Adherence to Pediatric Universal Cholesterol Testing Guidelines Across Body Mass Index Categories: A CER Cohort Study.

2020

CIRCOUTCOMES119006519

2020 Jul 17

1941-7705

<p>In 2011, the American Academy of Pediatrics (AAP) and NHLBI recommended universal cholesterol testing at age 9 to 11 years, discussing 2 rationales. The first rationale was identification of familial hypercholesterolemia, a severe disease with a prevalence of ≈ 1:300. The long-term safety and benefits of cholesteral-lowering medications for youth with severe hypercholesterolemia have been established. These known benefits increase the value of early disease identification. The second rationale was identification of less severe dyslipidemias associated with pediatric obesity that may represent a modifiable risk for cardiovascular disease. Before 2011, pediatric cholesterol testing was most common among children with known cardiovascular risks, particularly obesity. Questions remain about the role of universal testing in pediatrics, and the United States Preventive Services Task Force has not endorsed universal testing. This uncertainty may influence guideline uptake.</p>

<p>Prior reports examining cholesterol testing in pediatric cohorts predate the 2011 guideline, evaluate specific efforts to adopt the guideline, or were unable to evaluate other cardiovascular risk factors that may be associated with testing. This study asks whether, and to what extent, universal testing has been adopted since the 2011 guideline.</p>

10.1161/CIRCOUTCOMES.119.006519

Circ Cardiovasc Qual Outcomes

32674639

Preventive Health Care Utilization Among Mother-Infant Dyads With Medicaid Insurance in the Year Following Birth.

2020

2020 Mar 06

1537-1948

<p><strong>BACKGROUND: </strong>Following birth, women may access preventive care in adult settings or, with their infants, in pediatric settings. Preventive care can improve future birth outcomes and long-term health, particularly for women with health risks.</p>

<p><strong>METHODS: </strong>This cohort study linked mother-infant Medicaid claims from 12 states for 2007-2011 births. Pregnancy claims identified health risk categories: maternal cardiovascular (diabetes, hypertension, pre-eclampsia, obesity), maternal mental health (depression, anxiety), and premature birth. Claims for 1 year following birth identified adult and pediatric preventive visits. Logistic regression assessed the relationship between visits and risks, adjusting for maternal demographics, perinatal health care utilization, year, and state.</p>

<p><strong>RESULTS: </strong>Of 594,888 mother-infant dyads with Medicaid eligibility for 1 year following birth, 36% had health risks. In total, 38% of all dyads, and 33% with health risks, had no adult preventive visits. Dyads had a median of 1 (IQR, 0-2) adult and 3 (IQR, 2-5) pediatric preventive visits. A total of 72% of dyads had more preventive visits in pediatric than adult settings. In regression, preterm birth was associated with lower odds of any adult preventive visits [odds ratio (OR), 0.97; 95% confidence interval (CI), 0.95-0.99], and maternal health risks with higher odds (cardiovascular OR, 1.19; 95% CI, 1.18-1.21; mental health OR, 1.87; 95% CI, 1.84-1.91), compared with dyads without risk.</p>

<p><strong>CONCLUSIONS: </strong>Maternal health risks were associated with increased adult preventive visits, but 38% of dyads had no adult preventive visits in the year following birth. Most dyads had more opportunities for preventive care in pediatric settings than adult settings.</p>

10.1097/MLR.0000000000001310

Med Care

32149923

Roles of registered nurses in pediatric preventive care delivery: A pilot study on between-office variation and within-office role overlap.

2020

5-9

2020 Feb 07

1532-8449

<p><strong>PURPOSE: </strong>Registered nurses (RN) participate in delivery of routine pediatric preventive care. This pilot study characterized variation in RN roles and overlap with other team roles.</p>

<p><strong>METHODS: </strong>We conducted a pilot cross-sectional survey of RNs from an urban/suburban pediatric primary care network. RNs described tasks during preventive visits and other staff completing similar tasks. Health system data characterized office staffing, volume, and patient population. We assessed whether role overlap and time on key tasks was associated with office characteristics or staffing ratios.</p>

<p><strong>RESULTS: </strong>Twenty-three offices reported a mean ratio of RNs to physicians and nurse practitioners of 0.99 (range 0.62-1.33). Of tasks RNs completed during preventive care, health education overlapped most with physician/nurse practitioner roles (17 sites with overlap) and rooming patients overlapped most with medical assistant roles (20 sites with overlap). Across sites, RNs spent 9% of time on health education and 26% on rooming. Offices with more role overlap between RNs and physicians/nurse practitioners had higher RN to physician/nurse practitioner ratios (1.13 versus 0.86, t-test p-value 0.002). There was no association between role overlap and other office characteristics, or between RN time on key tasks and staffing ratios.</p>

<p><strong>CONCLUSIONS: </strong>RN staffing ratios varied twofold across offices. RNs spent more time on tasks that overlapped with medical assistant roles than tasks that overlapped with physician/nurse practitioner roles.</p>

<p><strong>PRACTICE IMPLICATIONS: </strong>Opportunities exist to optimize RN pediatric primary care roles, for example by delegating certain tasks. Optimization may reduce costs, while improving quality, patient experience, and staff satisfaction.</p>

10.1016/j.pedn.2020.01.012

J Pediatr Nurs

32044532

Association of a Targeted Population Health Management Intervention with Hospital Admissions and Bed-Days for Medicaid-Enrolled Children.

