Children In Primary Care Research Articles

Benefactors and Beneficiaries? Disability and Care to Others

AbstractIndividuals with disabilities often have limitations that require care from others to increase functioning and facilitate activities of daily living. Despite these care‐receiving needs, evidence suggests people with disabilities are also care givers. This study uses the 2008–2015 American Time Use Survey to examine the association between the presence of sensory, mental or cognitive, physical, or multiple limitations and the likelihood and intensity of time spent in primary child care, secondary child care, adult care, care of nonhouseholders, and support care (housework). Net of socioeconomic characteristics, the authors do not observe consistent differences in predicted child care time by disability status, although men with disabilities spend less time in care to adults and nonhouseholders. The largest difference in predicted care time by disability status occurs in support care. Overall, the results challenge the traditional focus on people with disabilities as only beneficiaries of care to document their role as benefactors.

Addressing Parental Health in Pediatrics: Physician Perceptions of Relevance and Responsibility

Pediatric guidelines recommend that providers address a range of parental health issues; however, adherence to these guidelines has been suboptimal. Drawing on a nationally-representative sample of children's primary care physicians, we examined whether providers view parental issues as relevant to child health and whether they believe it is their personal responsibility to address them. Issues included maternal depression, tobacco use, intimate partner violence, Tdap (tetanus, diphtheria, and acellular pertussis) immunization, family planning, and health insurance. While the majority of respondents endorsed the relevance of these issues to child health, particularly for issues with an established evidencebase, significantly fewer felt responsible for addressing them. Physicians who endorsed relevance or responsibility were almost always more likely to address these issues in their clinical practice. To advance parental health promotion practices, highlighting relevance to pediatric outcomes is an important first step, particularly for novel areas, while understanding what factors influence personal responsibility is necessary for all issues.

The effect of macroeconomic conditions on parental time with children: evidence from the American time use survey

This paper investigates the effect of changes in macroeconomic conditions on time allocation to children among mothers and fathers in the US. The study relies on 2003–2013 American Time Use Survey (ATUS) data. Accounting for a variety of personal demographic characteristics, as well as state and year fixed effects, we find that an increase in state-level unemployment rates is associated with an increase in enriching child–father time in families with small children (ages 0–4). However, there is heterogeneity in results by race, education and marital status, with results being statistically significant for white, married and college-educated fathers. Additionally, we find some evidence that an increase in unemployment rates is also associated with an increase in primary childcare for fathers in families with small children, as well as some declines in total time that fathers spend with older children. In contrast to this result, we find that mothers’ total time with children, as well as primary childcare time, is invariant to macroeconomic fluctuations in the labor market, however, as the unemployment rate goes up we do observe small declines in enriching time that white mothers in families with small children devote to enriching activities.

Comparison of the quality of night paediatric urgent care in rural and urban areas of Lublin Province, eastern Poland - Appraisals by parents of children requiring medical attention.

The aim was assessing the quality as well as the level of satisfaction with the night paediatric urgent care in the Lublin Province of eastern Poland. The materials for this study consisted of 540 parents of children aged 6-16 years benefiting from night paediatric urgent medical assistance in Lublin Province. The survey was conducted using the Original Survey Questionnaire. Inhabitants of the Lublin Province (regardless of place of residence) generally assessed the quality and accessibility of night paediatric urgent care facilities as only satisfactory. Inhabitants living in rural areas have worse access to night paediatric urgent care facilities because of having to travel greater distances, and receive less comprehensive medical assistance than inhabitants living in more urbanized areas, and they are more often referred to hospital emergency departments. During the past five years, both the availability and quality of night paediatric urgent care did not change significantly. Inhabitants of the Lublin Province (regardless of place of residence) generally assessed the quality as well as accessibility of night paediatric urgent care facilities as only satisfactory. Rural residents have more reasons for dissatisfaction than urban dwellers. Both the quality and availability of such medical care needs to be improved.

Pediatricians' Comfort Level in Caring for Children With Special Health Care Needs

BackgroundFew studies have investigated pediatrician attitudes about providing primary medical care for children with special health care needs. The objective of this study was to determine pediatrician perspectives on their comfort level in providing care and on where the medical home should be for children with chronic medical and developmental conditions. MethodsSurvey of pediatricians in California in 2014. Pediatricians were randomized to receive surveys featuring either a case of a child with a chronic medical (neurofibromatosis) or a developmental condition (autism). They were then asked about their comfort level in providing primary care for the child. We developed logistic regression models to adjust for practice and provider factors, and availability of family social resources. ResultsThe survey response rate was 50.2%. Primary care pediatricians expressed more comfort than nonprimary care pediatricians in providing a medical home for a child with chronic medical or developmental condition (range, 84%–92% comfortable vs 58%–79% comfortable), respectively. All pediatricians expressed more comfort providing care for a child with autism than neurofibromatosis. Nearly all primary care pediatricians (90%) believed that the medical home should be in pediatric primary care practice. Pediatrician comfort in becoming a medical home was higher when the family had more social resources. ConclusionsMost pediatricians endorse that the medical home for children with special health care needs be in the primary care setting. Improving access to subspecialty care and providing resources, such as case management, to address family social complexity might raise pediatrician comfort in providing primary care to children with medical and developmental conditions.

