Using electronic health records to identify asthma-related acute care encounters.

BACKGROUND: Leveraging "big data" to improve care requires that clinical concepts be operationalized using available data. Electronic health record (EHR) data can be used to evaluate asthma care, but relying solely on diagnosis codes may misclassify asthma-related encounters. OBJECTIVE: We created streamlined, feasible and transparent prototype algorithms for EHR data to classify emergency department (ED) encounters and hospitalizations as "asthma-related." METHODS: As part of an asthma program evaluation, expert clinicians conducted a multi-phase iterative chart review to evaluate 467 pediatric ED encounters and 136 hospitalizations from calendar years 2017 and 2019, rating the likelihood that each encounter was asthma-related. Using this as a reference standard, we developed rule-based algorithms for EHR data to classify visits. Accuracy was evaluated using sensitivity, specificity, and positive and negative predictive values (PPV, NPV). RESULTS: Clinicians categorized 38% of ED encounters as "definitely" or "probably" asthma-related; 13% as "possibly" asthma-related; and 49% as "probably not" or "definitely not" related to asthma. Based on this reference standard, we created two rule-based algorithms to identify "definitely" or "probably" asthma-related encounters, one using text and non-text EHR fields and another using non-text fields only. Sensitivity, specificity, PPV, and NPV were >95% for the algorithm using text and non-text fields and >87% for the algorithm using only non-text fields compared to the reference standard. We created a two-rule algorithm to identify asthma-related hospitalizations using only non-text fields. CONCLUSIONS: Diagnostic codes alone are insufficient to identify asthma-related visits, but EHR-based prototype algorithms that include additional methods of identification can predict clinician-identified visits with sufficient accuracy.

Disparities in Child Welfare Referrals for Patients Seen in a Pediatric Emergency Department for Unintentional Ingestions.

OBJECTIVE: To examine the characteristics of patients visiting the pediatric emergency department (PED) for unintentional ingestions and associations between patient race and ethnicity in referrals to Child Protective Services (CPS) for supervisory neglect. METHODS: We conducted a cross-sectional analysis of children <12 years old who presented to the PED between October 2015 and December 2020 for an unintentional ingestion. Patients were identified by searching the electronic health record for diagnosis codes corresponding to unintentional ingestions. Patient demographics, ingestion type, disposition, and referrals to CPS were abstracted by manual chart review. Logistic regression models were used to evaluate associations between patient demographics and visit characteristics with referral to CPS. RESULTS: We identified 129 PED encounters for unintentional ingestions that were included for analysis. Overall, 22 patients (17.1%) were referred to CPS for neglect. In the univariate analysis, both ingestion of an illicit drug and arrival to the PED by ambulance were associated with a higher odds of referral to CPS. In the multivariable model adjusted for parent language, ingestion type, and mode of arrival to the PED, Hispanic patients had higher odds of referral to CPS than White patients (adjusted odds ratio (aOR) = 17.2, 95% confidence intervals [1.8-162.3], P = .03). There was not a statistically significant association between Black race and referral to CPS. CONCLUSIONS: Referrals to CPS from the PED after unintentional ingestions are common and disproportionally involve Hispanic patients. More research is needed to promote equitable child maltreatment reporting for children presenting to the PED following unintentional ingestions.

Food Pantry Referral and Utilization in a Pediatric Primary Care Clinic.

