Assessing patient experiences in the pediatric patient-centered medical home: a comparison of two instruments.

The Patient-Centered Medical Home (PCMH) is a model of care that has been promoted as a way to transform a broken primary care system in the US. However, in order to convince more practices to make the transformation and to properly reimburse practices who are PCMHs, valid and reliable data are needed. Data that capture patient experiences in a PCMH is valuable, but which instrument should be used remains unclear. Our study aims to compare the validity and reliability of two national PCMH instruments. Telephone surveys were conducted with children who receive care from 20 pediatric practices across Florida (n = 990). All of the children are eligible for Medicaid or the Children's Health Insurance Program. Analyses were conducted to compare the Consumer Assessment of Health Plan Survey-Patient-Centered Medical Home (CAHPS-PCMH) and the National Survey of Children with Special Health Care Needs (NS-CSHCN) medical home domain. Respondents were mainly White non-Hispanic, female, under 35 years old, and from a two-parent household. The NS-CSHCN outperformed the CAHPS-PCMH in regard to scale reliability (Cronbach's alpha coefficients all ≥0.81 vs. 0.56-0.85, respectively). In regard to item-domain convergence and discriminant validity the CAHPS-PCMH fared better than the NS-CSHCN (range of convergence 0.66-0.93 vs. 0.32-1.00). The CAHPS-PCMH did not correspond to the scale structure in construct validity testing. Neither instrument performed well in the known-groups validity tests. No clear best instrument was determined. Further revision and calibration may be needed to accurately assess patient experiences in the PCMH.

Child Abuse and Neglect: The Role of the Primary Care Pediatrician.

Child abuse affects more than 10% of children in the United States. For most children it is the result of family dysfunction. Child abuse affects children from all socioeconomic classes. Pediatricians have an important role to play in prevention and early detection of abuse. There are sentinel injuries, now summarized as Clinical Prediction Rules that can guide the general pediatrician to take more definitive steps to suspect and report child abuse and neglect. Primary prevention should be part of the anticipatory guidance and support that pediatricians provide to all of their families.

Cluster Randomized Trial Reducing Missed Elevated Blood Pressure in Pediatric Primary Care: Project RedDE.

Recognition of childhood hypertension is essential, but pediatricians routinely fail to identify elevated blood pressure (BP). This study investigated if a quality improvement collaborative (QIC) reduces missed elevated BP in primary care. METHODS: During a cluster-randomized clinical trial, a national cohort worked sequentially to reduce each of three different errors, including missed elevated BP. While working on their first error during an 8-month action period, practices collected control data for a different error. Practices worked to reduce two additional errors in subsequent action periods but continued to provide sustain and maintainenance data on BP. QIC intervention included video learning sessions, transparent data, failures analysis, coaching, and tools to reduce errors. Mixed-effects logistic regression models compared the mean percentage of patients with an elevated BP with appropriate actions taken and documented. RESULTS: We randomized 43 practices and included 30 in the final analysis. Control and intervention phases included 1,728 and 1,834 patients with an elevated BP, respectively. Comparing control versus intervention phases, the mean percentage of patients who received appropriate actions increased from 58% to 74% [risk difference (RD) 16%; 95% CI;12%, 20%]. Practices continued to improve during the sustain phase as compared to the intervention phase (RD 5%; 95% CI; 2%, 9%) and did not worsen during the maintenance phase (RD 0.9%; 95% CI -5%, 7%). CONCLUSIONS: Missed pediatric elevated BP can be sustainably reduced via a QIC intervention, demonstrating a possible model for other error reduction efforts.

Expanding the pediatrician's black bag: a psychosocial care improvement model to address the "new morbidities".

BACKGROUND: Behavioral, developmental, and psychosocial problems ("new morbidities") significantly affect the well-being of children ages 0-3 years. Practices generally fail to deliver consistent anticipatory guidance or counseling to parents. A multifaceted intervention was designed to increase the capacity of three very different practice types to adopt and implement Practicing Safety, a child abuse and neglect prevention program. METHODS: Using a feasibility intervention study, a combination of organizational change approaches, including complexity science principles--self-organization, emergence, and co-evolution--were tested. The multimethod assessment process (MAP) was employed to understand the unique characteristics of each practice that could impede or promote innovation. Findings guided a facilitated, team-based change intervention, the Reflective Adaptive Process (RAP) to restructure psychosocial care. FINDINGS: Each practice demonstrated fundamental changes in decision making, developmental assessment, and parent education processes. Practicing Safety tools were adopted and incorporated into daily routines. RAP team members exhibited new patterns of communication and relationships that supported organizationwide preventive service innovations. DISCUSSION: The MAP and RAP interventions enabled study practices to integrate novel methods for prevention of child abuse and neglect into daily routines.

