Pediatric Primary Care Research Articles

Developing the Technology-based Parenting Young Children Check-Up Intervention for Disruptive Behavior Problems Identified in Pediatric Primary Care.

Behavioral parent training programs show clear efficacy and effectiveness in response to young children's disruptive behavior problems, but limitations in engagement and accessibility prevent many families from benefiting from these programs. The Parenting Young Children Check-up (PYCC) is a technology-based program designed to overcome these barriers and increase the reach of behavioral parent training. Developed for use in pediatric health care, the PYCC includes three components: 1) an initial check-up designed to motivate program involvement; 2) text messages to connect parents with program content and reinforce content; and 3) a parent training website involving video-based content to teach parenting skills. This report details initial steps to refine PYCC intervention components. Seventeen mothers and 17 primary care physicians participated in this mixed methods data collection across three iterations by providing feedback on early drafts of the three components of the PYCC and completing a feedback questionnaire. Feedback from one iteration informed modifications that were then evaluated in subsequent iterations. Saturation of qualitative input, positive qualitative feedback, and positive quantitative ratings on the feedback questionnaire was achieved in iteration three. Outcomes of this investigation informed the full version of the PYCC that will subsequently be tested in a proof-of-concept trial. Several barriers limit the reach of parenting skills programs that reduce child problem behavior. We gathered feedback from parents and physicians to refine a parenting program that uses technology and delivery in pediatrics to overcome barriers. Future testing of the program will further inform implementation in pediatric settings.

Trends in Pediatric Primary Care Visits During the COVID-19 Pandemic: Opportunity to Address Adolescent Behavioral Health Through Telemedicine.

The COVID-19 pandemic impacted the volume and nature of pediatric primary care visits nationwide. This study aimed to identify trends in pediatric visits at our institution during the pandemic to reveal opportunities to improve care of children and adolescents. We performed a retrospective chart review of all pediatric visits conducted at a single family medicine clinic within a large academic medical center in Northern California from January 1, 2019, through September 30, 2021. Data collected for each visit included age, sex, type of visit (preventive or problem-focused), reason for visit (if problem-focused), and mode of visit (in-person or telehealth). We analyzed data using descriptive statistics and χ2 tests. A total of 4,844 pediatric visits occurred during the study period. Visit volume dropped 9% from 2019 to 2020 and recovered to prepandemic levels in 2021. During the study period from 2019 to 2021, the percentage of problem-focused visits increased from 30% to 37% (P=.008) among adolescents, driven largely by an increase in the percentage of behavioral health visits from 14% to 29% (P<.001). We found no significant changes in the age or sex of patients seen. Telemedicine visit volume decreased from 2020 to 2021 in all age categories except for adolescents, which remained stable at 43% of all visits. A sharp increase in behavioral health concerns among adolescents stands out as the most notable impact of COVID-19 on pediatric care at our institution. Our findings raise questions about how behavioral health care can be optimized for adolescents in the postpandemic era.

Barriers and Facilitators to Optimal Fluoride Varnish Application

ObjectiveNational guidelines recommend that all children under age six receive fluoride varnish (FV) in medical settings. However, application rates remain low. This study aimed to update understanding of barriers and facilitators to guideline concordant FV application. MethodsWe conducted virtual semi-structured interviews with a purposive sample (eg, FV application rates, geographic location, practice size and type) of pediatric primary care clinicians and medical assistants in Massachusetts between February 1 and June 30, 2022. The Consolidated Framework for Implementation Research (CFIR) served as the study’s theoretical framework and data were analyzed using a modified grounded theory approach. ResultsOf the 31 participants, 90% identified as White and 81% as female. Major themes, which linked to four CFIR domains, included: variation in perceived adequacy of reimbursement; differences in FV application across practice types; variation in processes, protocols, and priorities; external accountability for quality of care; and potential levers for change. Important subthemes included challenges for small practices; role of quality measures in delivering guideline-concordant preventive oral health care; and desire for preventive care coordination with dentists. ConclusionsThis study suggests that potential barriers and facilitators to guideline concordant FV application exist at multiple levels that may warrant further study. Examples include testing the effectiveness of quality measures for FV application and testing strategies for implementing consistent processes and protocols for improving FV application rates.

