A randomized trial of practice-based education to improve delivery systems for anticipatory guidance

BACKGROUND: Communication between physicians and patients is an important component of medical encounters and has been identified by the Institute of Medicine as a point of intervention to increase quality of care. In pediatric health maintenance visits, substantial recommended communication, in the form of anticipatory guidance, is not provided. OBJECTIVE: To examine the effectiveness of an intervention of continuing medical education and process improvement methods to implement "office systems" to improve the delivery of anticipatory guidance for parents of young children. METHODS: We performed a randomized controlled trial of a practice-based quality improvement intervention among 44 pediatric practices in North Carolina. In the 22 intervention practices, project staff coached practice staff in auditing performance and identifying, testing, and implementing new care processes to improve delivery of anticipatory guidance. We surveyed parents of 1-month-olds and 6-month-olds regarding their recollection of anticipatory guidance as well as parent knowledge and parent behaviors and used cluster analysis to determine the effects of the intervention. RESULTS: The proportion of parents of 1-month-olds who reported that they received all age-appropriate anticipatory guidance changed from 15.9% (95% confidence interval [CI], 8.9%-26.7%) to 10.0% (95% CI, 5.1%-18.8%) in the control practices and from 7.3% (4.1%-12.9%) to 24.0% (95% CI, 14.6%-36.9%) in the intervention practices (difference between 2 differences, P = .002). The proportion of parents of 6-month-olds who reported that they received all age-appropriate anticipatory guidance changed from 8.2% (95% CI, 3.6%-17.8%) to 5.4% (95% CI, 2.8%-10.2%) in the control practices and from 2.2% (95% CI, 0.8%-5.9%) to 18.1% (95% CI, 10.3%-29.9%) in the intervention practices (difference between 2 differences, P = .001). There were no differences in self-reported parent knowledge and parent behavior. CONCLUSION: An office system intervention improved parent reports of quantity of anticipatory guidance but did not change parent knowledge or parent behavior. Future research should examine how to use systems improvement methods to improve the impact of anticipatory guidance.     

Mental Health Service Use Before and After a Suicidal Crisis Among Children and Adolescents in a United States National Medicaid Sample

IntroductionMental health follow-up after an emergency department (ED) visit for suicide ideation/attempt is a critical component of suicide prevention for young people.MethodsWe analyzed 2009 to 2012 Medicaid Analytic EXtract for 62,139 treat-and-release ED visits and 30,312 ED-to-hospital admissions for suicide ideation/attempt among patients ages 6 to 17 years. We used mixed-effects logistic regression models to examine associations between patients’ health care utilization prior to the ED visit and likelihood of completing a 30-day mental health follow-up visit.ResultsOverall, for treat-and-release ED visits, 49% had a 30-day follow-up mental health visit, and for ED-to-hospital admissions, 67% had a 30-day follow-up mental health visit. Having a mental health visit in the 30 days preceding the ED visit was the strongest predictor of completing a mental health follow-up visit (ED treat-and-release: adjusted odds ratio [AOR] 11.01; 95% confidence interval [CI] 9.82–12.35; ED-to-hospital AOR 4.60; 95% CI 3.16–6.68). Among those with no mental health visit in the 30 days preceding the ED visit, only 25% had an ambulatory mental health follow-up visit. Having a general health care visit in the 30 days preceding the ED visit had a much smaller association with completing a mental health follow-up visit (ED treat-and-release: AOR 1.17; 95% CI 1.09–1.24; ED-to-hospital AOR 1.25; 95% CI 1.17–1.34).ConclusionsYoung people without an existing source of ambulatory mental health care have low rates of mental health follow-up after an ED visit for suicide ideation or attempt, and opportunities exist to improve mental health follow-up for youth with recent general health care visits.     

