Assessment of Screening Tools to Identify Substance Use Disorders Among Adolescents.

Importance: Efficient screening tools that effectively identify substance use disorders (SUDs) among youths are needed. Objective: To evaluate the psychometric properties of 3 brief substance use screening tools (Screening to Brief Intervention [S2BI]; Brief Screener for Tobacco, Alcohol, and Drugs [BSTAD]; and Tobacco, Alcohol, Prescription Medication, and Other Substances [TAPS]) with adolescents aged 12 to 17 years. Design, Setting, and Participants: This cross-sectional validation study was conducted from July 1, 2020, to February 28, 2022. Participants aged 12 to 17 years were recruited virtually and in person from 3 health care settings in Massachusetts: (1) an outpatient adolescent SUD treatment program at a pediatric hospital, (2) an adolescent medicine program at a community pediatric practice affiliated with an academic institution, and (3) 1 of 28 participating pediatric primary care practices. Participants were randomly assigned to complete 1 of the 3 electronic screening tools via self-administration, followed by a brief electronic assessment battery and a research assistant-administered diagnostic interview as the criterion standard measure for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnoses of SUDs. Data were analyzed from May 31 to September 13, 2022. Main Outcomes and Measures: The main outcome was a DSM-5 diagnosis of tobacco/nicotine, alcohol, or cannabis use disorder as determined by the criterion standard World Mental Health Composite International Diagnostic Interview Substance Abuse Module. Classification accuracy of the 3 substance use screening tools was assessed by examining the agreement between the criterion, using sensitivity and specificity, based on cut points for each tool for use disorder, chosen a priori from previous studies. Results: This study included 798 adolescents, with a mean (SD) age of 14.6 (1.6) years. The majority of participants identified as female (415 [52.0%]) and were White (524 [65.7%]). High agreement between screening results and the criterion standard measure was observed, with area under the curve values ranging from 0.89 to 1 for nicotine, alcohol, and cannabis use disorders for each of the 3 screening tools. Conclusions and Relevance: These findings suggest that screening tools that use questions on past-year frequency of use are effective for identifying adolescents with SUDs. Future work could examine whether these tools have differing properties when used with different groups of adolescents in different settings.

Racial and Ethnic Differences in Length of Stay for US Children Hospitalized for Acute Osteomyelitis.

OBJECTIVE: To examine the associations between race and ethnicity and length of stay (LOS) for US children with acute osteomyelitis. STUDY DESIGN: Using the Kids' Inpatient Database, we conducted a cross-sectional study of children <21 years old hospitalized in 2016 or 2019 with acute osteomyelitis. Using survey-weighted negative binomial regression, we modeled LOS by race and ethnicity, adjusting for clinical and hospital characteristics and socioeconomic status. Secondary outcomes included prolonged LOS, defined as LOS of >7 days (equivalent to LOS in the highest quartile). RESULTS: We identified 2388 children discharged with acute osteomyelitis. The median LOS was 5 days (IQR, 3-7). Compared with White children, children of Black race (adjusted incidence rate ratio [aIRR] 1.15; 95% CI, 1.05-1.27), Hispanic ethnicity (aIRR 1.11; 95% CI, 1.02-1.21), and other race and ethnicity (aIRR 1.12; 95% CI, 1.01-1.23) had a significantly longer LOS. The odds of Black children experiencing prolonged LOS was 46% higher compared with White children (aOR, 1.46; 95% CI, 1.01-2.11). CONCLUSIONS: Children of Black race, Hispanic ethnicity, and other race and ethnicity with acute osteomyelitis experienced longer LOS than White children. Elucidating the mechanisms underlying these race- and ethnicity-based differences, including social drivers such as access to care, structural racism, and bias in provision of inpatient care, may improve management and outcomes for children with acute osteomyelitis.

A Patient Portal Intervention to Promote Adolescent and Young Adult Self-Management Skills.