Recomendaciones de “no hacer” en la consulta de Atención Primaria

Introduction: in recent years, there has been an excess of unnecessary clinical practices in pediatrics that lack sufficient scientific evidence and generate significant costs, in addition to being bothersome and not providing additional benefits. For this reason, various scientific societies and institutions have proposed recommendations to avoid these ineffective and scientifically unjustified interventions. Material and methods: the project was coordinated by the PrevInfad working group of the Spanish Association of Primary Care Pediatrics (AEPap). It was developed in two phases through the exchange of e-mails. In the first phase, the coordinators were asked to disseminate the project and to collect proposals for unnecessary interventions. In the second phase, the recommendations were selected using the Delphi method and two rounds of voting. Results: in the first phase, 40 proposals for 'do not do' recommendations were obtained. In the first round of the second phase, seven proposals were accepted. Five recommendations were rejected and 28 were considered doubtful and passed to a second assessment. One additional recommendation was accepted in the second round. In total, 8 'do not do' recommendations were approved. Conclusions: the AEPap developed a list of 'do not do' recommendations in pediatrics in collaboration with its working groups and federated associations using the Delphi methodology for consensus among experts. These recommendations aim to improve the quality of care and promote the appropriate use of resources in pediatric primary care.

Miocardiopatía hipertrófica: pistas en el electrocardiograma

We continue with the series of clinical cases in Pediatric Cardiology reviewing the frequent reasons for consultation in Primary Care Pediatrics, presented in a brief and practical way and trying to show the usefulness of the electrocardiogram, a diagnostic method available in Primary Care. In this issue we present the case of a 15-year-old adolescent who attended a cardiology consultation for evaluation of a heart murmur. We discuss the electrocardiographic and echographic findings and the orientation in the management of this patient.

45.1 Approaches to Addressing Parent Mental Health in Pediatric Primary Care

45.1 Approaches to Addressing Parent Mental Health in Pediatric Primary Care

Improving human papilloma virus vaccination rates among adolescents.

The human papilloma virus (HPV) is the leading cause of cervical cancer worldwide and is responsible for genital warts and five other types of cancers. The HPV vaccine was introduced in 2006 and demonstrated to be safe and more effective than expected, yet adolescent rates of immunization in the United States remain low. Adolescent HPV vaccine rates were below the national average, and effective vaccine recommendation strategies were not used at an urban pediatric primary care office in southern Florida. The percentage of HPV vaccine rates in this primary care office were measured among adolescents ages 13-17 years using data obtained from Florida's state vaccine registry before implementation of the intervention, after the intervention, and monthly over a 90-day period. Interventions aimed to improve vaccine rates included implementing an HPV protocol consisting of education on providing a strong bundled recommendation, appointing a vaccine champion, implementing standing vaccine orders, and educational materials. The vaccine rates among adolescents increased by 11% for the initial dose, 7% for the second dose, and 6% for the vaccine completion rate. Chi-square test demonstrated statistical significance, for the initial vaccine. A nurse practitioner-led application of an evidenced-based HPV vaccine protocol positively affected the care of adolescents in this primary care setting.

1.11 Anxiety Screening in Pediatric Primary Care Setting

1.11 Anxiety Screening in Pediatric Primary Care Setting

3.25 Examining Practice Change Among Pediatric Primary Care Providers Participating in Maryland’s Child Psychiatry Access Program

3.25 Examining Practice Change Among Pediatric Primary Care Providers Participating in Maryland’s Child Psychiatry Access Program

Using ECHO (Extension of Healthcare Outcomes) to Partner With Pediatric Primary Care Providers

Using ECHO (Extension of Healthcare Outcomes) to Partner With Pediatric Primary Care Providers

