Ambulatory Pediatrics Research Articles

Racial, Ethnic, and Language Inequities in Ambulatory Pediatrics Patient Family Experience

ObjectiveTo determine the association of patient race, patient-provider racial congruence, patient ethnicity, and family primary language with patient family experience (PFE) survey responses. MethodsCross-sectional review of PFE survey responses from all ambulatory medical encounters at a large, urban children’s hospital system June 1, 2020—May 31, 2022. Exposures were patient race, patient-provider racial congruence, patient ethnicity, and family primary language. We adjusted analyses for neighborhood-level socioeconomic deprivation, patient sex and age, encounter specialty, and location of care. Outcomes were PFE survey scores for five questions focused on overall experience, respect, and safety; categorized using industry standard metric of presence of a “top-box” score, defined as a nine or 10 for questions on an 11-point scale or as four on a four-point scale. ResultsWe included 89,175 surveys (15.6% response rate). The odds of having optimal, “top-box” responses for several assessed questions were lower for patients identified as Asian (eg, adjusted odds ratio [OR] 0.46; 95% confidence interval [CI] 0.40, 0.52) or Black (eg, OR 0.65; CI 0.60, 0.70) compared to White, and for Hispanic (eg, OR 0.84; CI 0.72, 0.97) compared to non-Hispanic. Similarly, the odds of having “top-box” scores were lower for Spanish-primary-language (eg, OR 0.38; CI 0.30, 0.48) compared to English-primary-language patients. Patient-provider racial congruence had higher odds of “top-box” responses for two of five assessed questions (eg, OR 1.18; CI 1.04, 1.35). ConclusionsWe found previously unreported inequities in ambulatory pediatric PFE outcomes, with worse experiences reported by Asian, Black, Hispanic, and Spanish-language patients.

Maternal, prenatal and postnatal risk factors for early child physical abuse: a French nationwide cohort study

Identifying risk factors for early child physical abuse (CPA) is crucial for understanding its mechanisms and defining effective preventive interventions. We aimed to identify maternal, prenatal and postnatal factors associated with early CPA. This cohort study was based on comprehensive data from the Mother-Child EPI-MERES nationwide register and included all infants born alive in France between 2010 and 2019. Factors associated with early CPA (before age 1) were identified with a multilevel Cox regression model with random intercepts at the regional level. Among the 6,897,384 included infants, 2994 (40/100,000) had a diagnosis of early CPA, at a median age of 4months. Independent factors most strongly associated with early CPA were maternal low financial resources (adjusted hazard ratio [aHR] 1.91; 95% confidence interval [95% CI] 1.67-2.18), maternal age <20 years versus 35-40 years (aHR 7.06; 95% CI 6.00-8.31), maternal alcohol use disorder (aHR 1.85; 95% CI 1.48-2.31), opioid use disorder (aHR 1.90; 95% CI 1.41-2.56), intimate partner violence (aHR 3.33; 95% CI 2.76-4.01), diagnosis of a chronic mental disorder (aHR 1.50; 95% CI 1.14-1.97) or somatic disorder (aHR 1.55; 95% CI 1.32-1.83), hospitalisation for a mental disorder (aHR 1.88; 95% CI 1.49-2.36), very preterm birth (aHR 2.15; 95% CI 1.68-2.75), and diagnosis of a chronic severe neurocognitive disorder in the infant (aHR 14.37; 95% CI 11.85-17.44). Independent risk factors of early CPA identified at the national level in France may help in understanding CPA mechanisms and developing effective prevention programs including risk-stratification tools to optimise the allocation of parenting interventions to parents who could most benefit from them. Ile-de-France regional council, L'Oréal-UNESCO For Women In Science France Young Talent Award, French National Observatory for Child Protection [ONPE], French Association of Ambulatory Paediatrics [AFPA], HUGO university hospitals network, Mustela Foundation and Sauver la Vie prizes.

Ambulatory pediatricians: how to bridge the gaps in diagnosis and care coordination for neurodevelopmental disorders in France.

