Pediatric Emergency Medicine Physicians' Perceptions of Colleagues' Clinical Performance Over Career Span.

2022

06/2022

1535-1815

OBJECTIVE: The US physician workforce is aging, prompting concerns regarding clinical performance of senior physicians. Pediatric emergency medicine (PEM) is a high-acuity, multitasking, diagnostically complex and procedurally demanding specialty. Aging's impact on clinical performance in PEM has not been examined. We aimed to assess PEM physician's' perceptions of peers' clinical performance over career span.

METHODS: We surveyed 478 PEM physician members of the American Academy of Pediatrics' Section on Emergency Medicine survey study list-serve in 2020. The survey was designed by the investigators with iterative input from colleagues. Respondents rated, using a 5-point Likert scale, the average performance of 4 age categories of PEM physicians in 9 clinical competencies. Additional items included concerns about colleague's performance and preferences for age of physician managing a critically ill child family member.

RESULTS: We received 232 surveys with responses to core initial items (adjusted response rate, 49%). Most respondents were 36 to 49 (34.9%) or 50 to 64 (47.0%) years old. Fifty-three percent reported ever having concern about a colleague's performance. For critical care-related competencies, fewer respondents rated the ≥65-year age group as very good or excellent compared with midcareer physicians (36-49 or 50-64 years old). The ratings for difficult communications with families were better for those 65 years or older than those 35 years or younger. Among 129 of 224 respondents (58%) indicating a preferred age category for a colleague managing a critically ill child relative, most (69%) preferred a 36 to 49-year-old colleague.

CONCLUSIONS: Pediatric emergency medicine physicians' perceptions of peers' clinical performance demonstrated differences by peer age group. Physicians 65 years or older were perceived to perform less well than those 36 to 64 years old in procedural and multitasking skills. However, senior physicians were perceived as performing as well if not better than younger peers in communication skills. Further study of age-related PEM clinical performance with objective measures is warranted.

10.1097/PEC.0000000000002785

Pediatr Emerg Care

35766881

Caregiver perspectives of pre-transplant evaluation in children.

2022

2022 Jan 05

1432-198X

<p><strong>BACKGROUND: </strong>Pre-transplant evaluation is mandated by Centers for Medicare and Medicaid Services, but there is wide institutional variation in implementation, and the family experience of the process is incompletely understood. Current literature largely focuses on adult transplant recipients.</p>

<p><strong>METHODS: </strong>This qualitative study begins to fill the knowledge gap about family experience of the pre-transplant evaluation for children through interviews with caregivers at a large pediatric transplant center.</p>

<p><strong>RESULTS: </strong>Prominent themes heard from caregivers include (1) the pre-transplant evaluation is overwhelming and emotional, (2) prior experiences and background knowledge frame the evaluation experience, and (3) frustration with communication among teams is common.</p>

<p><strong>CONCLUSIONS: </strong>These findings are relevant to efforts by transplant centers to optimize information delivery, minimize concrete barriers, and address healthcare systems issues. A higher resolution version of the Graphical abstract is available as Supplementary information.</p>

10.1007/s00467-021-05354-8

Pediatr Nephrol

34985556

Experience of Chest Dysphoria and Masculinizing Chest Surgery in Transmasculine Youth.

2021

2021 Feb 03

1098-4275

<p><strong>OBJECTIVES: </strong>Transmasculine individuals, those assigned female sex at birth but who identify as masculine, have high rates of suicidal behavior and often suffer from chest dysphoria (discomfort and distress from unwanted breast development). Growing numbers of transmasculine youth are pursuing definitive treatment with masculinizing chest surgery (MCS), and adult studies reveal marked benefits of MCS, although little is known about the impact of chest dysphoria on transmasculine youth or the optimal timing of MCS. In this study, we aimed to explore youth experiences of chest dysphoria and the impact of MCS.</p>