Practicing safety: a quality improvement intervention to test tools to enhance pediatric psychosocial care for children 0-3 years.

BACKGROUND: Child maltreatment is a significant public health issue in the United States. Yet, fewer than half of pediatricians discuss behavioral, developmental, or parenting issues with parents. OBJECTIVE: This paper describes the testing of bundles of tools and processes, part of a larger intervention, Practicing Safety, targeted at changing physician and staff behavior to identify families at risk for child maltreatment, provide anticipatory guidance, refer to community resources, and follow-up and track at-risk families. The intervention was implemented with 14 pediatric primary care practices throughout the United States; the study was completed in 2011. METHODS: A within-subjects repeated measures pre-post follow-up design was used to evaluate the intervention. Baseline and repeated measurements of pediatric practices' processes were collected using qualitative and quantitative methods. In total, 14 core improvement teams from across the country tested three bundles of tools (maternal, infant, toddler) within a quality improvement framework over seven months. RESULTS: Quantitative results showed statistically significant adoption of tools and processes and enhancement of practice behaviors and office environmental supports. The increase in tool use was immediate and was sustained for six months after implementation. Qualitative data provided insight as to how meaningful the intervention was to the core improvement teams, especially with more complicated behaviors (eg, engaging social workers or community agencies for referrals). Barriers included lack of community resources. Findings showed unanticipated outcomes such as helping practices to become medical homes. CONCLUSION: Lessons learned included that practices appreciate and can adopt brief interventions that have meaningful and useful tools and process to enhance psychosocial care for children 0-3 and that do not place a burden on pediatric practice. An innovative, quality improvement strategy, intuitive to pediatricians, with a brief intervention may help prevent child maltreatment.

Diagnostic Errors in Primary Care Pediatrics: Project RedDE.

OBJECTIVE: Diagnostic errors (DEs), which encompass failures of accuracy, timeliness, or patient communication, cause appreciable morbidity but are understudied in pediatrics. Pediatricians have expressed interest in reducing high-frequency/subacute DEs, but their epidemiology remains unknown. The objective of this study was to investigate the frequency of two high-frequency/subacute DEs and one missed opportunity for diagnosis (MOD) in primary care pediatrics. METHODS: As part of a national quality improvement collaborative, 25 primary care pediatric practices were randomized to collect 5 months of retrospective data on one DE or MOD: elevated blood pressure (BP) and abnormal laboratory values (DEs), or adolescent depression evaluation (MOD). Relationships between DE or MOD proportions and patient age, gender, and insurance status were explored with mixed-effects logistic regression models. RESULTS: DE or MOD rates in pediatric primary care were found to be 54% for patients with elevated BP (n = 389), 11% for patients with abnormal laboratory values (n = 381), and 62% for adolescents with an opportunity to evaluate for depression (n = 400). When examining the number of times a pediatrician may have recognized an abnormal condition but either knowingly or unknowingly did not act according to recommended guidelines, providers did not document recognition of an elevated BP in 51% of patients with elevated BP, and they did not document recognition of an abnormal laboratory value without a delay in 9% of patients with abnormal laboratory values. CONCLUSIONS: DEs and MODs occur at an appreciable frequency in pediatric primary care. These errors may contribute to care delays and patient harm.

Using a registry to improve immunization delivery.

The NJIPSP was successful in encouraging a group of small urban practices to adopt the use of immunization registry and to transform immunization delivery from a mechanistic well-child service to a visible, monitored process of care. The project represents a unique combination of technology, public-private collaboration, and well-established quality improvement techniques. The change process involved the whole office as a team in adopting new immunization delivery roles and services. The greatest barrier to acceptance of the registry was (and continues to be) the need for manual data entry as the primary source of data collection, rather than electronic data transfer from other systems. The manual entry of data was labor intensive for participating practices and affected data measurement. Despite this barrier, however, the majority of practices substantially improved the quality of their immunization delivery practices in multiple areas. The rapid movement of primary care practices toward some form of electronic record may reduce this barrier and increase the percentage of practices willing to use a community registry. Practices that engaged collectively in the change process gained momentum from the group effort. Equally important was the public health partnership that helped identify and reduce improvement obstacles. Sustainability of practice-based immunization changes will rely, in part, on the registry's ease of use and the continued visibility of public health at the practice level. Active practice level collaboration by public health adds great value to change efforts. We believe that the best possible immunization delivery relies on both technology (registries and the EMR) and effective office systems. Projects like the NJIPSP are models for systems that integrate technology, practice change, and quality improvement, and their success has the potential to foster the spread of this approach to other primary care practices (especially in New Jersey). The NJIPSP combination of office-based change approaches and an active partnership and hands on involvement with public health has the potential to support the delivery of consistently excellent immunization delivery.

