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The Clinical Effort Against Secondhand Smoke Exposure (CEASE) is an evidence-based framework that increases pediatric providers’ ability to address secondhand smoke exposure of minors. Physician champions at 4 University of California sites conducted regular 1-hour didactic trainings on CEASE principles to pediatric residents as part of a longitudinal curriculum. At the conclusion of the academic year, 111 of 284 residents (39%) completed an anonymous survey. CEASE-trained residents reported significantly higher rates than untrained residents of counseling on smoking cessation (adjusted odds ratio [OR] = 4.50, P = .009), and referring to the smokers’ quitline (adjusted OR 3.6, P = .007) to 50% or more of their patients’ caregivers who smoked. In addition, among CEASE-trained residents, there were significant increases in multiple post-training knowledge and self-efficacy items. Our results show that a brief educational curriculum can be helpful in changing pediatric residents’ attitudes and behavior toward assisting adult caregivers to pediatric patients in smoking cessation.

Objectives Adverse events that affect patient safety are a significant concern in pediatrics. Increasing situational awareness, identifying errors and near misses, and reporting them using organizational incident reporting systems enables mitigation of harm. Methods We designed and tested a brief, interactive, and easily replicable simulation activity for medical students, and emergency medicine interns and pediatric interns to strengthen their skills and enhance their self-efficacy in identifying and reporting patient safety hazards. Hazards fell into the categories of situational safety, patient identification and privacy, infection prevention, treatment errors, and issues with electronic health records (EHRs). Results The simulation training significantly increased the self-efficacy of medical students and interns in identifying and reporting patient safety hazards. Learners were very satisfied with the simulation training, successfully recognized key patient safety hazards, provided feedback to improve the training, and improved their ability to report hazards through organizational incident reporting systems. Patient safety hazards associated with patient misidentification were recognized most frequently, whereas safety hazards associated with EHRs were missed with the greatest frequency. Conclusions The simulation training enabled learners to identify hazards and near misses and enhanced their ability to report hazards through organizational incident reporting systems. Learners at all levels of training identified safety hazards at comparable rates, which demonstrates the role that trainees play in critically observing clinical settings with fresh eyes and identifying and reporting patient safety hazards. Interventions to promote patient safety need to prioritize building situational awareness of potential hazards associated with EHR use.

BackgroundTobacco smoke exposure leads to numerous adverse health effects in children. Providing cessation interventions to caregivers who smoke during pediatric hospitalizations can help protect children from such exposure. Both pediatric registered nurses (RNs) and pediatric respiratory therapists (RTs) are well positioned to provide these interventions. Little is known about their rates of participation in cessation efforts. Our objective was to compare the attitudes and practice of pediatric RNs versus pediatric RTs to evaluate their relative cessation-intervention practices in the in-patient pediatric setting.MethodsAn online survey was sent to pediatric RNs and RTs at 4 tertiary pediatric hospitals in California. The survey assessed individual demographics, work environment, experience, beliefs, and practices related to smoking cessation activities. Questions used 3-point and 5-point Likert scales and were compared with the chi-square test. Institutions with a response rate < 20% were excluded.ResultsA total of 401 respondents were included in the final analysis (292 RNs, 109 RTs). RTs versus RNs were older (42.0 y vs 35.4 y, respectively, P < .001) and more likely to be former smokers (29.9% vs 13.3%, respectively, P < .001). RNs reported lower levels of confidence in discussing smoking cessation with parents, with 11.7% saying they felt "very confident" compared to 29.0% of RTs (P < .001). RNs also reported screening for smoke exposure less frequently than RTs, with 18.8% responding "often" or "always" compared to 28.9% of RTs (P = .033). RNs had lower rates of advising parents "to make a smoke-free home policy" compared to RTs (ie, 13.4% vs 26.9%, respectively, P = .002).ConclusionsCompared to in-patient pediatric RNs, RTs reported higher rates of confidence in providing cessation interventions, screening for smoke exposure, and counseling on reducing smoke exposure, suggesting that they may be better positioned for intervening. These results can inform the design of an in-patient cessation intervention for caregivers of hospitalized children.

Medication administration errors that take place in the home are common, especially when liquid preparations are used and complex medication schedules with multiple medications are involved; children with chronic conditions are disproportionately affected. Parents and other caregivers with low health literacy and/or limited English proficiency are at higher risk for making errors in administering medications to children in their care. Recommended strategies to reduce home medication errors relate to provider prescribing practices; health literacy–informed verbal counseling strategies (eg, teachback and showback) and written patient education materials (eg, pictographic information) for patients and/or caregivers across settings (inpatient, outpatient, emergency care, pharmacy); dosing-tool provision for liquid medication measurement; review of medication lists with patients and/or caregivers (medication reconciliation) that includes prescription and over-the-counter medications, as well as vitamins and supplements; leveraging the medical home; engaging adolescents and their adult caregivers; training of providers; safe disposal of medications; regulations related to medication dosing tools, labeling, packaging, and informational materials; use of electronic health records and other technologies; and research to identify novel ways to support safe home medication administration.

