Search

Population health management (PHM) dashboards using electronic health record (EHR) data can teach trainees about the population they serve while also delivering data on their clinical practice. Yet, few studies have demonstrated their use. In this pilot study, we assessed baseline resident perceptions of population health metrics for continuity clinic panels by comparing resident estimates with EHR-reported values delivered by individualized PHM dashboards.A descriptive, comparative study was conducted at a primary continuity clinic site for pediatric residents in January 2018. Residents were surveyed about population health metrics for their patient panels, including demographics, utilization, and medical diagnoses. We compared resident estimates to corresponding EHR-reported values using 2-tailed paired t tests.A total of 42 out of 55 eligible residents (76%) completed the survey. Compared with EHR-reported values, residents estimated higher percentages of emergency department utilization (22.1% vs 10.3%, P.01) and morbidity, including medical complexity (15.6% vs 5.9%, P.01), overweight (38.1% vs 11.7%, P.01), obesity (20.5% vs 15.8%, P = .02), and asthma (34.6% vs 21.4%, P.01).In this pilot study of PHM dashboards, resident perceptions of continuity clinic population health metrics did not align with EHR data. Estimates were higher for measures of utilization and morbidity. PHM dashboards may help trainees better understand their patient populations and serve as a consistent source of objective practice data. However, further research and investment is needed to evaluate dashboard implementation and impact on trainee and patient outcomes.

Poverty threatens child health. In the United States, financial strain, which encompasses income and asset poverty, is common with many complex etiologies. Even relatively successful antipoverty programs and policies fall short of serving all families in need, endangering health. We describe a new approach to address this pervasive health problem: antipoverty medicine. Historically, medicine has viewed poverty as a social problem outside of its scope. Increasingly, health care has addressed poverty's downstream effects, such as food and housing insecurity. However, strong evidence now shows that poverty affects biology, and thus, merits treatment as a medical problem. A new approach uses Medical-Financial Partnerships (MFPs), in which healthcare systems and financial service organizations collaborate to improve health by reducing family financial strain. MFPs help families grow assets by increasing savings, decreasing debt, and improving credit and economic opportunity while building a solid foundation for lifelong financial, physical, and mental health. We review evidence-based approaches to poverty alleviation, including conditional and unconditional cash transfers, savings vehicles, debt relief, credit repair, financial coaching, and employment assistance. We describe current national MFPs and highlight different applications of these evidence-based clinical financial interventions. Current MFP models reveal implementation opportunities and challenges, including time and space constraints, time-sensitive processes, lack of familiarity among patients and communities served, and sustainability in traditional medical settings. We conclude that pediatric health care practices can intervene upon poverty and should consider embracing antipoverty medicine as an essential part of the future of pediatric care.

BACKGROUND: Children of parents with substance use disorders are at greater risk for mental and physical health co-morbidities. Despite guidelines, pediatricians rarely screen for substance use in the family/household, citing fear of offending parents. The objectives of this study were to examine 1) caregiver acceptance of pediatricians screening for family/household substance use during well-child visits, 2) prevalence of family/household substance use, and 3) the association between family/household substance use and trust in their child’s pediatrician. METHODS: This cross-sectional study surveyed adult caregivers presenting a child for medical care at two urban pediatric outpatient clinics using a brief anonymous computer-based survey. The primary outcome measured acceptability of pediatrician screening for family/household substance use. Substance use and concerns about use in the family/household were also assessed. RESULTS: Adult caregivers (N=271) surveyed were mean age 35 years, 73% mothers, 90% African American, and 85% on Medicaid. Over half (51%) of caregivers reported substance use by someone in the family/household, most commonly cigarettes (38%), followed by alcohol (19%) and marijuana (10%). Sixty-one percent of caregivers who reported family substance use, expressed concern about use of this substance. The majority (87%) agreed it is appropriate for pediatricians to ask caregivers about family/household substance use. No differences were found between caregivers who did and did not report substance use in their family/household. Caregivers with concerning substance use in their family/household were less likely to trust their pediatrician [OR=0.21, 95%CI:0.05, 0.85] CONCLUSIONS: Caregivers endorsed acceptance of universal screening for substance use, including illicit substances, and substance use disorders in the family/household during well-child visits. Pediatricians are trusted professionals with expertise in communicating with parents to maximize the health of their patients; assessing family history of substance use and substance use disorders is a natural extension of their role.

Little is known about parents’ perceptions and prevention strategies regarding childhood falls. In this qualitative study using semi-structured interviews, we sought to describe parental reports of child fall experiences, concerns, and prevention strategies in the home. Sixteen parents with at least one child younger than 18 months were asked about their awareness of fall risks, falls experienced by the child, fall concerns, prevention strategies, and where in the home the child spends time throughout the day. Seven themes emerged: (1) “falls are unexpected,” (2) “role of the physical environment,” (3) “children’s temperament and developmental stage,” (4) “physical barriers and baby products,” (5) “addressing walking surfaces,” (6) “modifying the height of a fall,” and (7) “supervision.” Parents are aware of in-home fall hazards and actively use strategies to lessen fall risk. Anticipatory guidance should promote evidence-based and evidence-informed prevention strategies and augment effective strategies some parents use to lower fall risk.

To describe the social needs of families working with Health Leads (HL) at 18 pediatric practices in 9 US cities and how reported social needs and success addressing them varied according to parents' preferred health care language.We evaluated the social needs of English and Spanish speakers who received assistance from HL from September 2013 to August 2015. The study sample included 11,661 households in the 4 regions where HL provided support within pediatric primary care practices. We used multivariable regression stratified by region to assess the association between language and successful resource connections.Reported social needs differed by language. Spanish speakers most frequently reported needs related to food (eg, food stamps, Special Supplemental Nutrition Program for Women, Infants, and Children, and food pantries). English speakers most frequently reported child-related needs (eg, childcare vouchers, Head Start, and school enrollment). The association between household language and the odds of a successful resource connection varied by region.Our findings highlight the importance of considering language barriers and community context when addressing unmet social needs as part of primary care.