The organization of healthcare pathways for neurodevelopmental disorders (NDD) relies on different levels of expertise depending on the complexity of these disorders. NDDs affect between 8% and 15% of children. Historically, national recommendations and healthcare planning measures were initially devoted to autism spectrum disorders and were gradually extended to Attention deficit hyperactivity disorder (ADHD) and specific learning and development disorders. Private doctors play an increasing role in these pathways at different levels of care due to difficulties in organization, particularly in the health and social sector. The aim of this work was to evaluate the contribution of second-line private doctors in the diagnosis and care of children affected by NDD. A first series of surveys in 2016 evaluated the level of commitment of primary care pediatricians; this online national survey was repeated in 2023 among 1,430 members of the French Association of Ambulatory Pediatrics (Association Française de Pédiatrie Ambulatoire: AFPA) to assess their training, current and future involvement, and activity in NDD care. Analysis was performed by the main author using Epi-Info software. The study identified in 2023 214 second-line private doctors (14% of all pediatricians in activity), of which 185 agreed to appear in a directory published the same year by the AFPA to facilitate referrals from other professionals. Sex ratio of responders is usual for paediatricians: 79.5%/20.5% (F/M), with a distribution among ages showing a slight increase of the age range between age 51-60 (30.5%). Our data indicate that in France in 2022, second-line private doctors made 48%-53% of NDD diagnoses, 24%-26.4% of follow-up consultations and declare to be accountable for 21% of initial prescriptions for Methylphenidate. Among these second-line doctors, 40% had completed a post-university degree on NDD, 74.3% had completed professional development training (PDT) and 85.2% had completed either or both types of training. Most doctors participating in the survey wanted to improve their level of practice, suggesting that in five years, the number of second-line private doctors will increase by 20% to 244 despite 24 planned retirements within the same period. This data probably underestimates the role of private doctors in NDD diagnosis, follow-up, and initial Methylphenidate prescriptions given the unfavourable working conditions (no financial compensation for long appointments, difficulty accessing paramedical and psychological assessments). Our data confirms that diagnosis and care coordination in the various presentations of NDD may rely on different types of practices and specializations: medical and social professionals, mental health professionals, but also a growing body of medical doctors involved in developmental and behavioural pediatrics. This data and reflection will be helpful for organizing healthcare in France or in other countries. Main study limitation relies in the self-declaration of MD's involvement in NDD and could not evaluate the activity of employed MD's from the social and medico social sector, nor be based on the national databases for prescription. It remains however the first attempt of characterization of medical activity at the national level in France for NDD.

Assessing the Burden of Respiratory Syncytial Virus-related Bronchiolitis in Primary Care and at 15-Day and 6-Month Follow-up Before Prophylaxis in France: A Test-negative Study.

To assess the burden of respiratory syncytial virus (RSV)-related bronchiolitis in primary care and at 15 days and 6 months after a primary care visit. In this test-negative study, children <2 years old with a first episode of bronchiolitis were prospectively enrolled by 45 ambulatory pediatricians in France from February 2021 to April 2023. RSV was assessed with a rapid antigen detection test. The burden of the disease was assessed with a questionnaire, including quality of life (PedsQL 1.0 Infant Scales), at 15-day and 6-month follow-up. Children with a positive RSV test result (RSV+) were compared to those with a negative test result (RSV-). Among the 1591 children enrolled, 750 (47.1%) were RSV+. At 15 days follow-up (data availability: 69%), as compared with RSV- children, RSV+ children more frequently had fever (20.5% vs. 13.7%, P = 0.004) and decreased food intake (27.0% vs. 17.4%, P < 0.001) during the last 3 days. They had higher rates of hospitalization (11.8% vs. 5.8%, P < 0.001), childcare absenteeism (83.5% vs. 66.1%, P < 0.001) and parents who had to stop working to care for them (59.1% vs. 41.0%, P < 0.001) as well as lower quality of life (median PedsQL score 76.2 vs. 78.4, P = 0.03). At 6 months (data availability: 48.5%), the 2 groups did not differ in proportion of medical attendance, hospitalization, antibiotic treatment or quality of life. RSV+ children experienced much more severe disease and follow-up family and societal burden than RSV- children. These data may be used as baseline data as RSV prophylaxis is about to be implemented.

