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The objective of the study is to report the feasibility, acceptability, and adoption of the "Access to Tailored Autism Integrated Care (ATTAIN)," a model to identify mental health needs and link to mental health care for autistic children. The Exploration, Preparation, Implementation, and Sustainment framework informed implementation outcome measurement and analysis. Thirty-six providers from seven pediatric primary care clinics within three health care systems enrolled and received an initial Access to Tailored Autism Integrated Care training and ongoing online support over 4 months with autistic patients ages 4--16 years old. Survey and interview assessments measured perceptions of feasibility, acceptability, and intentions to sustain Access to Tailored Autism Integrated Care use. Electronic health record (EHR) data assessed child characteristics and Access to Tailored Autism Integrated Care adoption. Descriptive statistics and one-way analyses of variance characterized implementation outcomes and differences between health care systems. Rapid qualitative methods were used to analyze interview data that were integrated with survey data for convergence and expansion. Providers reported that Access to Tailored Autism Integrated Care was feasible, acceptable, and that the initial training was helpful. Reports were mixed about providers' intentions to continue using Access to Tailored Autism Integrated Care. Providers offered recommendations for more specific and tailored implementation support. There were significant differences in provider-reported adoption rates between health care systems. This is one of the first implementation studies examining integrated mental health care for autistic children and highlighted specific areas for refinement to facilitate scale-up.

Youth with autism spectrum disorder often have complex medical needs. Disruptions of healthcare during the transition from pediatric to adult healthcare may put youth with autism spectrum disorder at higher risk of medical emergencies and high medical costs. We conducted a study among transition-age youth (14-25 years old) receiving healthcare at Kaiser Permanente Northern California during 2014-2015. We examined the differences in healthcare utilization and costs among youth with autism spectrum disorder (n = 4123), attention deficit and hyperactivity disorder (n = 20,6015), diabetes mellitus (n = 2156), and general population controls (n = 20,615). Analyses were also stratified by age and sex. Youth with autism spectrum disorder had the highest utilization of outpatient primary care, mental health, and psychotropic medications and the lowest utilization of obstetrics/gynecology and urgent care. Costs for youth with autism spectrum disorder were higher than those for attention deficit and hyperactivity disorder and general population peers and lower than for diabetes mellitus. Utilization patterns varied by age. Transition-age youth with autism spectrum disorder generally utilize healthcare at higher rates relative to attention deficit and hyperactivity disorder and general population peers but at similar or lower rates than diabetes mellitus peers, indicating this group's complex combination of psychiatric and medical healthcare needs. The relatively high utilization of psychiatric services and low utilization of women's health services in transition-age youth with autism spectrum disorder may have implications for long-term health and warrants additional research.

Hematopoietic stem cell transplantation (HSCT) is an accepted medical treatment for many serious childhood diseases. HSCT is a demanding procedure that creates both physical and emotional challenges for patients and their family members. Research has demonstrated that siblings of children undergoing HSCT are at risk for developing psychosocial problems such as posttraumatic stress, anxiety, and low self-esteem. This study examined psychosocial changes in siblings ("N" = 30) of pediatric HSCT recipients. These siblings participated in an art therapy intervention session 1 week, 1 month, and 3 months after their siblings' HSCT procedure. Results showed improvements in sibling psychosocial functioning associated with participation in the art therapy interventions. Compared to a control group ("n" = 10), the intervention group ("n" = 20) showed lower levels of posttraumatic stress symptoms at the final session.

Objective: The goal of this study was to investigate the adverse childhood experiences (ACEs) in youth in a low-income, urban community. Study design: Data from a retrospective chart review of 701 subjects from the Bayview Child Health Center in San Francisco are presented. Medical chart documentation of ACEs as defined in previous studies were coded and each ACE criterion endorsed by a traumatic event received a score of 1 (range = 0-9). This study reports on the prevalence of various ACE categories in this population, as well as the association between ACE score and two pediatric problems: learning/behavior problems and body mass index (BMI) greater than or equal to 85% (i.e., overweight or obese). Results: The majority of subjects (67.2%, N = 471) had experienced 1 or more categories of adverse childhood experiences (ACE greater than or equal to 1) and 12.0% (N = 84) had experienced 4 or more ACEs (ACE greater than or equal to 4). Increased ACE scores correlated with increased risk of learning/behavior problems and obesity. Conclusions: There was a significant prevalence of endorsed ACE categories in this urban population. Exposure to 4 or greater ACE categories was associated with increased risk for learning/behavior problems, as well as obesity. Practice implications: Results from this study demonstrate the need both for screening of ACEs among youth in urban areas and for developing effective primary prevention and intervention models. (Contains 2 tables and 2 figures.)

Objective: To determine health care provider needs related to pediatric obesity management in rural California and to explore strategies to improve care through telehealth. Methods: Cross-sectional survey of health care providers who treated children and adolescents at 41 rural clinics with existing telehealth connectivity. Results: Most of the 135 respondents were family physicians at designated rural health clinics serving low-income families. Respondents had practiced in rural areas for an average of 10 years. Most providers rated their self-efficacy in managing pediatric obesity as 2 or 3 on a 5-point scale. The barriers most frequently reported by health care providers were lack of local weight management programs, lack of patient motivation, and lack of family involvement in treatment. Providers reported that the resources they would find most helpful were readily accessible patient education materials, strategies to link patients with community treatment programs and training in brief, focused counseling skills. Three-quarters of providers already used telehealth for distance learning. Providers reported very high interest in participating in continuing education on pediatric obesity delivered by telehealth, specifically Internet communication with specialists, web-based education, and interactive video case-conferencing. Conclusions: Rural health care providers face several barriers related to pediatric obesity management. Targeted interventions provided via telehealth to rural health care providers may enhance the care of obese children and adolescents. The results of this study provide directions and priorities for the design of appropriate interventions.

Social psychologists have shown experimentally that implicit race bias can influence an individual's behavior. Implicit bias has been suggested to be more subtle and less subject to cognitive control than more explicit forms of racial prejudice. Little is known about how implicit bias is manifest in naturally occurring social interaction. This study examines the factors associated with physicians selecting children rather than parents to answer questions in pediatric interviews about routine childhood illnesses. Analysis of the data using a Generalized Linear Latent and Mixed Model demonstrates a significant effect of parent race and education on whether physicians select children to answer questions. Black children and Latino children of low-education parents are less likely to be selected to answer questions than their same aged white peers irrespective of education. One way that implicit bias manifests itself in naturally occurring interaction may be through the process of speaker selection during questioning. (Contains 9 footnotes, 4 tables, and 1 figure.)