Leading reasons for antibiotic prescriptions in pediatric respiratory infections: influence of fever in a primary care setting

BackgroundAntibiotic overuse in children is a significant public health concern, as it can lead to the emergence and spread of antibiotic-resistant bacteria. Although respiratory infections account for most antibiotic prescriptions in children, many of these infections are viral and do not require antibiotics. In this study, we aimed to investigate the use of antibiotics in children with respiratory infections in a primary care setting and to explore the possible role of fever on antibiotic prescription.MethodsWe conducted a prospective observational study that evaluated preschool children aged 0–5 years who were assessed by their primary care pediatricians for respiratory infectious diseases between October 2019 and March 2021. The study involved 69 public primary care pediatricians and a total of 678 pediatric episodes for respiratory infections.ResultsAmoxicillin/clavulanate was the most frequently prescribed drug. Bronchitis accounted for most of inappropriate antibiotic prescriptions (73%). Furthermore, the presence of fever was associated with a ~ 300% increase in the likelihood of prescribing antibiotics for respiratory infections that do not typically require antibiotics.ConclusionOur findings emphasize the need for adherence to international guidelines and recommendations in the primary care of children to reduce unnecessary antibiotic use and prevent the development of antibiotic resistance. This study also underscores the potential relevance of new studies to evaluate antibiotic prescription attitudes in other clinical settings and geographical areas.

Adolescent cancer prevention in rural, pediatric primary care settings in the United States: A scoping review

Adolescence is a critical period for establishing habits and engaging in health behaviors to prevent future cancers. Rural areas tend to have higher rates of cancer-related morbidity and mortality as well as higher rates of cancer-risk factors among adolescents. Rural primary care clinicians are well-positioned to address these risk factors. Our goal was to identify existing literature on adolescent cancer prevention in rural primary care and to classify key barriers and facilitators to implementing interventions in such settings.We searched the following databases: Ovid MEDLINE®; Ovid APA PsycInfo; Cochrane Library; CINAHL; and Scopus. Studies were included if they reported on provider and/or clinic-level interventions in rural primary care clinics addressing one of these four behaviors (obesity, tobacco, sun exposure, HPV vaccination) among adolescent populations. We identified 3,403 unique studies and 24 met inclusion criteria for this review.16 addressed obesity, 6 addressed HPV vaccination, 1 addressed skin cancer, and 1 addressed multiple behaviors including obesity and tobacco use. 10 studies were either non-randomized experimental designs (n = 8) or randomized controlled trials (n = 2). The remaining were observational or descriptive research.We found a dearth of studies addressing implementation of adolescent cancer prevention interventions in rural primary care settings. Priorities to address this should include further research and increased funding to support EBI adaptation and implementation in rural clinics to reduce urban–rural cancer inequities.

Addressing Adolescent Suicidality in Pediatric Primary Care.

This study examines prevalence rates of reported suicidal ideation (SI) in 2107 adolescents, characterizes recommendations and interventions given by primary care providers (PCPs) and behavioral health clinicians (BHCs) in response to SI on the Patient Health Questionnaire 9-Item Modified for Adolescents (PHQ-9A) for 140 adolescents, and identifies factors associated with a decrease in the frequency of SI at follow-up visits for 85 adolescents. A retrospective mixed-method approach was taken. Clinical informatics was used to extract visit data, demographics, and PHQ-9A scores for all visits between January 3, 2017, and August 31, 2018. Conventional content analysis of electronic medical records was used to examine qualitative results, and qualitative codes were then analyzed using point-biserial correlations. The setting includes a fully integrated behavioral health team within the primary care clinic. Of the 2107 adolescents, 140 (7%) endorsed SI within the past 2 weeks. Content analysis yielded 40 actions (17 PCP codes and 23 BHC codes) used in response to SI. Significant correlations were found between decreased SI frequency and the PCP referring to integrated behavioral health ( r = 0.24) and family navigators ( r = 0.26) and BHCs conducting a risk assessment ( r = 0.24), completing a safety plan ( r = 0.21), involving caregivers ( r = 0.29), sending the adolescent to the emergency department ( r = 0.28), and referring to family navigators ( r = 0.21; all p values < 0.05). The findings from this study support screening for SI and highlight specific multidisciplinary and family-centered interventions and recommendations to address adolescent endorsement of SI in pediatric primary care settings.