OBJECTIVE: Failure to transfer care to adult medicine is associated with gaps in health care access and poor health outcomes among young adults. We examined whether a patient portal educational intervention is acceptable and can improve adolescent and young adult (AYA) self-management skills toward transition readiness to adult care. METHODS: We conducted a single site feasibility study using a mixed research method consisting of 1) a patient portal one-on-one educational intervention with pre- and postsurveys adapted from the Transition Readiness Assessment Questionnaire to assess participant self-management skills and portal user activity; 2) portal user experience was assessed through semistructured interviews until thematic saturation was reached. Study participants were 13 to 25 years old and received care at an academic-affiliated community pediatric clinic. Descriptive statistics were used to describe participant characteristics, paired t tests, or Wilcoxon signed-rank tests to assess outcomes of survey response changes pre- versus postintervention. RESULTS: Sixty percent of enrolled participants (N = 78) completed the surveys. Following the educational intervention, we observed an increase in participants self-reporting knowing how to access their protected health information P < .0001, (95%, confidence interval [CI], 1-2) and in the proportion of participants self-reporting to strongly agree to know their medication P = .025 (95%, CI 0-1). We also observed an increase in portal user access at 3 weeks; the median number of logins was 2 per participant (range 1-36, P < .0001). The Portal user experience was strongly positive. CONCLUSION: Our patient portal educational intervention suggests that AYAs welcome a patient portal to access protected health information and is associated with an increase in the proportion of participants self-reporting to strongly agree with knowing their medication. While these results are encouraging, this is a quasiexperimental study designed on the frame of feasibility. Our study was not adequately powered, limiting our findings' significance. Future interventions would benefit from a larger sample size with a comparison group to ascertain the effect of a patient portal on self-management skills in a diverse AYA population and inform best practices.

Improving HPV Vaccination Rates in a Racially and Ethnically Diverse Pediatric Population.

BACKGROUND AND OBJECTIVES: Nationally, 54.2% of youth are fully vaccinated for human papilloma virus (HPV) with persistent gender and racial/ethnic disparities. We used a quality improvement approach to improve completion of the HPV vaccine series by age 13 years. As a secondary aim, we examined racial/ethnic and gender differences in vaccine uptake. METHODS: The study setting included 2 pediatric, academic, primary care practices in Massachusetts. We designed a multilevel patient-, provider-, and systems-level intervention addressing parental hesitancy, provider communication, and clinical operations. Rates of HPV series completion by age 13 were monitored using a control p chart. Bivariate and multivariate analyses evaluated vaccine completion differences on the basis of clinic size, gender, and race/ethnicity. RESULTS: Between July 1, 2014, and September 30, 2021, control p charts showed special cause variation with HPV vaccine initiation by age 9 years, increasing from 1% to 52%, and vaccine completion by 13 years, increasing from 37% to 77%. Compared with White and Black children, Hispanic children were more likely to initiate the HPV vaccine at age 9 (adjusted odds ratio [95% confidence interval] = (1.4-2.6)] and complete the series by age 13 (adjusted odds ratio [95% confidence interval] = 2.3 (1.7-3.0). CONCLUSIONS: A multilevel intervention was associated with sustained HPV vaccine series completion by age 13 years. Hispanic children were more likely to be vaccinated. Qualitative family input was critical to intervention design. Provider communication training addressed vaccine hesitancy. Initiation of the vaccine at age 9 and clinicwide vaccine protocols were key to sustaining improvements.

A Patient Navigator Intervention Supporting Timely Transfer Care of Adolescent and Young Adults of Hispanic Descents Attending an Urban Primary Care Pediatrics Clinic.

While comprehensive health care transition is associated with better health outcomes, navigating health care transition can be difficult for adolescents and young adults (AYAs), especially those with fewer resources. Our practice serves low-income patients from birth to their 26th birthday; many are medically and socially complex and experience several obstacles to navigate care. As a result, most have not initiated a transfer to adult medicine by age 25. This quality-improvement initiative was designed to implement a structured intervention that supports the planned transfer of care to adult primary care. METHODS: Informed by our baseline data on all patients eligible to transfer care, we designed a patient outreach workflow centered on a patient navigator (PN) intervention. We used a Plan-Do-Study-Act format to optimize our process and run charts to evaluate our intervention. RESULTS: Over 3 years, our PN reached out to 96% of patients (n = 226) eligible to transfer care and offered transfer assistance in person or in writing. Among those surveyed, 92% (n = 93) reported awareness of our practice transition policy, and 83% (n = 64) rated their confidence to transfer care at 3 or higher on a 5-point scale. CONCLUSIONS: AYAs are aware of our practice transition policy, yet they welcome in-person transfer assistance. This intervention seems to improve their confidence to transfer care. However, despite PN outreach efforts, many remain empaneled in our practice and thus lack the self-care skills necessary to complete the transfer independently. Future transition interventions should address AYA's self-management skills toward transition readiness.

Assessment of: self-management skills towards transition readiness and patient portal use among Hispanic adolescent and young adult patients.