Objective Although frontline clinicians are crucial in implementing and spreading innovations, their engagement in quality improvement remains suboptimal. Our goal was to identify facilitators and barriers to the development and engagement of clinicians in quality improvement. Design A 25-item questionnaire informed by theoretical frameworks was developed, tested and disseminated by email. Settings Members and fellows of the International Society for Quality in Healthcare. Participants 1010 eligible participants (380 fellows and 647 members). Interventions None. Main Outcome Measures Self-efficacy and effectiveness in conducting and leading quality improvement activities. Results We received 212 responses from 50 countries, a response rate of 21%. Dedicated time for quality improvement, mentorship and coaching and a professional quality improvement network were significantly related to higher self-efficacy. Factors enhancing effectiveness were dedicated time for quality improvement, multidisciplinary improvement teams, professional development in quality improvement, ability to select areas for improvement and organizational values and culture. Inadequate time, mentorship, organizational support and access to professional development resources were key barriers. Personal strengths contributing to effectiveness were the ability to identify problems that need to be fixed, reflecting on and learning from experiences and facilitating sharing of ideas. Key quality improvement implementation challenges were adopting new payment models, demonstrating the business case for quality and safety and building a culture of accountability and transparency. Conclusions Our findings highlight areas that organizations and professional development programs should focus on to promote clinician development and engagement in quality improvement. Barriers related to training, time, mentorship, organizational support and implementation must be concurrently addressed to augment the effectiveness of other approaches.

Background Obesity and overweight have increased dramatically in the United States over the last decades. The complexity of interrelated causal factors that result in obesity needs to be addressed within the cultural dynamic of sub-populations. In this study, we sought to estimate the effects of a multifaceted, community-based intervention on body mass index (BMI) among Mexican-heritage children. Methods Niños Sanos, Familia Sana (Healthy Children, Healthy Family) was a quasi-experimental intervention study designed to reduce the rate of BMI growth among Mexican-heritage children in California’s Central Valley. Two rural communities were matched based on demographic and environmental characteristics and were assigned as the intervention or comparison community. The three-year intervention included parent workshops on nutrition and physical activity; school-based nutrition lessons and enhanced physical education program for children; and a monthly voucher for fruits and vegetables. Eligible children were between 3 and 8 years old at baseline. Intent-to-treat analyses were estimated using linear mixed-effect models with random intercepts. We ran a series of models for each gender where predictors were fixed except interactions between age groups and obesity status at baseline with intervention to determine the magnitude of impact on BMI. Results At baseline, mean (SD) BMI z-score (zBMI) was 0.97 (0.98) in the intervention group (n = 387) and 0.98 (1.02) in the comparison group (n = 313) (NS). The intervention was significantly associated with log-transformed BMI (β = 0.04 (0.02), P = 0.03) and zBMI (β = 0.25 (0.12), P = 0.04) among boys and log-transformed BMI among obese girls (β = − 0.04 (0.02), P = 0.04). The intervention was significantly and inversely associated with BMI in obese boys and girls across all age groups and normal weight boys in the oldest group (over 6 years) relative to their counterparts in the comparison community. Conclusions A community-based, multifaceted intervention was effective at slowing the rate of BMI growth among Mexican-heritage children. Our findings suggest that practitioners should consider strategies that address gender disparities and work with a variety of stakeholders to target childhood obesity. Trial registration clinicaltrials.gov Identifier: NCT01900613. Registered 16th July 2013.

The goal of the University of California Davis Health Blood Pressure (BP) Quality Improvement Initiative was to improve the diagnosis, management and control of high BP. Patients aged 18–85 years were included in the initiative. Lean A3 problem solving was used to implement the following evidence-based interventions based on stakeholder interviews, value stream mapping and the Centers for Disease Control and Prevention’s Million Hearts Initiative: staff training on accurate BP measurement, visual cues and reminders for BP screening, virtual case-based videoconferences, standardised clinical management algorithm, academic detailing visits, clinical decision support tools, access to pharmacists for medication comanagement, clinician workflow modification, patient education and access to home BP monitors. Following implementation of interventions, accurate screening of BP increased from 14% to 87% and BP control increased from 62% to 75%. Strategies that contributed the most to improvements were using a team-based approach, adjusting clinic workflow and frequent communication of results to staff.

