A Cluster Randomized Controlled Trial of a Primary Care Provider-Delivered Social Media Counseling Intervention.

PURPOSE: Evidence and clinical policy support that providers screen and counsel for media use for youth, but most pediatricians lack this training. The purpose of this study was to test a primary care provider (PCP)-delivered intervention to promote safe social media use among youth. METHODS: We enrolled pediatric PCP practices for this clinical trial to test a social media counseling intervention (SMCI) between 2011 and 2013. Youth were recruited during clinic visits; follow-up interviews were conducted at 6 months. Outcomes included media behaviors and caregiver communication. Multivariate regression models examined associations between social media counseling and PCP counseling score. Multivariate logistic regression evaluated four social media behavior outcomes. RESULTS: A total of 120 practices enrolled; PCPs in the SMCI were more likely to provide social media counseling (B = 1.43, 95% confidence interval [CI]: 1.1-1.7). Youth whose PCP received the SMCI were twice as likely to report a decrease in online "friending" of strangers (adjusted odds ratio = 2.23, 95% CI 1.17-4.25) and were more likely to report communication with their caregivers about their social media use (adjusted odds ratio = 1.2; 95% CI: 1.1-1.4) compared to youth whose PCPs were in the active control group. DISCUSSION: Youth whose PCP had received social media counseling training reported a higher receipt of counseling about social media and improved safety behaviors.

Delivery and Impact of a Motivational Intervention for Smoking Cessation: A PROS Study.

OBJECTIVES: We tested a Public Health Service 5As-based clinician-delivered smoking cessation counseling intervention with adolescent smokers in pediatric primary care practice. METHODS: We enrolled clinicians from 120 practices and recruited youth (age ≥14) from the American Academy of Pediatrics Pediatric Research in Office Settings practice-based research network. Practices were randomly assigned to training in smoking cessation (intervention) or social media counseling (attentional control). Youth recruited during clinical visits completed confidential screening forms. All self-reported smokers and a random sample of nonsmokers were offered enrollment and interviewed by phone at 4 to 6 weeks, 6 months, and 12 months after visits. Measures included adolescents' report of clinicians' delivery of screening and counseling, current tobacco use, and cessation behaviors and intentions. Analysis assessed receipt of screening and counseling, predictors of receiving 5As counseling, and effects of interventions on smoking behaviors and cessation at 6 and 12 months. RESULTS: Clinicians trained in the 5As intervention delivered more screening (ß = 1.0605, P < .0001) and counseling (ß = 0.4354, P < .0001). In both arms, clinicians more often screened smokers than nonsmokers. At 6 months, study arm was not significantly associated with successful cessation; however, smokers in the 5As group were more likely to have quit at 12 months. Addicted smokers more often were counseled, regardless of study arm, but were less likely to successfully quit smoking. CONCLUSIONS: Adolescent smokers whose clinicians were trained in 5As were more likely to receive smoking screening and counseling than controls, but the ability of this intervention to help adolescents quit smoking was limited.

Variations in Mental Health Diagnosis and Prescribing Across Pediatric Primary Care Practices.

BACKGROUND: Primary care pediatricians increasingly care for children's mental health problems, but little is known about practice-level variation in diagnosis and psychotropic medication prescribing practices. METHODS: This retrospective review of electronic heath records from 43 US primary care practices included children aged 4 to 18 years with ≥1 office visit from January 1, 2009, to June 30, 2014. We examined variability in diagnosis and psychotropic prescribing across practices using logistic regression with practice fixed effects and evaluated associations of the availability of colocated or community-based mental health providers or the proportion of children in foster care with diagnosis and prescribing using generalized linear mixed models. RESULTS: Among 294 748 children, 40 932 (15%) received a mental health diagnosis and 39 695 (14%) were prescribed psychotropic medication. Attention deficit/hyperactivity disorder was most commonly diagnosed (1%-16% per practice). The proportion of children receiving any psychotropic medication (4%-26%) and the proportion receiving ≥2 medication classes (1%-12%) varied across practices. Prescribing of specific medication classes also varied (stimulants, 3%-18%; antidepressants, 1%-12%; α-agonists, 0%-8%; second-generation antipsychotics, 0%-5%). Variability was partially explained by community availability of psychiatrists (significantly higher odds of a diagnosis or prescription when not available) but not by colocation of mental health professionals or percentage of children in foster care. CONCLUSIONS: The prevalence of mental health diagnosis and psychotropic medication prescribing varies substantially across practices and is only partially explained by psychiatrist availability. Research is needed to better define the causes of variable practice-level diagnosis and prescribing and implications for child mental health outcomes.

Changing patterns of alpha agonist medication use in children and adolescents 2009-2011.

OBJECTIVES: The purpose of this study was to describe rates and patterns of long- and short-acting alpha agonist use for behavioral problems in a primary care population following Food and Drug Administration (FDA) approval of the long-acting alpha agonists guanfacine and clonidine. METHODS: Children and adolescents 4-18 years of age, who received an alpha agonist prescription between 2009 and 2011, were identified from a sample of 45 United States primary care practices in two electronic health record-based research networks. Alpha agonist receipt was identified using National Drug Codes and medication names. The proportion of subjects receiving long- and short-acting prescriptions in each year was calculated and examined with respect to reported mental health diagnoses, and whether indications for use were on-label, had evidence from clinical trials, or had no trial evidence. RESULTS: In a cohort of 282,875 subjects, 27,671 (10%) received any psychotropic medication and only 4,227 subjects (1.5%) received at least one prescription for an alpha agonist, most commonly a short-acting formulation (83%). Only 20% of alpha agonist use was on-label (use of long-acting formulations for attention-deficit/hyperactivity disorder [ADHD]). Most subjects (68%) received alpha agonists for indications with evidence of efficacy from clinical trials but no FDA approval, primarily short-acting formulations for ADHD and autism; 12% received alpha agonists for diagnoses lacking randomized clinical trial evidence in children, including sleep disorders and anxiety, or for which there was no documented mental health diagnosis. Rates of long-acting alpha agonist use increased more than 20-fold from 0.2% to 4%, whereas rates of short-acting alpha agonist use grew only slightly between 2009 and 2011 from 10.6% to 11.3%. CONCLUSIONS: Alpha agonist use was uncommon in this population, and most subjects received short-acting forms for conditions that were off-label, but with clinical trial evidence. The safety and efficacy of use for conditions, including sleep disorders and anxiety, lacking evidence from randomized trials, warrant further investigation.

