Pediatric Primary Care Practices Research Articles

678. Rapid Molecular SARS-CoV-2 Detection by Abbott ID NOW Is Reliable in Pediatric Patients

BackgroundThe COVID-19 Pandemic demonstrated the importance of rapid, accurate, point of care testing to control spread of the virus. The availability of this testing has been crucial to re-opening schools, keeping children safely in schools, and returning children to school quickly following illness. The Abbott ID Now molecular assay to detect SARS-CoV-2 was granted Emergency Use Authorization in March 2020. Reports of lower sensitivity compared with conventional PCR prompted some school districts to require confirmatory conventional PCR for negative rapid molecular results to return children to school. In this study we aim to determine the sensitivity and specificity of the Abbott ID NOW molecular SARS-CoV-2 test in a large pediatric primary care practice.MethodsA retrospective observational study was performed using data from 25 pediatric primary care sites in the Boston Children’s Health Physicians network, a large multispecialty pediatric practice in New York and Connecticut. Data were extracted from the electronic health record for all patients 0-22 years of age who had an Abbott ID NOW rapid molecular COVID-19 assay from October 1, 2020 - February 28, 2021. For all patients with rapid tests, we identified patients who had a conventional PCR test sent within 1 day before or 1 day after the ID NOW test. The result of the conventional PCR test was considered the “true” result. All discrepant test results were identified.ResultsDuring the study period, 14993 patients had ID NOW testing performed. The percent positivity was 8.5%. The percent positivity in our practices paralleled that in the surrounding community throughout the winter surge of COVID-19. 500 patients had confirmatory testing sent within 1 day before or after the ID NOW test (15 positive and 485 negative results). Based on the conventional PCR test results, 2 of 15 positive results were false positive and only 1 of 485 negative results was a false negative, resulting in a sensitivity of 93% and specificity of 99.6%. The false negative result was in a patient with nasal congestion whose mother was COVID positive.ConclusionRapid, molecular, point of care testing is an important tool to identify SARS-CoV-2 in pediatric patients and limit school absences. The ID NOW assay is highly sensitive and specific in a real-world pediatric setting. Disclosures All Authors: No reported disclosures

162. The Impact of the COVID-19 Pandemic on Antibiotic Prescribing in Pediatric Primary Care

BackgroundWith the onset of the coronavirus disease 2019 (COVID-19) pandemic, pediatric primary care delivery changed rapidly. Prior studies have demonstrated a reduction in ambulatory encounters and antibiotic prescriptions with the pandemic onset; however, the durability of these reductions in pediatric primary care in the United States has not been assessed. MethodsWe conducted a retrospective cohort study to assess the impact of the COVID-19 pandemic and associated public health measures (e.g. social distancing, masking, school closures, and increased availability of telemedicine) on antibiotic prescribing and encounter volume in 27 pediatric primary care practices, and the duration of these changes. Patients under age 19 with an encounter from January 1, 2018 through December 31, 2020 were included. The primary outcome was monthly antibiotic prescriptions per 1000 patients, in the overall population and a subset of encounters with infectious diagnoses, including respiratory tract infections (RTIs). Interrupted time series (ITS) analysis was performed.ResultsThere were 60,562 total antibiotic prescriptions from April to December in 2019 and 14,605 antibiotic prescriptions during the same months in 2020, a 76% reduction. The reduction in RTI encounter prescriptions accounted for 91.5% of the overall reduction in prescriptions from 2019 to 2020. Using ITS analysis, there was an immediate decrease from 31.6 to 7.4 prescriptions/1000 patients (predicted means) in April 2020 (-24.2 prescriptions/1000 patients; 95% CI: -31.9, -16.4) (Figures 1 and 2). This was followed by a stable rate of antibiotic prescriptions that remained flat through December 2020. For RTI encounters, a similar pattern was seen, with a decrease by 21.8 prescriptions/1000 patients; 95% CI: -29.5, -14.2) (Figures 1 and 2). Encounter volume also decreased immediately, and while overall encounter volume began returning to a pre-pandemic baseline volume toward the end of the study period, RTI encounter volume remained persistently lower through December 2020 (Figure 3).Figure 1. Antibiotic prescriptions per 1000 patients prescribed by month from January 2018 to December 2020, overall and for disease-specific subgroups RTI = respiratory tract infection; UTI = urinary tract infection; SSTI = skin and soft tissue infection. Months are numbered sequentially, starting with January (number 1). Dashed line indicates first full month of the pandemic, April 2020.Interrupted time series analysis for antibiotic prescriptions per 1000 patients by month from January 2018 to December 2020 for (A) all antibiotics as well as antibiotics prescribed at encounters with (B) respiratory tract infections (RTIs), (C) urinary tract infections (UTIs), and (D) skin and soft tissue infections (SSTIs) Intervention starts in April 2020 (dashed line). Months are numbered sequentially, starting with January (number 1). Dashed line indicates first full month of the pandemic, April 2020.Antibiotic prescriptions per 1000 billed encounters by month from January 2018 to December 2020 for (A) all encounters, as well as antibiotics prescribed at encounters with (B) respiratory tract infections (RTIs), (C) urinary tract infections (UTIs), and (D) skin and soft tissue infections (SSTIs) Months are numbered sequentially, starting with January (number 1).ConclusionDramatic reductions in antibiotic prescribing in pediatric primary care during the COVID-19 pandemic were sustained through 2020, primarily driven by reductions in RTI encounters.Disclosures All Authors: No reported disclosures

