Performance Feedback for Human Papillomavirus Vaccination: A Randomized Trial From the American Academy of Pediatrics Pediatric Research in Office Settings Research Network.

2023

47-56

12/2023

1876-2867

OBJECTIVE: To test the hypothesis that a feedback-based intervention would reduce human papillomavirus (HPV) vaccine missed opportunities.

METHODS: In a longitudinal cluster randomized controlled trial of 48 pediatric primary care practices, we allocated half the practices to receive a sequential, multicomponent intervention phased over consecutive periods. In a prior trial (period 1), communication skills training reduced missed opportunities for the initial HPV vaccine dose at well visits but not at acute/chronic visits. The current trial (period 2) evaluated the added value of performance feedback to clinicians after communication training. Performance feedback consisted of an introductory training module, weekly electronic "Quick Tips," and 3 individualized performance feedback reports to clinicians. We fit logistic regression models for the primary outcome of HPV vaccination missed opportunities using generalized estimating equations with independence working correlation, accounting for clustering at the practice level.

RESULTS: Performance feedback resulted in a 3.4 (95% confidence interval [CI]: -6.8, 0.0) percentage point greater reduction in missed HPV vaccine opportunities for the intervention versus control group during acute/chronic visits for subsequent HPV vaccinations (dose 2 or 3). However, during well visits for HPV vaccination dose #1, intervention practices increased missed opportunities (worsened) by 4.2 (95% CI: 1.0, 7.4) percentage points more than control practices, reducing the prior period 1 improvements and blunting the overall effect of performance feedback. We did not observe differences for the other visit/dose categories.

CONCLUSIONS: Performance feedback improved HPV vaccination for one subset of visits (acute/chronic, subsequent HPV vaccinations due), but not for well visits.

10.1016/j.acap.2022.07.006

Acad Pediatr

35853600

Neighborhood Greenspace and Changes in Pediatric Obesity During COVID-19.

2023

33-41

01/2023

1873-2607

INTRODUCTION: Pediatric obesity rates increased during the COVID-19 pandemic. This study examined the associations of neighborhood greenspace with changes in pediatric obesity during the pandemic.

METHODS: Electronic health record data from a large pediatric primary care network were extracted to create a retrospective cohort of patients aged 2-17 years with a visit in each of 2 periods: June 2019-December 2019 (before pandemic) and June 2020-December 2020 (pandemic). Multivariable longitudinal generalized estimating equations Poisson regression estimated the associations of census tract‒level Normalized Difference Vegetation Index with (1) changes in obesity risk during the pandemic and (2) risk of new-onset obesity among children who were not obese prepandemic. Analyses were conducted between November 2021 and May 2022.

RESULTS: Among 81,418 children (mean age: 8.4 years, 18% Black), the percentage of children who were obese increased by 3.2% during the pandemic. Children in Normalized Difference Vegetation Index Quartiles 2-4 had smaller increases in obesity risk during the pandemic than those in Quartile 1 (risk ratio=0.96, 95% CI=0.93, 0.99; Quartile 3 risk ratio=0.95; 95% CI=0.91, 0.98; Quartile 4 risk ratio=0.95, 95% CI=0.92, 0.99). Among the subset who were not obese before the pandemic, children in Normalized Difference Vegetation Index quartiles 3-4 had a lower risk of new-onset obesity during the pandemic (Quartile 3 risk ratio=0.82, 95% CI=0.71, 0.95; Quartile 4 risk ratio=0.73, 95% CI=0.62, 0.85). Higher Normalized Difference Vegetation Index was associated with smaller increases in obesity risk and lower risk of new-onset obesity among children in urban and suburban areas, but results were in the opposite direction for children in rural areas.

CONCLUSIONS: Children living in greener neighborhoods experienced smaller increases in obesity during the pandemic than children in less green neighborhoods, although findings differed by urbanicity.

