IMPORTANCE: The variability in timing of middle and secondary school reopenings during the 2020 to 2021 school year in the US presents an opportunity to examine the associations of different approaches to in-person education with changes in community COVID-19 incidence. Early studies on this topic have reached mixed conclusions and may be biased by unmeasured confounders.

OBJECTIVE: To estimate the association of in-person vs virtual instruction for students at the sixth grade level or above with county-level COVID-19 incidence in the first year of the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study included matched pairs of counties resuming school programs with in-person vs virtual instruction, drawn from 229 US counties that contained a single public school district and with county populations exceeding 100 000 residents. Counties that contained 1 single public school district and reopened in-person schooling for students at the sixth grade level or above during the fall of 2020 were matched 1-to-1 with counties whose school district reopened with only virtual instruction, based on geographic proximity, population-level demographic factors, the resumption of school district-level fall sports activity, and baseline county COVID-19 incidence rates. Data were analyzed from November 2021 to November 2022.

EXPOSURES: In-person instruction for students at the sixth grade level or above resuming between August 1 and October 31, 2020.

MAIN OUTCOMES AND MEASURES: County-level daily COVID-19 incidence per 100 000 residents.

RESULTS: The inclusion criteria and subsequent matching algorithm led to the identification of 51 pairs of matched counties among 79 total unique counties. Exposed counties had a median (IQR) of 141 840 (81 441-241 910) residents each, and unexposed counties had a median (IQR) of 131 412 (89 011-278 666) residents each. County schools with in-person vs virtual instruction had similar daily COVID-19 case incidence within the first 4 weeks after in-person reopening, but counties with in-person instruction had higher daily incidence beyond 4 weeks. Daily case incidence per 100 000 residents among counties with in-person instruction, compared with counties with virtual instruction, was higher at 6 weeks (adjusted incidence rate ratio, 1.24 [95% CI, 1.00-1.55]) and at 8 weeks after (adjusted incidence rate ratio, 1.31 [95% CI, 1.06-1.62]). This outcome was also concentrated in counties where schools provided full rather than hybrid instructional models.

CONCLUSIONS AND RELEVANCE: In a cohort study of matched pairs of counties that reopened with in-person vs virtual instruction at the secondary school level in the 2020 to 2021 academic year, counties with in-person school instructional models early in the COVID-19 pandemic experienced increases in county-level COVID-19 incidence at 6 and 8 weeks after in-person reopening, compared with counties with virtual instructional models.

<p><strong>OBJECTIVES: </strong>To develop and test the feasibility of a caregiver self-administered social needs screener, a Web-based searchable community resource map, and a process map for implementation of these tools as part of social needs screening and referral on a pediatric inpatient unit.</p>

<p><strong>METHODS: </strong>A multidisciplinary team used quality improvement methodology to develop an electronic social needs screener, resource map Web site, and electronic health record enhancements. A process map for implementation of these tools was refined through plan-do-study-act cycles before full implementation. Weekly measures included the number of eligible caregivers screened, prevalence of reported social needs, and use of social work resources.</p>

<p><strong>RESULTS: </strong>During the 22-week study period, 147 caregivers were screened and 2 declined to participate. Thirty-four percent of caregivers endorsed ≥1 social need. The most common needs identified were depressive symptoms (23%), food insecurity (19%), and need for assistance with utilities (10%). All participants received information about the resource map, and 99% of caregivers with an identified need met with a social worker during their admission.</p>

<p><strong>CONCLUSIONS: </strong>Using quality improvement methodology and technology, the team implemented a new standardized process for addressing social needs on an inpatient unit. This led to identification of social needs in more than one-third of caregivers screened and provision of resource map information to all caregivers. These findings reinforce the importance of standardized assessment of social needs in the pediatric inpatient setting. The role of technology, including resource maps and electronic health record enhancements, was highlighted.</p>

<p><strong>PURPOSE: </strong>Despite American Academy of Pediatrics recommendations that adolescents receive healthcare transition (HCT) services starting at age 12, few do. Electronic health record-based clinical decision support (CDS) tools are effective at promoting healthcare provider adherence to clinical guidelines. This study's purpose was to increase provider HCT services engagement through implementation of a transition-specific CDS and participation in a transition-focused Learning Collaborative (LC).</p>

<p><strong>DESIGN AND METHODS: </strong>Three pediatric primary care sites of an urban, academic medical center implemented a transition CDS tool for ≥14-year-olds. Previously, one site had a version for ≥16-year-olds. Two sites participated in a LC with Plan-Do-Study-Act cycles targeting HCT services engagement, measured by CDS use and practice-level guideline implementation.</p>

<p><strong>RESULTS: </strong>From July 2018 through June 2019, providers at LC-participating sites engaged in HCT services at 8.0% (n&nbsp;=&nbsp;480) and 5.3% (n&nbsp;=&nbsp;145) of eligible patient visits compared to the control's 3.1% (n&nbsp;=&nbsp;69). Engagement was highest for ≥18-year-olds at the LC-participating sites, 26.0% (n&nbsp;=&nbsp;263) and 12.0% (n&nbsp;=&nbsp;80), compared to the control's 7.2% (n&nbsp;=&nbsp;31). After expanding from ≥16 to ≥14-year-olds, engagement decreased by 9.5% at ≥16-year-old visits. LC-participating sites reported increased HCT guideline adherence.</p>

