Pediatric Primary Care Clinic Research Articles

Addressing Adolescent Depression in Primary Care: Building Capacity Through Psychologist and Pediatrician Partnership.

Early identification and treatment of depression during adolescence can contribute to healthier outcomes across the lifespan, yet adolescent depression has been underidentified and undertreated. The American Academy of Pediatrics' (AAP) Guidelines for Adolescent Depression in Primary Care (GLAD-PC) were created to enhance the identification and treatment of adolescent depression. Integrated psychologists in a pediatric primary care setting partnered with providers and clinic staff to implement an adolescent depression screening initiative and transform primary care practice around identification and management. From January 2017 through August 2018, 2107 adolescents between the ages of 11 and 18 were screened using the PHQ-9A. Eleven percent (n = 226) of adolescents had an elevated screen with a score of ≥ 10 and 7% (n = 151) screened positive for suicidal ideation. Identification of depressive symptoms led to increased integrated behavioral health services delivered by psychologists, psychiatrists, and psychology trainees. Psychologists integrated in primary care can support primary care practices to develop service delivery systems aligned with AAP's GLAD-PC and address the diverse implementation barriers associated with incorporating clinical practice guidelines in real-world settings. Universal screening for adolescent depression and response protocols were successfully implemented in a pediatric primary care clinic under the leadership of psychologists and pediatrician partners.

Screening for Adverse Childhood Experiences in Primary Care: A Quality Improvement Project.

The American Academy of Pediatrics (AAP) advocates for the screening of Adverse Childhood Experiences (ACEs) during well-child care visits by pediatric health care providers. The evidence shows a strong correlation between children with high ACE scores and the likelihood of physical and mental health problems as adults. The purpose of this Quality Improvement (QI) project was to increase pediatric providers' awareness on ACEs through education and increase the utilization of an ACE screening tool. This QI project used a pre-post test to evaluate the effectiveness of the educational model and the utilization of the screening tool within an urban pediatric primary care clinic. This project demonstrated an increase in provider awareness as well as a marked increase in the utilization of the screening tool. Four hundred eighty ACE screening tools were collected over a 12-week period. By introducing the ACE screening tool as the standard of care in the primary care office, providers can provide early interventions to mitigate the potential untoward outcomes. This QI project also demonstrated that there was a statistical and clinical significance (p value < 0.001) in the provider's knowledge pre-post the educational intervention.

Previsit Screening for Parental Vaccine Hesitancy: A Cluster Randomized Trial

To evaluate the effect of vaccine hesitancy screening on childhood vaccine uptake. We conducted a cluster randomized controlled trial in pediatric primary care clinics in Washington state. Vaccine-hesitant parents (VHPs) with a healthy newborn receiving health supervision at participating clinics were eligible. VHPs were identified by using a 4-item version of the validated Parent Attitudes About Childhood Vaccines Survey (PACV). Before their child's 2- and 6-month health supervision visits, VHPs at intervention clinics completed the 15-item PACV embedded in a survey containing placebo items. Intervention providers received a summary of parents' 15-item PACV responses and interpretation of their PACV score; discretion was given to providers regarding how they acted on this information. VHPs at control clinics completed only the placebo survey items, and their child's provider received a summary of their responses; control providers remained blinded to parent VHP status. Our outcome was child immunization status at 8 months of age expressed as percent of days underimmunized. We compared outcomes in control and intervention participants using t test and linear mixed-effects regression. We enrolled 24 clinics (12 in each arm) and 156 parents (65 in the intervention arm). Parent characteristics were similar across arms except more intervention (versus control) parents had a first-born child (60.9% vs 44%; P = .04). No significant difference in outcome was detected between arms (25.2% [95% confidence interval: 16.0% to 34.5%] vs 19.1% [95% confidence interval: 12.0% to 26.3%] mean days underimmunized in the intervention and control arms, respectively). Vaccine hesitancy screening was not significantly associated with days underimmunized.

