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OBJECTIVE: To identify factors associated with participation in group well-child care (GWCC), wherein families share preventive health care visits. METHODS: We extracted electronic health record data of mother-infant dyads with infants born 2013--18 at Yale New Haven Hospital and followed at the primary care center. Using chi-square analysis and multivariate logistic regression, we examined the extent to which 1) maternal/infant characteristics and recruitment timing were associated with GWCC initiation and continued engagement and 2) initiation was associated with primary care visits. RESULTS: Of 2046 eligible mother-infant dyads, 11.6% initiated GWCC. The odds of initiation were higher among mothers with Spanish versus English primary language (odds ratio: 2.36 [95% confidence interval: 1.52--3.66]), with 1 child versus ≥ 3 children (1.58 [1.13--2.22]), and of non- Hispanic Black versus non-Hispanic White infants (2.72 [1.39--5.32]). Initiation was lower among infants born in 2016 (0.53 [0.32--0.88]) and 2018 (0.29 [0.17--0.52]) versus 2013. Among GWCC initiators with follow-up data (n = 217), continued engagement (n = 132, 60.8%) was positively associated with maternal age of 20--29 years (2.85 [1.10--7.34]) and > 30 years (3.46 [1.15--10.43]) compared with < 20 years, and mothers with 1 child versus ≥ 3 (2.28 [1.04--4.98]). GWCC initiators, versus non-initiators, had 5.06 times higher adjusted odds of attending > 9 primary care appointments in the first 18 months (95% confidence interval: 3.74--6.85). CONCLUSIONS: As evidence builds on health and social benefits of GWCC, recruitment efforts may gain from considering multi-level socio-economic, demographic, and cultural factors associated with GWCC participation. Higher participation among systemically marginalized groups may present unique opportunities for family-based health promotion to mitigate health inequities. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To explore clinicians' perspectives about the impact of group well-child care (GWCC) on equitable health care delivery. METHODS: In this qualitative study, we conducted semistructured interviews with clinicians engaged in GWCC recruited via purposive and snowball sampling. We first conducted a deductive content analysis using constructs from Donabedian's framework for health care quality (structure, process, and outcomes) followed by inductive thematic analysis within these constructs. RESULTS: We completed 20 interviews with clinicians who deliver or research GWCC in 11 institutions across the United States. Four major themes around equitable health care delivery in GWCC emerged from clinicians' perspectives: 1) shifts in power dynamics (process); 2) enabling relational care, social support, and a sense of community (process, outcome); 3) centering multidisciplinary care delivery around patient and family needs (structure, process, and outcomes); and 4) unaddressed social and structural barriers limit patient and family participation. CONCLUSIONS: Clinicians perceived that GWCC enhances equity in health care delivery by shifting hierarchies in clinical visits and promoting relational, patient, and family-centered care. However, potential opportunities exist to further address provider implicit bias in group care delivery and structural inequities at the level of the health care institution. Clinicians underscored the need to address barriers to participation so that GWCC can more fully enhance equitable health care delivery. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Part C Early Intervention (EI) services have been shown to reduce autism symptoms and promote healthy development among young children. However, EI participation remains low, particularly among children from structurally marginalized communities. We investigated whether family navigation (FN) improved EI initiation following positive primary care screening for autism compared to conventional care management (CCM). METHODS: We conducted a randomized clinical trial among 339 families of children (ages 15-27 months) who screened as having an increased likelihood for autism at 11 urban primary care sites in 3 cities. Families were randomized to FN or CCM. Families in the FN arm received community-based outreach from a navigator trained to support families to overcome structural barriers to autism evaluation and services. EI service records were obtained from state or local agencies. The primary outcome of this study, EI service participation, was measured as the number of days from randomization to the first EI appointment. RESULTS: EI service records were available for 271 children; 156 (57.6%) children were not engaged with EI at study enrollment. Children were followed for 100 days after diagnostic ascertainment or until age 3, when Part C EI eligibility ends; 65 (89%, 21 censored) children in the FN arm and 50 (79%, 13 censored) children in the CCM arm were newly engaged in EI. In Cox proportional hazards regression, families receiving FN were approximately 54% more likely to engage EI than those receiving CCM (1.54 (95% confidence interval: 1.09-2.19), P = .02). CONCLUSIONS: FN improved the likelihood of EI participation among urban families from marginalized communities. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To evaluate the Healthy Eating through Group Well-Child Care (GWCC) intervention, a Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and primary care partnership which seeks to promote responsive feeding practices among low-income caregivers, by examining its impact on infant growth and exploring the experiences of caregivers who participated in this intervention. METHODS: Using a difference-in-differences approach, we examined change in weight-for-length among infants in GWCC before versus after implementation of the intervention compared with infants in individual well-child care (IWCC) over the same time-period. In parallel, we conducted semistructured interviews in English and Spanish with caregivers who participated in the intervention to explore their perspectives and analyzed transcripts via the constant comparative method to identify salient themes. RESULTS: Using electronic health record data from 279 GWCC and 6134 IWCC participants, we found no significant difference in first-year weight-for-length trajectory associated with participation in the intervention. We reached thematic saturation after 19 interviews with 22 caregivers and identified four major themes around feeding: 1) structural barriers limit access to healthy foods through WIC, 2) conflicting sources of nutrition advice challenge parental decision making, 3) exposure to novel foods facilitated further experimentation with healthier foods, and 4) discussion of responsive feeding facilitated awareness and adoption. CONCLUSIONS: A primary care and WIC partnership to promote responsive feeding in the context of GWCC was well received by caregivers but was not associated with improved weight-for-length among infants. Structural barriers to implementing responsive feeding and healthy eating practices may have impacted lack of measurable results from the intervention. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Medical-Legal Partnerships (MLPs) integrate medical and legal care to address prevalent health-harming legal needs (HHLN) among socioeconomically marginalized populations. MLPs address a diverse array of social determinants of health (SDOH) and have been shown to positively impact children's health. Less is known, however, about how MLPs affect health care providers. MLPs may affect child health by changing clinical practice and provider behavior, and transforming providers" relationships with their patients and patients' families. Examining and understanding how MLPs affect providers is thus critical to elucidating how MLPs may ultimately impact child health. METHODS: We examined one pediatric MLP at an academic medical center in New Haven, Connecticut. We conducted semi-structured interviews with 20 pediatric providers who had engaged with the MLP and 20 parents/guardians who had interacted with the MLP. We analyzed the qualitative data using inductive coding, primarily drawing upon provider interviews. RESULTS: The MLP affected providers in five major ways. The MLP 1) improved provider awareness of SDOH and HHLN, 2) expanded provider perceptions of their role and responsibilities as clinicians, 3) improved provider efficacy in addressing SDOH and HHLN, 4) empowered providers to engage in systemic advocacy, and 5) improved providers' relationships with patients' families. CONCLUSION: Our study identifies multiple ways that a pediatric MLP affects providers. Our findings suggest that MLPs can improve patient and population health by equipping providers with the knowledge and tools needed to assist patients with HHLN and SDOH, improving provider-family relationships, and encouraging providers to engage in systemic and institutional advocacy. [ABSTRACT FROM AUTHOR]