<p><strong>CONCLUSIONS: </strong>Implementation of a transition-specific CDS with LC participation increased provider HCT services engagement and practice-level guideline implementation. Expansion to younger adolescents contributed to decreased engagement for older patients. Future research should assess opportunities to improve uptake and patient outcomes of transition CDS engagement.</p>

<p><strong>PRACTICE IMPLICATIONS: </strong>Quality improvement activities and transition clinical decision supports can improve provider engagement in recommended transition services for adolescents and young adults.</p>

<p>The School District of Philadelphia reopened for in-school instruction the week of March 21, 2021, and required weekly testing for SARS-CoV-2, the virus that causes COVID-19, for all employees returning to in-school responsibilities. The resumption of in-school instruction followed a mass vaccination program using the Pfizer-BioNTech 2-dose vaccine offered under a partnership between the Philadelphia Department of Public Health and Children's Hospital of Philadelphia to all 22,808 School District of Philadelphia employees during February 23-April 3, 2021.* The subsequent mandatory testing program provided an opportunity to assess the percentage of positive BinaxNow point-of-care antigen tests (Abbott Laboratories) identified among school staff members based on their self-reported vaccination status (i.e., received zero, 1, or 2 vaccine doses) at the time of testing. During the initial 5 weeks after schools reopened, 34,048 screening tests were performed. Overall, 0.70% of tests returned a positive result. The percentage of positive test results was lower among persons who reported receipt of 2 vaccine doses (0.09%) compared with those who reported receipt of 1 dose (1.21%) or zero doses (1.76%) (p&lt;0.001) representing a 95% reduction in percentage of positive SARS-CoV-2 test results among persons reporting receipt of 2 compared with zero doses of Pfizer-BioNTech vaccine. Vaccination of school staff members has been highlighted as an important strategy to maximize the safety of in-person education of K-12 students this fall (1). These findings reinforce the importance of promoting COVID-19 vaccination among school staff members before commencement of the 2021-22 school year.</p>

<p><b>BACKGROUND: </b>Chronic school absenteeism and frequent school changes, particularly among younger children, may be antecedents for the high rates of school failure and subsequent dropout among youth in foster care. However, the relationship of foster care experience to absenteeism and school change has not been well studied.</p><p><b>OBJECTIVE: </b>This study examined the association of placement experience with absenteeism and changing schools among 209 urban children in foster care enrolled in public elementary schools.</p><p><b>METHODS: </b>A cohort of children aged 5 to 8 years who entered non-relative or kinship foster care from 2006-2008 were followed longitudinally for 2 years from entry into foster care. Children residing in foster care were categorized at the end of the study as early stable, late stable, or unstable, if they achieved a permanent placement prior to 45 days, between 45 days and 9 months, or failed to do so within 9 months, respectively. Children who reunified home were classified as a fourth category. Poisson regression, controlling for baseline factors, was used to compare days absent and number of schools attended across categories of placement experience.</p><p><b>RESULTS: </b>Among the 209 children, 51% were male, 79% were African American, and 55% were initially placed with kin. One third of children reunified home; among children who did not reunify, one half was early stable, and a third was unstable. Adjusted rates of school absenteeism increased in stepwise fashion as children's placements became more unstable; children with unstable placements were 37% more likely to be absent than those with early placement stability (p=0.029). Children who reunified during the study demonstrated the highest rates of absenteeism; however, there was no significant difference in absenteeism before or after reunification. Number of schools attended increased as stability worsened, with the standardized rate of schools attended reaching 3.6 schools (95% CI 3.1-4.1) over a two year period among children in unstable placements.</p><p><b>CONCLUSIONS: </b>The relationship between placement experience and school absenteeism and school change illustrates the need to better coordinate the educational experience of high-risk children in foster care. The secondary finding of high absenteeism among children in the process of returning home illustrates that educational challenges for youth may be equally if not more concerning among the greater majority of youth in child welfare who remain home with birth parents.</p>

<p><b>OBJECTIVE: </b>Reducing overuse of second-generation antipsychotics among Medicaid-enrolled children is a national priority, yet little is known about how service organization affects use. This study compared differences in second-generation antipsychotic utilization among Medicaid-enrolled children across fee-for-service, integrated managed care, and managed behavioral health carve-out organizational structures.</p><p><b>METHODS: </b>Organizational structures of Medicaid programs in 82 diverse counties in 34 states were categorized and linked to child-level cross-sectional claims data from the Medicaid Analytic Extract covering fiscal years 2004, 2006, and 2008. To approximate the population at risk of antipsychotic treatment, the sample was restricted to stimulant-using children ages three to 18 (N=419,226). The sample was stratified by Medicaid eligibility group, and logistic regression models were estimated for probability of second-generation antipsychotic use. Models included indicators of county-level organizational structure as main predictors, with sequential adjustment for personal and county-level covariates.</p><p><b>RESULTS: </b>With adjustment for person-level covariates, second-generation antipsychotic use was 31% higher among youths in foster care in fee-for-service counties than for youths in counties with carve-outs (odds ratio [OR]=1.69, 95% confidence interval [CI]=1.26-2.27). Foster care youths in integrated counties had the second highest adjusted odds (OR=1.31, CI=1.08-1.58). Similar patterns of use also were found for youths eligible for Supplemental Security Income but not for those eligible for Temporary Assistance for Needy Families. Differences persisted after adjustment for county-level characteristics.</p><p><b>CONCLUSIONS: </b>Carve-outs, versus other arrangements, were associated with lower second-generation antipsychotic use. Future research should explore carve-out features (for example, tighter management of inpatient or restricted access, as well as care coordination) contributing to lower second-generation antipsychotic use.</p>