Parents of hospitalized children are exposed to a multitude of psychological, emotional, and physical stressors. This exploratory program examined the feasibility of songwriting interventions to reduce parental stress levels during hospitalization. Board-certified music therapists facilitated songwriting sessions with parents of hospitalized children within two inpatient children's hospitals. Fifteen parents' stress levels were measured over the course of 5 months. The validated Stress Numeric Rating Scale (SNRS-11) was used to measure parents' pre- and post-stress levels when songwriting interventions were facilitated, with 0 indicating low-stress levels and 10 indicating high-stress levels. Results showed a significant reduction in mean stress levels, from 6.07 pre-session to 2.33 post-session (p  = .002). Our findings support the existing data on the feasibility and effectiveness of songwriting as part of a music therapy program to provide non-pharmacological stress management. To our knowledge, our pilot is one of the first to specifically investigate the impact of songwriting on parent stress levels in the inpatient pediatric hospital setting. [ABSTRACT FROM AUTHOR]

Background: Patients with public insurance (PUBs) face more difficulty obtaining orthopaedic appointments and have longer wait times than privately insured patients (PVTs). These delays are associated with greater injury severity at the time of surgery, which affects sports injuries such as anterior cruciate ligament tears where early surgical stabilization leads to better outcomes. Additionally, previous evidence showed that patients with limited English proficiency often must rely on informal translation services, such as family members or friends, to communicate with their orthopaedic surgeons, which may represent a disparity in the care provided. Hypothesis: It was hypothesized that PUBs would be less likely to obtain an appointment compared with PVTs and that most providers would not offer professional translation services to Spanish-speaking patients. Study Design: Cross-sectional study. Methods: The authors called 50 randomly selected orthopaedic surgeons' offices in California specializing in sports medicine to request an appointment. Each office was called 4 times in random order for the hypothetical patient having either private or public insurance and speaking either Spanish or English. Results: The hypothetical PUB had significantly decreased access to an appointment (19% of offices offered an appointment) when compared to the PVT (73.8% offered an appointment). Independent private practice (IPP) offices were less likely to accept public insurance (13.3%) compared with offices at academic medical centers (57.1%). There was no difference in access to an appointment for the Spanish- versus English-speaking patient. Translation services were offered at 73.8% of the orthopaedic offices. Conclusion: Overall, the data illustrated disparities in access to pediatric orthopaedic care for PUBs compared to those with private insurance. Disparities were most prominent in IPP settings, which were less likely than academic offices to accept public insurance. Additionally, it was found that 73.8% of the offices the authors contacted offered Spanish translation services. Interventions should focus on increasing acceptance of public insurance and translation services in IPP settings. Future studies should expand this analysis to other languages and investigate the potential impacts of language on the quality of care provided. [ABSTRACT FROM AUTHOR]

Background: Foreign national patients and families can face life-limiting illness and end-of-life care far from home; this palliative need has not been well described. Case Description: We present a case of a 20-year-old Ugandan patient diagnosed with metastatic alveolar rhabdomyosarcoma who presented to a pediatric academic medical center in California. Despite treatment, her disease progressed and she was unable to return to Uganda due to symptom burden. The patient and her family met regularly with palliative care during their hospital stay; the palliative approach included cross-cultural sharing, connecting across differences, and fostering community. The family additionally cultivated a support system within the hospital and local African communities. This was illustrated in the memory album the patient created, and in her family's extensive bereavement support. Conclusions: This case explores opportunities for individualized psychosocial care and community-based support to enhance palliative care for foreign national patients and families. [ABSTRACT FROM AUTHOR]

Objective: To evaluate social drivers of health and how they impact pediatric oncology patients' clinical outcomes during pediatric intensive care unit (PICU) admission via correlation with patient ZIP codes. Methods: Demographic, clinical, and outcome variables from Virtual Pediatric Systems®, LLC for oncology patients (2009–2021) in California PICUs (excluding postoperative) using 3‐digit ZIP Codes with social drivers of health variables linguistic isolation, poverty, race/ethnicity, and education abstracted from American Community Survey data for 3‐digit ZIP Codes using the Environmental Protection Agency's EJScreen tool. Outcomes of length of stay (LOS), mortality, acuity scores, were compared with social variables. Results: Positive correlation between mortality and minority racial groups (Hispanic/Latino) across ZIP Codes (correlation coefficients of 0.45 (95% CI: 0.22–0.64, p < 0.001) in 2017, 0.50 (95% CI: 0.27–0.68, p < 0.001) in 2018, 0.33 (95% CI: 0.07–0.54, p = 0.013) in 2020, and 0.32 (95% CI: 0.06–0.53, p = 0.018) in 2021). Median PICU length of stay significantly correlated with linguistic isolation (coefficient of 0.42 (95% CI: 0.18–0.61, p = 0.001) in 2021 versus −0.41 (95% CI: −0.61 to −0.16, p = 0.002) in 2019), which included PRISMIII (n = 7417). Mixed effects logistic regression model for other constant variables (PRISMIII, cancer type, race/ethnicity, year), random effect of patient, linguistic isolation (percentage as a continuous value) was significantly associated (95% CI: 1.01–1.06; p = 0.02) with mortality; (OR = 1.03). Conclusions: Linguistic isolation was correlated with LOS and mortality, however variable year to year. [ABSTRACT FROM AUTHOR]

Objective: To assess nationally endorsed claims-based quality measures in pediatric sickle cell anemia (SCA). Methods: Using data from the Sickle Cell Data Collection programs in California and Georgia from 2010 to 2019, we evaluated 2 quality measures in individuals with hemoglobin S/S or S/β-zero thalassemia: (1) the proportion of patients aged 3 months to 5 years who were dispensed antibiotic prophylaxis for at least 300 days within each measurement year and (2) the proportion of patients aged 2 to 15 years who received at least 1 transcranial Doppler ultrasound (TCD) within each measurement year. We then evaluated differences by year and tested whether performance on quality measures differed according to demographic and clinical factors. Results: Only 22.2% of those in California and 15.5% in Georgia met or exceeded the quality measure for antibiotic prophylaxis, with increased odds associated with rural residence in Georgia (odds ratio 1.61; 95% confidence interval 1.21-2.14) compared with urban residence and a trend toward increased odds associated with a pediatric hematologist prescriber (odds ratio 1.28; 95% confidence interval 0.97, 1.69) compared with a general pediatrician. Approximately one-half of the sample received an annual assessment of stroke risk using TCD (47.4% in California and 52.7% in Georgia), with increased odds each additional year in both states and among younger children. Conclusions: The rates of receipt of recommended antibiotic prophylaxis and annual TCD were low in this sample of children with SCA. These evidence-based quality measures can be tracked over time to help identify policies and practices that maximize survival in SCA. [ABSTRACT FROM AUTHOR]