Early Intervention (EI) programs promote early childhood development but remain underutilized. Few studies have examined correlations with completion of EI referrals using a standardized referral system. Our study examined a minority, underserved population for characteristics that affect this critical step. Subjects were referred from an inner-city pediatric primary care clinic for EI evaluation from 3/1/15-5/31/18. Subjects were <3 years of age at the time of referral, received pediatric care at the clinic, and were referred for EI. The dependent variable was completion of EI evaluation, verified by the medical record. Independent variables included demographic, maternal (eg, depression), child (eg, chronic illness), and referral characteristics. A multivariable logistic regression model was used to determine the predictors for completing an evaluation. Of 181 children referred to EI, 61.9% completed an EI evaluation; the average age was 18.9 (SD 7.4) months at first referral. For every additional month of age at the initial referral, a child was 5.0% less likely to complete an evaluation (adjusted odds ratio [aOR], 0.95; 95% confidence interval [CI], 0.90–0.99; P =.02). Two factors more than doubled the odds of completing an EI evaluation: having a chronic medical illness at the time of referral (aOR = 2.41, CI 1.21–4.79; P =.01), and being a child from a non-English speaking family (aOR = 2.22, CI 1.09–4.50; P =.03). The child's age and medical history, and language spoken at home affected the odds of successfully completing an EI evaluation. These findings can help clinicians target families at risk of failing to complete EI programs. [ABSTRACT FROM AUTHOR]

Many internal medicine residency programs have transitioned to an X + Y clinic schedule, in which weekly continuity clinics are removed and clinic experience is instead condensed into 2-week blocks interspersed throughout the year, but few pediatric training programs have adopted this approach. We initiated X + Y scheduling in the 2015 academic year, with the hypothesis that outpatient continuity could be maintained or improved while inpatient handoffs would be reduced. We also hypothesized that learner experience with X + Y scheduling would be positive. Continuity and handoffs were compared over a 7-month period in 2013 to 2014 and 2015 to 2016. Outpatient continuity was calculated as the proportion of visits in which the patient was seen by the designated primary care provider (PCP). Handoffs were calculated through analysis of the online resident schedule with comparison of weekly totals for all inpatient teams. Resident perceptions were obtained in an online survey of residents who experienced both systems. With X + Y scheduling, overall outpatient continuity improved from 2914 of 9882 (29.5%) of visits seen by a patient's PCP to 3066 of 9769 (31.4%) (P =.004), but preventive visit continuity decreased from 2170 of 4687 (46.2%) to 2025 of 4709 (43%) (P =.001). Inpatient handoffs decreased with X + Y scheduling from 30 to 20 weekly handoffs (P <.001). In total, 85% of residents reported a positive experience with X + Y scheduling. An X + Y scheduling approach in pediatrics is a viable alternative to weekly clinics, resulting in improved learner experience, reductions in inpatient handoffs, and small mixed effects on outpatient continuity. [ABSTRACT FROM AUTHOR]

Background The majority of pediatricians encounter vaccine hesitancy in their practices. As part of a broad discussion about vaccination, school requirements arise as a topic yet providers may lack information about the effects of immunization on university matriculation. Methods We surveyed the top-ranked 200 universities regarding required immunizations, medical, religious, and philosophical exemptions, and noncompliance policies. We examined the legal requirements for involved jurisdictions. Results Of 129 responding universities (64%), 94% had ≥1 pre-matriculation immunization requirement (PIR), with a mean of 3.53 (95%CI 3.17–3.89) requirements. In unadjusted analyses, funding, region, jurisdictional requirements, undergraduate size, and tuition were significant predictors of the number of PIRs. In multivariate modeling, jurisdictional requirements outperformed all other university demographics, but excluding these, Northeast and South region and smaller undergraduate size persisted. The most common PIR was measles (93%). 67% of involved jurisdictions have laws mandating ≥1 university PIR, and 45% of universities surpassed their jurisdiction’s law. With respect to medical, religious, and philosophical exemptions, 24%, 40%, and 60% of universities with PIRs had the highest hardship category, and 2%, 2%, and 46% disallowed these outright. Frequent responses to student noncompliance were: hold on classes (89%), additional registration fees (13%), and hold on housing (11%). Conclusions Requirements for pre-matriculation immunizations in top universities are common and exemptions are difficult to obtain. Conversations between providers and vaccine-hesitant families may be enriched by discussion of these future effects of their decision on immunization. [ABSTRACT FROM AUTHOR]