Pediatric Primary Care Research Articles

Clinical Manifestations of Acute COVID-19 in Previously Healthy Pediatric Patients Diagnosed by Rapid Antigen Screening in a Community-Based, Outpatient Primary Care Pediatrics Practice

Background: The PediCenter and Niles Children’s Clinic provide pediatric primary and urgent care services in central California. We remained open throughout the COVID-19 pandemic, providing scheduled well child-care and sick visits. Methods: Beginning in September 2020, we implemented a COVID-19 screening program. Screening was performed on all patients presenting for care and was made available to patients requiring testing for any purpose. Herein, we provide results from that program, including a description of clinical characteristics of COVID-19 in our patients. Results: Key findings: A total of 11,649 COVID-19 antigen screening tests were performed (age range 0.1 to 17.0, mean 8.7, SD 4.5). In total, 1560 pts. (13.4%) tested positive. Among these, 665 (43%) were asymptomatic, 560 (36%) had mild disease, 318 (20%) had moderate disease, and 17 (1%) had severe disease. No critical cases or transfers to the emergency room were reported. Younger patient age was associated with an increased severity of illness, as was time from the onset of the pandemic. A total of 4446 patients reported no symptoms at the time of screening, 15% of whom tested positive. In total, 7203 patients reported symptoms at the time of testing. Among these, 87.6% tested negative and 12.4% tested positive. Disease severity was similar between these two groups. COVID-19 is generally a mild respiratory tract infection in healthy children. Conclusions: Screening is effective in identifying cases, including asymptomatic cases. Statistical models further revealed associations between patient age, time from the onset of the pandemic, and disease severity.

Adaptation of an evidence-based, preventive intervention to promote mental health in Hispanic adolescents: eHealth Familias Unidas Mental Health.

Youth internalizing symptoms (i.e., depression and anxiety), suicide ideation and attempts have been rising in recent years, including among Hispanics. Disparities in mental healthcare are concerning and require intervention, ideally prevention or early intervention. Familias Unidas is a culturally-syntonic, family-centered intervention effective in reducing youth drug use and sexual risk, with evidence of unanticipated effects on internalizing symptoms. This paper describes the systematic process used to adapt the eHealth version of the Familias Unidas intervention to more directly address internalizing symptoms and suicide risk in preparation for an effectiveness-implementation hybrid trial for youth with elevated internalizing symptoms, a history of suicide ideation/attempts, or poor parent-youth communication. The resulting eHealth Familias Unidas Mental Health intervention is described. Guided by a 4-phase framework, the steps in the adaptation process involved: assessment of the community and intervention delivery setting (pediatric primary care clinics); integration of previous intervention research, including intervention mechanisms of action; and expert and community consultation via focus groups. Focus group analyses showed that youth and parents perceived that the intervention was helpful. Their feedback was categorized into themes that were used to directly target mental health by addressing technology use, parent mental health, and social support. Effective and scalable preventive interventions are needed to address mental health disparities. The systematic adaptation process described in this paper is an efficient approach to expanding interventions while maintaining known, empirical and theoretical mechanisms of action. Findings from the ongoing effectiveness-implementation trial will be critical.

Understanding Family Caregiver's Self-Initiated Expressions of Concern: Prevalence, Content, Emotional Implication, and Opportunity for Doctor's Empathic Responses in Chinese Pediatric Primary Care.

Despite the significance of patient expressions of concern in medical interaction, existing research has found that doctors often fail to respond to them or even overlook them. Based on a dataset of video-recorded naturally occurring medical conversations in Chinese pediatric primary care, this study aims to systematically investigate the expressions of concern initiated by the family caregivers of pediatric patients and the responses of doctors. The results show that family caregivers actively initiate expressions of concern, covering a wide range of topics. Doctors respond to these concerns in 68.8% of the cases, while the rest are interrupted, ignored, or minimally acknowledged. In addition, as commonly found in other clinical and cultural contexts, family caregivers rarely express their emotional distress explicitly but rather indicate their underlying emotions implicitly. These findings suggest that a better understanding of the full range of family caregiver's self-initiated expressions of concern and their complexities provide important opportunities for doctors to identify and respond to them empathically.