Author(s): Shaikh, Ulfat; Yin, H Shonna; Mistry, Kamila B; Randolph, Greg D; Sanders, Lee M; Ferguson, Laura E

CONTEXT: Hospital-to-home transitions are critical opportunities to promote patient safety and high-quality care. However, such transitions are often fraught with difficulties associated with increased health care use and poor patient satisfaction. OBJECTIVE: In this review, we determine which pediatric hospital discharge interventions affect subsequent health care use or parental satisfaction compared with usual care. DATA SOURCES: We searched 7 bibliographic databases and 5 pediatric journals. STUDY SELECTION: Inclusion criteria were: (1) available in English, (2) focused on children DATA EXTRACTION: Two reviewers independently abstracted data using modified Cochrane data collection forms and assessed quality using modified Downs and Black checklists. RESULTS: Seventy one articles met inclusion criteria. Although most interventions improved satisfaction, interventions variably reduced use. Interventions focused on follow-up care, discharge planning, teach back–based parental education, and contingency planning were associated with reduced use across patient groups. Bundled care coordination and family engagement interventions were associated with lower use in patients with chronic illnesses and neonates. LIMITATIONS: Variability limited findings and reduced generalizability. CONCLUSIONS: In this review, we highlight the utility of a pediatric discharge bundle in reducing health care use. Coordinating follow-up, discharge planning, teach back–based parental education, and contingency planning are potential foci for future efforts to improve hospital-to-home transitions.

Author(s): Shaikh, Ulfat; Acosta, David A; Freischlag, Julie A; Young, Heather M; Villablanca, Amparo C

The California Tobacco Control Program is the longest standing, publicly funded tobacco control program in the U.S. California's adult smoking rate declined from 23.7% (1989) to 11% (2016) but California still has more than 3 million smokers dispersed over 58 counties, requiring a coordinated approach to further tobacco control. Early California Tobacco Control Program success is rooted in public health policy strategies and a statewide media campaign that shifted social norms. In 2009, concepts for a coordinated approach were introduced by the California Tobacco Control Program in the state's first tobacco quit plan. The state quit plan called for public health's tobacco control programs to engage healthcare systems and insurers to work more directly with the California Smoker's Helpline (Helpline). With California's Medicaid (Medi-Cal) program expansion and the implementation of electronic medical record systems, health care plans and providers received additional support for system changes. Simultaneous with these changes, coordinated tobacco control efforts began, including California's Medi-Cal Incentives to Quit Smoking project (2012-2015). In the Medi-Cal Incentives to Quit Smoking project, safety-net providers and Medi-Cal plans were outreached and engaged to promote incentives for Medi-Cal members to utilize Helpline services. In another effort, UC Quits (2013-2015), the five University of California health systems used electronic medical record tools to promote tobacco treatments and electronic referrals to the Helpline. Now, as tobacco prevention is increasingly prioritized for quality improvement, California Tobacco Control Program is funding CA Quits, a statewide tobacco-cessation learning collaborative and technical assistance resource to promote integration of tobacco treatment services and quality improvement activities into safety-net health systems. CA Quits, in coordination with the Helpline, will connect public health departments, Medi-Cal plans, and safety-net providers to accelerate health systems change for tobacco-cessation treatment throughout the state. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Background: Standardized systematic approaches to asthma management result in increased adherence to asthma care guidelines and decreased medical service utilization. There is currently a gap between provided care and optimal care for asthma in resident clinics, and education tools such as practice improvement modules which can address this gap are not consistently utilized. Problem: There is significant variation in pediatric asthma management in the outpatient setting. Practice improvement modules aimed at improving resident physician adherence to asthma care guidelines have not yet been studied. Objective: Our objectives were that in a twelve month period, that …

© 2017, © The Author(s) 2017. California’s Delivery System Reform Incentive Payment (DSRIP) Program provided $3.3 billion over 5 years to support 21 public hospitals improve the quality of health care delivery and population health. The Institute for Population Health Improvement provided technical support and quality improvement mentorship to the California Department of Health Care Services in implementing the DSRIP Program. This report describes the following key observations on the implementation of the program: the need to reduce variability in data collection and management, memorialize decision-making processes, build broad quality improvement capacity, define and revisit improvement targets, anticipate evolution of clinical definitions and guidelines, provide frequent feedback to participating hospitals, engage frontline clinicians, balance short- and long-term improvement goals, acknowledge regulatory requirements and improvement efforts that may compete for resources, and build in shared learning and dissemination of interventions. The authors believe this experience with implementing California’s DSRIP Program may assist other states as they implement similarly intended reform programs.

Background Complete and accurate discharge summaries can improve communication and continuity of care between inpatient and ambulatory settings as well as reduce adverse events. However, discharge summaries commonly lack key information. Objective To determine if a quality improvement intervention that actively engages residents and attending physicians would improve the timeliness and quality of hospital discharge summaries at our academic children's hospital, and would help trainees and clinicians complete educational requirements. Methods Electronic health record queries were used to assess time to completion of discharge summaries. A total of 120 discharge summaries from 36 eligible residents were reviewed by 9 attending pediatricians using an objective discharge summary scoring instrument. Improvement was facilitated through monthly learning sessions and Plan-Do-Study-Act cycles. Results The proportion of summaries completed within 24 hours of discharge increased from 38% to 73%; mean discharge summary scores improved from 54% to 99%; and percentage of summaries that included all 13 elements in the scoring instrument increased from 0% to 80%. All elements most likely to be deficient at baseline showed a higher likelihood of being included in summaries following the intervention. The rate of summaries that were scored as containing appropriate detail and being an appropriate length also increased from 0% to 80%. The 9 attending pediatricians received maintenance of certification credits for their participation. Conclusions A multifaceted quality improvement intervention, which included stakeholder involvement, clinician education, standardization of documentation, policy changes, and provision of board certification credits, improved the quality and timeliness of discharge summaries at our academic children's hospital.

