Pediatric Primary Care Physicians Research Articles

Pediatric dermatology eConsultation: Insights to reduce barriers to utilization and increase access to care.

Provider-to-provider outpatient pediatric dermatology eConsultation services increase access to care, but barriers exist that may prevent eConsult implementation and survival. We deployed cross-sectional surveys to referring pediatric primary care physicians and consulting pediatric dermatologists participating in our eConsult program to identify barriers to utilization and sustainability. Our data suggest that eConsultation increases access to care and offers iterative educational opportunities for primary care providers, which may ultimately reduce office referrals for common outpatient skin issues. Sustainability of eConsult services requires simple order templates, clear representative photos, concise submission reports, and provider reimbursement.

21.1 ACCESS MENTAL HEALTH CONNECTICUT: FAMILY-CENTERED PEDIATRIC MENTAL HEALTH CONSULTATIONS

The objective of this presentation is to review the family-centered, well-being-focused nature of the ACCESS (Access to all of Connecticut’s Children of Every Socioeconomic Status) Mental Health program and its contributions to improving mental health treatment for children in the state of Connecticut. ACCESS Mental Health Connecticut is a state-funded initiative created as a line item in the Department of Children and Families’ budget as a component of the gun-control legislation passed in the wake of the Sandy Hook school shooting. Initiated in June 2014 and modeled after the Massachusetts Child Psychiatry Access Project (MCPAP), the Connecticut model includes 3 Hubs to support mental health education and the well-being of pediatric primary care providers, and to support families regardless of insurance status. The model incorporates a team of child and adolescent psychiatrists, licensed social work clinicians, a program coordinator, and, uniquely, a peer specialist. The peer specialist is a parent with a child with mental health challenges who can support pediatric patients’ parents emotionally and practically as they attempt to process and navigate the mental health landscape. Since its inception in June 2014, the ACCESS Mental Health Hubs have provided over 36,700 consultations supporting over 7000 youth and their families. During the early months of the COVID-19 pandemic, the ACCESS Mental Health Teams initiated weekly well-being support Zoom meetings for the state’s pediatric primary care physicians (PPCPs). Now monthly, the Zoom “Clinical Conversations with ACCESS Mental Health” provides mental health education to address the PPCP’s unique needs. Hub child and adolescent psychiatrists also participate in Project ECHO (Extension of Community Healthcare Outcomes), AAP Connecticut webinars, grand rounds, and other venues. PPCP mental health education and early access to mental healthcare promises to identify, support, and treat children and families experiencing mental health challenges that have previously been unable to access services. The trusting personal relationships between the Hub teams and the PPCPs is a cherished component of the ACCESS Mental Health program service.

Pediatric primary care and subspecialist providers\u2019 comfort, attitudes and practices screening and referring for social determinants of health

BackgroundEarly detection and management of poverty-related disorders is a recommended pediatric practice; however, little is known about variations of practice between pediatric primary care physicians and subspecialists. The objectives of this study were to assess (1) provider perceptions and attitudes toward caring for low-income children in an urban academic medical center, and (2) variations between primary care physicians and subspecialists in social and financial needs screening and referral practices for low-income children.Design/Methods Primary care providers (pediatric and family medicine) and subspecialists providing direct patient care in an urban academic medical center (response rate = 24 %, n = 85/356) completed a 24-item survey (adapted with permission from the AAP Periodic Survey of Fellows No.90) assessing feasibility and comfort screening and addressing social and financial needs, rates of screening for financial hardship, and referrals to local resources. Chi-square tests were performed.ResultsAmong respondents, 88 % (75/85) reported comfort caring for low-income children, while 28 % (24/85) reported comfort inquiring about social and financial needs and 34 % (29/85) referring to community resources. Primary care providers more commonly than subspecialists screened for childcare (80 % vs. 59 %, p = 0.04), parental: employment (84 % vs. 59 %, p = 0.01), education (40 % vs. 17 %, p = 0.02) and mental health (86 % vs. 46 %, p = 0.0001), and less commonly screened for transportation (47 % vs. 73 %, p = 0.01). Primary care providers more commonly referred for public health insurance (74 % vs. 39 %, p = 0.001), public food assistance (30 % vs. 12 %, p = 0.04), and adult mental health services (65 % vs. 44 %, p < 0.05).ConclusionsIn an urban academic institution serving a population with high poverty rates, pediatric providers feel comfortable providing medical care for low-income children but lack comfort screening and addressing SDH. Though most feel it is their job to refer to resources, less than half felt it was feasible to screen for or address financial needs. Pediatric primary care providers report higher rates of screening and referring than subspecialists. Understanding variations in practice and perceptions among primary care providers and subspecialists may aid in creating interventions to increase screening and referral rates.