34 Using Spatial Analysis to Identify Access to IFHP-registered Paediatric Providers in Ontario

Abstract Introduction/Background Compared to non-refugees, child refugees face a wide array of health disparities, including higher levels of nutritional deficiencies, infectious diseases, and mental illness secondary to experienced poverty, trauma, and migration. After migration, refugee families continue to face health inequities, necessitating access to health care. In Canada, the Interim Federal Health Program (IFHP) provides temporary health care benefits to refugees and refugee claimants who are ineligible for provincial or territorial health insurance. The program requires healthcare providers to register to be reimbursed for care provided. However, physicians are not required to register for IFHP, leading to fewer providers. Objectives This study aimed to map where IFHP-registered primary care physicians (PCPs) and paediatricians live and work in Ontario, relative to where IFHP-insured patients live, to identify geographic accessibility of primary healthcare services for paediatric refugee populations. Design/Methods We performed spatial analysis using ArcMap (version 10.8.2), a geographic information system (GIS). The practice location of PCPs and paediatricians registered for IFHP as of December 2021 were geocoded and the percent of IHFP provider per population for each Census Tract (CT) was calculated. Refugee populations eligible for IFHP in Ontario by CT, as identified by the 2016 Canadian Census, were calculated as percentages and per 10,000 population, and linked to geospatial data for comparison. Ratios of IFHP providers to refugees were calculated for each CT. Results At the time of data collection, there were 481,710 documented refugees living in Ontario, and 11,854 IFHP-registered paediatricians or PCPs. Toronto, Windsor, and Kitchener-Waterloo had the largest percentages of refugees per population (5.4%, 5.1%, and 4.6%, respectively), while Toronto, Hamilton, and London had the highest percentage of IFHP providers per population (0.13%, 0.11%, and 0.09%, respectively). Generally, CTs with the highest proportion of refugees had more IFHP-registered providers, and rural areas had the fewest number of both refugees and IFHP-registered providers. However, there were 941 CTs recognized across Ontario with identified refugee populations but no registered IFHP providers. The CTs with the highest ratio of IFHP providers to refugees were in Toronto and Ottawa (3.9, 2.0 in Toronto, and 2.1 in Ottawa, respectively). Conclusion While some regions with large refugee populations have registered IFHP PCP providers, there are regions that are relative IFHP provider-deserts for resident refugees. Identifying areas where geographic barriers are likely to exist in Ontario is necessary to improve accessibility of existing services and could help reduce healthcare inequities faced by the refugee population.

Beyond Medicine: Bridging the Gap Between Health and Wealth in Pediatric Primary Care

Beyond Medicine: Bridging the Gap Between Health and Wealth in Pediatric Primary Care

Translated article] What Proportion of the Spanish Dermatology Caseload Corresponds to Pediatric Dermatoses? Results From the DIADERM National Random Sampling Survey

BackgroundVisits for skin conditions are very common in pediatric primary care, and many of the patients seen in outpatient dermatology clinics are children or adolescents. Little, however, has been published about the true prevalence of these visits or about their characteristics. Material and methodsObservational cross-sectional study of diagnoses made in outpatient dermatology clinics during 2 data-collection periods in the anonymous DIADERM National Random Survey of dermatologists across Spain. All entries with an International Classification of Diseases, Tenth Revision code related to dermatology in the 2 periods (84 diagnoses) were collected for patients younger than 18 years and classified into 14 categories to facilitate analysis and comparison. ResultsIn total, the search found 20 097 diagnoses made in patients younger than 18 years (12% of all coded diagnoses in the DIADERM database). Viral infections, acne, and atopic dermatitis were the most common, accounting for 43.9% of all diagnoses. No significant differences were observed in the proportions of diagnoses in the respective caseloads of specialist vs. general dermatology clinics or public vs. private clinics. Seasonal differences in diagnoses (January vs. May) were also nonsignificant. ConclusionsPediatric care accounts for a significant proportion of the dermatologist's caseload in Spain. Our findings are useful for identifying opportunities for improving communication and training in pediatric primary care and for designing training focused on the optimal treatment of acne and pigmented lesions (with instruction on basic dermoscopy use) in these settings.