1123. Specificity of Diagnosis Codes and Adequacy of Supportive Documentation for Common Acute Pediatric Infections: Implications for Ambulatory Stewardship

BackgroundAssessing the appropriateness of antibiotic prescribing in ambulatory care generally relies on the accuracy of diagnosis codes, which is uncertain. It is also uncertain if documented history and physical findings support antibiotic indications (AI). We completed a retrospective study of pediatric primary care (PPC) encounters to determine: A) if documented findings supported documented AI; and B) whether diagnosis codes captured documented AI (figure).MethodsWe conducted point-prevalence audits of the 9 PPC clinics in our healthcare system, randomly selecting one weekday per month to review all visits between 9/2017 and 4/2018. We included only encounters with antibiotic prescribing. We reviewed clinician notes, orders, laboratory results, and ICD-10 diagnosis codes. We recorded demographics; visit date/location; AI as documented in notes; history, examination, and laboratory findings; and diagnosis codes. We used national guidelines to determine whether documentation supported AI. We calculated the sensitivity of diagnosis codes using documented AI as the gold standard.ResultsThe sample included 452 encounters. The most common AI were acute otitis media (AOM), pharyngitis, and sinusitis. For AOM, 163 of 168 encounters (97.0%) had an appropriate diagnosis code; for pharyngitis, 127 of 138 (92.0%); and for sinusitis, 68 of 75 (90.7%). For AOM, 160 of 168 encounters (95.2%) had adequate documentation of supportive findings. For sinusitis, 44 of 75 encounters had adequate supporting history and/or examination findings (58.7%). For pharyngitis, while 135 of 139 (97.1%) had a positive streptococcal test, 104 of 139 (74.8%) had history and examination findings to support testing.ConclusionBy chart review, we identified each AI and evaluated whether findings supported those AI. The sensitivity of diagnosis codes for AI ranged from 90.7–97.0% for common conditions; this result can inform the design of ambulatory stewardship programs. Only 74.8% of children treated for pharyngitis and 58.7% of children treated for sinusitis had sufficient supporting documentation. Use of discrete data elements alone (Figure 1) may result in overestimates of the proportion of children for whom antibiotics are appropriate. Further research is needed across healthcare settings. Disclosures All authors: No reported disclosures

2127. Parental Acceptance of Over-the-Counter (OTC) Testing for Streptococcal Pharyngitis

BackgroundGroup A Streptococcus (GAS), is currently diagnosed by throat culture or rapid antigen detection test (RADT) by a healthcare provider (HP), usually in an outpatient (OP) setting. There is current interest in expanding OTC diagnostics (FDA approved for HIV and hepatitis C) to other infectious diseases such as GAS pharyngitis. There are no data on parental acceptance of such a test. Our aim was to determine parental acceptance of expanding OTC diagnostic availability for GAS pharyngitis testing.MethodsCaregivers of 3–18 years old in OP primary care pediatric clinics were given a questionnaire: data included demographics (excluding all patient identifiers), interest in buying/using an OTC GAS test, education level, type of health insurance (HI), comfort level swabbing their child, interest in available support/free hotline with the test. Statistical analysis included Mann–Whitney U test for non-continuous and T-test for continuous variables.Results90 questionnaires were collected, 14 duplicates excluded. 34 (45%) parents indicated they would buy an OTC GAS test, 35 (46%) would not, 4 (5%) were unsure, 3 (4%) did not respond. There was no correlation between interest in OTC test and age (P = NS), or education level (P = NS). There was a trend of OTC test interest among those with private HI vs. Medicaid (P = 0.067). There was a statistically significant association between interest in buying an OTC GAS test and the following variables: high self-swab comfort level and availability of support (P = 0.009 and 0.001, respectively). The majority of participants [73/76 (96%)] did not respond to questions about acceptable pricing.ConclusionThere was mixed interest in OTC GAS testing among respondents. Neither age nor educational level affected interest. Surprisingly, 96% of respondents declined to select a price they would pay for an OTC GAS test. Greater interest in OTC GAS testing among respondents with private HI suggests those parents are more likely to purchase the kits to avoid an HP visit (and co-payment). Since most respondents were comfortable self-swabbing or unsure, further education including swab tutorial and support availability may lead to greater comfort level with such testing.Disclosures All authors: No reported disclosures.

