Primary care provider perceptions of an asthma home visiting program.

INTRODUCTION: Pediatric asthma home visiting programs have improved clinical outcomes, but little is known about how providers perceive these programs. The purpose of this study was to understand how primary care providers and their colleagues in a medical home perceive an asthma home visiting program that is available at no cost to their patients. METHODS: After several years of running an asthma home visiting program using community health workers (CHW) in 10 pediatric primary care offices in the South Coast of Massachusetts, we surveyed the providers of patients who had enrolled in the program. An anonymous online survey was developed by the program leaders, the program analytics team, and the CHWs for quality improvement purposes. Survey domains included the perceived utility of various aspects of the program, impact on patients, and interaction with CHWs, as well as demographic information about the providers. RESULTS: Of the 24 providers asked to complete the survey from eight primary care practices, 21 completed the survey (88%). Respondents perceived that the most beneficial aspects were environmental assessment (95%), asthma education (91%), and addressing environmental issues (86%). In addition to numerous positive free-text responses, suggestions for improvement were in the areas of referral completion, post-visit communication, and patient identification in the medical record. All respondents would continue to refer to the program. CONCLUSIONS: Primary care providers and medical home staff perceived an asthma home visiting program to have high utility, particularly the environmental assessment, asthma education, and mitigation of environmental issues. Additional opportunities for improvement were identified.

Improved 10-year cost savings for patients served by the Boston Children's Hospital Community Asthma Initiative.

OBJECTIVE: To provide a 10-year follow-up of asthma cost-savings for patients served by the Community Asthma Initiative (CAI) group compared to a coarsely cost-matched comparison group from similar neighborhoods (comparison group). METHODS: CAI provided home visits and case management services for patients identified through emergency department (ED) visits and hospitalizations. Asthma costs for the two groups were extracted from the hospital administrative database for ED visits and hospitalizations for one year before and 10 years of follow-up. To eliminate cost differences at intake, a coarse cost-matching was implemented by randomly selecting comparison patients with similar costs to CAI patients (N = 208 pairs). The difference in cost-reduction between CAI and comparison patients was used to compute the adjusted Return on Investment (aROI). RESULTS: There were no significant differences between CAI and comparison groups, including baseline age (5.9 years [SD 2.9] v. 4.4 [SD 3.1]); Hispanic (46.2% v. 35.1%) and Black (43.9% v. 53.0%) race/ethnicity; and public insurance (71.2% v. 68.8%). The cost reduction difference for CAI was significant at one year (P = 0.0001) and two years (P = 0.03), but did not reach the level of significance for years 3-10. The CAI group had a greater cumulative cost reduction of $5,321 (P = 0.08, not significant). Average program cost per patient was $2,636. CAI broke-even after 3 years (aROI = 1.04) and yielded an adjusted ROI of 1.99 at 10 years. CONCLUSIONS: The greater reduction in cumulative cost for CAI patients suggested a shift in trajectory at 10 years of follow-up, resulting in a positive aROI after three years.

Community Asthma Initiative: Cost Analyses using Claims Data from a Medicaid Managed Care Organization.

Objective: Use claims data to examine the cost benefit of the Community Asthma Initiative (CAI), a Boston area nurse-supervised community health worker (CHW) asthma home-visiting program. Methods: The reduction in asthma treatment costs was assessed using Massachusetts claims data from one Medicaid Managed Care Organization (MCO) in the north east that included all costs between January 1, 2011 and December 31, 2016. The data was used to determine asthma-related utilization cost reductions between 1 year pre- and 1, 2 and 3 years post-intervention. The cost reductions for 45 CAI patients and 45 cost-matched comparison patients were measured. Return on investment (ROI) was computed as the difference in cost reduction for CAI patients and a cost-matched comparison population divided by CAI program cost. Results: The excess reduction in per patient asthma-related utilization costs among CAI patients compared to the comparison population was $806 (p = 0.047), $1,253 (p = 0.01) and $1,549 (p = 0.005) between 1 year pre- and 1, 2 and 3 years post-intervention. These yielded adjusted ROI's of 0.31, 0.78 and 1.37 after 1, 2 and 3 years post-CAI intervention. Conclusions: The reduction in asthma utilization costs of a home visit program by nurse-supervised CHWs exceeds program costs. The findings support the business case for the provision of secondary prevention of home-based asthma services through reimbursement from payers or integration into Accountable Care Organizations (ACOs).