Exploring Pediatric Obesity Training, Perspectives, and Management Patterns Among Pediatric Primary Care Physicians.

Significant variability exists in the amount of formal obesity training obtained by physicians caring for pediatric patients. The study objective was to assess the relationship between formal obesity training and pediatrics physicians' perceptions, practice patterns, overall knowledge, and confidence during management of pediatric obesity. An anonymous survey was distributed via email from February 2020 through March 2020 at a large academic system. Internal medicine/pediatrics (46 total) and pediatrics (104 total) primary care providers were selected. Data were collected on the total number of obesity-related training hours by quartiles, demographics, physicians' clinical practice patterns, and physicians' knowledge of pediatric obesity management, along with their perceptions, attitudes, and beliefs. A total of 73 survey participants completed the survey: 69% were female, 77% were older than 40 years, and 74% were White. Physicians with the highest training were most likely to feel confident when managing pediatric obesity. However, only 20% of all physicians felt confident providing pre- and post-bariatric surgery care, and just 6% of physicians self-reported achieving management success. Increased obesity training improves physicians' confidence and leads to familiarity with management guidelines. Formal obesity training should be prioritized during residency and beyond so that physicians who care for pediatric patients are better equipped to offer unbiased and effective care.

Incorporating the Voice of Community Based Pediatricians to Improve Discharge Communication.

Communication between pediatric hospitalists and primary care physicians (PCPs) at discharge is an essential part of a successful transition to home. While many hospitals require communicating with PCPs for all admitted patients, it is unknown if PCPs find such communication valuable or if it improves outcomes. Our global aim was to improve discharge communication for patients that pediatric hospitalists and PCPs deemed appropriate. We sent surveys to 422 outpatient pediatricians in our care network to understand their communication preferences. Survey results informed local guidelines for when hospitalists should directly contact PCPs. We determined the proportion of inpatient discharges meeting those guidelines and set a target for our primary process metric: the proportion of discharges with attempted direct PCP contact. We engaged in Plan-Do-Study-Act cycles, including a discharge documentation tool in the electronic health record, education of inpatient teams, email reminders including group performance data, asynchronous Health Insurance Portability and Accountability Act-compliant messaging application, and competitions that shared blinded individual data. We increased the percentage of documented direct communication with the PCPs from 2% to 33% and from 4% to 65% for those who met guidelines for direct communication. PCPs only want direct communication on a subset of discharges. Interventions focused on high-yield populations improved discharge communication in our institution.

Physicians’ perspectives on receiving unsolicited genomic results

PurposePhysicians increasingly receive genomic test results they did not order, which we term “unsolicited genomic results” (UGRs). We asked physicians how they think such results will affect them and their patients. MethodsSemistructured interviews were conducted with adult and pediatric primary care and subspecialty physicians at four sites affiliated with a large-scale return-of-results project led by the Electronic Medical Records and Genomics (eMERGE) Network. Twenty-five physicians addressed UGRs and (1) perceived need for actionability, (2) impact on patients, (3) health care workflow, (4) return of results process, and (5) responsibility for results. ResultsPhysicians prioritize actionability of UGRs and the need for clear, evidence-based “paths” for action coupled with clinical decision support (CDS). They identified potential harms to patients including anxiety, false reassurance, and clinical disutility. Clinicians worried about anticipated workflow issues including responding to UGRs and unreimbursed time. They disagreed about who was responsible for responding to UGRs. ConclusionThe prospect of receiving UGRs for otherwise healthy patients raises important concerns for physicians. Their responses informed development of an in-depth survey for physicians following return of UGRs. Strategic workflow integration of UGRs will likely be necessary to empower physicians to serve their patients effectively.