Purpose: The nonbinary and genderqueer (NBGQ) youth population is growing, yet scant research focuses on this distinct group. We aim to gain a deeper understanding of desired gender-affirming care and interventions pursued by NBGQ youth. Methods: A retrospective chart review of NBGQ patients seen at the University of California, San Francisco Child and Adolescent Gender Center from January 1, 2009, to December 31, 2020, was performed. Demographic information, desired gender-affirming care, and gender-affirming interventions pursued at initial and most recent visits were collected. Results: Initial visit charts of 116 NBGQ youth who attended more than one clinic visit were reviewed. In total, 48 unique genders were documented; gender evolved over time for some youth, as did desired gender-affirming care. At the most recent visit, 15 youth (12.9%) had a binary gender, and 101 youth (87.1%) had an NBGQ gender. At the initial visit, 56 youth (48.3%) were interested in gender-affirming hormone therapy, compared with 75 youth (65.6%) at the most recent visit. In addition, 21 (18.1%) and 49 (42.2%) youth were interested in surgery at the initial and most recent visits, respectively. In general, interest in interventions was higher than pursuit of interventions. Conclusion: There is vast diversity of gender and differences in desired gender-affirming care within the NBGQ youth population. Desires for gender-affirming care within the cohort changed over time, and not all those who expressed a desire for an intervention received it. The reasons are likely multifactorial, highlighting the need for expectation-free and patient-specific affirming care and research on the NBGQ youth population, while also considering barriers to care. [ABSTRACT FROM AUTHOR]

Background: In the past decade, there have been substantial advances in our understanding of the pathobiology of pediatric acute kidney injury (AKI). In particular, animal models and studies focused on the relationship between kidney development, nephron number, and kidney health have identified a number of heterogeneous pathophysiologies underlying AKI. Despite this progress, gaps remain in our understanding of the pathobiology of pediatric AKI. Methods: During the 26th Acute Disease Quality Initiative (ADQI) Consensus conference, a multidisciplinary group of experts discussed the evidence and used a modified Delphi process to achieve consensus on recommendations for opportunities to advance translational research in pediatric AKI. The current state of research understanding as well as gaps and opportunities for advancement in research was discussed, and recommendations were summarized. Results: Consensus was reached that to improve translational pediatric AKI advancements, diverse teams spanning pre-clinical to epidemiological scientists must work in concert together and that results must be shared with the community we serve with patient involvement. Public and private research support and meaningful partnerships with adult research efforts are required. Particular focus is warranted to investigate the pediatric nuances of AKI, including the effect of development as a biological variable on AKI incidence, severity, and outcomes. Conclusions: Although AKI is common and associated with significant morbidity, the biologic basis of the disease spectrum throughout varying nephron developmental stages remains poorly understood. An incomplete understanding of factors contributing to kidney health, the diverse pathobiologies underlying AKI in children, and the historically siloed approach to research limit advances in the field. The recommendations outlined herein identify gaps and outline a strategic approach to advance the field of pediatric AKI via multidisciplinary translational research. [ABSTRACT FROM AUTHOR]

In 2019, the University of California at San Francisco (UCSF) launched the Child and Adolescent Psychiatry Portal (CAPP), a pediatric mental health care access (PMHCA) program providing remote mental health consultation services to pediatric primary care providers (PCPs) throughout Northern and Central California. The development and implementation of CAPP was guided by Human-Centered Design (HCD), an iterative, rapid-paced innovation process focusing on stakeholders' needs and experiences, which shaped the development of CAPP's programs. The resulting key programmatic elements are designed for pediatric workforce development: (1) PCP consultation with a child and adolescent psychiatrist via a telephone warmline; and (2) training and education for providers. CAPP has grown rapidly since its launch, having enrolled 1,714 providers from 257 practices spread across 36 counties and provided 3,288 consults on 2,703 unique lives as of August 2023. Preliminary evaluation findings indicate high PCP satisfaction with CAPP's services, despite continued challenges of integrating behavioral health into primary care. Throughout the HCD and implementation process, multidisciplinary partnerships have proven critical in providing end-user input to inform and improve program design. This growing network of partnerships, developed through the cultivation of personal relationships and trust over time, has also proven essential for CAPP's rapid growth and sustainability. Overall, this Community Case Study highlights the critical role of partnerships and the importance of taking a people-centered approach, as captured in CAPP's motto, "Connecting for Care. [ABSTRACT FROM AUTHOR]

To quantify self-reported difficulty accessing Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)-issued infant formula among participants early in the coronavirus disease 2019 (COVID-19) pandemic, to determine if infant formula redemption was associated with self-reported difficulty accessing infant formula, and to quantify changes in formula redemption during the 2022–2023 US infant formula shortages. A cross-sectional study and time series data. Families participating in the WIC program in the Los Angeles metropolitan area from November 2019 to June 2023. Families with infants (aged 0–12 months) issued infant formula by WIC with a completed 2020 Los Angeles County WIC Survey (n = 1,897) or issued infant formula by a large WIC program in Southern California between November 2019 and June 2023 (n = 109,135). Incidence of ≥ 30% reduction in infant formula redemption and interval-scaled infant formula redemption. Special Supplemental Nutrition Program for Women, Infants, and Children formula redemption data were matched to 2020 Los Angeles County WIC Survey data to determine if self-reported difficulty accessing infant formula was associated with administrative infant formula redemption data using negative binomial regression and were used to quantify the prevalence and severity of incomplete formula redemption during 2020–2023 formula shortages using ordinal logistic regression (outcome: interval-scaled formula redemption). Few (13.0%) caregivers reported difficulty accessing the WIC-issued formula early in the COVID-19 pandemic. The 2.8% who reported an unresolved shortage early in the COVID-19 pandemic had 201% higher rates of ≥ 30% declines in formula redemption (incidence rate ratio [IRR], 3.01; 95% confidence interval, 1.57–5.79, P < 0.001) than those with no difficulties. Incomplete formula redemption odds were significantly elevated throughout the COVID-19 pandemic from March 2020 to January 2022 and increased further during the 2022–2023 infant formula shortages from February 2022 to June 2023, reaching 342% higher in October 2022 than February 2020 (odds ratio, 4.42; 95% confidence interval, 4.14–4.72; P < 0.001). Special Supplemental Nutrition Program for Women, Infants, and Children redemption data are an adequate proxy for population-level infant formula access issues among households with low income but are insufficiently sensitive for screening at a household level. US formula shortages (2020–2023) demonstrate the need for improved coordination between nutrition assistance programs, regulatory bodies, and commercial food systems, particularly during acute supply crises. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To evaluate whether maltreatment investigated during infancy affects high-acuity health care utilization patterns during early childhood. METHODS: Retrospective case-control study based on linked data between child protection and hospital encounter records conducted to review health records of infants investigated for abuse and/or neglect. Cases and controls were followed longitudinally through the Rady Children's Hospital electronic health records for 4 years starting at the age of 1 year. RESULTS: A total of 3692 children were investigated for maltreatment within the first year of life. When comparisons were made between children reported for maltreatment and matched controls, children with infancy maltreatment reports had significantly more high-acuity health care encounters than matched controls (average treatment effect = 1.53, 95% Confidence Interval 1.08-1.99, P < .001). CONCLUSIONS: Infants investigated for maltreatment have greater high-acuity health care utilization in early childhood. These findings highlight this population's need for well-defined medical homes to ensure appropriate health care. Further understanding of the underlying reasons for this increased health care burden will help inform these efforts. [ABSTRACT FROM AUTHOR]