How do you define recovery? A qualitative study of patients with eating disorders, their parents, and clinicians.

OBJECTIVE: Recovery from an eating disorder (ED) may be defined differently by different stakeholders. We set out to understand the definition of ED recovery from the perspective of patients, their parents, and clinicians. METHOD: We recruited patients with EDs (n = 24, ages 12-23 years) representing different diagnoses (anorexia nervosa n = 17, bulimia nervosa n = 4, binge-ED n = 2, avoidant/restrictive food intake disorder n = 1), along with their parents (n = 20), dietitians (n = 11), therapists (n = 14), and primary care providers (n = 9) from three sites: Boston Children's Hospital, University of Michigan C. S. Mott Children's Hospital, and Penn State Hershey Children's Hospital. In-depth, semi-structured, qualitative interviews explored participants' definitions of recovery. Interviews were analyzed using inductive data-driven thematic analysis. Statistical analyses followed to examine the distribution within each theme by respondent type. RESULTS: Qualitative analysis resulted in the emergence of four overarching themes of ED recovery: (a) psychological well-being, (b) eating-related behaviors/attitudes, (c) physical markers, and (d) self-acceptance of body image. Endorsement of themes two and four did not significantly differ between patients, parents, and clinicians. Clinicians were significantly more likely to endorse theme one (χ2 = 9.90, df = 2, p = .007, φc = 0.356) and theme three (χ2 = 6.42, df = 2, p = .04, φc = 0.287) than patients and parents. DISCUSSION: Our study demonstrates overwhelming support for psychological markers as indicators of ED recovery by all three groups. Clinicians should remain open to additional markers of recovery such as body acceptance and eating-related behaviors/emotions that may be of critical importance to patients and their caregivers.

Parent experiences with a nurse-supervised community health worker asthma home-visiting program.

Objective: This study seeks to identify helpful components of a nurse-supervised Community Health Worker (CHW) asthma home-visiting program, obtain feedback from parents and families about their experiences, and receive suggestions for new services that the program could provide. Methods: Likert scale ratings and semi-structured qualitative interviews were conducted with parents who were selected from a representative sample and previously participated in the program. Five-point Likert scale ratings from 1 (not helpful) to 5 (very helpful) were obtained for 11 program components. Interviews were analyzed using a grounded theory participatory approach. Data were analyzed and themes were identified by two different coders using Dedoose software. Results: A total of 22 participants were enrolled and 20 participants completed Likert scale ratings and qualitative interviews. Likert scale ratings (mean standard deviation [SD]) show that program strengths include asthma education (4.75 [0.55]), supplies (4.65 [0.99]), help with housing conditions (3.94 [1.56], pest management (3.79 [1.69]) and greater access to community resources (3.70 [1.30]). The ratings suggest that families need more help with other social determinants of health, such as school, lack of enough money or food, and mental health and behavioral concerns (3.05 [1.78]). Interviews echoed these ratings and revealed several themes about family and parental stress, children's activity limitations, desire for outreach after the 12-month intervention, a need for help with other social determinants and more emotional support. Conclusions: This study shows that the program was well received and reveals the importance of addressing social determinants of health and behavioral health concerns.

Evaluation of the Environmental Scoring System in Multiple Child Asthma Intervention Programs in Boston, Massachusetts.

OBJECTIVES: To test the applicability of the Environmental Scoring System, a quick and simple approach for quantitatively measuring environmental triggers collected during home visits, and to evaluate its contribution to improving asthma outcomes among various child asthma programs. METHODS: We pooled and analyzed data from multiple child asthma programs in the Greater Boston Area, Massachusetts, collected in 2011 to 2016, to examine the association of environmental scores (ES) with measures of asthma outcomes and compare the results across programs. RESULTS: Our analysis showed that demographics were important contributors to variability in asthma outcomes and total ES, and largely explained the differences among programs at baseline. Among all programs in general, we found that asthma outcomes were significantly improved and total ES significantly reduced over visits, with the total Asthma Control Test score negatively associated with total ES. CONCLUSIONS: Our study demonstrated that the Environmental Scoring System is a useful tool for measuring home asthma triggers and can be applied regardless of program and survey designs, and that demographics of the target population may influence the improvement in asthma outcomes.