Primary Care Physicians' Decision Making Regarding Initial Oncology Referral for Adolescents and Young Adults With Cancer

PurposeThe objectives of this study were to determine whether pediatricians are more likely than other primary care physicians (PCPs) to refer newly diagnosed adolescent and young adult patients with cancer to pediatric oncological specialists, and to assess the physician and patient characteristics that affect patterns of referral. MethodsA cross-sectional vignette survey was mailed to PCPs to examine hypothetical referral decisions as a function of physician characteristics and patient characteristics, including diagnosis, age, gender, race/ethnicity, family support, transportation, insurance, and patient preference for site of care. Pediatrician PCPs and nonpediatrician PCPs (family medicine, internal medicine, and emergency medicine physicians) practicing in North Carolina and in Washington State participated in the study. ResultsA total of 406 surveys were completed (35.8% response rate). Sixty percent of pediatric PCPs referred their hypothetical patients with cancer to pediatric specialists (PSs), compared with only 37% of nonpediatric PCPs. Patient age also influenced referral patterns; 89% of 13-year-olds, 74% of 16-year-olds, 25% of 19-year-olds, and only 9% of 22-year-old patients were referred to a PS. Multivariate logistic regression demonstrated that diagnosis and physician practice setting also were associated with referral patterns. ConclusionsBoth patient age and PCP specialty were significant predictors of referral patterns in hypothetical vignettes of newly diagnosed adolescent and young adult patients with cancer. Pediatricians were more likely than nonpediatrician PCPs to refer patients to a PS. Referrals to PSs decreased dramatically between ages 16 and 19. Because the site of oncological care can impact outcomes, these data have the potential to inform awareness and education initiatives directed at PCPs.

How Primary Care Pediatricians Manage Behavioral Health Problems in Integrated and Non-Integrated Clinics

Introduction: Pediatric primary care physicians (PPCPs) are often the first professionals families consult for management of child behavioral health (BH) problems but may vary in their level of training and experience with these issues. These factors, as well as patient access to BH providers, is likely to influence how PPCP’s manage presenting BH concerns. Method: This study assessed PPCP’s perceptions on identification, treatment, and referral follow-up of patients with common BH problems (i.e., issues with anxiety, depression, feeding, sleep, toileting, behavior, and ADHD). Surveys were completed by 60 PPCPs practicing in 20 clinics within two major academic medical centers. Responses were on a 7-point Likert Scale (1= Very Uncomfortable/Unlikely to 7 = Very Comfortable/Likely). Results: PPCP’s endorsed relative comfort with differential diagnosis of all types of BH concerns (range of 5.17 to 6.20) but indicated significantly less comfort providing treatment for all concerns (p The likelihood of using medication to treat BH problems was examined for various patient age groups (0 to 2; 3 to 5; 6 to 12; 13 and up). PPCP’s only endorsed greater than neutral likelihood (M> 4.00) for ADHD ages 6 and up (M= 6.15), depression ages 13 and up (M= 4.32), sleep issues ages 13 and up (M= 4.05), and toileting problems at all ages (M= 4.41). PPCPs were significantly more likely (p The likelihood of patient follow-up with on-site BH services (M= 6.03) was rated significantly higher than off-site (M= 4.05), p Conclusions: PPCPs endorsed discomfort treating all common BH problems with the exception of ADHD but felt comfortable with differential diagnosis of these issues. Use of medication was deemed unlikely for most ages and BH problems and was less supported for younger children. PPCPs were highly confident their patients with BH problems received care when referred to an on-site psychologist but not off-site. Lessons Learned: PPCP’s feel comfortable identifying BH problems but are substantially less comfortable treating the majority of these conditions, especially those presenting in young children. PPCP’s acknowledge that clinics with integrated BH providers improve patient care and enhance patient access to BH services. These findings indicate a need for integration of BH services witihin the primary care setting and provide insight on specific issues PPCP's feel most ill-equipped to manage independently. Limitations: It is unclear what accounts for PPCP’s higher comfort with treating behavioral health concerns relative to their likelihood of using medication. Future Research: It would be useful to examine whether or not integrated care clinics influence PPCP’s management of BH problems in terms of diagnoses, treatment, and referrals.