<p><strong>METHODS: </strong>Transmasculine youth aged 13 to 21 were recruited from a pediatric hospital-based gender clinic. Participants completed a semistructured qualitative interview exploring the experience of chest dysphoria and thoughts about or experiences with MCS. Interview transcripts were coded by 3 investigators employing modified grounded theory, with the median interrater reliability at κ = 0.92.</p>

<p><strong>RESULTS: </strong>Subjects ( = 30) were a mean age of 17.5 years, and 47% had undergone MCS. Youth reported that chest dysphoria triggered strong negative emotions and suicidal ideation, caused a myriad of functional limitations, and was inadequately relieved by testosterone therapy alone. All post-MCS youth reported near or total resolution of chest dysphoria, lack of regret, and improved quality of life and functioning.</p>

<p><strong>CONCLUSIONS: </strong>We observed consensus that chest dysphoria is a major source of distress and can be functionally disabling to transmasculine youth. MCS performed during adolescence, including before age 18, can alleviate suffering and improve functioning. Additional research is needed to develop patient-reported outcome measures to assess the impact of chest dysphoria and MCS.</p>

10.1542/peds.2020-013300

Pediatrics

33536330

Barriers and Facilitators of PrEP Adherence for Young Men and Transgender Women of Color.

2019

2019 Apr 16

1573-3254

<p>We aimed to discover barriers and facilitators of HIV pre-exposure prophylaxis (PrEP) adherence in young men and transgender women of color who have sex with men (YMSM/TW). Short-term and sustained adherence were measured by urine tenofovir concentration and pharmacy refills, respectively. Optimal adherence was defined as having both urine tenofovir concentration consistent with dose ingestion within 48&nbsp;h and pharmacy refills consistent with ≥ 4 doses per week use. Participants completed semi-structured interviews exploring adherence barriers and facilitators. Participants (n = 31) were primarily African-American (68%), mean age 22&nbsp;years (SD: 1.8), and 48% had optimal adherence. Adherence barriers included stigma, health systems inaccessibility, side effects, competing stressors, and low HIV risk perception. Facilitators included social support, health system accessibility,&nbsp;reminders/routines, high HIV risk perception, and personal agency. Our findings identify targets for intervention to improve PrEP adherence in these populations, including augmenting health activation and improving accuracy of HIV risk perception.</p>

10.1007/s10461-019-02502-y

AIDS Behav

30993479

Development of a Sexual Health Screening Tool for Adolescent Emergency Department Patients.

2016

809-15

2016 Jul

1553-2712

<p><strong>OBJECTIVE: </strong>The objective was to develop a content-valid audio computer-assisted self-interview (ACASI) sexual health survey (SHS) that is understandable and acceptable to adolescents and can be feasibly implemented in a pediatric emergency department (ED) for sexually transmitted infection (STI) risk assessment.</p>

<p><strong>METHODS: </strong>Multistep iterative qualitative study utilizing a Delphi panel of key informants for survey development and content validity, cognitive interviews with end-users to evaluate understanding, and pilot testing with end-users to evaluate acceptability and feasibility.</p>

<p><strong>RESULTS: </strong>We developed a 20-item questionnaire through an iterative modified Delphi process with experts in adolescent and pediatric emergency medicine. All items were assessed as understandable by &gt;90% of adolescents during the cognitive interviews. All respondents found the SHS easy to use. A total of 76.5% preferred answering questions related to sexual health through the SHS compared to face-to-face interviews. Mean (±SD) length of survey completion was 17.5 (±6.7) minutes and 88.6% of participants found survey length to be "just right." With respect to feasibility testing, there was no statistically significant difference in median ED LOS between those who piloted the SHS and those who did not (230.0 minutes vs. 219.0 minutes; p = 0.7).</p>

<p><strong>CONCLUSIONS: </strong>We developed a content-valid ACASI for the identification of adolescents at risk for STIs that was understandable, acceptable, and easy to use by adolescent patients and feasible for implementation in the pediatric ED. Future planned steps include the evaluation of the SHS in providing clinical decision support for targeted STI screening in the ED.</p>

10.1111/acem.12994

Acad Emerg Med

27126128

The impact of access to immunization information on vaccine acceptance in three countries.