Bicycle-related falls are a significant cause of mortality and morbidity. Use of bicycle helmets substantially reduces risk of severe traumatic brain injury but compliance with this safety practice is particularly low in urban children. Given the lack of educational interventions for urban youth, our research team created a youth-informed, culturally relevant educational video on bike helmet safety, which was informed by focus groups with Baltimore City youth. This video, You Make the Call, linked the concept of use of cases to protect phones to use of helmets to protect heads and can be viewed at http://bit.ly/2Kr7UCN . The impact of the video as part of an intervention (coupled with a free helmet, fit instructions, and a parent guidance document) was tested with 20 parent–child dyads. The majority (80%) of youth (mean age 9.9 ± 1.8 years) reported not owning or wearing a helmet. At 1-month follow-up (n = 12, 60% response rate), helmet use was higher in the five youth reporting bike-riding after the intervention; 100% “always” used helmets compared to 0% preintervention. There were increases in youth reporting that parents required helmet use (35% pre vs. 67% post) and that is was possible to fall when bike-riding (60% pre vs. 92% post). These pilot results support the use of this video and educational intervention along with further evaluation in a larger sample size. This youth-informed and culturally tailored approach could be explored as a strategy to address other pediatric injury topics.

Financial stress is the root cause of many adverse health outcomes among poor and low-income children and their families, yet few clinical interventions have been developed to improve health by directly addressing patient and family finances. Medical-Financial Partnerships (MFPs) are novel cross-sector collaborations in which health care systems and financial service organizations work collaboratively to improve health by reducing patient financial stress, primarily in low-income communities. Financial services provided by MFPs include individually tailored financial coaching, free tax preparation, budgeting, debt reduction, savings support, and job assistance, among others. MFPs have been shown to improve finances and, in the few existing studies available, health outcomes. We describe the rationale for MFPs and examine eight established MFPs providing financial services under 1 of 3 models: full-scope on-site service partnerships; targeted on-site service partnerships; and partnerships facilitating referral to off-site financial services. The services MFPs provide complement clinical social risk screening and navigation programs by preventing or repairing common financial problems that would otherwise lead to poverty-related social needs, such as food and housing insecurity. We identify common themes, as well as unique strengths and solutions to a variety of implementation challenges MFPs commonly encounter. Given that the financial circumstances and health outcomes of socially marginalized patients and families are closely linked, MFPs represent a promising and feasible cross-sector service delivery approach and a new model for upstream health care to promote synergistic financial well-being and health improvement.

Evidence for social needs interventions on resource linkage has grown over the past decade. Though social and economic needs predict health care utilization, few studies have assessed social needs interventions on these outcomes. The objective of this study was to examine the association between enrollment in a clinic-based social needs program on subsequent well-child visit (WCV) attendance and emergency department (ED) use in 2 primary care clinics.A retrospective cohort study was conducted of patients in 2 clinics referred to a social risk screening and navigation program between June and August 2018. We compared health care utilization over the subsequent 12 months for those who completed a full intake and received resource navigation (enrolled) to those referred (not enrolled). Logistic regression was used to assess the association between enrollment with WCV attendance and ED visits.During the study period, of the 969 patients referred to the program, 761 were enrolled across the 2 clinics. At both sites, the majority of enrolled patients had high WCV attendance postintervention (Site A: 81.6%, Site B: 71.4%). High WCV attendance for nonenrolled but referred patients was significantly lower (Site A: 52.7%, Site B: 35.0%). Enrolled participants were significantly more likely to have high WCV attendance than nonenrolled patients, adjusting for preintervention utilization (Site A adjusted odds ratio [aOR]: 5.83, Site B aOR : 4.20). There were no significant differences in ED use at either clinic.Addressing families' social needs through resource linkage and navigation can improve WCV attendance.

A novel coronavirus disease, named coronavirus disease 2019 or COVID-19, which sparked an outbreak in Wuhan, China in December 2019, is now a pandemic. The rapid spread of this disease from one to more than 155 regions worldwide in 2.5 months highlights the need for better preparation to manage a pandemic. In this commentary, we describe how Human Factors and Ergonomics (HFE) can contribute to the COVID-19 pandemic response. Specifically, we provide an example of how HFE methodologies informed workflow redesigns implemented as part of COVID-19 pandemic preparations in an academic pediatric ambulatory clinic. We then identify key mechanisms and areas where HFE can contribute to and improve the effectiveness of a pandemic response: Just-in-time (JIT) training development, adapting workflows and processes, restructuring teams and tasks, developing effective mechanisms and tools for communication, engaging patient and families to follow the recommended practices (e.g., social distancing, revised hospital visitation policies), identifying and mitigating barriers to implementation of plans, and learning from failures and successes to improve both the current and future pandemic responses. We recommend integrating HFE approaches and tools across health care systems, state health organizations, and the Centers for Disease Control and Prevention (CDC) as they confront this pandemic.

Introduction Adverse childhood experiences (ACEs) and trauma are common and can negatively impact children's health. Standardized patient (SP) learning may provide trainees with knowledge and skills to screen for and manage ACEs, apply trauma-informed care approaches, and teach resilience strategies. Methods With content experts, we developed three SP cases based on common clinical encounters, as well as didactic and debriefing materials. Case 1 focused on somatic symptoms in an adolescent with ACEs, case 2 focused on an ACE disclosure by a parent, and case 3 focused on de-escalation. The workshop required facilitators, SPs, simulation exam room and meeting space, and audiovisual equipment. It lasted 4 hours and included an orientation (1 hour), the three SP cases (totaling 2 hours), and group debriefing (1 hour). Results We conducted five identical workshops with 22 pediatric residents. Participants responded favorably to case fidelity and applicability to their clinical work. Resident mean self-assessment scores improved significantly from baseline. Specifically, we assessed comfort with inquiring about and discussing ACEs, explaining the health impacts of trauma, identifying protective factors, resilience counseling, and de-escalation. Over 90% of responses indicated that residents were likely to apply what they had learned to their clinical practice. Discussion These findings demonstrate that our SP cases were well received and suggest that such curricula can help pediatric residents feel more prepared to address trauma and promote resilience. Future work will assess these outcomes, as well as behavior change, in a larger sample to further substantiate these promising findings.