Urgency of Emergency Department Visits by Children With Sickle Cell Disease: A Comparison of 3 Chronic Conditions

ObjectiveChildren with sickle cell disease (SCD) often receive care in the emergency department (ED), but the urgency of these frequent visits is not well understood. This study examined ED use by children with SCD by comparing the urgency of ED visits among children with SCD, asthma, and diabetes mellitus.MethodsWe conducted a retrospective cohort study of Maryland ED visits for SCD, diabetes, or asthma from 2000 to 2004. ED visits resulting in hospital admission were deemed urgent. The urgency of ED visits not resulting in admission was determined using 2 methodologies: evaluation and management (E/M) coding and resource utilization. Multivariable logistic regression models were used to compare the likelihood of admission or urgent, treat-and-release ED visits across the 3 chronic conditions.ResultsNearly half (45%) of ED visits with a primary diagnosis of SCD resulted in admission, which was substantially higher than the 12% seen for asthma (adjusted odds ratio [AOR] 6.9, 95% confidence interval [CI], 6.4–7.4) and comparable to that seen for diabetes (41%). ED visits associated with primary diagnoses of SCD (AOR 5.9, 95% CI, 5.3–6.5) and diabetes (AOR 6.6, 95% CI, 6.0–7.3) were more likely than those associated with asthma to result in either admission or a discharge of higher urgency, as measured by E/M coding. These relationships persisted among repeat ED visitors, for visits with any diagnosis (ie, primary or nonprimary) of SCD, diabetes, and asthma, and when evaluated using the resource utilization method.ConclusionsSimilar to visits by children with diabetes, ED visits by children with SCD are substantially more likely than those by children with asthma to be of high urgency.     

Relating intimate partner violence to heath-care utilisation and injuries among Pacific children in Auckland: The Pacific Islands Families Study

Aim:   Despite well-known emotional and behavioural sequela, few studies investigate health-care utilisation and injury impacts of children exposed to intimate partner violence (IPV). This study examines the association between mothers' IPV experience and general practitioner (GP) and hospital presentations by their children within the first 6 years of life.
Methods:   In 2000, a cohort of Pacific infants born in Auckland was established. At 6 weeks, 2 years and 6 years post-partum, maternal home interviews were conducted and IPV experience elicited using the Conflict Tactic Scale, together with reports of children's GP and hospital visitations.
Results:   At 6 weeks, 2 years and 6 years, 1098, 921 and 799 participating mothers were in intimate relationships. Severe physical IPV was reported by 22.1, 23.0 and 7.1% of mothers, respectively, and minor IPV was reported by another 18.7, 16.9 and 6.1%, respectively. Compared with children without maternal physical IPV exposure, children of mothers disclosing severe physical IPV were 1.19 (95% confidence interval (CI): 1.08–1.31) times as likely to visit GPs, and children of mothers disclosing minor physical IPV were 1.13 (95% CI: 1.02–1.25) times as likely to visit GPs, after adjusting for socio-demographic, maternal mental health and other confounding factors. No significant association was found between maternal IPV and children's hospital visits, or GP or hospital visits for injury.
Conclusions:   IPV is common for many mothers of Pacific children, and is associated with significantly more GP visits for exposed children. Identification of maternal IPV during mothers' and children's GP and hospital visits may help guide services to prevent future presentations to children.     

Pediatrician-Reported Injury Prevention Anticipatory Guidance by Patient Age Group

ObjectiveUnintentional injuries remain a leading cause of death for children and adolescents older than 1 year. Injury prevention has long been a cornerstone of anticipatory guidance. Previous studies have established the sustained efficacy of injury prevention anticipatory guidance in pediatric primary care. This study examines the topical emphasis of injury prevention anticipatory guidance by patient age, with special attention given to the rate of water safety anticipatory guidance across 4 patient age groups.MethodsA nationwide, random sample of AAP member pediatricians was surveyed on their experiences, attitudes, and practices related to injury prevention anticipatory guidance, including barriers to delivering anticipatory guidance.ResultsOf the respondents who reported providing direct patient care, 92% considered injury prevention anticipatory guidance a priority issue. The content of that injury prevention guidance varied considerably by patient age. Roughly half (53%) reported counseling families with adolescents on water safety/drowning prevention, which represents a statistically significant decrease relative to other patient age groups.ConclusionsReported injury prevention anticipatory guidance is high across different mechanisms of injury. However, fewer pediatricians deliver drowning prevention anticipatory guidance to adolescents than to younger patients. Targeted outreach and education to increase injury prevention anticipatory guidance, especially for adolescent patients, should be part of a multipronged approach to decrease drowning and other injury deaths.     

