Pediatric Primary Care Practices Research Articles

A pediatric primary care practice-based obesity intervention to support families: a cluster-randomized clinical trial.

The American Academy of Pediatrics recommends that pediatric practices help families make lifestyle changes to improve BMI, but provider time and access to treatment are limited. This study compared the effectiveness of two pediatric practice-based referral interventions in reducing BMI. In this cluster-randomized clinical trial, 20 pediatric primary care practices were randomized to telephonic coaching (Fitline Coaching) or mailed workbook (Fitline Workbook). Parents and their 8- to 12-year-old children with BMI ≥ 85th percentile completed assessments at baseline and at6 and 12 months post baseline. Primary outcomes were 12-month BMI percentile and z score. A total of 501 children and their parents received Fitline Coaching (n = 243) or Fitline Workbook (n = 258); 26.8% had overweight, 55.4% had obesity, and 17.8% had severe obesity. Mean (SD) age was 10.5 (1.4), and 47.5% were female. BMI percentile improved in both groups; 12-month decline in continuous BMI z score was not statistically significant in either group. However, 20.8% of telephonic coaching participants and 12.4% of workbook participants achieved a clinically significant reduction of at least 0.25 in BMI z score, a significant between-group difference (p = 0.0415). Both low-intensity interventions were acceptable and produced modest improvements in BMI percentile. One in five children in the telephonic coaching condition achieved clinically meaningful BMI z score improvements. However, more research is needed before such a program could be recommended for pediatric primary care practice.

A Qualitative Study of Breastfeeding Mothers' Perspectives Regarding Lactation Support Services.

Although breastfeeding is widely accepted as beneficial, only half of U.S. mothers are breastfeeding at 6 months. This study aimed to learn whether a quality improvement project to embed lactation support services into the newborn visit at a primary pediatric practice met families' needs. Mothers who were aged 18+ years, had an infant born in October 2021 with a well-child visit to the study practice (urban, 85% Medicaid, and 90% African American), and planned to breastfeed were invited to participate in a semi-structured telephone interview about their experience with breastfeeding and lactation support. We interviewed 18 mothers and, using a descriptive qualitative approach (thematic analysis), found that early support was helpful in addressing initial challenges such as latching pain but did not adequately anticipate later barriers to continued breastfeeding. This suggests lactation support offered by pediatric primary care practices should extend beyond the newborn period and be tailored to families' evolving needs.

Initial Feeding Method, WIC-Provided Lactation Support, and Breastfeeding Duration at an Urban Pediatric Primary Care Practice.

Breastfeeding (BF) is associated with improved maternal and infant health outcomes. However, underserved populations have limited access to lactation support. Our urban pediatric primary care practice partnered with WIC to integrate a BF peer counselor (BFPC) into newborn visits. To study the association of BF duration with (1) BFPC integration, (2) initial infant feeding methods (IFM). This is a retrospective cohort study of patients receiving BFPC support matched with those that did not based on race, ethnicity, and insurance. IFM were compared using chi-square. BF duration was compared using a t-test. These variables were compared across IFM using ANOVA. A cohort of 111 infant-mother dyads received BFPC support and 222 dyads did not (7/09/2019-4/25/2022). There was no significant difference in feeding methods between these groups. Compared to infants whose IFM was exclusive BF, fewer infants who initially used formula or both formula and breastmilk were exclusively BF at 2-month (55.8%, 8.2%, 10.9%), 4-month (54.8%, 6.3%, 14.5%), and 6-month visits (54.8%, 4.3%, 14.1%) (p < 0.001). There was a significant association between IFM and duration of any and exclusive BF (Formula only: 1week; BF and Formula: 3weeks; Exclusive BF: 14weeks; p < 0.001). A significant association was found between IFM and duration of BF. Early formula introduction was negatively associated with BF duration. The prenatal period may therefore be optimal for initiating BF support. Although there was no association between BFPC and BF duration, additional benefits of this intervention should be explored.