Changes in psychosocial functioning among urban, school-age children during the COVID-19 pandemic

BackgroundThere is concern about the effect of the COVID-19 pandemic on psychosocial functioning among school-age children, who have faced unusual stressors during this time. Our goal was to assess mental health symptoms and social risks during COVID-19, compared to before the pandemic, for urban, racial and ethnic minority school-age children, and investigate the relationship between mental health and social risks.MethodsWe conducted a cohort study from September 2019 until January 2021 of children age 5–11 years old recruited from an urban safety net hospital-based pediatric primary care practice. We measured emotional and behavioral symptoms (including attention, internalizing, and externalizing symptoms) before and during the pandemic with the Pediatric Symptom Checklist (PSC-17). We measured social risks (including food and housing insecurity) before and during the pandemic with the THRIVE screener. We measured additional mid-pandemic COVID-related stressors with items on school participation, screens/media use, illness exposure, and caregiver mental health. We compared pre- and mid-pandemic PSC-17 symptom scores across 4 domains (total, attention, internalizing, and externalizing) and used path analysis to examine the relationship between mental health and social risks pre- and mid-pandemic.ResultsCaregivers of 168 children (54% non-Hispanic Black, 29% Hispanic, and 22% non-English speaking) completed the study. Children had significantly higher levels of emotional and behavioral symptoms midpandemic- vs. pre-pandemic in all domains. Significantly more children had a positive PSC-17 total score (18% vs. 8%, p < 0.01) and internalizing (depression and anxiety) score (18% vs. 5%, p < 0.001) during the pandemic vs. before, indicating clinical concerns in these areas. Caregivers reported significantly more social risks during vs. before the pandemic (p < 0.001). Mental health symptoms significantly correlated with number of social risks before the pandemic, but not during the pandemic. Less school assignment completion, increased screen time, and caregiver depression were all significantly associated with worse mid-pandemic mental health in children.ConclusionThe COVID-19 pandemic has led to a dramatic increase in depression/anxiety problems and social risks among urban, racial and ethnic minority school-age children compared to before the pandemic. More research is needed to understand if these changes will persist.

