Screening for Toxic Stress Risk Factors at Well-Child Visits: The Addressing Social Key Questions for Health Study.

OBJECTIVES: To determine the prevalence of and demographic characteristics associated with toxic stress risk factors by universal screening, the impact of screening on referral rates to community resources, and the feasibility and acceptability of screening in a medical home setting. STUDY DESIGN: We developed the Addressing Social Key Questions for Health Questionnaire, a 13-question screen of adverse childhood experiences (ACEs) and unmet social needs. Parents/guardians of children 0-17 years of age received this questionnaire at well-child visits at 4 academic clinics from August 1, 2016 to February 28, 2017. Providers reviewed the tool and referred to community resources as needed. A subset of families completed demographic and satisfaction surveys. Prevalence of ACEs and unmet social needs, community referral rates at 1 site with available data, and family acceptability data were collected. Analyses included frequency distributions, χ2 tests, and Poisson regression. RESULTS: Of 2569 families completing an Addressing Social Key Questions for Health Questionnaire, 49% reported ≥1 stressor; 6% had ≥1 ACE; 47% had ≥1 unmet social need. At 1 site, community referral rates increased from 2.0% to 13.3% (P < .0001) after screening implementation. Risk factors for having a stressor include male sex and African American or Hispanic race. 86% of 446 families want clinics to continue screening. CONCLUSIONS: Universal screening for toxic stress risk factors in pediatric primary care improved identification and management of family needs. Screening was feasible and acceptable to families. Prevalence of unmet social needs but not ACEs was comparable with prior studies. Further evaluation and modification of the screening protocol is needed to increase screening and identification.

Parent Perspectives on Adverse Childhood Experiences & Unmet Social Needs Screening in the Medical Home: A Qualitative Study.

OBJECTIVES: To explore parental perspectives regarding disclosure of child and parental adverse childhood experiences (ACE) and family unmet social needs (USN) and to elicit parental recommendations for screening in the pediatric medical home. METHODS: We conducted a qualitative study using a purposive sample of English- and Spanish-speaking parents in our urban academic community clinic. Between January 2018 and March 2019, each parent underwent one semistructured interview that was audiotaped, transcribed, and independently coded in Atlas.ti by 2 study team members. Data analysis was based in constructivist grounded theory methodology to identify common themes and subthemes. RESULTS: We interviewed 25 English-speaking and 15 Spanish-speaking parents who were mostly female, racial/ethnic minorities with ≥1 ACE. English-speaking subjects were more likely to have a high school degree and be single parents. Four themes were identified: 1) Pediatricians should ask about ACE and USN. 2) Disclosure is a longitudinal process, not a discrete event. 3) Barriers to disclosure are significant, involving concrete and emotional risks for the family. 4) Trauma-informed providers and practices support disclosure. CONCLUSIONS: Families support pediatricians addressing ACE and USN in the medical home despite significant barriers. Even if providers screen using trauma-informed principles, parents may prefer not to disclose ACE initially because they regard disclosure as a stepwise process. These findings contribute to a new conceptual framework for thinking of ACE screening not merely as a way to generate information, but as an interactive, therapeutic relationship-building activity irrespective of whether or when it produces disclosure.

Comparing Software Determination of Readmission Preventability With Chart Review, Provider, and Family Assessments.

OBJECTIVES: To explore the concordance between software, chart reviewer, provider, and parent perspectives when assessing whether readmissions are preventable or clinically related to the initial admission. METHODS: Providers and parents of patients readmitted within 3 days to a tertiary children's hospital were enrolled in this single-site observational study. 3M Potentially Preventable Readmissions Grouping Software, chart reviewers, discharge and readmission providers, and parents assessed if readmissions were clinically related to the index admission or potentially preventable. Agreement between perspectives was measured by using Cohen's κ values. RESULTS: The software found 67 of 118 (57%) clinically related readmissions; the identical 67 of 118 cases (57%) were found to be potentially preventable. Chart reviewers found 107 of 125 (86%) clinically related and 60 of 125 (47%) preventable readmissions compared to 68 of 92 (74%) and 27 of 92 (28%) for discharge physicians and 69 of 93 (74%) and 33 of 93 (34%) for readmitting physicians. Parents reported 9 of 36 (25%) preventable readmissions. Cohen κ values revealed no to minimal agreement on clinical relatedness of readmissions between software and chart reviewer, discharge provider, and readmission provider (0.12-0.20), whereas chart reviewers and providers had weak to moderate agreement with each other (0.43-0.75). There was no to minimal agreement on preventability between software and the other perspectives (-0.04 to 0.21), whereas chart reviewers and providers had minimal to weak agreement (0.27-0.56). CONCLUSIONS: Measurement of preventable readmissions remains problematic, and using financial penalties for readmissions on the basis of software determinations may be unwise given low levels of agreement. Chart review supplemented by information from providers and families offers a more inclusive way to identify potentially preventable readmissions.

