(2014) Using parental perceptions of childhood allergic rhinitis to inform primary care management.
Objective: To describe parents’ experience with their child’s allergic rhinitis (AR) to inform management by the primary care provider (PCP).
Study Design: Two hundred parents with a child 7 to 15 years old with AR symptoms within the past 12-months completed a paper survey.
Results: The child’s AR was identified as a significant problem in spring (89.3%), fall (63.4%), summer (50.3%) and winter (21.4%); 51.3% had persistent disease. AR symptoms most commonly interfered with the child’s outdoor activities and sleeping, and frequently bothered the parent and other family members. Most parents (88.3%) wanted to know what their child was allergic to and had many concerns about treatment options. 62.9% had sought AR care from the PCP in the past 12 months.
Conclusions: Many families experience significant morbidity from their child’s AR and turn to their PCP for help. We identified opportunities for the PCP to reduce AR morbidity.
Asthma - PARTNER Study (2008-2013)
(2014) A cluster-randomized trial shows telephone peer coaching for parents reduces children's asthma morbidity.
Background: Childhood asthma morbidity remains significant,especially in low-income children. Most often, asthma management is provided by the child’s primary care provider.Objective: We sought to evaluate whether enhancing primary care management for persistent asthma with telephone-based peer coaching for parents reduced asthma impairment and risk in children 3 to 12 years old.
Methods: Over 12 months, peer trainers provided parents with asthma management training by telephone (median, 18 calls) and encouraged physician partnership. The intervention was evaluated in a cluster-randomized trial of 11 intervention and 11 usual care pediatric practices (462 and 486 families, respectively). Patient outcomes were assessed by means of telephone interviews at 12 and 24 months conducted by observers blinded to intervention assignment and compared by using mixed-effects models,controlling for baseline values and clustering within practices. In a planned subgroup analysis we examined the heterogeneity of the intervention effect by insurance type (Medicaid vs other).
Results: After 12 months, intervention participation resulted in 20.9 (95% CI, 9.1-32.7) more symptom-free days per child than in the control group, and there was no difference in emergency department (ED) visits. After 24 months, ED visits were reduced(difference in mean visits/child, 20.28; 95% CI, 20.5 to 20.02),indicating a delayed intervention effect. In the Medicaid subgroup, after 12 months, intervention participation resulted in 42% fewer ED visits (difference in mean visits/child, 20.50; 95%CI, 20.81 to 20.18) and 62% fewer hospitalizations (difference in mean hospitalizations/child, 20.16; 95% CI, 20.30 to 20.014).Reductions in health care use endured through 24 months.
Conclusions: This pragmatic telephone-based peer-training intervention reduced asthma impairment. Asthma risk was reduced in children with Medicaid insurance.
(2012) Partner randomized controlled trial: study protocol and coaching intervention.
Background: Many children with asthma live with frequent symptoms and activity limitations, and visits for urgent care are common. Many pediatricians do not regularly meet with families to monitor asthma control, identify concerns or problems with management, or provide self-management education. Effective interventions to improve asthma care such as small group training and care redesign have been difficult to disseminate into office practice.
Methods and Design: This paper describes the protocol for a randomized controlled trial (RCT) to evaluate a 12-month telephone-coaching program designed to support primary care management of children with persistent asthma and subsequently to improve asthma control and disease-related quality of life and reduce urgent care events for asthma care. Randomization occurred at the practice level with eligible families within a practice having access to the coaching program or to usual care. The coaching intervention was based on the transtheoretical model of behavior change. Targeted behaviors included 1) effective use of controller medications, 2) effective use of rescue medications and 3) monitoring to ensure optimal control. Trained lay coaches provided parents with education and support for asthma care, tailoring the information provided and frequency of contact to the parent's readiness to change their child's day-to-day asthma management. Coaching calls varied in frequency from weekly to monthly. For each participating family, follow-up measurements were obtained at 12- and 24-months after enrollment in the study during a telephone interview.
The primary outcomes were the mean change in 1) the child's asthma control score, 2) the parent's quality of life score, and 3) the number of urgent care events assessed at 12 and 24 months. Secondary outcomes reflected adherence to guideline recommendations by the primary care pediatricians and included the proportion of children prescribed controller medications, having maintenance care visits at least twice a year, and an asthma action plan. Cost-effectiveness of the intervention was also measured.