2019

e1918306

2019 Dec 02

2574-3805

<p><strong>Importance: </strong>As the proportion of children with Medicaid coverage increases, many pediatric health systems are searching for effective strategies to improve management of this high-risk population and reduce the need for inpatient resources.</p>

<p><strong>Objective: </strong>To estimate the association of a targeted population health management intervention for children eligible for Medicaid with changes in monthly hospital admissions and bed-days.</p>

<p><strong>Design, Setting, and Participants: </strong>This quality improvement study, using difference-in-differences analysis, deployed integrated team interventions in an academic pediatric health system with 31 in-network primary care practices among children enrolled in Medicaid who received care at the health system's hospital and primary care practices. Data were collected from January 2014 to June 2017. Data analysis took place from January 2018 to June 2019.</p>

<p><strong>Exposures: </strong>Targeted deployment of integrated team interventions, each including electronic medical record registry development and reporting alongside a common longitudinal quality improvement framework to distribute workflow among interdisciplinary clinicians and community health workers.</p>

<p><strong>Main Outcomes and Measures: </strong>Trends in monthly inpatient admissions and bed-days (per 1000 beneficiaries) during the preimplementation period (ie, January 1, 2014, to June 30, 2015) compared with the postimplementation period (ie, July 1, 2015, to June 30, 2017).</p>

<p><strong>Results: </strong>Of 25 460 children admitted to the hospital's health system during the study period, 8418 (33.1%) (3869 [46.0%] girls; 3308 [39.3%] aged ≤1 year; 5694 [67.6%] black) were from in-network practices, and 17 042 (67.9%) (7779 [45.7%] girls; 6031 [35.4%] aged ≤1 year; 7167 [41.2%] black) were from out-of-network practices. Compared with out-of-network patients, in-network patients experienced a decrease of 0.39 (95% CI, 0.10-0.68) monthly admissions per 1000 beneficiaries (P = .009) and 2.20 (95% CI, 0.90-3.49) monthly bed-days per 1000 beneficiaries (P = .001). Accounting for disproportionate growth in the number of children with medical complexity who were in-network to the health system, this group experienced a monthly decrease in admissions of 0.54 (95% CI, 0.13-0.95) per 1000 beneficiaries (P = .01) and in bed-days of 3.25 (95% CI, 1.46-5.04) per 1000 beneficiaries (P = .001) compared with out-of-network patients. Annualized, these differences could translate to a reduction of 3600 bed-days for a population of 93 000 children eligible for Medicaid.</p>

<p><strong>Conclusions and Relevance: </strong>In this quality improvement study, a population health management approach providing targeted integrated care team interventions for children with medical and social complexity being cared for in a primary care network was associated with a reduction in service utilization compared with an out-of-network comparison group. Standardizing the work of care teams with quality improvement methods and integrated information technology tools may provide a scalable strategy for health systems to mitigate risk from a growing population of children who are eligible for Medicaid.</p>

10.1001/jamanetworkopen.2019.18306

JAMA Netw Open

31880799

Enabling Factors Associated with Receipt of Interconception Health Care.

2019

2019 Dec 14

1573-6628

<p><strong>OBJECTIVES: </strong>Preventive health care between pregnancies may benefit future pregnancies and women's long-term health, yet such care is frequently incomplete. We used Andersen's Model of Health Services Use to identify factors associated with receipt of interconception care.</p>

<p><strong>METHODS: </strong>This secondary analysis uses data from a trial that recruited women from four health centers in the Baltimore metropolitan area. We used data on factors associated with Andersen's model reported up to 15&nbsp;months postpartum. Factors included health history (diabetes, hypertension, prematurity), self-rated health, demographics (age, race/ethnicity, education, marital status, employment, income, parity), predisposing factors (depression, stress, social support), and enabling factors (usual place of care, personal doctor or nurse, insurance). Relative risk regression modeled the relationship between these factors and a dependent variable defined as completing both a postpartum visit and one subsequent health care visit. Models also accounted for time since birth, clustering by site, and trial arm.</p>