Multilevel Interventions and Dental Attendance in Pediatric Primary Care

Untreated tooth decay is disproportionately present among low-income young children. While American Academy of Pediatrics (AAP) guidelines require pediatric clinicians to implement oral health care, the effectiveness of these oral health interventions has been inconclusive. To test the effectiveness of multilevel interventions in increasing dental attendance and reducing untreated decay among young children attending well-child visits (WCVs). The Pediatric Providers Against Cavities in Children's Teeth study is a cluster randomized clinical trial that was conducted at 18 pediatric primary care practices in northeast Ohio. The trial data were collected between November 2017 and July 2022, with data analyses conducted from August 2022 to March 2023. Eligible participants included Medicaid-enrolled preschoolers aged 3 to 6 years attending WCVs at participating practices who were enrolled at baseline (WCV 1) and followed-up for 2 consecutive examinations (WCV 2 and WCV 3). Clinicians in the intervention group received both the practice-level (electronic medical record changes to document oral health) and clinician-level (common-sense model of self-regulation theory-based oral health education and skills training) interventions. Control group clinicians received AAP-based standard oral health education alone. Dental attendance was determined through clinical dental examinations conducted by hygienists utilizing International Caries Detection and Assessment System criteria and also from Medicaid claims data. Untreated decay was determined through clinical examinations. A generalized estimating equations (GEE) approach was used for both clinical examinations and Medicaid claims data. Eighteen practices were randomized to either intervention or control. Participants included 63 clinicians (mean [SD] age, 47.0 [11.3] years; 48 female [76.2%] and 15 male [23.8%]; 28 in the intervention group [44.4%]; 35 in the control group [55.6%]) and 1023 parent-child dyads (mean [SD] child age, 56.1 [14.0] months; 555 male children [54.4%] and 466 female children [45.6%]; 517 in the intervention group [50.5%]; 506 in the control group [49.5%]). Dental attendance from clinical examinations was significantly higher in the intervention group (170 children [52.0%]) vs control group (150 children [43.1%]) with a difference of 8.9% (95% CI, 1.4% to 16.4%; P = .02). The GEE model using clinical examinations showed a significant increase in dental attendance in the intervention group vs control group (adjusted odds ratio, 1.34; 95% CI, 1.07 to 1.69). From Medicaid claims, the control group had significantly higher dental attendance than the intervention group at 2 years (332 children [79.6%] vs 330 children [73.7%]; P = .04) but not at 3 years. A clinically but not statistically significant reduction in mean number of untreated decay was found in the intervention group compared with controls (B = -0.27; 95% CI, -0.56 to 0.02). In this cluster randomized clinical trial, children in the intervention group had better dental outcomes as was evidenced by increased dental attendance and lower untreated decay. These findings suggest that intervention group clinicians comprehensively integrated oral health services into WCVs. ClinicalTrials.gov Identifier: NCT03385629.

Comparing 2 Training Modalities Supporting the Adoption of the Safe Environment for Every Kid Approach in Pediatric Primary Care

ObjectiveTo compare the impact of 2 common continuing medical education training modalities—independent online training (IND) and a Maintenance of Certification-4 (MOC) activities—on primary care professionals’ (PCPs’) thinking and practice behavior regarding the Safe Environment for Every Kid (SEEK) approach. This was part of an implementation science study scaling up the evidence-based practice, SEEK. MethodsThis is a longitudinal, multisite, mixed methods, cluster randomized controlled trial comparing 21 pediatric primary care practices across the United States randomized to 1 of 2 training modalities. Two hundred ten PCPs completed surveys up to 4 times over a 2-year period to assess their thinking and practice regarding SEEK; a subset was interviewed up to 3 times. ResultsTraining led to significant and sustained improvements in PCPs’ thinking and behavior related to SEEK, with no significant differences between the IND and MOC groups. PCPs mostly viewed their training positively, but several described shortcomings. PCP characteristics, such as age and sex, did not moderate the impact of the training, nor did the presence of a behavioral health professional. ConclusionsThe lack of significant differences between the training modalities favors the simpler IND modality. This was despite the MOC training employing key principles of adult education. Of note, MOC-4 credits are required for pediatric board certification. More research is needed to optimize continuing medical education and tailor approaches for different learners. Clinical Trial Registry and Data Sharing StatementSEEK: Dissemination and Implementation, NCT03642327: https://clinicaltrials.gov/ct2/show/NCT03642327.

