Well-child Care Visits Research Articles

Implementing a clinical decision support tool to increase early peanut introduction guidance

BackgroundGeneral pediatric providers are the frontline for early peanut introduction discussions, but many feel ill-equipped to handle such discussions as guidelines have quickly changed. ObjectiveWe hypothesized that a clinical decision support (CDS) tool could improve peanut introduction discussions. MethodsCDS tools were designed by stakeholders, improved through usability testing, and integrated into the current note templates. Based on queries of electronic health record (EHR), we did a pre-post performance evaluation of peanut introduction conversations, barriers for introduction, and percentage of 12-month WCC visits that had successfully introduced peanut. Providers completed surveys before and after intervention to assess awareness of early peanut introduction and comfort using CDS. ResultsProviders’ awareness of early peanut introduction guidelines increased from 17.8% to 66.7% after the CDS tool was implemented. 79.1% were comfortable using the tool. The CDS tool improved peanut introduction conversations at the 4-month well-child (WCC) care visit from 2.4% to 81.2%, at the 6-month WCC visit from 3.0% to 84.2%, and at the 12-month WCC visit from 2.7% to 82.9%. 56.6% of families had a plan to introduce peanut at the 4-month WCC visit. Of those who did not have a plan, the most common barrier was family's unawareness of the benefits of early peanut introduction. At the 12-month visit, 62.8% of families had introduced peanut without concerns. ConclusionA point-of-care CDS tool encouraged more discussions by general pediatric providers on early peanut introduction to all patients. CDS tools should be considered in quality improvement projects as an implementation method for the most up-to-date guidelines.

Referral from well-child care clinics to dental clinics leads to earlier initiation of preventive dental visits: A quasi-experimental study.

An ealy first preventive dental visit for children is recommended no later than twelve months. However, still many children have their first dental visit relatively late. To evaluate whether active or passive referral by a well-child care (WCC) physician of babies for a first preventive dental visit leads to earlier initiation of dental care. From WCC clinics in two Dutch regions, 629 parents of babies participated. Parents received an active referral from a WCC physician for a dental visit for their babies (n = 204) or received care as usual (CAU) (n = 136) in one region and a passive referral (n = 143) or CAU (n = 146) in the other region. Active referral involved parents receiving a scheduled appointment at the dental practice, and passive referral involved parents making an appointment themselves. During the WCC visit, parents completed a baseline questionnaire. At age 2.5 years, parents received a follow-up questionnaire about dental attendance. Of the active referral intervention group, 59.3% had their first preventive dental visit in their first year compared with 3.7% in the CAU group (p < .001); for the passive referral group, 46.9% compared with 9.6% (p < .001). Referral of babies by WCC for their first preventive dental visit leads to earlier initiation of dental care. An active referral had a larger effect than passive referral.

Time Spent at Well-Child Care Visits for English- and Spanish-Speaking Parents.

To measure duration of well-child care (WCC) visits at 2 federally qualified health centers (FQHCs), across 10 clinic sites, and determine if differences exist in visit duration for English- and Spanish-speaking parents. Upon arrival to their child's 2- to 24-month well visit, a research team member followed families throughout their visit noting start and end times for a series of 5 WCC visit tasks. The average time to complete each visit task for the entire sample was then calculated. Mann-Whitney U tests were run to determine if task completion time differed significantly between English- and Spanish-speaking parents. The total sample included 199 parents of infants and children between 2 and 24 months old. Over one third of the sample spoke Spanish as their primary language (37%). The average visit time was 77 minutes (standard deviation [SD]=48). Median time spent with the clinician was 14 minutes (SD=5). Clinician visit time was significantly different U=2608, P < .001, r=0.38 between English- (median=15 minutes) and Spanish (median=11 minutes)-speaking parents. No other significant differences were identified. Our findings align with previous studies showing the average time spent with a clinician during a WCC visit was 15 minutes. Further, the average time with a clinician was less for Spanish-speaking parents. With limited visit length to address child and family concerns, re-designing the structure and duration of WCC visits is critical to best meet the needs of families living in poverty, and may ensure that Spanish-speaking parents receive appropriate guidance and support without time limitations.

