Screening for Depression and Suicide Risk in Children and Adolescents: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Depression, suicidal ideation, and self-harm behaviors in youth are associated with functional impairment and suicide. Objective: To review the evidence on screening for depression or suicide risk in children and adolescents to inform the US Preventive Services Task Force (USPSTF). Data Sources: PubMed, Cochrane Library, PsycINFO, CINAHL, and trial registries through July 19, 2021; references, experts, and surveillance through June 1, 2022. Study Selection: English-language, randomized clinical trials (RCTs) of screening for depression or suicide risk; diagnostic test accuracy studies; RCTs of psychotherapy and first-line pharmacotherapy; RCTs, observational studies, and systematic reviews reporting harms. Data Extraction and Synthesis: Two reviewers assessed titles/abstracts, full-text articles, and study quality and extracted data; when at least 3 similar studies were available, meta-analyses were conducted. Main Outcomes and Measures: Test accuracy, symptoms, response, remission, loss of diagnosis, mortality, functioning, suicide-related events, and adverse events. Results: Twenty-one studies (N = 5433) were included for depression and 19 studies (N = 6290) for suicide risk. For depression, no studies reported on the direct effects of screening on health outcomes, and 7 studies (n = 3281) reported sensitivity of screening instruments ranging from 0.59 to 0.94 and specificity from 0.38 to 0.96. Depression treatment with psychotherapy was associated with improved symptoms (Beck Depression Inventory pooled standardized mean difference, -0.58 [95% CI, -0.83 to -0.34]; n = 471; 4 studies; and Hamilton Depression Scale pooled mean difference, -2.25 [95% CI, -4.09 to -0.41]; n = 262; 3 studies) clinical response (3 studies with statistically significant results using varying thresholds), and loss of diagnosis (relative risk, 1.73 [95% CI, 1.00 to 3.00; n = 395; 4 studies). Pharmacotherapy was associated with improvement on symptoms (Children's Depression Rating Scale-Revised mean difference, -3.76 [95% CI, -5.95 to -1.57; n = 793; 3 studies), remission (relative risk, 1.20 [95% CI, 1.00 to 1.45]; n = 793; 3 studies) and functioning (Children's Global Assessment Scale pooled mean difference, 2.60 (95% CI, 0.78 to 4.42; n = 793; 3 studies). Other outcomes were not statistically significantly different. Differences in suicide-related outcomes and adverse events for pharmacotherapy when compared with placebo were not statistically significant. For suicide risk, no studies reported on the direct benefits of screening on health outcomes, and 2 RCTs (n = 2675) reported no harms of screening. One study (n = 581) reported on sensitivity of screening, ranging from 0.87 to 0.91; specificity was 0.60. Sixteen RCTs (n = 3034) reported on suicide risk interventions. Interventions were associated with lower scores for the Beck Hopelessness Scale (pooled mean difference, -2.35 [95% CI, -4.06 to -0.65]; n = 644; 4 RCTs). Findings for other suicide-related outcomes were mixed or not statistically significantly different. Conclusion and Relevance: Indirect evidence suggested that some screening instruments were reasonably accurate for detecting depression. Psychotherapy and pharmacotherapy were associated with some benefits and no statistically significant harms for depression, but the evidence was limited for suicide risk screening instruments and interventions.

