Primary Care Provider Perceptions and Practices Regarding Dosing Units for Oral Liquid Medications

Introduction

To prevent errors, health care professional and safety organizations recommend using milliliters (mL) alone for oral liquid medication dosing instructions and devices. In 2018, for federal incentives under the Quality Payment Program, one requirement is for electronic health records to automatically use mL alone whenever oral liquid medications are prescribed. Current perceptions and practices of primary care providers (PCPs) regarding dosing units for oral liquid medications were assessed.

Liquid Medication Dosing Errors in Children: Role of Provider Counseling Strategies

ObjectiveTo examine the degree to which recommended provider counseling strategies, including advanced communication techniques and dosing instrument provision, are associated with reductions in parent liquid medication dosing errors.MethodsCross-sectional analysis of baseline data on provider communication and dosing instrument provision from a study of a health literacy intervention to reduce medication errors. Parents whose children (<9 years) were seen in 2 urban public hospital pediatric emergency departments (EDs) and were prescribed daily dose liquid medications self-reported whether they received counseling about their child's medication, including advanced strategies (teachback, drawings/pictures, demonstration, showback) and receipt of a dosing instrument. The primary dependent variable was observed dosing error (>20% deviation from prescribed). Multivariate logistic regression analyses were performed, controlling for parent age, language, country, ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease status; and site.ResultsOf 287 parents, 41.1% made dosing errors. Advanced counseling and instrument provision in the ED were reported by 33.1% and 19.2%, respectively; 15.0% reported both. Advanced counseling and instrument provision in the ED were associated with decreased errors (30.5 vs 46.4%, P = .01; 21.8 vs 45.7%, P = .001). In adjusted analyses, ED advanced counseling in combination with instrument provision was associated with a decreased odds of error compared to receiving neither (adjusted odds ratio 0.3; 95% confidence interval 0.1–0.7); advanced counseling alone and instrument alone were not significantly associated with odds of error.ConclusionsProvider use of advanced counseling strategies and dosing instrument provision may be especially effective in reducing errors when used together.     

Why Parents Seek Care for Acute Illness in the Clinic or the ED: The Role of Health Literacy

Objective

To explore the decision to seek care and decision-making regarding location of care among parents with low and adequate health literacy.

Caregiver Low Health Literacy and Nonurgent Use of the Pediatric Emergency Department for Febrile Illness

ObjectiveTo examine the association between caregiver health literacy and the likelihood of a nonurgent emergency department (ED) visit in children presenting for fever.MethodsThis cross-sectional study used the Newest Vital Sign to assess the health literacy of caregivers accompanying children with fever to the ED. Visit urgency was determined by resources utilized during the ED visit. Findings were stratified by race and child age. Chi-square and logistic regression analysis controlling for race were conducted to determine the association between low health literacy and ED visit urgency.ResultsA total of 299 caregivers completed study materials. Thirty-nine percent of ED visits for fever were nonurgent, and 63% of caregivers had low health literacy. Low health literacy was associated with a higher proportion of nonurgent ED visits for fever (44% vs 31%, odds ratio 1.8, 95% confidence interval [CI] 1.1, 2.9). Low health literacy was associated with higher odds of a nonurgent visit in white and Hispanic caregivers but not in black caregivers. In regression analysis, children ≥2 years old had higher odds of a nonurgent visit if caregivers had low health literacy (adjusted odds ratio 2.0; 95% CI 1.1, 4.1); this relationship did not hold for children <2 years old (adjusted odds ratio 0.8; 95% CI 0.4, 1.8).ConclusionsNearly two-thirds of caregivers with their child in the ED for fever have low health literacy. Caregiver low health literacy is associated with nonurgent ED utilization for fever in children over 2 years of age. Future interventions could target health literacy skills regarding fever in caregivers of children ≥2 years.     

