Predictors of Subspecialty Appointment Scheduling and Completion for Patients Referred From a Pediatric Primary Care Clinic.

Failure to complete subspecialty referrals decreases access to subspecialty care and may endanger patient safety. We conducted a retrospective analysis of new patient referrals made to the 14 most common referral departments at Boston Children's Hospital from January 1 to December 31, 2017. The sample included 2031 patient referrals. The mean wait time between referral and appointment date was 39.6 days. In all, 87% of referrals were scheduled and 84% of scheduled appointments attended, thus 73% of the original referrals were completed. In multivariate analysis, younger age, medical complexity, being a non-English speaker, and referral to a surgical subspecialty were associated with a higher likelihood of referral completion. Black and Hispanic/Latino race/ethnicity, living in a Census tract with Social Vulnerability Index (SVI) ≥ 90th percentile, and longer wait times were associated with a lower likelihood of appointment attendance. Future interventions should consider both health care system factors such as appointment wait times and community-level barriers to referral completion.

Education on Preventing Early Childhood Injuries Using a Video Game: The VirtualSafeHome Platform.

Poisonings and household injuries are frequent events among toddlers. We developed VirtualSafeHome (VSH)-a novel self-contained, Internet-based home-safety learning tool-to improve awareness of household hazards. Study aims were to investigate VSH usage characteristics. A prototype, screen-based VSH kitchen was built in Unity and delivered through the web using 3DVista and Wix. Players spot and click 21 embedded hazards. A unique feature is the ability to capture the "child's perspective" in identifying hazards. We recruited a convenience sample of adults in 2021-2022. Outcomes included number of hazards discovered, session duration, and pretest/posttest knowledge scores. Twenty-four adults identified a median 15.5 hazards; median playing time was 1022 seconds. Players reported satisfaction with ease of navigation and game features. Mean pretest/posttest knowledge scores rose from 2.0 to 2.79 (P < .035). A web-enabled video game can provide easily accessed, enjoyable training on home safety.

Environmental Impact of a Pediatric and Young Adult Virtual Medicine Program: A Lesson from the COVID-19 Pandemic.

OBJECTIVES: The Coronavirus Disease 2019 (COVID-19) pandemic led to the expansion of virtual medicine as a method to provide patient care. We aimed to determine the impact of pediatric and young adult virtual medicine use on fossil fuel consumption, greenhouse gas, and nongreenhouse traffic-related air pollutant emissions. METHODS: We conducted a retrospective analysis of all virtual medicine patients at a single quaternary-care children's hospital with a geocoded address in the Commonwealth of Massachusetts prior to (March 16, 2019-March 15, 2020) and during the COVID-19 pandemic (March 16, 2020-March 15, 2021). Primary outcomes included patient travel distance, gasoline consumption, carbon dioxide and fine particulate matter emissions as well as savings in main hospital energy use. RESULTS: There were 3,846 and 307,273 virtual visits performed with valid Massachusetts geocoded addresses prior to and during the COVID-19 pandemic, respectively. During 1 year of the pandemic, virtual medicine services resulted in a total reduction of 620,231 gallons of fossil fuel use and $1,620,002 avoided expenditure as well as 5,492.9 metric tons of carbon dioxide and 186.3 kg of fine particulate matter emitted. There were 3.1 million fewer kilowatt hours used by the hospital intrapandemic compared to the year prior. Accounting for equipment emissions, the combined intrapandemic emission reductions are equivalent to the electricity required by 1,234 homes for 1 year. CONCLUSIONS: Widespread pediatric institutional use of virtual medicine provided environmental benefits. The true potential of virtual medicine for decreasing the environmental footprint of health care lies in scaling this mode of care to patient groups across the state and nation when medically feasible.

Preferred Language Mediates Association Between Race, Ethnicity, and Delayed Presentation in Critically Ill Patients With COVID-19.