Dental Care Differences Among the Behavioral Health Population in an Accountable Care Organization: A Retrospective Cohort

ObjectiveTo compare dental utilization and expenditures between children with and without behavioral health (BH) diagnoses in an accountable care organization.MethodsThis retrospective cohort study used enrollment and claims data of Medicaid-enrolled children in Ohio. Children with 7 years of continuous enrollment from 2013 to 2019 were included. We calculated 5 dental utilization outcomes: 1) Diagnostic only visits, 2) Preventive visits, 3) Treatment visits, 4) Treatment visits under general anesthesia (GA), and 5) Orthodontic visits. Total 7-year cumulative expenditures were calculated for each outcome. Multivariable logistic regression models were run for each outcome adjusting for demographics and medical comorbidities.ResultsAmong 77,962 children, 23% had ≥1 BH diagnosis. No utilization differences were noted between children with and without BH for diagnostic only visits, treatment visits, and orthodontic visits. BH status modified the likelihood of having a preventive visit and dental GA visits based on medical comorbidity. For example, children with BH diagnoses had significantly lower odds of a preventive visit (eg, non-complex chronic comorbidity: odds ratio [OR] = 0.87, 95% confidence interval [CI]: 0.85–0.89), and significantly higher odds of a dental treatment under general anesthesia visit (eg, non-chronic comorbidity: OR = 3.69, 95% CI: 3.26–4.18). The total cumulative dental expenditures were $10.5M greater for children with BH.ConclusionsChildren with BH diagnoses were significantly less likely to have preventive visits and more likely to have dental GA visits, which was expensive. Early identification and intervention could alter treatment approaches, improve care, reduce risk of harm, and achieve cost-savings within a pediatric accountable care organization.     

Association between evidence-based standardized protocols in emergency departments with childhood asthma outcomes: a canadian population-based study

OBJECTIVE To determine whether children treated in emergency departments (EDs) with evidence-based standardized protocols (EBSPs) containing evidence-based content and format had lower risk of hospital admission or ED return visit and greater follow-up than children treated in EDs with no standardized protocols in Ontario, Canada. DESIGN Retrospective population-based cohort study of children with asthma. We used multivariable logistic regression to estimate risk of outcomes. SETTING All EDs in Ontario (N?=?146) treating childhood asthma from April 2006 to March 2009. PARTICIPANTS Thirty-one thousand one hundred thirty-eight children (aged 2 to 17 years) with asthma. MAIN EXPOSURE Type of standardized protocol (EBSPs, other standardized protocols, or none). MAIN OUTCOME MEASURES Hospital admission, high-acuity 7-day return visit to the ED, and 7-day outpatient follow-up visit. RESULTS The final cohort made 46?510 ED visits in 146 EDs. From the index ED visit, 4211 (9.1%) were admitted to the hospital. Of those discharged, 1778 (4.2%) and 7350 (17.4%) had ED return visits and outpatient follow-up visits, respectively. The EBSPs were not associated with hospitalizations, return visits, or follow-up (adjusted odds ratio, 1.17 [95% CI, 0.91-1.49]; adjusted odds ratio, 1.10 [95% CI, 0.86-1.41]; and adjusted odds ratio, 1.08 [95% CI, 0.87-1.35], respectively). CONCLUSIONS The EBSPs were not associated with improvements in rates of hospital admissions, return visits to the ED, or follow-up. Our findings suggest the need to address gaps linking improved processes of asthma care with outcomes.     

Children hospitalized early and increased risk for future serious injury

OBJECTIVE: To determine if infants hospitalized for any reason before 90 days of age are at increased risk for future serious injury. SETTING: Washington State. METHODS: A population based retrospective cohort study, using data from Washington State birth and death certificates linked to a statewide hospital discharge database for the years 1989 through 1997. Participants included healthy full term infants born in Washington State between 1989 and 1995. A total of 29,466 infants hospitalized <90 days of age (early hospitalization) were compared to 29,750 randomly selected infants not hospitalized early. The primary outcome was an injury resulting in hospitalization or death between 3-24 months. RESULTS: Among infants hospitalized early, 76/10,000 had a subsequent serious injury before age 2, compared with 47/ 10,000 infants without an early hospitalization (relative risk (RR) 1.6; 95% confidence interval (CI) 1.3 to 2.0). In a multivariate model including maternal age and parity, the adjusted RR for serious injury associated with early hospitalization was 1.5 (95% CI 1.2 to 1.8). Infants hospitalized early were three times as likely to be hospitalized between 3-24 months of age for intentional injury compared with infants not hospitalized early (RR 3.3; 95% CI 1.1 to 10.1). CONCLUSIONS: Infants hospitalized in the first three months of life for any reason were 50% more likely to have a subsequent serious injury compared with infants not hospitalized early and were also at increased risk of intentional injury. This identifiable group of infants might be suitable for targeted childhood injury prevention programs including those involving prenatal and postnatal visits.     