Accuracy of Parent Perception of Comprehension of Discharge Instructions: Role of Plan Complexity and Health Literacy

ObjectiveInpatient discharge education is often suboptimal. Measures of parents’ perceived comprehension of discharge instructions are included in national metrics given linkage to morbidity; few studies compare parents’ perceived and actual comprehension. We 1) compared parent perceived and actual comprehension of discharge instructions and 2) assessed associations between plan complexity and parent health literacy with overestimation of comprehension (perceive comprehension but lack actual comprehension).MethodsProspective cohort study of English/Spanish-speaking parents (n = 192) of inpatients ≤12 years old and discharged on ≥1 daily medication from an urban public hospital. We used McNemar's tests to compare parent perceived (agree/strongly agree on 5-point Likert scale) and actual comprehension (concordance of parent report with medical record) of instructions (domains: medications, appointments, return precautions, and restrictions). Generalized estimating equations were performed to assess associations between low parent health literacy (Newest Vital Sign score ≤3) and plan complexity with overestimation of comprehension.ResultsMedication side effects were the domain with lowest perceived comprehension (80%), while >95% of parents perceived comprehension for other domains. Actual comprehension varied by domain (41%–87%) and was lower than perceived comprehension. Most (84%) parents overestimated comprehension in ≥1 domain. Plan complexity (adjusted odds ratio 3.6; 95% confidence interval 2.9–4.7) and low health literacy (adjusted odds ratio 1.9; 1.3–2.6) were associated with overestimation of comprehension.ConclusionsParental perceived comprehension of discharge instructions overestimated actual comprehension in most domains. Plan complexity and low health literacy were associated with overestimation of comprehension. Future interventions should incorporate assessment of actual comprehension and standardization of discharge instructions.     

Health literacy and disease-specific knowledge of caregivers for children with sickle cell disease

This study was conducted to measure the health literacy (HL) and disease-specific knowledge (DSK) of caregivers for children with sickle cell disease (SCD) and relate them to their child's health care utilization. The authors conducted a cross-sectional study of caregiver-child dyads attending an urban pediatric sickle cell clinic. Caregivers were administered the Shortened Test of Functional Health Literacy (S-TOFHLA) and a locally developed DSK questionnaire. Retrospective review of the child's electronic medical record (EMR) was performed to determine annual emergency department (ED) visits and hospitalizations. A total of 142 caregiver-child dyads were recruited for the study. Less than 5% of caregivers had limited HL, with less education (P =.03) and primary language other than English (P =.04) being the only risk factors. Although caregiver HL was not associated with ED visits or hospitalizations, surprisingly DSK was. Caregivers with higher DSK scores had children with higher annual rates of ED utilization (P =.002) and hospitalizations (P =.001), and these children were also more likely to be classified as high ED utilizers (≥4 visits per year; P =.01). Further, caregiver adherence to medication and clinic visits was associated with their child's age (P =.01). Although HL and DSK are both constructs that measure basic health understanding, they differently affect caregivers' ability to navigate and understand the health care system of children with chronic illnesses. This study suggests that the DSK/health care utilization relationship may be a more important measure than HL for programs following children with sickle cell disease and could also have applications in other pediatric chronic diseases.     

Low Caregiver Health Literacy Is Associated With Higher Pediatric Emergency Department Use and Nonurgent Visits

ObjectiveWe sought to determine the association between low caregiver health literacy and child emergency department (ED) use, both the number and urgency of ED visits.MethodsThis year long cross-sectional study utilized the Newest Vital Sign questionnaire to measure the health literacy of caregivers accompanying children to a pediatric ED. Prior ED visits were extracted from a regional database. ED visit urgency was classified by resources utilized during the index ED visit. Regression analyses were used to model 2 outcomes—prior ED visits and ED visit urgency—stratified by chronic illness. Analyses were weighted by triage level.ResultsOverall, 503 caregivers completed the study; 55% demonstrated low health literacy. Children of caregivers with low health literacy had more prior ED visits (adjusted incidence rate ratio 1.5; 95% confidence interval 1.2, 1.8) and increased odds of a nonurgent index ED visit (adjusted odds ratio 2.4; 95% confidence interval 1.3, 4.4). Among children without chronic illness, low caregiver health literacy was associated with an increased proportion of nonurgent index ED visits (48% vs 22%; adjusted odds ratio 3.2; 1.8, 5.7).ConclusionsOver half of caregivers presenting with their children to the ED have low health literacy. Low caregiver health literacy is an independent predictor of higher ED use and use of the ED for nonurgent conditions. In children without a chronic illness, low health literate caregivers had more than 3 times greater odds of presenting for a nonurgent condition than those with adequate health literacy.     