2188. Provider Education and Rapid Antigen Detection Test Use in Private and Academic Pediatric Clinics

BackgroundRapid antigen detection testing (RADT) is needed to differentiate Group A Streptococcal (GAS) pharyngitis from viral pharyngitis. Guidelines do not recommend RADT in patients with viral symptoms or in children <3 years old without GAS exposure. Reduction in unnecessary RADT use may impact inappropriate antibiotic use by decreasing prescriptions in children likely colonized with GAS. We examined the impact of guideline concordant education of appropriate RADT and antibiotic use in pharyngitis on providers’ (physician and APRN) use of RADT in an academic and private pediatric primary care clinic.MethodsRetrospective chart review of 1,085 healthy children, age 1–5 years old, seen in clinics between September 2015 and March 2019 (355 pre- and 730 post-education; 211 academic and 874 private). Education occurred in 3/2017. Cases selected had either complaint of sore throat, RADT, or diagnosis of GAS pharyngitis or pharyngitis. Data collected included the presence of viral symptoms (e.g., cough, rhinorrhea), RADT/GAS culture results, diagnosis, and prescribed antibiotics. RADT was deemed unnecessary for all children < 3 years old without GAS exposure, in patients with ≥ 2 viral symptoms, or in patients ≥ 3 years old without pharyngitis.ResultsOverall, RADT use decreased from pre to post intervention (72.1% vs. 23.4% of patients, P ≤ 0.0001). Unnecessary RADT use decreased overall (50.4% vs. 16.2%, P ≤ 0.0001), in all clinics (private: 56.2% vs. 16.0%, P ≤ 0.0001; academic: 38.1% vs. 17.4%, P = 0.0012), and with all providers (physician: 41.6% vs. 18.3%, P ≤ 0.0001; APRN: 58.8% vs. 14.1%, P ≤ 0.0001). Unnecessary RADT use decreased for children <3 years old (28.1% vs. 7.4%, P ≤ 0.0001) and ≥2 viral symptoms (65.7% vs. 16.5%, P ≤ 0.0001).ConclusionUnnecessary RADT use decreased in the post-education period overall (34%), in children <3 years old (21%), and in patients with ≥ 2 viral symptoms (49%). Reductions were also seen in both academic (21%) and private (40%) clinics as well as with both physicians (23%) and ARPNs (45%). Limitations include lack of a control group and sample size variance by the clinic. We observed positive trends in RADT reduction following provider education in private and academic settings; however, further research including control and optimal sample size is needed to confirm any direct impact. Disclosures All authors: No reported disclosures.

Written Versus Verbal Food Insecurity Screening in One Primary Care Clinic.

Clinics are increasingly interested in identifying food insecurity (FI), but there are limited data on how to implement FI screening. Our objective was to determine the difference in FI disclosure rates by parents/guardians screened by a written questionnaire compared to verbally. The study occurred in 1 pediatric primary care clinic in which we screened for FI using the 2-item Hunger Vital Sign. We used interrupted time series to evaluate the effect of changing from the clinician verbal screening to a written questionnaire. Screening results were extracted for all well-child visits from 4/2017 to 10/2018 for children age 0 to 18 years. The outcome was the proportion who screened positive for FI 9 months before and 9 months after the implementation of the written questionnaire. We estimated the difference in the level and trend of positive screens using ordinary least squares regression using Newey-West standard errors and adjusting for autocorrelation. In 7996 well-child visits, 1141 patients (14.3%) screened positive. In bivariate analysis, there was a significant difference in the FI disclosure rates between patients screened by written questionnaire compared to verbally (16.3% vs 10.4%, P < .001). In interrupted time series, changing to the written questionnaire was associated with a significant increase in FI disclosure rates (β = .04, 95% confidence interval: 0.01, 0.07; P = .02). There was no significant change in the trend in disclosure rates. Multiple barriers exist to effectively implementing FI screening in clinical care. Changing from a verbal to a written questionnaire resulted in an immediate and significant increase in the number of parents/guardians who reported FI.