INTRODUCTION: This study aimed to characterize progression from screening for food insecurity risk to on-site food pantry referral to food pantry utilization in pediatric primary care. METHODS: This retrospective study included 14,280 patients aged 0-21 years with ≥1 pediatric primary care visit from March 2018 to February 2020. Analyses were conducted in 2020-2022 using multivariable regression to examine patient-level demographic, clinical, and socioeconomic characteristics and systems-related factors associated with progression from screening positive for food insecurity risk to food pantry referral to completing ≥1 food pantry visit. RESULTS: Of patients screened for food insecurity risk, 31.9% screened positive; 18.5% of food-insecure patients received an on-site food pantry referral. Among patients referred, 28.9% visited the food pantry. In multivariable models, higher odds of referral were found for patients living near the clinic (AOR=1.28; 95% CI=1.03, 1.59), for each additional health-related social need reported (AOR=1.23; 95% CI=1.16, 1.29), and when the index clinic encounter occurred during food pantry open hours (AOR=1.62; 95% CI=1.30, 2.02). Higher odds of food pantry visitation were found for patients with a preferred language of Haitian Creole (AOR=2.16; 95% CI=1.37, 3.39), for patients of Hispanic race/ethnicity (AOR=3.67; 95% CI=1.14, 11.78), when the index encounter occurred during food pantry open hours (AOR=1.96; 95% CI=1.25, 3.07), for patients with a clinician letter referral (AOR=6.74; 95% CI=3.94, 11.54), or for patients with a referral due to a screening-identified food emergency (AOR=2.27; 95% CI=1.30, 3.96). CONCLUSIONS: There was substantial attrition along the pathway from screening positive for food insecurity risk to food pantry referral and utilization as well as patient-level characteristics and systems-related factors associated with successful referrals and utilization.

Child Maltreatment.

Child maltreatment is associated with significant morbidity, and prevention is a public health priority. Given evidence of interpersonal and structural racism in child protective service assessment and response, equity must be prioritized for both acute interventions and preventive initiatives aimed at supporting children and their families. Clinicians who care for children are well positioned to support families, and the patient-centered medical home, in collaboration with community-based services, has unique potential as a locus for maltreatment prevention services. Clinicians can advocate for policies that support families and decrease the risk of child maltreatment.

Effect of Immediate Referral vs a Brief Problem-solving Intervention for Screen-Detected Peripartum Depression: A Randomized Clinical Trial.

Importance: The US Preventive Services Task Force recommends screening adults for depression in settings with programs in place to ensure receipt of appropriate care. Best practices regarding how to ensure such care are unknown, particularly for pregnant and postpartum persons. Objective: To compare the effectiveness of 2 strategies for the initial management of screen-detected peripartum depressive symptoms. Design, Setting, and Participants: This randomized comparative effectiveness trial was performed from February 1, 2018, to June 30, 2020, at the prenatal clinic, postpartum unit, and pediatric clinic within an urban safety-net hospital. Participants included peripartum persons with positive depression screen results. Data were analyzed from July 6, 2020, to September 21, 2022, based on intention to treat. Interventions: Engagement-focused care coordination (EFCC), which used shared decision-making and motivational techniques to refer patients to outside mental health services, and problem-solving education (PSE), a brief cognitive-behavioral program delivered at the screening site. Main Outcomes and Measures: The primary outcome consisted of severity of depressive symptoms; secondary outcomes included severity of anxiety symptoms and engagement with care, each measured bimonthly over 12 months. Rates of symptom elevations were modeled using negative binomial regression; rates of symptom trajectories were modeled using treatment × time interactions. Results: Among the 230 participants (mean [SD] age, 29.8 [5.8] years), 125 (54.3%) were Black and 101 (43.9%) were Hispanic or Latina. At baseline, 117 participants (50.9%) reported at least moderately severe depressive symptoms (Quick Inventory of Depressive Symptomatology score ≥11), and 56 (24.3%) reported clinically significant anxiety symptoms (Beck Anxiety Inventory score ≥21). Across 6 assessment time points, the mean (SD) number of moderately severe depressive symptom episodes in EFCC was 2.2 (2.2), compared with 2.2 (2.1) in PSE, for an adjusted rate ratio (aRR) of 0.95 (95% CI, 0.77-1.17). The mean (SD) number of anxiety symptom elevations in EFCC was 1.1 (1.8), compared to 1.1 (1.6) in PSE, for an aRR of 0.98 (95% CI, 0.69-1.39). There were significant treatment × time interactions relative to mean depressive symptom scores (-0.34 [95% CI, -0.60 to -0.08]; P = .009 for interaction term), favoring EFCC. There were no differences in engagement with care. Conclusions and Relevance: In this randomized comparative effectiveness trial, there were no differences in depressive or anxiety symptom burden across comparators; however, the evidence suggested improved depressive symptom trajectory with immediate referral. Further work is necessary to guide approaches to management following depression screening for peripartum persons. Trial Registration: ClinicalTrials.gov Identifier: NCT03221556.