Boston children's hospital community asthma initiative: Five-year cost analyses of a home visiting program.

OBJECTIVE: To evaluate the costs and benefits of the Boston Children's Hospital Community Asthma Initiative (CAI) through reduction of Emergency Department (ED) visits and hospitalizations for the full pilot-phase program participants. METHODS: A cost-benefit analyses was conducted using hospital administrative data to determine an adjusted Return on Investment (ROI): on all 268 patients enrolled in the CAI program during the 33-month pilot program phase of CAI intervention between October 1, 2005 and June 30, 2008 using a comparison group of 818 patients from a similar cohort in neighboring ZIP codes without CAI intervention. Cost data through June 30, 2013 were used to examine cost changes and calculate an adjusted ROI over a 5-year post-intervention period. RESULTS: CAI patients had a cost reduction greater than the comparison group of $1,216 in Year 1 (P = 0.001), $1,320 in Year 2 (P < 0.001), $1,132 (P = 0.002) in Year 3, $1,123 (P = 0.004) in Year 4, and $997 (P = 0.022) in Year 5. Adjusting for the cost savings for the comparison group, the cost savings from the intervention resulted in an adjusted ROI of 1.91 over 5 years. CONCLUSIONS: Community-based, multidisciplinary, coordinated disease management programs can decrease the incidence of costly hospitalizations and ED visits from asthma. An ROI of greater than one, as found in this cost analysis, supports the business case for the provision of community-based asthma services as part of patient-centered medical homes and Accountable Care Organizations.

Redesign of chronic illness care in children and adolescents: evidence for the chronic care model.

PURPOSE OF REVIEW: This article provides an overview of the chronic care model (CCM), examines the evidence for its utility in pediatric and adolescent chronic illness, and discusses practical steps for improving chronic illness care in the pediatric medical home. RECENT FINDINGS: Few studies have used the CCM as an improvement framework in pediatrics. However, in recent years, several quality improvement efforts based on the CCM have demonstrated improvement in important process measures or clinical outcomes in pediatric or adolescent obesity, inflammatory bowel disease, attention-deficit/hyperactivity disorder, depression, and asthma. SUMMARY: The CCM is an improvement framework that has demonstrated success in improving the care of children and adolescents with chronic disease. More research is needed to identify priority conditions for improvement efforts, to better understand the mediators of health outcomes in pediatric chronic disease, and to rigorously demonstrate the effectiveness of new models of chronic illness care. The evidence to date suggests that the CCM may be useful in guiding the redesign of care delivery systems to improve the health outcomes of young people with chronic disease.

Gastrointestinal Manifestations of Eating Disorders.

Individuals with eating disorders, including anorexia nervosa and bulimia nervosa, may present with a range of gastrointestinal (GI) manifestations. The oral cavity, salivary glands, GI tract, pancreas, and liver can be impacted by nutritional restrictive and binge/purging behaviors. Complications are often reversible with appropriate nutritional therapy. At times, however, the complications in these disorders may be severe, irreversible and even life threatening. Given the often covert nature of eating disorders, the practitioner must be attentive to subtle clues that may indicate their presence. Extensive diagnostic evaluations of the GI manifestations of eating disorders should be used only when nutritional rehabilitation does not remedy the problems.

Factors Associated With HIV Testing in Adolescent and Young Adult Females With a History of STI.

To determine the percentage of female adolescent patients (13-26 years old) who had HIV testing ordered within 90 days of incident sexually transmitted infection (STI) diagnosis during an outpatient clinic visit. This was a retrospective chart review study evaluating 830 visits among 589 female patients 13 to 26 years who had an incident STI diagnosed in outpatient Adolescent Medicine or Pediatric Practices in an urban, nonprofit, academic, free-standing children's hospital at the main campus and a community site in the Northeast United States. Odds of HIV screening was greater at the community-based adolescent medicine practice (odds ratio [OR] = 3.17; 95% confidence interval [CI]: [1.92, 5.24]) and when seen by an adolescent medicine provider (OR = 1.44; 95% CI: [1.02, 2.03]). Only 33.5% (n = 283) of 844 clinical encounters had HIV screening obtained within 90 days of incident STI diagnosis. Overall, HIV screening rates within 90 days of STI diagnosis was low, and there is much room for improvement.