Sudden Infant Death Syndrome is a leading cause of mortality in infants, and pediatric providers can influence caregiver infant safe sleep practices. We described the content of safe sleep counseling by pediatric providers and examined pediatric provider and caregiver factors that may be related to the delivery of safe sleep counseling.A sample of mothers and providers enrolled in the Safe Start Study, a randomized controlled trial assessing a safe sleep intervention, were audio-recorded during the 2-week well child visits (WCV) at a large urban pediatric practice in Baltimore, Maryland from October 2015 to April 2017. Provider counseling content related to infant sleep was transcribed and coded based on American Academy of Pediatrics (AAP) policy statement Grade A recommendations. Maternal reported infant sleep practices were defined by items on an interviewer administered survey. Multivariate logistic regression analyses were used to examine the relation between maternal reported infant sleep practices and provider counseling.Most, 92%, of WCVs included at least 1 safe sleep topic, but there was inconsistency in content delivered based on AAP recommendations. Yet, only 12% of WCVs included all 4 components of ABC counseling. Maternal report of infant sleeping with a person or an object in sleep space was associated with decreased odds of receiving counseling on alone no person, no objects (adjusted odds ratio: 0.34, 95% confidence interval: 0.13, 0.90).Pediatric provider counseling on safe sleep is inconsistent across AAP recommendations demonstrating a need for enhanced provider education and a more standardized approach to assess infant sleep practices.

Problem In 2017, there were 25.4 million refugees worldwide, of whom 33,400 were resettled in the United States. In fiscal year 2016, 20,455 individuals were granted permanent asylum status in the United Sates. Both in the United States and overseas, refugees/asylees face significant disparities in accessing needed medical, mental health, and social support. Approach The Refugee Health Partnership (RHP) was developed by Johns Hopkins University School of Medicine students and colleagues at a local refugee resettlement agency in 2011. The program pairs teams of preclinical medical students with recently resettled refugees/asylees who have special health care needs. After receiving training, students conducted monthly home visits and accompanied patients to appointments to assist them in navigating the health care system over one year. Students participated in monthly reflection exercises to process experiences and attended monthly seminars facilitated by expert faculty and guests. Outcomes From 2012 to 2016, the RHP served 20 refugee families and engaged 60 students across four cohorts. Refugee participant retention was 20/22 (90.9%), and student retention was 57/60 (95.0%). In surveys completed at the end of their programs, students reported improvement in all measures, including understanding of different patient perspectives as well as comfort in communicating with patients across cultures and language barriers. Next steps The authors plan to integrate more objective measures of students' progress into the evaluations. They are scaling this model up both locally and beyond and plan to gather data from refugee/asylee participants to more accurately assess how they benefit from the program.

Statement of purpose Falls are the leading cause of emergency department visits among children less than five years old. Parents are encouraged to supervise their children and provide a safe environment to prevent injuries, but there are few evidence-based interventions to prevent child falls. This analysis aimed to identify factors related to unintentional nonfatal fall injuries in children under five. Methods/Approach Data about children under five years who experienced a fall in 2015 were extracted from the National Electronic Injury Surveillance System All Injury Program. The case narratives were reviewed and coded for what the child fell from, fell onto, the fall action (i.e. tripped, dropped, rolled), and the precipitating event leading up to the fall. Results In 2015, an estimated 121,531 infants ( Conclusion Infants primarily fall from beds; toddlers and preschoolers fall most often from standing by slipping or tripping. Significance Understanding the circumstances of fall injuries can help identify new opportunities for prevention and intervention.

Background: Children with medical complexity and technology dependence (CMC-TD) have significant health care and care coordination needs, with increased risk for medical errors. Standardizing pediatric resident documentation for these patients may help to improve patient safety. Objective: To increase the percentage of patients with care coordination notes containing specific documentation on technology from a baseline of 8% to a target goal of 55% among CMC-TD in a pediatric resident continuity clinic. Methods: …

Acute otitis media is often misdiagnosed. Pediatric trainees learn otoscopy from supervisors who cannot concurrently view the eardrum. Digital, smartphone otoscopes show promise to improve the visibility and learning due to a concurrent view by trainees and supervisors. We aimed to determine whether use of digital otoscopes improved accuracy of the ear exams between medical trainees and their supervisors, compared to using traditional otoscopes. Secondarily, we evaluated whether the use of digital otoscopes reduced the number of repeat ear examinations by supervisors, changed the trainee's confidence in their exam findings, and led to differences in the rate of antibiotics prescribed.This study was a randomized controlled trial comparing use of a digital otoscope to a traditional otoscope, in a pediatric emergency department and primary care clinic in an academic tertiary care children's center. We used a modified validated image-based grading scale to compare accuracy of the ear exam between trainees and supervisors. Surveys documented modified OMgrade scores, frequency of supervisor exams, trainee confidence on a 5-point Likert scale, and antibiotic prescriptions. Inter-rater agreement of trainees and supervisors, the number of supervisor confirmatory examinations performed, trainee confidence, and antibiotic prescription rates were evaluated.Amongst 188 children, 375 ears were examined by 85 trainees and 22 supervisors. The digital otoscope was utilized in 92 (48.9%) exams and 96 (51.1%) used the traditional otoscope. Accuracy of ear exam findings between trainees and supervisors improved by 11.2% (95% CI: 1.5, 21.8%, p = 0.033) using the Cellscope Oto (74.8%, 95% CI: 67.3, 82.1%) compared to the traditional otoscope (63.5%, 95% CI: 56.7, 70.4%). Fewer repeat supervisor exams were performed in the digital otoscope group (27.2%) vs. the traditional otoscope group (97.9%) (p0.001). There was no difference in mean trainee confidence in their examination (p = 0.955) or antibiotic prescription rates when using digital versus traditional otoscopes (p = 0.071).Utilization of a digital otoscope resulted in increased accuracy of the ear exam between trainees and supervisors, and fewer total number of examinations performed on a given child. Compared to a traditional otoscope, a digital otoscope may be a more efficient and effective diagnostic tool.