Parent-focused prevention of adolescent health risk behavior: Study protocol for a multisite cluster-randomized trial implemented in pediatric primary care

Evidence-based parenting interventions play a crucial role in the sustained reduction of adolescent behavioral health concerns. Guiding Good Choices (GGC) is a 5-session universal anticipatory guidance curriculum for parents of early adolescents that has been shown to reduce substance use, depression symptoms, and delinquent behavior. Although prior research has demonstrated the effectiveness of evidence-based parenting interventions at achieving sustained reductions in adolescent behavioral health concerns, public health impact has been limited by low rates of uptake in community and agency settings. Pediatric primary care is an ideal setting for implementing and scaling parent-focused prevention programs as these settings have a broad reach, and prevention programs implemented within them have the potential to achieve population-level impact. The current investigation, Guiding Good Choices for Health (GGC4H), tests the feasibility and effectiveness of implementing GGC in 3 geographically and socioeconomically diverse large integrated healthcare systems. This pragmatic, cluster randomized clinical trial will compare GGC parenting intervention to usual pediatric primary care practice, and will include approximately 3750 adolescents; n = 1875 GGC intervention and n = 1875 usual care. The study team hypothesizes that adolescents whose parents are randomized into the GGC intervention arm will show reductions in substance use initiation, the study's primary outcomes, and other secondary (e.g., depression symptoms, substance use prevalence) and exploratory outcomes (e.g., health services utilization, anxiety symptoms). The investigative team anticipates that the implementation of GGC within pediatric primary care clinics will successfully fill an unmet need for effective preventive parenting interventions.Trial registration: Clinicaltrials.govNCT04040153

Pediatrician Adherence to Guidelines for Diagnosis and Management of High Blood Pressure

To assess pediatrician adherence to the 2017 American Academy of Pediatrics' clinical practice guideline for high blood pressure (BP). Pediatric primary care practices (n=59) participating in a quality improvement collaborative submitted data for patients with high BP measured between November 2018 and January 2019. Baseline data included patient demographics, BP, body mass index (BMI), and actions taken. Logistic regression was used to test associations between patient BP level and BMI with provider adherence to guidelines (BP measurement, counseling, follow-up, evaluation). A total of 2677 patient charts were entered for analysis. Only 2% of patients had all BP measurement steps completed correctly, with fewer undergoing 3-limb and ambulatory BP measurement. Overall, 46% of patients received appropriate weight, nutrition, and lifestyle counseling. Follow-up for high BP was recommended or scheduled in 10% of encounters, and scheduled at the appropriate interval in 5%. For patients presenting with their third high BP measurement, 10% had an appropriate diagnosis documented, 2% had appropriate screening laboratory tests conducted, and none had a renal ultrasound performed. BMI was independently associated with increased odds of counseling, but higher BP was associated with lower odds of counseling. Higher BP was independently associated with an increased likelihood of documentation of hypertension. In this multisite study, adherence to the 2017 American Academy of Pediatrics' guideline for high BP was low. Given the long-term health implications of high BP in childhood, it is important to improve primary care provider recognition and management. ClinicalTrials.gov: NCT03783650.

Adolescent and Parent Perceptions of Telehealth Visits: A Mixed-Methods Study

PurposeTelehealth presents unique benefits and challenges for adolescents and their parents. This study aimed to explore adolescent and parent perceptions of privacy, confidentiality, and therapeutic alliance during telehealth video visits. MethodsThis was a cross-sectional convergent parallel mixed-methods study. English-speaking parents and 13- to 17-year-old adolescents who completed a video visit at eight academic-affiliated pediatric primary care practices in the Southeastern U.S. were recruited between September 2020 and January 2021. Online surveys were administered and analyzed using descriptive and bivariable analysis. Subsequent semi-structured qualitative interviews were conducted and analyzed using thematic analysis. ResultsForty-eight adolescents and 104 parents completed surveys. Fourteen adolescents and 20 parents were interviewed. Mean ages of adolescents and parents were 15 and 46 years, respectively, and most participants identified as female, non-Hispanic, and white. Seventy-seven percent of adolescents reported very private telehealth visits. Most privacy concerns were related to the location of the visit in the patient's home or family members overhearing. Adolescents reported that alone time with their provider increased comfort in discussing sensitive issues, although only 31% of adolescents reported having time alone with their provider during their telehealth visit. Neither adolescents nor parents reported concerns about confidentiality. Interviews suggested that adolescent autonomy and independence in accessing health care may explain the positive relationship observed between therapeutic alliance and privacy. ConclusionsAdolescents and parents describe telehealth as convenient, useful, private, and confidential. Providers should strive to maximize privacy and the therapeutic alliance during video visits, including encouraging alone time and supporting adolescent autonomy and independence.