<p><strong>RESULTS: </strong>We included 376 women followed a mean of 272&nbsp;days postpartum (SD 57), of whom 226 (60%) completed a postpartum and subsequent visit. Women were predominantly non-Hispanic Black (84%) and low income (50% household income &lt; $20,000/year). In regression, two enabling factors were associated with increased receipt of care: having a personal doctor or nurse (RR 1.38, 95% CI 1.11-1.70) and non-Medicaid insurance (RR 1.64, 95% CI 1.09-2.56).</p>

<p><strong>CONCLUSIONS FOR PRACTICE: </strong>Enabling factors were associated with receipt of recommended care following birth. These factors may be modifiable components of efforts to improve care during this critical life course period.</p>

10.1007/s10995-019-02850-0

Matern Child Health J

31838666

Routine cholesterol tests and subsequent change in BMI among overweight and obese children.

2019

2019 May 29

1876-2867

<p><strong>INTRODUCTION: </strong>In 2011 the NHLBI and AAP concluded that both familial and obesity associated dyslipidemias increase cardiovascular risk and recommended universal cholesterol testing at ages 9 - 11. It remains unknown whether testing influences body mass index (BMI) trajectory, a key modifiable cardiovascular outcome.</p>

<p><strong>METHODS: </strong>This quasi-experimental matched cohort includes children aged 9 - 11 years completing well visits in a diverse primary care network from 2012 - 2014. Participants had baseline BMI &gt;= 85% and no prior cholesterol testing. Propensity score matching identified untested children similar to tested children on weight measures, practice site, sex, age, race, ethnicity, insurance, and well visit frequency. Change in BMI z-score was assessed over 18 months. Regression adjusted for residual confounding following matching. Data was analyzed in 2018.</p>

<p><strong>RESULTS: </strong>Matching improved balance between tested and untested children for all characteristics. The matched cohort of 1,808 children was predominantly non-Latino black (48%) or non-Latino white (33%), and Medicaid insured (39%). Baseline BMI z-score was 1.88 for tested and 1.84 for untested children. Of tested children, 25% had cholesterol levels above the 2011 guideline's "acceptable" range. Two children received cholesterol lowering medications. Adjusted analysis found no difference in change in BMI z-score between tested and untested children (0.02, 95% CI -0.01, 0.04).</p>

<p><strong>CONCLUSIONS: </strong>Individual risk assessment in the form of cholesterol testing is not associated with change in BMI trajectory among overweight and obese children. Though testing may identify familial hypercholesterolemia, results suggest testing does not change BMI trajectory, a key strategy to reduce cardiovascular risk.</p>

10.1016/j.acap.2019.05.131

Acad Pediatr

31152795

Support for Self-Management and Prenatal Health Behavior Change: Implications for Pediatric Promotion of Interconception Care.

2018

2333794X18765368

2018

2333-794X

<p>Pediatricians increasingly endorse a dual generation approach to health, in which parental health behaviors are recognized as critical to promoting child health. Positive parental behaviors often emerge during pregnancy, for reasons that remain incompletely described. We surveyed mothers in the immediate postpartum period to identify beliefs about health behavior change and characteristics of prenatal care associated with successful change. Sampling at a tertiary care hospital captured an English-speaking adult population with healthy infants. Respondents (n = 225) were predominantly non-Hispanic Black (64%) and Medicaid insured (44%). Most (71%) reported successful behavior change during pregnancy. Of those reporting change, 91% intended to sustain behaviors postnatally. Most believed that sustained change was important for their own health (94%) and their infant's health (93%). In logistic regression, support for self-management was associated with prenatal health behavior change (odds ratio = 1.64, 95% confidence interval = 1.09-2.46). Continued support for self-management by pediatricians may benefit long-term family health.</p>

10.1177/2333794X18765368

Glob Pediatr Health

29623289

Parent and Clinician Perspectives on Sustained Behavior Change after a Prenatal Obesity Program: A Qualitative Study.

2017

85-92

2017 Apr

2153-2176

<p><strong>BACKGROUND: </strong>Infants of obese women are at a high risk for development of obesity. Prenatal interventions targeting gestational weight gain among obese women have not demonstrated consistent benefits for infant growth trajectories.</p>

<p><strong>METHODS: </strong>To better understand why such programs may not influence infant growth, qualitative semi-structured interviews were conducted with 19 mothers who participated in a prenatal nutrition intervention for women with BMI 30 kg/m2 or greater, and with 19 clinicians (13 pediatric, 6 obstetrical). Interviews were transcribed and coded with themes emerging inductively from the data, using a grounded theory approach.</p>