Pediatric Readmissions Within 3 Days of Discharge: Preventability, Contributing Factors, and Necessity.

OBJECTIVES: Among pediatric 30-day readmissions, 20% to 30% are preventable, and ∼25% are within 3 days of discharge. We investigated the preventability, contributing factors, and necessity of 3-day pediatric readmissions. METHODS: We enrolled patients who were readmitted within 3 days at a freestanding tertiary children's hospital in this single-site observational study from July 2016 to February 2017. We performed chart reviews and interviews with discharge and readmission providers and families. Preventability was defined by the chart reviewer's determination. Contributing factors for readmission, demographics, and clinical characteristics were analyzed for association with preventability and necessity. We analyzed qualitative data using content analysis. RESULTS: Of the 125 readmission cases included, 60 (48%) were preventable per chart reviewer compared with 27 of 92 (29%) per discharge providers, 33 of 93 (35%) per readmission providers, and 9 of 36 (25%) per families. Preventability was associated with the following contributing factors: problems with clinical decision-making in 54 of 125 (43%) readmissions (P < .001), issues with the discharge process in 25 of 125 (20%) readmissions (P = .01), clinically related admission and readmission (P = .004), and weekday of initial discharge (P = .02). Seventeen percent were unnecessary per readmission provider. Clinically unnecessary readmissions were associated with Hispanic ethnicity (P = .02), outside-hospital transfer (P = .05), and problems with clinical decision-making (P = .01). Qualitative data highlighted disagreement on readiness for discharge and the necessity of readmission among various providers and family. CONCLUSIONS: More than one-half of 3-day readmissions were considered either preventable or unnecessary. Clinical decision-making, discharge processes, and improving consensus among families and providers may be valuable areas for future efforts to reduce readmission.

Evaluation of Pediatric Human Papillomavirus Vaccination Provider Counseling Written Materials: A Health Literacy Perspective.

BACKGROUND AND OBJECTIVES: Despite recommendations supporting human papillomavirus (HPV) vaccination, pediatric vaccination rates remain suboptimal in the United States; lack of tools to support provider counseling is one barrier. We sought to evaluate HPV-related counseling materials for readability, suitability, and content, and assess parent perceptions of materials, using a health literacy perspective. METHODS: A systematic search was conducted for written materials developed for HPV vaccination counseling by examining state Department of Health Web sites and associated links to local and national organizations. Materials were assessed for the following: 1) readability (Flesch Reading Ease, Flesch-Kincaid, Gunning Fog, Simple Measure of Gobbledygook, Fry), 2) suitability (understandability and actionability) (Suitability Assessment of Materials; Patient Education Materials Assessment Tool for Printable Materials), and 3) coverage of 8 key content areas (recommended by Centers for Disease Control and Prevention). Semistructured interviews were conducted with English-speaking parents or caregivers of children 9 to 17 years of age from 3 pediatric clinics (New York, Ohio, Illinois) serving predominantly low-income families to assess perceptions and usefulness of 4 handouts selected for review. RESULTS: Thirty-eight documents were assessed. Mean ± standard deviation (SD) reading grade level was 9.4 ± 2; 10.5% (n = 4) had a reading level of 6th grade or below; 68.4% (n = 26) were considered not suitable. Mean understandability was 41.7% and mean actionability was 20.7%. Only 5.3% (n = 2) addressed all 8 content areas mean ± SD (number of areas = 6.7 ± 1.2). Brochure comprehensiveness and inclusion of a personal story were cited as factors that would be helpful in influencing parents to vaccinate against HPV. CONCLUSIONS: Few written materials for HPV vaccination counseling were optimal from a health literacy best practices perspective. Content comprehensiveness was important for informed decision making.