Report: Patient Safety Incidents Involving Sick Children in Primary Care

Report: Patient Safety Incidents Involving Sick Children in Primary Care

Education on the Brain: A Partnership Between a Pediatric Primary Care Center and Neurology Residency.

The national shortage of pediatric neurologists is worsening, yet referral rates by pediatricians are high. Suboptimal training of pediatric residents in care of patients with neurologic disease may be a contributing factor. We formed a partnership between the Boston Children's Primary Care at Longwood clinic and Child Neurology Residency Training Program. The educational intervention included lectures, observed neurologic examinations, in-person and virtual triage, and an electronic medical record-based consult system. Residents in other primary care clinics served as the comparison group. Intervention-group residents reported significantly improved confidence in diagnosis of chronic/recurrent headache, attention deficit hyperactivity disorder (ADHD), and developmental delay; initial management of ADHD and developmental delay; and secondary management of ADHD, developmental delay, and concussion/traumatic brain injury. Comparison-group residents reported significantly improved confidence only in diagnosis of developmental delay. Our multipronged intervention is a promising approach to improving pediatric resident training in pediatric neurology and may be generalizable to subspecialty collaborations for other residency programs.

The influence of social deprivation on dental caries in Swedish children and adolescents, as measured by an index for primary health care: The Care Need Index

The objective was to examine associations between a primary Care Need Index (CNI) and dental caries experience. Dental journal records for 300 988 individuals in western Sweden, aged 3-19 years in 2007-09, were completed with official socioeconomic information. The CNI (independent variable), originally developed for assessing primary care need, was calculated for residential areas (small areas, parishes, dental clinics) based on markers of material deprivation, sociodemographic characteristics, social instability and cultural needs. Dental caries (dependent variable) was registered using the decayed, missing, filled teeth (DMFT) system. Multilevel Poisson regression and logistic regression models were used. All analyses were adjusted for age and gender. In the most deprived areas, the incidence rate ratio (IRR) for dental caries was up to five times higher than in the most affluent areas (reference); in small areas, the IRR for decayed teeth (DT) was 3.74 (95% CI: 3.39-4.12) and 5.11 (CI: 4.45-5.87) for decayed surfaces approximally (DSa). Caries indices including fillings (decayed filled teeth [DFT], decayed filled surfaces approximally [DFSa]) produced lower IRRs, with similar pictures at the parish and dental clinic level. The intracluster correlation was low overall, but stronger at lower geographical levels. The odds ratios for ≥3 caries lesions in the two most deprived areas of the CNI deciles were high, with a DT OR of 3.55 in small areas (95% CI: 3.39-3.73), compared with the eight more affluent deciles. There were strong associations between an index for assessing need in primary care, the CNI and dental caries in Swedish children and adolescents.

Patient Safety Incidents Involving Sick Children in Primary Care in England and Wales: A Mixed Methods Analysis.

BackgroundThe UK performs poorly relative to other economically developed countries on numerous indicators of care quality for children. The contribution of iatrogenic harm to these outcomes is unclear. As primary care is the first point of healthcare contact for most children, we sought to investigate the safety of care provided to children in this setting.Methods and FindingsWe undertook a mixed methods investigation of reports of primary care patient safety incidents involving sick children from England and Wales’ National Reporting and Learning System between 1 January 2005 and 1 December 2013. Two reviewers independently selected relevant incident reports meeting prespecified criteria, and then descriptively analyzed these reports to identify the most frequent and harmful incident types. This was followed by an in-depth thematic analysis of a purposive sample of reports to understand the reasons underpinning incidents. Key candidate areas for strengthening primary care provision and reducing the risks of systems failures were then identified through multidisciplinary discussions.Of 2,191 safety incidents identified from 2,178 reports, 30% (n = 658) were harmful, including 12 deaths and 41 cases of severe harm. The children involved in these incidents had respiratory conditions (n = 387; 18%), injuries (n = 289; 13%), nonspecific signs and symptoms, e.g., fever (n = 281; 13%), and gastrointestinal or genitourinary conditions (n = 268; 12%), among others. Priority areas for improvement included safer systems for medication provision in community pharmacies; triage processes to enable effective and timely assessment, diagnosis, and referral of acutely sick children attending out-of-hours services; and enhanced communication for robust safety netting between professionals and parents. The main limitations of this study result from underreporting of safety incidents and variable data quality. Our findings therefore require further exploration in longitudinal studies utilizing case review methods.ConclusionsThis study highlights opportunities to reduce iatrogenic harm and avoidable child deaths. Globally, healthcare systems with primary-care-led models of delivery must now examine their existing practices to determine the prevalence and burden of these priority safety issues, and utilize improvement methods to achieve sustainable improvements in care quality.