Impact of early COVID-19 pandemic events in Singapore on clinic attendance and default rates in a hospital-based ambulatory paediatrics service

Impact of early COVID-19 pandemic events in Singapore on clinic attendance and default rates in a hospital-based ambulatory paediatrics service

Use of Rapid Antigen Triple Test Nasal Swabs (COVID-VIRO ALL-IN TRIPLEX: Severe Acute Respiratory Syndrome Coronavirus 2, Respiratory Syncytial Virus, and Influenza) in Children With Respiratory Symptoms: A Real-life Prospective Study.

In autumn 2022, the epidemics due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), respiratory syncytial virus (RSV), and influenza overlapped, and these diseases can present with the same symptomatology. The use of a triple antigen test (SARS-CoV-2 + influenza A/B + RSV) seems crucial for accurate viral diagnosis in the context of implementing long-acting monoclonal antibody vaccination against RSV in the upcoming RSV season. We assessed the usefulness of the triple test in real life in this prospective study performed from October 2022 to May 2023 and involving 116 pediatricians (2 emergency department pediatricians and 114 ambulatory pediatricians). Children <15 years old with flu-like illness (with fever), bronchiolitis (dyspnea ± wheezing), otitis, and croup were enrolled and sampled with a nasal triple test. For 8329 children with flu-like illness (65.3%), bronchiolitis (17.9%), otitis (8.8%), and croup (6.3%), the use of the triple test led to a viral diagnosis in 47.9% of cases. The highest RSV positivity occurred in children with bronchiolitis (32.9%). The highest influenza A and B positivity (24.6% and 19.6%) occurred in children with flu-like illness. A succession of 3 epidemics (RSV and influenza A and B) occurred over time with several overlap periods. The triple test allowed for a viral diagnosis in half of our cases. The upcoming introduction of RSV prevention will emphasize the need for active surveillance with viral results both in ambulatory settings and hospitals. Clinical Trials Registration. NCT0441231.

Surveillance of noninvasive group A Streptococcus infections in French ambulatory pediatrics before and during the COVID-19 pandemic: a prospective multicenter study from 2018-2022

We evaluated the burden of noninvasive group A Streptococcus (GAS) infections in ambulatory pediatrics before and during the COVID-19 pandemic in France. We analyzed data from a national network of ambulatory pediatricians between 2018 and 2022. Clinicians evaluating children ≤15 years old for tonsillopharyngitis, perianal infections, paronychia/blistering dactylitis, and scarlet fever were invited to perform a rapid antigen detection test (RADT) for GAS. Monthly incidence of noninvasive GAS infections per 10,000 visits was modeled using time series analysis, considering two breakpoints: March 2020 (first national lockdown) and March 2022 (end of mandatory mask-wearing in schools). Over the study period, 125 pediatricians recorded 271,084 infectious episodes. GAS-related illnesses represented 4.3% of all infections. In March 2020, the incidence of GAS diseases decreased by 84.5% (P <0.001), with no significant trend until March 2022. After March 2022, the incidence significantly increased (+23.8% per month, P <0.001), with similar patterns across all monitored GAS-related diseases. By using routine clinical data and RADTs, we have monitored changes in the incidence of noninvasive GAS infections in ambulatory pediatrics. COVID-19 mitigation measures have had a major impact on the epidemiology of noninvasive GAS infections, but their relaxation was followed by a surge above baseline levels.

Quality improvement in pediatrics: Survey Needs Assessment for Ambulatory Pediatric Specialties (SNAAPS).

Quality improvement in pediatrics: Survey Needs Assessment for Ambulatory Pediatric Specialties (SNAAPS).