Funding of child abuse evaluations: survey of child abuse evaluation programs.

This article delineates the current fiscal management and reimbursement for child abuse examinations. These financial issues are high priority for child abuse programs because most programs lack the revenues to meet the demands for service, education, advocacy and research. Programs may share medical protocols and standards but have yet to share management solutions. The authors present the administrative details of 75 child abuse evaluation programs and highlight innovative approaches to increase funding and stabilize the funding for the programs. They present information on billing, contracts, costs of care, and state-based initiatives that can be reproduced by other programs and states.

Role of Participation of Pediatricians in the "Activated Autism Practice" Program in Practicing Children With Autism Spectrum Disorders at the Primary Care Setting.

Primary care of children with autism spectrum disorders (ASD) is an important public health concerns. In this survey study of 73 pediatricians, we determined whether pediatricians' practice of autism screening and perception of management of ASD is associated with participation in a learning collaborative, "Activated Autism Practice". Overall, the majority recognized the lack of care coordination, inadequate time, poor reimbursement, and language difference as barriers to the delivery of medical care to children with ASD. Pediatricians with prior training were more likely to report use of autism-specific screening and understanding the different aspects of ASD management including the need to coordinate special services and long-term surveillance at pediatric sites. Therefore, participation in "Activated Autism Practice" may facilitate use of ASD-specific screening and manage ASD cases as a complex of neurodevelopmental/underlying problems with the need for enhancement of clinical attention and coordination of medical care at the pediatric primary care level.

Primary care pediatricians' interest in diagnostic error reduction.

BACKGROUND: Diagnostic errors causing harm in children are understudied, resulting in a knowledge gap regarding pediatricians' interest in reducing their incidence. METHODS: Electronic survey of general pediatricians focusing on diagnostic error incidence, errors they were interested in trying to improve, and errors reduced by their electronic health record (EHR). RESULTS: Of 300 contacted pediatricians, 77 (26%) responded, 58 (19%) served ambulatory patients, and 48 (16%) completed the entire questionnaire. Of these 48, 17 (35%) reported making a diagnostic error at least monthly, and 16 (33%) reported making a diagnostic error resulting in an adverse event at least annually. Pediatricians were "most" interested in "trying to improve" missed diagnosis of hypertension (17%), delayed diagnosis due to missed subspecialty referral (15%), and errors associated with delayed follow-up of abnormal laboratory values (13%). Among the 44 pediatricians with an EHR, 16 (36%) said it reduced the likelihood of missing obesity and 14 (32%) said it reduced the likelihood of missing hypertension. Also, 15 (34%) said it helped avoid delays in follow-up of abnormal laboratory values. A third (36%) reported no help in diagnostic error reduction from their EHR. CONCLUSIONS: Pediatricians self-report an appreciable number of diagnostic errors and were most interested in preventing high frequency, non-life-threatening errors. There exists a need to leverage EHRs to support error reduction efforts.

Improving delivery of Bright Futures preventive services at the 9- and 24-month well child visit.

OBJECTIVES: To determine if clinicians and staff from 21 diverse primary care practice settings could implement the 2008 Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd edition recommendations, at the 9- and 24-month preventive services visits. METHODS: Twenty-two practice settings from 15 states were selected from 51 applicants to participate in the Preventive Services Improvement Project (PreSIP). Practices participated in a 9-month modified Breakthrough Series Collaborative from January to November 2011. Outcome measures reflect whether the 17 components of Bright Futures recommendations were performed at the 9- and 24-month visits for at least 85% of visits. Additional measures identified which office systems were in place before and after the collaborative. RESULTS: There was a statistically significant increase for all 17 measures. Overall participating practices achieved an 85% completion rate for the preventive services measures except for discussion of parental strengths, which was reported in 70% of the charts. The preventive services score, a summary score for all the chart audit measures, increased significantly for both the 9-month (7 measures) and 24-month visits (8 measures). CONCLUSIONS: Clinicians and staff from various practice settings were able to implement the majority of the Bright Futures recommended preventive services at the 9- and 24-month visits at a high level after participation in a 9-month modified Breakthrough Series collaborative.

Summary of STARNet: Seamless Transitions and (Re)admissions Network.