2017

e0180759

2017

1932-6203

<p><strong>INTRODUCTION: </strong>Vaccine acceptance is a critical component of sustainable immunization programs, yet rates of vaccine hesitancy are rising. Increased access to misinformation through media and anti-vaccine advocacy is an important contributor to hesitancy in the United States and other high-income nations with robust immunization programs. Little is known about the content and effect of information sources on attitudes toward vaccination in settings with rapidly changing or unstable immunization programs.</p>

<p><strong>OBJECTIVE: </strong>The objective of this study was to explore knowledge and attitudes regarding vaccines and vaccine-preventable diseases among caregivers and immunization providers in Botswana, the Dominican Republic, and Greece and examine how access to information impacts reported vaccine acceptance.</p>

<p><strong>METHODS: </strong>We conducted 37 focus groups and 14 semi-structured interviews with 96 providers and 153 caregivers in Botswana, the Dominican Republic, and Greece. Focus groups were conducted in Setswana, English, Spanish, or Greek; digitally recorded; and transcribed. Transcripts were translated into English, coded in qualitative data analysis software (NVivo 10, QSR International, Melbourne, Australia), and analyzed for common themes.</p>

<p><strong>RESULTS: </strong>Dominant themes in all three countries included identification of health care providers or medical literature as the primary source of vaccine information, yet participants reported insufficient communication about vaccines was available. Comments about level of trust in the health care system and government contrasted between sites, with the highest level of trust reported in Botswana but lower levels of trust in Greece.</p>

<p><strong>CONCLUSIONS: </strong>In Botswana, the Dominican Republic, and Greece, participants expressed reliance on health care providers for information and demonstrated a need for more communication about vaccines. Trust in the government and health care system influenced vaccine acceptance differently in each country, demonstrating the need for country-specific data that focus on vaccine acceptance to fully understand which drivers can be leveraged to improve implementation of immunization programs.</p>

10.1371/journal.pone.0180759

PLoS ONE

28771485

A Computerized Sexual Health Survey Improves Testing for Sexually Transmitted Infection in a Pediatric Emergency Department.

2017

147-152.e1

2017 Apr

1097-6833

<p><strong>OBJECTIVES: </strong>To assess whether clinical decision support, using computerized sexually transmitted infection (STI) risk assessments, results in increased STI testing of adolescents at high risk for STI.</p>

<p><strong>STUDY DESIGN: </strong>In a 2-arm, randomized, controlled trial conducted at a single, urban, pediatric emergency department, adolescents completed a computerized sexual health survey. For patients assigned to the intervention arm, attending physicians received decision support to guide STI testing based on the sexual health survey-derived STI risk; in the usual care arm, decision support was not provided. We compared STI testing rates between the intervention and usual care groups, adjusting for potential confounding using multivariable logistic regression.</p>

<p><strong>RESULTS: </strong>Of the 728 enrolled patients, 635 (87.2%) had evaluable data (323 intervention arm; 312 usual care arm). STI testing frequency was higher in the intervention group compared with the usual care group (52.3% vs 42%; aOR 2 [95% CI 1.1, 3.8]). This effect was even more pronounced among the patients who presented asymptomatic for STI (28.6 vs 8.2%; aOR 4.7 [95% CI 1.4-15.5]).</p>

<p><strong>CONCLUSIONS: </strong>Providing sexual health survey-derived decision support to emergency department clinicians led to increased testing rates for STI in adolescents at high risk for infection, particularly in those presenting asymptomatic for infection. Studies to understand potential barriers to decision support adherence should be undertaken to inform larger, multicenter studies that could determine the generalizability of these findings and whether this process leads to increased STI detection.</p>

<p><strong>TRIAL REGISTRATION: </strong>ClinicalTrials.gov: NCT02509572.</p>

10.1016/j.jpeds.2016.12.045

J. Pediatr.

28081888

Healthcare system supports for young adult patients with pediatric onset chronic conditions: a qualitative study.