Welfare reform and the health of young children: a sentinel survey in 6 US cities

CONTEXT: Welfare reform under the 1996 Personal Responsibility and Work Opportunity Reconciliation Act replaced entitlement to cash assistance for low-income families with Temporary Assistance to Needy Families, thereby terminating or decreasing cash support for many participants. Proponents anticipated that continued receipt of food stamps would offset the effects of cash benefit losses, although access to food stamps was also restricted. OBJECTIVE: To examine associations of loss or reduction of welfare with food security and health outcomes among children aged 36 months or younger at 6 urban hospitals and clinics. DESIGN AND SETTING: A multisite retrospective cohort study with cross-sectional surveys at urban medical centers in 5 states and Washington, DC, from August 1998 through December 2000. PARTICIPANTS: The caregivers of 2718 children aged 36 months or younger whose households received welfare or had lost welfare through sanctions were interviewed at hospital clinics and emergency departments. MAIN OUTCOME MEASURES: Household food security status, history of hospitalization, and, for a subsample interviewed in emergency departments, whether the child was admitted to the hospital the day of the visit. RESULTS: After controlling for potential confounding factors, children in families whose welfare was terminated or reduced by sanctions had greater odds of being food insecure (adjusted odds ratio [AOR], 1.5; 95% confidence interval [CI], 1.1-1.9), of having been hospitalized since birth (AOR, 1.3; 95% CI, 1.0-1.7) and, for the emergency department subsample, of being admitted the day of an emergency department visit (AOR, 1.9; 95% CI, 1.2-3.0) compared with those without decreased benefits. Children in families whose welfare benefits were decreased administratively because of changes in income or expenses had greater odds of being food insecure (AOR, 1.5; 95% CI, 1.1-2.2) and of being admitted the day of an emergency department visit (AOR, 2.8; 95% CI, 1.4-5.6). Receiving food stamps does not mitigate the effects of the loss or reduction of welfare benefits on food security or hospitalizations. CONCLUSION: Terminating or reducing welfare benefits by sanctions, or decreasing benefits because of changes in income or expenses, is associated with greater odds that young children will experience food insecurity and hospitalizations.     

Effects of removing gatekeeping on specialist utilization by children in a health maintenance organization

BACKGROUND: The "gatekeeping" model of access to specialty care has been an essential managed care tool, intended to control costs of care and promote coordination between generalists and specialists. OBJECTIVE: To investigate the impact of removing gatekeeping on specialist utilization. METHODS: A capitated multispecialty group discontinued a gatekeeping system on April 1, 1998. We assessed the overall number and distribution of patient visits to primary care physicians and specialists and initial patient visits to specialists before and after the removal of gatekeeping. We performed focused analyses for specific specialties, children with chronic conditions, and children with specific diagnoses. RESULTS: Elimination of gatekeeping was not associated with changes in the mean number of visits to specialists (0.28 visits per 6 months before and after gatekeeping was removed) or the percentage of all child visits to specialists (11.6% vs 12.1%; 95% confidence interval, 11.3%-11.9% vs 11.8%-12.4%). The proportion of all specialist visits that were initial consultations increased after gatekeeping was removed, from 30.6% (95% CI, 29.4%-31.8%) to 34.8% (95% CI, 33.6%-36.1%). Visits to any specialist by children with chronic conditions increased from 18.6% (95% CI, 17.7%-19.1%) to 19.8% (95% CI, 19.0%-20.7%). New patient visits to specialists by children with chronic conditions as a proportion of all specialist visits increased from 28.1% (95% CI, 25.9%-30.2%) to 32.3% (95% CI, 30.1%-34.5%). CONCLUSIONS: Replacing a gatekeeping system with open access to all specialty physicians in a managed care organization resulted in minimal changes on the utilization of specialists. Visits to specialists by children with chronic conditions increased after the removal of gatekeeping.     