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.

Decreasing Variation to Enhance Accurate Identification of Hypothermic Infants in Pediatric Primary Care.

Hypothermia can be the first and only sign of sepsis in young infants, yet there is a paucity of standard recommendations for pediatric primary-care office management of those infants identified. The SMART aim of this study was to standardize the identification and care of infants age 0 to 49 days at risk of hypothermia in pediatric primary care by decreasing the percent of infants with temperatures ≤36.5°C from 24% to 10% within 2 years. Over the course of this project, variation in documented temperatures ≤36.5°C decreased from 24% to 7% of encounters. Temperatures ≤36.5°C were documented for 951 infants or 13.4% (1078 of 8020 encounters). Of the 951 infants with temperatures ≤36.5°C, 96.1% were rewarmed in the office. Thirty-one patients ultimately required hospitalization. Application of quality improvement in a primary-care office decreased low temperatures by standardizing care, empowering staff, and triaging at-risk infants to the most appropriate level of care.

Improving Mental Health Outcomes in Adolescent Patients With Universal Anxiety Screening in an Outpatient Pediatric Primary Care Office: A Quality Improvement Project

In the wake of the cultural and mental health consequences that arose since the COVID-19 pandemic, primary care providers must be able to assess and initiate treatment of anxiety disorders in the pediatric population. Only 59% of children with a diagnosable anxiety disorder are identified and receive treatment. This quality improvement project aimed to evaluate the implementation of universal anxiety screening using the General Anxiety Disorder-7 tool in pediatric primary care. Screening was performed on adolescents (aged 12-18 years) to evaluate the frequency and acceptability of tool administration and identification of anxiety and referrals to mental health care for treatment. Employing a pretest-posttest design, the effect of universal anxiety screening for adolescents was measured at well-child visits. Anxiety screening and anxiety diagnosis rates were significantly increased post-implementation. Universal screening for anxiety was efficacious in the project setting for identifying cases of anxiety.

Towards practice change: a qualitative study examining the impact of a Child Psychiatric Access Program (Project TEACH) on Primary Care Provider practices in New York State during pandemic times

BackgroundThis study aims to explore the perceived impact of Project TEACH (Training and Education for the Advancement of Children’s Health), a New York State Office of Mental Health funded Child Psychiatric Access Program (CPAP), on pediatric Primary Care Providers (PCPs) and their practice. Practice change over time was assessed in the context of rising mental health needs and in the context of COVID19 pandemic.MethodsFocus groups utilizing a semi-structured format were conducted with pediatric PCPs who have been high utilizers of Project TEACH over the past 5–10 years and PCPs in similar regions who have been low or non-utilizers of the program. The semi-structured interview focused on practice change, asking about pediatric mental health, practice setting and flow, professional development, and changes over time in the context of COVID-19 pandemic and Project TEACH.ResultsThemes identified include increasing confidence of PCPs, particularly those who are high utilizers of the phone consultation line, increased routine use of screening and comfort bridging pediatric patients with mental health needs. Challenges include rising mental health needs, inadequate mental health services, difficulties with family follow through and high emotional burden on PCPs caring for these patients. In this context, participants noted that collaboration with Project TEACH provided needed emotional support.ConclusionsIntegrated care and CPAPs such as Project TEACH are vital to helping PCPs handle rising mental health needs particularly in current crisis times. Ongoing systemic challenges accessing care remain and contribute to emotional burden placed on pediatric PCPs.