Developmental Milestone Attainment in US Children Before and During the COVID-19 Pandemic

Restrictions related to the COVID-19 pandemic disrupted the lives of young children, but the association between the pandemic and any changes in early childhood developmental milestone achievement in the US remains unclear. To determine the association between the COVID-19 pandemic and changes in developmental screening scores among US children aged 0 to 5 years and to investigate whether caregivers self-reported more worries about their children or concerns about children's behavior during the pandemic, regardless of milestone achievement. This was a cohort study using an interrupted time series analysis comparing prepandemic (March 1, 2018, to February 29, 2020), interruption (March 1 to May 31, 2020), and intrapandemic (June 1, 2020, to May 30, 2022) periods among 50 205 children (randomly sampled from a population of 502 052 children) aged 0 to 5 years whose parents or caregivers completed developmental screening at pediatric visits at US pediatric primary care practices participating in a web-based clinical process support system. COVID-19 pandemic period. Age-standardized Ages and Stages Questionnaire, Third Edition (ASQ) domain scores (communication, personal-social, problem-solving, gross motor, fine motor), and rate of caregivers' concerns about the child's behavior or worries about the child as measured on the ASQ. A total of 50 205 children (25 852 [51.5%] male; mean [SD] age, 18.6 [16.0] months) and 134 342 ASQ observations were included. In adjusted models, significant age-specific mean score decreases from prepandemic to intrapandemic were observed in communication (-0.029; 95% CI, -0.041 to -0.017), problem-solving (-0.018; 95% CI, -0.030 to -0.006), and personal-social (-0.016; 95% CI, -0.028 to -0.004) domains. There were no changes in fine or gross motor domains prepandemic to intrapandemic. For infants aged 0 to 12 months, similar effect sizes were observed but only for communication (-0.027; 95% CI, -0.044 to -0.011) and problem-solving (-0.018; 95% CI, -0.035 to -0.001). After accounting for age-standardized ASQ scores, caregiver worries about the child increased slightly in the intrapandemic period compared with the prepandemic period (rate ratio, 1.088; 95% CI, 1.036-1.143), but there were no changes in caregiver concerns about the child's behavior. While changes in developmental screening scores were modest (2%-3%), nationwide, this could translate to more than 1500 additional recommended developmental referrals over baseline each month. Modest changes in developmental screening scores are reassuring in the short term but may tax an already overburdened developmental behavioral pediatrics infrastructure. Continued attention to developmental surveillance is critical since the long-term population- and individual-level implications of these changes are unclear.

Computer-Facilitated Screening and Brief Intervention for Alcohol Use Risk in Adolescent Patients of Pediatric Primary Care Offices: Protocol for a Cluster Randomized Controlled Trial.

Alcohol and other substance use disorders usually begin with substance use in adolescence. Pediatric primary care offices, where most adolescents receive health care, are a promising venue for early identification of substance use and for brief intervention to prevent associated problems and the development of substance use disorder. This study tests the effects of a computer-facilitated screening and brief intervention (cSBI) system (the CRAFFT [Car, Relax, Alone, Forget, Family/Friends, Trouble] Interactive System [CRAFFT-IS]) on heavy episodic drinking, riding with a driver who is substance impaired, or driving while substance impaired among adolescents aged 14 to 17 years presenting for a well visit at pediatric primary care practices. We are conducting a cluster randomized controlled trial of the CRAFFT-IS versus usual care and recruiting up to 40 primary care clinicians at up to 20 pediatric primary care practices within the American Academy of Pediatrics (AAP) Pediatric Research in Office Settings network. Clinicians are randomized 1:1 within each practice to implement the CRAFFT-IS or usual care with a target sample size of 1300 adolescent patients aged 14 to 17 years. At study start, intervention clinicians complete web-based modules, trainer-led live sessions, and mock sessions to establish baseline competency with intervention counseling. Adolescents receive mailed recruitment materials that invite adolescents to complete an eligibility survey. Eligible and interested adolescents provide informed assent (parental permission requirement has been waived). Before their visit, enrolled adolescents seeing intervention clinicians complete a self-administered web-based CRAFFT screening questionnaire and view brief psychoeducational content illustrating substance use-associated health risks. During the visit, intervention clinicians access a computerized summary of the patient's screening results and a tailored counseling script to deliver a motivational interviewing-based brief intervention. All participants complete previsit, postvisit, and 12-month follow-up study assessments. Primary outcomes include past 90-day heavy episodic drinking and riding with a driver who is substance impaired at 3-, 6-, 9-, and 12-month follow-ups. Multiple logistic regression modeling with generalized estimating equations and mixed effects modeling will be used in outcomes analyses. Exploratory aims include examining other substance use outcomes (eg, cannabis and nicotine vaping), potential mediators of intervention effect (eg, self-efficacy not to drink), and effect moderation by baseline risk level and sociodemographic characteristics. The AAP Institutional Review Board approved this study. The first practice and clinicians were enrolled in August 2022; as of July 2023, a total of 6 practices (23 clinicians) had enrolled. Recruitment is expected to continue until late 2024 or early 2025. Data collection will be completed in 2025 or 2026. Findings from this study will inform the promotion of high-quality screening and brief intervention efforts in pediatric primary care with the aim of reducing alcohol-related morbidity and mortality during adolescence and beyond. ClinicalTrials.gov NCT04450966; https://www.clinicaltrials.gov/study/NCT04450966. DERR1-10.2196/55039.