Opportunities to Increase Well-Child Care Engagement for Families Affected by Maternal Opioid Use Disorder: Perceptions of Mothers and Clinicians.

Previous research suggests gaps in well-child care (WCC) adherence, quality, and effectiveness for children impacted by parental opioid use disorder (OUD). The objective of this study was to gather in-depth information regarding maternal and clinician-reported factors that enhance ("facilitators") or hinder ("barriers") WCC engagement as well as mothers' experiences during WCC visits. Thirty mothers who were in treatment for OUD and 13 clinicians working at a pediatric primary care clinic participated in this qualitative study. All participants completed one data collection telephone session which involved a brief questionnaire followed by a semi-structured interview. Thematic analyses of the interview transcripts were conducted using an inductive approach. Three broad themes were identified as facilitators of WCC by mothers and clinicians, including: 1) continuity in care, 2) addressing material needs, and 3) clinician OUD training and knowledge. Themes identified as barriers to WCC included: 1) stigma toward mothers with OUD, 2) gaps in basic parenting knowledge, 3) competing specialized health care needs, and 4) insufficient time to address all concerns. WCC programs or clinical pathways designed for families affected by maternal OUD should consider these barriers and facilitators of WCC engagement and affect experiences of WCC for mothers and clinicians.

Effect of Electronic Outreach Using Patient Portal Messages on Well Child Care Visit Completion

Outreach messages to patients overdue for well child care (WCC) can be delivered different ways (ie, telephone calls and text messages). Use of electronic health record patient portals is increasingly common but their effectiveness is uncertain. To determine the effectiveness of patient portal outreach messages, with and without the date of the last WCC, on the scheduling and completion of WCC visits and completion of vaccinations. An intention-to-treat, multigroup, randomized clinical trial was conducted at 3 academic primary care practices from July 30 to October 4, 2021. The population included predominantly non-Hispanic Black, low-income children (age, 6-17 years) whose parent had an active portal account. Participants were randomized to the standard message, tailored message, or no message (control) group. Two messages were delivered to those in the message groups. Outcomes included WCC visit scheduled within 2 weeks of the first intervention message, WCC visit completed within 8 weeks (primary outcome), and receipt of COVID-19 vaccine within 8 weeks. Nine hundred forty-five patients participated (mean [SD] age, 9.9 [3.3] years, 493 [52.2%] girls, 590 [62.4%] non-Hispanic Black, 807 [85.4%] publicly insured). Scheduling rates were 18.4% in the standard message group (adjusted risk ratio [aRR], 1.97; 95% CI, 1.32-2.84) and 14.9% in the tailored message group (aRR, 1.57; 95% CI, 1.02-2.34) compared with the control group (9.5%). Well child care visit completion rates were 24.1% in the standard message group (aRR, 1.92; 95% CI, 1.38-2.60) and 19.4% in the tailored message group (aRR, 1.52; 95% CI, 1.06-2.13) compared with the control group (12.7%). Among eligible children, rates of receiving the COVID-19 vaccine were 16.7% in the standard message group compared with 4.8% in the tailored message (aRR, 3.41; 95% CI, 1.14-9.58) and 3.7% in the control groups (aRR, 4.84; 95% CI, 1.44-15.12). In this randomized clinical trial, outreach messages delivered via electronic health record patient portals increased the rates of scheduling and completing WCC visits and receiving the COVID-19 vaccine, providing a useful tool to help restore WCC in populations whose care was delayed during the pandemic. ClinicalTrials.gov Identifier: NCT04994691.

Siblings of Children with Medical Complexity-A Vulnerable Population in the Medical Home.