Screening for Anxiety in Children and Adolescents: Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Anxiety in children and adolescents is associated with impaired functioning, educational underachievement, and future mental health conditions. Objective: To review the evidence on screening for anxiety in children and adolescents to inform the US Preventive Services Task Force. Data Sources: PubMed, Cochrane Library, PsycINFO, CINAHL, and trial registries through July 19, 2021; references, experts, and surveillance through June 1, 2022. Study Selection: English-language, randomized clinical trials (RCTs) of screening; diagnostic test accuracy studies; RCTs of cognitive behavioral therapy (CBT) or US Food and Drug Administration-approved pharmacotherapy; RCTs, observational studies, and systematic reviews reporting harms. Data Extraction and Synthesis: Two reviewers assessed titles/abstracts, full-text articles, and study quality and extracted data; when at least 3 similar studies were available, meta-analyses were conducted. Main Outcomes and Measures: Test accuracy, symptoms, response, remission, loss of diagnosis, all-cause mortality, functioning, suicide-related symptoms or events, adverse events. Results: Thirty-nine studies (N = 6065) were included. No study reported on the direct benefits or harms of screening on health outcomes. Ten studies (n = 3260) reported the sensitivity of screening instruments, ranging from 0.34 to 1.00, with specificity ranging from 0.47 to 0.99. Twenty-nine RCTs (n = 2805) reported on treatment: 22 on CBT, 6 on pharmacotherapy, and 1 on CBT, sertraline, and CBT plus sertraline. CBT was associated with gains on several pooled measures of symptom improvement (magnitude of change varied by outcome measure), response (pooled relative risk [RR], 1.89 [95% CI, 1.17 to 3.05]; n = 606; 6 studies), remission (RR, 2.68 [95% CI, 1.48 to 4.88]; n = 321; 4 studies), and loss of diagnosis (RR range, 3.02-3.09) when compared with usual care or wait-list controls. The evidence on functioning for CBT was mixed. Pharmacotherapy, when compared with placebo, was associated with gains on 2 pooled measures of symptom improvement-mean difference (Pediatric Anxiety Rating Scale mean difference, -4.0 [95% CI, -5.5 to -2.5]; n = 726; 5 studies; and Clinical Global Impression-Severity scale mean difference, -0.84 [95% CI, -1.13 to -0.55]; n = 550; 4 studies) and response (RR, 2.11 [95% CI, 1.58 to 2.98]; n = 370; 5 studies)-but was mixed on measures of functioning. Eleven RCTs (n = 1293) reported harms of anxiety treatments. Suicide-related harms were rare, and the differences were not statistically significantly different. Conclusions and Relevance: Indirect evidence suggested that some screening instruments were reasonably accurate. CBT and pharmacotherapy were associated with benefits; no statistically significant association with harms was reported.

Screening for Prediabetes and Type 2 Diabetes in Children and Adolescents: Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Of youths diagnosed with type 2 diabetes, many develop microvascular complications by young adulthood. Objective: To review the evidence on benefits and harms of screening children and adolescents for prediabetes and type 2 diabetes to inform the US Preventive Services Task Force (USPSTF). Data Sources: PubMed/MEDLINE, Cochrane Library, and trial registries through May 3, 2021; references; experts; literature surveillance through July 22, 2022. Study Selection: English-language controlled studies evaluating screening or interventions for prediabetes or type 2 diabetes that was screen detected or recently diagnosed. Data Extraction and Synthesis: Dual review of abstracts, full-text articles, and study quality; qualitative synthesis of findings. Main Outcomes and Measures: Mortality, cardiovascular morbidity, diabetes-related morbidity, development of diabetes, quality of life, and harms. Results: This review included 8 publications (856 participants; mean age, 14 years [range, 10-17 years]). Of those, 6 were from the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study. No eligible studies directly evaluated the benefits or harms of screening. One randomized clinical trial (RCT) (TODAY; n = 699 adolescents with obesity; mean age, 14 years) comparing metformin, metformin plus rosiglitazone, and metformin plus lifestyle intervention reported that 2 youths with recently diagnosed diabetes developed kidney impairment (0 vs 1 vs 1, respectively; P > .99) and 11 developed diabetic ketoacidosis (5 vs 3 vs 3, respectively; P = .70). One RCT of 75 adolescents (mean age, 13 years) with obesity with prediabetes compared an intensive lifestyle intervention with standard care and reported that no participants in either group developed diabetes, although follow-up was only 6 months. Regarding harms of interventions, 2 RCTs assessing different comparisons enrolled youths with recently diagnosed diabetes. Major hypoglycemic events were reported by less than 1% of participants. Minor hypoglycemic events were more common among youths treated with metformin plus rosiglitazone than among those treated with metformin or metformin plus lifestyle intervention in TODAY (8.2% vs 4.3% vs 3.4%, P = .05). In 1 study, gastrointestinal adverse events were more commonly reported by those taking metformin than by those taking placebo (abdominal pain: 25% vs 12%; nausea/vomiting: 17% vs 10%; P not reported). Conclusions and Relevance: No eligible studies directly evaluated the benefits or harms of screening for prediabetes and type 2 diabetes in children and adolescents. For youths with prediabetes or recently diagnosed (not screen-detected) diabetes, the only eligible trials reported few health outcomes and found no difference between groups, although evidence was limited by substantial imprecision and a duration of follow-up likely insufficient to assess health outcomes.

