Impact of Stressful Climates on Provider Perceptions of Integrated Behavioral Health Services in Pediatric Primary Care: An Exploratory Study.

OBJECTIVE: Pediatric primary care providers (PCPs) work in challenging environments and are increasingly called to implement complex interventions, such as behavioral health (BH) service integration. We explore how perceived stressful practice climates (1) change over time in and (2) influence provider perceptions of collaborative care versus usual care, 2 models of integrated BH care. METHODS: Secondary exploratory analysis using hierarchical linear modeling was performed on an 18-month cluster-randomized trial of 8 pediatric primary care practices to Doctor-Office Collaborative Care (DOCC), where an on-site care manager delivered BH services in coordination with PCPs, or Enhanced Usual Care (EUC), where a care manager facilitated referrals to local BH providers. Various indicators of PCP perceptions of BH services, including satisfaction with practice, burdens and beliefs regarding psychosocial problems, and effectiveness in treating behavioral problems, were assessed as outcomes. Moderators were 2 domains of stressful climates, role conflict and role overload. RESULTS: Role conflict and role overload stayed stable in both conditions. Role conflict strengthened the positive effect of DOCC on PCP perceived effectiveness in treating behavioral problems (ß [SE], 0.04 [0.02]; p = 0.04) and improvement in managing oppositional/aggressive behavior (0.02 [0.01]; p = 0.02). Role overload strengthened the positive effect of DOCC on PCP-perceived improvement in managing attention-deficit hyperactivity disorder (0.03 [0.01]; p = 0.01). Stressful climates did not influence perceptions for EUC providers. CONCLUSIONS: Providers experiencing more stressful practice climates developed more positive perceptions of collaborative care. This may encourage stressed providers to make effective practice changes and promote practice integration of BH services.

Factors Associated with Attention Deficit Hyperactivity Disorder Medication Use in Community Care Settings.

OBJECTIVES: To examine patient- and provider-level factors associated with receiving attention-deficit/hyperactivity disorder (ADHD) medication treatment in a community care setting. We hypothesized that the likelihood of ADHD medication receipt would be lower in groups with specific patient sociodemographic (eg, female sex, race other than white) and clinical (eg, comorbid conditions) characteristics as well as physician characteristics (eg, older age, more years since completing training). STUDY DESIGN: A retrospective cohort study was conducted with 577 children (mean age, 7.8 years; 70% male) presenting for ADHD to 50 community-based practices. The bivariate relationship between each patient- and physician-level predictor and whether the child was prescribed ADHD medication was assessed. A multivariable model predicting ADHD medication prescription was conducted using predictors with significant (P < .05) bivariate associations. RESULTS: Sixty-nine percent of children were prescribed ADHD medication in the year after initial presentation for ADHD-related concerns. Eleven of 31 predictors demonstrated a significant (P < .05) bivariate relationship with medication prescription. In the multivariable model, being male (OR, 1.34; 95% CI, 1.01-1.78; P = .02), living in a neighborhood with higher medical expenditures (OR, 1.11 for every $100 increase; 95% CI, 1.03-1.21; P = .005), and higher scores on parent inattention ratings (OR, 1.06; 95% CI, 1.03-1.10; P < .0001) increased the likelihood of ADHD medication prescription. CONCLUSIONS: We found that some children, based on sociodemographic and clinical characteristics, are less likely to receive an ADHD medication prescription. An important next step will be to examine the source and reasons for these disparities in an effort to develop strategies for minimizing treatment barriers.

Venous thromboembolism and adolescent and young adult oncology inpatients in US children's hospitals, 2001 to 2008.

OBJECTIVES: To determine the frequency of venous thromboembolism (VTE) in the adolescent and young adult oncology population and the effects of age and cancer type on VTE, and to characterize adolescent and young adult oncology admissions at US children's hospitals. STUDY DESIGN: We extracted data on oncology patients 15 to 24 years of age who were discharged from 35 hospitals in the Pediatric Hospital Information System (PHIS) between 2001 and 2008. RESULTS: Of 9721 unique patients, VTE occurred in 511 (5.3%). An elevated OR of VTE occurred in patients 18 to 20 and 21 to 24 years of age (OR, 1.65; 95% CI, 1.36-2.00 and OR, 1.67; 95% CI, 1.21-2.32, respectively) compared with that in patients 15 to 17 years old. Patients with leukemia (OR, 5.53; 95% CI, 3.63-8.42) and bone/soft tissue sarcomas (OR, 4.32; 95% CI, 2.80-6.69) had a higher risk of VTE compared with patients with brain tumors. The number of adolescent and young adult oncology admissions to pediatric hospitals increased 31.9%, from 5409 admissions in 2001 to 7134 admissions in 2008. CONCLUSIONS: Adolescent and young adult oncology patients, a growing population at pediatric hospitals, experience VTE as a common complication. Pediatricians should implement adolescent and young adult-specific studies to develop a standardized approach to preventing this adverse event.

Follow-up care of children identified with ADHD by primary care clinicians: A prospective cohort study.

OBJECTIVE: To document follow-up care received by children identified with attention deficit hyperactivity disorder (ADHD) by primary care clinicians (PCCs). STUDY DESIGN: We surveyed families of children 4 to 15 years of age who had been diagnosed with ADHD. At an index office visit, parents and clinicians completed questionnaires. Six months after the index visit, parents completed a questionnaire (N = 659 returned surveys, 68% return rate). The main outcome measure was the number of visits with the patients' PCCs or mental health specialists during the 6 months after the index visit. RESULTS: Children had a median of one visit PCC over a period of 6 months. Children who had prescriptions for psychotropic medications (78%) did not differ from others in the number of visits. Follow-up visits with the child's own doctor were more common when the PCC had completed mental health training. Only 26% of patients saw a mental health specialist. Children who were black, on Medicaid, or with higher levels of internalizing symptoms were more likely to see a mental health specialist. CONCLUSIONS: Children treated for ADHD need more follow-up visits to permit adjustment of medication and support continuation of patients in treatment. Systematic quality improvement efforts are warranted.

Recurrent pain, emotional distress, and health service use in childhood.

OBJECTIVES: To determine the psychosocial correlates of recurrent pediatric pain and its relationship to health service use and medical presentations for "unexplained" symptoms in primary care. STUDY DESIGN: Children 4 to 15 years of age who complained frequently of aches and pains to parents were compared with those with infrequent or no pain on measures of demographics, psychopathology, school attendance and performance, perceived health, and service use. Univariate analysis was followed by logistic regression. RESULTS: Children who complained often of aches and pains used more health services, had more psychosocial problems, missed more school, and did worse academically. After controlling for health service use and demographics, recurrent pain was significantly associated with negative parental perceptions of child health and the presence of internalizing psychiatric symptoms. Higher levels of ambulatory health service use were associated with negative perceptions of child health, recurrent pain, visits for "unexplained" symptoms, and internalizing psychiatric symptoms. CONCLUSIONS: Pediatric recurrent pain challenges traditional service delivery models characterized by segregated systems of care for physical and mental disorders. Longitudinal and psychobiological studies of the relationship between recurrent pain, internalizing psychopathology, and health beliefs are warranted to direct future treatment efforts.