<p><b>BACKGROUND: </b>Home visiting programs represent an important primary prevention strategy for adverse prenatal health behaviors; the various ways in which home visiting programs impact prenatal smoking cessation and reduction behaviors remain understudied.</p><p><b>METHODS: </b>Mixed methods approach using a retrospective cohort of propensity score matched home visiting clients and local-area comparison women with first births between 2008-2014 in a large Northeast state. Multivariable logistic and linear regression estimated third trimester prenatal tobacco smoking cessation and reduction. Additionally, qualitative interviews were conducted with 76 home visiting clients.</p><p><b>RESULTS: </b>A program effect was seen for smoking cessation such that clients who smoked less than ten cigarettes per day and those who smoked 20 or more cigarettes per day during the first trimester were more likely to achieve third trimester cessation than comparison women (p &lt;0.01 and p = 0.01, respectively). Only for heavy smokers (20 or more cigarettes during the first trimester) was there a significant reduction in number of cigarettes smoked by the third trimester versus comparison women (p = 0.01). Clients expressed the difficulty of cessation, but addressed several harm-reduction strategies including reducing smoking in the house and wearing a smoking jacket. Clients also described smoking education that empowered them to ask others to not smoke or adopt other harm reducing behaviors when around their children.</p><p><b>CONCLUSIONS: </b>While a significant impact on smoking cessation was seen, this study finds a less-clear impact on smoking reduction among women in home visiting programs. As home visiting programs continue to expand, it will be important to best identify effective ways to support tobacco-related harm reduction within vulnerable families.</p>

<p><strong>Importance: </strong>Local variation in the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) across the United States has not been well studied.</p>

<p><strong>Objective: </strong>To examine the association of county-level factors with variation in the SARS-CoV-2 reproduction number over time.</p>

<p><strong>Design, Setting, and Participants: </strong>This cohort study included 211 counties, representing state capitals and cities with at least 100 000 residents and including 178 892 208 US residents, in 46 states and the District of Columbia between February 25, 2020, and April 23, 2020.</p>

<p><strong>Exposures: </strong>Social distancing, measured by percentage change in visits to nonessential businesses; population density; and daily wet-bulb temperatures.</p>

<p><strong>Main Outcomes and Measures: </strong>Instantaneous reproduction number (Rt), or cases generated by each incident case at a given time, estimated from daily case incidence data.</p>

<p><strong>Results: </strong>The 211 counties contained 178 892 208 of 326 289 971 US residents (54.8%). Median (interquartile range) population density was 1022.7 (471.2-1846.0) people per square mile. The mean (SD) peak reduction in visits to nonessential business between April 6 and April 19, as the country was sheltering in place, was 68.7% (7.9%). Median (interquartile range) daily wet-bulb temperatures were 7.5 (3.8-12.8) °C. Median (interquartile range) case incidence and fatality rates per 100 000 people were approximately 10 times higher for the top decile of densely populated counties (1185.2 [313.2-1891.2] cases; 43.7 [10.4-106.7] deaths) than for counties in the lowest density quartile (121.4 [87.8-175.4] cases; 4.2 [1.9-8.0] deaths). Mean (SD) Rt in the first 2 weeks was 5.7 (2.5) in the top decile compared with 3.1 (1.2) in the lowest quartile. In multivariable analysis, a 50% decrease in visits to nonessential businesses was associated with a 45% decrease in Rt (95% CI, 43%-49%). From a relative Rt at 0 °C of 2.13 (95% CI, 1.89-2.40), relative Rt decreased to a minimum as temperatures warmed to 11 °C, increased between 11 and 20 °C (1.61; 95% CI, 1.42-1.84) and then declined again at temperatures greater than 20 °C. With a 70% reduction in visits to nonessential business, 202 counties (95.7%) were estimated to fall below a threshold Rt of 1.0, including 17 of 21 counties (81.0%) in the top density decile and 52 of 53 counties (98.1%) in the lowest density quartile.2.</p>

<p><strong>Conclusions and Relevance: </strong>In this cohort study, social distancing, lower population density, and temperate weather were associated with a decreased Rt for SARS-CoV-2 in counties across the United States. These associations could inform selective public policy planning in communities during the coronavirus disease 2019 pandemic.</p>