Background: Mental, emotional, and behavioral disorders are chronic pediatric conditions, and their prevalence has been on the rise over recent decades. Affected children have long-term health sequelae and a decline in health-related quality of life. Due to the lack of a validated database for pharmacoepidemiological research on selected mental, emotional, and behavioral disorders, there is uncertainty in their reported prevalence in the literature. Objectives: We aimed to evaluate the accuracy of coding related to pediatric mental, emotional, and behavioral disorders in a large integrated health care system's electronic health records (EHRs) and compare the coding quality before and after the implementation of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding as well as before and after the COVID-19 pandemic. Methods: Medical records of 1200 member children aged 2-17 years with at least 1 clinical visit before the COVID-19 pandemic (January 1, 2012, to December 31, 2014, the ICD-9-CM coding period; and January 1, 2017, to December 31, 2019, the ICD-10-CM coding period) and after the COVID-19 pandemic (January 1, 2021, to December 31, 2022) were selected with stratified random sampling from EHRs for chart review. Two trained research associates reviewed the EHRs for all potential cases of autism spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD), major depression disorder (MDD), anxiety disorder (AD), and disruptive behavior disorders (DBD) in children during the study period. Children were considered cases only if there was a mention of any one of the conditions (yes for diagnosis) in the electronic chart during the corresponding time period. The validity of diagnosis codes was evaluated by directly comparing them with the gold standard of chart abstraction using sensitivity, specificity, positive predictive value, negative predictive value, the summary statistics of the F-score, and Youden J statistic. κ statistic for interrater reliability among the 2 abstractors was calculated. Results: The overall agreement between the identification of mental, behavioral, and emotional conditions using diagnosis codes compared to medical record abstraction was strong and similar across the ICD-9-CM and ICD-10-CM coding periods as well as during the prepandemic and pandemic time periods. The performance of AD coding, while strong, was relatively lower compared to the other conditions. The weighted sensitivity, specificity, positive predictive value, and negative predictive value for each of the 5 conditions were as follows: 100%, 100%, 99.2%, and 100%, respectively, for ASD; 100%, 99.9%, 99.2%, and 100%, respectively, for ADHD; 100%, 100%, 100%, and 100%, respectively for DBD; 87.7%, 100%, 100%, and 99.2%, respectively, for AD; and 100%, 100%, 99.2%, and 100%, respectively, for MDD. The F-score and Youden J statistic ranged between 87.7% and 100%. The overall agreement between abstractors was almost perfect (κ=95%). Conclusions: Diagnostic codes are quite reliable for identifying selected childhood mental, behavioral, and emotional conditions. The findings remained similar during the pandemic and after the implementation of the ICD-10-CM coding in the EHR system. INSET: cc. [ABSTRACT FROM AUTHOR]

Despite documented healthcare disparities among Latino autistic children, little is known about how their families experience the autism "diagnostic odyssey." Pediatricians have a critical role in the "diagnostic odyssey," but when it becomes arduous, parents may also use complementary health approaches, particularly when conventional care does not adequately address their concerns. Shared decision-making is important in healthcare for autistic children, especially when parents also choose complementary health approaches; but little is known about shared decision-making among Latino parents of autistic children. We conducted a 12-month ethnography with 12 bicultural/bilingual Latino families of autistic children to understand their healthcare experiences (conventional and complementary health approaches) for their children, focusing on shared decision-making. Thematic analysis revealed: (1) most pediatricians were involved early in the "diagnostic odyssey" but were largely uninvolved thereafter; (2) conventional healthcare was satisfactory to the parents for physical health, but not developmental issues; and (3) parents who used complementary health approaches were more frustrated about a lack of autism information from pediatricians than those who did not. Finally, (4) we describe two exemplars of successful shared decision-making between Latino parents and pediatricians. Increasing pediatricians' autism knowledge and ability to discuss complementary health approaches may facilitate shared decision-making and reduce healthcare disparities for Latino autistic children. Latino parents may choose to use complementary health approaches, such as vitamins, supplements, and special diets, for their autistic children. However, they might not tell their pediatrician about their complementary health approach use if they worry that the pediatrician will disapprove or judge them. This fear, along with pediatricians' lack of autism knowledge, creates barriers to "shared decision-making" between parents and pediatricians. Shared decision-making is a process where families and healthcare providers collaborate and exchange information in order to come to an agreement about treatment options. In our qualitative study with 12 bilingual Latino families of autistic children, we interviewed and observed families to learn about their experiences with both conventional healthcare (their pediatrician) and complementary health approaches. Our study results describe the parents' different pathways to an autism assessment, a process that is sometimes called the "diagnostic odyssey." The parents reported that conventional healthcare met their needs for their child's physical health but not for their child's developmental challenges. The parents who used complementary health approaches for their autistic children were more frustrated about a lack of autism information from pediatricians than those who did not use complementary health approaches. Finally, we describe two examples of successful shared decision-making between parents and pediatricians. We conclude that pediatricians who are able to talk about complementary health approaches with Latino families may help to facilitate shared decision-making and reduce healthcare disparities for Latino autistic children. [ABSTRACT FROM AUTHOR]

The article focuses on highlighting the agenda for the 40 Advances in Neonatal and Pediatric Cardiorespiratory Care conference, including discussions led by Donald Null, MD, MBA, Mitchell Goldstein, MD, MBA, CML, and Arun Pramanick, MD.