© 2014 by the American College of Medical Quality. Clinicians vary significantly in their adherence to clinical guidelines for overweight/obesity. This study assessed the impact of electronic health record–based clinical decision support in improving the diagnosis and management of pediatric obesity. The study team programmed a point-of-care alert linked to a checklist and standardized documentation templates to appear during health maintenance visits for overweight/obese children in an outpatient teaching clinic and compared outcomes through medical record reviews of 574 (287 control and 287 intervention) visits. The results demonstrated a statistically significant increase in the diagnosis of overweight/obesity, scheduling of follow-up appointments, frequency of ordering recommended laboratory investigations, and assessment and counseling for nutrition and physical activity. Although clinical guideline adherence increased significantly, it was far from universal. It is unknown if modest improvements in adherence to clinical guidelines translate to improvements in children’s health. However, this intervention was relatively easy to implement and produced measurable improvements in health care delivery.

Breastfeeding initiation and duration increase because of physician encouragement. However, many physicians have not received education on breastfeeding, and some may not have a supportive attitude or commitment to breastfeeding. Patients identify dissatisfaction with their current provider as a motivating factor in seeking health information on the Internet. This survey was performed to determine how many physicians with an interest and expertise in breastfeeding are being contacted for breastfeeding information over the Internet and to examine physicians' attitudes to these requests.An e-mail describing the survey, inviting participation, and containing a link to the online questionnaire was posted on the Web site of the Academy of Breastfeeding Medicine and as well as on the Listserv of the American Academy of Pediatrics-Section on Breastfeeding. Information collected included physician training, successes and challenges related to providing breastfeeding medicine support by e-mail, and current level of e-mail communication with patients regarding breastfeeding issues.One-fourth of physicians in our survey receive e-mails with questions about breastfeeding issues from patients with whom they have no preexisting relationships. More receive e-mail from known patients. This suggests that breastfeeding mothers seek expert information on the Internet. Over half of the physicians replied to e-mails individually and without any financial reimbursement.Many breastfeeding mothers reach out to breastfeeding experts over the Internet. Our findings suggest that physicians who provide care to breastfeeding mothers need further education on breastfeeding to provide adequate support to their own patients.

In California’s central valley, childhood obesity rates are above the national average. The majority of families living in the rural, agricultural communities of this region are immigrant of Mexican heritage, and face numerous social and environmental challenges. Demographic and anthropometric data were collected from a population of Mexican-heritage children 3–8 years (N = 609) and families (N = 466) living in two central valley communities. Overall, 45 % of children and 82 % of mothers were classified as overweight or obese. Multivariable analyses indicated that mother’s BMI and acculturation level were positively associated with child BMI z-score. Most children classified as overweight or obese (92 % and 53 %, respectively) were perceived as having ‘normal’ weight by their mothers. Childhood obesity remains a major public health issue in Mexican-heritage, central valley communities. Our model indicates that mother’s BMI is predictor of child obesity, and parents tend to underestimate their child’s weight status. These findings highlight a need for family-targeted and culturally-tailored approaches to address relevant perceptions of obesity and risk factors in these communities.

Quality issue Implementing quality improvement (QI) education during clinical training is challenging due to time constraints and inadequate faculty development in these areas. Initial assessment Quiz-based reinforcement systems show promise in fostering active engagement, collaboration, healthy competition and real-time formative feedback, although further research on their effectiveness is required. Choice of solution An online quiz-based reinforcement system to increase resident and faculty knowledge in QI, patient safety and care transitions. Implementation Experts in QI and educational assessment at the 5 University of California medical campuses developed a course comprised of 3 quizzes on Introduction to QI, Patient Safety and Care Transitions. Each quiz contained 20 questions and utilized an online educational quiz-based reinforcement system that leveraged spaced learning. Evaluation Approximately 500 learners completed the course (completion rate 66-86%). Knowledge acquisition scores for all quizzes increased after completion: Introduction to QI (35-73%), Patient Safety (58-95%), and Care Transitions (66-90%). Learners reported that the quiz-based system was an effective teaching modality and preferred this type of education to classroom-based lectures. Suggestions for improvement included reducing frequency of presentation of questions and utilizing more questions that test learners on application of knowledge instead of knowledge acquisition. Lessons learned A multi-campus online quiz-based reinforcement system to train residents in QI, patient safety and care transitions was feasible, acceptable, and increased knowledge. The course may be best utilized to supplement classroom-based and experiential curricula, along with increased attention to optimizing frequency of presentation of questions and enhancing application skills.

