu Vaccination Patterns.

While influenza vaccination in the prior year is a strong predictor of subsequent vaccination, many families do not have static vaccination patterns. This study examined factors guiding influenza vaccination decisions among parents whose children sporadically received the influenza vaccination (flu-floppers). We administered surveys to 141 flu-flopper families. Surveys included 21 factors associated with vaccine decision making. A conceptual framework of "passive" and "active" decision making was used to assess parental motivators behind vaccine decisions. The most common reason for vaccinating was a desire to prevent influenza (45%). The most common reason for not vaccinating was a belief that influenza vaccination is not effective (29%). Most parents (88%) reported an active reason in years when their child was vaccinated, while only 43% reported an active reason when their child was not vaccinated (P < .00001). These findings may guide efforts to increase influenza vaccination rates in children most amenable to vaccination.

Resident Experience and Education in Academic and Community Pediatric Primary Care Sites: Lessons for a Changing Healthcare Landscape.

INTRODUCTION: Efforts to improve pediatric primary care training in residency are important both for the residents and for the patients cared for in residency clinics. Pediatric residents typically get their primary care training at primary care centers affiliated with an academic center or at community-based locations. We aimed to compare residents' experience of continuity clinic in academic centers and community settings, and to identify relative strengths and weaknesses of each. METHODS: Survey data was evaluated for residents at one large pediatric residency program. RESULTS: Community sites had relative strengths in patient flow, population management, and perception of overall quality of care. Academic sites had relative strengths in continuity of care and ease of follow-up of results. CONCLUSIONS: Community and academic pediatric primary care training sites have varied strengths that could inform efforts to improve residency training to better meet the needs of residents and patients.

Impact of a "No Mobile Device" Policy on Developmental Surveillance in a Pediatric Clinic.

Children commonly use mobile devices at pediatric office visits. This practice may affect patient-provider interaction and undermine accuracy of developmental surveillance. A randomized, provider-blinded, controlled trial examined whether a policy prohibiting mobile device use in a pediatric clinic improved accuracy of pediatricians' developmental surveillance. Children, aged 18 to 36 months, were randomized to device-prohibited (intervention; n = 58) or device-allowed (control; n = 54) groups. After a 30-minute well-visit, development was evaluated as "normal," "borderline," or "delayed" in 5 categories using the Ages and Stages Questionnaire (ASQ-3). ASQ-3 results were compared with providers' clinical assessment in each category. Provider-ASQ discrepancies were more common for intervention participants ( P = .025). Providers "missed" more ASQ-3 "delayed" scores ( P = .005) in the intervention group, particularly in the fine motor domain ( P = .018). Prohibiting mobile device use at well-visits did not improve accuracy of providers' developmental surveillance. Mobile devices may entertain children at well-visits, allowing opportunities for parent-provider discussion, or observation of fine motor skills.

Exploratory study of barriers to successful office contacts for attention deficit hyperactivity disorder.

The American Academy of Pediatrics published attention deficit hyperactivity disorder (ADHD) guidelines, but significant variability exists in care. This exploratory study aimed to understand barriers to compliance with primary care office contacts for ADHD medication management. The study was conducted at a single academic medical center via retrospective chart review between 6/1/15 and 5/31/16 in combination with telephone interviews. Participants included 306 children 6-12 years old with an ADHD-related ICD-9/ICD-10 diagnosis. Factors affecting compliance were assessed via multivariable linear regression using the outcome of unsuccessful office contacts based on the percentage of missed, canceled, or rescheduled appointments. ADHD patients averaged 28.3% (SD 23.8%) unsuccessful office contacts. Unsuccessful contacts significantly increased by 15% for Hispanic ethnicity, 8% for public insurance, 8% for inattentive subtype, and 3% for every 10 miles additional distance from the office. Telephone interviews were attempted for those missing ≥ 3 appointments, which represented 18.3% (56/306) of the sample. Interviews were successfully completed with 37.5% (21/56). Of these, 52.3% (11/21) of parents preferred in-person visits. Structural barriers were not a concern, but 52.3% (11/21) reported high caregiver strain and fatigue. The results indicate that cultural barriers to understanding of ADHD and its management must be reconsidered. Use of Internet-based platforms may be a novel approach to address issues of distance, financial difficulty, and parental stress.

Change in Residents' Experience in Continuity Clinic After Patient-Focused Primary Care Redesign.

OBJECTIVE: Evaluation of efforts to redesign primary care has primarily focused on clinical services, with limited assessment of the effect on learners. This study evaluated the change in pediatric residents' perception of training, teamwork, and patient care in 2 different continuity clinic settings that were implementing patient-focused primary care redesign. METHODS: Continuity clinic residents at 2 large urban pediatric training programs completed a survey, developed de novo, before and after primary care redesign. Differences in the proportion of positive (≥4 of 5) ratings before and after redesign were compared using chi-squared tests in 2 practice sites, each of which focused on improving specific aspects of their practice. RESULTS: The response rate was >70% in both sites and in both years. Residents in the site focused on teamwork and continuity were more likely to report improved teamwork training (64% vs 83%; P < .05) and teamwork among residents (82% vs 98%; P < .05) after redesign. Perception of overall quality of care in clinic also improved (47% vs 68%; P < .05). Residents in the site focused on clinic flow were more likely to report that physicians, nurses, and administrative staff worked together to optimize patient flow after redesign (25% vs 48%; P < .05). No improvements were seen in domains without focused interventions in either site. CONCLUSIONS: Practice redesign focused on clinical outcomes can positively affect resident perception of their training and clinical experience in continuity clinic. Future redesign efforts deliberately involving residents might further enhance continuity clinic training.