Communication in healthcare represents the complex interplay between multiple individual and contextual factors unfolding over the course of the medical encounter. Despite significant improvements in patient-centered care delivery, studies of health communication typically focus exclusively on clinical interactions between adult patients and their clinicians. Much less is known about non-dyadic interactions, such as pediatric triads involving a child patient and accompanying parent. Understanding the dynamics of triadic pediatric healthcare communication is the first step toward evaluating and ultimately optimizing these healthcare interactions. Thus, we undertook a mixed-method analysis of 28 audio-recorded triadic medical interactions between healthcare providers, pediatric asthma and allergy patients, and their parents to explore the prevalence of various features of these interactions. Our findings point to mechanisms through which healthcare providers and parents may facilitate or hinder children's involvement in their own asthma and allergy care, including interruptions, unclarified technical medical language, the flow of information exchange, and the formation of dyadic conversational partnerships (coalitions) between providers and parents. Our analyses further reveal that children's participation during their medical visits was minimal (13% of the interaction). Providers in our sample elicited input directly from pediatric patients more often than from parents, though the difference was small. Taken together, these findings provide a foundation on which to develop training and communication interventions to ensure that children have a voice in their medical care. [ABSTRACT FROM AUTHOR]

PURPOSE To understand clinician and clinical staff perspectives on the implementation of routine Adverse Childhood Experience (ACE) screening in pediatric primary care. METHODS We conducted a qualitative evaluation in 5 clinics in Los Angeles County, California, using 2 rounds of focus group discussions: during an early phase of the initiative, and 7 months later. In the first round, we conducted 14 focus group discussions with 67 participants. In the second round, we conducted 12 focus group discussions with 58 participants. Participants comprised clinic staff involved in ACE screening, including frontline staff that administer the screening, medical clinicians that use screening to counsel patients and make referrals, and psychosocial support staff who may receive referrals. RESULTS Themes were grouped into 3 categories: (1) screening acceptability and perceived utility, (2) implementation and quality improvement, and (3) effects of screening on patients and clinicians. Regarding screening acceptability and perceived utility, clinicians generally considered ACE screening to be acceptable and useful. In terms of implementation and quality improvement, significant barriers included: insufficient time for screening and response, insufficient training, and lack of clarity about referral networks and resources that could be offered to patients. Lastly, regarding effects of screening, clinicians expressed that ACE screening helped elicit important patient information and build trust with patients. Further, no adverse events were reported from screening. CONCLUSIONS Clinic staff felt ACE screening was feasible, acceptable, and beneficial within pediatric care settings to improve trauma-informed care and that ACE screening could be strengthened by addressing time constraints and limited referral resources. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Infant well-child visits are increasingly being explored as opportunities to address parental postpartum health needs, including those related to reproductive health. To inform potential pediatric clinic-based interventions, this study assessed postpartum contraceptive needs and health services preferences. METHODS: We surveyed postpartum individuals attending 2 to 6-month well-child visits at three Northern California pediatric clinics (2019--20). We examined unmet contraceptive needs; the acceptability of contraceptive education, counseling, and provision at well-child visits; and sociodemographic and clinical correlates. We conducted univariate and multivariable regression modeling to assess associations between sociodemographic and clinical variables, the status of contraceptive needs, and acceptability measures. RESULTS: Study participants (n = 263) were diverse in terms of race and ethnicity (13% Asian, 9% Black, 37% Latinx, 12% Multi-racial or Other, 29% White), and socioeconomic status. Overall, 25% had unmet contraceptive needs. Unmet need was more common among participants who had delivered more recently, were multiparous, or reported ≥ 1 barrier to obtaining contraception; postpartum visit attendance, education, race, and ethnicity were not associated with unmet need. Most participants deemed the following acceptable in the pediatric clinic: receiving contraceptive information (85%), discussing contraception (86%), and obtaining a contraceptive method (81%). Acceptability of these services was greater among participants with unmet contraceptive needs, better self-rated health, and private insurance (all P < .05). CONCLUSIONS: A quarter of participants had unmet contraceptive needs beyond the early postpartum period. Most considered the pediatric clinic an acceptable place to address contraception, suggesting the pediatric clinic may be a suitable setting for interventions aiming to prevent undesired pregnancies and their sequelae. [ABSTRACT FROM AUTHOR]

Objective: Eating disorders are serious psychiatric conditions predominantly affecting children, adolescents, and young adults. While family‐based treatment (FBT) is the gold standard outpatient treatment approach for adolescents with restrictive eating disorders, there is not a universally recognized best practice within higher levels of care. There is a particular dearth of literature detailing recommended psychological and behavioral interventions in the inpatient medical setting. Method: The present article provides an account of how FBT principles have been incorporated in Children's Hospital of Orange County at Mission's inpatient medical stabilization program for children and adolescents with restrictive eating disorders. Practical examples illustrate how key FBT tenets are successfully translated into the inpatient multidisciplinary setting. Results: The use of FBT can encourage a unified approach among medical and psychosocial providers and serves to destigmatize patients with eating disorders and associated behaviors. The successes and challenges of FBT implementation are discussed. Discussion: Though anecdotal evidence and preliminary findings support positive outcomes from the implementation of FBT within a pediatric medical stabilization program for patients, families, and staff, research is needed to understand best practices within higher levels of care. Additional research efforts will also help elucidate whether adapted FBT can become a standard of care for patients with restrictive eating disorders in inpatient settings. Public Significance: This article describes how a children's hospital has adopted family‐based treatment (FBT) for youth who are hospitalized due to an eating disorder. FBT is the most efficacious treatment for youth with eating disorders. This article describes specific examples of how FBT can be implemented within a medical setting. This article will support a greater understanding of FBT principles and guide providers to translate FBT into higher level of care settings. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Acute agitation episodes in the emergency department (ED) can be distressing for patients, families, and staff and may lead to injuries. We aim to understand availability of ED resources to care for children with acute agitation, perceived staff confidence with agitation management, barriers to use of de-escalation techniques, and desired resources to enhance care. METHODS: We conducted a survey of pediatric emergency care coordinators (PECCs) in EDs in Massachusetts, Rhode Island, and Los Angeles County, California. RESULTS: PECCs from 63 of 102 (61.8%) EDs responded. PECCs reported that ED staff feel least confident managing agitation due to developmental delay (DD) or autism spectrum disorder (ASD) (52.4%). Few EDs had a separate space to care for children with mental health conditions (22.5%), a standardized agitation scale (9.6%), an agitation management guideline (12.9%), or agitation management training (24.2%). Modification of the environment was not perceived possible for 42% of EDs. Participants reported that a barrier to the use of the de-escalation techniques distraction and verbal de-escalation was perceived lack of effectiveness (22.6% and 22.6%, respectively). Desired resources to manage agitation included guidelines for medications (82.5%) and sample care pathways (57.1%). CONCLUSIONS: ED PECCs report low confidence in managing agitation due to DD or ASD and limited pediatric resources to address acute agitation. Additional pediatric-specific resources and training, especially for children with DD or ASD, are needed to increase clinician confidence in agitation management and to promote high-quality, patient-centered care. Training programs can focus on the early identification of agitation and the effective use of non-invasive de-escalation strategies. [ABSTRACT FROM AUTHOR]

The article discusses the iCAN (International Children's Advisory Network) annual summit to be held in San Diego, California from July 10-14, 2023.