Early life health adversity and internalizing disorders in the transition from adolescence to adulthood.

Early life adversity (ELA) and youth chronic health conditions have been examined as separate contributors to psychopathology. However, little work has specifically examined early life health adversity (ELHA) and its association with risk for internalizing disorders. This study seeks to examine the relationship between ELHA and internalizing disorders across adolescence. A sample of 705 Australian mother-youth dyads participated in a prospective longitudinal study. Mothers reported child health indicators at youth ages three-to-four days, six months, and five years and completed a psychiatric interview at 15 years. Youth completed a psychiatric interview, as well as measures of current health status, at age 20. ELHA was positively associated with both youth anxiety and depressive disorders from ages 15 to 20. When independently accounting for the role of (a) current health status and (b) exposure to traditionally conceptualized forms of ELA, these findings remained statistically significant for anxiety but not depressive disorders. ELHA interacted with maternal depression, such that ELHA was only associated with youth depressive disorders in cases where mothers themselves had experienced depression. Routine mental health screenings may be warranted for youth who experience ELHA and their mothers. Pediatric primary care may be an ideal setting for implementing prevention and intervention efforts.

Identifying and supporting vaccine champions in pediatric primary care: a qualitative interview study.

Implementation science research identifies clinical champions as instrumental in aligning healthcare professionals' (HCPs) behavior with practice guidelines for delivering health services, including vaccinations. However, we know relatively little about identifying or supporting champions. To characterize who vaccine champions are, what they do, and how to support their work in pediatric primary care. In 2022, we interviewed a purposive sample of peer-nominated or self-identified vaccine champions (n=20) and HCPs who worked with vaccine champions (n=4). We thematically analyzed qualitative data. Vaccine champions' defining characteristics were firsthand primary care experience, whether as providers or nursing staff, and a strong belief in vaccinations as uniquely effective tools for primary prevention. Participants noted these beliefs were "part of the DNA" of specialties like pediatrics and infectious disease, where they perceived champions as especially common. Being "insatiable in their quest for knowledge," champions primarily conceptualized their role as understanding and sharing complex information and performance metric data related to vaccine administration. Champions' role in leading other implementation strategies, such as communication training, was more peripheral. Champions reported that dedicated time and staff support helped them "go above and beyond" to improve vaccination rates. Our findings suggest that vaccine champions can be found among providers and nursing staff with deep clinical experience and commitment to primary prevention through vaccination, including through providing vaccine education to colleagues. Healthcare systems can allocate resources to support champions as educators, while exploring opportunities to extend their role in other implementation strategies to improve vaccination rates.

The Impact of Tele-Stewardship on Rural Antibiotic Prescribing Practices

Abstract Background Antibiotic prescribing for children is highest in rural areas. Tele-stewardship allows for implementation of antimicrobial stewardship (AS) via telecommunication with providers. There has been limited research on the effectiveness of tele-stewardship in the outpatient setting. In this study, we address the need for better AS in rural areas by developing, implementing, and evaluating AS interventions using tele-stewardship. Methods We employed bundled outpatient AS implementation strategies in rural pediatric primary care (PC) clinics and emergency departments (EDs) affiliated with Vanderbilt University Medical Center (VUMC) using tele-stewardship. The bundle includes (1) patient/guardian educational materials, (2) antibiotic use commitment posters (3) provider education through quarterly teaching pearls on common pediatric infections, communication skills training (DART modules), app-based microlearning modules (QuizTime), and implicit/explicit bias education and (4) quarterly audit and feedback with peer comparison on guideline-concordant antibiotic use. Participants are pediatric prescribers (physician, physician assistant, nurse practitioner). We compared antibiotic prescription data for children <18 years collected during the “baseline” period (Jan-Dec 2022) to the intervention period (Jan-Sept 2023). Two academic urban primary care clinics and one academic urban ED at which the interventions were not implemented were included as “control” sites. The primary outcome is percent of all encounters that result in an antibiotic prescription. Pre- and post-intervention data were analyzed in aggregate (not at the provider-level). Significance was determined via calculating a 95% confidence interval (CI) for the difference of proportions. Results To date, there have been 140,077 PC patient encounters (98,409 baseline and 41,065 intervention) and 94,205 ED encounters (61759 baseline and 32,446 intervention) across all sites. Change from baseline to intervention periods in academic PC sites was 0.9 percentage points (95% CI 0.556 to 1.243; 6.6% baseline, 7.5% intervention) while change in rural intervention sites was -1.05 percentage points (95% CI -0.409 to -1.667; 11.8% baseline, 10.75% intervention; Figure 1a). Only 1 of 3 rural EDs had a decrease in percent of encounters with an antibiotic prescription (Figure 1b). Overall the academic ED showed a 3.1 percentage point increase (95% CI 2.430 to 3.769; 18.0% baseline, 21.1% intervention) while the rural sites showed a 1.0 percentage point increase (95% CI -0.817 to 2.817; 24.2% baseline, 25.2% intervention). Conclusion Interim analysis shows that bundled implementation strategies using tele-AS led to significantly decreased overall antibiotic use in rural primary care clinics compared to urban academic control sites. The study is ongoing and will continue to evaluate outcomes over a longer intervention period to reduce seasonal bias.