Editorial Comment

Patients with new malignancies have a myriad of urgent therapeutic considerations. The authors demonstrated the value of a separately scheduled nursing counseling session regarding sperm banking and fertility preservation before oncologic therapy is initiated. 1 Rotker K. Vigneswaran H. Omil-Lima D. Sigman M. Hwang K. Efficacy of standardized nursing fertility counseling on sperm banking rates in cancer patients. Urology. 2017; https://doi.org/10.1016/j.urology.2017.01.041 Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar There are many reasons that oncologists may not offer counseling about fertility preservation. Among these reasons are lack of knowledge of options for fertility preservation, discomfort about discussing sperm banking, intense focus on the patient's malignancy while ignoring fertility considerations, and simple disinterest in fertility considerations. Similarly, both adult and pediatric primary care physicians usually are unfamiliar with fertility preservation options for patients undergoing oncologic treatment.

Mothers’ Perspectives on the Development of Their Preschoolers’ Dietary and Physical Activity Behaviors and Parent-Child Relationship: Implications for Pediatric Primary Care Physicians

The study explores female caregivers' reflections on their relationship with their child (2-5 years old) and the development of their child's dietary and physical activity behaviors. Five, 90-minute semistructured focus groups were conducted to inquire about children's growth, eating behaviors and routines, physical activity, personality, and the parent-child relationship. Nineteen female caregivers diverse in race/ethnicity, age, and educational attainment participated. Participants reported that they maintained a schedule, but needed to be flexible to accommodate daily responsibilities. Family, social factors, and day care routines were influences on their children's behaviors. The main physical activity barriers were safety and time constraints. Guidance from pediatric primary care providers aimed at supporting female caregivers to build a positive foundation in their parent-child relationship, and to adopt and model healthy diet and physical activity behaviors that are respectful of schedules and barriers should be a priority for childhood obesity prevention.

Primary Care Providers' Initial Evaluation of Children with Global Developmental Delay: A Clinical Vignette Study

To examine the decisions of pediatric primary care physicians about their diagnostic evaluation for a child with suspected global developmental delay (GDD). A survey was mailed to a sample of pediatricians (n = 600) and family physicians (n = 600) randomly selected from the American Medical Association Physician Masterfile. The survey contained a clinical vignette describing a 9-month-old nondysmorphic boy with GDD. Participants were asked their initial evaluation steps (test, refer, or both test and refer) and what types of referral and/or testing they would pursue. We examined bivariate associations between physician/clinical practice characteristics and participants' evaluation decision. More pediatricians than family physicians completed the survey (response rates: 55% vs 38%). Almost three-quarters of the respondents (74%) reported that their first step in a diagnostic evaluation would be to refer the child without testing, 22% would test only, and 4% would both test and refer. As their initial step, most physicians referred to a developmental pediatrician (58%), and only 5% would refer to a geneticist. The most commonly ordered test was general biochemical testing (64%). The most commonly ordered genetic test was a karyotype (39%). When evaluating a child with GDD, few primary care physicians would order genetic testing or refer to a genetics specialist as a first evaluation step. Future studies should examine both barriers to and utilization of a genetic evaluation for children with GDD.

Training in Psychotropic Prescribing Helps Pediatricians Improve Care

Pediatric primary care physicians are increasingly aware of the urgent need to address the overwhelming mental health needs of children and adolescents in primary care settings.

Brief training in patient-centered counseling for healthy weight management increases counseling self-efficacy and goal setting among pediatric primary care providers: results of a pilot program.

We hypothesized that training in patient-centered counseling would improve self-efficacy and quality of weight management-related counseling provided by pediatric primary care physicians (PCPs). A total of 36 PCPs attended a brief (2-hour) training and consented to participate in an evaluation. Training impact was assessed using self-administered, pretraining and posttraining surveys and a review of patient charts from prior to and from 6 and 12 months after training for a random subsample of 19 PCPs (10 charts/timepoint per PCP). Self-reported effectiveness at obesity prevention and treatment increased from 16.7% to 44.4% (P = .01) and from 19.4% to 55.6% (P < .001), respectively. Self-efficacy in counseling and motivating patients increased from 44.4% to 80.6% (P < .001) and 27.8% to 63.9% (P < .001), respectively. Goal documentation increased from 3.9% to 16.4% and 57.9% at 6 months and 12 months posttraining, respectively. Brief training in patient-centered counseling appears to increase self-efficacy and the frequency and quality of weight-related counseling provided by PCPs.