Objective: Cardiopulmonary bypass (CPB) is a requisite for correction of congenital heart disease by open-heart surgery and induces a systemic inflammatory response that can lead to complications such as acute lung injury and acute kidney injury. In addition, blood transfusions are commonly required for this type of surgery, and they may further exacerbate this inflammatory response and increase morbidity and mortality. We hypothesized that, in contrast to red blood cells, intraoperative cell saver (CS) blood transfusions attenuate the post-CPB proinflammatory cytokine response. Methods: Serum cytokine concentrations of IL-10, IL-1RA, IL-6, IL-8, and TNF-α were measured at four time points (preoperatively and postoperatively on postoperative days 0, 1, and 2). Results: Anti-inflammatory IL-10 levels were significantly lower in the CS group on POD 0 than in the control group (mean 1083.2 pg/mL vs 2080.2 pg/mL, 95%CI 357.4–1636.6, p =.0026). Of the clinical parameters measured, mean BUN and creatinine levels on POD 2 were significantly lower in the CS group (13.79 vs 21.88, p =.004 and 0.45 vs 0.55, p =.055, respectively). In addition, the duration of milrinone use decreased by 80% in the CS group (0.20, 95%CI 0.04, 0.94; p =.048), the median time to extubation in hours was significantly lower in the CS group (3.5 vs 6.5; 95%CI −38.00, −0.50; p =.026), and hospital length of stay was decreased by 60% in the CS group (p =.003). Conclusions: CS transfusions in children may lower postoperative anti-inflammatory IL-10 levels, possibly due to an overall decrease in proinflammatory state, and may be associated with improvements in renal and pulmonary functions. [ABSTRACT FROM AUTHOR]

Kidney transplantation in pediatric patients can lead to partial improvement of some of the cardiometabolic parameters that increase the risk for cardiovascular disease (CVD) in patients with chronic kidney disease. However, even after restoration of kidney function, transplant recipients remain at risk for CVD due to the continual presence of traditional and non-traditional risk factors, including the side effects of immunosuppression and chronic inflammation. This educational review describes the prevalence of CVD risk factors in pediatric kidney transplant recipients and presents available evidence for therapeutic lifestyle changes and other non-pharmacologic strategies that can be used to improve traditional and modifiable CVD risk factors. Although trial-grade evidence for interventions that improve CVD in pediatric kidney transplant recipients is limited, potential strategies include lowering dietary sodium and saturated fat intake and increasing physical activity levels. Intensive follow-up may help patients achieve guideline-recommended goals for reducing their overall CVD risk. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The emergency department (ED) is a demanding environment, and critical events have been identified as contributors to stress. Debriefing is a possible intervention for staff, but there is little information regarding formulation and implementation. A needs assessment was conducted to describe the emotions of pediatric ED (PED) staff following critical events and assess opinions regarding debriefing. METHOD: This mixed methods study used convergent design for triangulation. After critical cases, PED staff members were given the Peritraumatic Distress Inventory (PDI). Additionally, a questionnaire with 2 open-ended questions on debriefing was administered. Themes were extracted from the questionnaire using directed content analysis. RESULTS: A total of 719 responses were collected for 142 critical cases. Physical reactions were often endorsed in the PDI, and these reactions were mirrored in the qualitative data, which included physiological responses such as stress, adrenaline high, anxiety, fatigue, and overwhelm. Helplessness and grief were 2 of the emotional PDI items frequently endorsed, which were reflected in the qualitative strand by themes such as helplessness, sadness, disheartenment, and regret. There was considerable variability between critical cases such that not every critical case elicited a desire for a debrief. CONCLUSIONS: PED staff report measurable levels of stress after critical patient cases that warrant follow-up. Formal debriefing immediately after critical patient cases with specific caveats may be valuable for the reduction of stress. Any formal debriefing program will need to balance various goals with attention to the session length, setting, and timing. [ABSTRACT FROM AUTHOR]

The article reports that mindfulness, therapy, and schedule changes have shown small benefits but require learning a new skill, significant institutional resources, or organizational change. Topics include examines ability to safely participate in many group or self-care activities has been limited by the recent COVID-19 pandemic.

220 Background: Personal costs of childhood cancer can contribute to disparities in health outcomes. The purpose of ACCL20N1CD is to examine trajectories of parental costs and the associated financial distress, cost coping behaviors, and household material hardships (HMH) during treatment for pediatric ALL. Objective is to report baseline characteristics of the parents and their households. Methods: The study used a prospective cohort design with repeated measures. Setting was Children's Oncology Group (COG) practices at National Cancer Institute Community Oncology Research Program (NCORP) institutions. Parents who use English or Spanish, and have children newly diagnosed with ALL treated at COG NCORP practices were eligible. Parents were asked to complete surveys at 3 time points, including baseline (T1; during induction and <7 days after planned induction remission evaluation). Surveys included items about (a) parent socio‐economic status, financial distress measured by 8-item Personal Wellness Scale (PFWS), and cost coping behaviors, and (b) HMH. Factors related to high PFWS scores were evaluated by logistic regression. Results: Of 104 evaluable parents, most were female (83.7%), white (65.4%), non-Hispanic (48.1%), partnered (79.8%), > high school diploma (93.3%), used English (84.6%), worked full (48.1%) or part (5.8%) time, and paid for their child's care with public insurance (57.7%). Median household income=$50,000 (Inter-Quartile Range/IQR 20,000-100,000) for 4 (IQR 4-5) people. Not including wages lost due to caregiving, out of pocket payments for medical care + other ALL-related costs in the prior month >15% of monthly income for 51.9% of households, which is considered financially catastrophic. 24.0% of households lacked food stability; 21% had housing insecurity. Conclusions: At baseline, sizeable proportions of parents exhibit high out of pocket costs, high financial distress level, and multiple cost coping behaviors with implications for future health and individual and household quality of life. [ABSTRACT FROM AUTHOR]

Delayed medical care is a negative consequence of the COVID-19 pandemic for families with young children. Our study used data from the Accessing California Communities' Experiences with Safety net Supports (ACCESS) survey, a cross-sectional study that assessed experiences with safety-net programs among working families with low incomes (n=491). From August 2020 to May 2021, we conducted interviewer-administered surveys of low-income families with young children (ages zero to eight) in California and asked questions about whether participants had delayed medical care for their children or themselves. We found that delaying care for children was associated with lack of childcare and with the child having pre-existing conditions. Delaying parental medical care was associated with lack of childcare, experiences of racism, government mistrust, and perceptions of welfare stigma. These results suggest that health care access may be improved through a focus on supporting childcare systems and addressing structural racism. [ABSTRACT FROM AUTHOR]