Existing research examines the effectiveness of medical home initiatives for Children with medical complexity (CMC), but not their siblings. This research sheds light on the care these siblings receive in the medical home. We assessed the preventative care status and medical home use of the siblings of CMC in four academic pediatric medical homes. We conducted an 18-month retrospective chart review of 236 siblings of CMC and 230 nonsiblings, matched by age and medical home. We found a statistically significant difference in the medical home use of siblings of CMC compared with non-siblings. They are not up to date on well-child care visits and are much less likely to be identified as children with special health care needs (CSHCN). This may lead to omission from registries and fewer interventions for outreach and support. Further attention is needed to develop methods that ensure appropriate care for this vulnerable population.

Screening for Autism Spectrum Disorder in Toddlers During the 18- and 24-Month Well-Child Visits.

ObjectiveEarly screening contributes to the early detection of children with autism spectrum disorder (ASD). We conducted a longitudinal ASD screening study in a large community setting. The study was designed to investigate the diagnostic rate of ASD screening and determine the effectiveness of ASD screening model in a community-based sample.MethodsWe enrolled children who attended 18- and 24-month well-child care visits in Shanghai Xuhui District. Modified Checklist for Autism in Toddlers, Revised with Follow-up (M-CHAT-R/F) and Binomial Observation Test (BOT) were selected as screening instruments. Screen-positive children were referred to a tertiary diagnostic center for comprehensive ASD diagnostic evaluation. Screen-negative children received well-child checkups and follow-up every 3–6 months until age three and were referred if they were suspected of having ASD.ResultsA total of 11,190 toddlers were screened, and 36 screen-positive toddlers were diagnosed with ASD. The mean age at diagnosis for these children was 23.1 ± 4.55 months, diagnosed 20 months earlier than ASD children not screened. The diagnostic rate of ASD was 0.32% (95% CI: 0.23–0.45%) in this community-based sample. In addition, 12 screen-negative children were diagnosed with ASD during subsequent well-child visit and follow-up. The average diagnostic rate of ASD rose to 0.43% (95% CI: 0.32–0.57%) when toddlers were followed up to 3 years old. The positive predictive values (PPVs) of M-CHAT-R/F, M-CHAT-R high risk, and BOT for ASD were 0.31, 0.43, and 0.38 respectively.ConclusionOur findings provide reliable data for estimating the rate of ASD detection and identifying the validity of community-based screening model. M-CHAT-R/F combined with BOT can be an effective tool for early detection of ASD. This community-based screening model is worth replicating.

Improving Patient-Provider Continuity in a Large Urban Academic Primary Care Network.

Although patient-provider continuity improves care delivery and satisfaction, poor continuity with primary care providers (PCP) often exists in academic centers. We aimed to increase patient empanelment from 0% to 90% and then increase the percent of well-child care (WCC) visits scheduled with the PCP from 25.6% to 50%, without decreasing timely access that might result if patients waited for PCP availability. Nationwide Children's Hospital Primary Care Network cares for >120,000 mostly Medicaid-enrolled patients across 13 offices. Before 2017, patients were empaneled to an office, not individual PCPs. We empaneled patients to PCPs, reduced provider floating, implemented continuity-promoting scheduling guidelines, scheduled future WCC visits for patients ≤15 months during check-in for their current one, and encouraged online scheduling. We tracked the percentage of all WCC visits that were scheduled with the patient's PCP and the percentage of subsequent WCC visits for patients ≤15 months that were scheduled during the current visit, and provided feedback to schedulers. We followed emergency department (ED) utilization and visit show rates. WCC visit completion rates were tracked using HEDIS metrics. Patient empanelment increased from 0% to >90% (P < .001). Patient-provider WCC continuity increased from 25.6% to 54.7% (P < .001). A 20.5% decrease in ED utilization rate was associated with continuity project initiation. Empaneled patients demonstrated higher show rates (76.9%) versus unempaneled patients (71.4%; P < .001). WCC completion rates increased from 52.6% to 60.7%. WCC continuity more than doubled after interventions and was associated with decreased ED utilization, higher show rates, and increased timely WCC completion.