A Quality Improvement Approach to Enhance LGBTQ+ Inclusivity in Pediatric Primary Care.

BACKGROUND: Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) teens are at higher risk of illness as a result of bias but are less likely than peers to attend well visits. Medical organizations recommend improving care through staff education, visual cues, and routine inquiry of sexual orientation and gender identity (SO/GI) and pronouns. It is unknown how to do this confidentially in pediatrics. This quality improvement (QI) project aimed to confidentially collect and document SO/GI and pronouns early in at least 90% of teen acute care visits. METHODS: A diverse, representative QI team in a resident primary care clinic conducted a series of staff and clinician trainings to improve knowledge, then displayed welcoming signage and offered staff pronoun and rainbow pins. Multiple Plan-Do-Study-Act cycles developed methods of routine and private collection of SO/GI and pronouns. Outcome measures included proportion of teen acute visits with such documentation collected via weekly chart reviews. Process measures included staff/clinician preparedness, assessed by surveys. RESULTS: SO/GI and pronouns were documented in 0% of teen acute visits at baseline, 70% after 6 months, and 90% during the 20-week sustainment measurement phase. The proportion of staff and clinicians who felt prepared to provide care for LGB and transgender patients increased (53% to 68% for LGB, P = .07; and 30% to 57% for transgender, P = .002). CONCLUSIONS: QI methods can create protocols for confidential, sustainable SO/GI and pronoun collection from teens early in acute visits. This allows clinicians and staff to address patients appropriately and for clinicians to better meet their needs.

Preparing Medical Students to Address Health Disparities Through Longitudinally Integrated Social Justice Curricula: A Systematic Review.

PURPOSE: The education of health care professionals is a contributing factor to persistent health disparities. Although medical students are expected to understand racism, classism, and other social and structural drivers of health (SDH), standardization and best practices for teaching these concepts are lacking. Some medical schools are adopting social justice curricula (SJC) that prioritize health equity in teaching students to recognize SDH and preparing them to address the consequent health disparities. This systematic review sought to evaluate how these schools have integrated SJC into their core teaching; the criteria they have used to measure success and to what extent these criteria are met; and best practices in planning, implementing, and evaluating SJC. METHOD: The authors searched 7 databases for English-language studies published between January 2000 and April 2020, reporting on longitudinally integrated SJC at U.S. medical schools intended for all students. Quantitative and qualitative outcomes were synthesized and summarized. RESULTS: Searches identified 3,137 articles, of which 11 met inclusion criteria. Results demonstrated schools use a variety of teaching methods over a wide range of didactic hours to teach SJC concepts. Surveys and objective tests indicated students in SJC are generally satisfied and demonstrated improved knowledge and skills related to understanding and mitigating SDH, although findings related to changes in attitudes were equivocal. Evaluations at graduation and in residency demonstrated students who experience SJC are more prepared than their peers to work with patients who are underserved. Best practices in SJC included addressing the hidden curriculum, considering medical mistrust, and using tools like the Racial Justice Report Card and Tool for Assessing Cultural Competence Training. CONCLUSIONS: These findings indicated SJC can prepare students to better address the root causes of health disparities. Future research should consider the long-term influences of these curricula on students, patients, and the community.