Objective: Racial/ethnic minority pediatric otolaryngology patients experience health disparities, including barriers to accessing health care. Our hypothesis for this study is that Hispanic or economically disadvantaged patients would represent a larger percentage of missed appointments and report more barriers to receiving care during the COVID-19 pandemic. Methods: A cross-sectional survey utilizing a modified version of the Barriers to Care Questionnaire was administered via telephone to no-show patients, and median income by zip code was collected. Chi-squared, logistic regression, and Student's t-tests were used to investigate any differences in those who did and did not keep their appointments as well as any differences in mean questionnaire scores. Results: No-show patients were more likely to be Hispanic than not (OR 2.3, 95% CI: 1.3, 3.9, P = .002) and to live in a zip code that had a median income less than 200% of the federal poverty level (OR 1.7, 95% CI: 1.2, 2.4, P = .004). Respondents with a high school degree tended to report more barriers to care compared to those with less education. Conclusion: In our study, we identified ethnic, financial, and logistic concerns that may contribute to patients failing to keep their appointments with the otolaryngology clinic. Future studies are needed to assess the efficacy of measures aimed to reduce these barriers to care such as preventive plans to assist new patients and expanding telehealth services. [ABSTRACT FROM AUTHOR]

Families of children receiving palliative care depict lack of respite services as a top unmet need. Although the benefits of access to respite services are notable, little is known on a state-by-state basis about respite provision or funding. The study objective was to conduct a national evaluation of pediatric respite care programs to identify and describe how states provide and fund respite care for children. The study approach adhered to the Scale for the Assessment of Narrative Review Articles quality standards using multiple data sources including engagement with the existing literature, content analyses of public-facing websites, and conversations with 40 stakeholders from 15 states. States offered respite services in a variety of ways: Medicaid waivers used to fund respite care, state-funded programs that provide respite, and philanthropy-based respite facilities. This narrative review revealed the creativity involved in different settings to improve respite access, staffing, and reimbursement. Suggestions to address the unmet respite needs of families included establishing a respite home, improving Medicaid reimbursement, expanding Medicaid waiver eligibility, providing a respite benefit through Medicaid, implementing nursing workforce initiatives, and centralizing staffing databases. [ABSTRACT FROM AUTHOR]

Objective: This study identifies risk factors for late positional plagiocephaly (PP) diagnosis and impact on helmet therapy., Design: We conducted a retrospective review of all patients diagnosed with PP over 10 years at five Southern California hospitals., Setting: Patients diagnosed with PP at an included hospital., Patients: 25,332 patients were diagnosed with PP over 10 years., Interventions: Patients diagnosed with PP early (< = 6 months) and late (>6 months) were compared., Main Outcome Measures: Cohorts were evaluated for demographics, gestational history, associated conditions, and hospitalizations through direct comparison, logistic regression, and correlation analyses. Rates of referrals and helmet orders were compared., Results: Of patients reviewed, 4.8% (n  =  1216) were diagnosed late. On multivariate analysis, late diagnoses were more likely Hispanic or Black/African-American. Early gestational age, hydrocephalus, and VP shunt were more frequent in late diagnoses. Patients diagnosed late had longer NICU and overall hospital stays. Earlier gestational age, longer NICU or overall hospital stay correlated with later age at PP diagnosis. 8.9% of patients were referred for helmet therapy evaluation. Patients diagnosed late were 2.63 and 1.64 times as likely to be referred and require helmet therapy, respectively., Conclusions: Patients who are Hispanic or Black/African-American, premature, have hydrocephalus, or VP shunt have higher rates of delayed PP diagnosis. Shorter gestational age or longer NICU or hospital stay correlates with later diagnosis, which increases helmet therapy requirements. Additional interventions are needed for at risk patients to routinely evaluate for and minimize the risk of developing PP., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: The purpose of this study was to compare three models of pediatric physiatry care (in-person, hybrid, and all-virtual) in terms of parent experience and physician- and therapist-reported quality of care. We hypothesized that the all-virtual model would have lower parent experience scores and lower quality scores compared with the other two models of care., Methods: We designed a convergent parallel mixed methods study incorporating a cluster-randomized crossover design. Quantitative data included surveys of parents, physicians, and therapists after visits to 13 medical therapy units in Northern California between January 2020 and January 2022. Qualitative data were collected in six focus groups with parents, physicians, and therapists., Results: A total of 2455 visits were completed for 1281 unique children during the study period, including 507 in-person visits, 246 hybrid visits, and 1702 all-virtual visits. There were no differences in parent experience scores between the three models of care. Physicians and therapists rated all-virtual visits significantly lower in terms of quality of care, parent education, and physical exam, compared with the other two models of care, but qualitative results highlighted specific instances where all-virtual visits could be useful., Conclusions: Our findings suggest that parents, therapists, and physicians find a hybrid virtual model is an acceptable model of care that maintains the quality of care and facilitates parent education. All-virtual models may be appropriate for specific circumstances but are perceived as lower quality. Research exploring implementation of these models would be valuable for providing practical guidance in the future., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: This study examined atypical antipsychotic prescribing by Food and Drug Administration (FDA) approved-use (on-label) status for adolescents before and during the COVID-19 pandemic., Methods: Retrospective data were collected from electronic health records (EHRs) of adolescents aged 10-17 years in Kaiser Permanente Northern California. New outpatient atypical antipsychotic prescription orders during 2013-2021 were evaluated. Prescriptions were categorized as on-label if linked in EHRs to autism, psychosis, bipolar disorder, or Tourette's diagnoses; otherwise, they were potentially off-label (herein, off-label). Trend analysis of monthly prescribing rates assessed slope change at pandemic onset for the cohort and by sex and age groups., Results: Among 5828 patients, 74.5% of new antipsychotic orders were off-label in 2021. Overall prescribing decreased significantly until early 2020 (slope = -0.045, P < .01) but then significantly increased through 2021 (post-March 2020 slope change = 0.211, P = .01). Off-label prescriptions increased at a similar rate during the COVID-19 time period, but on-label prescriptions did not change significantly. Males and younger adolescents (ages 10-14 years) showed significant decreases until early 2020, while females and older adolescents (ages 15-17 years) did not. Females and younger adolescents exhibited significant increases in overall and off-label prescribing rates following pandemic onset; older adolescents exhibited increases in overall prescriptions while males had no detectable changes., Conclusions: Antipsychotic prescribing declined slightly but then increased significantly following COVID-19 onset for overall and off-label prescriptions. Pandemic onset differentially impacted antipsychotic prescribing by sex and age, with overall and off-label prescribing driven by increases among female and younger adolescents., Competing Interests: Declaration of Competing Interest Dr. Costales reports grant support from the National Institute of Mental Health (T32MH125792) during the conduct of this study. Dr. Penfold reports receiving research funding to his institution from Janssen Research & Development, Otsuka Pharmaceuticals, and SAGE Therapeutics., (Copyright © 2024 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

An editorial is presented on Acute Disease Quality Initiative (ADQI) has a more than two-decade legacy. Topics include relates to the current state of practice of diagnosis and management of acute kidney injury and other conditions in critical care nephrology; and have a focus on AKI education in resource-plentiful and resource-challenged areas.