Maintenance of Certification Part 4 Credit and recruitment for practice-based research.

BACKGROUND: Competing priorities in pediatric practice have created challenges for practice-based research. To increase recruitment success, researchers must design studies that provide added value to participants. This study evaluates recruitment of pediatricians into a study, before and after the development and addition of a quality improvement (QI) curriculum approved for American Board of Pediatrics Maintenance of Certification (MOC) Part 4 Credit as an enrollment incentive. METHODS: Researchers implemented multiple outreach methods to enroll pediatric practices over 28 months. Field note review revealed that many physicians declined enrollment, stating that they prioritized MOC Part 4 projects over research studies. A QI curriculum meeting standards for MOC Part 4 Credit was developed and added to the study protocol as an enrollment incentive. Enrollment rates and characteristics of practitioners enrolled pre- and post-MOC were compared. RESULTS: Pre-MOC enrollment contributed 48% of practices in 22 months; post-MOC enrollment contributed 49% of practices in 6 months. An average of 3.5 practices enrolled per month pre-MOC, compared with 13.1 per month post-MOC (P < .001). Clinicians in pre- and post-MOC groups were similar in age, gender, race, and time spent on patient care; practices enrolled post-MOC were more likely to be located in federally designated Medically Underserved Areas than those enrolled pre-MOC (28.6% vs 12%, P = .03). CONCLUSIONS: Addition of MOC Part 4 Credit increased recruitment success and increased enrollment of pediatricians working in underserved areas. Including QI initiatives meeting MOC Part 4 criteria in practice-based research protocols may enhance participation and aid in recruiting diverse practice and patient populations.

Helping adolescents with attention-deficit/ hyperactivity disorder transition toward adulthood.

Pediatricians can help adolescents with attention-deficit/hyperactivity disorder prepare to enter post-high school training and the workforce. In this article peer-reviewed studies and other resources for informing patients of the issues ahead are identified. We discuss preventive counseling, including long-term monitoring, adherence to treatment, driving, tobacco, alcohol, and other drug usage, career planning, and intimacy. The current status of insurance coverage for young adults and federal programs to assist students with attention-deficit/hyperactivity disorder are reviewed also. Consideration is given for applying for precollege testing and college accommodations and traveling abroad with medications. Pediatricians and young adults are directed to Web-based and other self-management information and tools.

Assessing voids in SNOMED CT for pediatric concepts.

Reference terminologies such as SNOMED CT may have voids in their representation of concepts important to the practice of pediatrics. In this project, relevant pediatric concepts were extracted from an American Academy of Pediatrics guideline and were mapped to SNOMED CT. Concepts were identified that should be included in the standard reference terminology. A process for formally evaluating voids in reference terminologies for concepts needed in pediatric clinical decision-making is planned as a next step.

Attention-deficit/hyperactivity disorder among adolescents: a review of the diagnosis, treatment, and clinical implications.

Attention-deficit/hyperactivity disorder (ADHD) is the most common mental disorder in childhood, and primary care clinicians provide a major component of the care for children with ADHD. However, because of limited available evidence, the American Academy of Pediatrics guidelines did not include adolescents and young adults. Contrary to previous beliefs, it has become clear that, in most cases, ADHD does not resolve once children enter puberty. This article reviews the current evidence about the diagnosis and treatment of adolescents and young adults with ADHD and describes how the information informs practice. It describes some of the unique characteristics observed among adolescents, as well as how the core symptoms change with maturity. The diagnostic process is discussed, as well as approaches to the care of adolescents to improve adherences. Both psychosocial and pharmacologic interventions are reviewed, and there is a discussion of these patients' transition into young adulthood. The article also indicates that research is needed to identify the unique adolescent characteristics of ADHD and effective psychosocial and pharmacologic treatments.

Telemedicine: pediatric applications.

The newly developing field of telemedicine has the potential to benefit pediatric care by increasing access to pediatric specialists and services. This report explores the current uses and limitations of telemedicine in pediatrics.

A proposal for electronic medical records in U.S. primary care.

Delivery of excellent primary care-central to overall medical care-demands that providers have the necessary information when they give care. This paper, developed by the National Alliance for Primary Care Informatics, a collaborative group sponsored by a number of primary care societies, argues that providers' and patients' information and decision support needs can be satisfied only if primary care providers use electronic medical records (EMRs). Although robust EMRs are now available, only about 5% of U.S. primary care providers use them. Recently, with only modest investments, Australia, New Zealand, and England have achieved major breakthroughs in implementing EMRs in primary care. Substantial benefits realizable through routine use of electronic medical records include improved quality, safety, and efficiency, along with increased ability to conduct education and research. Nevertheless, barriers to adoption exist and must be overcome. Implementing specific policies can accelerate utilization of EMRs in the U.S.