General Academic Pediatrics Research Articles

Improving Evidence-based Management of Children and Adolescents with Elevated Blood Pressure during a Well-Child Encounter: A Quality Initiative

INTRODUCTION: Pediatric hypertension requires accurate diagnosis and management to reduce the burden of cardiovascular disease across the lifespan. Despite national guidelines, hypertension (HTN) is one of the most frequently missed diagnoses within pediatric primary care. This quality improvement (QI) project aimed to improve the management of patients aged 3–18 years with elevated blood pressure (BP) by 25% during a well-child encounter. METHODS: Over one year, a single-center QI project was conducted at an academic general pediatrics center. Multidisciplinary interventions, including team education, workflow standardization, and clinical decision support tools, were implemented using Plan-Do-Study-Act cycles to improve adherence to evidence-based guidelines. Outcome measures were the percentage of youth with an elevated BP on screening who had documentation of provider actions. We used run charts to analyze the effect of interventions, and descriptive statistics for demographic data and process measures pre- and postintervention. Chi-square tests compared process measures pre- and postintervention and provider actions stratified by age. RESULTS: Key drivers of change were the percentage of documented confirmatory BPs, BP stage, and scheduled follow-up appointments. At baseline, 13% of children with elevated BP on screening had guideline-adherent provider actions documented. This increased to 40% postintervention; however, discrepancies in adherence stratified by age were observed. Youth 13 and older were significantly more likely to receive a provider action than younger children (P < 0.0001). CONCLUSION: BP management during a well-child encounter improved with multidisciplinary interventions that increased knowledge of evidence-based guidelines and standardized care.

ADHD prescription patterns and medication adherence in children and adolescents during the COVID-19 pandemic in an urban academic setting

BackgroundCOVID-19 impacted all students, especially those with attention deficit hyperactivity disorder (ADHD), putting them at risk for disruption to their medication regimen and school performance. Our study aimed to identify if ADHD medication regimens were disrupted through analyzing prescription refills and if telehealth management demonstrated a higher rate of adherence.MethodsA total of 396 patients from the General Academic Pediatrics (GAP) clinic at Children’s Hospital of The King’s Daughters (CHKD) were included in the study. Patients were between the ages of 8–18 with a history of ADHD for three or more years that was medically managed with four or more prescription refills between January 2019 and May 2022. A retrospective chart review collected age, sex, race, refill schedule, appointment schedule, and number of telehealth appointments. Data analysis compared the variables and defined “pre-pandemic months” as January 2019 through March 2020 and “pandemic months” as April 2020 through June 2022.ResultsThe total percentage of patients who had their ADHD medications during pre-pandemic months ranged from 40 to 66% versus 31–44% during pandemic months. Additionally, the total percentage of patients who had quarterly ADHD management appointments during pre-pandemic months ranged between 59 and 70% versus 33–50% during pandemic months. The number of months with ADHD prescription refills over the last three years was significantly higher among those who had both virtual and in-person visits than those who had just in-person visits, p < 0.001. Regarding race, Black patients had a lower number of medication refills compared to White patients when controlled for appointment type. They also had a lower number of total appointments, but there was not a significant difference in the number of virtual appointments.ConclusionsSince the start of the pandemic, ADHD patients have both refilled their prescriptions and returned to clinic less frequently. This data suggests a need to re-evaluate the ADHD symptoms of GAP patients periodically and return them to a more consistent medication regimen. Telehealth appointments are a potential solution to increase adherence. However, racial inequities found in this study need to be addressed.

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Lifetime Earning Potential and Workforce Distribution in Developmental and Behavioral Pediatrics.