Discussion: Twenty-two practices (66 physicians) were randomized (11 per treatment group), and 950 families with a child 3-12 years old with persistent asthma were enrolled. A description of the coaching intervention is presented.
Asthma - Telephone Coaching (2004-2009)
(2013) A telephone coaching intervention to improve asthma self-management behaviors.
Long recognizing that asthma, one of the most common chronic childhood diseases, is difficult to manage, the National Asthma Education Prevention Program developed clinical practice guidelines to assist health care providers, particularly those in the primary care setting. Yet, maintenance asthma care still fails to meet national standards. Therefore, in an attempt to improve and support asthma self-management behaviors for parents of children 5 to 12 years of age with persistent asthma, a novel nurse telephone coaching intervention was tested in a randomized, controlled trial. A detailed description of the intervention is provided along with parent satisfaction results, an overview of the training used to prepare the nurses, and a discussion of the challenges experienced and lessons learned.
(2010) Telephone coaching for parents of children with asthma: impact and lessons learned.
Objective: To determine whether an asthma coaching program can improve parent and child asthma-related quality of life (QOL) and reduce urgent care events.
Design: Randomized controlled trial of usual care vs usual care with coaching. Comparisons were made between groups using mixed models.
Setting: A Midwest city.
Participants: A community-based sample of 362 families with a child aged 5 to 12 years with persistent asthma.
Intervention: A 12-month structured telephone coaching program in which trained coaches provided education and support to parents for 4 key asthma management behaviors.
Main Outcome Measures: Parental and child QOL measured with a validated, interview-administered, 7-point instrument and urgent care events in a year (unscheduled office visits, after-hours calls, emergency department visits, or hospitalizations) determined by record audit.
Results: Parental asthma-related QOL scores improved by an average of 0.67 units (95% confidence interval [CI], 0.49 to 0.84) in the intervention group and 0.28 units (95% CI, 0.10 to 0.46) in the control group. The difference between study groups was statistically significant (difference, 0.38; 95% CI, 0.14 to 0.63). No between-group difference was found in the change in the child's QOL (difference, -0.17; 95% CI, -0.47 to 0.12) or in the mean number of urgent care events per year (difference, 1.15; 95% CI, 0.82 to 1.61). The proportion of children with very poorly controlled asthma in the intervention group decreased compared with the control group (difference, 0.34; 95% CI, 0.21 to 0.48).
Conclusions: A telephone coaching program can improve parental QOL and can be implemented without additional physician training or practice redesign.
(2009) Collaboration With Pediatric Call Centers for Patient Recruitment.
Recruitment of study subjects who are representative of community members is difficult. We describe our experience with a novel approach to subject recruitment for consideration by other investigators involved in community-based research.
(2009) Socioeconomic, family, and pediatric practice factors that affect level of asthma control.
Background: Multiple issues play a role in the effective control of childhood asthma.
Objective: To identify factors related to the level of asthma control in children receiving asthma care from community pediatricians.
Patients and Methods: Data for 362 children participating in an intervention study to reduce asthma morbidity were collected by a telephone-administered questionnaire. Level of asthma control (well controlled, partially controlled, or poorly controlled) was derived from measures of recent impairment (symptoms, activity limitations, albuterol use) and the number of exacerbations in a 12-month period. Data also included demographic characteristics, asthma-related quality of life, pediatric management practices, and medication usage. Univariable and multivariable analyses were used to identify factors associated with poor asthma control and to explore the relationship between control and use of daily controller medications.
Results: Asthma was well controlled for 24% of children, partially controlled for 20%, and poorly controlled for 56%. Medicaid insurance, the presence of another family member with asthma, and maternal employment outside the home were significant univariable factors associated with poor asthma control. Medicaid insurance had an independent association with poor control. Seventy-six percent of children were reported by parents as receiving a daily controller medication. Comparison of guideline recommended controller medication with current level of asthma control indicated that a higher step level of medication would have been appropriate for 74% of these children. Significantly lower overall quality-of-life scores were observed in both parents and children with poor control.