Childhood asthma is a prevalent and costly chronic condition. Optimal management enables secondary and tertiary prevention. The goal was to identify population health considerations for pediatric asthma in California to inform the development of quality improvement interventions. California Health Interview Survey 2011-2012 is a random-digit dial telephone survey conducted in 5 languages. It includes 44,000 households from all 58 counties in California. This study assessed factors related to symptom control and health care use in children ages 2-11 years with asthma. An estimated 492,385 (9.6%) of children in California currently have asthma. Urban and rural residents face comparable asthma disease burdens. School-age male children as well as Asian and African American children are disproportionately affected. Asthma causes significant morbidity, with poorer health status, high utilization of emergency care, and the need for daily medication use. Only 38% of children with asthma have a recent asthma management plan. Half of all children with asthma did not receive influenza immunization in the past year, although this reflects the overall low rate of influenza vaccination. Parents of children with asthma frequently utilize the Internet for health information and communication with their child's health care provider. Children with asthma in California face several population-level challenges, including poor health status, low influenza vaccination rates, high use of emergency care, and suboptimal use of health literacy tools. Focusing on improved care coordination and preventive care for high-risk groups is especially urgent given the expansion of public health insurance and impending shortages in the primary care workforce. (Population Health Management 2016;19:145-151).

There is variation in pediatric asthma management in the outpatient setting. Adherence to national asthma guidelines provides a systematic standardized approach to asthma management. There is a gap between usual and guideline-consistent asthma care in resident clinics. Practice improvement modules aimed at improving resident physician adherence to asthma care guidelines have not been consistently utilized and have not yet been studied. Our aim was to increase guideline consistent care in our pediatric resident clinic in a twelve-month period via increasing performance on the following measures to 75%: spirometry testing; influenza immunization recommendation; level of control assessed through the use of a standardized questionnaire; appropriate medications per national guideline; and use of written asthma action plans. A summarized pediatric-specific version of the National Heart Lung and Blood Institute National Asthma Education and Prevention Program Expert Panel Report 3 (NHLBI EPR-3) guidelines was made readily available to increase provider education. Electronic health record (EHR) enhancements included adding templates to create standardized asthma action plan, asthma control test and a pediatric asthma controller medication order-set. We also addressed the education of patients by simplifying patient instructions. We monitored our progress through the use of an online practice improvement module. We found statistically significant increases in use of a standardized instrument to determine level of control (20% to 81%); recommendation of influenza immunization (56% to 97%); use of national medication treatment guidelines (28% to 98%); distribution of asthma action plans (29% to 65%); and provision of asthma self-management education (35% to 74%). Standardizing the implementation of national guidelines for pediatric asthma through the use of a practice improvement module and electronic health records improved adherence to guidelines. The module allowed us to identify goals for improvement, collect and analyze our group performance data over time, assess the impact of each change, and redesign our process. Improving adherence to national pediatric asthma care guidelines is especially important in settings such as resident teaching clinics which provide care to underserved populations at higher risk for complications related to asthma.

© 2016 International Pediatric Research Foundation, Inc. The regionalization of pediatric services has resulted in differential access to care, sometimes creating barriers to those living in underserved, rural communities. These disparities in access contribute to inferior healthcare outcomes among infants and children. We review the medical literature on telemedicine and its use to improve access and the quality of care provided to pediatric patients with otherwise limited access to pediatric subspecialty care. We review the use of telemedicine for the provision of pediatric subspecialty consultations in the settings of ambulatory care, acute and inpatient care, and perinatal and newborn care. Studies demonstrate the feasibility and efficiencies gained with models of care that use telemedicine. By providing pediatric subspecialty care in more convenient settings such as local primary care offices and community hospitals, pediatric patients are more likely to receive care that adheres to evidence-based guidelines. In many cases, telemedicine can significantly improve provider, patient, and family satisfaction, increase measures of quality of care and patient safety, and reduce overall costs of care. Models of care that use telemedicine have the potential to address pediatric specialists' geographic misdistribution and address disparities in the quality of care delivered to children in underserved communities.

Objective: To determine whether parental reports and electronic health record documentation of physician counseling on nutrition and physical activity reflect actual counseling provided. Methods: Participants were parents of 198 children 2 to 12 years of age seen in a primary care pediatric clinic at an academic medical center for well child care and their 38 physicians. Parents completed a post-visit questionnaire to report discussions on weight, nutrition, and physical activity that occurred during the visit. Electronic health records were reviewed to measure documentation of these topics during the visit. Parental reports and records were compared with actual discussions on the basis of coded audiotapes. Counseling was coded as having occurred if specific topics were mentioned during the encounter, however brief this mention was. Results: A total of 48% of the children were female, they were a mean age of 5.4 years, and 28% were overweight or obese. Sensitivity of parental report was high (63%-96%), but specificity was low (43%-77%) because of parents' tendency to overreport counseling. Sensitivity of electronic health record documentation was generally low (40%-53%) except for discussion of screen time (92%) and physical activity (88%); the specificity of these data was also poor (42% and 21%, respectively, for screen time and physical activity). Conclusions: Electronic health record documentation may not be the most valid method of measuring physician counseling on weight, nutrition, and physical activity in pediatric primary care. Parental report via the use of a questionnaire administered immediately after the visit is a better alternative in quality improvement or research studies when resources do not allow for direct observation, with the caveat that parents may overreport whether counseling was provided. © 2012 by Academic Pediatric Association.