10.1016/j.amepre.2022.07.014

Am J Prev Med

36116998

Trends in Positive Depression and Suicide Risk Screens in Pediatric Primary Care during COVID-19.

2022

12/2022

1876-2867

OBJECTIVE: Adolescent mental health concerns increased during COVID-19, but it is unknown whether early increases in depression and suicide risk have been sustained. We examined changes in positive screens for depression and suicide risk in a large pediatric primary care network through May 2022.

METHODS: Using an observational repeated cross-sectional design, we examined changes in depression and suicide risk during the pandemic using electronic health record data from adolescents. Segmented logistic regression was used to estimate risk differences (RD) for positive depression and suicide risk screens during the early pandemic (June 2020-May 2021) and late pandemic (June 2021-May 2022) relative to before the pandemic (March 2018-February 2020). Models adjusted for seasonality and standard errors accounted for clustering by practice.

RESULTS: Among 222,668 visits for 115,627 adolescents (mean age 15.7, 50% female), the risk of positive depression and suicide risk screens increased during the early pandemic period relative to the pre-pandemic period (RD: 3.8%; 95% CI: 2.9, 4.8; RD: 2.8%, 95% CI: 1.7, 3.8). Risk of depression returned to baseline during the late pandemic period, while suicide risk remained slightly elevated (RD: 0.7% 95% CI: -0.4, 1.7; RD: 1.8% 95% CI: 0.9%, 2.7%).

CONCLUSIONS: During the early months of the pandemic, there was an increase in positive depression and suicide risk screens, which later returned to pre-pandemic levels for depression but not suicide risk. Results suggest that pediatricians should continue to prioritize screening adolescents for depressive symptoms and suicide risk and connect them to treatment.

10.1016/j.acap.2022.12.006

Acad Pediatr

36584938

HPV Vaccinations at Acute Visits and Subsequent Adolescent Preventive Visits.

2022

12/2022

1098-4275

10.1542/peds.2022-058188

Pediatrics

36205071

Performance Feedback for Human Papillomavirus Vaccination: A Randomized Trial From the American Academy of Pediatrics Pediatric Research in Office Settings Research Network.

2022

07/2022

1876-2867

OBJECTIVE: To test the hypothesis that a feedback-based intervention would reduce human papillomavirus (HPV) vaccine missed opportunities.

METHODS: In a longitudinal cluster randomized controlled trial of 48 pediatric primary care practices, we allocated half the practices to receive a sequential, multicomponent intervention phased over consecutive periods. In a prior trial (period 1), communication skills training reduced missed opportunities for the initial HPV vaccine dose at well visits but not at acute/chronic visits. The current trial (period 2) evaluated the added value of performance feedback to clinicians after communication training. Performance feedback consisted of an introductory training module, weekly electronic "Quick Tips," and 3 individualized performance feedback reports to clinicians. We fit logistic regression models for the primary outcome of HPV vaccination missed opportunities using generalized estimating equations with independence working correlation, accounting for clustering at the practice level.

RESULTS: Performance feedback resulted in a 3.4 (95% confidence interval [CI]: -6.8, 0.0) percentage point greater reduction in missed HPV vaccine opportunities for the intervention versus control group during acute/chronic visits for subsequent HPV vaccinations (dose 2 or 3). However, during well visits for HPV vaccination dose #1, intervention practices increased missed opportunities (worsened) by 4.2 (95% CI: 1.0, 7.4) percentage points more than control practices, reducing the prior period 1 improvements and blunting the overall effect of performance feedback. We did not observe differences for the other visit/dose categories.

CONCLUSIONS: Performance feedback improved HPV vaccination for one subset of visits (acute/chronic, subsequent HPV vaccinations due), but not for well visits.

10.1016/j.acap.2022.07.006

Acad Pediatr

35853600

A Pediatric Telemedicine Research Agenda: Another Important Task for Pediatric Chairs.

2022

08/2022

1097-6833

10.1016/j.jpeds.2022.07.048

J Pediatr

35944724

A Pediatric Telemedicine Research Agenda: Another Important Task for Pediatric Chairs.