Implications of the COVID-19 Pandemic for Pediatric Primary Care Practice in Europe

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The Early STEPS Pilot Study: The Impact of a Brief Consultation Session on Self-reported Parenting Satisfaction.

Evidence-based parenting interventions can augment parental knowledge and skills to reduce parental stress and increase self-efficacy, leading to improved developmental outcomes for children. However, parenting interventions are often multi-session and require considerable time commitments from parents and primary care physicians. We conducted a pilot study to evaluate the effect of a brief consultation session on self-reported parental satisfaction and to assess the feasibility and effectiveness of incorporating occupational therapists (OTs) into a low-income urban pediatric primary care setting to conduct developmental screenings. OTs conducted one 45-min consultation on positive parenting practices and promoting child development with parents in a pediatric primary care practice. A one group pretest-posttest design with 6-month follow-up was utilized. Participants included 55 families with 60 children, ages 2 to 65months 30days. The primary outcome measure was the change in Parenting Sense of Competence Scale (PSOC) scores from baseline to 6-month follow-up. Additional outcomes were screening results, referral numbers, and follow through in obtaining early intervention services. The paired difference between PSOC scores at baseline and 6months indicated a significant increase in parenting satisfaction (p < 0.0001). Of 41 children referred, 26 were eligible and obtained services, 12 were lost to follow-up, and 3 did not qualify for services. Our preliminary findings suggest one consultation session on positive parenting practices and promoting child development may increase parenting satisfaction. Moreover, OTs can reduce the burden on primary care physicians by providing screenings, consultations, and follow-up. Further research is warranted to evaluate these findings.

Rating Scales for Behavioral Health Screening System Within Pediatric Primary Care.

Barriers to conducting standardized behavioral health screening within pediatric primary care settings include engaging youth and families, limited time available for this activity, and difficulties related to obtaining behavioral health consultation and treatment from specialists. Child and adolescent psychiatrists may assist pediatric primary care practices with engaging youth and families around screening by assisting with identifying rating scales that have good psychometric characteristics across multiple languages and are validated in diverse samples and available within the public domain. Additionally, they may partner with pediatric primary care professionals to assist with optimizing screening workflows and linkage to specialized services.

COVID-19 Pandemic Impact on Respiratory Infectious Diseases in Primary Care Practice in Children.

Background: The coronavirus disease 2019 (COVID-19) pandemic led to day care and school closures and children staying home for several months. When they gradually returned, aggressive regulations were implemented in New York State to reduce viral transmission.Method: An ongoing prospective study occurring in the Rochester, NY region, focused on early childhood respiratory infectious diseases, afforded an opportunity to assess the impact of the pandemic on the incidence of these illnesses in a primary care outpatient setting. Physician-diagnosed, medically attended infection visits were assessed in two child cohorts, age 6–36 months old: from March 15 to December 31, 2020 (the pandemic period) compared to the same months in 2019 (prepandemic). Nasopharyngeal colonization by potential otopathogens during healthy/well-child and acute otitis media (AOM) visits was evaluated.Results: One hundred and forty-four children were included in the pandemic cohort and 215 in the prepandemic cohort. The pandemic cohort of children experienced 1.8-fold less frequent infectious disease visits during the pandemic (p < 0.0001). Specifically, visits for AOM were 3.7-fold lower (p < 0.0001), viral upper respiratory infections (URI) 3.8-fold lower (p < 0.0001), croup 27.5-fold lower (p < 0.0001), and bronchiolitis 7.4-fold lower (p = 0.04) than the prepandemic cohort. Streptococcus pneumoniae (p = 0.03), Haemophilus influenzae (p < 0.0001), and Moraxella catarrhalis (p < 0.0001) nasopharyngeal colonization occurred less frequently among children during the pandemic.Conclusion: In primary care pediatric practice, during the first 9 months of the COVID-19 pandemic, significant decreases in the frequency of multiple respiratory infections and nasopharyngeal colonization by potential bacterial respiratory pathogens occurred in children age 6–36 months old.