Screening for Hypertension in Children and Adolescents: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Childhood hypertension can result in adverse outcomes during adulthood; identifying and treating primary and secondary childhood hypertension may reduce such risks. Objective: To update the evidence on screening and treatment of hypertension in childhood and adolescence for the US Preventive Services Task Force. Data Sources: PubMed, Cochrane Library, International Pharmaceutical Abstracts, EMBASE, and trial registries through September 3, 2019; bibliographies from retrieved articles, experts, and surveillance of the literature through October 6, 2020. Study Selection: Fair- or good-quality English-language studies evaluating diagnostic accuracy of blood pressure screening; cohort studies assessing the association of hypertension in childhood and adolescence with blood pressure or other intermediate outcomes in adulthood; randomized clinical trials (RCTs) or meta-analyses of pharmacological and lifestyle interventions. Data Extraction and Synthesis: Two reviewers independently assessed titles/abstracts and full-text articles, extracted data, and assessed study quality; the evidence was synthesized qualitatively. Main Outcomes and Measures: Sensitivity, specificity, and measures of association between childhood and adulthood blood pressure; reduction of childhood blood pressure; adverse effects of treatments. Results: Forty-two studies from 43 publications were included (N>12 400). No studies evaluated the benefits or harms of screening and the effect of treating childhood hypertension on outcomes in adulthood. One study reported a sensitivity of 0.82 and a specificity of 0.70 for 2 office-based blood pressure measurements. Twenty observational studies suggested a significant association between childhood hypertension and abnormal blood pressure in adulthood (odds ratios, 1.1-4.5; risk ratios, 1.45-3.60; hazard ratios, 2.8-3.2). Thirteen placebo-controlled RCTs and 1 meta-analysis assessed reductions in systolic (SBP) and diastolic blood pressure from pharmacological treatments. Pooled reductions of SBP were -4.38 mm Hg (95% CI, -7.27 to -2.16) for angiotensin-converting enzyme inhibitors and -3.07 mm Hg (95% CI, -4.99 to -1.44) for angiotensin receptor blockers. Candesartan reduced SBP by -6.56 mm Hg (P < .001; n = 240). ß-Blockers, calcium channel blockers, and mineralocorticoid receptor antagonists did not achieve significant reductions over 2 to 4 weeks. SBP was significantly reduced by exercise over 8 months (-4.9 mm Hg, P ≤ .05; n = 69), by dietary approaches to stop hypertension over 3 months (-2.2 mm Hg, P < .01; n = 57), and by a combination of drug treatment and lifestyle interventions over 6 months (-7.6 mm Hg; P < .001; n = 95). Low-salt diet did not achieve reductions of blood pressure. Conclusions and Relevance: Observational studies indicate an association between hypertension in childhood and hypertension in adulthood. However, the evidence is inconclusive whether the diagnostic accuracy of blood pressure measurements is adequate for screening asymptomatic children and adolescents in primary care.

Improving Culture, One Quality Improvement Project at a Time.