50 Years Ago in TheJournalofPediatrics: Pediatric Nurse Practitioners: 50 Years of Partnering for Children's Health

Silver HK. A blueprint for pediatric health manpower for the 1970's: the 1972 George Armstrong Lecture. J Pediatr 1973;82:149-56. Dr Henry Silver's lecture to the Ambulatory Pediatric Association is as resonant today as it was 50 years ago. He noted that there was an inadequate supply of pediatric health care providers and recounted a few rejected solutions, such as shortening the medical school curriculum. The focus of his lecture, however, was emphasizing the importance of nurse practitioners (NPs) in providing care for children. The first NPs in the US graduated from Dr Silver's program in 1965 after 4 months of postnursing training. Dr Silver found that both pediatricians and parents were satisfied with care received from the NP when using a combined model: having a NP provide care with a physician available for consultation as needed. NPs showed the potential to provide quality health care in primary are settings, and Dr Silver proposed that their roles could be expanded into the community by providing care in school-based clinics. The role of the NP has continued to evolve, and training has become more intense since Dr Silver's “blueprint for pediatric health manpower” lecture. NPs can select a master's program that can be completed in 2-3 years and, for those interested in educational advancement, a post-master's doctoral program that can be completed in 2-3 years. They also have the option to select the primary care or acute care tracks. The primary care track focuses education within the primary care setting, specialty clinics, or in the community, whereas the acute care track focuses on the care of hospitalized patients. Today, NPs have a presence in a variety of settings fulfilling their roles in the “diagnosis and management of acute and chronic illness, health promotion, disease prevention, health education and counseling.”1American Association of Nurse PractitionersDiscussion Paper: Standards of Practice for Nurse Practitioners, 2019 update.https://storage.aanp.org/www/documents/advocacy/position-papers/StandardsOfPractice.pdfDate accessed: October 11, 2020Google Scholar NPs play critical roles partnering with pediatricians in the care of children in primary care offices, school-based health centers, neonatal intensive care units, as members of surgical teams, and many other areas. Dr Silver was prescient in his call for enhancing the care for children by partnering with NPs, yet the shortage of health care providers is likely to continue. By the year 2030, there is estimated to be 76.3 million children in the US, with a decreasing number of pediatricians and only 1025 pediatric NPs becoming licensed yearly.2Gigli K.H. Beauchesne M.A. Dirks M.S. Peck J.L. White Paper: Critical shortage of pediatric nurse practitioners predicted.J Pediatr Health Care. 2019; 33: 347-355Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar It remains as important as ever for pediatricians and NPs to continue working together and encourage ongoing development of both workforces.

Factors Associated With Clinician Self-Reported Resource Use in Acute Care and Ambulatory Pediatrics.

The objective of this study is to determine predictors of resource use among pediatric providers for common respiratory illnesses. We surveyed pediatric primary care, emergency department (ED)/urgent care (UC), and hospital medicine providers at a free-standing children's hospital system. Five clinical vignettes assessed factors affecting resource use for upper respiratory infections, bronchiolitis, and pneumonia, including provider-type, practice location, tolerance to uncertainty, and medical decision-making behaviors. The response rate was 75.3% (168/223). The ED/UC and primary care providers had higher vignette scores, indicating higher resource use, compared with inpatient providers; advanced practice providers (APPs) had higher vignette scores compared with physicians. In multivariate analysis, being an ED/UC provider, an APP, and greater concern for bad outcomes were associated with higher vignette scores. Overall, provider type and location of practice may predict resource use for children with respiratory illnesses. Interventions targeted at test-maximizing providers may improve quality of care and reduce resource burden.

Supplemental Material for Quality Improvement in Pediatrics: Survey Needs Assessment for Ambulatory Pediatric Specialties (SNAAPS)

Supplemental Material for Quality Improvement in Pediatrics: Survey Needs Assessment for Ambulatory Pediatric Specialties (SNAAPS)

Development of a Training Textbook for Countermeasures to “Verbal Abuse, Physical Assault, and Harassment in Pediatric Medical Settings”

Background: Recently, abuse, assault, and harassment in pediatric medical settings have become more serious. We extracted typical problems from a nationwide simultaneous survey on abuse in the pediatric medical field and developed a training textbook to simulate or discuss these issues with colleagues. This study aimed to confirm the validity and usability of the contents of this training textbook. Methods: The textbook was mailed to the heads of 51 medical institutions affiliated with the Society of Ambulatory and General Pediatrics of Japan (SAGPJ) and the participants of the SAGPJ online workshop, who were asked to evaluate the textbook using a three-point scale to answer the following questions and provide opinions and impressions about the textbook. Q1. Do you think the whole content and structure of this textbook are useful? Q2. Would you use this textbook as a training textbook for all staff at your facility? A simple tabulation was performed on the evaluation using a three-point scale, while content analysis was performed on the opinions and impressions of the participants. Results: In response to Q1 and Q2, all 63 staff members from 55 facilities answered “3: Yes.” Opinions and impressions on the training textbook included “I think it can be used for workplace training” and “it is useful for exchanging various opinions among staff members and gaining a common opinion.” Conclusion: We developed a training textbook on abuse, assault, and harassment in pediatric medical settings based on a nationwide survey and confirmed the validity and usability of its contents.