Artificial intelligence-assisted clinical decision support for childhood asthma management: A randomized clinical trial.

RationaleClinical decision support (CDS) tools leveraging electronic health records (EHRs) have been an approach for addressing challenges in asthma care but remain under-studied through clinical trials.ObjectivesTo assess the effectiveness and efficiency of Asthma-Guidance and Prediction System (A-GPS), an Artificial Intelligence (AI)-assisted CDS tool, in optimizing asthma management through a randomized clinical trial (RCT).MethodsThis was a single-center pragmatic RCT with a stratified randomization design conducted for one year in the primary care pediatric practice of the Mayo Clinic, MN. Children (<18 years) diagnosed with asthma receiving care at the study site were enrolled along with their 42 primary care providers. Study subjects were stratified into three strata (based on asthma severity, asthma care status, and asthma diagnosis) and were blinded to the assigned groups.MeasurementsIntervention was a quarterly A-GPS report to clinicians including relevant clinical information for asthma management from EHRs and machine learning-based prediction for risk of asthma exacerbation (AE). Primary endpoint was the occurrence of AE within 1 year and secondary outcomes included time required for clinicians to review EHRs for asthma management.Main resultsOut of 555 participants invited to the study, 184 consented for the study and were randomized (90 in intervention and 94 in control group). Median age of 184 participants was 8.5 years. While the proportion of children with AE in both groups decreased from the baseline (P = 0.042), there was no difference in AE frequency between the two groups (12% for the intervention group vs. 15% for the control group, Odds Ratio: 0.82; 95%CI 0.374–1.96; P = 0.626) during the study period. For the secondary end points, A-GPS intervention, however, significantly reduced time for reviewing EHRs for asthma management of each participant (median: 3.5 min, IQR: 2–5), compared to usual care without A-GPS (median: 11.3 min, IQR: 6.3–15); p<0.001). Mean health care costs with 95%CI of children during the trial (compared to before the trial) in the intervention group were lower than those in the control group (-$1,036 [-$2177, $44] for the intervention group vs. +$80 [-$841, $1000] for the control group), though there was no significant difference (p = 0.12). Among those who experienced the first AE during the study period (n = 25), those in the intervention group had timelier follow up by the clinical care team compared to those in the control group but no significant difference was found (HR = 1.93; 95% CI: 0.82–1.45, P = 0.10). There was no difference in the proportion of duration when patients had well-controlled asthma during the study period between the intervention and the control groups.ConclusionsWhile A-GPS-based intervention showed similar reduction in AE events to usual care, it might reduce clinicians’ burden for EHRs review resulting in efficient asthma management. A larger RCT is needed for further studying the findings.Trial registrationClinicalTrials.gov Identifier: NCT02865967.

COVID pandemic as an incubator for a renewed vision of pediatric value-based healthcare

COVID-19 has stressed primary care pediatric practices. In addition, other market pressures that began before the pandemic make this an optimal time to re-examine pediatric payment models. CMS is encouraging changes in the Medicare market toward alternative payment models. However, success is limited for older adults, and while components of these models can work for pediatricians, the needs of children, young adults and their families are different from older adults. The rapid evolution of telemedicine, and the incursion of retail clinics and urgent care centers are eroding same day office visits and at the same time practices are merging or being acquired by larger organizations including hospitals and insurance companies. All of these changes will require a change in culture and approach in pediatric practice, and modified payment models must incentivize the best care for patients and families and create the opportunity for pediatricians to succeed.

Diagnostic Accuracy of SARS-CoV-2 Antigen Detection Test in Children: A Real-Life Study.