The Seamless Transitions and (Re)admissions Network (STARNet) met in December 2012 to synthesize ongoing hospital-to-home transition work, discuss goals, and develop a plan to centralize transition information in the future. STARNet participants consisted of experts in the field of pediatric hospital medicine quality improvement and research, and included physicians and key stakeholders from hospital groups, private payers, as well as representatives from current transition collaboratives. In this report, we (1) review the current knowledge regarding hospital-to-home transitions; (2) outline the challenges of measuring and reducing readmissions; and (3) highlight research gaps and list potential measures for transition quality. STARNet met with the support of the American Academy of Pediatrics' Quality Improvement Innovation Networks and the Section on Hospital Medicine.

Challenges and strategies for improving the mental health of New Jersey children and adolescents.

Mental health issues facing children and adolescents in New Jersey are an under-recognized health care issue. Insufficient data are available to fully define the scope of the problem. Current resources for early diagnosis and treatment do not meet the need. In an era in which the usual stress of adolescence is compounded by violence in schools and the threat of terrorism, more needs to be done to ensure the mental health of all of our children and adolescents.

Association between medical home characteristics and staff professional experiences in pediatric practices.

BACKGROUND: The patient-centered medical home (PCMH) model has been touted as a potential way to improve primary care. As more PCMH projects are undertaken it is critical to understand professional experiences as staff are key in implementing and maintaining the necessary changes. A paucity of information on staff experiences is available, and our study aims to fill that critical gap in the literature. METHODS: Eligible pediatric practices were invited to participate in the Florida Pediatric Medical Home Demonstration Project out which 20 practices were selected. Eligibility criteria included a minimum of 100 children with special health care needs and participation in Medicaid, a Medicaid health plan, or Florida KidCare. Survey data were collected from staff working in these 20 pediatric practices across Florida. Ware's seven-point scale assessed satisfaction and burnout was measured using the six-point Maslach scale. The Medical Home Index measured the practice's medical home characteristics. Descriptive and multivariate analyses were conducted. In total, 170 staff members completed the survey and the response rate was 42.6%. RESULTS: Staff members reported high job satisfaction (mean 5.54; SD 1.26) and average burnout. Multivariate analyses suggest that care coordination is positively associated (b = 0.75) and community outreach is negatively associated (b = -0.18) with job satisfaction. Quality improvement and organizational capacity are positively associated with increased staff burnout (OR = 1.37, 5.89, respectively). Chronic condition and data management are associated with lower burnout (OR = 0.05 and 0.20, respectively). Across all models adaptive reserve, or the ability to make and sustain change, is associated with higher job satisfaction and lower staff burnout. CONCLUSIONS: Staff experiences in the transition to becoming a PCMH are important. Although our study is cross-sectional, it provides some insight about how medical home, staff and practice characteristics are associated with job satisfaction and burnout. Many PCMH initiatives include facilitation and it should assist staff on how to adapt to change. Unless staff needs are addressed a PCMH may be threatened by fatigue, burnout, and low morale.

Using genograms to understand pediatric practices' readiness for change to prevent abuse and neglect.

A novel use of genograms in primary care practice is to identify processes and relationships among physicians and staff prior to implementing practice change. The authors hypothesized that the genogram would inform researchers and practice staff, participating in a child maltreatment prevention study, how practice members function in a practice. They describe the use of genograms and show how the genogram results are associated with intervention uptake. Researchers constructed genograms, collected baseline surveys, and conducted postintervention interviews with physicians. Data were analyzed to determine processes associated with intervention uptake. While survey results supported the relationships and conflicts observed in the genograms, the genogram provided more multilevel information that reflected practices' abilities to implement change. By providing a snapshot of the relationship and organizational dynamics within a practice, genograms can assess culture for practice change. Genograms describe organizational dynamics and are useful tools to use prior to initiating new programs.

Kawasaki disease following Rocky Mountain spotted fever: a case report.

INTRODUCTION: Kawasaki disease is an idiopathic acute systemic vasculitis of childhood. Although it simulates the clinical features of many infectious diseases, an infectious etiology has not been established. This is the first reported case of Kawasaki disease following Rocky Mountain spotted fever. CASE PRESENTATION: We report the case of a 4-year-old girl who presented with fever and petechial rash. Serology confirmed Rocky Mountain spotted fever. While being treated with intravenous doxycycline, she developed swelling of her hands and feet. She had the clinical features of Kawasaki disease which resolved after therapy with intravenous immune globulin (IVIG) and aspirin. CONCLUSION: This case report suggests that Kawasaki disease can occur concurrently or immediately after a rickettsial illness such as Rocky Mountain spotted fever, hypothesizing an antigen-driven immune response to a rickettsial antigen.