Structural Racism in Behavioral Health Presentation and Management.

Nia is a first-grade student with a history of trauma who was brought in by ambulance to the pediatric emergency department for "out of control behavior" at school. This is the first of multiple presentations to the emergency department for psychiatric evaluation, stabilization, and management throughout her elementary and middle school years. Several of the visits resulted in admission to the inpatient pediatric service, where she "boarded" while awaiting transfer to an inpatient psychiatric facility. At times, clinical teams used involuntary emergency medications and physical restraints, as well as hospital security presence at the bedside, to control Nia's behavior. Nia is Black and her story is a case study of how structural racism manifests for an individual child. Her story highlights the impact of adultification bias and the propensity to mislabel Black youth with diagnoses characterized by fixed patterns of negative behaviors, as opposed to recognizing normative reactions to trauma or other adverse childhood experiences-in Nia's case, poverty, domestic violence, and Child Protective Services involvement. In telling Nia's story, we (1) define racism and discuss the interplay of structural, institutional, and interpersonal racism in the health care, education, and judicial systems; (2) highlight the impact of adultification bias on Black youth; (3) delineate racial disparities in behavioral health diagnosis and management, school discipline and exclusion, and health care's contributions to the school-to-prison pipeline; and finally (4) propose action steps to mitigate the impact of racism on pediatric mental health and health care.

Association between unmet social needs and healthy lifestyle parenting behaviors.

Objective: To examine cross-sectional associations of food and housing security risks and healthy lifestyle parenting behaviors related to nutrition and physical activity among families with children with overweight/obesity. Methods: We surveyed 407 parents of children ages 6-12 years with overweight/obesity. Exposures were measures of food and housing insecurity risk. Outcomes were healthy lifestyle parenting behaviors related to nutrition and physical activity. Logistic regression models for each exposure-outcome relationship were adjusted for parental educational attainment, parental cohabitation status, household size, and household income. Results: In multivariable-adjusted models, food insecurity was associated with significantly lower odds of parent modeling exercise {aOR 0.60 [95% confidence interval (CI): 0.37, 0.96]} and parent modeling eating healthy foods [aOR 0.42 (95% CI: 0.24, 0.73)]. Housing insecurity was associated with significantly lower odds of parent modeling exercise [aOR 0.57 (95% CI: 0.35, 0.95)]. Conclusions: Food insecurity and housing insecurity may be barriers to parents adopting and modeling healthy lifestyle parenting behaviors related to physical activity and nutrition.

Trends from 2005 to 2018 in child maltreatment outcomes with caregivers' substance use.

BACKGROUND: Caregivers' substance use is associated with child maltreatment. OBJECTIVE: Examine trends from 2005 to 2018 in percentages of three outcomes with caregivers' drug or alcohol use: child protective services (CPS) referrals, substantiated maltreatment reports, and foster care placements. PARTICIPANTS AND SETTING: 22 U.S. states that contributed child-level maltreatment outcomes and caregivers' substance use data to the National Child Abuse and Neglect Data System from 2005 to 2018. METHODS: Joinpoint regression was used to examine the average annual percent change (AAPC) in outcomes with caregivers' drug or alcohol use and to identify temporal changes. RESULTS: From 2005 to 2018, CPS referrals with caregivers' drug use increased (AAPC 2.33, p < .001), while referrals with alcohol use remained unchanged (AAPC -0.11, p = .92) (trend difference p = .04). Substantiated reports with caregivers' drug and alcohol use increased (AAPC drug use 3.63, p < .001, AAPC alcohol use 1.28, p = .03), with a greater increase observed with drug use (difference p = .03). Foster care placements with caregivers' drug use increased (AAPC 2.54, p < .001), while placements with alcohol use did not change (AAPC -1.22, p = .29), (difference p = .005). Within the study period, changes in trends with caregivers' drug use included increased substantiated reports from 2010 to 2018 (p < .001) and increased foster care placements from 2009 to 2018 (p < .001). With caregivers' alcohol use, CPS referrals and foster care placements decreased from 2007 to 2018 (all p < .001). CONCLUSIONS: Trends differed for outcomes with caregivers' drug versus alcohol use. Findings can inform policies to improve care for families affected by substance use.