High caregiver adverse childhood experiences are associated with increased pediatric infection-related healthcare utilization and antibiotic use

Abstract Background Higher caregiver adverse childhood experiences (ACEs) have been associated with a range of pediatric outcomes, including hospitalizations. We recently found that higher caregiver ACEs are associated with higher rates of influenza vaccine uptake. However, to our knowledge, no studies have examined links between caregiver ACEs and specific infections or infection-related outcomes, such as antibiotics prescribed. We sought to evaluate associations between caregiver ACEs and pediatric infection-related outcomes. Methods We conducted a retrospective cohort study of two pediatric primary care sites, each serving a predominantly non-Hispanic Black, publicly insured population. At one primary care site (Clinic A), routine screenings for caregiver ACEs began in 2019 at the 1-month well-child check and were retrieved from the electronic health record. For the other primary care site (Clinic B), a prior research study surveyed caregiver ACEs of 283 children. Focusing on children 0-4 years of age in both primary care sites, we retrieved data from the electronic health record, including patient infection-related outcomes, demographic characteristics, and social risk screen results for those who had caregiver ACEs systematically recorded. The number of reported caregiver ACEs was our exposure variable, dichotomized as high (≥4) or low (≤3). Patient demographic characteristics, results of the overall social risk and maternal depression screen, and area deprivation index scores linked to patients’ geocoded home addresses were also collected. Bivariate analyses were pursued using chi square test statistics. Results A total of 1,442 children 0-4 years of age were included in the study, and 50.0% were female, 74.7% Black, and 2.6% Hispanic. Fifteen percent of caregivers had high (≥4) ACEs. Differences in infection-related outcomes, and relevant covariates, based on high and low caregiver ACEs are depicted in Table 1. Children of caregivers with high ACEs had more outpatient infection-related visits (80% versus 72.6%, p = 0.03), including more diagnoses of streptococcal pharyngitis (10.1% versus 4.1%, p = 0.0004). They also had more prescriptions for any oral antibiotic (30.9% versus 23.2%, p = 0.02). In bivariate analyses, high caregiver ACEs (31.3% versus 23.7%, p = 0.03), lower area deprivation index score (mean (SD) of 0.47 (0.16) versus 0.50 (0.16), p < 0.01), older patient age (mean (SD) of 2.73 (1.10) versus 1.73 (1.00) years, p < 0.0001), and any outpatient (35.9% versus 2.2%, p < 0.0001), emergent (40.0% versus 10.9%, p < 0.0001), or inpatient visit (42.7% versus 23.0%, p < 0.0001) were each associated with the presence of antibiotic use. Race, ethnicity, a positive social risk screen, and positive depression screen were not associated with antibiotic use. Conclusion High caregiver ACEs appear to be associated with some types of pediatric infectious diagnoses, antibiotic use and increased infection-related outpatient healthcare utilization. Future adjusted analyses assessing for potential links between ACEs and infection-related outcomes, independent of variables like insurance status, social risk, and area-level deprivation, are warranted and planned.

