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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 were3 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.

Psychoeducation, where clinicians teach problem-solving skills in a supportive environment, can help address families’ social vulnerabilities and promote well-being. Group well-child care (GWCC) may provide unique opportunities for pediatric residents to improve their skills in psychoeducation. Our aim was to characterize pediatric residents’ perspectives and experiences of communication while conducting both individual well-child care and GWCC. We used a longitudinal qualitative study design to conduct 15 semistructured interviews with five pediatric residents who facilitated GWCC. Using the constant comparative method, we characterized pediatric residents’ perspectives and experiences of communication while conducting both individual well-child care and GWCC. Four themes emerged. Residents perceived that GWCC (i) enabled families to honestly share their knowledge and parenting practices, (ii) allowed time and a space for families to share personal stories and scenarios, (iii) facilitated discussions of maternal health and psychosocial matters, toward which residents felt ambivalence, and (iv) fostered skills in psychoeducation that transferred to the rest of their clinical practice. When pediatric residents lead GWCC, they perceive that they can facilitate key aspects of psychoeducation, enabling them to assist families in meeting complex social needs. Residents describe that they transfer psychoeducation skills learned in GWCC to the rest of their practice.

BACKGROUND AND OBJECTIVESChildren in families facing energy insecurity have greater odds of poor health and developmental problems. In this study of families who requested and received medical certification for utility shut-off protection and were contacted by our Medical Legal Partnership (MLP), we aimed to assess concurrent health-related social needs related to utilities, housing, finances, and nutrition.METHODSAfter medical certificates were completed at our academic pediatric center, our MLP office contacted families and assessed utility concerns as well as other health, social, and legal needs. In this observational study, we present descriptive analyses of patients who received certificates from September 2019 to May 2020 via data collected through the MLP survey during the coronavirus disease 2019 pandemic (June 2020–December 2021).RESULTSOf 167 families who received utility shut-off protection from September 2019 to May 2020, 84 (50.3%) parents and guardians were successfully contacted. Most (93%) found the medical certificate helpful. Additionally, 68% had applied for Energy Assistance, and 69% reported they were on utility company payment plans. Most (78%) owed arrearages, ranging from under $500 to over $20 000, for gas, electric, and/or water bills. Food, housing, and financial insecurity screening positivity rates were 65%, 85%, and 74%, respectively.CONCLUSIONSPatients who were contacted by an MLP after receiving medical certification for utility shutoff protection were found to have challenges paying for utilities and faced multiple food, housing, and financial stressors. Through consultation and completion of medical forms for utility shutoff protection, pediatricians and MLPs can provide resources and advocacy to support families’ physical, emotional, and psychosocial needs.

To evaluate the Healthy Eating through Group Well-Child Care (GWCC) intervention, a 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.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 semi-structured 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.Using EHR data from 279 GWCC and 6,134 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.A primary careWIC 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.

Objective Families, pediatric providers, and service systems would benefit from expanded knowledge regarding (1) who is most likely to receive a recommended diagnostic evaluation after a positive primary care-administered autism screen and (2) of those who screen positive, who is most likely to be diagnosed with autism? Method Participants included 309 predominantly low-income, racial/ethnic minority parents and their child, aged 15 to 27 months, who screened positive on the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F). Generalized estimating equations were used to fit models of predictors for each binary outcome: receiving a diagnostic evaluation and receiving an autism diagnosis on evaluation. Results Significant predictors of diagnostic evaluation receipt included the parent being older or non-Hispanic and the child having private insurance, lower child communication functioning, or receiving Early Intervention services. Significant predictors of an autism diagnosis on evaluation included male child, lower child communication functioning, screening directly in the parent's preferred language, White/non-Hispanic parent, and no parent history of mood disorder. Conclusion Children with younger parents, Hispanic ethnicity, relatively higher communication skills, public insurance, and no Early Intervention services were less likely to receive recommended diagnostic care. Reduced likelihood of autism diagnosis after a positive screen in non-White/non-Hispanic subgroups supports previous research indicating issues with M-CHAT-R/F positive predictive power for racial/ethnic minorities. The use of telephonic interpreters to administer screens, as opposed to directly screening in families' preferred languages, may lead to identification of fewer true autism cases. Thus, multilingual clinical staff capacity may improve positive predictive power of autism screening.