Disparities in School Referrals for Agitation and Aggression to the Emergency Department.

OBJECTIVES: Describe the demographic and clinical characteristics of children presenting to the emergency department (ED) for agitation and aggression from school versus other sites. METHODS: We performed a retrospective cross-sectional study of children 5 to 18 years old who were evaluated in an urban tertiary care pediatric ED with a chief complaint of agitation or aggression. We examined demographics, disposition, and payments for children presenting from school versus other sites. We conducted multivariable logistic regression to identify predictors of referral site (school versus all other sites, school versus home) and discharge status (home versus higher level of psychiatric care). RESULTS: Of the 513 included children, 147 (29%) presented from school. Children were more likely to present from school versus other sites if they were Black (adjusted odds ratio [aOR] 2.26, 95% confidence interval [CI] 1.32, 3.88), Latinx (aOR 2.91, 95% CI 1.42, 5.97), or had special educational needs (aOR 2.55, 95% CI 1.64, 3.97). These associations persisted in the analysis of school versus home referrals. Children presenting from school versus all other sites were more likely to be discharged home (aOR 1.60, 95% CI 1.05, 2.44), although this difference did not persist when comparing school versus only home referral. A total of $154,269 (median $367 per encounter) was paid for school referrals to the ED. CONCLUSIONS: Children with agitation and aggression referred from school were more likely to be Black, Latinx, or have special educational needs. Future efforts should identify and address root causes of this disparity to decrease ED referrals, reduce healthcare spending, and address inequities.

Achieving Diagnostic Resolution in Young Children with Social Communication Concerns in a Predominantly Low-Income Population.

Children in low-income families are at risk for delayed diagnosis of autism spectrum disorder (ASD). The cascade-of-care model, which examines steps of care for quality and efficacy, can identify lesions in the process for evaluation and diagnosis for children at risk for ASD. Little is known about predictors that influence key steps in this process. We performed a retrospective chart review of 110 children under age five years from an academic medical center with social communication concerns. We assessed predictors of age of referral for ASD diagnostic evaluation, time to diagnosis, and likelihood of diagnostic completion. Children with continuity of primary care were referred at an earlier age than those receiving primary care at multiple centers. Compared with children with missed visits, children attending all well-child visits had a shorter median time to diagnosis. These findings illustrate a need for primary medical homes to facilitate early and timely ASD evaluations.

Implementation of the Connect for Health pediatric weight management program: study protocol and baseline characteristics.

We are implementing Connect for Health, a primary care-based intervention to improve family-centered outcomes for children, ages 2-12 years, in organizations that care for low-income children. We will use the 'Reach-Effectiveness-Adoption-Implementation-Maintenance' framework to guide our mixed-methods evaluation to examine the effectiveness of stakeholder-informed strategies in supporting program adoption and child outcomes. We also describe characteristics of children, ages 2-12 years with a BMI ≥85th percentile and obesity-related care practices. During the period prior to implementation, 26,161 children with a BMI ≥85th percentile were seen for a primary care visit and a majority lacked recommended diagnosis codes, referrals and laboratory evaluations. The findings suggest the need to augment current approaches to increase uptake of proven-effective weight management programs. Clinical trial registration number: NCT04042493 (Clinicaltrials.gov), Registered on 2 August 2019; https://clinicaltrials.gov/ct2/show/NCT04042493.

Asians and Asian Subgroups are Underrepresented in Medical Research Studies Published in High-Impact Generalist Journals.

Including diverse participants in biomedical research is essential to reduce health disparities. We assessed the inclusion of Asians in original research studies conducted in North America and published from 2015-2016 in six high-impact generalist journals: New England Journal of Medicine, Journal of the American Medical Association (JAMA), JAMA Internal Medicine, JAMA Pediatrics, Annals of Internal Medicine, and Pediatrics. We determined race reporting method, participant percentage, and reporting of outcomes or implications of findings for Asians and Asian subgroups. Of 1077 studies, 263 articles (24.4%) identified Asians as a distinct race/ethnicity; the median percentage of Asians per study was 3.8%. Of the 263 articles, 28 (10.6%) studies reported outcomes for Asians; nine (3.4%) articles included information about Asian subgroups. Asians are underrepresented in high-impact medical research studies in North America. Efforts to improve study enrollment, data collection, and reporting of findings of Asians in studies remain essential to improve health outcomes for this population.