Objective: Childhood obesity is a serious health concern, especially in rural areas. Its management involves in-depth lifestyle and psychosocial assessment as well as patient-centered counseling. Telemedicine has increased the ability of patients in rural areas to obtain subspecialty consultations. Our objective was to determine whether a significant difference in quality of care, as measured by parent satisfaction, existed between consultations for childhood obesity delivered face to face and by telemedicine. Materials and Methods: We performed a pilot study in which questionnaires were distributed to parents of children under 12 years of age who had received consultations for childhood obesity at a university-affiliated pediatric weight management clinic, either face to face or by telemedicine. The questionnaires assessed various aspects of quality of care and patient-centered care including consulting providers' listening skills, ease of understanding instructions delivered to patients and the...

Background Assessment of weight and counselling on nutrition and physical activity is infrequently conducted during well child visits, despite recent expert recommendations. Objective We investigated whether automatic calculation of body mass index (BMI) in an electronic health record improved assessment of weight and counselling on nutrition and physical activity. Methods Retrospective review of well child visit records of children between two and 18 years of age (n=550) before and after implementation of an electronic health record system at an academic medical centre's paediatric clinic. Body mass index was automatically calculated and presented within the electronic health record. We measured clinicians' documentation of assessment of weight status, and assessment of and counselling for nutrition and physical activity risk factors. Results Documentation of assessment of BMI and weight status did not increase. There were no consistent increases in assessment for or counselling on specific nutrition and physical activity behaviours, except with respect to high calorie food intake. Although overall assessment of physical activity decreased, physical activity counselling significantly increased. Documentation of the presence of highrisk family history increased significantly; the provision of counselling for high-risk family history did not show any corresponding increase. Patients with higher BMI percentile scores were more completely assessed for weight status. Completeness of weight status assessment was associated with increased counselling for nutrition and physical activity. Conclusions Passive changes, such as automatic calculation of BMI, are insufficient to result in systematic improvements in assessment of weight and counselling for nutrition and physical activity.

The prevalence of obesity has doubled among children aged 2 to 5 years, and it has tripled among children aged 6-11 years, over the past 30 years.1 Obesity is now considered a public health “epidemic” in the United States affecting 17% of children, with an additional 15% of children qualifying as overweight.2 Childhood obesity has been identified as a risk factor for the development of multiple health problems, including type 2 diabetes, hypertension, hypercholesterolemia, obstructive sleep apnea, anxiety, depression,3-8 and adult obesity and its complications.9,10 Childhood obesity is a particularly challenging problem in rural areas. Parents of obese rural children report that lack of local weight loss resources, lack of exercise facilities, and lack of access to healthy foods are barriers to weight loss.11 Rural residents have lower access to pediatric and specialty care, greater travel time to health care providers, less availability of health insurance, lower likelihood of exercising, and higher rates of obesity, heart disease and diabetes compared to their urban counterparts.12-15 Since approximately 90% of children have a source of ongoing health care, clinicians have recurring opportunities to contribute to the management of pediatric obesity.12,13 However, unique challenges faced by rural clinicians include professional isolation, reduced access to medical information and continuing education, and limited communication with sub-specialists and ancillary support services.16,17 Telehealth is defined as the use of electronic information and telecommunication technologies to support long-distance clinical health care, patient and health care professional education, and public health.18 Telehealth has been successfully used in dermatology, psychiatry, pulmonary medicine, obesity, and cardiology,19-23 and it has reduced the cost of health care and time related to travel.24-26 Few studies have assessed rural health care providers’ challenges related to pediatric obesity and their interest in telehealth applications to address these challenges. Our goals were to determine: (1) self-efficacy and perceived effectiveness of health care providers in rural California in managing child and adolescent obesity; (2) perceived barriers in the treatment of overweight rural children and adolescents; (3) clinical resources that may enhance the effectiveness of obesity management in rural areas, and (4) potential strategies to improve obesity management and rural health care provider training through telehealth. In addition, we assessed whether there were differences in attitudes, barriers, and need for clinical resources based on professional group, years of practice and duration of practice in rural settings. The Chronic Care Model offers a framework to identify factors influencing the management of pediatric obesity and guided the design of the questionnaire used in our study.27 The Model has been used to improve the quality of disease management for other chronic illnesses in a variety of settings and populations. The 6 key areas identified within the Chronic Care Model are (1) self-management support, (2) decision support, (3) delivery system design, (4) clinical information system, (5) organization of the health care system, and (6) community resources.