Low-Income Parents’ Perceptions of and Engagement With a Digital Behavioral Training Program: Mixed Methods Study

Background Parent training is a method for strengthening parenting skill, reducing child behavior problems, and promoting positive parent-child relationships. However, few parents have access to these evidence-based programs. The ezParent program, a tablet-based delivery adaptation of the group-based Chicago Parent Program (CPP), is a parent training program designed to address the needs of families raising young children in urban poverty. There is extensive evidence that positive parenting practices can be a powerful buffer against the negative effects of poverty and adversity and is one of the strongest predictors of children’s social and behavioral well-being. Objective This study aimed to explore (1) parents’ perceptions of the benefits and barriers associated with their use of the ezParent program; and (2) the ways in which the ezParent components and perceived usability varied by program use (module completion). Methods This study uses an explanatory mixed-method design. Data were collected from 92 participants recruited from two pediatric primary care clinics (PPC) based in two urban cities with a high proportion of low income and minority families: Chicago, Illinois (cohort 1) and Baltimore, Maryland (cohort 2). Cohort 1 (n=42) was recruited between October 2013 and June 2014 as part of a randomized controlled tirla. Cohort 2 (n=50) was recruited between May 2017 and July 2017 as part of a single group design. The current report focuses on a subsample from cohorts 1 and 2 who were interviewed about their experiences using the program. To explore parents’ perceptions of ezParent (ie, perceived usefulness of content, ease of use, barriers to use, qualities affecting interest, and intention), all participants were invited to participate in an individual interview after the 12th week. Based on degree of module completion, we grouped parents into two user groups: high (completed 4-6 modules) and low (completed 0-3 modules). This cut-off was chosen based on previous data showing that parents who attended at least 50% of the CPP group sessions reported greater improvements in parenting self-efficacy, use of discipline, and warmth towards their children, as well as fewer child behavior problems. Results Fifty-nine parents participated in follow-up interview: 32 (54.24%) from cohort 1 and 27 (45.76%) from cohort 2. Among those interviewed, 23 (38.9.5%) parents completed all six modules and 12 parents (20.3%) completed none of the modules. Specifically, among those interviewed, parents completed an average of 3.73 (SD 2.39) modules compared to an average of 1.79 (SD 2.38) modules completed among those not interviewed. Parents who completed more modules reported more program benefits and those who completed fewer modules reported more barriers. Conclusions Exploring users’ experience with current digital applications, researchers and application developers can better design future tablet-based interventions to be both effective and acceptable by end users. Furthering our understanding of factors associated with engagement will inform more effective tailoring and improvements of mHealth interventions, particularly those targeting vulnerable populations.

Does Level of Engagement in a Digital Parent Training Program Impact Improvements in Parenting and Child Outcomes?

Background Approximately 8% to 10% of children younger than 5 years of age experience emotional, behavioral, and social relationship problems. These children are more likely to exhibit poor social interactions, problematic parent–child relationships, and school related setbacks, thus reinforcing the need for early interventions such as parent training programs. The ezParent program is a tablet-based delivery adaptation of the group-based Chicago Parent Program, a program designed to address the needs of families raising young children in urban poverty. The growing interest in and adoption of mHealth has changed the way people receive and seek treatment and the way clinicians deliver care. Despite the usefulness of mHealth apps in helping people manage various aspects of health, people’s use of those technologies often lasts only for a short period of time. This suggests a need to delve more deeply into user behaviors. Objective The purpose of this study was to (1) classify levels of engagement by identifying individual usage of ezParent based on observed user activity (ie, “metadata”) and (2) examine whether levels of ezParent engagement is associated with changes in parenting and child behavior over time (ie, parenting stress, self-efficacy, warmth, follow through, punishment, child behavior problems and intensity). Methods This study used a single-group, pre- and posttest design with repeated measures follow-up. Survey measures were collected at baseline (T1), 12 weeks postbaseline (T2) and 24 weeks postbaseline (T3). The study included 92 parents with data collected from two pediatric primary care clinics based in two urban cities with a high proportion of low income and minority families: Chicago, Illinois (cohort 1) and Baltimore, Maryland (cohort 2). Engagement was conceptualized based on total number of modules completed, amount of time spent in the program, and number of skills saved by the parent. Each outcome variable was modeled using a separate mixed-effects model to determine the model of best fit and was analyzed across time and level of engagement. Results Overall, 78 parents logged in to the ezParent program. The data aggregation resulted in 41 parents categorized as high engagers (cohort 1 n=29; cohort 2 n=12) and 37 parents as low engagers (cohort 1 n=13; cohort 2 n=24). Significant differences were across all outcome variables: parenting stress (P&lt;.05), self-efficacy (P&lt;.05), warmth (P&lt;.05), punishment (P&lt;.05), follow-through (P&lt;.05), child behavior intensity (P&lt;.05), and child behavior problems (P&lt;.05). Although parenting outcomes improved, improvements were not significantly associated with levels of engagement. Conclusions This study provides insight into engagement of parents participating in a digitally delivered parent training program. Although level of engagement was not associated with improvements in parenting and child outcomes, we were able to systematically identify and test key usage metrics to ope rationalize engagement. This indicates that further study may help researchers identify other usage metrics more indicative of engagement. By exploring usage data, researchers, app developers, and clinicians can better understand how users engage with future tablet-based interventions.