Compare lifetime earning potential (LEP) for developmental and behavioral pediatrics (DBP) to general pediatrics and other pediatric subspecialties. Evaluate association between LEP for DBP and measures of workforce distribution. Using compensation and debt data from 2018 to 2019 and a net present value analysis, we estimated LEP for DBP compared to general pediatrics and other pediatric subspecialties. We evaluated potential effects of eliminating educational debt, shortening length of fellowship training, and implementing loan repayment or forgiveness programs for pediatric subspecialists. We evaluated the association between LEP for DBP and measures of workforce distribution, including distance to subspecialists, percentage of hospital referral regions (HRRs) with a subspecialist, ratio of subspecialists to regional child population, and fellowship fill rates. LEP was lower for DBP than for general private practice pediatrics ($1.9 million less), general academic pediatrics ($1.1 million less), and all other pediatric subspecialties. LEP of DBP could be improved by shortening fellowship training or implementing loan repayment or forgiveness programs. LEP for subspecialists, including DBP, was associated with distance to subspecialists (-0.5 miles/$100,000 increase in LEP, 95% confidence interval [CI] -0.98 to -0.08), percentage of HRRs with a subspecialist (+1.1%/$100,000 increase in LEP, 95% CI 0.37-1.83), ratio of subspecialists to regional child population (+0.1 subspecialists/100,000 children/$100,000 increase in LEP, 95% CI 0.04-0.17), and average 2014 to 2018 fellowship fill rates (+1% spots filled/$100,000 increase in LEP, 95% CI 0.25-1.65). DBP has the lowest LEP of all pediatric fields and this is associated with DBP workforce shortages. Interventions to improve LEP may promote workforce growth.

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Improving Adherence to AAP Acute Otitis Media Guidelines in an Academic Pediatrics Practice through a Quality Improvement Project.

Introduction:Acute otitis media (AOM) is the most common reason for antibiotic use in children. The American Academy of Pediatrics (AAP) published its latest AOM guidelines in 2013. A safety-net antibiotic prescription (SNAP) is recommended for some patients based on age, severity, and duration of symptoms. At baseline, 78% of patients diagnosed with AOM in our general pediatrics practice met AAP guidelines, and 20% of eligible patients received a SNAP according to guidelines. We aimed to increase adherence to AAP AOM guidelines in an academic general pediatrics clinic from 78% to 90% by January 2020.Methods:A quality improvement team determined key drivers and developed interventions. Patients included were 6 months to 12 years old with AOM. Encounters were reviewed for adherence to AAP AOM guidelines. During the project, interventions included an ear pain note template, which generated guideline-based recommendations, note template education in clinic orientation sessions, a didactic session on AOM management, and reminders on workstations. Data were analyzed using P-charts.Results:Percent of AOM encounters (n = 1266) adhering to AAP AOM guidelines increased from 78% to 92%. We also reviewed two process measures. First, the use of the ear pain note template increased from 0% to 44%. Second, the percent of AOM encounters where an eligible patient received a SNAP increased from 21% to 78% (encounters n = 421).Conclusion:We demonstrate increased adherence to AAP AOM guidelines, including improved use of SNAPs after introducing a note template with clinical decision support and provider educational sessions.

Adolescents With Inflammatory Bowel Disease Have Decreased Rates of Health Maintenance Visits.

∗Division of Pediatric Gastroenterology, Hepatology, & Nutrition, MassGeneral Hospital for Children †Department of Pediatrics, Harvard Medical School ‡Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston, MA.

Caring for Children With Medical Complexity in the Early COVID-19 Pandemic in an Ambulatory Primary Care Setting.

BackgroundChildren with medical complexity (CMC) have multiple chronic conditions and require a high level of coordinated healthcare. The risk of COVID-19 among CMC is unclear.ObjectivesWe aim to identify and describe the prevalence and experience of COVID-19 among CMC and their caregivers during the initial weeks of the COVID-19 pandemic in the NY metropolitan area.MethodsWe performed a cross-sectional study of children enrolled in a structured clinical program for CMC at a large urban, academic general pediatrics practice in NY.ResultsIn our patient population (n = 132), 16 patients had a known exposure with parents being the most common exposure in 37.5% (n = 6). Two patients were hospitalized for COVID-19 while the remainder of the confirmed or suspected COVID-19 cases were managed as an outpatient.ConclusionsCommon sources of COVID-19 exposure were family members and home care providers. Almost all of our patients experienced interruption of medical care including missed therapies and visits.