Introduction Health literacy is the “capacity to obtain, communicate, process, and understand basic health information and services to make health decisions”. There is significant room for improvement in physician-patient communication strategies to enhance health literacy. For example, prior studies have documented that only 25-40% of clinicians use recommended strategies such as teach-back. During 2015-2016, the AAP Council on Quality Improvement and Patient Safety tested a prototype for a quality improvement (QI) learning collaborative for members to earn Maintenance of Certification credits utilizing distance education and a learning session at the AAP National Conference and Exhibition (NCE). …

Rural residents report lower likelihood of exercising, and higher rates of obesity, heart disease, and diabetes compared to their urban counterparts. Our goals were to (1) investigate the outcomes of telemedicine consultations for pediatric obesity on changes/additions to diagnoses, diagnostic evaluation or treatment, and (2) determine whether changes in diagnostic and management recommendations made by the consultant were associated with improvements in patient nutrition, activity level, and weight. We conducted a retrospective medical record review of patients referred to a University-affiliated Children's Hospital Pediatric Telemedicine Weight Management Clinic for a diagnosis of obesity. Of the 139 children and adolescents who received pediatric weight management consultations during the study period, 99 patients met inclusion criteria. Weight management consultations resulted in changes/additions to diagnoses in 77.8% of patients and changes/additions to diagnostic evaluation in 79.8% of patients. Of patients seen more than once, 80.7% showed improvement in clinical outcomes. Of patients seen more than once, 80.6% improved their diet, 69.4% increased activity levels, 21.0% showed slowing of weight gain or weight maintenance, and 22.6% showed weight reduction. Improvements in clinical outcomes were not associated with changes/additions to diagnoses (Odds Ratio [OR] = 0.98; 95% Confidence Interval [CI] = 0.25-3.98) and were weakly associated with changes/additions to diagnostic evaluations (OR = 2.23; 95% CI = 0.58-8.73). However, changes/additions to treatment were associated with improvement in weight status (OR = 9.0; 95% CI = 1.34-76.21). Obesity consultations were associated with changes/additions to diagnoses, diagnostic evaluation, and treatment. Treatment changes were associated with improvement in weight status. Telemedicine weight management consultations have the potential to result in modifications in patient care plans and outcomes.

Attrition of exclusive breastfeeding is highest during the first 3 months postpartum. Timely management of breastfeeding in the outpatient setting through innovative models of healthcare delivery may increase its duration and exclusivity. Our goal was to examine the structure and function of physician-led clinics in the United States that specialize in providing outpatient clinical support for breastfeeding-related issues ("breastfeeding medicine clinics"). We posted a survey on Listservs of the American Academy of Pediatrics, American Academy of Family Physicians, and Academy of Breastfeeding Medicine. The survey collected information on (1) clinic and physician demographics, (2) visit characteristics, (3) referral and reimbursement, (4) clinical activities, (5) continuing education resources, (6) teaching/education activities, and (7) advocacy activities, of physician-led outpatient breastfeeding medicine clinics. Lead physicians from 13 clinics responded to the survey. Their clinics provided clinical care for time-intensive breastfeeding problems. The clinics we described that were in existence longer than 2 years appeared to be economically sustainable. Most physicians who had provided specialized breastfeeding support for more than 5 years reported that their income was commensurate with others in their specialty. Most physicians who provided specialized breastfeeding medicine care additionally provided primary care services within the same clinical setting. Further research into fiscal and organizational aspects of establishing specialized physician-led breastfeeding clinics is needed. The potential of such clinics in contributing to collaborative practice-based research, as well as medical student and house staff education, needs to be explored.

The United States has the highest teen birth rate in the industrialized world, and adolescents continue to have the lowest rates of breastfeeding. Although individual pregnancy and parenting experiences in adolescents are modified by a variety of factors, common themes of adolescent psychology and behavior may help plan effective strategies for breastfeeding promotion and support. Breastfeeding promotion and support in adolescents need to be developmentally appropriate, patient centered, and linked to multidimensional support. J Hum Lact. 23(4):362-367.

Individuals are capable of producing vitamin D with proper exposure to sunlight. However, several factors can interfere with the effectiveness of this process. Most sunscreens filter out UVB light, thus inhibiting vitamin D production. Individuals with more darkly pigmented skin have greater difficulty producing vitamin D because melanin acts as an effective natural sunscreen, requiring longer sun exposure to produce an adequate daily allotment of vitamin D. Additionally, solely breastfed infants whose mothers suffered from vitamin D deficiency or insufficiency when pregnant have smaller reserves of the nutrient and are at greater risk of developing nutritional rickets. Vitamin D deficiency leads to rickets, osteomalacia, and osteoporosis. Long-term vitamin D insufficiency can lead to paracrine effects such as type 1 diabetes, cancer, and multiple sclerosis. This article reviews the current literature on vitamin D deficiency and insufficiency and their relation to different disease states. Potential areas for research are discussed.