HIV/Pre-Exposure Prophylaxis Knowledge and Acceptability of Rapid HIV Testing Among Transgender Adolescents in a Multidisciplinary Gender Clinic.

Purpose: The objectives of this study were to assess the knowledge of HIV and pre-exposure prophylaxis (PrEP) in transgender adolescents and young adults (AYAs) and to test the acceptability of rapid HIV testing among transgender adolescents in a multidisciplinary gender clinic. Methods: Participants enrolled on the same day as their mental health or medical appointment in a multidisciplinary gender clinic. They completed survey questions regarding HIV and PrEP knowledge and were also offered an optional same-day, rapid, fourth-generation HIV test. Participants who had an HIV test answered additional questions about their testing experience. Results: We enrolled 61 participants; just over half (n=31) were assigned female at birth. Less than a third (n=20, 32.8%) scored 80% or above regarding HIV knowledge. Nearly half of the participants (n=29, 47.5%) were not interested in PrEP. Forty-one percent of participants chose to have a rapid HIV test; all were "satisfied" with the testing experience. There were no positive HIV results. Conclusions: Transgender AYAs have gaps in their understanding of HIV acquisition and transmission. Rapid HIV testing in the setting of gender care is well received by those who desire testing and may be a way to increase knowledge of transgender AYA HIV status.

A cost analysis for a community-based case management intervention program for pediatric asthma.

OBJECTIVE: Evaluate the costs and benefits of the Boston Children's Hospital Community Asthma Initiative (CAI) program through reduction of Emergency Department (ED) visits and hospitalizations and quality of life (QOL) for patients and their families due to reduced missed school days and work days. METHODS: Cost-benefit analysis was used to determine an adjusted Return on Investment (ROI) for all 102 patients enrolled in the CAI program in the calendar year 2006 after controlling for changes in a comparable population without CAI intervention. A societal ROI (SROI) was also computed by including additional indirect benefits due to reduced missed school days for patients and work days for caregivers. RESULTS: Adjusted cost savings from fewer ED visits and hospitalizations resulted in an adjusted ROI of 1.33 (adjusted Net Present Value, (NPV) of savings = $83,863) during the first 3 years after controlling for factors other than the CAI intervention. When benefits due to reduced missed school days and missed work days were added to adjusted cost savings, the SROI increased to 1.85 (Societal NPV of savings = $215,100). CONCLUSIONS: Multidisciplinary, coordinated disease management programs offer the opportunity to prevent costly complications and hospitalizations for chronic diseases, while improving QOL for patients and families. This cost analysis supports the business case for the provision of proactive community-based asthma services that are traditionally not reimbursed by the fee-for-service health care system.

Anal dysplasia in adolescent and young adult men who have sex with men: a single-center retrospective and descriptive study (2010-2020).

Objective: There are limited studies evaluating anal cytology results or the prevalence of anal human papiloma virus in adolescent and young adult (AYA) men who have sex with men (MSM). The purpose of this study was to review anal cytology screening results and determine whether abnormal findings resulted in completion of anoscopy in AYA MSM (13-26 years old). Patients and Methods: This was a retrospective study evaluating 84 anal Papanicolaou screening results among 36 AYA MSM patients aged 13-26 years who had an anal Papanicolaou test completed at an outpatient Adolescent/Young Adult Medicine Practice at Boston Children's Hospital, an urban, nonprofit, academic, free-standing children's hospital, from January 1, 2010, to December 31, 2020. Results: The findings of anal Papanicolaou screening included atypical squamous cells of undetermined significance (ASCUS) (37%), negative for squamous intraepithelial lesion (31%), inability to read (21.3%), and low-grade squamous intraepithelial lesion (10.8%). Most patients who had ASCUS results were referred for anoscopy (n = 28, 90.3%), and of those referred only 6.5% (n = 2) completed an anoscopy. Of those with low-grade squamous cell intraepithelial lesion results, 88.9% (n = 8) were referred for anoscopy, and among those who were referred, only 3.3% (n = 3) had completed an anoscopy. Conclusion: This study showed that there were abnormalities in cytology when anal Papanicolaou test screening was performed in this population, and the completion rates for anoscopy were low.

Evaluation of raising adolescent families together program: a medical home for adolescent mothers and their children.