Embedding Physical Therapy in the Pediatric Primary Care Setting: Qualitative Analysis of Pediatricians' Insights on Potential Collaborative Roles and Benefits.

The growing need for collaborative healthcare teams to meet complex health challenges has led to physical therapists (PTs) being embedded in adult primary care settings for many years now. However, this model of care has not been found in pediatrics. This qualitative study sought to gain insights from pediatricians on the potential of embedding pediatric PTs in primary care. Participants were nine pediatricians practicing in both urban and rural, hospital-based and private settings. Semi-structured interviews were recorded, transcribed, and analyzed via thematic analysis per published methods, assuring trustworthiness. Three overarching themes emerged: pediatricians' priorities aligned with the Quadruple Aim of Healthcare, embedded PTs could fill multiple roles in pediatrics, and they could see a wide variety of patients, highlighting real potential benefits in primary care. Participants endorsed in-office focused treatments, screening to determine optimal care pathways, and ongoing patient follow-up as potential PT roles in this setting. Providers thought that PTs could help manage care for musculoskeletal complaints, high-risk infants, medically complex children, autism, and obesity. An advanced-trained PT having attributes of confidence, adaptability, and open-mindedness was desired. All participants endorsed pediatric primary care PTs as having potentially high value in their practice. This is the first known study on the potential of embedding a PT in the pediatric primary care setting, offering valuable insights from pediatricians to be leveraged in implementation planning.

Recorded diagnosis of overweight/obesity in primary care is linked to obesity care performance rates.

Periodical BMI measurement during visits with primary care pediatricians (PCP) can be central to diagnosing, managing, and treating overweight/obesity. The aim was to evaluate among children and adolescents with similar BMI percentiles, whether recording a formal diagnosis by PCP, of overweight/obesity is associated with improved performance rates of obesity-related care. The electronic database of the largest health maintenance organization in Israel was searched for all patients aged 2-18 years with BMI recorded at a visit with the PCP during 2017-2023. Among children with BMI percentiles consistent with overweight/obesity, performance rates of obesity care were compared between those with a recorded diagnosis of "overweight"/"obesity" placed by the PCP, and those with similar BMI percentiles without these recorded diagnoses. Among children with versus without recorded diagnoses of overweight/ obesity, rates were higher of referrals for screening measurements for obesity-related comorbidities, for dietitian and endocrine counseling, of performing subsequent BMI measurements, and of prescribing anti-obesity medications (p < 0.001 for all). Obesity-related comorbidities were more prevalent among those with than without recorded diagnoses (P < 0.001). Beyond BMI measurement, a recorded diagnosis of overweight/obesity by a PCP is linked to higher rates of obesity care performance and interventions, which may improve clinical outcomes. BMI measurement during visits with primary care pediatricians (PCP) can be central to diagnosing, managing, and treating overweight/obesity. We evaluated among children and adolescents with similar BMI percentiles, whether recording a formal diagnosis by PCP, of overweight/obesity is associated with improved performance rates of obesity-related care. We found that among children with versus without recorded diagnoses of overweight/obesity, rates were higher of referrals for screening measurements for obesity-related comorbidities, for dietitian and endocrine counseling, and of prescribing anti-obesity medications. Therefore, PCP should increase rates of recording diagnoses of overweight/obesity, to promote screening for obesity-related comorbidities, and aim to treat obesity as a chronic disease.

Caregiver Perspectives on Improving Government Nutrition Benefit Programs.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and Supplemental Nutrition Assistance Program (SNAP) provide essential nutrition support for low-income families. However, many eligible families do not receive or fully redeem these benefits. We aimed to understand current and former WIC and SNAP beneficiaries' perceptions of and suggestions for improving both programs. We conducted semistructured phone interviews with caregivers of pediatric patients who were current or former WIC and SNAP beneficiaries at 2 academic pediatric primary care clinics. Interviews were recorded, transcribed, and coded by 2 independent coders using thematic analysis, resolving discrepancies by consensus. Interviews continued until data saturation was reached. We interviewed 40 caregivers who were predominantly Black (88%) mothers (90%), with 53% and 83% currently using WIC and SNAP, respectively. We identified 4 themes related to participation barriers: (1) limited product variety available through WIC, (2) inconvenience and stigma associated with purchasing WIC products, (3) SNAP income-based eligibility criteria, and (4) burdensome SNAP enrollment and recertification processes. We identified 3 themes related to suggestions for improvement: (a) decreasing stigma associated with participation, (b) allowing online or phone-based enrollment, and (c) improving coordination with health care systems. WIC and SNAP beneficiaries identified several modifiable barriers to enrollment and benefits redemption. Pediatric providers should advocate for programmatic improvements that make it easier for families to access and redeem benefits and should consider implementing innovative cross-sector interventions like medical-financial partnerships, direct WIC and SNAP referrals, and data sharing with government assistance offices.