Naso-pharyngeal RT-PCR is the gold standard for the diagnosis of COVID-19, but there is a need for rapid and reliable tests. Some validation studies have used frozen aliquots mainly from adults. The aim of this real-life study was to test the performance of a SARS-CoV-2 rapid antigen test (SC2-RAT) in children. Symptomatic patients aged 0 to 17 years were recruited in the emergency department of the University Hospital of Creteil and in primary care pediatric practices from October 10, 2020 for 7 weeks. Each enrolled child had a SARS-CoV-2 RT-PCR test and a SC2-RAT from two distinct nasopharyngeal swabs. Among the 308 patients (mean [SD] age 4.9 [5.3] years), fever was the main symptom (73.4%), with no difference between COVID-19–negative and –positive groups. The prevalence of COVID-19 was 10.7% (95% CI 7.5–14.7). On the whole cohort, the sensitivity and specificity of the SC2-RAT compared to RT-PCR was 87.9% (95% CI 71.8–96.6) and 98.5% (95% CI 96.3–99.6). Considering samples with cycle threshold >25, the sensibility was lower: 63.6% (95% CI 30.8–89.1) and the specificity 99.6% (95% CI 98.0–100.0). The mean delay to obtain an SC2-RAT result was <15 min but was 3.2 h (SD 5.5) for an RT-PCR result. Contact with a COVID-19–positive person was more frequent for COVID-19–positive than –negative patients (n = 21, 61.6%, vs. n = 64, 24.6%; p < 0.01). In real life, SC2-RAT seems reliable for symptomatic children, allowing to detect contagious children.

AAP Publications Reaffirmed or Retired

Clinical Report. Providing psychosocial support to children and families in the aftermath of disasters and crises. Pediatrics. 2015;136(4). Available at: https://pediatrics.aappublications.org/content/136/4/e1120. Reaffirmed December 2020Policy statement. Firearm-related injuries affecting the pediatric population. Pediatrics. 2012;130(5):e1416–e1423. Available at: https://pediatrics.aappublications.org/content/130/5/e1416. Reaffirmed January 2021Policy statement. Handoffs: Transitions of care for children in the emergency department. Pediatrics. 2016;138(5):e20162680. Available at: https://pediatrics.aappublications.org/content/138/5/e20162680. Reaffirmed December 2020Clinical report. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics. 2012;130(5):e1391–e1405. Available at: https://pediatrics.aappublications.org/content/130/5/e1391. Reaffirmed December 2020Policy statement. Literacy promotion: an essential component of primary care pediatric practice. Pediatrics. 2014;134(2):404–409. Available at: https://pediatrics.aappublications.org/content/134/2/404. Reaffirmed December 2020Clinical report. Promoting optimal development: screening for behavioral and emotional problems. Pediatrics. 2015;135(2):384–395. Available at: https://pediatrics.aappublications.org/content/135/2/384. Reaffirmed December 2020Clinical report. The pediatrician's role in the prevention of missing children. Pediatrics. 2004;114(4):1100–1105. Available at: https://pediatrics.aappublications.org/content/114/4/1100. Retired December 2020

Effect of Training Pediatric Clinicians in Human Papillomavirus Communication Strategies on Human Papillomavirus Vaccination Rates