Parents of children with autism spectrum disorder (ASD) show increased levels of parenting stress, but only one study has examined this association before a diagnostic evaluation. We conducted a cross-sectional study of parenting stress in 317 low SES parents with children at-risk for ASD before a diagnostic evaluation. Multiple regression modeling evaluated the associations between parenting stress and parent and child factors. Parenting stress was negatively associated with social support and positively associated with active avoidance coping and parental worry. However, parenting stress was not associated with the child’s ASD symptom severity or adaptive functioning, except for self-direction. Findings suggest parenting stress among parents of children at risk of ASD should be assessed prior to diagnosis.

Racially and ethnically diverse young children who live with socioeconomic adversity are at high risk for sleep deficiency, but few behavioral sleep interventions (BSIs) are tailored to their needs. To support the future development of a feasible, acceptable, and culturally relevant sleep intervention, we conducted a community-engaged, mixed-methods study with 40 low-income, racially and ethnically diverse parents to describe sleep characteristics, sleep habits, and parental sleep knowledge of their 6–36 month-old children and to examine the associations between children’s sleep characteristics and sleep habits. This report presents the quantitative data from this mixed methods study. We measured objective (actigraphy) and parent-reported sleep (Brief Infant Sleep Questionnaire) characteristics, sleep habits at bedtime, sleep onset, and during night awakenings, parental sleep knowledge (Parental Sleep Knowledge), psychological function (Brief Symptom Inventory), and parenting stress (Parenting Stress Index). Children had low sleep duration (537.2 ± 54.7 nighttime and 111.2 ± 29.8 nap minutes), late bedtimes (22:36 ± 1.5 hours), and high bedtime variability (mean squared successive difference = 3.68 ± 4.31 hours) based on actigraphy. Parental knowledge about sleep recommendations was limited. Sleep habits before bedtime, at sleep onset, and during night awakenings were varied. Sixty-five percent of parents reported co-sleeping. Feeding near bedtime or during the night was associated with later bedtimes, more fragmented sleep, and increased bedtime variability. These findings suggest the need for BSIs to support earlier bedtimes and improve sleep duration and continuity by addressing modifiable behaviors. Tailored BSIs that consider socioecological influences on the development of sleep habits are needed.

Well-child care has suboptimal outcomes regarding adherence to appointments and recall of guidance, especially among families facing structural barriers to health. Group well-child care (GWCC) aims to improve these outcomes by enhancing anticipatory guidance discussions and peer education. We conducted a randomized controlled trial, comparing GWCC with traditional, individual well-child care (IWCC) and assessed health care utilization, immunization timeliness, recall of anticipatory guidance, and family-centered care. Ninety-seven mother-infant dyads were randomized to GWCC or IWCC. Compared with IWCC infants, GWCC infants attended more of the 6 preventive health visits (5.41 vs 4.87, P < .05) and received more timely immunization at 6 months and 1 year but did not differ in emergency or hospital admission rates. There were no differences in mothers’ reports of anticipatory guidance received or family-centered care. As primary care is redesigned for value-based care and structural vulnerabilities are considered, GWCC may be a key option to consider.

Asthma health disparities are widely recognized, with worse outcomes in children from low income families. In a Medical-Legal Partnership (MLP), an attorney is embedded in a healthcare setting to address social determinants of health. We studied whether an MLP could impact asthma exacerbation rates in a vulnerable urban population at an academic children's hospital.The study population comprised children with asthma who were referred to the MLP between 2013 and 2017. We compared healthcare utilization for asthma exacerbations managed in primary care, emergency department and inpatient settings in the year before and year after MLP intervention.98 children with asthma were included in the study. The mean total encounters per person per year decreased from 1.16 to 0.66 (relative reduction 44.2%,In a pediatric population with asthma, an MLP intervention was associated with a significant reduction in asthma exacerbation encounters and hospitalizations comparing the year before and after MLP intervention. Further studies are needed to better understand which interventions are most effective, and for which patient groups MLP referral would be particularly useful. MLPs may be an important way to reduce health disparities in patients with asthma and other chronic illnesses.