Which social factors explain racial and ethnic disparities in COVID-19 access to care and outcomes remain unclear. OBJECTIVES: We hypothesized that preferred language mediates the association between race, ethnicity and delays to care. DESIGN SETTING AND PARTICIPANTS: Multicenter, retrospective cohort study of adults with COVID-19 consecutively admitted to the ICU in three Massachusetts hospitals in 2020. MAIN OUTCOME AND MEASURES: Causal mediation analysis was performed to evaluate potential mediators including preferred language, insurance status, and neighborhood characteristics. RESULTS: Non-Hispanic White (NHW) patients (157/442, 36%) were more likely to speak English as their preferred language (78% vs. 13%), were less likely to be un- or under-insured (1% vs. 28%), lived in neighborhoods with lower social vulnerability index (SVI) than patients from racial and ethnic minority groups (SVI percentile 59 [28] vs. 74 [21]) but had more comorbidities (Charlson comorbidity index 4.6 [2.5] vs. 3.0 [2.5]), and were older (70 [13.2] vs. 58 [15.1] years). From symptom onset, NHW patients were admitted 1.67 [0.71-2.63] days earlier than patients from racial and ethnic minority groups (p < 0.01). Non-English preferred language was associated with delay to admission of 1.29 [0.40-2.18] days (p < 0.01). Preferred language mediated 63% of the total effect (p = 0.02) between race, ethnicity and days from symptom onset to hospital admission. Insurance status, social vulnerability, and distance to the hospital were not on the causal pathway between race, ethnicity and delay to admission. CONCLUSIONS AND RELEVANCE: Preferred language mediates the association between race, ethnicity and delays to presentation for critically ill patients with COVID-19, although our results are limited by possible collider stratification bias. Effective COVID-19 treatments require early diagnosis, and delays are associated with increased mortality. Further research on the role preferred language plays in racial and ethnic disparities may identify effective solutions for equitable care.

Students' Risks for Out-of-School Suspensions: Indigenous Heritage and Child Protective Services Involvement.

Disproportionality in out-of-school suspensions (OSS) is a persistent social and racial justice issue. Available research indicates that Indigenous children are disproportionately represented in both OSS and the child protective services (CPS) system. This secondary data analysis followed a cohort of 3rd grade students (n = 60,025) in Minnesota public schools from 2008- 2014. It examined the relationship between CPS involvement, Indigenous heritage, and OSS. Results from a zero-inflated negative binomial regression indicated that Indigenous students had two times the odds of suspension compared to white students (OR = 2.06, p < .001). Furthermore, there was a significant interaction between CPS involvement and Indigeneity on frequency of OSS (OR = 0.88, p < .05). Indigenous students showed a much higher odds ratio of OSS compared to white students, but the distance between the odds ratios of the two groups decreased as the number of child maltreatment allegations increased. Indigenous students may experience relatively high levels of both CPS and OSS due to systematic racism. We discussed implications for practice and policy to reduce discipline disparities.

Bridging the gap, how interprofessional collaboration can support emergency preparedness for children with disabilities and their families: an exploratory qualitative study.

BACKGROUND: Children with disabilities and their families are at higher risk during emergencies and disasters, which is often attributed to the lack of disability inclusion in emergency response as well as disparities in preparedness. This disparity speaks to a need for emergency preparedness that centers children with disabilities and their families. The purpose of this study was to elicit the perspectives of health professionals (nurses, occupational therapists, social workers), disability advocates, and public safety personnel (e.g., fire fighters, police officers, emergency management administrators) on what would enable these types of professionals to support family-centered emergency preparedness for families who care for children with disabilities. One goal of this research is to provide recommendations for practice and policy to improve safety outcomes for children with disabilities and their families in emergency situations. METHODS: This study consisted of 46 qualitative interviews with nurses, occupational therapists, social workers, public safety personnel, and advocacy organization representatives about their role in emergency preparedness for families of children with disabilities. Qualitative content analysis was used to identify themes from participants' responses. RESULTS: Participants expressed interest in family-centered emergency preparedness, and stated that greater awareness, more education and training, increased networking between professions, and institutional support would enable their involvement. CONCLUSIONS: These findings have implications for the importance of interprofessional collaboration in supporting family-centered emergency preparedness for families of children with disabilities. Stronger interprofessional networks would help overcome many of the barriers identified by participants, and advocacy groups appear to be well-positioned to bridge the gap between these professionals and their areas of expertise.

The Coronavirus Disease 2019 Pandemic and Mental Health-Related School-Nurse Visits in United States Schools.

OBJECTIVE: No studies have examined school-nurse visits related to mental health (MH) during the coronavirus disease 2019 (COVID-19) pandemic. We examined changes in the rate of MH-related school-nurse visits before and during the COVID-19 pandemic. METHODS: We analyzed school-nurse visit data (n = 3,445,240) for subjects Grade K-12 in US public schools using electronic health record software (SchoolCare, Ramsey, NJ). Data between January 1 and December 31 in 2019 (pre-COVID-19 pandemic) versus January 1 to December 31 in 2020 (during COVID-19 pandemic) were compared. For each year, total visits to a school-nurse were calculated for general MH, anxiety, and self-harm. The exposure was number of school-nurse visits in each time period (2019 vs 2020). The main outcome was change in the rate of general MH, anxiety, and self-harm visits in 2019 versus 2020. RESULTS: There were 2,302,239 total school-nurse visits in 2019 versus 1,143,001 in 2020. During the COVID-19 pandemic, the rate of visits for general MH increased by 30% (4.7-6.1 per 10,000 visits, 95% confidence interval [CI] {18%, 43%}; P < .001), and visits for anxiety increased by 25% (24.8-31 per 10,000 visits, 95% CI [20%,30%]; P < .001). There was no significant difference in self-harm visits across all ages during the COVID-19 pandemic. CONCLUSIONS: Our study found a significant increase in the rate of school-nurse visits for MH and anxiety during the COVID-19 pandemic, suggesting the pediatric population is at-risk for increased negative MH-effects associated with the pandemic and highlights a critical role of school-nurses in identifying youth with potential MH-needs.