Problem Some focus on recognizing excellence in clinical teaching has been lost with the increasing emphasis placed on clinical efficiency and value. Clinical teaching awards and academies of educators aim to address this problem. In 2015, medical student leaders at the Johns Hopkins University School of Medicine created the Distinguished Teaching Society (DTS), a student-driven program to recognize the best clinical educators. Approach Medical students designed a comprehensive scoring rubric focusing on 3 domains: feedback and evaluation, role model behavior, and teaching process. A student committee solicits student nominations providing narratives endorsing faculty or housestaff for potential inclusion in the DTS. Using the rubric, student judges score each deidentified narrative nomination, as well as an application from finalists and comments about finalists submitted by the student body. Inductees are recognized at an annual ceremony. Outcomes From academic years 2015-2016 to 2018-2019, students nominated 254 unique candidates, and 82 nominees (32%) were inducted into the DTS. The majority of inductees were faculty and male. In 2017-2018 and 2018-2019, nearly half of inductees were female, and less than 10% of inductees self-reported as underrepresented in medicine and/or LGBTQ+. The Department of Internal Medicine had the greatest departmental representation. There were no statistically significant differences in the proportional representation within the nomination and inductee cohorts by gender, rank, and department. Several process changes were made in response to student feedback and to increase nominee and inductee diversity. Next steps Next steps include adding a diversity and inclusion chair to the student committee and collecting survey data on student and DTS inductee opinions on how to improve learner-teacher engagement and the clinical learning environment. Future activities may include educational workshops, panel discussions, mentorship programs, and networking events. Other medical schools may find value in considering similar structures.

Objective To understand views of adolescent and adult caregivers on integrating employment and financial services into a pediatric primary care clinic serving low-income families. Methods Eighteen in-depth qualitative interviews were conducted among caregivers of pediatric patients. Participants were recruited from those who completed a survey assessing financial and employment needs. Audio-recorded transcripts were analyzed using line-by-line coding of emerging themes. Results Adolescent and adult caregivers expressed difficulty managing financial stress. They cited having a criminal history, limited financial literacy, and lack of available quality jobs as barriers to achieving financial stability. A clinic-based employment and financial program was highly acceptable among potential users for the convenience it offers and the established trust and understanding between patients and clinical providers. Participants preferred one-on-one counseling for sensitive employment and financial issues, although they did believe that some topics, such as building a resume, could be accomplished in group workshops. Conclusions Caregivers attending a pediatric clinic expressed interest in and anticipated value from clinic-based employment and financial services if implemented services are relevant, accessible, and provide options for group and individualized approaches.

Bicycle-related falls are a significant cause of mortality and morbidity. Use of bicycle helmets substantially reduces risk of severe traumatic brain injury but compliance with this safety practice is particularly low in urban children. We recruited eleven 8- to 15-year-old youth to participate in focus groups to inform the creation of a video promoting helmet use. Key emerging themes included that youth were responsible for keeping themselves safe and that most youth had cell phones with cases to protect them. A video was created that linked the concept of use of cases to protect phones to use of helmets to protect heads. Soliciting information from urban youth was helpful for developing this educational video.

The impact of electronic health record (EHR) immunization clinical alert systems on the delivery of other preventive services remains unknown. We assessed for spillover effects of an EHR immunization alert on delivery of 6 other preventive services, in children 18 to 30 months of age needing immunizations. We conducted a secondary data analysis, with additional primary data collection, of a randomized, historically controlled trial to improve immunization rates with EHR alerts, in an urban, primary care clinic. No significant differences were found in screening for anemia, lead, development, nutrition, and injury prevention counseling in children prompting EHR immunization alerts (n = 129), compared with controls (n = 135). Significant increases in oral health screening in patients prompting EHR alerts (odds ratio = 4.8, 95% CI = 1.8-13.0) were likely due to practice changes over time. An EHR clinical alert system targeting immunizations did not have a spillover effect on the delivery of other preventive services.

Although father engagement in pediatric care is associated with positive child health outcomes, pediatric primary care providers (PCPs) often focus on the mother-child dyad. This study sought to characterize pediatric PCPs’ engagement of fathers in care. Pediatric PCPs affiliated with an academic health system were invited to complete an online survey. The primary outcome was the proportion of providers who routinely implement American Academy of Pediatrics recommendations for father engagement. There were 100 respondents. Of the 23 recommended practices for engaging fathers, 18 were routinely implemented by

Maternal depression is associated with an array of poor child health outcomes, and low-income women face many barriers to accessing treatment. In this pilot study, we assessed treatment engagement in a maternal mental health clinic staffed by a case manager and psychiatrist in an urban pediatric practice. We also examined factors associated with engagement as well as child health outcomes and health care use. Nearly half of the women enrolled attended at least 4 sessions with a psychiatrist in 6 months. Text messaging with the case manager was associated with a greater compliance with psychiatrist sessions. Comparing index children with their siblings prior to enrollment, a higher percentage had immunizations up to date at 1 year of age (82% vs 43%, P = .01), and well-child visit compliance trended toward significance (65% vs 35%, P = .06). The pediatric setting holds promise as an innovative venue to deliver maternal mental health care.