Physician burnout impacts all levels of medical education and has a relatively unknown impact on those responsible for medical student education, particularly in paediatrics. This study examines the prevalence of burnout among paediatric undergraduate medical educators and explores the impact of roles in medical education on medical educator burnout.This cross-sectional mixed-methods study utilised a binational survey of paediatricians involved in undergraduate medical education. Respondents answered demographics, standardised questions about burnout and attitudes towards students, and an open-ended probe about interactions between medical student education and wellness.Of 445 possible, 120 (26.9%) responded to demographic and burnout questions. Of these, 23.3% endorsed burnout, 21.7% high emotional exhaustion (EE) and 10.8% high depersonalisation (DP). High levels of student-related burnout symptoms were reported by fewer than 5% of respondents and were correlated with overall EE and DP. Content analysis revealed four emergent themes: positive effect of student-related role, need to balance medical education and clinical roles, impact of protected time and medical education-related autonomy on educator well-being, and the burden of the administrative portion of educational roles.Participating paediatric educators had low rates of burnout compared with paediatricians as a whole in prior studies. The vast majority found working with students rewarding and described the overall positive impact of their medical education role on wellness.Physician involvement in rewarding non-clinical activities may improve their overall well-being. Providing dedicated time for these activities may ameliorate the difficulty that many medical educators described in balancing their clinical and educational roles. Future studies should continue to explore how we can better support medical educators and the impact of this support on burnout.

Objective Alternative primary care structures such as group well-child care (GWCC) may enhance care for families, particularly those subject to structural vulnerabilities such as poverty or restrictive immigration policies. The purpose of this study was to characterize how group dynamics in GWCC impact the perceptions of low-income, immigrant, and/or Spanish-speaking parents of health services. Methods Using Spanish and English interview guides that were conceptually identical, we conducted semi-structured interviews with parents who elected to participate in GWCC at an urban academic center. We drew from directed content analysis, grounded theoretically in the Andersen model of health services utilization. Modeling a bilingual, multicultural analytic strategy, we preserved the narrative of participants in the source language through all stages of analysis. Results From March through August 2017, we interviewed 22 caregivers in their preferred language. Most (82%) were mothers and half spoke Spanish only. Three themes emerged: participants perceived that (1) GWCC facilitates their and their peers' discovery of inherent expertise, which moderates parents' use of health services, (2) GWCC encourages rearrangements of hierarchies of knowledge, professional roles and genders; and (3) in the context of structural vulnerabilities, relationships formed in GWCC facilitate collective efficacy. Conclusions for Practice By considering the self and peer as sources of health-related expertise, GWCC may extend current theoretical models of health services utilization. GWCC provides opportunities to impact health services utilization among families subject to structural vulnerabilities.

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.

Parents of children with autism spectrum disorder (ASD) show increased levels of parenting stress, but only one study has examined this association before a diagnostic evaluation. We conducted a cross-sectional study of parenting stress in 317 low SES parents with children at-risk for ASD before a diagnostic evaluation. Multiple regression modeling evaluated the associations between parenting stress and parent and child factors. Parenting stress was negatively associated with social support and positively associated with active avoidance coping and parental worry. However, parenting stress was not associated with the child's ASD symptom severity or adaptive functioning, except for self-direction. Findings suggest parenting stress among parents of children at risk of ASD should be assessed prior to diagnosis.