Mental Health Emergency Department Visits by Children Before and During the COVID-19 Pandemic

ObjectivesTo describe pediatric mental health emergency department (ED) visit rates and visit characteristics before and during the COVID-19 pandemic.MethodsWe conducted a cross-sectional study of ED visits by children 5–17 years old with a primary mental health diagnosis from March 2018 to February 2021 at a 10-hospital health system and a children's hospital in the Chicago area. We compared demographic and clinical characteristics of children with mental health ED visits before and during the pandemic. We conducted an interrupted time series analysis to determine changes in visit rates.ResultsWe identified 8,127 pediatric mental health ED visits (58.5% female, 54.3% White, Not Hispanic/Latino and 42.4% age 13–15). During the pandemic, visits for suicide or self-injury increased 6.69% (95% CI 4.73, 8.65), and visits for disruptive, impulse control, conduct disorders increased 1.94% (95% CI 0.85, 3.03). Mental health ED visits by children with existing mental health diagnoses increased 2.29% (95% CI 0.34, 4.25). Mental health ED visits that resulted in medical admission increased 4.32% (95% CI 3.11, 5.53). The proportion of mental health ED visits at community hospitals increased by 5.49% (95% CI 3.31, 7.67). Mental health ED visit rates increased at the onset of the pandemic (adjusted incidence rate ratio [aIRR] 1.27, 95% CI 1.06, 1.50), followed by a monthly increase thereafter (aIRR 1.04, 95% CI 1.02, 1.06).ConclusionMental health ED visit rates by children increased during the COVID-19 pandemic. Changes in mental health ED visit characteristics during the pandemic may inform interventions to improve children's mental health.     

Chlamydial screening in urgent care visits: adolescent-reported acceptability associated with adolescent perception of clinician communication

OBJECTIVE: To examine the association between adolescents' perception of clinician communication and adolescents' reported acceptability of the steps involved in chlamydial screening during urgent care visits. DESIGN: Cross-sectional survey of adolescents after urgent care visits. SETTING: Four pediatric clinics in a health maintenance organization. PARTICIPANTS: Three hundred sixty-five adolescents aged 13 to 18 years. OUTCOME MEASURES: Participants' ratings of the acceptability of talking about sexual health and providing a urine sample for chlamydial testing in an urgent care visit. RESULTS: Most adolescents found sexual health discussions and urine collection for chlamydial screening acceptable in the urgent care setting (84% and 80%, respectively). Acceptability of sexual health discussion was significantly associated with adolescents' perception that the clinician explained confidentiality (adjusted odds ratio [AOR], 2.7; 95% confidence interval [CI], 1.3-5.5), knew "how to talk to teens like me" (AOR, 9.0; 95% CI, 3.5-24.2), and "listened carefully as I explained my concerns" (AOR, 14.3; 95% CI, 4.3-54.9). Acceptability of providing a urine sample for chlamydial testing was associated with the adolescents' perception that the clinician knew "how to talk to teens like me" (AOR, 3.7; 95% CI, 1.5-9.3) and "listened carefully as I explained my concerns" (AOR, 3.6; 95% CI, 1.1-11.5). CONCLUSIONS: Sexual history taking and urine collection are 2 key components of chlamydial screening and were reported as acceptable by the great majority of adolescents in the urgent care setting. Aspects of clinician communication appear to be important target areas for pediatric clinician education in supporting expansion of chlamydial screening to adolescents in urgent care visits.     