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A quality improvement initiative to improve primary care referral rates for penicillin allergy delabeling

BackgroundOf the US population, 10% reports a penicillin allergy but more than 90% can ultimately tolerate penicillin. Confirmation of these allergies in the pediatric population may improve future health outcomes and decrease costs. Referring patients for confirmatory testing is the first step in clarifying penicillin allergies. ObjectiveTo increase the number of referrals of patients with listed penicillin allergies from the University of California, San Diego academic general pediatrics clinics to Rady Children's Hospital allergy clinics using an educational session and a best practice advisory (BPA) in the electronic medical record. MethodsAn educational session with attendings and 3 plan-do-study-act (PDSA) cycles were completed using a BPA alert that triggered for all patients with a documented penicillin-class drug allergy to draw attention and facilitate referral. The BPA was modified at each PDSA cycle based on physician input. ResultsAt baseline, 1.9% of referrals to the allergy clinic were for penicillin-class drug allergies. After an attending physician educational session, the percentage increased to 13.7%. The BPA was implemented with further increase to 27.8% of all allergy referrals in the course of 3 PDSA cycles. Not all patients with penicillin-class drug allergies were referred, and the reasons were documented when the physicians dismissed the BPA. Physicians did not refer 35% of the time because of time constraints, as opposed to patient or parent disinterest, which was 8% of the time. ConclusionReferrals to the allergist for confirmatory testing in patients with listed penicillin allergies increased by more than 10 fold. This study illustrates successful tools to support delabeling.

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Academic General Pediatrics Hiring Practices and Completion of Academic General Pediatrics Fellowships.

Academic General Pediatrics (AGP) is a pediatric subspecialty with substantial faculty contributions in clinical care, research, education, and advocacy. However, AGP fellowship recruitment challenges exist. We aimed to describe AGP hiring practices from 2014 to 2019 and the role of fellowship training in hiring decisions. We conducted a cross-sectional survey study of AGP Division Directors (DDs) and Fellowship Program Directors (PDs) from US-based academic institutions. Survey questions were developed iteratively and pilot-tested for content validity. Participants were identified from the Association of American Medical Colleges' directory of pediatric departments, Academic Pediatric Association's AGP Accreditation Committee's list of fellowship programs, and institutional websites. Descriptive analysis was used for close ended survey questions. Narrative responses were reviewed for trends. Forty-nine DDs (57%) and 22 PDs (73%) responded. All DDs reported at least one available faculty position and 73% reported filling a position with protected time.PDs reported 89 graduating fellows, 88% of whom secured an academic position with protected time. Seventy-percent of DDs and 100% of PDs reported that AGP fellows could secure an academic position with protected time, while only 22% and 1%, respectively, reported a graduating pediatric resident could secure a similar position. DDs indicated AGP fellowship trained candidates are preferable for enhancing research and education programs. AGP remains an active subspecialty and the majority of graduating fellows secured faculty positions with protected time. Further studies are needed to understand ways to improve visibility of AGP fellowships.

Can you hear me now? A toolkit for telemedicine training.