A recent study by the Legal Services Corporation reported that 71% of low-income U.S. households experienced at least one civil legal problem in 2017 and that 86% of these needs went unresolved. In this article, we examine the potential for medical-legal partnerships (MLPs) to address this "justice gap." We draw on qualitative interviews, conducted with 20 parents and guardians in one pediatric MLP, to identify barriers to legal access and examine how the MLP model may uniquely address these barriers. Our data suggest that MLPs can (1) identify legal needs and create awareness of legal rights among individuals who would not have sought legal services; (2) create an access point for legal services; (3) improve access to legal advice and brief intervention; (4) support ongoing relationships between patients and lawyers that allow for the timely identification of subsequent legal needs; (5) foster trust and confidence in the legal system; and (6) address affordability concerns. These findings suggest that by improving access to justice, MLPs can address critical social and legal determinants of health and, ultimately, advance health equity.

Objective To describe the perceptions of (1) parents, childcare, and health care providers regarding sleep health among multiethnic infants and toddlers living with socioeconomic adversity, (2) factors that contribute to sleep health and its consequences, and (3) best ways to promote sleep health in these children. Methods Nested within a larger community-engaged mixed methods study, we used a descriptive qualitative design to describe the experience of multiethnic young parents who were raising 6- to 36-month-old children, pediatric health care providers, and childcare providers living and working in an urban under-resourced community. Semistructured interviews with 25 parents and 16 providers were conducted, transcribed, coded, and analyzed using thematic analysis by a 6-member research team. Interviews continued until themes were saturated. Results Parent responses and provider responses resulted in overlapping and divergent findings. Common themes among all respondents were the importance of sleep, interest and desire for more sleep health information, and common environmental/social impediments to healthy family sleep. Divergent themes included the importance of bedtime routines and timing, views on the family bed, importance of naps, and healthy sleep aids. Childcare centers were suggested as good sites for sleep health promotion programs. Conclusion Sleep is a topic of interest and importance for young families. There are unique family challenges to be considered in any sleep health promotion program tailored to the needs of the community. The voices of parents and community providers are valuable assets informing the development of novel family-friendly approaches for decreasing sleep disparities and improving the health of young children and families.

Increasing use of social networking sites (SNS) among youth prompted professional organizations to urge pediatricians to promote healthy media use. Electronic questionnaires were distributed to 76 pediatric residents at one academic center measuring attitudes, practices, and familiarity with SNS. Of 43 respondents (response rate = 57%), most reported personal SNS use (98%) and familiarity with SNS used by youth (72%), and 88% agreed that pediatricians should provide counseling on SNS use. Only 5% felt they had adequate training on SNS use in children, and just 26% felt comfortable advising families. Residents were less likely to discuss SNS use than general media use (19% vs 56%, P = .007). Media counseling was correlated with SNS counseling ( r = .38, P = .01). Pediatric residents recognize the importance of guiding families on SNS use, yet do not routinely provide counseling despite high levels of personal SNS use and familiarity. Focused training is necessary for pediatricians to prioritize practical guidance.

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.

Little is known about provider beliefs related to sexual and gender minority (SGM) youth, and how these have changed over time. Our objective was to compare pediatric residents’ beliefs and behaviors about SGM youth to historical data. Forty-eight of 76 (63%) residents completed a survey of items drawn from 2 existing scales. Results were compared with historical data from 1998 to 2012. Compared to historical respondents, residents indicated that they were significantly more likely to take a sexual history from patients under 14 years old and ask about sexual orientation. Residents were significantly less likely to fear offending parents or patients with such discussions. While responses indicated SGM-affirming beliefs, 45% of residents felt they may not know enough about SGM needs to have effective discussions, similar to historical respondents. Ongoing challenges include a perceived lack of knowledge about the needs of SGM youth, representing avenues for future educational intervention.