<p><strong>RESULTS: </strong>Mothers were interviewed a mean of 18 months postpartum and reported successful postnatal maintenance of behaviors that were relevant to the family food environment (Theme 1). Ambivalence around the importance of postnatal behavior maintenance (Theme 2) and enhanced postnatal healthcare (Theme 3) emerged as explanations for the failure of prenatal interventions to influence child growth. Mothers acknowledged their importance as role models for their children's behavior, but they often believed that body habitus was beyond their control. Though mothers attributed prenatal behavior change, in part, to additional support during pregnancy, clinicians had hesitations about providing children of obese parents with additional services postnatally. Both mothers and clinicians perceived a lack of interest or concern about infant growth during pediatric visits (Theme 4).</p>

<p><strong>CONCLUSIONS: </strong>Prenatal interventions may better influence childhood growth if paired with improved communication regarding long-term modifiable risks for children. The healthcare community should clarify a package of enhanced preventive services for children with increased risk of developing obesity.</p>

10.1089/chi.2016.0149

Child Obes

27854496

Infant Growth following Maternal Participation in a Gestational Weight Management Intervention.

2016

2016 Apr 28

2153-2176

<p><strong>BACKGROUND: </strong>Obesity is widespread and treatment strategies have demonstrated limited success. Changes to obstetrical practice in response to obesity may support obesity prevention by influencing offspring growth trajectories.</p>

<p><strong>METHODS: </strong>This retrospective cohort study examined growth among infants born to obese mothers who participated in Nutrition in Pregnancy (NIP), a prenatal nutrition intervention at one urban hospital. NIP participants had Medicaid insurance and BMIs of 30 kg/m(2) or greater. We compared NIP infant growth to a historical control cohort, matched on maternal factors: age, race/ethnicity, prepregnancy BMI, parity, and history of prepregnancy hypertension or preterm birth.</p>

<p><strong>RESULTS: </strong>Growth data were available for 61 NIP and 145 control infants. Most mothers were African American (94%). Mean maternal BMI was 39.9 kg/m(2) (standard deviation [SD], 5.6) for NIP participants and 38.8 kg/m(2) (SD, 6.0) for controls. Pregnancy outcomes, including preterm birth, gestational diabetes, and birth weight, did not differ between groups. NIP participants were more likely to attend a postpartum visit (69% vs. 52%; p value, 0.03). At 1 year, 17% of NIP infants and 15% of controls had weight-for-length (WFL) ≥95th percentile (p value, 0.66). Other markers of accelerated infant growth, including crossing WFL percentiles and peak infant BMI, did not differ between groups.</p>

<p><strong>CONCLUSIONS: </strong>There was no difference in growth between infants whose mothers participated in a prenatal nutrition intervention and those whose mothers did not. Existing prenatal programs for obese women may be inadequate to prevent pediatric obesity without pediatric collaboration to promote family-centered support beyond pregnancy.</p>

10.1089/chi.2015.0238

Child Obes

27123956

Met Expectations and Satisfaction with Duration: A Patient-Centered Evaluation of Breastfeeding Outcomes in the Infant Feeding Practices Study II.

2015

444-51

2015 Aug

1552-5732

<p><strong>BACKGROUND: </strong>Breastfeeding expectations predict breastfeeding duration. The extent to which expectations for duration are met remains unknown.</p>

<p><strong>OBJECTIVES: </strong>To evaluate prospective measures of expected breastfeeding duration, changes in expectations over time, and factors associated with meeting expectations.</p>

<p><strong>METHODS: </strong>The Infant Feeding Practices Study II followed women from late pregnancy to 1 year postpartum. Expected breastfeeding duration was assessed 5 times. Logistic regression identified factors associated with met prenatal expectations. Subgroup analysis compared met prenatal expectations to satisfaction with breastfeeding duration.</p>

<p><strong>RESULTS: </strong>One-year postpartum, 34.7% of 1802 participants had met prenatal expected breastfeeding duration, and 23.9% were still breastfeeding. Fifty-eight percent of women met expectations stated at 7 months postpartum. Modifiable risk factors associated with meeting prenatal expectations included early regular breast pump use (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.18-2.07). Return to work was negatively associated with met expectations (return by 6 weeks postpartum: OR, 0.48; 95% CI, 0.33-0.71; later return: OR, 0.73; 95% CI, 0.56-0.95). Among those who reported on satisfaction with duration (n = 1226), 40.4% were satisfied. Satisfaction was associated with meeting expectations (OR, 10.56; 95% CI, 7.67-14.55), but expectation and satisfaction measures were not equivalent. Elevated body mass index and depressive symptoms at 2 months postpartum were negatively associated with both measures.</p>

<p><strong>CONCLUSION: </strong>Most participants did not meet prenatal or postnatal expectations for breastfeeding duration and were unsatisfied with duration. However, at 12 months, more participants felt they had met their expectations and were satisfied with their breastfeeding duration than were actually breastfeeding. Therefore, women may perceive greater breastfeeding progress than suggested by Healthy People 2020 benchmarks.</p>

10.1177/0890334415579655

J Hum Lact

25858883