Low-Income Parents' Perceptions of and Engagement With a Digital Behavioral Parent Training Program: A Mixed-Methods Study.

BACKGROUND: Parent training is a method for strengthening parenting skills, reducing child behavior problems, and promoting positive parent-child relationships. However, few parents have access to these evidence-based programs. The ezParent program, a tablet-based delivery adaptation of the group-based Chicago Parent Program, is a parent training program designed to address the needs of families raising young children in urban poverty. AIMS: This study aimed to explore (a) parents' perceptions of the benefits and barriers associated with their use of the ezParent program and (b) the ways in which the ezParent components and perceived usability varied by program use (module completion). METHOD: An explanatory mixed-methods design was used with the overall intent to use the qualitative data to help explain in greater detail the quantitative results. RESULTS: Fifty-nine parents of 2- to 5-year-old children from two pediatric primary care clinics serving predominantly low-income and racial/ethnic minority families in Chicago (Cohort 1) and Baltimore (Cohort 2) participated in follow-up interviews. Among those interviewed, 23 (38.9.5%) parents completed all six modules and 12 parents (20.3%) completed none of the modules. However, of those 12, 8 (67%) logged in to the program and completed portions of Module 1. Parents who completed more modules reported more program benefits, and those who completed fewer modules reported more barriers. CONCLUSIONS: Exploring users' experience with current digital applications, researchers and application developers can better design future tablet-based interventions to be both effective and acceptable by consumers.

Parents’ interest in resources to address their child’s behavioral health through primary care.

The purpose of this study was to investigate parents' interest in additional primary care-based resources for their children's behavioral health, including parenting support. We surveyed 264 English- or Spanish-speaking parents (80% mothers) of children between the ages of 3 and 11 years as they arrived for an appointment at an urban, pediatric primary care clinic. Measures included demographics, the Pediatric Symptom Checklist (PSC-17) as a parent report of the child's behavioral health, and interest in behavioral resources (e.g., a parenting class, online videos). We used multiple regression to evaluate the predictors of resource interest. Most parents reported interest in behavioral health resources, including many parents not reporting behavioral symptoms high enough to meet criteria for a positive PSC-17. Overall, 82% of parents reported interest in at least 1 resource item; 28% reported interest in all 7 resource items. The resource item with the most interest was online videos and resources (64%). More behavioral health issues (indicated by higher PSC-17 total scores) were positively related to interest in resources; 20% screened positive for behavioral health concerns. Parental report of child behavioral health issues was related to greater interest in resources for children's behavioral health; of note, much of the interest came from parents reporting levels of behavioral health concerns that would be scored as negative on the screening tool in practice. These results provide support for efforts to increase parenting and behavioral health resources through primary care, and raise questions about how to best direct resources. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Embedded Maternal Mental Health Care in a Pediatric Primary Care Clinic: A Qualitative Exploration of Mothers’ Experiences

ObjectiveThe American Academy of Pediatrics recommends screening parents for postpartum depression during pediatric primary care visits. Unfortunately, many women who screen positive do not obtain treatment. Providing mental health services for women in the same location as their children's primary care may facilitate treatment, but few such clinics exist. We designed a qualitative study to evaluate women's perceptions and experiences with receiving mental health services from psychiatrists embedded in a safety-net pediatric primary care clinic. MethodsSemistructured interviews were conducted with women receiving mental health care from embedded psychiatrists in a safety-net pediatric clinic. Data were analyzed using an inductive approach. ResultsTwenty women participated. Five major themes emerged: 1) barriers to maternal mental health care, including psychiatric symptoms impairing access, stigma, and fear of Child Protective Services; 2) benefits of embedded care, including convenience, low barrier to entry and trust; 3) motherhood as facilitator to care, with early motherhood described as a time of vulnerability to relapse; 4) focus on parenting, including appreciation for parenting skills and normalization of the mothering experience; 5) treatment modality preferences, including concerns about medications and a preference for psychotherapy. ConclusionsPostpartum women face many barriers to psychiatric care. Mental health care embedded within the pediatric setting lowers barriers to care during this critical period. These insights should inform further collaboration between adult psychiatrists and pediatric care providers.