Pediatrician Use of Down Syndrome Health Supervision Guidelines

Objective: The primary care of children with Down syndrome (DS) requires close attention to specific medical vulnerabilities to maximize quality of life and prevent secondary disability. To help optimize adulthood outcomes for children with DS, the AAP Council on Genetics published health supervision guidelines to promote standardized care that adheres to the latest evidence based information. Our primary objective was to determine primary care pediatrician comfort, familiarity and frequency of referral to the 2011 AAP health supervision guidelines for children with DS. A secondary objective was to identify interventions that would improve compliance. Methods: A voluntary, self-administered e-mail survey was distributed to Washington State AAP members using Survey Monkey. The questionnaire targeted information regarding demographics, guideline knowledge, perceived barriers to guideline utilization and interventions to improve use. General pediatricians living in Washington State with self-reported past, current or expected future experience with the pediatric DS population were included. Results: Our response rate was 17% (N=161). Approximately 80% of pediatricians reported being comfortable using guidelines. About 20% of pediatricians were unfamiliar with the guidelines and do not refer to them. An additional 20% refer to the guidelines only sometimes. When asked a specific question regarding a guideline recommendation, 72% answered incorrectly. Over three-quarters of participants reported that electronic health record reminders would be the most beneficial. Conclusions: Opportunities to improve general pediatrician awareness and utilization of the DS guidelines exist. The most beneficial perceived intervention among pediatricians is guideline integration into the electronic health record. Studies measuring compliance and awareness of guidelines with a variety of interventions will be necessary in the future.

Location, Location, Location: Teaching About Neighborhoods in Pediatrics

Location, Location, Location: Teaching About Neighborhoods in Pediatrics

When Pediatric Primary Care Providers Prescribe Nature Engagement at a State Park, Do Children “Fill” the Prescription?

Abstract The use of a written nature prescription (Park Rx) written by a child's primary care provider (PCP), physician, or nurse practitioner, is one hypothesized approach to encouraging children to participate in free, unstructured play in nature. PCPs recruited through the local chapter of the American Academy of Pediatrics were provided Park Rxs to write for children aged 6–10 attending a well-child visit. The written prescription was a tool for the PCP to use to start a conversation on the value of nature for physical and mental health. In addition, the Park Rx could be redeemed as a free day pass to any state park. The prescribing and redemption patterns for the Park Rxs were studied over the 15-week summer season in a rural state in the Northeast. The nature relatedness (NR) of PCPs and their likelihood to prescribe nature with a Park Rx prior to, during, and after the project were also examined. Eleven PCP offices in six counties participated in the pilot study and wrote a combined 1,935 park pres...

Caregiver Health Promotion in Pediatric Primary Care Settings: Results of a National Survey

To assess practice patterns, barriers, and facilitators related to caregiver health promotion in pediatric primary care settings. We conducted a mail-based survey of a nationally representative sample of 1000 children's primary care physicians (trained in pediatrics, family medicine, or medicine-pediatrics). We assessed engagement in 6 caregiver health issues (maternal depression, tobacco use, intimate partner violence, family planning, health insurance, and tetanus, diphtheria, and acellular pertussis immunization status) along with barriers and facilitators related to engagement. We used multivariable logistic regression to identify physician and practice correlates of engagement. The response rate was 30%. The majority of respondents (79.3%) regularly addressed at least 3 caregiver health issues during well infant/child visits, most commonly maternal depression, tobacco use, and tetanus, diphtheria, and acellular pertussis immunization immunization status. Screening was the most common activity. In adjusted analyses, pediatricians were less likely to screen for intimate partner violence and family planning compared with other providers. There were no other differences in engagement by physician specialty. Lack of time was the most commonly endorsed barrier (by 85.2% of respondents). Co-location of auxiliary services was the most frequently cited facilitator for the majority of issues. Children's primary care physicians and their care teams routinely engage in a variety of activities promoting caregiver health, largely independent of training background and despite multiple practice-related barriers. Co-location of auxiliary services could support the efforts of pediatric care teams. Future efforts that investigate care models which address these barriers and facilitators will help to realize the potential of pediatric settings to impact adult health.