Knowledge and perception of asthma among parents of children with asthma.

Parents' knowledge is an integral part of healthcare quality, impacting treatment adherence, patient loyalty and healthcare utilisation in pediatric asthma. Parental knowledge is particularly crucial as parents influence decision-making for their child's healthcare. To assess parents' knowledge and perceptions of their children's asthma and to identify areas for weakness in therapeutic education. This is transversal survey study based on validated and translated self-administered questionnaire (Arabic asthma knowledge questionnaire AAKQ). The study was conducted in 2 departments: pediatric primary care department at Elomrane and pediatric pneumology outpatient clinics at Bechir Hamza children's hospital of Tunis during 6 months (March2022- October2022). One hundred forty-four parents were involved in the study. Most of the participants were mothers. The mean age was 38 years. Only 27,0% had higher education and smoking in parents was observed in 58% of cases. Our results showed moderate knowledge in 67,9% of participants. The mean of the total knowledge score was 57,7/85. Forty-six per cent of parents had poor knowledge for the first category of the questionnaire. The second category was the most successful part where only 14% had poor knowledge. The mean score of the third category was 13,5/20 with 35,4% of parents having poor knowledge. The mean of total knowledge was found to be higher among participants with higher education (P=0,000), when the gender of the child is masculine (P=0,038), when the parents were asked in Hospital of children of Tunis (P=0,003) and when there is a history of asthma in the siblings (P=0,05). No difference in caregiver's knowledge was based on their age or gender or history of asthma, on the age of the child, his hospitalization for asthma, his asthma control level or his compliance with medication. Knowledge of parents and their children suffering from asthma is acceptable but insufficient. An approach focusing on improving patient education skills is needed to help families understand and accept the disease and achieve optimal control.

Decreasing Social Media Use Through Motivational Interviewing: A Pediatric Primary Care Quality Improvement Project

BackgroundSocial media use has been correlated to worsening anxiety and depression in teenagers. Local ProblemIn the United Staes, social media is frequently used amongst adolescents, and rates of anxiety and depression in this population have increased over time. MethodsA convenience sample of adolescents aged 12 to 18 years old were evaluated using a pre-post design. InterventionsThis quality improvement project introduced screen time assessment and motivational interviewing to decrease social media use and improve mental health among adolescents. ResultsPHQ-9 scores remained consistent throughout the project. There was an overall decrease in participant SCARED scores and social media use declined over the 12-week period. ConclusionsResults from this project suggest an opportunity for pediatric healthcare providers to standardize social media use screening in adolescent care and utilize motivational interviewing to promote adolescent wellbeing.

Investigating the Impact of Caregiver Adverse Childhood Experiences Screening and Pediatrician-Led Discussions on Posttraumatic Stress Disorder Symptoms in a Majority-Hispanic Pediatric Primary Care Clinic Setting