Outcome of BMI2+: Motivational Interviewing to Reduce BMI Through Primary Care AAP PROS Practices.

Pediatric obesity rates in the United States remain at an all-time high. Pediatric primary care clinicians and registered dietitians can help treat childhood obesity, and motivational interviewing (MI) has shown promising effects in prior trials. We randomized 18 pediatric primary care practices to receive the Brief Motivational Interviewing to Reduce BMI or BMI2+ intervention or continue with usual care (UC). Practices were recruited through the American Academy of Pediatrics Pediatric Research in Office Settings network. The intervention comprised 4 components1: in-person and telehealth MI counseling by pediatric clinicians; 4 recommended sessions,2 6 telephone MI counseling sessions from a registered dietitian,3 text message reminders and tailored motivational messages, and4 parent educational materials. The main outcome was the change in the percentage of the 95th percentile of BMI. The study was conducted 2017 through 2021. There was a significant treatment x time interaction (b = 0.017, 95% confidence interval: [0.0066-0.027]) for the main outcome, favoring the UC group, with youth in the intervention arm showing a greater relative increase in their percent of the 95th percentile. There was no overall benefit of the intervention and, contrary to expectations, youth in the intervention arm gained more weight, based on percent of the distance from the 95th percentile than matched youth from UC practices. The absolute excess weight gain among intervention relative to UC youth was small, approximately 0.5 BMI units and 1 kg over 2 years. We offer several potential explanations for these unexpected findings.

Integrated behavioral health services in pediatric primary care and emergency department utilization for suicide risk.

Universal screening for suicide risk in primary care settings is a promising avenue for preventing self-harm and improving health outcomes. Triaging youth to an appropriate level of care, including diverting lower-risk patients from the emergency department (ED) is a meaningful goal. Previous research indicates integrated behavioral health (IBH) may prevent unnecessary admission to the ED on the day of suicide risk screening. We hypothesized that youth who received an IBH consultation the same day as suicide risk screening would be less likely to be admitted to the ED, but more likely to contact IBH services and utilize primary care in the following month. We conducted a retrospective chart review of 3,649 youth aged 10-18 years who were screened with the Ask Suicide-Screening Questions (ASQ) in two pediatric primary care practices. We collected demographic data, ASQ and Patient Health Questionnaire-9 (PHQ-9) scores, as well as patient contacts with IBH, the ED, and medical primary care the day of screening and the following 31 days. We conducted a series of logistic regressions and chi-square analyses to determine whether contact with IBH on the same day as positive suicide risk screenings predicted same-day admission to the ED, IBH contact, and medical primary care utilization. Among the 7,982 ASQ scores, 1,380 (18%) were non-acute and 87 ASQs (1%) screened acutely positive. Over 90% of positive screens were diverted from the ED regardless of IBH contact. None of the patients died from suicide. Same-day IBH was associated with higher likelihood of general ED visits for all positive screens (acute and non-acute together). None of the positive screens that received an IBH consultation on the same day as screening were admitted to the ED in the subsequent month. Contact with IBH the same day as screening positively predicted utilization of IBH and medical primary care services in the subsequent month, especially for youth with minority race and ethnicity identities. In the context of clinics with IBH and systematic risk assessment processes, most youth who screen positive for suicide risk are diverted from the ED. However, contrary to our hypothesis, our study showed that youth who received same-day IBH consultations were more likely to be admitted to the ED compared to peers who did not receive IBH consultations. These findings suggest that systematic suicide screening combined with IBH consultations in pediatric primary care can effectively identify risk levels and triage patients to appropriate care.