A Parent Coach-Led Model of Well-Child Care for Young Children in Low-Income Communities: Protocol for a Cluster Randomized Controlled Trial.

BackgroundThe Parent-focused Redesign for Encounters, Newborns to Toddlers (PARENT) intervention was created as a team-based approach to well-child care (WCC) that relies on a health educator (Parent Coach) to provide the bulk of WCC services, address specific needs faced by families in low-income communities, and decrease reliance on the clinician as the primary provider of WCC services.ObjectiveThis study aims to evaluate the impact of PARENT using a cluster randomized controlled trial.MethodsThis study tested the effectiveness of PARENT at 10 clinical sites in 2 federally qualified health centers in Tacoma, Washington, and Los Angeles, California. We conducted a cluster randomized controlled trial that included 916 families with children aged ≤12 months at the time of the baseline survey. Parents will be followed up at 6 and 12 months after enrollment. The Parent Coach, the main element of PARENT, provides anticipatory guidance, psychosocial screening and referral, developmental and behavioral surveillance, screening, and guidance at each WCC visit. The coach is supported by parent-focused previsit screening and visit prioritization, a brief, problem-focused clinician encounter for a physical examination and any concerns that require a clinician’s attention, and an automated text message parent reminder and education service for periodic, age-specific messages to reinforce key health-related information recommended by Bright Futures national guidelines. We will examine parent-reported quality of care (receipt of nationally recommended WCC services, family-centeredness of care, and parental experiences of care), and health care use (WCC, urgent care, emergency department, and hospitalizations), conduct a cost analysis, and conduct a separate time-motion study of clinician time allocation to assess efficiency. We will also collect data on exploratory measures of parent-and parenting-focused outcomes. Our primary outcomes were receipt of anticipatory guidance and emergency department use.ResultsParticipant recruitment began in March 2019. After recruitment, 6- and 12-month follow-up surveys will be completed. As of August 30, 2021, we enrolled a total of 916 participants.ConclusionsThis large pragmatic trial of PARENT in partnership with federally qualified health centers will assess its utility as an evidence-based and financially sustainable model for the delivery of preventive care services to children in low-income communities.Trial RegistrationClinicalTrials.gov: NCT03797898; https://clinicaltrials.gov/ct2/show/NCT03797898International Registered Report Identifier (IRRID)DERR1-10.2196/27054

Effect of Electronic Health Record Reminders for Routine Immunizations and Immunizations Needed for Chronic Medical Conditions.

Immunization reminders in electronic health records (EHR) provide clinical decision support (CDS) that can reduce missed immunization opportunities. Little is known about using CDS rules from a regional immunization information system (IIS) to power local EHR immunization reminders. This study aimed to assess the impact of EHR reminders using regional IIS CDS-provided rules on receipt of immunizations in a low-income, urban population for both routine immunizations and those recommended for patients with chronic medical conditions (CMCs). We built an EHR-based immunization reminder using the open-source resource used by the New York City IIS in which we overlaid logic regarding immunizations needed for CMCs. Using a randomized cluster-cross-over pragmatic clinical trial in four academic-affiliated clinics, we compared captured immunization opportunities during patient visits when the reminder was "on" versus "off" for the primary immunization series, school-age boosters, and adolescents. We also assessed coverage of CMC-specific immunizations. Up-to-date immunization was measured by end of quarter. Rates were compared using chi square tests. Overall, 15,343 unique patients were seen for 26,647 visits. The alert significantly impacted captured opportunities to complete the primary series in both well-child and acute care visits (57.6% on vs. 54.3% off, p = 0.001, and 15.3% on vs. 10.1% off, p = 0.02, respectively), among most age groups, and several immunization types. Captured opportunities for CMC-specific immunizations remained low regardless of alert status. The alert did not have an effect on up-to-date immunization overall (89.1 vs. 88.3%). CDS in this population improved captured immunization opportunities. Baseline high rates may have blunted an up-to-date population effect. Converting Centers for Disease Control and Prevention (CDC) rules to generate sufficiently sensitive and specific alerts for CMC-specific immunizations proved challenging, and the alert did not have an impact on CMC-specific immunizations, potentially highlighting need for more work in this area.