The more you know: Insights from integrated pre-visit surveys in a pediatric environmental health center.

The Pediatric Environmental Health Center (PEHC) at Boston Children's Hospital is a specialty referral clinic that provides consultation for approximately 250 patients annually. Identifying environmental hazards is key for clinical management. Exposure concerns include lead, mold, pesticides, perfluoroalkyl substances (PFAS), impaired air quality, and more. Our goal was to identify concerns and visit priorities of our patient population to guide visits. A 47-question pre-visit survey was created exploring potential environmental hazards and administered prior to visits using a platform integrated into the electronic medical record (EMR). The study group was a convenience sample of patients from June 2021 to June 2022. Of 204 total visits, 101 surveys were submitted, yielding a response rate of 49.5%. 66/101 (65.3%) were surveys from initial consultations used for descriptive analysis. The majority of patients were seen for a chief complaint of lead exposure (90.1%). Most respondents had concerns about peeling paint (40.0%), and those reporting peeling paint were more likely to report additional concerns [75.0%, p < 0.001]. Other concerns highlighted were mold (15.2%), pests (15.2%), asbestos (10.6%), air pollution (9.1%), temperature regulation (7.6%), pesticides (6.1%), PFAS (4.5%), and formaldehyde (4.5%). A knowledge gap was identified; 45.5% (30/66) respondents responded "no" to the question asking if the Poison Control Center phone number was stored in their phone. This study illustrates how the implementation of a pre-visit EMR integrated survey engages families, informs clinical care, and serves as a point-of-care education tool for specific knowledge gaps. Findings will guide development of future environmental health screeners.

Childhood Overweight/Obesity and the Physical Activity Environment in Rhode Island.

OBJECTIVE: This study seeks to better understand the relationship between the physical activity environment and child overweight/obesity in Rhode Island. METHODS: Using geographic information systems (GIS), this study calculated distances from residences to physical activity resources to assess the relationship distance has with childhood overweight/obesity. RESULTS: Mean distances in high-risk towns ranged from 0.61 to 3.15 miles compared to physical activity resources in low-risk towns, where distances ranged from 1.25 to 7.43 miles. For each additional mile to reach the closest indoor facility, there is a 0.41 (95% CI: -0.78, -0.03) percentage point decrease in the child overweight/obesity rate.  Conclusion: High-risk block groups and towns have higher rates of child overweight/obesity and show shorter distances to physical activity resources. This study demonstrates that simply having physical activity structures in place is not enough to reduce child overweight/obesity and further research should examine the quality and usage patterns of these resources.

Asexual-Identified Adults: Interactions with Health-Care Practitioners.

Historically, people with minority sexual and gender identities (e.g., gay, lesbian, bisexual, transgender) have been pathologized by mental and medical health practitioners. The potential for pathologization of asexuality is particularly salient considering a lack of sexual desire or interest has been studied in relationship to depression, antidepressant medication, and hypothyroidism. To explore this potential pathologization, asexual individuals were asked about their interactions with mental health and medical practitioners. The study included 136 adult participants, primarily from the U.S., who self-identified as asexual. Participants completed an online survey which contained questions about their experiences with mental health and medical practitioners. Results indicated that the majority of participants did not disclose their identity and felt uncomfortable discussing issues related to sexuality with their providers. Participants were more likely to disclose their asexual identity to mental health providers, as compared to medical providers. Participants who had positive experiences were more likely than those who had negative experiences to indicate that their practitioners were familiar with asexuality, accepted the participant's identity completely, and reacted to the disclosure in a positive and affirming manner. Positive experiences included practitioners educating themselves about asexuality, while negative experiences included practitioners disbelieving the existence of asexuality, and between one quarter and one half of participants reported that practitioners attributed their asexuality to a health condition. The findings from this study demonstrate the importance of including information about asexual identities in health education and ongoing diversity training in order to increase the cultural sensitivity of health practitioners.