Clinician Prompts for Human Papillomavirus Vaccination: A Cluster Randomized Trial

ObjectiveWe assessed the impact of an online intervention using clinician prompts for human papillomavirus (HPV) vaccination with a cluster randomized controlled trial. MethodsThe randomized trial occurred July 2021–January 2022 in 48 primary care pediatric practices (24 intervention, 24 control) across the US. We trained clinicians via two online learning modules, plus weekly ‘‘quick tips’’ delivered via text or email. The training taught practices to implement a staff prompt to the clinician (e.g., printed reminders placed on the keyboard) plus electronic health record (EHR) prompts (if not already done) at well and acute/chronic visits for initial and subsequent HPV vaccination. We assessed missed opportunities for HPV vaccination using logistic regression models accounting for clustering by practice on an intent to treat basis. Surveys assessed facilitators and barriers to using prompts. ResultsDuring the 6-month intervention, missed opportunities for HPV vaccination increased (worsened) in both intervention and control groups. However, at well child care visits, missed opportunities for the initial HPV vaccine increased by 4.5 (95% CI: −9.0%, −0.1%) percentage points less in intervention versus control practices. Change in missed opportunities for subsequent doses at well child care and non-well child care visits did not differ between trial groups. An end-of trial survey found understaffing as a common challenge. ConclusionsClinician prompts reduced missed opportunities for HPV vaccination at well child care visits. Understaffing related to the COVID-19 pandemic may have led to worsening missed opportunities for both groups and likely impeded practices in fully implementing changes.

Effect of Automated and Personalized Outreach Messages on Well-Child Visit Catch Up: A Randomized Clinical Trial

ObjectiveTo determine the effectiveness of text/telephone outreach messages and personal contact attempts on well-child care (WCC) scheduling and completion and measles, mumps, and rubella (MMR) vaccine receipt. MethodsWe conducted an intent-to-treat, 2 × 2 factorial randomized clinical trial with 3 replications at 3 academic pediatric primary care practices from September 27, 2020 to August 6, 2021. We randomized participants to 1 of 4 groups: 1 automated message (group 1), 2 automated messages (group 2), 1 automated message plus personal contact attempts (group 3), or 2 automated messages plus personal contact attempts (group 4). Outcomes included: 1) scheduled WCC within 2 weeks (secondary outcome), 2) completed WCC within 8 weeks (secondary outcome), 3) receipt of first MMR by 15 months of age or second MMR within 3 months of first message for 4-year-olds (primary outcome). ResultsWe randomized 1312 patients (mean [SD] age = 38.8 [19.3] months, 53.5% male, 72.8% non-Hispanic Black, 86.9% Medicaid-enrolled). Scheduling rates were significantly higher in groups with personal contact attempts compared to those without (1 = 15.2%, 2 = 12.5%, 3 = 29.3%, and 4 = 31.5%). WCC completion rates also differed across groups: 1 = 27.4%, 2 = 22.3%, 3 = 32.0%, and 4 = 29.4%, with groups 3 and 4 having significantly higher rates than group 2. Similarly, groups 3 (30.2%) and 4 (31.8%) had significantly higher rates of receiving the MMR vaccine compared to group 2 (23.5%) but not group 1 (28.0%). ConclusionsOutreach messages that were followed by personal contact attempts increased the rates of scheduling and completing WCCs and receiving the MMR vaccine, providing a useful tool to re-engage at-risk populations.

Clinician Champions' Influence on Social Needs Screening Volumes in Pediatric Practices.

Health systems face barriers implementing routine screening for social needs. We assessed the impact of "clinician champions" on social needs screening. Screening data were assessed at 11 pediatric primary care practices in Bronx, NY, between April 2018 and August 2021. Three intervention practices had clinician champions; 8 control practices did not. The Wald chi-square tests and Poisson regressions evaluated the relationship between screening and introduction of clinician champions. The introduction of a clinician champion was a significant predictor of screening (P < .001). Within a practice, screening after the introduction of a clinician champion was higher than before the introduction (P < .001). The rate of screening for practices with a clinician champion was 2.8 times higher per month than for practices without a clinician champion. Furthermore, practices with clinician champions had higher rates of screening during the pandemic. In summary, the presence of clinician champions increased social needs screening rates in pediatric primary care practices.

Implementing Parenting Programs in Primary Care: A Framework and a Call for Action.