Association between iron deficiency and blood lead level in a longitudinal analysis of children followed in an urban primary care clinic

OBJECTIVE: To determine if iron deficiency (ID) is longitudinally associated with lead poisoning. STUDY DESIGN: Blood lead levels, hemoglobin, mean corpuscular volume (MCV), red cell distribution width (RDW), insurance status, and age were determined for 1,275 children. ID was defined as MCV <70 fl and RDW >14.5 if age was <2 years and MCV <73 fl and RDW >14.5 if age was >/=2 years. Logistic regression models were constructed by using the second-visit blood lead levels dichotomized at >/=0.48 microm/L (10 microg/dL) as the outcome. RESULTS: The odds ratio (OR) for baseline ID predicting lead poisoning at the second visit was 4.12 (95% CI, 1.96-8.65). In the second model, using children who were iron-replete at both visits as the referent group, for children with ID at both visits, the OR for predicting lead poisoning at the second visit was 5.54 (95% CI, 2.25-13.62). For children with ID at the first visit and iron-replete at the second visit, the OR was 2.73 (95% CI, 0.90-8.27), and for children iron-replete at the first visit and ID at the second visit, the OR was 0.81 (95% CI, 0.10-6.30). CONCLUSIONS: ID is associated with subsequent lead poisoning. These data are consistent with a biological mechanism of increased lead absorption among iron deficient children.     

Professional interpreters and bilingual physicians in a pediatric emergency department: effect on resource utilization

OBJECTIVE: To determine the impact of interpreters and bilingual physicians on emergency department (ED) resource utilization. DESIGN: Cohorts defined by language concordance and interpreter use were prospectively studied preceding and following the availability of dedicated, professional medical interpreters. SETTING: Pediatric ED in Chicago, Ill. PARTICIPANTS: We examined 4146 visits of children (aged 2 months to 10 years) with a presenting temperature of 38.5 degrees C or higher or a complaint of vomiting or diarrhea; 550 families did not speak English. In 170 cases, the treating physician was bilingual. In 239, a professional interpreter was used. In the remaining 141, a professional medical interpreter was unavailable. MAIN OUTCOME MEASURES: Incidence and costs of diagnostic testing, admission rate, use of intravenous hydration, and length of ED visit. RESULTS: Regression models incorporated clinical and demographic factors. Compared with the English-speaking cohort, non-English-speaking cases with bilingual physicians had similar rates of resource utilization. Cases with an interpreter showed no difference in test costs, were least likely to be tested (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.56-0.97), more likely to be admitted (OR, 1.7; 95% CI, 1.1-2.8), and no more likely to receive intravenous fluids, but had longer lengths of visit (+16 minutes; 95% CI, 6.2-26 minutes). The barrier cohort without a professional interpreter had a higher incidence (OR, 1.5; 95% CI, 1.04-2.2) and cost (+$5.78; 95% CI, $0.24-$11.21) for testing and was most likely to be admitted (OR, 2.6; 95% CI, 1.4-4.5) and to receive intravenous hydration (OR, 2.2; 95% CI, 1.2-4.3), but showed no difference in length of visit. CONCLUSION: Decision making was most cautious and expensive when non-English-speaking cases were treated in the absence of a bilingual physician or professional interpreter.     

Effectiveness of anticipatory guidance: recent developments

PURPOSE OF REVIEW: Anticipatory guidance is a key component of child health supervision. This review discusses the latest evidence on the effectiveness of anticipatory guidance and its impact on child and family functioning. RECENT FINDINGS: Anticipatory guidance on parent-infant interaction, sleep patterns, and injury prevention improve functional outcomes of children and their families. Recent findings also demonstrate that encouraging parents to share books with their children and free book distribution during well child care visits are associated with improved child language development and increased home literacy activities. Guidance promoting injury prevention and reading at home is supported by the best evidence. SUMMARY: Future models of child health supervision should address missed opportunities for anticipatory guidance and parents' desire for more information about what they can do to enhance their children's growth, development, and functioning.     

Parent-reported quality of preventive care for children at-risk for developmental delay