Abstract 10889: Impact of the COVID-19 Pandemic on Ambulatory Pediatric Cardiology Care by Race/Ethnicity

Introduction: Racial/ethnic disparities in congenital heart disease outcomes are well documented. The impact of COVID-19 on race/ethnicity in access to ambulatory pediatric cardiology care is unknown. Methods: To examine differences in ambulatory care visits by race/ethnicity and whether differences were exacerbated by the COVID pandemic (March 2020), we examined number of visits scheduled (0-18 years old) and visit completion (as scheduled, delayed completion within 6 months, incomplete) by race/ethnicity. We focused on early pandemic, April 2020 (vs April 2019) and later pandemic, July 2020 (vs April 2020), using chi-square and logistic regression. Results: Annual clinic volume fell by 4.5% during the pandemic (18,725 to 17,866). Race/ethnicity shifted slightly towards white compared to non-white minority (NWM) 30% vs 28%, p &lt;0.001. Public insurance was constant at 33%, p =0.83. Telehealth visits accounted for 46% of visits during the pandemic (0.8% pre-pandemic), with different utility by white than NWM patients (49% vs 43%, p &lt;0.001). Visits in April 2020 fell by 57% from April 2019 and percent of visits completed without delay declined from 69% to 39%, p &lt;0.001. Visits in July were similar from 2019 to 2020 but visits completed without delay declined from 71% to 62%, p &lt;0.001. Visit completion rates varied by race/ethnicity (Figure 1), with differences between white vs NWM early in the pandemic ( p =0.01). Differences in visit completion rates by race/ethnicity were not significantly different from the year prior ( p for interaction=0.74) or from April to July 2020 ( p for interaction=0.48). Conclusions: NWM have higher rates of incomplete/delayed visits compared to whites, though the difference was not statistically heightened by the pandemic. Telehealth visits have become a prominent part of ambulatory care, with higher completion rates by white patients. Efforts to reduce lapses in care are needed across demographics to ensure equitable care delivery.

Assessment of SARS-CoV-2 testing in children during a low prevalence period (VIGIL study 1)

ObjectivesSARS-CoV-2 induces a broad spectrum of clinical manifestations, which overlap with other viral infections very common in children. We aimed to describe the percentage of positive SARS-CoV-2 RT-PCR tests in symptomatic and asymptomatic ambulatory children and to determine the predictive factors for positivity. Patients and MethodsFrom June 1 to July 31, 2020, we conducted a cross-sectional prospective, multicenter study (13 hospital emergency units and 59 ambulatory pediatricians) throughout France. Children under 15 years of age with a prescription of nasopharyngeal SARS-CoV-2 RT-PCR test were enrolled. ResultsAmong the 1,553 RT-PCR tests, 22 were positive (1.4%; 95%CI [0.9; 2.1]). In both univariate and multivariate analyses, the predictive factors for positivity were age below 2 years (OR: 4.5 [1.6; 12.7]) and history of contact (OR: 12.3 [4.6; 32.8]). ConclusionsIn an epidemic stage with low SARS-CoV-2 circulation, sampling of children with nonspecific symptoms and without known contact could be questioned.

Increasing Use of Ambulatory Video Visits for Pediatric Patients by Using Quality Improvement Methods.

Live video visits for ambulatory encounters offer potential benefits, including access to remote subspecialty services, care coordination between providers, and improved convenience for patients. We aimed to increase the utilization of video visits for pediatric patients at our medical center using an iterative quality improvement process. A multispecialty improvement team identified opportunities to increase video visit utilization and prioritized interventions using benefit-effort analyses. Interventions focused on 6 key drivers. The outcome measure was the percentage of ambulatory encounters conducted by video. The process measure was the percentage of ambulatory pediatricians conducting video visits. The balancing measure was the percentage of no-shows among scheduled video visits. All measures were analyzed using statistical process control. Interventions were associated with increases in our outcome and process measures from 0.1% to 1.2% and 0.6% to 6.3%, respectively, during the first 8 months. Subsequently, the novel coronavirus (COVID-19) pandemic was associated with further increases in these measures to 41.8% and 73.5%, respectively, over 3 months. The balancing measure increased from 0% at baseline to 14.7% with no special cause variation during the intervention period. The most impactful interventions included clinician training outreach, providing equipment, and streamlining MyChart patient enrollment. This improvement project effectively increased pediatric ambulatory video visit utilization, although the most significant driver of utilization was the COVID-19 pandemic. Project interventions implemented before COVID-19 facilitated rapid video visit adoption during the pandemic. A similar improvement process may be beneficial for other medical centers aiming to improve video visit utilization.