OBJECTIVES: This study described a medical home model for adolescent mothers and their children, and their 1- and 2-year preventive care, repeat pregnancy, and psychosocial outcomes. METHODS: In this prospective, single cohort demonstration project, adolescent mothers (14-18 years old) and their children received care in a medical home. Demographic, medical and social processes, and outcomes data were collected at enrollment through 24 months. Change over time and predictors of repeat pregnancy were analyzed. RESULTS: A total of 181 adolescents enrolled, with 79.6% participating for 2 years. At 2 years, 90.2% of children were completely immunized. Children and adolescent mothers met standards for health care visits, and adolescent condom use improved. Rates of cumulative repeat pregnancy were 14.7% and 24.6%, school attendance 77.6% and 68.7%, and employment 21.2% and 32.3% at 1 and 2 years, respectively. CONCLUSIONS: A medical home model with comprehensive and integrated medical care and social services can effectively address the complex needs of adolescent parents and their children.

Longitudinal study of depressive symptoms and social support in adolescent mothers.

Previous studies have suggested that adolescent mothers with higher social support have lower depressive symptoms. This is a longitudinal study of adolescent mothers to examine the association of social support and depressive symptoms over one year postpartum. This was a prospective study of adolescent mothers (N at baseline = 120, N at 1 year = 89; age < 19 years) enrolled in a teen tot program. Participants completed the Center for Epidemiological Studies Depression Scale for children (CES-DC) and the Duke-UNC Functional Social Support Questionnaire at baseline, 12 weeks, and 1 year. A score of ≥ 16 on the CES-DC was suggestive of major depression. The mean CES-DC scores of the adolescent mothers were ≥ 16 points at all three time points (baseline: mean = 18.7 ± 10.3; 53% ≥ 16; 12 weeks: mean = 18.4 ± 11.4, 57% ≥ 16; one year: mean = 20.0 ± 11.4; 57% ≥ 16). Social support had a significant, inverse association with depressive symptoms for all participants from baseline to 12 weeks with a stronger association for those with more depressive symptoms (score ≥ 16) at baseline (beta = -0.030 ± 0.007; P < 0.001) than for those with fewer depressive symptoms (score < 16) at baseline (beta = -0.013 ± 0.006; P = 0.021). From 12 weeks to one year, increased social support was only significantly associated with decreased depressive symptoms for those with a higher baseline level of depressive symptoms (beta = - 0.039 ± 0.009; P < 0.001). Depressive symptoms were prevalent among adolescent mothers. For more depressed adolescent mothers, higher levels of social support were associated with less depressive symptoms over the 1 year follow-up. Effective long-term interventions are needed to lessen depression and enhance social support.

COVID-19 related familial economic disruptions and eating disorder patients' mental health concerns and motivation to recover.

BACKGROUND: Family support has been shown to be important for adolescents and young adults (AYA) in eating disorder (ED) treatment. Many families were impacted by the pandemic, potentially altering their ability to support individuals in ED treatment. This study examined the association of COVID-19 related familial economic change with self-reported mental health (MH) and ED concerns in AYA seeking treatment for ED. METHODS: AYA patients with EDs aged 10-27 years enrolled in the Registry of Eating Disorders and their Co-morbidities OVER time in Youth (RECOVERY) completed an additional COVID-19-specific survey (n = 89) that assessed their perception of the effects of the pandemic on their lives and their ED. Participants self-reported on familial economic disruptions, measured through a composite score of four markers: (1) family member's work hours cut, (2) family member was required to stop working, (3) family member lost job permanently, and (4) family lost health insurance/benefits. In bivariate analyses, we examined the association between self-reporting any familial economic disruption and self-reported changes in intrusive ED thoughts, feelings of anxiety, feelings of depression, feelings of isolation, and motivation to recover from their ED. Logistic regression models were used to examine the association between familial economic disruptions on self-reported changes in ED/MH affect and motivation to recover adjusting for age and ED diagnosis. RESULTS: Forty-six percent of participants self-reported that the pandemic had resulted in at least one economic familial disruption. Of patients reporting any familial economic disruption, 29% reported decreased motivation for ED recovery, and over 75% reported worsening feelings of depression, anxiety, isolation, and/or intrusive eating disorder thoughts. Reporting any COVID-19 familial economic disruption was marginally associated with feelings of isolation (p = 0.05). Though the findings were only marginally significant, the odds of reporting worsening feelings of depression, anxiety, intrusive ED thoughts or motivation to recover were nearly twice in those who reported a COVID-19-related familial economic disruption compared to those who did not report such a disruption. CONCLUSIONS: Family-related economic disruptions are associated with ED/MH-related concerns and motivation to recover from an ED during the COVID-19 pandemic in AYA patients.