Neuromonitoring has become more standardized in adult neurocritical care, but the utility of different neuromonitoring modalities in children remains debated. We aimed to describe the use of neuromonitoring in critically ill children with and without primary neurological diseases. We conducted a retrospective review of patients admitted to a 32-bed, non-cardiac PICU during a 12-month period. Neuro-imaging, electroencephalogram (EEG), cerebral oximetry (NIRS), automated pupillometry, transcranial doppler (TCD), intracranial pressure (ICP) monitoring, brain tissue oxygenation (PbtO2), primary diagnosis, and outcome were extracted. Neuromonitoring use by primary diagnosis and associations with outcome were observed. Of 1946 patients, 420 received neuro-imaging or neuromonitoring. Primary non-neurological diagnoses most frequently receiving neuromonitoring were respiratory, hematologic/oncologic, gastrointestinal/liver, and infectious/inflammatory. The most frequently used technologies among non-neurological diagnoses were neuro-imaging, EEG, pupillometry, and NIRS. In the multivariate analysis, pupillometry use was associated with mortality, and EEG, NIRS, and neuro-imaging use were associated with disability. Frequencies of TCD and PbtO2 use were too small for analysis. Neuromonitoring is prevalent among various diagnoses in the PICU, without clear benefit on outcomes when used in an ad hoc fashion. We need standard guidance around who, when, and how neuromonitoring should be applied to improve the care of critically ill children. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To explore pediatric residents' perspectives on humanism and how residency impacts humanism formation. METHODS: We conducted a qualitative study with pediatric resident focus groups at Stanford. Transcripts were analyzed by two investigators using grounded theory. Subsequent literature review led us to adapt Cruess et al. 2015's professional identity formation framework to describe development of a humanism identity in residency. Member check was done to verify themes and the adapted framework. RESULTS: Thirty two pediatric residents participated. Five themes emerged: 1) Empathy, compassion, and respect are foundational elements of humanism. 2) Each resident had a unique view of humanism derived from personal values. 3) Residents felt that the terms excellence and resilience (Gold Foundation IECARES model) did not fit with their own definitions. 4) Residents felt that humanism is a central part of their practice and training. 5) The demands, structure, and culture of residency were often in conflict with promoting humanism in residents. Based on residents' perspectives, we modified the professional identity formation and socialization conceptual framework proposed by Cruess et al. 2015 to reflect humanism identity formation during pediatrics residency. The new framework emphasizes the increased power of the healthcare system and unconscious acquisition on humanism formation in residency as compared to medical school. CONCLUSIONS: Residents believe that humanism is a core part of practicing medicine and should be reinforced during residency training. Cruess' professional identity and socialization framework is a tool for a better understanding of the complexity of humanism development in residency. [ABSTRACT FROM AUTHOR]

The article focuses on California's expansion of funding for children's hospitals, aimed at enhancing healthcare services for critically ill children across the state. It mentions this initiative, supported by Governor Gavin Newsom and the California Children's Hospital Association, seeks to provide additional financial support to ensure better medical care for children facing severe and life-threatening illnesses, thereby avoiding the need for a costly ballot initiative.

Background: Health care disparities have been highlighted in pediatric sports medicine, but the association between insurance status and delayed care for patients undergoing surgery for patellar instability has not been defined. Purpose: To determine whether there is an association between insurance status and delays in care in pediatric and adolescent patients undergoing surgery for patellar instability. Study Design: Cohort study; Level of evidence, 3. Methods: This was a retrospective case series at a safety-net tertiary referral center of pediatric and adolescent patients undergoing surgical treatment for patellar instability. Insurance status was classified as public or private. We calculated the times from injury to clinical evaluation, injury to magnetic resonance imaging (MRI), injury to surgery, clinical evaluation to MRI, and clinical evaluation to surgery. Comparisons were made between insurance groups. Results: Included were 78 patients (38 public, 40 private insurance) who underwent surgery for patellar instability. The public insurance group was older (P =.019), with a lower proportion of White patients (15.8% vs 52.5%; P =.0005), higher proportion with Hispanic ethnicity (55.3% vs 15.0%; P =.0001), and higher proportion of Spanish-speaking patients (21.1% vs 2.5%; P =.007). Publicly insured patients had longer times from initial injury to clinical evaluation (466 vs 77 days; P =.002), MRI (466 vs 82 days; P =.003), and surgery (695 vs 153 days; P =.0003), as well as a longer time from clinical evaluation to surgery (226 vs 73 days; P =.002). Multivariable models confirmed insurance status as an independent predictor in each of the identified delays. Conclusion: Significant delays were seen for pediatric and adolescent patients with patellar instability and public insurance (approximately 6 times longer to clinical evaluation, more than 5.5 times longer to obtain MRI, and 4.5 times longer to surgery) relative to injured patients with private insurance. Even after adjusting for delays to clinical evaluation, publicly insured patients had a delay from clinic to surgery that was triple that of privately insured patients. [ABSTRACT FROM AUTHOR]

BACKGROUND: Outcome and utilization quality measures are adjusted for patient case-mix including demographic characteristics and comorbid conditions to allow for comparisons between hospitals and health plans. However, controversy exists around whether and how to adjust for social risk factors. OBJECTIVE: To assess an approach to incorporating social risk variables into a pediatric measure of utilization from the Pediatric Quality Measures Program (PQMP). METHODS: We used data from California Medicaid claims (2015-16) and Massachusetts All Payer Claims Database (2014-2015) to calculate health plan performance using measure specifications from the Pediatric Asthma Emergency Department Use measure. Health plan performance categories were assessed using mixed effect negative binomial models with and without adjustment for social risk factors, with both models adjusting for age, gender and chronic condition category. Mixed effects linear models were then used to compare patient social risk for health plans that changed performance categories to patient social risk for health plans that did not. RESULTS: Of 133 health plans, serving 404,649 pediatric patients with asthma, 7% to 13% changed performance categories after social risk adjustment. Health plans that moved to higher performance categories cared for lower socioeconomic status (SES) patients whereas those that moved to lower performance categories cared for higher SES patients. CONCLUSIONS: Adjustment for social risk factors changed performance rankings on the PQMP Pediatric Asthma Emergency Department Use measure for a substantial number of health plans. Some health plans caring for higher risk patients performed more poorly when social risk factors were not included in risk adjustment models. In light of this, social risk factors are incorporated into the National Quality Forum-endorsed measure; whether to incorporate social risk factors into pediatric quality measures will differ depending on the use case. [ABSTRACT FROM AUTHOR]