Healthy parent-child relationships are clearly critical to healthy child development. Parenting programs develop caregivers' skills to support the health and well-being of children. Rigorous evidence has demonstrated the efficacy of these programs. Rising rates of child and youth depression, anxiety, grief, and suicide, both prior to and compounded by the COVID-19 pandemic, provide further reasons to implement parenting programs that support all parents in their essential roles. Parents can act as a buffer to stressors and support for children's well-being when they have the knowledge and skills to do so. Pediatric primary care practices are a natural setting for parenting programs, but challenges, including stigma, technology, workflow issues, and funding, have prevented their broad dissemination, implementation, and sustainability. In this article, we develop a framework for implementing parenting programs in primary care and present key considerations for selecting programs that fit the needs of parents, providers, patients, and the practice. We offer lessons from our experiences in overcoming these challenges, using the updated Consolidated Framework for Implementation Research to structure our discussion. We also provide an initial stepwise process which readers may use to plan their own parenting program implementation. Pediatric clinicians and practices can use this article and associated resources to plan, implement, and evaluate parenting programs in their practices as a strategy to help address the growing youth mental health crisis. Improving parenting behaviors can reduce the need for current or future mental health interventions by supporting optimal child development, emotional regulation, and parent-child relationships.

Assessment of Adoption and Early Implementation Barriers and Facilitators of the Safe Environment for Every Kid (SEEK) Model.

Although the use of interventions for screening for social determinants of health of families in pediatric primary care clinics has increased in the past decade, research on the barriers and facilitators of implementing such interventions has been limited. We explored barriers, facilitators, and the mechanisms clarifying their roles in the adoption and implementation of the Safe Environment for Every Kid (SEEK) model, an approach for strengthening families, promoting children's health and development, and preventing child maltreatment. A total of 28 semistructured interviews were completed with 9 practice champions, 11 primary care professionals, 5 behavioral health professionals, and 3 nursing/administrative staff representing 12 pediatric primary care practices participating in a larger randomized control trial of implementing SEEK. We identified several barriers and facilitators in the stages of SEEK's adoption and early implementation. Barriers associated with outer and inner setting determinants and poor innovation-organization fit declined in importance over time, while facilitators associated with SEEK characteristics increased in importance based on participants' responses. Barriers and facilitators were linked by mechanisms of comparison and contrast of burdens and benefits, and problem-solving to address limited capacity with available resources. Any screening for and addressing social determinants of health demands greater attention to adoption and implementation mechanisms and the processes by which primary care professionals assess and utilize facilitators to address barriers. This occurs in a context defined by perceived burdens and benefits of innovation adoption and implementation, the capacity of the practice, and changes in perception with experiencing the innovation.

Group Well Child Care for Mothers with Opioid Use Disorder: Framework for Implementation

ObjectiveFor parents with opioid use disorder (OUD) and their children, group well child care (WCC) is an under-studied intervention that may reduce stigma, increase quality of care, and improve clinical outcomes. We explored barriers and facilitators to this intervention using an implementation science framework.MethodsA qualitative study was conducted from October 2020–March 2021 as part of the planning phase of a cluster-randomized trial of group WCC. Parent participants were recruited from one urban, university-affiliated OUD treatment center to participate in semi-structured telephone interviews. Eligible parents had a child under two years old and were English speaking. Clinician participants were recruited from a nearby pediatric primary care practice. Inductive thematic analysis of interview responses was led by two investigators using open coding procedures.ResultsThirty-one parents and thirteen pediatric clinicians participated in the interviews. Most parents (68%) reported that they would be likely or very likely to bring their child to the OUD treatment center for WCC. Six themes emerged describing perceived implementation barriers, including intervention difficulty, complexity, and potential negative outcomes such as loss of privacy. Six themes emerged as implementation facilitators: (1) focus on parental OUD and recovery, (2) peer support, (3) accessibility and coordination of care, (4) clinician skill and expertise in parental OUD, (5) increased time for patient care, and (6) continuity of care.Conclusions for PracticeParents and clinicians expressed multiple perceived benefits of this intervention. Identified barriers and facilitators will inform implementation and evaluation of group WCC within one OUD treatment program.

Specialist use among privately insured children with disabilities.