The Clinical TeacherVolume 18, Issue 4 p. 348-353 CLINICAL TEACHER'S TOOLBOX Can you hear me now? A toolkit for telemedicine training Lauren T. Roth, Corresponding Author LaRoth@montefiore.org orcid.org/0000-0001-5592-3927 Department of Pediatrics, Children’s Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY, USA Correspondence Lauren T Roth, Division of Academic General Pediatrics, Children’s Hospital at Montefiore, 1525 Blondell Avenue, Suite 102, Bronx, NY 10461. Email: LaRoth@montefiore.orgSearch for more papers by this authorMarguerite Costich, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USASearch for more papers by this authorScott Moerdler, Department of Pediatrics (Pediatric Hematology Oncology), Rutgers Cancer Institute of New Jersey/Rutgers Robert Woot Johnson Medical School, New Brunswick, NJ, USASearch for more papers by this authorMariellen Lane, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USASearch for more papers by this authorLaura Robbins-Milne, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USASearch for more papers by this authorEdith Bracho-Sanchez, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USASearch for more papers by this authorSuzanne Friedman, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USASearch for more papers by this author Lauren T. Roth, Corresponding Author LaRoth@montefiore.org orcid.org/0000-0001-5592-3927 Department of Pediatrics, Children’s Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY, USA Correspondence Lauren T Roth, Division of Academic General Pediatrics, Children’s Hospital at Montefiore, 1525 Blondell Avenue, Suite 102, Bronx, NY 10461. Email: LaRoth@montefiore.orgSearch for more papers by this authorMarguerite Costich, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USASearch for more papers by this authorScott Moerdler, Department of Pediatrics (Pediatric Hematology Oncology), Rutgers Cancer Institute of New Jersey/Rutgers Robert Woot Johnson Medical School, New Brunswick, NJ, USASearch for more papers by this authorMariellen Lane, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USASearch for more papers by this authorLaura Robbins-Milne, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USASearch for more papers by this authorEdith Bracho-Sanchez, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USASearch for more papers by this authorSuzanne Friedman, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USASearch for more papers by this author First published: 10 June 2021 https://doi.org/10.1111/tct.13390Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat Volume18, Issue4August 2021Pages 348-353 RelatedInformation

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Evaluating a No Hit Zone program and provider interventions at an urban academic pediatric practice

BackgroundVery few analyses of the effectiveness of No Hit Zone (NHZ) programs have been done to date. Prior research has demonstrated the negative impacts of corporal punishment (CP) as well as the positive role healthcare providers can play in providing information on disciplinary techniques. The Children’s Hospital of The King’s Daughters (CHKD) set up a NHZ program to address these needs. ObjectivesTo determine the effect of a fully-implemented No Hit Zone program and provider intervention on caregiver beliefs around discipline.To determine how effectively the program was implemented. Participants and settingThose surveyed were 244 parents or guardians of children between the ages of 18 months and 5 years at the General Academic Pediatrics (GAP) clinic at CHKD. MethodsParticipants were approached in their individual exam rooms. Once consent was obtained, participants were given a survey with questions investigating demographics, discipline use, NHZ awareness, and intervention effectiveness. ResultsAnalyses revealed about half of all participants reported having previously used corporal punishment to discipline their child at least once. Only 30% of participants reported having heard about the NHZ. Among those who had, self-reported viewpoint change about discipline style use had been significantly affected by the NHZ education and discussion with their pediatrician (p < 0.001). ConclusionsProvider interventions and establishment of a NHZ was found to be significantly associated with self-reported changes in attitudes about the use of discipline by caregivers. Areas of improvement include the dissemination of NHZ materials and applying the education interventions with more families.

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COVID-19 and Telehealth: Prevention of Exposure in a Medically Complex Patient With a Mild Presentation

The novel coronavirus disease-2019 (COVID-19) was declared a pandemic by the World Health Organization on March 11, 2020. We discuss a less common presentation of COVID-19 in a patient where the use of telemedicine technology prevented the exposure of the healthcare team in an academic general pediatrics clinic. A medically complex 20-year-old male presented via virtual visit for unilateral eye redness and discharge. He received topical ophthalmic antibiotics for presumed acute bacterial conjunctivitis and was counseled on return precautions. Three days later, the patient developed shortness of breath, fever to 102.6°F, and chest pain. COVID-19 testing returned positive. Conjunctivitis is a presenting symptom in 32% of COVID-19 cases. Current evidence suggests that these patients may transmit their illness at the time of presentation. Using telehealth, we avoided exposure to a COVID-19–positive patient who would not have met criteria for testing or droplet precautions. Telehealth allows providers to triage patients, identifying those who need to be seen in person, thereby minimizing exposure. Transitioning toward virtual practice, particularly during a pandemic, prepares for the possibility of healthcare workers being quarantined but still able to provide care and minimizes exposure to asymptomatic patients or those with atypical symptoms.