Face Masks in Young Children During the COVID-19 Pandemic: Parents' and Pediatricians' Point of View.

Background: In countries with high SARS-CoV-2 circulation, the pandemic has presented many challenges on different fronts, affecting lives and livelihoods; efforts to keep schools open are among the most important. In France, to keep schools open, wearing a face mask has been mandatory for children from age 6 years since November 2020.Objective: To evaluate the acceptability and tolerance of this measure by children as well as both parents and pediatricians.Setting: Parents registered on the website of the French Association of Ambulatory Pediatrics and pediatricians members of this association.Participants: All parents and pediatricians who agreed to take part in the survey.Results: Among the 2,954 questionnaires for the parents' survey, the reasons for wearing a mask were understood by 54.6% of parents, most of whom (84.6%) explained the reasons to their children. The parents applied this measure because it was mandatory (93.4%) even if they disagreed (63.3%). When interviewed by parents, children said they were usually embarrassed (80.9%) by the mask. The main symptoms or changes of behavior attributed to the mask according to parents were headache (49.0%), speaking difficulties (45%), change in mood (45.2%) and breathing discomfort (28.1%). Among the 663 pediatricians who responded, many agreed with mandatory mask-wearing at age 6 years (67.7%). Overall, 15% of pediatricians systematically asked about the mask tolerance during the consultation. During the medical consultation, when the parents complained about the mask (64.3%), the main drawbacks were related to fog on glasses (reported by 68.2% of pediatricians), breathing discomfort (53.1% of pediatricians), cutaneous disorders (42.4% of pediatricians) and headaches (38.2% of pediatricians).Conclusion: Despite the many inconveniences reported, children agree to wear the mask better than their parents think. Pediatricians should sufficiently take the opportunity during the consultation to further explain the reasons for wearing the mask because their pedagogical role is crucial.

Head circumference from birth to five years in France: New national reference charts and comparison to WHO standards.

BackgroundThe monitoring of head circumference (HC) is essential to early detect any conditions affecting its growth in early childhood. A positive secular trend and regional specificities in HC suggested the need to provide updated national HC reference growth charts.MethodsWe extracted all growth data collected from 42 primary-care physicians from across the French metropolitan territory who used the same electronic medical-records software. We selected HC measurements up to age five years for all children who were born after 1990 with birth weight > 2500 g. We derived new HC growth charts by using Generalized Additive Models for Location, Scale and Shape, then externally validated them until 30 months of age by comparison with the national population-based Étude Longitudinale Française depuis l'Enfance (ELFE) birth cohort and compared them to previous French and WHO growth charts.FindingsWith 973,869 HC measurements from 157,762 children, new calibrated HC growth charts from birth to age five years were generated. The new HC growth charts showed good external fit by comparison with the ELFE birth cohort. As compared with the new HC growth charts, the previous French and WHO growth charts mean HC z-scores were, respectively, -0.4 and -0.6 SD for girls and -0.2 and -0.6 SD for boys.InterpretationWe produced and validated national calibrated HC growth charts by using a novel big-data approach applied to data routinely collected in clinical practice. Comparison with previous French and WHO growth charts confirmed a positive secular trend since the 1960s and regional specificities.FundingThe French Ministry of Health; Laboratoires Guigoz—General Pediatrics section of the French Society of Pediatrics—Paediatric Epidemiological Research Group; the French Association of Ambulatory Pediatrics; and educational grant from the Regional Health Agency of Ile-de-France.

New Approach to the Surveillance of Pediatric Infectious Diseases From Ambulatory Pediatricians in the Digital Era.