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Children in rural areas face higher rates of obesity than children in urban areas, and their clinicians face challenges with preventing and managing obesity and translation of evidence into practice. We evaluated how the quality improvement (QI) intervention, Healthy Eating Active Living TeleHealth Community of Practice (HEALTH COP), at 7 rural California clinics addressed these challenges. Focus group interviews with QI team members assessed their experiences and factors related to adoption of key changes. Key challenges were clinician and staff buy-in, changing ingrained clinical practices, and motivating patient and families. Facilitators were top-down organizational requirements for QI, linkages to local QI resources, involvement of clinical champions, alignment with existing practices, incorporating a learning system connecting similar clinics, and clear and consistent communication channels. Evaluations of QI interventions should include not only measurement of effectiveness but also identification of factors associated with change and interactions with organizational processes and contexts.

Copyright © 2015 by the American Academy of Pediatrics. The Seamless Transitions and (Re)admissions Network (STARNet) met in December 2012 to synthesize ongoing hospital-to-home transition work, discuss goals, and develop a plan to centralize transition information in the future. STARNet participants consisted of experts in the field of pediatric hospital medicine quality improvement and research, and included physicians and key stakeholders from hospital groups, private payers, as well as representatives from current transition collaboratives. In this report, we (1) review the current knowledge regarding hospital-to-home transitions; (2) outline the challenges of measuring and reducing readmissions; and (3) highlight research gaps and list potential measures for transition quality. STARNet met with the support of the American Academy of Pediatrics' Quality Improvement Innovation Networks and the Section on Hospital Medicine.

Few physicians in the United States receive formal education related to principles of infant care in Islamic families. Breastfeeding has a religious basis in Islam and it is recommended that the mother suckle her offspring for 2 years if possible. Weaning from the breast before that period is allowed if mutually decided on by both parents. The infant's father has an obligation to support his wife through any circumstances that may affect breastfeeding and, in case of divorce, provide shelter and financial support to the mother-infant dyad for as long as breastfeeding continues. By showing understanding and respect of Islamic beliefs related to infant feeding, clinicians can help support healthy early feeding of Muslim infants.

Our objective was to test and describe a model for evaluating Websites related to breastfeeding. Forty Websites most likely to be accessed by the public were evaluated for extent, accuracy, credibility, presentation, ease of use, and adherence to ethical and medical Internet publishing standards. Extent and accuracy of Website content were determined by a checklist of critical information. The majority of Websites reviewed provided accurate information and complied with the International Code of Marketing of Breast-milk Substitutes. Approximately half the Websites complied with standards of medical Internet publishing. While much information on breastfeeding on the Internet is accurate, there is wide variability in the extent of information, usability of Websites, and compliance with standards of medical Internet publishing. Results of this study may be helpful to health care professionals as a model for evaluating breastfeeding-related Websites and to highlight considerations when recommending or designing Websites. Journal of Human Lactation. 21(2):175-183.

© 2013 by the American College of Medical Quality. This study assessed the impact of participation in a virtual quality improvement (QI) learning network on adherence to clinical guidelines for childhood obesity prevention in rural clinics. A total of 7 primary care clinics in rural California included in the Healthy Eating Active Living TeleHealth Community of Practice and 288 children seen in these clinics for well-child care participated in this prospective observational pre-post study. Clinics participated in a virtual QI learning network over 9 months to implement best practices and to exchange strategies for improvement. Following the intervention, documentation of weight assessment and counseling increased significantly. Children who received care from clinicians who led the implementation of the intervention at their clinic showed significant improvements in nutrition and physical activity. Virtual QI learning networks in geographically dispersed clinics can significantly increase clinicians’ adherence to guidelines for childhood obesity and improve access to recommended care for rural and underserved children.

The University of California Davis Medical Center (Sacramento, CA) has pioneered the use of telemedicine in its approach to childhood obesity to cover more than 20 rural clinics in California. In our study, we compared the outcomes of the Telemedicine Weight Management Clinic (TM) with those of its face-to-face (FTF) Weight Management Clinic counterpart over the last 5 years, predicting the results to be equivalent or in favor of TM. All children seen in the TM from June 2006 to June 2011 were included (n=121), and encounter notes in medical records were reviewed. For comparison, an equivalent sample of FTF patients was selected from that time frame (n=122). Data that were also abstracted from the medical record included age at first visit, gender, race, referral site, and comorbid diagnoses. Forty-two percent of TM patients compared with 52% of FTF patients received a change in diagnosis. Thirty-nine percent of TM patients received a change in diagnostic evaluation compared with 67% of patients in FTF. When comparing patients who received more than one visit with either form of consultation, the TM group demonstrated substantially more improvement than the FTF group in improving nutrition (88% versus 65%), increasing activity (76% versus 49%), and decreasing screen time (33% versus 8%). Substantially more TM patients were successful with a combined outcome of any one of the weight parameters that included weight loss, weight maintenance, or slowing of weight gain (69% TM versus 44% FTF). Our study suggests that telemedicine can serve as a feasible strategy to increase access to medical care for childhood obesity in rural communities and promote changes in lifestyle with the goal of maintaining a healthy weight.