To investigate primary care practice ownership and specialist-use patterns for commercially insured children with disabilities. A national commercial claims database and the Health Systems and Provider Database from 2012 to 2016 are the data sources for this study. This cross-sectional, descriptive study examines: (1) the most visited type of pediatric primary care physician and practice (independent or system-owned); (2) pediatric and non-pediatric specialist-use patterns; and (3) how practice ownership relates to specialist-use patterns. This study identifies 133,749 person-years of commercially insured children with disabilities aged 0-18 years with at least 24 months of continuous insurance coverage by linking a national commercial claims data set with the Health Systems and Provider Database and applying the validated Children with Disabilities Algorithm. Three-quarters (75.9%) of children with disabilities received their pediatric primary care in independent practices. Nearly two thirds (59.6%) used at least one specialist with 45.1% using nonpediatric specialists, 28.8% using pediatric ones, and 17.0% using both. Specialist-use patterns varied by both child age and specialist type. Children with disabilities in independent practices were as likely to see a specialist as those in system-owned ones: 57.1% (95% confidence interval [95% CI] 56.7%-57.4%) versus 57.3% (95% CI 56.6%-58.0%), respectively (p = 0.635). The percent using two or more types of specialists was 46.1% (95% CI 45.4%-46.7%) in independent practices, comparable to that in systems 47.1% (95% CI 46.2%-48.0%) (p = 0.054). However, the mean number of specialist visits was significantly lower in independent practices than in systems-4.0 (95% CI 3.9%-4.0%) versus 4.4 (95% CI 4.3%-4.6%) respectively-reaching statistical significance with p < 0.0001. Recognizing how privately insured children with disabilities use pediatric primary care from pediatric and nonpediatric primary care specialists through both independent and system-owned practices is important for improving care quality and value.

Missed Opportunities for Adolescent Immunizations at Well-Care Visits During the COVID-19 Pandemic

PurposeThe Coronavirus Disease 2019 pandemic disrupted healthcare, but the impact on vaccination missed opportunities (MOs, vaccine-eligible visits without vaccination) is unknown. We evaluated pandemic-related trends in MOs at adolescent well-care visits for three vaccines: human papillomavirus; quadrivalent meningococcal conjugate; and tetanus, diphtheria, and acellular pertussis (Tdap). MethodsWe analyzed electronic health record data from 24 pediatric primary care practices in 13 states from 1/1/2018 to 12/31/2021. Segmented logistic regression estimated risk differences for MOs during the pandemic relative to prepandemic trends. ResultsAmong 106,605 well-care visits, we observed decreases in MOs prepandemic followed by an increase in MOs during the pandemic for all three vaccines. Relative to prepandemic, MOs increased for human papillomavirus (+15.9%, 95% confidence interval [CI]: 11.7%, 20.1%), meningococcal conjugate (+9.4%, 95% CI: 5.2%, 13.7%), and tetanus, diphtheria, and acellular pertussis (Tdap) (+ 8.2%, 95% CI: 4.3%, 12.1%). DiscussionIncreases in vaccine MOs during the pandemic equaled or exceeded pre-pandemic decreases. Reducing MOs in adolescent well-care could raise vaccine coverage.

Recommendations for post-implementation adaptations to optimize family navigation in pediatric primary care: a qualitative study with parents and navigators

BackgroundFamily Navigation (FN) is an evidence-based care management intervention designed to reduce disparities in access to care by providing families with individually tailored support and care coordination. Early data suggest FN is effective, but effectiveness is significantly influenced by both contextual (e.g. setting) and individual (e.g., ethnicity) variables. To better understand how FN could be tailored to address this variability in effectiveness, we set forth to explore proposed adaptations to FN by both navigators and families who received FN.MethodsThis study was a nested qualitative study set within a larger randomized clinical trial of FN to improve access to autism diagnostic services in urban pediatric primary care practices in Massachusetts, Pennsylvania, and Connecticut serving low-income, racial and ethnic minority families. Following FN implementation, key informant interviews were conducted based on the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) with a purposeful sample of parents of children who received FN (n = 21) and navigators (n = 7). Interviews were transcribed verbatim and were coded using framework-guided rapid analysis to categorize proposed adaptations to FN.ResultsParents and navigators proposed 38 adaptations in four domains: 1) content of the intervention (n = 18), 2) context of the intervention (n = 10), 3) training and evaluation (n = 6), and 4) implementation and scale-up (n = 4). The most frequently endorsed adaptation recommendations focused on content (e.g., lengthening FN, providing parents with additional education on autism and parenting children with autism) and implementation (e.g., increasing access to navigation). Although probes targeted critical feedback, parents and navigators were overwhelmingly positive about FN.ConclusionsThis study builds upon prior FN effectiveness and implementation research by providing concrete areas for adaptation and refinement of the intervention. Recommendations by parents and navigators have the potential to inform improvement of existing navigation programs and development of new programs in similarly underserved populations. These findings are critical as adaptation (cultural and otherwise) is an important principle in the field of health equity. Ultimately, adaptations will need to be tested to determine clinical and implementation effectiveness.Trial registrationClinicalTrials.gov, registration number NCT02359084, February 9, 2015.