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

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

The prevalence of low serum levels of Vitamin D, Vitamin B12, folate and ferritin in adolescents: Single center experience.

In this study, the aim was to evaluate the prevalence of vitamin D, vitamin B12, ferritin, and folate deficiencies in adolescence to clarify the need for early diagnosis and therapy. The medical records of adolescents between 10 and 18 years of age between 01 September 2018 and 28 February 2019 as healthy with non-specific complaints, or due to well-child care visits, were analyzed retrospectively. A total of 1847/2507 (73.6%) adolescents were included in the study. The prevalence of vitamin D deficiency was 25.7% (n: 178/691). Vitamin B12 deficiency prevalence was 69.2% (n: 753/1088). The prevalence of anemia and ferritin deficiency was 4.8% and 13.26%. The prevalence of folate deficiency was 37.9% (n: 413/1088). VDD prevalence was statistically significantly higher in females than males (F/M:116/62). VB12D prevalence, the number and mean age of females with hemoglobin deficiency, and low ferritin levels was found to be statistically significantly higher in females than males. The prevalence of vitamin D, vitamin B12, folate deficiency and low ferritin levels was found to be high among adolescents. In particular, adolescents admitting with non-specific complaints and for control purposes in big cities must be considered to be at risk for the deficiency of these vitamins and low level of ferritin.

Effect of Brief Training to Identify Autism Spectrum Disorder During Toddler Well-Child Care Visits.

To examine the effect of a brief Enhanced training using the information-motivation-behavior (IMB) change model on improving providers' surveillance rates and accuracy of autism spectrum disorder (ASD) detection. Toddlers (n = 5,672) were screened for ASD during their pediatric well-child visits. Pediatric providers (n = 120) were randomized to receive Enhanced (incorporating components of the IMB model) or Control training. Providers indicated whether they had an ASD concern at each well-child visit. Toddlers who were positive on any screener and/or whose provider indicated ASD concern were invited for a diagnostic evaluation. Differences in provider-indicated ASD concerns before and after training were evaluated using log-linear analyses. The Enhanced training did not have a significant effect on provider-endorsed ASD concerns (p = 0.615) or accuracy of endorsing concerns (p = 0.619). Providers in the Control training showed a significant reduction in indicating whether or not they had concerns after the training (from 71.9% to 64.3%), which did not occur in the Enhanced group. The Enhanced training led to more frequent endorsements of language (χ2 = 8.772, p = 0.003) and restricted and repetitive behavior (χ2 = 7.918, p = 0.005) concerns for children seen after training. Provider training had limited impact on ASD surveillance, indicating the importance of using formal screening instruments that rely on parent report during well-child visits to complement developmental surveillance. Future research should examine whether providers who indicate specific concerns are more likely to accurately refer children for ASD evaluations.

Protecting the American Dream: a Pediatric Imperative.

* Abbreviations: AAP — : American Academy of Pediatrics VVN — : Vital Village Network The American dream is a fundamental ethos of the nation passed from generation to generation. In 1931, James Truslow Adams coined the term as “that dream of a land in which life should be better and richer and fuller for everyone.” Most Americans across all incomes still believe their children and grandchildren will achieve the American dream.1 Yet, in reality, it is out of most children’s reach. The American dream is intrinsically tied to the capacity for upward mobility, whereby children can grow up to surpass their parent’s income level. The groundbreaking work of Harvard Professor of Public Economics Dr Raj Chetty reveals that there is less upward mobility in the United States today than at any other time, likely because of lower overall economic growth and greater inequality in its distribution. Specifically, Chetty et al2 found that, since 1940, the fraction of children who earn more than their parents has fallen from >90% to ∼50%. However, the decline in the American dream is not equally distributed across the United States. Chetty et al3 has revealed great variation in upward mobility, with significant differences even among neighborhoods within the same city. Higher–upward-mobility areas are associated with less residential segregation and income inequality and greater … Address correspondence to Arvin Garg, MD, MPH, Department of Pediatrics, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655. E-mail: Arvin.Garg{at}umassmemorial.org

Well-Child Care Attendance and Risk of Asthma Exacerbations.