Importance Early identification of autism spectrum disorder (ASD) is associated with improved cognitive and behavioral outcomes. Targeted strategies are needed to support equitable access to diagnostic services to ensure that children from low-income and racial/ethnic minority families receive the benefits of early ASD identification and treatment. Objective To test the efficacy of family navigation (FN), an individually tailored, culturally informed care management strategy, to increase the likelihood of achieving diagnostic ascertainment among young children at risk for ASD. Design, Setting, and Participants This randomized clinical trial of 249 families of children aged 15 to 27 months who had positive screening results for possible ASD was conducted in 11 urban primary care sites in 3 cities. Data collection occurred from February 24, 2015, through November 5, 2018. Statistical analysis was performed on an intent-to-treat basis from November 5, 2018, to July 27, 2020. Interventions Families were randomized to FN or conventional care management (CCM). Families receiving FN were assigned a navigator who conducted community-based outreach to families to address structural barriers to care and support engagement in recommended services. Families receiving CCM were assigned to a care manager, who did limited telephone outreach. Families received FN or CCM after positive initial screening results and for 100 days after diagnostic ascertainment. Main Outcomes and Measures The primary outcome, diagnostic ascertainment, was measured as the number of days from randomization to completion of the child's clinical developmental evaluation, when a diagnosis of ASD or other developmental disorder was determined. Results Among 250 families randomized, 249 were included in the primary analysis (174 boys [69.9%]; mean [SD] age, 22.0 [3.5] months; 205 [82.3%] publicly insured; 233 [93.6%] non-White). Children who received FN had a greater likelihood of reaching diagnostic ascertainment over the course of 1 year (FN, 108 of 126 [85.7%]; CCM, 94 of 123 [76.4%]; unadjusted hazard ratio [HR], 1.39 [95% CI, 1.05-1.84]). Site (Boston, New Haven, and Philadelphia) and ethnicity (Hispanic vs non-Hispanic) moderated the effect of FN (treatment × site interaction; P = .03; Boston: HR, 2.07 [95% CI, 1.31-3.26]; New Haven: HR, 1.91 [95% CI, 0.94-3.89]; and Philadelphia: HR, 0.91 [95% CI, 0.60-1.37]) (treatment × ethnicity interaction; P

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.

There is growing interest in Family Navigation as an approach to improving access to care for children with autism spectrum disorder, yet little data exist on the implementation of Family Navigation. The aim of this study was to identify potential failures in implementing Family Navigation for children with autism spectrum disorder, using a failure modes and effects analysis. This mixed-methods study was set within a randomized controlled trial testing the effectiveness of Family Navigation in reducing the time from screening to diagnosis and treatment for autism spectrum disorder across three states. Using standard failure modes and effects analysis methodology, experts in Family Navigation for autism spectrum disorder (n = 9) rated potential failures in implementation on a 10-point scale in three categories: likelihood of the failure occurring, likelihood of not detecting the failure, and severity of failure. Ratings were then used to create a risk priority number for each failure. The failure modes and effects analysis detected five areas for potential “high priority” failures in implementation: (1) setting up community-based services, (2) initial family meeting, (3) training, (4) fidelity monitoring, and (5) attending testing appointments. Reasons for failure included families not receptive, scheduling, and insufficient training time. The process with the highest risk profile was “setting up community-based services.” Failure in “attending testing appointment” was rated as the most severe potential failure. A number of potential failures in Family Navigation implementation—along with strategies for mitigation—were identified. These data can guide those working to implement Family Navigation for children with autism spectrum disorder.

Beginning early in life, sleep health, including adequate quality, quantity, and consistent sleep routines, is critical to growth and development, behavior, and mental and physical health. Children who live in economically stressed urban environments are at particular risk for sleep deficiency and its negative consequences. Although efficacious sleep health interventions are available, few address the context of economically stressed urban environments. The purpose of this paper is to describe a two-phase protocol for an ongoing NIH/NINR-funded community-engaged study designed to understand the perspectives of parents, community child care and pediatric health care providers about sleep habits, factors that contribute to sleep and sleep habits, sleep difficulty, and potentially useful sleep promotion strategies among children living in economically stressed urban environments. The social-ecological model guides this study. Phase I employs a convergent mixed-methods design, in which we are conducting semi-structured interviews with parents, childcare providers, and primary health care providers. We are collecting nine days of objective sleep data (wrist actigraphy) from children who are 6–18 months (n = 15) and 19-36 months of age (n =15) and parent reports of sleep and sleep-related factors using standard questionnaires. In Phase I, we will use a qualitative descriptive approach to analyze the interview data, and descriptive statistics to analyze the survey and actigraph data. In Phase II, we will use the information to develop a contextually relevant program to promote sleep health. Our long-term goal is to improve sleep health and sleep-related outcomes in these children.