We conducted a 15-item self-answered survey to assess self-management skills and explore interest in a patient portal among publicly insured Hispanic youths ages 12-25. Out of 61 participants, 33% did not know how to schedule an appointment, 50% how to refill prescriptions, 58% how to access their personal health information, 84% were unaware of the portal and 92% never used it. Referring to the portal as an online application increased participants interest by 39%. Although study participants exhibit low self-management skills and awareness of a patient portal, most welcome using it to manage their health. Further research is needed to validate whether a patient portal can promote self-management skills towards transition readiness among Hispanic youths.

A Previsit Screening Checklist Improves Teamwork and Access to Preventive Services in a Medical Home Serving Low-Income Adolescent and Young Adult Patients.

Publicly insured adolescents and young adults experience significant obstacles in accessing primary care services. As a result, they often present to their medical appointments with multiple unmet needs, adding time and complexity to the visit. The goal of this project was to optimize team work and access to primary care services among publicly insured adolescents and young adults attending an urban primary care clinic, using a previsit screening checklist to identify patient needs and delegate tasks within a care team to coordinate access to health services at the time of the visit. We conducted an interventional quality improvement initiative in a PDSA (Plan-Do-Study-Act) cycle format; 291 patients, 13 to 25 years old were included in the study over an 8-months period. The majority of patients were receptive to the previsit screening checklist; 85% of services requested were provided; nonclinician staff felt more involved in patient care; and providers' satisfaction increased.

Functional significance of single nucleotide polymorphisms in the lactase gene in diverse US patients and evidence for a novel lactase persistence allele at -13909 in those of European ancestry.

OBJECTIVES: Recent data from mainly homogeneous European and African populations implicate a 140-bp region 5' to the transcriptional start site of LCT (the lactase gene) as a regulatory site for lactase persistence and nonpersistence. Because there are no studies of US nonhomogeneous populations, we performed genotype/phenotype analysis of the -13910 and -22018 LCT single nucleotide polymorphisms (SNPs) in New England children, mostly of European ancestry. METHODS: Duodenal biopsies were processed for disaccharidase activities, RNA quantification by reverse transcription polymerase chain reaction (RT-PCR), allelic expression ratios by PCR, and genotyping and SNP analysis. Results were compared with clinical information. RESULTS: Lactase activity and mRNA levels, and sucrase-to-lactase ratios of enzyme activity and mRNA, showed robust correlations with genotype. None of the other LCT SNPs showed as strong a correlation with enzyme or mRNA levels as did -13910. Data were consistent, with the -13910 being the causal sequence variant instead of -22018. Four individuals heterozygous for -13910T/C had allelic expression patterns similar to individuals with -13910C/C genotypes; of these, 2 showed equal LCT expression from the 2 alleles and a novel variant (-13909C>A) associated with lactase persistence. CONCLUSIONS: The identification of -13910C/C genotype is likely to predict lactase nonpersistence, consistent with prior published studies. A -13910T/T genotype will frequently, but not perfectly, predict lactase persistence in this mixed European-ancestry population; a -13910T/C genotype will not predict the phenotype. A long, rare haplotype in 2 individuals with -13910T/C genotype but equal allele-specific expression contains a novel lactase persistence allele present at -13909.

Final adult height of children with inflammatory bowel disease is predicted by parental height and patient minimum height Z-score.

BACKGROUND: This study was designed to elucidate the contribution of parental height to the stature of children with inflammatory bowel disease (IBD), who often exhibit growth impairment. Accordingly, we compared patients' final adult heights and target heights based on measured parental heights and examined predictors of final adult height in pediatric IBD patients. METHODS: We prospectively analyzed the growth of 295 patients diagnosed between ages 1 and 18 (211 Crohn's disease [CD], 84 ulcerative colitis [UC]) and their family members (283 mothers, 231 fathers, 55 siblings). RESULTS: Twenty-two percent had growth impairment (height for age Z-score <-1.64, equivalent to <5th percentile on growth curve) in more than 1 measurement since diagnosis; most growth-impaired patients had CD (88% CD versus 12% UC). Parents of the growth-impaired group had lower mean height Z-scores compared to parents of nongrowth-impaired patients (-0.67 versus 0.02 for mothers [P < 0.001]; -0.31 versus 0.22 for fathers [P = 0.002]). For 108 patients who reached adult heights and had available parental heights, the growth-impaired group continued to demonstrate lower adult height Z-scores (-1.38 versus 0.07; P < 0.001). Adult heights were within 1 SD of target heights even for the growth-impaired group. Only 11.3% remained persistently growth-impaired in adulthood. Multivariate regression analysis demonstrated lower parental height and minimum patient height Z-score as significant predictors of lower final adult height in IBD. CONCLUSIONS: Parental height is a powerful determinant of linear growth even in the presence of chronic inflammation, and should be an integral part of the evaluation of growth in IBD children.