Asthma remains a leading cause of hospitalization in US children. Well-child care (WCC) visits are routinely recommended, but how WCC adherence relates to asthma outcomes is poorly described. We conducted a retrospective longitudinal cohort study using electronic health records among 5 to 17 year old children residing in Durham County with confirmed asthma and receiving primary care within a single health system, to compare the association between asthma exacerbations and previous WCC exposure. Exacerbations included any International Classification of Diseases, Ninth Revision, or International Classification of Diseases, 10th Revision, coded asthma exacerbation encounter with an accompanying systemic glucocorticoid prescription. Exacerbations were grouped by severity: ambulatory encounter only, urgent care, emergency department, hospital encounters <24 hours, and hospital admissions ≥24 hours. In the primary analysis, we assessed time to asthma exacerbation based on the presence or absence of a WCC visit in the preceding year using a time-varying covariate Cox model. A total of 5656 children met eligibility criteria and were included in the primary analysis. Patients with the highest WCC visit attendance tended to be younger, had a higher prevalence of private insurance, had greater asthma medication usage, and were less likely to be obese. The presence of a WCC visit in the previous 12 months was associated with a reduced risk of all-cause exacerbations (hazard ratio: 0.90; 95% confidence interval: 0.83-0.98) and severe exacerbations requiring hospital admission (hazard ratio: 0.53; 95% confidence interval: 0.39-0.71). WCC visits were associated with a lower risk of subsequent severe exacerbations, including asthma-related emergency department visits and hospitalizations. Poor WCC visit adherence predicts pediatric asthma morbidity, especially exacerbations requiring hospitalization.

Well-Child Visits While in State Care.

* Abbreviations: CI — : confidence interval OR — : odds ratio WCV — : well-child care visit Given the rapid nature of development in early life (and the ability for developmental screenings to improve health trajectories), the American Academy of Pediatrics recommends that children attend regular well-child care visits (WCV) frequently between ages 0 and 5 years.1,2 Children involved in the child welfare system are more likely to have developmental delays compared with their peers.3–5 Thus, it is important for these children to attend recommended WCVs on time. National estimates suggest that 89% of children between ages 0 and 5 years attended a WCV in the past year.6 Yet we do not have comparable estimates for children involved in the child welfare system. Using state-level administrative data, we undertook the current study to identify the proportion of young children (aged 0–5 years) in state care who attended (1) all recommended WCVs on time (question 1) and (2) at least 1 WCV in the past year (question 2). We further explored correlates of WCV attendance. The University of Michigan Institutional Review Board approved this research. We obtained child welfare administrative records for all substantiated referrals of child maltreatment in a midwestern state where the child entered state care between January 2017 and December … Address correspondence to Rebeccah L. Sokol, PhD, School of Social Work, Wayne State University, 5447 Woodward Ave, Detroit, MI 48202. E-mail: rlsokol{at}wayne.edu

The Association Between Care Coordination and Preventive Care Among Children With Special Health Care Needs.

Care coordination (CC) has shown positive outcomes among children with special health care needs (CSHCN); however, the association between CC and well-child care (WCC) visits is unknown. We hypothesize that CSHCN who receive CC are more likely to attend the recommended WCC visits. A retrospective cohort analysis was conducted of patients aged 15 months attending the Arizona Children's Center clinic. Logistic regression models explored the association between children receiving CC and attending the recommended minimum WCC visits before 15 months of age. CC was associated with higher odds of proper WCC attendance (any CC service, adjusted odds ratio = 2.14, 95% confidence interval = 1.75-2.62; high level of CC, adjusted odds ratio = 2.61, 95% confidence interval = 1.73-3.94). Pediatric CC is associated with greater up-to-date status of the WCC schedule among CSHCN 15 months of age, and higher odds among children who receive higher levels of CC. Further research is needed to validate findings.