Quality of primary care for children: ASTHMA indicators in the EU MOCHA project

Quality of primary care for children: ASTHMA indicators in the EU MOCHA project

Quality of primary care for children: Autism Spectrum Disorders and Immunization indicators in the EU MOCHA project

Quality of primary care for children: Autism Spectrum Disorders and Immunization indicators in the EU MOCHA project

Quality Improvement in Primary Care for Children: Interest and Desire, but Lack of Action

Quality Improvement in Primary Care for Children: Interest and Desire, but Lack of Action

Enhanced Access and Parents' Preferred Contact for a Child's Chronic Condition

To assess whether the perception of enhanced access by parents in their child's primary care and main specialty practices is associated with preference for contacting either practice when problems arise with a child's chronic condition. In this cross-sectional survey study of parents whose children use both primary and specialty practices, we assessed perceptions of 3 components of enhanced access: (1) appointment availability when needed, (2) electronic communication with practices, and (3) other staff that help manage a child's health care needs. Parents also indicated which practice they would contact for an exacerbation of the main chronic condition for which the child receives specialty care. We used logistic regression to examine relationships of enhanced access components in both practices with parents' indicated practice. Among 609 parents, 244 (40%) would contact primary care and 365 (60%) the main specialty practice for a chronic condition exacerbation. Although parents perceived enhanced access components with similar frequency in both settings, enhanced access was associated only with preference for contacting the main specialty practice: e-mail communication (aOR for preferring the specialty practice 2.0 [1.3, 3.2]) and staff that coordinate a child's care needs (aOR 2.8 [1.4, 5.9]). Enhanced access is associated with preference for addressing chronic condition exacerbations in specialty but not primary care. Future study should further identify factors important to parents in deciding when and how to contact practices and should seek to develop family-centered communication within medical homes that integrate primary and specialty care.

Identification and Treatment of Generalized Anxiety Disorder in Children in Primary Care.

Youth with anxiety often present to their pediatricians with a chief complaint of physical symptoms without any mention of anxiety or worry. Even in the absence of reported symptoms of anxiety in such presentations, screening for an anxiety disorder as the potential source of the somatic complaints should be pursued. Generalized anxiety disorder (GAD) is a common disorder characterized by excessive anxiety and worry about a number of events coupled with at least one physical symptom. GAD is commonly underdiagnosed and treated. Consequently, many youth undergo extensive medical testing in search of a cause for their somatic symptoms before anxiety is considered. It is important to screen for anxiety early in the process of evaluating somatic complaints. This review highlights the evidence base for identifying and treating GAD in children and provides an update on its epidemiology and etiology. [Pediatr Ann. 2016;45(10):e349-e355.].

Health Services and Well-Being of Children in Estonia

Estonia has a population of 1.3 million, which makes it one of the least populous member states of the European Union. The fertility rate was 1.65 in 2011, and the average age of women at first child birth was 4years higher than in the early 1990s. Medical care is free for all children in Estonia. For the last 20years, family doctors have been responsible for the primary care of children. Pediatric subspecialists work mainly in 2 children's hospitals: the Children's Clinic of Tartu University Hospital and Tallinn Children's Hospital. The average duration of hospital stay has decreased year by year. Pediatric subspecialists take care of children with long-term conditions and chronic diseases. In recent years, electronic case reports and digital receipts have been in use in Estonia. New diagnostic tests and expensive medications, which are available, make the cost of medical care very high.

Antibiotic Treatment for First Episode of Acute Otitis Media Is Not Associated with Future Recurrences.

ObjectiveAntibiotic treatment of acute otitis media (AOM) has been suggested to increase the risk of future AOM episodes by causing unfavorable shifts in microbial flora. Because current evidence on this topic is inconclusive and long-term follow-up data are scarce, we wanted to estimate the effect of antibiotic treatment for a first AOM episode occurring during infancy on AOM recurrences and AOM-related health care utilization later in life.MethodsWe obtained demographic information and risk factors from data of the Wheezing Illnesses Study Leidsche Rijn, a prospective birth cohort study in which all healthy newborns born in Leidsche Rijn (between 2001 and 2012), The Netherlands, were enrolled. These data were linked to children’s primary care electronic health records up to the age of four. Children with at least one family physician-diagnosed AOM episode before the age of two were included in analyses. The exposure of interest was the prescription of oral antibiotics (yes vs no) for a child’s first AOM episode before the age of two years.Results848 children were included in analyses and 512 (60%) children were prescribed antibiotics for their first AOM episode. Antibiotic treatment was not associated with an increased risk of total AOM recurrences (adjusted rate ratio: 0.94, 95% CI: 0.78–1.13), recurrent AOM (≥3 episodes in 6 months or ≥4 in one year; adjusted risk ratio: 0.79, 95% CI: 0.57–1.11), or with increased AOM-related health care utilization during children’s first four years of life.ConclusionsOral antibiotic treatment of a first AOM episode occurring during infancy does not affect the number of AOM recurrences and AOM-related health care utilization later in life. This information can be used when weighing the pros and cons of various AOM treatment options.