Public health crises in primary care and psychiatry have prompted development of innovative, integrated care models, yet undergraduate medical education is not currently designed to prepare future physicians to work within such systems. To implement an integrated primary care–psychiatry clerkship for third-year medical students. Undergraduate medical education, amid institutional curriculum reform. Two hundred thirty-seven medical students participated in the clerkship in academic years 2015–2017. Educators in psychiatry, internal medicine, and pediatrics developed a 12-week integrated Biopsychosocial Approach to Health (BAH)/Primary Care–Psychiatry Clerkship. The clerkship provides students clinical experience in primary care, psychiatry, and integrated care settings, and a longitudinal, integrated didactic series covering key areas of interface between the two disciplines. Students reported satisfaction with the clerkship overall, rating it 3.9–4.3 on a 1–5 Likert scale, but many found its clinical curriculum and administrative organization disorienting. Students appreciated the conceptual rationale integrating primary care and psychiatry more in the classroom setting than in the clinical setting. While preliminary clerkship outcomes are promising, further optimization and evaluation of clinical and classroom curricula are ongoing. This novel educational paradigm is one model for preparing students for the integrated healthcare system of the twenty-first century.

This study aimed to examine pediatric residents' perspectives of primary care professional relationships. Using a longitudinal qualitative study design, we conducted 15 semi-structured interviews with five second-year pediatric residents who elected to participate in a one-year intervention, facilitating group well child care (GWCC). Pediatric residents described a spectrum of professional relationship types including: ignorant, transactional, workaround, educational and equitable. Residents described ignorant, transactional and workaround relationships with feelings of frustration, and they described educational and equitable relationships with feelings of satisfaction and humility. While residents described optimal relationships in both traditional WCC and GWCC, they described suboptimal relationships in only traditional WCC. Further study is needed to assess if our model of GWCC may create a scaffolding upon which optimal relationships in interprofessional teams are likely to flourish.

Summary Background: Transitioning between Electronic Medical Records (EMR) can result in patient data being stranded in legacy systems with subsequent failure to provide appropriate patient care. Manual chart abstraction is labor intensive, error-prone, and difficult to institute for immunizations on a systems level in a timely fashion. Objectives: We sought to transfer immunization data from two of our health system’s soon to be replaced EMRs to the future EMR using a single process instead of separate interfaces for each facility. Methods: We used scripted data entry, a process where a computer automates manual data entry, to insert data into the future EMR. Using the Center for Disease Control’s CVX immunization codes we developed a bridge between immunization identifiers within our system’s EMRs. We performed a two-step process evaluation of the data transfer using automated data comparison and manual chart review. Results: We completed the data migration from two facilities in 16.8 hours with no data loss or corruption. We successfully populated the future EMR with 99.16% of our legacy immunization data – 500,906 records – just prior to our EMR transition date. A subset of immunizations, first recognized during clinical care, had not originally been extracted from the legacy systems. Once identified, this data – 1,695 records – was migrated using the same process with minimal additional effort. Conclusions: Scripted data entry for immunizations is more accurate than published estimates for manual data entry and we completed our data transfer in 1.2% of the total time we predicted for manual data entry. Performing this process before EMR conversion helped identify obstacles to data migration. Drawing upon this work, we will reuse this process for other healthcare facilities in our health system as they transition to the future EMR. Citation: Michel J, Hsiao A, Fenick A. Using a scripted data entry process to transfer legacy immunization data while transitioning between electronic medical record systems. Appl Clin Inf 2014; 5: 284–298 http://dx.doi.org/10.4338/ACI-2013-11-RA-0096