Untreated perinatal mood and anxiety disorders can result in impaired maternal-infant interactions. Pediatricians have a unique opportunity to identify and support mothers with mood and anxiety disorders. A parenting intervention, Circle of Security, was delivered in a pediatric clinic targeting women with mood and anxiety disorders. A qualitative assessment of the program’s acceptability, participant engagement, and general experiences was conducted. Data collection included medical record abstraction, semistructured psychiatric diagnostic interviews, and semistructured questionnaires. Findings indicate Circle of Security is a feasible and practical approach to providing parenting support to women of young children with mood and anxiety disorders in the pediatric medical home. Additional larger studies will be helpful in tracking outcomes of participating women and infants and in further aiding pediatricians in teaching about attachment and emotions, empowering mothers to talk about their struggles, and ensuring support for mothers in reflecting on their emotions and experiences that affect parenting.

Objective Maternal family planning plays an important role in child, maternal, and family health; children's health care providers are in a unique position to counsel adult caregivers regarding contraception and appropriate birth spacing. We sought to determine the prevalence of caregiver family planning counseling by children's health care providers during preventive care visits for infants and young children. Methods Data from the National Ambulatory Medical Care Survey from 2009 to 2012 as well as National Hospital Ambulatory Medical Care Survey from 2009 to 2011 were analyzed to determine the weighted frequency of family planning/contraception counseling provided during preventive, primary care visits for children younger than the age of 2 years. Results Family planning/contraception counseling or education was documented in only 16 of 4261 preventive care visits in primary care settings for children younger than the age of 2 years, corresponding to 0.30% (95% confidence interval, −0.08% to 0.68%) of visits nationally. Similar frequencies were calculated for preventive visits with children younger than 1 year and with infants younger than 60 days of age. Conclusions Despite Bright Futures' recommendations for children's health care providers to address caregiver family planning during well infant visits, documented counseling is rare. The results indicate that there are missed opportunities to promote family health in the pediatric setting.

Background and Objective. This study is a qualitative analysis examining caregivers’ expectations for pediatricians with regard to behavioral health care. Methods. Fifty-five parents/caregivers of children seen in an urban primary care clinic participated in semistructured interviews. Participants were parents or guardians of children between the ages of 2 and 17 years, referred from the pediatric clinic to the mental health center. Interviews were analyzed using grounded theory methods. Results. Pertinent themes were the following: expected range of care, components of an effective primary care provider (PCP) relationship, action of the PCP, and parent reaction to PCP intervention. Forty-seven percent of caregivers saw the PCP role as strictly for physical health care; 53% expected the PCP to have a role in both physical and behavioral health. Responses were overwhelmingly positive from caregivers when the PCP asked about or conducted a behavioral health intervention. Conclusion. Caregivers did not consistently expect but responded positively to PCPs engaging around behavioral health concerns.

To determine the desirability of integrating financial services in pediatric primary care among caregivers and older adolescents.We conducted a cross-sectional study among caregivers and late adolescents 18 years and older attending an urban, pediatric primary care clinic.The 221 participants had a mean age of 32.1 years, with 28% of the sample aged 18-25 years. The majority were African American (90.1%), female (83.3%), and single parents (55.1%). More than one-third of the participants (35.8%) reported no household earned income, and 26.7% had a yearly household total income of$12,000. More than one-half (61.5%) reported financial stress in general, and 67.9% believed that the clinic should provide financial services, including financial education and job workshops. A greater proportion of those who desired clinic-based services were African American (94.7% vs 75%; P .001) and had a low or middle subjective social status (95.7% vs 83.7%; P = .01).Clinic-based financial services are desired by caregivers and late adolescents in an urban pediatric primary care practice. Prospective studies are needed to assess the long-term impact of integrated services on childhood poverty and family well-being.

Pediatric guidelines recommend that providers address a range of parental health issues; however, adherence to these guidelines has been suboptimal. Drawing on a nationally-representative sample of children's primary care physicians, we examined whether providers view parental issues as relevant to child health and whether they believe it is their personal responsibility to address them. Issues included maternal depression, tobacco use, intimate partner violence, Tdap (tetanus, diphtheria, and acellular pertussis) immunization, family planning, and health insurance. While the majority of respondents endorsed the relevance of these issues to child health, particularly for issues with an established evidencebase, significantly fewer felt responsible for addressing them. Physicians who endorsed relevance or responsibility were almost always more likely to address these issues in their clinical practice. To advance parental health promotion practices, highlighting relevance to pediatric outcomes is an important first step, particularly for novel areas, while understanding what factors influence personal responsibility is necessary for all issues.

BackgroundFew randomised controlled trials (RCTs) have been conducted to improve infant sleep practices. There is limited research on how best to integrate safe sleep information into routine paediatric anticipatory guidance delivered at well child visits (WCVs). This protocol paper describes the design of the Safe Start Study, which aims to evaluate the impact of safe sleep interventions on parents’ knowledge, beliefs and behaviours related to creating and maintaining a safe sleep environment for their infants.MethodsSafe Start is a three-group RCT comparing a safe sleep health education intervention delivered as part of the 2-week WCV, an attention-matched control group that receives a scald burn prevention intervention, and a standard of care group. A baseline survey is completed at the 2-week WCV; follow-up surveys and observations are completed in the home at 2–4 weeks and 2–3 months. Participants include mother–baby dyads attending a large urban paediatric primary care practice and their paediatricians. Primary outcomes are self-reported behaviours (baby sleeps alone, on back, in crib and in a smoke-free environment), observations of the sleep environment, paediatricians’ anticipatory guidance counselling about safe sleep and participants’ reported exposure to an existing city-wide safe sleep campaign.DiscussionProviding a theory-driven and evidenced-based safe sleep intervention is both a research and a clinical practice priority. This study will advance the application of educational and environmental interventions in the primary care setting to improve the safety of infant sleep environments in high-risk families.Trial registration numberNCT03070639; Pre-results.