CONTEXT: A culture of quality improvement (QI) values collaboration, transparency, and staff empowerment. Organizations exhibiting a culture of QI are more likely to engage in QI. OBJECTIVE: We examined whether local health departments' (LHDs') participation in a longitudinal, experiential QI training program changes QI culture. DESIGN: Prior to and following participation in a QI training program, all employees of participating LHDs were asked to complete an 8-item survey assessing components of QI culture on a 5-point scale. INTERVENTION: From 2010 to 2015, multidisciplinary teams from North Carolina LHDs participated in sequential cohorts of a 6-month QI training program, during which the teams completed a QI project. MAIN OUTCOME MEASURE: We dichotomized culture survey responses, with 4 or 5 being "Supportive." We compared adjusted proportions, using linear regression, clustering at LHD, and controlling for cohort. RESULTS: Data from 42 LHDs were included. At baseline, 7.8% responded that their LHD had a supportive culture for all 8 components, compared with 12% at follow-up (P < .001), adjusted for cohort and clustering by LHD. At follow-up, the percentage of employees responding that their LHDs had supportive cultures increased for all components of culture including communication by 4.1% (95% CI: 2.0%-6.2%), problem solving by 2.9% (95% CI: 1.6%-5.5%), team work by 5.2% (95% CI: 2.5%-7.8%), vision by 4.3% (95% CI: 1.1%-7.5%), performance measures by 5.6% (95% CI: 1.6%-9.6%), recognition by 4.7% (95% CI: 1.4%-8.0%), for conflict by 5.5% (95% CI: 1.7%-9.4%), and alignment by 5.8% (95% CI: 2.3%-9.2%). CONCLUSIONS: Engagement with structured QI training programs-and perhaps simply completing QI projects-can cause small, but important changes in organizations' cultures, thus increasing engagement in future QI and improving overall care and services. The article demonstrates that when LHDs participate in a longitudinal, experiential QI training program, their cultures of QI improve. Local health departments participating in similar training programs might experience similar improvements in culture, increasing subsequent participation in QI projects and improving related health outcomes.

A Pilot Quality Improvement Collaborative to Improve Safety Net Dental Access for Pregnant Women and Young Children.

Objectives To determine acceptability and feasibility of a quality improvement (QI) collaborative in safety net dental practices, and evaluate its effects on financial stability, access, efficiency, and care for pregnant women and young children. Methods Five safety net dental practices participated in a 15-month learning collaborative utilizing business assessments, QI training, early childhood oral health training, and prenatal oral health training. Practices collected monthly data on: net revenue, no-show rates, total encounters, and number of encounters for young children and pregnant women. We analyzed quantitative data using paired t-tests before and after the collaborative and collected supplemental qualitative feedback from clinic staff through focus groups and directed email. Results All mean measures improved, including: higher monthly revenue ($28,380-$33,102, p = 0.37), decreased no-show rate (17.7-14.3%, p = 0.11), higher monthly dental health encounters (283-328, p = 0.08), and higher monthly encounters for young children (8.8-10.5, p = 0.65), and pregnant women (2.8-9.7, p = 0.29). Results varied by practice, with some demonstrating largest increases in encounters for young children and others pregnant women. Focus group participants reported that the collaborative improved access for pregnant women and young children, and that QI methods were often new and difficult. Conclusion for practice Participation by safety net dental practices in a QI collaborative is feasible and acceptable. Individual sites saw greater improvements in different outcomes areas, based on their own structures and needs. Future efforts should focus on specific needs of each dental practice and should offer additional QI training.

Self-Management and Health Care Transition Among Adolescents and Young Adults With Chronic Kidney Disease: Medical and Psychosocial Considerations.

Health care transition (HCT) is a process that requires preparation as a continuum from pediatric- to adult-focused services. For adolescents and young adults with chronic or ESRD, this process can be prolonged due to their physical, psychological, family, or ecological factors. HCT preparation is a matter of patient safety and patient rights as the consequences of poor preparation at the time of transfer to adult-focused services are great, including rejection of organs, disease relapse, or even death. We present a case to illustrate important points of HCT preparation, with suggestions for intervention by the interdisciplinary team members who serve (and will serve) these survivors of pediatric-onset health conditions. To monitor the HCT process, yearly measurements of skill mastery need to take place guide interventions.

Understanding the relationship between religiosity and caregiver-adolescent communication about sex within African-American families.

Caregiver-adolescent communication about sex plays a critical role in the sexual socialization of youth. Many caregivers, however, do not engage their youth in such conversations, potentially placing them at risk for negative sexual health outcomes. Lack of caregiver-adolescent communication about sex may be particularly harmful for rural African American youth, as they often report early sex initiation and are disproportionately impacted by STIs. Moreover, sexual communication may be particularly challenging for families with strong religious backgrounds, potentially affecting the occurrence and breadth of topics covered during communication. Study aims were to: determine whether there was a relationship between caregiver religiosity and type of topics covered during communication about sex (e.g., general sexual health vs. positive aspects of sexuality) among 435 caregivers of early adolescent, African American youth; and if so, identify factors that might explain how religiosity affects communication about sex. Results indicated that caregiver religiosity was positively associated with communication about general, but not positive aspects of sexuality for caregivers of males. Attitudes towards communication about sex and open communication style mediated the relationship. There was no association between religiosity and communication about sex for caregivers of females. The findings from this study could provide a base to better understand and support the sexual socialization process within religious, African American families.