Missed opportunities for human papillomavirus (HPV) vaccination during pediatric health care visits are common. To evaluate the effect of online communication training for clinicians on missed opportunities for HPV vaccination rates overall and at well-child care (WCC) visits and visits for acute or chronic illness (hereafter referred to as acute or chronic visits) and on adolescent HPV vaccination rates. From December 26, 2018, to July 30, 2019, a longitudinal cluster randomized clinical trial allocated practices to communication training vs standard of care in staggered 6-month periods. A total of 48 primary care pediatric practices in 19 states were recruited from the American Academy of Pediatrics Pediatric Research in Office Settings network. Participants were clinicians in intervention practices. Outcomes were evaluated for all 11- to 17-year-old adolescents attending 24 intervention practices (188 clinicians) and 24 control practices (177 clinicians). Analyses were as randomized and performed on an intent-to-treat basis, accounting for clustering by practice. Three sequential online educational modules were developed to help participating clinicians communicate with parents about the HPV vaccine. Weekly text messages were sent to participating clinicians to reinforce learning. Statisticians were blinded to group assignment. Main outcomes were missed opportunities for HPV vaccination overall and for HPV vaccine initiation and subsequent doses at WCC and acute or chronic visits (visit-level outcome). Secondary outcomes were HPV vaccination rates (person-level outcome). Outcomes were compared during the intervention vs baseline. Altogether, 122 of 188 clinicians in intervention practices participated; of these, 120, 119, and 116 clinicians completed training modules 1, 2, and 3, respectively. During the intervention period, 29 206 adolescents (14 664 girls [50.2%]; mean [SD] age, 14.2 [2.0] years) made 15 888 WCC and 28 123 acute or chronic visits to intervention practices; 33 914 adolescents (17 069 girls [50.3%]; mean [SD] age, 14.2 [2.0] years) made 17 910 WCC and 35 281 acute or chronic visits to control practices. Intervention practices reduced missed opportunities overall by 2.4 percentage points (-2.4%; 95% CI, -3.5% to -1.2%) more than controls. Intervention practices reduced missed opportunities for vaccine initiation during WCC visits by 6.8 percentage points (-6.8%; 95% CI, -9.7% to -3.9%) more than controls. The intervention had no effect on missed opportunities for subsequent doses of the HPV vaccine or at acute or chronic visits. Adolescents in intervention practices had a 3.4-percentage point (95% CI, 0.6%-6.2%) greater improvement in HPV vaccine initiation compared with adolescents in control practices. This scalable, online communication training increased HPV vaccination, particularly HPV vaccine initiation at WCC visits. Results support dissemination of this intervention. ClinicalTrials.gov Identifier: NCT03599557.

Impact of Scribe Intervention on Documentation in an Outpatient Pediatric Primary Care Practice

The use of the electronic health record (EHR) has led to physician dissatisfaction, physician burnout, and delays in documentation and billing. Medical scribes can mitigate these unintended consequences by reducing documentation workload and increasing efficiency. To study the effects of medical scribes on time to completion of notes and clinician experience, with a focus on time spent charting during clinic and after-hours. We hypothesized that medical scribes in an outpatient pediatric setting would decrease clinician time spent charting, time to finalize encounter notes, and clinician's perceived documentation time. This 15-month single-center observational study was carried out with 3 study periods: pre-scribe, with-scribe, and scribe-withheld. Time spent in EHR was extracted by our EHR vendor. Participants completed surveys regarding time spent documenting. Six clinicians (5 physicians, 1 nurse practitioner) participated in this study to trial the implementation of medical scribes. EHR time data were collected for 4329 patient visits (2232 pre-scribe, 1888 with-scribe, 209 scribe-withheld periods). Comparing pre-scribe versus with-scribe periods, documentation time per patient decreased by 3-minutes 28-seconds per patient (pre-scribe IQR: 6, with-scribe IQR: 3, P=.028); note timeliness decreased from 0.96 days to 0.26 days (pre-scribe IQR: 0.22, with-scribe IQR: 0.11, P=.028); and clinicians' estimates of time spent in the EHR decreased by 1.2 hours per clinic session (pre-scribe IQR: 0.5, with-scribe IQR: 0.5, P=.031). Medical scribes in an outpatient pediatric setting result in: 1) decreased time spent charting, 2) reduced time to final sign clinic notes, and 3) decrease in clinician's perceived time spent documenting.

Paediatric primary care in Germany during the early COVID-19 pandemic: the calm before the storm

ObjectivesGlobally, the COVID-19 pandemic has a major impact on healthcare provision. The effects in primary care are understudied. This study aimed to explore changes in consultation numbers and patient management...

Managing the COVID-19 Pandemic Using Quality Improvement Principles: A New York City Pediatric Primary Care Experience.