The objective of the study was to examine differences in pediatric resident perceptions and practices related to child mental health conditions in continuity clinic settings with versus without on-site mental health professionals (MHPs). A 20-item questionnaire, based on the American Academy of Pediatrics Periodic Survey Number 59, was administered to pediatric residents in a medium-sized program from 2008 to 2011. Of 130 residents surveyed, compared with their peers, those practicing with the on-site MHPs were more likely to report mental health services as very available in their clinic (odds ratio [OR] = 39.7; P = .000). Residents with on-site MHPs inquired more frequently about attention-deficit/hyperactivity disorder (ADHD; OR = 2.96; P = .029) and referred more frequently for ADHD (OR = 3.68; P = .006), depression (OR = 2.82; P = .030), and behavioral problems (OR = 3.04; P = .012). On-site MHPs in continuity clinics offer great potential to improve resident education and patient care. Additional research is necessary to further understand their impact.

Objective. To examine associations between use of on-site multidisciplinary services at a pediatric primary care clinic, perceptions of the clinic, and health care utilization. Study Design. Eighty caregivers were interviewed during clinic visits assessing on-site service use, satisfaction, and perception of the clinic as a medical home. Acute care, emergency department, and well-child visit data were abstracted from children’s medical records. Student’s t test and multivariate regression were used to examine associations between service use, satisfaction, and health care utilization. Results. Use of ≥3 clinic services was associated with improved satisfaction (Client Satisfaction Questionnaire–8 mean: 31.8 vs 31.0, P < .05), stronger perception of the clinic as a medical home (Parents’ Perception of Primary Care mean: 97.6 vs 93.4, P < .01), and increased missed well-child care visits (mean: 0.49 vs 0.20, P < .05). Conclusions. On-site service use was associated with improved caregiver satisfaction but decreased well-child visit adherence. Caregivers using support services may face barriers to accessing preventive care.

To assess how exposures to community activities in residency impact anticipated future involvement in community child health settings.Prospective cohort study of pediatric residents from 10 programs (12 sites) who completed training between 2003 and 2009. Residents reported annual participation for ≥ 8 days in each of 7 community activities (eg, community settings, child health advocacy) in the prior year. At the start and end of residency, residents reported anticipated involvement in 10 years in 8 community settings (eg, school, shelter). Anticipated involvement was dichotomized: moderate/substantial ("high") versus none/limited ("low"). Logistic regression modeled whether residency exposures independently influenced anticipated future involvement at the end of residency.A total of 683 residents completed surveys at the start and end of residency (66.8% participation). More than half of trainees reported ≥ 8 days' of involvement in community settings (65.6%) or child health advocacy (53.6%) in residency. Fewer anticipated high involvement in at least 1 community setting at the end of residency than at the start (65.5% vs 85.6%, P.001). Participation in each community activity mediated but did not moderate relations between anticipated involvement at the start and end of residency. In multivariate models, exposure to community settings in residency was associated with anticipated involvement at end of residency (adjusted odds ratio 1.5; 95% confidence interval 1.2, 2.0). No other residency exposures were associated.Residents who anticipate high involvement in community pediatrics at the start of residency participate in related opportunities in training. Exposure to community settings during residency may encourage community involvement after training.

This study assesses the disclosure rates of African American new mothers regarding their infants’ unsafe sleep practices by analyzing the mothers’ responses during separate encounters with a research assistant, health educator, and pediatrician.

Objective Though an essential pediatric preventive service, immunizations are challenging to deliver reliably. Our objective was to measure the impact on pediatric immunization rates of providing clinicians with electronic health record–derived immunization prompting. Methods Operating in a large, urban, hospital-based pediatric primary care clinic, we evaluated 2 interventions to improve immunization delivery to children ages 2, 6, and 13 years: point-of-care, patient-specific electronic clinical decision support (CDS) when children overdue for immunizations presented for care, and provider-specific bulletins listing children overdue for immunizations. Results Overall, the proportion of children up to date for a composite of recommended immunizations at ages 2, 6, and 13 years was not different in the intervention (CDS active) and historical control (CDS not active) periods; historical immunization rates were high. The proportion of children receiving 2 doses of hepatitis A immunization before their second birthday was significantly improved during the intervention period. Human papillomavirus (HPV) immunization delivery was low during both control and intervention periods and was unchanged for 13-year-olds. For 14-year-olds, however, 4 of the 5 highest quarterly rates of complete HPV immunization occurred in the final year of the intervention. Provider-specific bulletins listing children overdue for immunizations increased the likelihood of identified children receiving catch-up hepatitis A immunizations (hazard ratio 1.32; 95% confidence interval 1.12–1.56); results for HPV and the composite of recommended immunizations were of a similar magnitude but not statistically significant. Conclusions In our patient population, with high baseline uptake of recommended immunizations, electronic health record–derived immunization prompting had a limited effect on immunization delivery. Benefit was more clearly demonstrated for newer immunizations with lower baseline uptake.

Objective To assess practice patterns, barriers, and facilitators related to caregiver health promotion in pediatric primary care settings. Study design We conducted a mail-based survey of a nationally representative sample of 1000 children's primary care physicians (trained in pediatrics, family medicine, or medicine-pediatrics). We assessed engagement in 6 caregiver health issues (maternal depression, tobacco use, intimate partner violence, family planning, health insurance, and tetanus, diphtheria, and acellular pertussis immunization status) along with barriers and facilitators related to engagement. We used multivariable logistic regression to identify physician and practice correlates of engagement. Results The response rate was 30%. The majority of respondents (79.3%) regularly addressed at least 3 caregiver health issues during well infant/child visits, most commonly maternal depression, tobacco use, and tetanus, diphtheria, and acellular pertussis immunization immunization status. Screening was the most common activity. In adjusted analyses, pediatricians were less likely to screen for intimate partner violence and family planning compared with other providers. There were no other differences in engagement by physician specialty. Lack of time was the most commonly endorsed barrier (by 85.2% of respondents). Co-location of auxiliary services was the most frequently cited facilitator for the majority of issues. Conclusions Children's primary care physicians and their care teams routinely engage in a variety of activities promoting caregiver health, largely independent of training background and despite multiple practice-related barriers. Co-location of auxiliary services could support the efforts of pediatric care teams. Future efforts that investigate care models which address these barriers and facilitators will help to realize the potential of pediatric settings to impact adult health.