Implementing American Academy of Pediatrics guidelines on adolescent depression screening in a pediatric primary care clinic

Background From 2005 to 2014, the 12-month prevalence of major depressive episode (MDE) has increased from 8.7% to 11.3% in adolescents of the United States. In Alabama, 10.7% of adolescents from 12 to 17 years old had at least one MDE in the prior year. Due to the severe shortage of child and adolescent psychiatrist, pediatrician's role in identification and management of adolescent depression has been emphasized. Local Problem and intended improvement In our continuity clinic at a pediatric residency program, we sought to use QI to reliably screen for depression to meet …

Implementing American Academy of Pediatrics guidelines on adolescent depression screening in a pediatric primary care clinic

Implementing American Academy of Pediatrics guidelines on adolescent depression screening in a pediatric primary care clinic

Electronic Health Record (EHR) Quality Tools Improved and Sustained Use of Asthma Action Plans for 3 years in a Primary Care Pediatric System

Background: 6 million US children have asthma resulting in 800,000 asthma-emergency room visits per year. Asthma Action Plans are recommended for patients to improve asthma control but are not consistently utilized in busy pediatric primary care clinics. Specific Aim: The specific aim of this project was to develop EHR quality tools to increase the use of written Asthma Action Plans (wAAP) to pediatric patients to improve asthma control and reduce asthma-related ER visits. Design/Methods: Our primary care pediatric system includes 8 clinics with 37 pediatricians serving 46,000 patients approximately 10% with asthma. Plan-Do-Check-Act quality improvement methods including fishbone diagrams and A3s were used to develop EHR pediatric asthma registries and team-based tools including well-child visit and …

Prenatal Drug and Related Exposures in Infant Patients of a Northeast Tennessee Pediatric Primary Care Clinic

Prenatal Drug and Related Exposures in Infant Patients of a Northeast Tennessee Pediatric Primary Care Clinic

The impact of RISE Up! in promoting positive parenting and safety behaviors of parents with young children

The objective of this study was to examine the extent to which a brief tailored parenting program administered in a pediatric clinic can change high-risk parenting behaviors. Parents with a child five years old or younger presenting to a University-based primary care pediatric clinic in a large Midwestern children's hospital were invited to participate in the study. Parents completed RISE UP!, which included an assessment completed on a tablet computer and then received a tailored, printed report that provided recommendations to address the personal high-risk parenting practices identified by the assessment. A follow-up assessment was completed with 125 parents (58%) about six weeks after the pediatric visit. Overall, 75% of parents reported trying at least one of the recommendations included in the report. Analysis of parenting risk indicated that 53% of parents had different highest parenting risk areas after RISE Up! and 33% of identified parenting risk scores decreased after RISE Up! Of the 231 priority unintentional injury risk behaviors identified, 34% were reported as non-risk behaviors at follow-up. Race and education were significantly associated with program effects in bivariate analysis; program effects were also correlated with communication mediators in a strong dose-response relationship. Reducing both child abuse and neglect and pediatric unintentional injuries are global priorities. Several childhood injury prevention frameworks and evidence-based policy recommendations highlight shared etiologies and opportunities for intervention. RISE Up! shows promise for universal prevention to promote the adoption of parenting practices to reduce injury risk and positive parenting behaviors.

Prenatal Risk Factors and Perinatal and Postnatal Outcomes Associated With Maternal Opioid Exposure in an Urban, Low-Income, Multiethnic US Population