Physician attitude, awareness, and knowledge regarding guidelines for transcranial Doppler screening in sickle cell disease.

We explored factors that may influence physician adherence to transcranial Doppler (TCD) screening guidelines among children with sickle cell disease. Pediatric hematologists, neurologists, and primary care physicians (n = 706) responded to a mailed survey in May 2012 exploring factors hypothesized to influence physician adherence to TCD screening guidelines: physician (internal) barriers and physician-perceived external barriers. Responses were compared by specialty using chi-square tests. Among 276 physicians (44%), 141 currently treated children with sickle cell disease; 72% recommend screening. Most primary care physicians (66%) did not feel well informed regarding TCD guidelines, in contrast to neurologists (25%) and hematologists (6%, P < .0001). Proportion of correct answers on knowledge questions was low (13%-35%). Distance to a vascular laboratory and low patient adherence were external barriers to receipt of TCD screening. Additional research regarding physicians' lack of self-efficacy and knowledge of recommendations could help clarify their role in recommendation of TCD screening.

Pediatricians' Self-Reported Knowledge, Attitudes, and Practices about Child Passenger Safety

To evaluate pediatricians' self-reported knowledge, attitudes, and dissemination practices regarding the new American Academy of Pediatrics' (AAP) child passenger safety (CPS) policy recommendations. A cross-sectional survey was distributed to pediatric primary care physicians via AAP e-mail distribution lists. Knowledge, attitudes, and practices related to current AAP CPS recommendations and the revised policy statement were ascertained. There were 718 respondents from 3497 physicians with active e-mail addresses, resulting in a 20.5% response rate, of which 533 were eligible based on the initial survey question. All 6 CPS knowledge and scenario-based items were answered correctly by 52.9% of the sample; these respondents were identified as the "high knowledge" group. Pediatricians with high knowledge were more likely to be female (P < .001), to have completed a pediatrics residency (vs medicine-pediatrics) (P = .03), and have a child between 4 and 7 years of age (P = .001). CPS information was distributed more frequently at routine health visits for patients 0-2 years of age vs those 4-12 years of age. Those with high knowledge were less likely to report several specific barriers to dissemination of CPS information, more likely to allot adequate time and discuss CPS with parents, and had greater confidence for topics related to all CPS topics. Although CPS knowledge is generally high among respondents, gaps in knowledge still exist. Knowledge is associated with attitudes, practices, barriers, and facilitators of CPS guideline dissemination. These results identify opportunities to increase knowledge and implement strategies to routinely disseminate CPS information in the primary care setting.

Abstract WP407: Physician Knowledge Regarding Transcranial Doppler Screening Recommendations Among Children with Sickle Cell Disease

Background: Transcranial Doppler (TCD) screening for stroke prevention among children with sickle cell disease (SCD) is recommended by the National Heart, Lung and Blood Institute (NHLBI); however, screening rates remain low. Little is known about provider knowledge of TCD recommendations. We explored knowledge of current TCD recommendations for children with SCD among pediatric hematologists and neurologists across the US, as well as pediatric primary care physicians (PCPs) of children with SCD in Michigan. Methods: Pediatric hematologists and neurologists (n=250 each) were sampled from the American Medical Association Masterfile, a listing of all US physicians. PCPs were pediatricians/family physicians treating children with SCD in Michigan identified through Medicaid claims 2008-2012 (n=206). A mailed survey was administered May 2012 with a 6 week follow-up to non-respondents. The survey included 6 questions regarding knowledge of TCD recommendations based on age and SC subtypes, as well as actions to take based on TCD results. The proportion of correct responses was classified based on NHLBI guidelines and compared across specialty using Fisher’s exact tests. Results: Among 638 deliverable surveys, 244 (38%) were returned (83 neurologists, 89 hematologists, 72 PCPs) and 103 indicated the respondent currently treats children with SCD and believes children with SCD should receive TCD screening. Among these respondents, 76% recommend TCD screening and 24% of the knowledge questions were answered correctly (Table 1). Differences in proportion correct overall and for specific questions were noted across specialty, with hematologists having the highest proportion correct. Conclusions: Although the majority of physicians recommend TCD screening, knowledge of specific TCD recommendations is low. Opportunities to improve knowledge of TCD recommendations span each physician specialty sampled, but are especially evident among PCPs and neurologists.