2022

08/2022

1097-6833

10.1016/j.jpeds.2022.07.048

J Pediatr

35944724

COVID-19 and Adolescent Depression and Suicide Risk Screening Outcomes.

2021

2021 Jun 17

1098-4275

10.1542/peds.2021-051507

Pediatrics

34140393

Effect of Training Pediatric Clinicians in Human Papillomavirus Communication Strategies on Human Papillomavirus Vaccination Rates: A Cluster Randomized Clinical Trial.

2021

2021 May 24

2168-6211

<p><strong>Importance: </strong>Missed opportunities for human papillomavirus (HPV) vaccination during pediatric health care visits are common.</p>

<p><strong>Objectives: </strong>To evaluate the effect of online communication training for clinicians on missed opportunities for HPV vaccination rates overall and at well-child care (WCC) visits and visits for acute or chronic illness (hereafter referred to as acute or chronic visits) and on adolescent HPV vaccination rates.</p>

<p><strong>Design, Setting, and Participants: </strong>From December 26, 2018, to July 30, 2019, a longitudinal cluster randomized clinical trial allocated practices to communication training vs standard of care in staggered 6-month periods. A total of 48 primary care pediatric practices in 19 states were recruited from the American Academy of Pediatrics Pediatric Research in Office Settings network. Participants were clinicians in intervention practices. Outcomes were evaluated for all 11- to 17-year-old adolescents attending 24 intervention practices (188 clinicians) and 24 control practices (177 clinicians). Analyses were as randomized and performed on an intent-to-treat basis, accounting for clustering by practice.</p>

<p><strong>Interventions: </strong>Three sequential online educational modules were developed to help participating clinicians communicate with parents about the HPV vaccine. Weekly text messages were sent to participating clinicians to reinforce learning. Statisticians were blinded to group assignment.</p>

<p><strong>Main Outcomes and Measures: </strong>Main outcomes were missed opportunities for HPV vaccination overall and for HPV vaccine initiation and subsequent doses at WCC and acute or chronic visits (visit-level outcome). Secondary outcomes were HPV vaccination rates (person-level outcome). Outcomes were compared during the intervention vs baseline.</p>

<p><strong>Results: </strong>Altogether, 122 of 188 clinicians in intervention practices participated; of these, 120, 119, and 116 clinicians completed training modules 1, 2, and 3, respectively. During the intervention period, 29 206 adolescents (14 664 girls [50.2%]; mean [SD] age, 14.2 [2.0] years) made 15 888 WCC and 28 123 acute or chronic visits to intervention practices; 33 914 adolescents (17 069 girls [50.3%]; mean [SD] age, 14.2 [2.0] years) made 17 910 WCC and 35 281 acute or chronic visits to control practices. Intervention practices reduced missed opportunities overall by 2.4 percentage points (-2.4%; 95% CI, -3.5% to -1.2%) more than controls. Intervention practices reduced missed opportunities for vaccine initiation during WCC visits by 6.8 percentage points (-6.8%; 95% CI, -9.7% to -3.9%) more than controls. The intervention had no effect on missed opportunities for subsequent doses of the HPV vaccine or at acute or chronic visits. Adolescents in intervention practices had a 3.4-percentage point (95% CI, 0.6%-6.2%) greater improvement in HPV vaccine initiation compared with adolescents in control practices.</p>

<p><strong>Conclusions and Relevance: </strong>This scalable, online communication training increased HPV vaccination, particularly HPV vaccine initiation at WCC visits. Results support dissemination of this intervention.</p>

<p><strong>Trial Registration: </strong>ClinicalTrials.gov Identifier: NCT03599557.</p>

10.1001/jamapediatrics.2021.0766

JAMA Pediatr

34028494

COVID-19 and Changes in Child Obesity.

2021

2021 Mar 02

1098-4275

10.1542/peds.2021-050123

Pediatrics

33653879