Assessment of the Smoke Free Families Tobacco Screening, Counseling, and Referral Program in Pediatric Primary Care Practices

ObjectiveThe Smoke Free Families (SFF) program trained pediatric providers to use an SFF tool during well-child visits (WCVs) of infants ≤12 months to “Ask” caregivers about tobacco use, “Advise” smokers to quit, and “Refer” smokers to cessation services (AAR). The primary objectives were to assess the prevalence and changes in caregiver tobacco use after being screened and counseled by providers using the SFF tool. A secondary objective was to examine providers’ AAR behavior facilitated by using the SFF tool. MethodsPediatric practices participated in 1 of 3 6–9-month SFF program waves. Over the 3 waves, all initial SFF tools completed on caregivers during their infant’s WCV were evaluated for the caregiver and household tobacco use and providers’ AAR rates. An infant’s first and next WCV was matched to determine changes in caregiver tobacco product use. ResultsIn total, the SFF tool was completed at 19,976 WCVs; 2081 (18.8%) infants were exposed to tobacco smoke. A total of 834 (74.1%) caregivers who smoked received counseling: 786 (69.9%) were advised to quit, 700 (62.2%) were given cessation resources, and 198 (17.6%) were referred to the Quitline. In total, 230 (27.6%) of caregivers who smoked had a second visit; 58 (25.2%) self-reported that they quit using tobacco. Among cigarette users (n = 183), 89 (48.6%) reported that they used fewer cigarettes or quit at their infants’ second WCV. ConclusionsSystematic use of the SFF AAR tool during infants’ WCVs could improve the health of caregivers and children, resulting in decreases in tobacco-related morbidity.

Assessment of Screening Tools to Identify Substance Use Disorders Among Adolescents

Efficient screening tools that effectively identify substance use disorders (SUDs) among youths are needed. To evaluate the psychometric properties of 3 brief substance use screening tools (Screening to Brief Intervention [S2BI]; Brief Screener for Tobacco, Alcohol, and Drugs [BSTAD]; and Tobacco, Alcohol, Prescription Medication, and Other Substances [TAPS]) with adolescents aged 12 to 17 years. This cross-sectional validation study was conducted from July 1, 2020, to February 28, 2022. Participants aged 12 to 17 years were recruited virtually and in person from 3 health care settings in Massachusetts: (1) an outpatient adolescent SUD treatment program at a pediatric hospital, (2) an adolescent medicine program at a community pediatric practice affiliated with an academic institution, and (3) 1 of 28 participating pediatric primary care practices. Participants were randomly assigned to complete 1 of the 3 electronic screening tools via self-administration, followed by a brief electronic assessment battery and a research assistant-administered diagnostic interview as the criterion standard measure for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnoses of SUDs. Data were analyzed from May 31 to September 13, 2022. The main outcome was a DSM-5 diagnosis of tobacco/nicotine, alcohol, or cannabis use disorder as determined by the criterion standard World Mental Health Composite International Diagnostic Interview Substance Abuse Module. Classification accuracy of the 3 substance use screening tools was assessed by examining the agreement between the criterion, using sensitivity and specificity, based on cut points for each tool for use disorder, chosen a priori from previous studies. This study included 798 adolescents, with a mean (SD) age of 14.6 (1.6) years. The majority of participants identified as female (415 [52.0%]) and were White (524 [65.7%]). High agreement between screening results and the criterion standard measure was observed, with area under the curve values ranging from 0.89 to 1 for nicotine, alcohol, and cannabis use disorders for each of the 3 screening tools. These findings suggest that screening tools that use questions on past-year frequency of use are effective for identifying adolescents with SUDs. Future work could examine whether these tools have differing properties when used with different groups of adolescents in different settings.