Engaging stakeholders in the adaptation of the Connect for Health pediatric weight management program for national implementation.

BACKGROUND: Connect for Health is an evidence-based weight management program with clinical- and family-facing components for delivery in pediatric primary care for families of children ages 2 to 12 years. We used the Consolidated Framework for Implementation Research (CFIR) to guide formative work prior to national implementation. The purpose of this study was to describe the process and results of stakeholder engagement and program adaptation. METHODS: We used mixed qualitative and quantitative methods to iteratively adapt and optimize the program by assessing needs and perspectives of clinicians and parents, as well as contextual barriers, facilitators, and organizational readiness for the uptake of the proposed program tools and implementation strategies. We conducted interviews with primary care clinicians from four health care organizations in Boston, MA; Denver, CO; and Greenville, SC, and used principles of immersion-crystallization for qualitative analyses. We also conducted surveys of parents of children with a body mass index ≥ 85th percentile. RESULTS: We reached thematic saturation after 52 clinician interviews. Emergent themes representing the CFIR domains of intervention characteristics, outer and inner setting, and process included (1) importance of evidence-based clinical decision support tools that integrate into the workflow and do not extend visit time, (2) developing resources that respond to family's needs, (3) using multimodal delivery options for family resources, (4) addressing childhood obesity while balancing competing demands, (5) emphasizing patient care rather than documentation and establishing sustainability plans, and (6) offering multiple training methods that incorporate performance feedback. Of the parents surveyed (n = 400), approximately 50% were Spanish-speaking and over 75% reported an annual income < $50,000. Parents affirmed the importance of addressing weight management during well-child visits, being provided with referrals and resources, and offering multiple methods for resource delivery. Decisions about program modifications were made at the program and healthcare-system level and based on stakeholder engagement findings. Modifications included cultural, geographic, and target audience adaptations, as well as varied resource delivery options. CONCLUSIONS: To ensure the fit between the Connect for Health program and national implementation settings, adaptations were systematically made through engagement of clinician and parent stakeholders to support adoption, sustainability, and health outcomes. TRIAL REGISTRATION: NCT04042493.

Women's Experiences of the Effect of Financial Strain on Parenting and Mental Health.

OBJECTIVE: To develop a conceptual theory to describe how financial strain affects women with young children to inform clinical care and research. DESIGN: Qualitative, grounded theory. SETTING: Participants were recruited from the waiting area of a pediatric clinic and an office of the Special Supplemental Nutrition Program for Women, Infants, and Children embedded within the largest safety-net academic medical center in New England. Participants were interviewed privately at the medical center or in the community. PARTICIPANTS: Twenty-six English-speaking women, mostly single and African American/Black, with at least one child 5 years old or younger, were sampled until thematic saturation was met. METHODS: We used grounded theory methodology to conduct in-depth, semistructured interviews with participants who indicated that they experienced financial strain. We analyzed the interview data using constant comparative analysis, revised the interview guide based on emerging themes, and developed a theoretical model. RESULTS: Five interrelated themes emerged and were developed into a theoretical model: Financial Strain Has Specific Characteristics and Common Triggers, Financial Strain Is Exacerbated by Inadequate Assistance and Results in Tradeoffs, Financial Strain Forces Parenting Modifications, Women Experience Self-Blame, and Women Experience Mental Health Effects. CONCLUSION: For women with young children, financial strain results in forced tradeoffs, compromised parenting practices, and self-blame, which contribute to significant mental health problems. These findings can inform woman-centered clinical practice and advocacy interventions. Women's health care providers should identify families experiencing financial strain, provide referrals to financial services, and join advocacy efforts to advance social policies that address the structural causes of poverty, such as increased minimum wage and paid family leave.

Impact of a community-delivered parenting curriculum on perceived parenting stress and parent-reported outcomes in a low-income diverse population.