Exploring caregiver understanding of medications immediately after a pediatric primary care visit.

OBJECTIVE: Assess accuracy of caregiver understanding of children's prescribed medications and examine factors associated with accurate recall. METHODS: Cross-sectional, observational study of English- or Spanish-speaking caregivers of primary care patients aged 0-7 years. Child and visit characteristics and caregiver health literacy (short test of health literacy in adults) were assessed. Post-visit, caregivers completed questionnaires on medications prescribed. Caregiver and medical record agreement on medication name and administration (dose and frequency) were examined using chi square and logistic regression. RESULTS: Analyses included 68 caregivers (28% low health literacy); 96% of children had public insurance. Caregivers indicated that the doctor provided clear medication information (100%) and they could follow instructions (98%). 101 medicines were prescribed; 6 were recalled by caregiver only. 71% of medications were accurately named; 37% of administration instructions were accurately recalled. Accurate naming was more often found for patients 3-7 years, without conditions requiring repeat visits, and new medications. Accurate administration responses were associated with having only 1 child at the visit. CONCLUSION: Unperceived medication instruction understanding gaps exist at physician visits for caregivers of all literacy levels. Communication and care delivery practices need further evaluation. PRACTICE IMPLICATIONS: Clinicians should be aware of the frequency of caregiver medication misunderstanding.

A novel program trains community-academic teams to build research and partnership capacity.

The Community-Engaged Research Team Support (CERTS) program was developed and tested to build research and partnership capacity for community-engaged research (CEnR) teams. Led by the Northwestern University Clinical and Translational Sciences Institute (NUCATS), the goals of CERTS were: (1) to help community-academic teams build capacity for conducting rigorous CEnR and (2) to support teams as they prepare federal grant proposal drafts. The program was guided by an advisory committee of community and clinical partners, and representatives from Chicago's Clinical and Translational Science Institutes. Monthly workshops guided teams to write elements of NIH-style research proposals. Draft reviewing fostered a collaborative learning environment and helped teams develop equal partnerships. The program culminated in a mock-proposal review. All teams clarified their research and acquired new knowledge about the preparation of NIH-style proposals. Trust, partnership collaboration, and a structured writing strategy were assets of the CERTS approach. CERTS also uncovered gaps in resources and preparedness for teams to be competitive for federally funded grants. Areas of need include experience as principal investigators, publications on study results, mentoring, institutional infrastructure, and dedicated time for research.

Pediatricians and health literacy: descriptive results from a national survey.

OBJECTIVE: To describe pediatricians' self-reported experiences with health literacy, use of basic and enhanced communication techniques, and perceived barriers to effective communication during office visits. DESIGN/METHODS: A national, random sample of 1605 nonretired, posttraining American Academy of Pediatrics members were surveyed in 2007 about health literacy and patient communication as part of the Periodic Survey of Fellows. The response rate was 56% (N = 900). RESULTS: Eight-one percent of the pediatricians were aware of a situation in the previous 12 months in which a parent had not sufficiently understood health information that had been delivered to him or her. In addition, 44% of all pediatricians were aware of a communication-related error in patient care within the previous 12 months. Using simple language (99%), repeating key information (92%), and presenting only 2 or 3 concepts at a time (76%) were the most commonly used communication strategies. Enhanced communication techniques recommended by health literacy experts such as teach-back and indicating key points on written educational materials were used less often (23% and 28%, respectively). The most common reported barriers to effective communication were limited time to discuss information (73%), volume of information (65%), and complexity of information (64%). The majority of physicians rated themselves highly in their ability to identify caregiver understanding (64%), but only 21% rated themselves as very good or excellent in identifying a parent with a literacy problem. Fifty-seven percent of the respondents were interested in training to improve communication skills, and 58% reported that they would be very likely to use easy-to-read written materials, if available from the American Academy of Pediatrics. CONCLUSIONS: Pediatricians are aware of health literacy-related problems and the need for good communication with families but struggle with time demands to implement these skills. Despite awareness of communication-related errors in patient care, pediatricians report underutilizing enhanced techniques known to improve communication.