Vision Screening in Children Aged 6 Months to 5 Years: Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Preschool vision screening could allow detection and treatment of vision abnormalities during a critical developmental stage, preserving function and quality of life. Objective: To review the evidence on screening for and treatment of amblyopia, its risk factors, and refractive error in children aged 6 months to 5 years to inform the US Preventive Services Task Force. Data Sources: MEDLINE, Cochrane Library, CINAHL, and trial registries through June 2016; references; and experts, with surveillance of the literature through June 7, 2017. Study Selection: English-language randomized clinical trials (RCTs) or prospective cohort studies that evaluated screening, studies evaluating test accuracy, RCTs of treatment vs inactive controls, and cohort studies or case-control studies assessing harms. Data Extraction and Synthesis: Dual review of abstracts, full-text articles, and study quality; qualitative synthesis of findings. Studies were not quantitatively pooled because of clinical and methodological heterogeneity. Main Outcomes and Measures: Visual acuity, amblyopia, school performance, functioning, quality of life, test accuracy, testability, and harms. Results: Forty studies were included (N = 34 709); 34 evaluated test accuracy. No RCTs compared screening with no screening, and no studies evaluated school performance, function, or quality of life. Studies directly assessing earlier or more intensive screening were limited by high attrition. Positive likelihood ratios were between 5 and 10 for amblyopia risk factors or nonamblyogenic refractive error in most studies of test accuracy and were greater than 10 in most studies evaluating combinations of clinical tests. Inability to cooperate may limit use of some tests in children younger than 3 years. Studies with low prevalence (<10%) of vision abnormalities showed high false-positive rates (usually >75%). Among children with amblyopia risk factors (eg, strabismus or anisometropia), patching improved visual acuity of the amblyopic eye by a mean of less than 1 line on a standard chart after 5 to 12 weeks for children pretreated with glasses (2 RCTs, 240 participants); more children treated with patching than with no patching experienced improvement of at least 2 lines (45% vs 21%; P = .003; 1 RCT, 180 participants). Patching plus glasses improved visual acuity by about 1 line after 1 year (0.11 logMAR [95% CI, 0.05-0.17]) for children not pretreated with glasses (1 RCT, 177 participants). Glasses alone improved visual acuity by less than 1 line after 1 year (0.08 logMAR [95% CI, 0.02-0.15], 1 RCT, 177 participants). Conclusions and Relevance: Studies directly evaluating the effectiveness of screening were limited and do not establish whether vision screening in preschool children is better than no screening. Indirect evidence supports the utility of multiple screening tests for identifying preschool children at higher risk for vision problems and the effectiveness of some treatments for improving visual acuity outcomes.

Perceptions of the medical home by parents of children with chronic illnesses.

OBJECTIVES: The patient-centered medical home (PCMH) strives to improve the quality of care in the primary care setting. Recently, certification programs for patient-centered coordinated care have expanded to subspecialty care. Children with chronic conditions are particularly in need of patient-centered and coordinated care. Our objective was to compare parent perceptions of PCMH elements at primary care and specialty practices for children receiving specialty care. STUDY DESIGN: Cross-sectional survey study. METHODS: We surveyed the parents of children returning for specialty care in a hospital-based pediatric subspecialty clinic on the presence of National Committee for Quality Assurance (NCQA) PCMH elements in their primary care practice and in their main specialty care practice. RESULTS: More parents perceived good appointment access at primary care practices than they did at specialty practices (93% vs 87%, respectively; P <.001). They perceived good care coordination and referral follow-up both at primary care and specialty practices (89% vs 88% and 92% vs 92%, respectively). However, parents less frequently perceived the presence of 7 other PCMH elements at primary care practices compared with specialty practices; these included appointment and tests due reminders, distributing handouts, electronic prescribing, sharing test results, surveying experiences, and e-mail capability. CONCLUSIONS: Despite an emphasis on PCMHs in primary care settings, parents of children seeking specialty care are more likely to perceive the presence of NCQA PCMH elements in specialty rather than primary care clinics. Future PCMH efforts should address parents' perceptions and interpretations of these services.