Background: Evidence suggests that screening and provider-led discussions of parental adverse childhood experiences (ACEs) may help identify at-risk families and be linked to positive health outcomes in caregivers and their children. However, the direct effect of ACEs screening and discussions on posttraumatic stress disorder (PTSD) has yet to be studied. Objectives: To determine if screening or provider-led discussions of parental ACEs are associated with inadvertent worsening of PTSD symptoms 1 week after screening. Research Design: Data was obtained as part of a cluster randomized controlled trial to examine the effects of ACEs screening and provider-led discussions on child health care utilization outcomes. Baseline surveys were completed before scheduled infant well child checks (WCCs). Providers were randomized into the standard of care or intervention (discussion) conditions. Intervention providers were trained in delivering brief trauma-informed discussions about the impact of ACEs on parenting during WCCs. Subjects: Caregivers in a pediatric primary care clinic serving predominantly Hispanic and low socioeconomically resourced families (N=179, 93% female, 87% Hispanic). Measures: The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5), Brief Resilience Scale (BRS), and ACEs screening were completed at baseline. PC-PTSD-5 was repeated 1-week after screening. Results: Mixed-effects ordinal logistic regression analysis of PTSD scores from baseline to 1-week postscreening with the full sample showed no significant effect of time [odds ratio (OR)=1.21, P=0.68], group (OR=1.68, P=0.33), or their interaction (OR=0.48, P=0.21). Conclusions: Screening or brief discussion of ACEs with providers trained in trauma-informed care were not associated with worsening PTSD symptoms.

Allergic rhinitis management: a survey on Italian primary care pediatricians.

Background. Allergic rhinitis (AR) is a widespread condition. The Italian Society of Pediatric Allergology and Immunology (SIAIP) promoted an initiative to update the knowledge on AR in children and adolescents. The present survey directly addressed primary care pediatricians, thus reflecting the real-world management of AR in children and adolescents. The aim was to investigate common practice in managing AR children. Methods. A panel of experts drafted a series of questions concerning the practical management of children with AR in clinical practice. The questionnaire was administered to a large sample of primary care pediatricians (864). Results. 864 primary care pediatricians participated to the survey. Each pediatrician on average follows 94 children with AR; globally 81,231 children. More than 70% of participants follow ARIA guidelines. Accordingly, 42% of children have mild AR and 58% moderate/severe. Asthma, conjunctivitis and adenoid hypertrophy are the most common comorbidity. Most pediatricians autonomously follow their patients. The intensity of treatment (use of medication) is directly proportional to the symptom severity. Intranasal corticosteroids are the most common medication used followed by oral antihistamines and nasal lavages (with hypertonic or isotonic solution). Up to 20% of participants prescribe the fixed association topical corticosteroids plus antihistamine. Conclusions. The present survey demonstrated that Italian primary care pediatricians accomplish ARIA guidelines and adapt treatment on the basis of the intensity of symptoms. Corticosteroids and antihistamines are the most common prescribed medications. Nasal lavages are also popular.

Transition from paediatric to adult neurological care: What do we know?

IntroductionHealthcare advances have allowed an increase in the survival of paediatric patients with neurological diseases. As a result, it is increasingly common to find these patients in adult neurology consultations. The aim of this study is to evaluate the current level of consensus on the transition of neuropaediatric patients among neurology and paediatric professionals in the Balearic Islands. Material and methodsWe conducted an observational, analytical, cross-sectional study through an anonymous questionnaire consisting of 27 questions, which was distributed to neurologists, paediatric neurologists, hospital paediatricians, and primary care paediatricians in the healthcare network of the Balearic Islands. It was developed using Google Forms and distributed by the competent professional societies. Consensus was considered to exist for answers with 70% or more agreement. ResultsResponses were received from 58 professionals; 46.6% were hospital paediatricians, 29.9% were neurologists, 13.8% were paediatric neurologists, and 13.8% were primary care paediatricians. Among other issues, consensus was observed on the need for a transition programme for patients with neurological diseases. No consensus was observed regarding the duration of the transition (P=.029) and how long simultaneous follow-up must last after the transfer (P=.09). ConclusionsDue to increased survival rates, there is a need to create transition programmes for paediatric patients with neurological diseases. In our study, more than 70% of professionals believed that it would be beneficial to create such programmes.