Objective Training pediatricians to understand child health in the context of community and to develop skills to engage with community organizations remain priorities for residency education in the United States. Our objectives were to: 1) determine use of strategies to influence community child health by graduates of the Community Pediatrics Training Initiative (CPTI); and 2) to identify personal, practice, and residency program factors associated with use of strategies 1 year after residency. Methods Analysis of data from the Dyson Initiative National Evaluation included surveys of physicians ("graduates") 1 year after residency and surveys of CPTI program leaders. Graduates reported personal and practice characteristics and use of one or more strategies to influence community child health. Chi-square and logistic regression were used to examine associations between personal, practice, and programmatic factors with use of strategies. Results Of the 511 graduates (68% participation), 44% reported use of one or more strategies. After adjusting for residency site, time spent in general pediatrics, and program emphasis on individual level advocacy, we found that graduates were more likely to report using strategies if they felt responsible for improving community child health (adjusted odds ratio [aOR] 4.1, 95% confidence interval [95% CI] 2.5–6.9), had contact with a person who provides guidance about community pediatrics (aOR 1.8, CI 1.2–2.6), or trained in a program that places great emphasis on teaching population level advocacy skills (aOR 2.3, CI 1.3–4.2). Conclusions Personal perspectives and residency education influence community involvement, even early in pediatricians' careers. Efforts are needed to understand how content and delivery of training influence community engagement over time.

OBJECTIVE: The goal was to determine patient-, provider-, and clinic-level predictors of unrecognized elevated blood pressure (BP) in children. We hypothesized that being of healthy weight, having a BP of METHODS: A cross-sectional study of clinic visits for children 3 to 20 years of age at an urban, pediatric primary care practice between January 1, 2006, and June 30, 2006, was performed. Children with elevated systolic or diastolic BP (≥90th percentile or ≥120/80 mmHg) were included. Recognition was defined as having any of the following documented: repeat BP measurement, elevated-BP/hypertension diagnosis, plan to recheck BP, or initiation of hypertension evaluation. Multivariate logistic regression analysis was used to identify characteristics associated with underrecognition. RESULTS: Elevated BP occurred in 779 (39%) of 2000 visits. Of 726 cases included in the analysis, 87% were not recognized by providers. Patient-level predictors of underrecognition included systolic BP of CONCLUSIONS: Most BP elevations were not recognized by providers. Poor recognition was most influenced by the absence of obviously elevated BP, obesity, and family history of cardiovascular disease.

Introduction: Pediatric guidelines emphasize the importance for healthcare providers to view children in the context of family and community, and promote community resources at visits. In 2006, a Family Help Desk (FHD) was established in an urban academic-based clinic in Baltimore, MD to assist healthcare providers in educating families about available community-based resources. Methods: A longitudinal cohort pilot study was conducted during a 6-week period in 2007 to evaluate the impact of the FHD in connecting at-risk families to community resources. Results: Overall, 6% of parents (n = 59) who brought their child for a scheduled clinic visit accessed the FHD. Parents had a mean of 1.7 social needs, including after-school programs and childcare (29%), employment (13%), housing (12%), and food (11%). Most parents who utilized the FHD (64%) contacted a community resource or service within 6 months of their clinic visit. Nineteen parents (32%) who utilized the FHD enrolled in community programs. Conclusion: A clinic-based multi-disciplinary model can empower families to connect with communitybased resources for basic social needs. Practice implications: The Family Help Desk model has great potential for addressing family psychosocial needs, and educating families about community resources within the context of pediatric primary care.

This paper presents a cross-sectional study examining the influence of neighborhood violence on multiple aspects of mothers’ health. While the influence of neighborhood violence on health is important to understand for all populations, mothers are especially important as they play a key role in protecting their children from the consequences of violence. Three hundred and ninety-two Baltimore City mothers of children 5 years and younger completed a self-administered survey that included questions about perceptions of their safety as well as their personal experiences with neighborhood violence. Separate models were run to compare the relationship between each measurement of neighborhood violence and five diverse health-related determinants and outcomes: self-reported health status, smoking, exercise, average hours of sleep a night, and sleep interruption. Controlling for mother’s age, child’s age, maternal education, and marital status, mothers with high exposure to neighborhood violence were twice as likely to report poorer health, smoking, never exercising, and poor sleep habits. Maternal perception of neighborhood safety was not related to any of the assessed health-related determinants and outcomes. This study emphasizes the importance of measuring exposure to neighborhood violence rather than solely assessing perceived safety. Neighborhood violence was a common experience for mothers in this urban sample, and should be considered by health professionals in trying to understand and intervene to improve the health of mothers and their children.

There is limited understanding of risk and protective factors associated with depression among African American adolescents living in impoverished, urban settings. A cross-sectional study was conducted to identify a range of risk and protective factors associated with depressive symptoms among low-income urban African American adolescents. The sample ( n = 467) comprised African American adolescents from three high-poverty urban neighborhoods in Baltimore, Maryland. A self-administered read aloud survey completed by adolescents assessed depressive symptoms as well as various individual- and environmental-level risk and protective factors. Multivariate analyses indicated that female gender, living with an adult with a substance abuse problem, greater exposure to physical violence, and greater peer delinquency were associated with higher depressive symptoms. Greater home assets and self-awareness were associated with lower depressive symptoms. Future interventions to prevent and treat depression among urban African American adolescents should focus on minimizing their risk factors while enhancing those factors found to be protective.