The opioid epidemic increasingly affects pregnant women and developing fetuses, resulting in high rates of neonatal abstinence syndrome. However, longitudinal studies that prospectively observe newborns with neonatal abstinence syndrome or with maternal opioid use and examine their long-term physical and neurodevelopmental outcomes are lacking. To examine prenatal risk factors associated with maternal opioid use during pregnancy and the short-term and long-term health consequences on their children. This cohort study analyzed data from the Boston Birth Cohort, an urban, low-income, multiethnic cohort that enrolled mother-newborn pairs at birth at Boston Medical Center (Boston, Massachusetts) starting in 1998, and a subset of children were prospectively observed at Boston Medical Center pediatric primary care and subspecialty clinics from birth to age 21 years. Data analysis began in June 2018 and was completed in May 2019. In utero opioid exposure was defined as maternal self-reported opioid use and/or clinical diagnosis of neonatal abstinence syndrome. Pregnancy outcomes, postnatal child physical health, and major neurodevelopmental disabilities, documented in maternal and child medical records. This study included 8509 Boston Birth Cohort mother-newborn pairs for prenatal and perinatal analyses. Of those, 3153 children continued to receive pediatric care at Boston Medical Center and were included in assessing postnatal outcomes. Overall, 454 of the 8509 children (5.3%) in the Boston Birth Cohort had in utero opioid exposure. At birth, opioid exposure was associated with higher risks of fetal growth restriction (odds ratio [OR], 1.87; 95% CI, 1.41-2.47) and preterm birth (OR, 1.49; 95% CI, 1.19-1.86). Opioid exposure was associated with increased risks of lack of expected physiological development (OR, 1.80; 95% CI, 1.17-2.79) and conduct disorder/emotional disturbance (OR, 2.13; 95% CI, 1.20-3.77) among preschool-aged children. In school-aged children, opioid exposure was associated with a higher risk of attention-deficit/hyperactivity disorder (OR, 2.55; 95% CI, 1.42-4.57). In this sample of urban, high-risk, low-income mother-child pairs, in utero opioid exposure was significantly associated with adverse short-term and long-term outcomes across developmental stages, including higher rates of physical and neurodevelopmental disorders in affected children. Efforts to prevent the opioid epidemic and mitigate its health consequences would benefit from more intergenerational research.

Dose Matters: A Smartphone Application to Improve Asthma Control Among Patients at an Urban Pediatric Primary Care Clinic.

Objective: As the most common chronic condition of childhood, asthma is a frequent target for family education. However, current educational strategies rarely tailor to learning style or literacy level. Thus, we developed and implemented a smartphone application (app) leveraging gamified features entitled CHANGE Asthma ("Clinic, Home, And on the Go Education for Asthma"). We subsequently assessed its impact on asthma control. Methods: Patients aged 4-11 years with a previously documented childhood asthma control test (C-ACT) score of <20, indicating poor control, were recruited to participate in this randomized control pilot study. The intervention group downloaded CHANGE Asthma; asthma control was assessed at enrollment and at follow-up. The changes in C-ACT score in both groups were compared using analysis of covariance (primary outcome). App usage was monitored for 4 months following download, and the relationship between usage time, and the change in C-ACT score was assessed via linear regression. Results: The control and intervention groups both included 20 caregivers with 75% of participants completing follow-up. Although C-ACT scores among intervention participants significantly improved at follow-up, compared to their own baseline (P = 0.04), the change of C-ACT score did not significantly differ from that of the control group (P = 0.78). Among the intervention participants, there was a positive, dose-dependent relationship between app usage time and positive change in C-ACT score (P = 0.03). Conclusion: Usage of a gamified app was associated with a dose-dependent improvement in asthma control over time, suggesting that further evaluation of apps for asthma education, and perhaps for other chronic conditions, is warranted.

The impact of behavioral health consultations on medical encounter duration in pediatric primary care: A retrospective match-controlled study.

The disproportionate time required to effectively manage psychosocial concerns is a key barrier to advancing delivery of behavioral care by primary care providers. Improved time efficiency is one potential benefit of the integration of behavioral health consultants (BHCs) into pediatric care, but few studies have systematically studied this outcome. We examined the impact of embedded BHCs on duration of medical encounters in a pediatric primary care clinic. We conducted a retrospective matched-pairs analysis of encounters involving behavioral consultations versus encounters for similar patients that did not include a consultation (N = 114) using electronic health record timestamp data. We examined both medical duration (i.e., medical provider services) and total duration (i.e., medical services + behavioral consultation). Patient encounters involving behavioral consultation had a significantly longer (+11.23 min) total duration than matched controls, but significantly shorter (-11.67 min) medical duration. The results indicate BHCs may improve primary care provider efficiency for patients with behavioral concerns, a notable finding given the impact of clinical time-constraints on important health care outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).