Objective. To determine if group well-child visits (WCV) can be cost neutral compared with individual WCV by varying health care providers, group size, and physician salary. Method. We created 6 economic models to evaluate the costs of WCV: 3 for individual WCV delivered by (1) advanced practice registered nurse (APRN), (2) resident, and (3) attending and 3 for group WCV delivered by (4) APRN with a nurse and social worker; (5) resident with an attending, nurse, and child life specialist; and (6)attending with a nurse. For group WCV, we performed sensitivity analyses on group size and duration of provider participation. Results. We achieved cost-neutrality at 4 families in the APRN group WCV model; at 3, 4, 5, and 6 families in the resident model with 30, 45, 60, and 90 minutes of attending supervision, respectively; and at 4 and 5 families in the low and high attending salary model, respectively. Conclusion. Group WCV can be delivered in a cost-neutral manner by optimizing group size and provider participation.

The engagement of families in health maintenance is associated with better child health outcomes, but demographic discordance between families and clinicians may be a barrier to family engagement. Using a longitudinal qualitative study design, we conducted 15 semi-structured interviews with five pediatric residents who elected to facilitate group well child care (GWCC). Four themes describing residents’ perceptions of the role of discordance in family-clinician engagement include: 1) discordance was not a barrier; 2) discordance leads to a lack of engagement and trust; 3) residents transcended discordance in GWCC because either GWCC led residents to change their communication techniques or because, with GWCC, parents have concordant adults in the room; and 4) the education residents obtained in GWCC allowed them to empathize with the families’ health-related decisions. Finding ways in which pediatric providers can improve skills in family engagement may be an important step in decreasing health inequities.

The American Academy of Pediatrics (AAP) recommends screening children for developmental delay and autism. Studies of current screening practice to date have been limited in scope and primarily focused on small, local samples. This study is designed to determine compliance with AAP screening recommendations: (1) developmental screening at 9, 18, and 24 or 30 months; (2) screening when concerns are raised at a surveillance visit; and (3) autism screening at 18 and 24 months and to examine pediatrician and practice characteristics associated with compliance. Pediatricians from 6 states completed a 38-item web-based questionnaire (N = 406) regarding compliance with recommendations, screening implementation, changes in screening practice since the publication of guidelines, and pediatrician and practice demographics. Overall, 17.8% of pediatricians were compliant with all 3 screening recommendations. A total of 41.6% of pediatricians screened for development at the 9-month visit, 58% at the 18-month visit, and 52% at the 24- or 30-month visit. A total of 59.8% of physicians screened for autism at the 18-month visit and 50.2% at 24-month visit. As compared with 5 years ago, 44.8% of pediatricians currently screen for development more often and 72.2% screen for autism more often. Pediatricians with 10%‐50% of patients of non-White race/ethnicity in their practice were significantly less likely to screen for developmental delay than pediatricians with more than 50% of patients (odds ratio [OR] = 0.30; 95% confidence interval [CI] = 0.13, 0.69; p = .004). Similarly, pediatricians with 10%‐30% of Medicaid-insured patients were less likely to screen for developmental delay than pediatricians with more than 30% of patients (OR = 0.45; 95% CI = 0.25, 0.80; p = .0007). In contrast, pediatricians with 10%‐30% of Medicaid-insured patients were significantly more likely to screen patients for autism than pediatricians with more than 30% of patients (OR = 2.46; 95% CI = 1.38, 4.40; p = .0002). Increasing numbers of pediatricians are screening children for developmental delays and autism. Economically disadvantaged children are significantly more likely to be screened for developmental delay but less likely to be screened for autism than do less disadvantaged children. Key words: autism, developmental screening, pediatricians, young children