Association between Unmet Social Need and Ambulatory Quality of Care for U.S. Children

ObjectivesChildren who experience socioeconomic adversity often have worse health; however, less is known about their quality of care. We sought to evaluate the association between parent/caregiver-reported socioeconomic adversity and quality of pediatric primary, acute, and chronic ambulatory care on a national level. MethodsThis was a retrospective cohort study of 5,368 representative U.S. children (1-17 years) in the 2021 Medical Expenditure Panel Survey. Socioeconomic adversity was defined as parent/caregiver-reported food, housing, transportation, or utility insecurity in the past 12 months. Outcomes included 10 quality measures of primary, acute, and chronic care, and experience of care measured through parent/caregiver survey. We described variation in socioeconomic adversity and used multivariable regression to examine associations with quality outcomes. ResultsOne-third of parent/caregivers reported socioeconomic adversity. Food insecurity (23.6%) was most common followed by utility (19.5%), housing (15.0%), and transportation (4.7%) insecurity. Black (53.2%) and Hispanic (46.9%) parent/caregivers experienced the highest rates of socioeconomic adversity. Children with socioeconomic adversity received lower quality of care for 4 quality measures, including more frequent ED visits (Odds Ratio (OR)=1.69 [95% Confidence Interval (CI):1.28-2.23]), less favorable asthma medication ratio (OR=0.04 [95%CI:0.01-0.31]), and less frequent well child (OR=0.73 [95%CI:0.59-0.90]) and dental care (OR=0.76 [95%CI:0.63-0.94], p <.05 for all). There were no statistically significant differences in experience of care. ConclusionsSocioeconomic adversity is common among U.S children with disproportionate impact on Black and Hispanic families. There are significant disparities in pediatric primary, acute, and chronic care quality, based on parent/caregiver-reported socioeconomic adversity, highlighting the need for systems-level interventions.

Rational application of the ESPGHAN 2022 recommendations for the follow-up of the paediatric coeliac patient: consensus document of scientific societies (SEGHNP, AEPAP, SEPEAP, SEEC, AEG, SEPD, SEMFYC, SEMG and SEMERGEN)

Coeliac disease is a common condition for which the only current treatment is a gluten-free diet. Adherence to this diet is not always easy and is associated with a reduction in quality of life for the patient and their family. Non-adherence is associated with complications of varying severity. The lack of control at the outpatient care level in a high percentage of these patients evinces the need to improve follow-up protocols and the approach to care delivery with coordination of paediatric gastroenterology units (PGU) and primary care paediatricians. With this aim in mind, the present document was developed by consensus to offer a set of recommendations adapted to our region, based on the recent recommendations published by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), and with participation of the pertinent scientific societies, including those concerning the adult population, for the management and follow-up of adolescents and the transition to adult care.

Comparison of Telemedicine Usage at Two Distinct Medicaid-Focused Pediatric Clinics.

Objective: To compare telemedicine versus office visit use at two Medicaid-focused pediatric primary care clinics. Methods: Retrospective cohort study from March 15, 2020 - March 15, 2021 at two Medicaid-focused pediatric primary care clinics. Site A and Site B care for different populations (Site B care for mostly immigrant families with preferred language Spanish). Outcomes included the percent of visits conducted through telemedicine and reason for visit. Descriptive statistics, univariable and multivariable mixed multilevel logistic regression, were used to assess relationship between patient demographics and telemedicine use. Results: Out of 17,142 total visits, 13% of encounters at Site A (n = 987) and 25% of encounters at Site B (n = 2,421) were conducted using telemedicine. Around 13.8% of well-child care (n = 1,515/10,997), 36.2% of mental health care (n = 572/1,581), and 25.0% of acute care/follow-up (n = 1,893/7,562) were telemedicine visits. After adjustment for covariates, there was no difference in odds of a patient having any telemedicine use by preferred language, sex, or payor. Patients 1-4 years of age had the lowest odds of telemedicine use. At Site A, patients who identified as Non-Hispanic Black (odds ratio [OR] = 0.33, 95% confidence interval [CI] = 0.24-0.45), Hispanic/Latinx (OR = 0.40, 95% CI = 0.24-0.66), or other race/ethnicity (OR = 0.35, 95% CI = 0.23-0.55) had lower odds of telemedicine use in comparison to Non-Hispanic White. Conclusions: Telemedicine was successfully accessed by Medicaid enrollees for different types of pediatric primary care. There was no difference in telemedicine use by preferred language and payor. However, differences existed by age at both sites and by race/ethnicity at one site. Future research should explore operational factors that improve telemedicine access for marginalized groups.