ObjectiveTo compare preventive care quality for children at risk and not at risk for developmental, behavioral, or social delays.MethodsUsing the 2007 National Survey of Children’s Health (n = 22,269), we used the Parents’ Evaluation of Developmental Status (PEDS) questionnaire to identify children ages 10 months to 5 years who were at risk for delays. We examined parent-reported quality measures to evaluate whether care was comprehensive, coordinated, family-centered, effective in providing developmental surveillance and screening, and provided within a medical home. Bivariate and multivariate analyses were used.ResultsTwenty-eight percent of children were at-risk for delay, with 17% at moderate risk and 11% at high risk. Greater proportions of children at high, moderate, and no/low risk had a usual source of care (89%–96%) and a personal doctor/nurse (91%–94%); smaller proportions of children underwent a standardized developmental screening (16%–23%) and had parental developmental concerns elicited from their doctor (47%–48%). In adjusted analyses, moderate-risk and high-risk children were less likely than no/low-risk children to receive needed care coordination (adjusted odds ratio [AOR] for high risk 0.33, 95% confidence interval [95% CI] 0.24–0.46) and referrals (high risk AOR 0.40, 95% CI 0.25–0.65), family-centered care (high-risk AOR 0.47, 95% CI 0.36–0.62), and to have a medical home (high-risk AOR 0.41, 95% CI 0.32–0.54).ConclusionsOur findings may reflect either poorer quality of care provided to at-risk children, or higher level of parental need that routine visits are not currently meeting. For at-risk children, enhanced screening and detection followed by targeted increases in communication and follow-up may help clinicians better anticipate families’ needs.     

Preventive Asthma Care Delivery in the Primary Care Office: Missed Opportunities for Children With Persistent Asthma Symptoms

ObjectiveTo describe which National Heart Lung and Blood Institute preventive actions are taken for children with persistent asthma symptoms at the time of a primary care visit and determine how care delivery varies by asthma symptom severity.MethodsWe approached children (2 to 12 years old) with asthma from Rochester, NY, in the waiting room at their doctor's office. Eligibility required current persistent symptoms. Caregivers were interviewed via telephone within 2 weeks after the visit regarding specific preventive care actions delivered. Bivariate and regression analyses assessed the relationship between asthma symptom severity and actions taken during the visit.ResultsWe identified 171 children with persistent asthma symptoms (34% black, 64% Medicaid) from October 2009 to January 2011 at 6 pediatric offices. Overall delivery of guideline-based preventive actions during visits was low. Children with mild persistent symptoms were least likely to receive preventive care. Regression analyses controlling for demographics and visit type (acute or follow-up asthma visit vs non-asthma-related visit) confirmed that children with mild persistent asthma symptoms were less likely than those with more severe asthma symptoms to receive preventive medication action (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.14–0.84), trigger reduction discussion (OR 0.39, 95% CI 0.19–0.82), recommendation of follow-up (OR 0.40, 95% CI 0.19–0.87), and receipt of action plan (OR 0.37, 95% CI 0.16–0.86).ConclusionsMany children with persistent asthma symptoms do not receive recommended preventive actions during office visits, and children with mild persistent symptoms are the least likely to receive care. Efforts to improve guideline-based asthma care are needed, and children with mild persistent asthma symptoms warrant further consideration.     

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

ObjectiveAlthough 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.MethodsNationwide 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.ResultsPatient 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%.ConclusionsWCC continuity more than doubled after interventions and was associated with decreased ED utilization, higher show rates, and increased timely WCC completion.     

US outpatient office visits for bronchiolitis, 1993-2004.

OBJECTIVE: To describe the clinical epidemiology of US outpatient visits for children younger than 2 years with bronchiolitis. METHODS: Data were obtained from the 1993-2004 National Ambulatory Medical Care Survey. Visits had ICD-9 code 466 and were restricted to patients younger than 2 years. National estimates were obtained by using assigned patient visit weights and reported with 95% confidence intervals (95% CIs) calculated by the relative standard error of the estimate; analysis included the chi2 test. RESULTS: From 1993 to 2004, bronchiolitis accounted for approximately 198 outpatient visits representing 8.75 million visits for children younger than 2 years. Among this same age group, the overall rate was 103 (95% CI, 83, 124) per 1000 US children and 17 (95% CI, 13, 20) per 1000 visits. When we compared bronchiolitis visits to all nonbronchiolitis visits, we found that those with bronchiolitis were less likely to be from the Northeast (12% vs 22%; P < .05) and more likely to be admitted to the hospital (2% vs 0.4%; P < .05). Fifty-two percent were prescribed albuterol; diagnostic tests were uncommon. CONCLUSIONS: The annual number of outpatient office visits for bronchiolitis among children younger than 2 years has remained stable over the last decade but has averaged almost 750,000 visits per year. More than half of primary care providers are prescribing medications to children with bronchiolitis.