INTRODUCTION: There is a need for effective, strengths-based parenting supports for diverse parent populations. We conducted a quasi-experimental study to investigate whether a 12-week parenting program delivered in the community decreases perceived parenting stress and improves parent-reported outcomes. METHOD: Parents in the intervention group participated in Parenting Journey, a curriculum designed to increase resilience and support nurturing family relationships. Parents who were eligible for Parenting Journey but did not enroll were included in the concurrent comparison group. Participants completed the Parenting Stress Index and the Parenting Journey Survey at baseline and follow-up. We conducted bivariate and multivariate analyses to evaluate differences between groups. RESULTS: We enrolled 244 parents, 123 in the intervention group and 121 in the comparison group. The majority of participants in the intervention and comparison groups were female, identified as Black or Latino, and reported an annual household income of less than $20,000. At baseline, intervention participants reported higher total parenting stress than comparison participants (mean percentile 70.7 vs. 55.8, p = .002). At follow-up, intervention participants' mean total parenting stress score decreased by 14.1 points, while comparison participants' score increased by 3.0 points (difference-in-difference p < .0001). Intervention participants were significantly more likely to demonstrate improvement in 4 or more of the 7 constructs measured by the Parenting Journey Survey (adjusted OR = 2.2, 95% CI [1.2, 4.1], p = .01). DISCUSSION: Participation in Parenting Journey is associated with decreased perceived parenting stress and improvement in parent-reported outcomes. Future work should evaluate the longitudinal impact on parental mental health and child socioemotional development. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Educators' Perspectives of Collaboration With Pediatricians to Support Low-Income Children.

BACKGROUND: Educational and healthcare systems operate in silos. Few studies explore educators' perspectives of collaboration with pediatricians or cross-system solutions for school-identified concerns. We sought to investigate educators' viewpoints of collaboration with pediatricians. METHODS: We conducted semistructured, qualitative interviews with full-time teachers, vice-principals, and principals, who worked with low-income first- or second-grade students. Interviews explored which students were concerning to educators, educators' experiences with collaboration, and barriers and facilitators of collaboration. Interview transcripts were analyzed with modified grounded theory. RESULTS: We interviewed 12 teachers and 3 principals/vice-principals. Students' socioemotional problems were a foremost concern. Effective collaboration with pediatricians was not typical. Participants described not knowing they could communicate with pediatricians or that collaboration was often limited or unidirectional. Respecting boundaries of parental privacy and maintaining parental trust emerged as potential barriers. Some participants described negative experiences with pediatricians and reflected on societal perceptions of doctors and teachers, which could affect the development of relationships. Participants recognized potential benefits to collaboration, including gaining a holistic understanding of a child's health and home life. CONCLUSIONS: Educators perceived collaboration with pediatricians as inadequate. More developed and tested programs that foster collaboration between schools and pediatricians are needed to support low-income youth.

First-Generation Immigrant Mothers Report Less Spanking of 1-Year-Old Children Compared with Mothers of Other Immigrant Generations.

Introduction The American Academy of Pediatrics discourages spanking, especially of infants and young toddlers. This study examines the association between maternal immigrant generation and reported spanking of 1-year-old children, and whether this association is impacted by domestic violence (DV). Methods We conducted a cross-sectional secondary data analysis using 1-year wave data from the Fragile Families and Child Wellbeing Study. We used descriptive statistics to explore demographic differences among first-generation, second-generation, and third-generation or higher (reference group) mothers. We conducted logistic regression to examine the association between immigrant generation and spanking, controlling for covariates. We used stratified logistic regression to evaluate how experiencing DV may impact the association between immigrant generation and spanking. Results The study included 370 first-generation mothers, 165 second-generation mothers, and 1754 reference group mothers. The prevalence of spanking differed across immigrant generations (p = 0.004). First-generation mothers had statistically significant lower odds of spanking compared with the reference group (adjusted OR 0.26; CI 0.11-0.64). Second-generation mothers also had lower odds of spanking compared with the reference group, although this result did not reach statistical significance (adjusted OR 0.60; CI 0.22-1.63). Mothers' report of experiencing DV appeared to impact the relationship between immigrant generation and spanking. Discussion First-generation immigrant mothers had lower odds of reported spanking compared to reference group mothers, an association which is attenuated for both second-generation immigrant mothers and mothers who have experienced DV. Future work should explore the potential factors that drive variations in spanking between immigrant generations.