2015

126-32

2015 Jan-Feb

1532-8449

<p>Over 90% of children with chronic conditions survive into adulthood necessitating primary care teams to care for adults with pediatric-onset chronic conditions. This study explores practice supports and barriers to care for this population via qualitative techniques. Using in depth interviews with twenty-two healthcare providers practice supports identified include: formalizing intake processes, interoperable electronic medical records, and leveraging care coordination. Barriers identified included: definition of the medical team, lack of appropriate medical records, time and administrative burden, lack of training, and financial constraints. Themes may be utilized to design interventions and improve care coordination for patients with pediatric-onset chronic conditions.</p>

10.1016/j.pedn.2014.09.015

J Pediatr Nurs

25450439

A qualitative assessment of reasons for nonurgent visits to the emergency department: parent and health professional opinions.

2012

220-5

2012 Mar

1535-1815

<p><strong>OBJECTIVE: </strong>Each day, children incur more than 69,000 emergency department (ED) visits, with 58% to 82% of them for nonurgent reasons. The objectives of this study were to elicit and to describe guardians' and health professionals' opinions on reasons for nonurgent pediatric ED visits.</p>

<p><strong>METHODS: </strong>Focus groups sessions were held with 3 groups of guardians, 2 groups of primary care practitioners, and 1 group of pediatric emergency medicine physicians. Participants identified unique factors and their importance related to nonurgent ED use.</p>

<p><strong>RESULTS: </strong>A total of 25 guardians and 42 health professionals participated. Guardians had at least 1 child younger than 5 years, most were self-identified racial/ethnic minorities, and nearly all had taken a child to an ED. Guardians focused on perceived illness severity in their children and needs for diagnostic testing or other interventions, as well as accessibility and availability at times of day that worked for them. Professionals focused on systems issues concerning availability of appointments, as well as parents' lack of knowledge of medical conditions and sense of when use of the ED was appropriate.</p>

<p><strong>CONCLUSIONS: </strong>Guardians' concerns about perceptions of severity of illness in children and their schedules must be considered to effectively reduce nonurgent ED use, which may differ from the perceptions of professionals. Health professionals and systems seeking ways to decrease ED utilization may be able to better match capacity to demand both by increasing accessibility to primary care and by working to overcome guardians' perceptions that only EDs can handle acute illnesses or injuries.</p>

10.1097/PEC.0b013e318248b431

Pediatr Emerg Care

22344210

Parent willingness to remind health care workers to perform hand hygiene.

2013

492-6

2013 Jun

1527-3296

<p><strong>BACKGROUND: </strong>Health care worker (HCW) hand hygiene (HH) is the core strategy to prevent health care-associated infections (HAI). Suboptimal HCW HH rates continue despite hospital efforts to increase compliance.</p>

<p><strong>OBJECTIVES: </strong>To determine whether parents of hospitalized children perceive they have a role in preventing HAI and whether they are willing to remind HCW to perform HH, with and without an invitation.</p>

<p><strong>METHODS: </strong>We conducted structured interviews of parents of children admitted to a pediatric hospital. Questions assessed knowledge, attitudes, and behaviors about HAI and HH. The primary outcome was willingness to remind a HCW to do HH (5-point Likert scale).</p>

<p><strong>RESULTS: </strong>We interviewed 115 parents, of whom 84% were aware of HAI. Most parents (78%) perceived HH as the most important practice to prevent HAI. However, only 67% would definitely remind a HCW to perform HH. Importantly, 92% said that an invitation from a HCW would make them more likely to remind a HCW to do HH in the future.</p>

<p><strong>CONCLUSION: </strong>Our results suggest that parents of hospitalized children are willing to help prevent HAI; however one-third are still reluctant to remind HCW to perform HH. An invitation by HCW to parents to remind HCW to perform HH might effectively engage parents as partners in HAI prevention.</p>

10.1016/j.ajic.2012.08.006

Am J Infect Control

23261347