Well-Child Care Adherence After Intrauterine Opioid Exposure.

For children with intrauterine opioid exposure (IOE), well-child care (WCC) provides an important opportunity to address medical, developmental, and psychosocial needs. We evaluated WCC adherence for this population. In this retrospective cohort study, we used PEDSnet data from a pediatric primary care network spanning 3 states from 2011 to 2016. IOE was ascertained by using physician diagnosis codes. WCC adherence in the first year was defined as a postnatal or 1-month visit and completed 2-, 4-, 6-, 9-, and 12-month visits. WCC adherence in the second year was defined as completed 15- and 18-month visits. Gaps in WCC, defined as ≥2 missed consecutive WCC visits, were also evaluated. We used multivariable regression to test the independent effect of IOE status. Among 11 334 children, 236 (2.1%) had a diagnosis of IOE. Children with IOE had a median of 6 WCC visits (interquartile range 5-7), vs 8 (interquartile range 6-8) among children who were not exposed (P < .001). IOE was associated with decreased WCC adherence over the first and second years of life (adjusted relative risk 0.54 [P < .001] and 0.74 [P < .001]). WCC gaps were more likely in this population (adjusted relative risk 1.43; P < .001). There were no significant adjusted differences in nonroutine primary care visits, immunizations by age 2, or lead screening. Children <2 years of age with IOE are less likely to adhere to recommended WCC, despite receiving on-time immunizations and lead screening. Further research should be focused on the role of WCC visits to support the complex needs of this population.

Caregiver and Clinician Perspectives on Missed Well-Child Visits.

Despite the benefits of well-child care visits, up to one-half of these visits are missed. Little is known about why children miss them, so we undertook a qualitative study to elucidate these factors. We interviewed 17 caregivers whose children had missed well-child visits and 6 clinicians, focusing on 3 areas: the value of well-child visits, barriers to attendance, and facilitators of attendance. Transcripts were analyzed with a grounded theory approach and thematic analysis. Caregivers and clinicians identified similar important aspects of well-child visits: immunizations, detection of disease, and monitoring of growth and development. Both groups identified similar barriers to attendance: transportation, difficulty taking time off from work, child care, and other social stressors. Further work to explore how addressing social determinants of health might improve attendance of well-child visits is needed.

The Relationship Between Social Risks and the Mental Health of School-Age Children in Primary Care.

The study's goal was to measure the association between social risks and the mental health of school-age children in primary care. We conducted a cross-sectional study in an urban safety-net hospital-based pediatric clinic using data collected from 2 standardized screening tools administered at well-child care visits for children age 6 to 11. Psychosocial dysfunction was measured with the Pediatric Symptom Checklist-17 (PSC-17), and 6 social risks (caregiver education, employment, child care, housing, food security, and household heat) were measured with the WE CARE screener. Multivariable linear and logistic regression analyses were conducted to measure the association between scores while controlling for sociodemographic characteristics. Among N=943 patients, cumulative social risks were significantly associated with a positive PSC-17 total score (adjusted odds ratio [aOR] 1.2; 95% confidence interval [CI] 1.1-1.5; P=.02), indicating psychosocial dysfunction. Children with ≥3 social risks were 2.4 times more likely to have a positive PSC-17 total score compared to children with <3 social risks (95% CI 1.5-3.9; P < .001). Of the individual social risks measured, only food insecurity significantly predicted a positive PSC-17 total score (aOR 1.9; 95% CI 1.1-3.2; P=.02) and attention score (aOR 1.9; 95% CI 1.1-3.4; P=.03). Number of risks on a social risk screener was associated with psychosocial dysfunction in school-age children. Food insecurity was the only individual risk associated with psychosocial dysfunction, in particular attention problems. Screening tools for social risks could be used to identify at-risk children whose mental health may be adversely impacted by their social conditions.