Family Impacts Among Children With Autism Spectrum Disorder: The Role of Health Care Quality

ObjectiveTo compare health care quality and family employment and financial impacts among children with special health care needs (CSHCN) with autism spectrum disorder (CSHCN + ASD), CSHCN with functional limitations (CSHCN + FL), and CSHCN lacking these conditions (other CSHCN); to test whether high health care quality was associated with reduced family impacts among CSHCN + ASD.MethodsData from the 2009–2010 National Survey of CSHCN were used to compare 3025 CSHCN + ASD, 6505 CSHCN + FL, and 28,296 other CSHCN. Weighted multivariate logistic regression analyses examined 6 age-relevant, federally defined health care quality indicators and 5 family financial and employment impact indicators. Two composite measures were additionally used: 1) receipt of care that met all age-relevant quality indicators; and 2) had ≥2 of the 5 adverse family impacts.ResultsAcross all health care quality indicators, CSHCN + ASD fared poorly, with only 7.4% meeting all age-relevant indicators. CSHCN + ASD had worse health care quality than other CSHCN, including CSHCN + FL. CSHCN + ASD also had high rates of adverse family impact, with over half experiencing ≥2 adverse impacts. Rates of adverse family impact were higher in CSHCN + ASD than other CSHCN, including CSHCN + FL. Among CSHCN + ASD, those whose health care that met federal quality standards were less likely to have multiple adverse family impacts than CSHCN + ASD whose health care did not meet federal quality standards.ConclusionsCSHCN + ASD are more prone to experience poor health care quality and family impacts than other CSHCN, even CSHCN + FL. Receipt of care meeting federal quality standards may potentially lessen adverse family impacts for CSHCN + ASD.     

HPV Vaccine Hesitancy: Findings From a Statewide Survey of Health Care Providers

IntroductionHealth care provider recommendations are critical for human papillomavirus (HPV) vaccine uptake. We sought to describe providers' HPV vaccine recommendation practices and explore their perceptions of parental hesitancy.MethodA statewide sample (n = 575) of Minnesota health care providers (20% pediatricians, 47% family medicine physicians, and 33% nurse practitioners) completed our online survey in April 2013.ResultsOnly 76% of health care providers reported routinely recommending HPV vaccine for girls ages 11 to 12 years, and far fewer (46%) did so for boys (p < .001). A majority of providers reported asking questions about parents' concerns (74%), but many lacked time to probe reasons (47%) or believed that they could not change parents' minds (55%). Higher levels of self-efficacy and outcome expectations were associated with routine recommendations (p < .05).DiscussionFindings suggest that providers' perceptions of hesitancy may discourage them from routinely recommending the HPV vaccine. Improving providers' self-efficacy to address hesitancy may be important for improving vaccination rates.     

Variation in Generational Perceptions of Child Health and Well-being

Objective

To assess adults' perceptions regarding the health and well-being of children today relative to their own health and well-being as youth and the potential for intergenerational differences in those perceptions.

Utilization of Primary Care versus Specialized Care in Children with and without Chronic Illness: A Population-Based Study

ABSTRACT. Children's utilization of curative care was studied to analyse the division of responsibilities between undifferentiated primary care and specialized care. All chronically ill ( n = 510), a control group ( n = 287) and the total population 0–15 years of age ( n = 6080) in a primary care district were studied using register data. Chronically ill children comprised 8.4% of the total child population and were registered for 1/10 of the primary health care visits, 1/3 of the specialized visits, 1/3 of the hospitalizations and 112 of the in-patient days of all children. The yearly ambulatory visits were 3.7/child in the chronically ill and 1.5/child in the control group, of which 1/3 and 2/3, respectively, were to primary care. Utilization of specialized care increased with disability. Chronically ill children visited primary care mainly for acute respiratory infections but seldom for allergic or other chronic conditions.