Following the adoption of stay-at-home regulations to curb the spread of the COVID-19 pandemic, children's hospitals and emergency rooms across the United States saw a tremendous uptick in adolescents and young adults with eating disorders (ED) and mental health (MH) concerns. COVID-19 related regulations had economic consequences, with family members reduction in work hours, temporary or permanent termination from work, and/or loss of their health insurance or benefits. This study sheds light on the association between COVID-19 related familial economic disruptions and mental health and eating disorders (MH/ED) concerns and motivation to recover from an ED in patients receiving care for ED (89 participants). Of patients reporting some economic familial disruption, three-fourths self-reported worsening mental health (i.e, worsening feelings of depression, anxiety, isolation, or intrusive eating disorder thoughts). Patients who perceived familial economic disruption due to the COVID-19 pandemic had almost a two-fold increased likelihood of worsening eating disorders and mental health (ED/MH) concerns and/or motivation to recover. Our study underscores the need to consider the economic effects of the pandemic on the well-being of adolescents/young-adults with ED, particularly those from financially vulnerable families.

A Digital Platform to Support HIV Case Management for Youth and Young Adults: Mixed Methods Feasibility Study.

BACKGROUND: Advances in medical treatments in recent years have contributed to an overall decline in HIV-related opportunistic infections and deaths in youth; however, mortality and morbidity rates in perinatally and nonperinatally infected adolescents and young adults (AYA) living with HIV remain relatively high today. OBJECTIVE: The goal of this project was to assess the use, utility, and cost-effectiveness of PlusCare, a digital app for HIV case management in AYA living with HIV. The app supports routine case management tasks, such as scheduling follow-up visits, sharing documents for review and signature, laboratory test results, and between-visit communications (eg, encouraging messages). METHODS: We conducted a single-group mixed methods pre-post study with HIV case management programs in 2 large urban hospitals in the Boston metro area. Case management staff (case managers [CMs], N=20) and AYA living with HIV participants (N=45) took part in the study with access to PlusCare for up to 15 and 12 months, respectively. RESULTS: The CMs and AYA living with HIV reported mean System Usability Scale scores of 51 (SD 7.9) and 63 (SD 10.6), respectively. Although marginally significant, total charges billed at 1 of the 2 sites compared with the 12 months before app use (including emergency, inpatient, and outpatient charges) decreased by 41% (P=.046). We also observed slight increases in AYA living with HIV self-reported self-efficacy in chronic disease management and quality of life (Health-Related Quality of Life-4) from baseline to the 12-month follow-up (P=.02 and P=.03, respectively) and increased self-efficacy from the 6- to 12-month follow-up (P=.02). There was no significant change in HIV viral suppression, appointment adherence, or medication adherence in this small-sample pilot study. CONCLUSIONS: Although perceived usability was low, qualitative feedback from CMs and use patterns suggested that direct messaging and timely, remote, and secure sharing of laboratory results and documents (including electronic signatures) between CMs and AYA living with HIV can be particularly useful and have potential value in supporting care coordination and promoting patient self-efficacy and quality of life. TRIAL REGISTRATION: ClinicalTrials.gov NCT03758066; https://clinicaltrials.gov/ct2/show/NCT03758066.

Association of the COVID-19 Pandemic With Adolescent and Young Adult Eating Disorder Care Volume.