BackgroundOur goal was to assess the impact of a standardized residency curriculum in ambulatory pediatrics on residents' participation, satisfaction, and confidence.MethodsA case-based curriculum for weekly primary care conference was developed to replace the existing free-form review of topics at the Yale Pediatrics Residency Program. Before the curricular switch, faculty preceptors and members of the academic year 2005–2006 intern class completed surveys designed to measure conference occurrence and resident attendance, participation, satisfaction, and confidence in clinical skills. One year after the curricular switch, identical surveys were completed by faculty preceptors and members of the academic year 2006–2007 intern class.ResultsFaculty surveys indicated that conferences took place significantly more often after the curricular switch. The number of residents at conference each day (3.18 vs 4.50; P ConclusionImplementation of a structured curriculum for ambulatory care improved interns' self-reported participation, satisfaction, and confidence. The primary care conference occurred more dependably after the curricular change, and improvements in attendance and participation were documented. Pediatric residency programs may make better use of conference time in the ambulatory setting through the use of structured, case-based educational material.

Introduction Extramural curricula developed for the purpose of sharing with other institutions have been designed to improve education on important topics in ambulatory care. We sought to assess the usage rates of these curricula among paediatric, internal medicine, and combined medicine-paediatrics residency programmes in the United States. Methods Surveys on aspects of trainee continuity clinic were sent to paediatric and medicine-paediatrics programme directors in 2012. Surveys contained an item asking respondents about their use of extramural ambulatory care curricula. Since no similar recent data were available for internal medicine, and to verify the accuracy of the paediatric survey data, we queried the editors of four widely used curricula for subscription information. Descriptive and inferential statistics were calculated. Results Responses from paediatric programmes indicated that 48 of 111 (43 %) were using an extramural curriculum, compared with 39 of 60 (65 %) medicine-paediatrics programmes (p = 0.007). Editor query revealed a collective subscription rate of internal medicine programmes (300 of 402, 75 %), which was greater than the subscription rate of paediatric programmes (90 of 201, 45 %) (p

Although electronic health records (EHRs) promise to be efficient resources for measuring metrics of quality, they are not designed for such population-based analyses. Thus, extracting meaningful clinical data from them is not straightforward. To avoid poorly executed measurements, standardized methods to measure and to validate metrics of quality are needed. This study provides and evaluates a use case for a generally applicable approach to validating quality metrics measured electronically from EHR-based data. The authors iteratively refined and validated 4 outpatient quality metrics and classified errors in measurement. Multiple iterations of validation and measurement resulted in high levels of sensitivity and agreement versus the “gold standard” of manual review. In contrast, substantial differences remained for measurement based on coded billing data. Measuring quality metrics using an EHR-based electronic process requires validation to ensure accuracy; approaches to validation such as those described in this study should be used by organizations measuring quality from EHR-based information.

Obsessionality and obsessive-compulsive symptoms have been regarded as important characteristics in the clinical presentation of the eating disorders. In this report, we examined the relation between obsessionality and the clinical presentation and outcome of a sample of eating-disordered patients. Self-rated obsessional symptoms, defined by the obsessive-compulsive subscale of the Symptom Checklist 90 (revised version), were compared with presenting clinical symptomatology, and scores on the Eating Disorder Inventory (EDI) and Beck Depression Inventory (BDI) in a sample of 110 consecutively evaluated women who met DSM-IIIR criteria for eating disorders. Forty patients were contacted for a follow-up investigation, 2 years after the initial evaluation. Higher obsessive-compulsive subscale scores at presentation were associated with more severe dieting, a greater number of psychiatric hospitalizations, and higher EDI, SCL-90R and BDI scores. Initial obsessive-compulsive scores did not predict the subsequent outcome of a sample of these patients in the community. However, elevated obsessive-compulsive scores obtained at follow-up were associated with the presence of lower body weight and more severe eating-disorder symptoms at that time. These results support the hypothesis that elevated obsessionality is associated with more severe eating disorder symptomatology. In addition, obsessional symptoms change along with those of the eating disorder, and their persistence may be associated with a poorer outcome.