Enhanced Access and Parents' Preferred Contact for a Child's Chronic Condition.

OBJECTIVES: To assess whether the perception of enhanced access by parents in their child's primary care and main specialty practices is associated with preference for contacting either practice when problems arise with a child's chronic condition. STUDY DESIGN: In this cross-sectional survey study of parents whose children use both primary and specialty practices, we assessed perceptions of 3 components of enhanced access: (1) appointment availability when needed, (2) electronic communication with practices, and (3) other staff that help manage a child's health care needs. Parents also indicated which practice they would contact for an exacerbation of the main chronic condition for which the child receives specialty care. We used logistic regression to examine relationships of enhanced access components in both practices with parents' indicated practice. RESULTS: Among 609 parents, 244 (40%) would contact primary care and 365 (60%) the main specialty practice for a chronic condition exacerbation. Although parents perceived enhanced access components with similar frequency in both settings, enhanced access was associated only with preference for contacting the main specialty practice: e-mail communication (aOR for preferring the specialty practice 2.0 [1.3, 3.2]) and staff that coordinate a child's care needs (aOR 2.8 [1.4, 5.9]). CONCLUSIONS: Enhanced access is associated with preference for addressing chronic condition exacerbations in specialty but not primary care. Future study should further identify factors important to parents in deciding when and how to contact practices and should seek to develop family-centered communication within medical homes that integrate primary and specialty care.

Association of Picky Eating and Food Neophobia with Weight: A Systematic Review.

BACKGROUND: Picky eating and food neophobia are common during childhood. Childhood eating behaviors are often predictive of adult eating behaviors. OBJECTIVES: Determine if childhood picky eating or food neophobia is associated with childhood weight status, or with becoming underweight, overweight, or obese later in childhood. DATA SOURCES: We identified relevant studies from searches of PubMed, PsycINFO, and NEOHAL, as well as citations from identified studies. Study Eligibility Criteria and Participants: Inclusion criteria were original research articles examining a relationship between picky eating and/or food neophobia with childhood weight status. We summarized definitions and prevalence of picky eating or food neophobia and association with weight status. STUDY APPRAISAL: Two independent investigators assessed bias and confounding using the Agency for Healthcare Research and Quality's RTI Item Bank. RESULTS: Forty-one studies met inclusion criteria. Picky eating was defined inconsistently, and a large variation in prevalence was found (5.8%-59%). Food neophobia was consistently defined as an unwillingness to try new foods, with a prevalence between 40% and 60%. No association existed between childhood weight status and food neophobia, and results were unclear for picky eating. LIMITATIONS: Risk of bias and confounding were moderate. Parental report was commonly used to assess picky eating, height, and weight and parental weight, feeding styles, and community characteristics were infrequently considered. CONCLUSIONS AND IMPLICATIONS: Heterogeneous definitions used for picky eating led to a wide range of reported prevalence and an unclear relationship with weight. Consistent definitions and an improved understanding of such a relationship could help clinicians provide appropriate anticipatory guidance.

Translating Clinical Guidelines Into Practice: Challenges and Opportunities in a Dynamic Health Care Environment.

Clinical practice guidelines are evidence-based recommendations with the potential to improve population health, yet they remain inconsistently utilized. In this commentary we discuss barriers and drivers to implementing clinical practice guidelines. We also suggest ways to support their translation into practice.