Importance: The COVID-19 pandemic has affected youth mental health. Increases in site-specific eating disorder (ED) care have been documented; however, multisite studies demonstrating national trends are lacking. Objective: To compare the number of adolescent/young adult patients seeking inpatient and outpatient ED care before and after onset of the COVID-19 pandemic. Design, Setting, and Participants: Using an observational case series design, changes in volume in inpatient and outpatient ED-related care across 15 member sites (14 geographically diverse hospital-based adolescent medicine programs and 1 nonhospital-based ED program) of the US National Eating Disorder Quality Improvement Collaborative was examined. Sites reported monthly volumes of patients seeking inpatient and outpatient ED care between January 2018 and December 2021. Patient volumes pre- and postpandemic onset were compared separately for inpatient and outpatient settings. Demographic data such as race and ethnicity were not collected because this study used monthly summary data. Exposures: Onset of the COVID-19 pandemic. Main Outcomes and Measures: Monthly number of patients seeking inpatient/outpatient ED-related care. Results: Aggregate total inpatient ED admissions were 81 in January 2018 and 109 in February 2020. Aggregate total new outpatient assessments were 195 in January 2018 and 254 in February 2020. Before the COVID-19 pandemic, the relative number of pooled inpatient ED admissions were increasing over time by 0.7% per month (95% CI, 0.2%-1.3%). After onset of the pandemic, there was a significant increase in admissions over time of 7.2% per month (95% CI, 4.8%-9.7%) through April 2021, then a decrease of 3.6% per month (95% CI, -6.0% to -1.1%) through December 2021. Prepandemic, pooled data showed relative outpatient ED assessment volume was stable over time, with an immediate 39.7% decline (95% CI, -50.4% to -26.7%) in April 2020. Subsequently, new assessments increased by 8.1% (95% CI, 5.3%-11.1%) per month through April 2021, then decreased by 1.5% per month (95% CI, -3.6% to 0.7%) through December 2021. The nonhospital-based ED program did not demonstrate a significant increase in the absolute number of admissions after onset of the pandemic but did see a significant increase of 8.2 (95% CI, 6.2-10.2) additional inquiries for care per month in the first year after onset of the pandemic. Conclusions and Relevance: In this study, there was a significant COVID-19 pandemic-related increase in both inpatient and outpatient volume of patients with EDs across sites, particularly in the first year of the pandemic. Given inadequate ED care availability prior to the pandemic, the increased postpandemic demand will likely outstrip available resources. Results highlight the need to address ED workforce and program capacity issues as well as improve ED prevention strategies.

Common and Emergent Oral and Gastrointestinal Manifestations of Eating Disorders.

Eating disorders (EDs) such as anorexia nervosa, bulimia nervosa, and avoidant/restrictive food intake disorder are associated with restricted diets and abnormal compensatory behaviors, frequently leading to malnutrition and oral and gastrointestinal manifestations. Dental and oral complications are generally caused by malnutrition, micro-nutrient deficiency, and chronic acid exposure; hence, treatment of the ED and frequent dental examinations are essential to reduce morbidity. Gastrointestinal manifestations are multifactorial in origin, and may be caused by disordered behaviors, malnutrition, anxiety, and/or may be a function of the ED itself. This article reviews the most common oral and gastrointestinal manifestations of EDs and describes emergent complications such as acute gastric dilation and superior mesenteric artery syndrome. It is important for providers to recognize complications associated with EDs to provide the best treatment possible.

Community Health Workers in Home Visits and Asthma Outcomes.

BACKGROUND: The Community Asthma Initiative (CAI) was included in the New England Asthma Innovations Collaborative, which received a Centers for Medicare and Medicaid Services (CMS) Innovation grant. Under this grant, CAI transitioned from a mixed community health worker and nurse model to a nurse-supervised community health worker model. CMS limited enrollment to patients with Medicaid and encouraged 3 home visits per family. METHODS: A total of 389 patients enrolled under the CMS grant at Boston Children's Hospital from 2013 to 2015 (CMS group) were compared with 733 CAI patients with Medicaid enrolled from 2005 to 2012 (comparison group). Changes in 5 asthma-related measures (emergency department visits, hospitalizations, physical activity limitations, missed school days, and parent and/or guardian missed workdays) were compared between baseline and 6 and 12 months postenrollment. Measures were analyzed as dichotomous variables using logistic regression. Numbers of occurrences were analyzed as continuous variables. Changes in quality of life (QoL) among the CMS group were examined through a 13-question survey with activity and emotional health subscales. RESULTS: Although patients in both groups exhibited improvement in all measures, the CMS group had greater odds of decreased hospitalizations (odds ratio 3.13 [95% confidence interval 1.49-6.59]), missed school days (1.91 [1.09-3.36]), and parent and/or guardian missed workdays (2.72 [1.15-6.41]) compared to the comparison group. Twelve months postenrollment, the CMS group experienced improvement in all QoL questions and subscales (all P values <.01). CONCLUSIONS: The CMS group showed improved outcomes for hospitalizations and missed school and workdays compared to the comparison group. The CMS group also exhibited significant improvement in QoL.