Introduction:In the setting of COVID-19, pediatric primary care in New York City faced multiple challenges, requiring large-scale practice reorganization. We used quality improvement principles to implement changes to care delivery rapidly.Methods:Plan-do-study-act cycles were used, based on primary drivers of consolidation, reorganization of in-person and urgent care, telehealth expansion, patient outreach, mental health linkages, team communication, and safety.Results:The average visit volume in pediatrics decreased from 662 per week to 370. Telehealth visits increased from 2 to 140 per week, whereas urgent in-person visits decreased from 350 to 8 per week. Adolescent visits decreased from 57 to 46 per week. Newborn Clinic visits increased from 37 per week to 54. Show rates increased significantly for pediatrics and adolescent (P = 0.003 and P = 0.038, respectively).Conclusions:Quality improvement methodology allowed for the consolidation of pediatric primary care practices during the first wave of the COVID-19 pandemic, ensuring care for patients while prioritizing safety, evidence-based practices, and available resources.

Cost-effectiveness of a Smoking Cessation Intervention for Parents in Pediatric Primary Care

Parental smoking adversely affects parents' and children's health. There are effective interventions delivered in pediatric settings to help parents quit smoking. The cost-effectiveness of this type of intervention is not known. To evaluate the cost-effectiveness of a parental smoking cessation intervention, the Clinical Effort Against Secondhand Smoke Exposure (CEASE) program, delivered in pediatric primary care, compared with usual care from a health care organization's perspective. This economic evaluation used data on intervention costs and parental smoking cessation collected prospectively as part of the CEASE randomized clinical trial. Data were collected at pediatric offices in 5 US states from April 2015 to October 2017. Participants included parents of children attending 10 pediatric primary care practices (5 control, 5 intervention). Data analysis was performed from October 2019 to August 2020. The trial compared CEASE (practice training and support to address family tobacco use) vs usual care. The overall cost and incremental cost per quit of the CEASE intervention were calculated using microcosting methods. CEASE effectiveness was estimated using 2 trial outcomes measures assessed in repeated cross-sections: (1) change in smoking prevalence assessed by parental report for intervention vs usual care practices at 2 weeks after program initiation (baseline) and at 2-year follow-up and (2) changes in the proportion of smokers who achieved cotinine-confirmed smoking cessation in the previous 2 years at baseline vs follow-up. Monte Carlo analyses were used to provide 95% CIs. The study included a total of 3054 participants (1523 at baseline and 1531 at follow-up); 2163 (70.8%) were aged 25 to 44 years old, and 2481 (81.2%) were women. Over 2 years, the total cost of implementing and sustaining CEASE across 5 intervention practices was $115 778. The incremental cost per quit for CEASE compared with usual care was $1132 (95% CI, $653-$3603), according to the change in parent-reported smoking prevalence, and $762 (95% CI, $418-$2883), according to cotinine-confirmed cessation. CEASE was cost-effective at a willingness-to-pay threshold of $2000 per quit in 88.0% of simulations based on the parent-reported smoking prevalence and 94.6% of simulations based on cotinine-confirmed smoking cessation measures. These findings suggest that the CEASE intervention was associated with an incremental cost per quit that compared favorably with those of other clinical smoking cessation interventions. CEASE is inexpensive to initiate and maintain in the clinical pediatric setting, suggesting that it has the potential for a high impact on population health.

A Learning Collaborative to Improve Antibiotic Prescribing in Primary Care Pediatric Practices.

An American Academy of Pediatrics State Chapter organized a 6-month, mostly online quality improvement learning collaborative to improve antibiotic prescribing and patient education for upper respiratory infection (URI) and acute otitis media (AOM). Practices submitted data on quality measures at baseline, monthly, and 4 months post-project. Fifty-three clinicians from 6 independent, private primary care pediatric practices participated. Use of first-line antibiotics for AOM increased from 63.5% at baseline to 80.4% 4 months post-project. Use of safety-net antibiotic prescriptions (SNAP) for AOM increased from 4.5% to 16.9%. Educating patients about management for URI increased from 66.1% to 88.0% and for AOM from 20.4% to 85.6%. Practices maintained high performance for not prescribing antibiotics for URI (94.4% to 96.2%). Leveraging local relationships and national resources, this replicable antibiotic stewardship project engaged independent private practices to improve patient education for URI and AOM and prescribing and use of SNAP for AOM.