Many ambulatory networks in several countries have established syndromic surveillance systems to detect outbreaks of different illnesses. Here, we describe a new Pediatric and Ambulatory Research in Infectious diseases network that combined automated data extraction from the computers of primary care pediatricians. Pediatricians who used the same software, AxiSanté 5-Infansoft for electronic medical records were specially trained in infectious diseases, encouraged to comply with French treatments' recommendations, use of point-of-care tests and vaccination guidelines. Infectious disease diagnoses in children <16 years old in the records triggered automatic data extraction of complete records. A quality control process and external validation were developed. From September 2017 to February 2020, 107 pediatricians enrolled 57,806 children (mean age 2.9 ± 2.6 years at diagnosis) with at least one infectious disease diagnosis among those followed by the network. Among the 118,193 diagnoses, the most frequent were acute otitis media (n = 44,924, 38.0%), tonsillopharyngitis (n = 13,334, 11.3%), gastroenteritis (n = 12,367, 10.5%), influenza (n = 11,062, 9.4%), bronchiolitis (n = 10,531, 8.9%), enteroviral infections (n = 8474, 7.2%) and chickenpox (n = 6857, 5.8%). A rapid diagnostic test was performed in 84.7% of cases of tonsillopharyngitis and was positive in 44%. The antibiotic recommendations from French guidelines were strictly followed: amoxicillin was the most prescribed antibiotic and less than 10% of presumed viral infections were treated. This "tailor-made" network set up with quality controls and external validation represents a new approach to the surveillance of pediatric infectious diseases in the digital era and could highly optimize pediatric practices.

Patient Safety in Ambulatory Pediatrics.

Purpose of ReviewThe majority of patient care occurs in the ambulatory setting, and pediatric patients are at high risk of medical error and harm. Prior studies have described various safety threats in ambulatory pediatrics, and little is known about effective strategies to minimize error. The purpose of this review is to identify best practices for optimizing safety in ambulatory pediatrics.Recent FindingsThe majority of the patient safety literature in ambulatory pediatrics describes frequencies and types of medical errors. Study of effective interventions to reduce error, and particularly to reduce harm, have been limited. There is evidence that medical complexity and social context are important modifiers of risk. Telemedicine has emerged as a care delivery model with potential to ameliorate and exacerbate safety threats. Though there is variation across studies, developing a safety culture, partnerships with patients and families, and use of structured communication are strategies that support patient safety.SummaryThere is no standardized taxonomy for errors in ambulatory pediatrics, but errors related to medications, vaccines, diagnosis, and care coordination and care transitions are commonly described. Evidence-based approaches to optimize safety include standardized prescribing and medication reconciliation practices, appropriate use of decision support tools in the electronic health record, and communication strategies like teach-back. Further high-quality intervention studies in pediatric ambulatory care that assess impact on patient harm and clinical outcomes should be prioritized.

The Key to Antibiotic Stewardship Is Combining Interventions.

* Abbreviation: DART — : Dialogue Around Respiratory Tract Illness Treatment More than 10 million antibiotics are unnecessarily prescribed to children in the United States every year, contributing to increasing antibiotic resistance and adverse drug events. The reasons for inappropriate antibiotic prescribing in ambulatory pediatrics are multifactorial, including patient pressures and demand, actual or perceived parental satisfaction, provider knowledge, and provider time constraints.1,2 An effective approach to decreasing inappropriate antibiotic prescribing must therefore address each of these contributing factors. Reflective models of adult learning theory are based on the premise that we learn best when we are told (1) what we are supposed to do, (2) how we should do it, and (3) receive feedback to reflect on how we did.3,4 In this issue of Pediatrics , Kronman et al,5 in their clinical trial based on the theory of planned behavior, also seem to recognize that clinicians are adult learners, and they combine interventions to implement these adult learning theory tenets to improve appropriate antibiotic prescribing. In their cluster-randomized stepped-wedge clinical trial among pediatric providers across the United States, they use (1) … Address correspondence to Rana F. Hamdy, MD, MPH, MSCE, Division of Infectious Diseases, Children’s National Hospital, 111 Michigan Ave NW, West Wing 3.5, Suite 100, Washington, DC 20010. E-mail: rhamdy2{at}childrensnational.org