Understanding healthcare professionals’ responses to patient complaints in secondary and tertiary care in the UK: A systematic review and behavioural analysis using the Theoretical Domains Framework

BackgroundThe path of a complaint and patient satisfaction with complaint resolution is often dependent on the responses of healthcare professionals (HCPs). It is therefore important to understand the influences shaping HCP behaviour. This systematic review aimed to (1) identify the key actors, behaviours and factors influencing HCPs’ responses to complaints, and (2) apply behavioural science frameworks to classify these influences and provide recommendations for more effective complaints handling behaviours.MethodsA systematic literature review of UK published and unpublished (so-called grey literature) studies was conducted (PROSPERO registration: CRD42022301980). Five electronic databases [Scopus, MEDLINE/Ovid, Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL) and Health Management Information Consortium (HMIC)] were searched up to September 2021. Eligibility criteria included studies reporting primary data, conducted in secondary and tertiary care, written in English and published between 2001 and 2021 (studies from primary care, mental health, forensic, paediatric or dental care services were excluded). Extracted data included study characteristics, participant quotations from qualitative studies, results from questionnaire and survey studies, case studies reported in commentaries and descriptions, and summaries of results from reports. Data were synthesized narratively using inductive thematic analysis, followed by deductive mapping to the Theoretical Domains Framework (TDF).ResultsIn all, 22 articles and three reports met the inclusion criteria. A total of 8 actors, 22 behaviours and 24 influences on behaviour were found. Key factors influencing effective handling of complaints included HCPs’ knowledge of procedures, communication skills and training, available time and resources, inherent contradictions within the role, role authority, HCPs’ beliefs about their ability to handle complaints, beliefs about the value of complaints, managerial and peer support and organizational culture and emotions. Themes mapped onto nine TDF domains: knowledge, skills, environmental context and resources, social/professional role and identity, social influences, beliefs about capability, intentions and beliefs about consequences and emotions. Recommendations were generated using the Behaviour Change Wheel approach.ConclusionsThrough the application of behavioural science, we identified a wide range of individual, social/organizational and environmental influences on complaints handling. Our behavioural analysis informed recommendations for future intervention strategies, with particular emphasis on reframing and building on the positive aspects of complaints as an underutilized source of feedback at an individual and organizational level.

Sensitisation to Lep d 2- Lepidoglyphus destructor allergy in asthma and rhinitis.

Background. Mites are responsible for allergic diseases, such as asthma and rhinitis, in nearly 1.5% of the world population. It is known that nowadays, besides House Dust Mites (HDM), Storage Mites (SM) are important sensitisers in urban non-occupational dwellings, predominantly in the Mediterranean area. The main objective of our study was to analyse the clinical relevance of the most prevalent SM, Lepidoglyphus destructor, by assessing the relationship between sensitisation to the major molecular allergen Lep d 2 and allergic respiratory disease phenotype in an urban population monosensitised to this molecular allergen. Methods. Cross-sectional study which included consecutive patients evaluated in our Allergy Department between 2012 and 2018, from urban non-occupational setting, with rhinitis and/or asthma, perennial symptoms and proven sensitisation to SM Lep d 2, tested using ImmunoCAP Immuno Solid-phase Allergen Chip (ISAC) technology, which detects 112 allergens. Results. A total of 37 allergic patients were included (23 female), aged 20.1 ± 12.8, min-max 5-58 years-old. The molecular sensitisation profile showed 18.9% of L. destructor mite monosensitised patients, having only sIgE to Lep d 2. This subset of patients mainly had allergic rhinitis, with 28.6% also being asthmatic. Regarding severity, most patients showed a persistent moderate phenotype of respiratory disease. The mean value of Lep d 2 sIgE was 8.3 ± 9.8 ISU-E, lower than in mite polysensitised patients (21.7 ± 21.5, p = 0.049). Conclusions. Our proof-of-concept study focused on Lep d 2 monosensitisation, showed that SM may have clinical relevance in perennial allergic asthma and rhinitis, and should be taken into account when assessing and treating allergic respiratory disease. Conclusions. The present survey demonstrated that Italian primary care pediatricians accomplish ARIA guidelines and adapt treatment on the basis of the intensity of symptoms. Corticosteroids and antihistamines are the most common prescribed medications. Nasal lavages are also popular.