Adolescent academic achievement is closely linked to numerous health outcomes. Studies have demonstrated a positive relationship between parental academic monitoring and adolescent academic achievement. Less is known about factors associated with parental academic monitoring, and research is particularly lacking with low-income, African American young adolescents who are at high risk for school disengagement and underachievement. Data were collected from a sample of incoming urban sixth graders using a computer- assisted questionnaire. Data were analyzed as cross-sectional using the responses of 111 African American adolescents, ages 10–14

Introduction Effective mentoring relationships are important contributors to career satisfaction, academic productivity, perceived self-efficacy, and successful networking. They are especially critical during times of transition in one's career. Unfortunately, such relationships can be difficult to find and challenging to sustain. In recent years, the concept of mentee-driven mentoring relationships has been proposed as a method of improving mentoring relationships. In this workshop, we apply the widely utilized concept of the individualized learning plan to examine and optimize the mentee-driven mentorship. Methods In small-group discussions, participants reflect on their unique mentoring needs as they transition into the next stage of their careers. Next, participants apply the corporate concept of managing up to their current mentoring relationships. Workshop leaders then introduce the optimal characteristics of mentors as well as the concept of a mentoring mosaic. Participants then create their own mentoring mosaics that describe the depth and breadth of their potential and of existing mentoring networks. With guidance from the workshop facilitators and other small-group discussants, participants then expand their mentoring mosaics by exploring possibilities for untapped mentoring resources (recognizing that mentors can come from the junior, peer, and senior levels). Finally, participants discuss in small groups strategies to overcome several challenging mentoring scenarios, including how to recruit new mentors and maximize the limited time of a mentor. Participants will leave with a better understanding of their roles as mentees and mentors. Results This workshop has been presented at the 2014 and 2015 Pediatric Academic Societies' Annual Meetings and at the Association of Pediatric Program Directors' Annual Spring Meeting in 2013 and 2014. Participants have included pediatric residents, chief residents, fellows, junior faculty, mid-level faculty, and senior-level faculty. Ninety-five percent of participants agreed or strongly agreed that their participation would improve the quality of their mentoring relationships. Discussion Although we have not collected data on the career outcomes of our workshop participants, literature suggests that mentees who utilize the principles we present will benefit greatly (e.g., attainment of leadership positions, academic promotion, career satisfaction).

Depression is one of the most debilitating chronic disorders in the United States, affecting 15 million children in homes with depressed mothers, many of whom endure household chaos, inconsistent nurturing, inadequate safety practices, and harsh discipline. Depressed mothers are under diagnosed and undertreated, yet there is broad consensus about the importance of identifying and managing maternal depression, as reflected in recommendations by pediatric and obstetric professional organizations to routinely screen for perinatal depression. Screening was shown to be acceptable to women and most pediatric providers, and adding a screening component need not impair clinic efficiency. Screening, however, is not sufficient, and there are few models in the literature to guide medical practices in implementing successful interventions to identify, treat, and prevent maternal depression, particularly in the pediatric setting. We reviewed the literature and identified six studies that evaluated models for screening and managing mothers' depression in pediatric primary care settings. Some of these interventions have promise, but no studies characterized health outcomes of the depressed mothers and children. We discuss the components of these models, their implementation, and the practice and research needed to create effective pediatrics-based systems to reduce the negative effects of maternal depression on mothers, children, and families.

Objective The Future of Pediatric Education II Report affirmed the importance of providing resident education in community settings. Yet we know little about related experiences of trainees and whether experiences and perspectives regarding community involvement vary by gender. We assessed gender differences in pediatric residents' involvement in and perspectives regarding community activities. Methods A national survey of US pediatric residents assessed residents' involvement in 14 activities before medical school and the intensity and perceived importance of involvement in 17 activities during medical school and residency. Expected future involvement 10 years hence was assessed for 11 community settings. χ 2 and analysis of variance were used to examine bivariate relations by gender. Multivariate linear regression was used to model the relationship between gender and expected future involvement. Results Of the 700 respondents, 68% were women. Relative to men, more women reported exposure to child health advocacy and other community activities before and during medical school. Women and men reported similar involvement in residency, although women placed greater importance on inclusion of 16 of 17 community activities in their training. Female residents were more likely to report that current training in the community would influence their future career activities. Women anticipated greater future involvement in 6 of 11 settings. In adjusted analyses, gender remained associated with future involvement in 5 settings. Conclusions As women come to comprise an increasing proportion of the pediatric workforce, further efforts are needed to understand the impact of gender on future involvement in community child health activities.

Objectives To describe baseline perceptions of first-year pediatric residents of participating in community activities, to determine whether demographic factors are related to perceived benefits and constraints, and to identify factors associated with expected community involvement. Methods Pediatric residents beginning their training in the fall of 2000 to 2003 participated in a 12-item self-administered written survey as part of the national evaluation of the Dyson Community Pediatrics Training Initiative. Results Of the 612 first-year residents surveyed (90% response rate), most reported they receive personal satisfaction (92%) and gain valuable skills and knowledge (83%) from their involvement in community activities. Less than a quarter felt peer support and professional recognition were benefits. Almost two thirds reported logistics and lost personal time as constraints to community involvement. Compared with their colleagues, older residents (>29 years) and underrepresented minority residents reported fewer constraints. Most residents (72%) expect moderate to substantial involvement in community activities after graduating. Those expecting greater involvement were more likely to report personal satisfaction, gaining valuable skills and knowledge, peer support, and the opportunity to spend time with like-minded peers as benefits. Conclusions Pediatric residents beginning their postgraduate training perceive numerous benefits from their participation in community activities and most expect a moderate degree of future community involvement. Residency directors should: 1) consider their trainees' insights from prior community involvement and 2) integrate meaningful community experiences in ways that confront logistic barriers and time constraints.