Pediatric Primary Care Physicians’ Practices Regarding Newborn Hearing Screening

Approximately 2 to 3 out of 1000 infants are born with hearing loss in the United States each year. Pediatric primary care physicians (PCPs) can play an important role in ensuring that infants with hearing loss are identified early and provided appropriate services. In this study, pediatric PCPs were surveyed about their practices regarding early hearing detection and intervention. Responses from the 2008 DocStyles survey were used to examine patient, physician, and practice variables associated with actions consistent with the 2007 Joint Committee on Infant Hearing position statement, which includes follow-up protocols for medical home providers. Pediatricians working in a group setting were more likely to receive hearing screening results than were those in individual practices or hospitals and clinics. Family/general physicians with heavier caseloads were more likely to receive hearing screening results for their pediatric patients than were those with lighter caseloads. Few pediatric PCPs reported contacting their state's early hearing detection and intervention program if they knew that an infant failed the newborn hearing screening. Although high proportions of pediatric PCPs reported referring an infant with hearing loss to an otolaryngologist, only about half reported referring a child with risk factors for hearing loss for audiological and speech-language assessment, even if the parents expressed concern or if the results of a developmental screening indicated a possible delay. Few respondents reported referring an infant with hearing loss under their care to an ophthalmologist. This study highlights the need to improve infrastructure for pediatric PCPs to receive and request infant hearing screening results to facilitate reporting and coordinate follow-up services for infants identified with hearing loss.

Evaluating Communication Between Pediatric Primary Care Physicians and Hospitalists

To determine the preferences for and satisfaction with communication between pediatric primary care physicians (PCPs) and hospitalists, 2 surveys (PCP and hospitalist versions with matching questions) were developed. Overall, PCPs were less satisfied than hospitalists with communication (P < .01). The 2 provider types had differing opinions on responsibility for care after hospital discharge, with hospitalists more likely than PCPs to assign responsibility to the PCP for pending labs (65% vs 49%; P < .01), adverse events (85% vs 67%; P < .01), or status changes (85% vs 69%; P < .01). Whereas satisfaction with and preferences for patient-related communication differed between hospitalists and PCPs, the incongruent views on the responsibility for care after patient discharge have major implications for safety particularly if poor communication occurs at discharge. Successful transitions from the hospital to primary care require communication between hospitalists and PCPs to be consistent, timely, and informative with responsibility for care discussed at discharge.

Spirometry Use Among Pediatric Primary Care Physicians

This study explores the use of spirometry in primary care settings. A 4-page survey was mailed to a national, random sample of office-based family physicians and pediatricians. Survey items addressed knowledge, attitudes, and practices regarding spirometry and standardized clinical vignettes. Data were analyzed by using χ2 tests and multivariate logistic regression. Among the 360 respondents who provided care to children with asthma, 52% used spirometry in clinical practice, whereas 80% used peak flow meters and 10% used no lung function tests. Only 21% routinely used spirometry for all guideline-recommended clinical situations. More family physicians than pediatricians reported using spirometry (75% vs 35%; P<.0001), and family physicians were more comfortable in interpreting spirometric results (50% vs 25%; P<.0001). Only one-half of respondents interpreted correctly the spirometric results in a standardized clinical vignette, and the frequency of underrating asthma severity increased with the inclusion of spirometric results. The most common barriers to the use of spirometry, that is, time and training, were cited more often by physicians who did not use spirometry. Two-thirds of respondents agreed that they would want additional training regarding implementing spirometry in their clinical practices. The use of spirometry in primary care settings for children with asthma does not conform to national guidelines. Widespread implementation of national asthma guidelines likely would require a major educational initiative to address deficiencies in spirometry interpretation and other barriers.

Spirometry Use Among Pediatric Primary Care Physicians

Spirometry Use Among Pediatric Primary Care Physicians