Conclusions: Despite substantial use of daily controller medication, children with asthma continue to experience poorly controlled asthma and reduced quality of life. Although Medicaid insurance and aspects of family structure are significant factors associated with poorly controlled asthma, attention to medication use and quality-of-life indicators may further reduce morbidity.
Childhood Obesity (2012-2015)
(2014) Opportunities to Reduce Children’s Excessive Consumption of Calories From Beverages.
Objective: To describe children’s consumption of sugar-sweetened beverages (SSBs) and 100% fruit juice (FJ), and identify factors that may reduce excessive consumption.
Design: A total of 830 parents of young children completed a 36-item questionnaire at the pediatricians’ office.
Results: Children consumed soda (62.2%), other SSBs (61.6%), and FJ (88.2%): 26.9% exceeded the American Academy of Pediatrics’ recommended daily FJ intake. 157 (18.9%) children consumed excessive calories (>200 kcal/d) from beverages (median = 292.2 kcal/d, range 203.8-2177.0 kcal/d). Risk factors for excessive calorie consumption from beverages were exceeding recommendations for FJ (odds ratio [OR] = 119.7, 95% confidence interval [CI] = 52.2-274.7), being 7 to 12 years old (OR = 4.3, 95%CI = 1.9-9.9), and having Medicaid insurance (OR = 2.6, 95%CI = 1.1-6.0). Parents would likely reduce beverage consumption if recommended by the physician (65.6%).
Conclusions: About 1 in 5 children consumes excessive calories from soda, other SSBs and FJ, with FJ the major contributor.
(2013) The comparative effectiveness of prednisolone and dexamethasone for children with croup: A community-based randomized trial.
Background: Although common practice, evidence to support treatment of croup with prednisolone is scant.
Methods: We conducted a community-based randomized trial to compare the effectiveness of prednisolone (2mg/kg/day for 3 days, n=41) versus one dose of dexamethasone (0.6 mg/kg) and two doses of placebo (n=46). Participants were children 1–8 years of age with croup symptoms ≤48hr, categorized as mild (42%) or moderate (58%).
Results: There were no differences for those treated with dexamethasone or prednisolone for additional healthcare for croup (2% vs. 7%, p=0.34), duration of croup symptoms (2.8 days vs. 2.2 days, p=0.63), non-barky cough (6.1 days vs. 5.9 days, p=0.81), nights with disturbed sleep for the parent (0.68 nights vs. 1.21 nights, p=0.55), and days with stress (1.39 days vs. 1.56 days, p=0.51).
Conclusion: There were no detected differences in outcomes between the two croup treatments for either child or parent.
(2011) Providing Depression Care in the Medical Home: What Can We Learn from ADHD?
Introduction: Although many primary care providers (PCPs) are reluctant to manage adolescent depression,they commonly provide care for children with attention deficit hyperactivity disorder (ADHD).1, 2 We sought to describe differences in care for these common diseases in order to identify opportunities to improve depression care.
Methods: PCPs from the St. Louis area completed a 29-item self-administered, mailed questionnaire (see eQuestionnaire). Questions assessed attitudes towards and behaviors regarding screening, diagnosis, and management of depressed adolescent patients. Four-point categorical scales were used to indicate agreement with attitudinal statements and confidence in delivery of depression care. Respondents also agreed or disagreed with statements about care for depression and ADHD. Washington University Human Research Protection Office approved the study.
Results: Of the respondents (100 pediatricians, 4 PNPs, 45% response), 96% wanted to improve the care they provided and 47% agreed (strongly agree or agree) that adolescent depression should be cared for in the medical home. PCPs cared for few of their depressed patients (median 5%, IQR 0–25%), although many reported frequent problems accessing psychiatry (83%) and psychotherapy (46%). Patients were identified by parental (median 50%, IQR 10–88%) or patient complaint (median 30%, IQR 0–70%); only 4% of PCPs used a validated screening tool at annual visits. PCPs lacked confidence (not very or not confident) in interpreting screening tools (43%), assessing suicide risk (37%), providing supportive counseling (60%), and monitoring treatment response (39%), and 74% suggested additional training was needed.
In contrast, PCPs cared for almost all their patients with ADHD (80%, IQR 70–90%) and felt adequately trained and confident to do so (Table 1). The difference in agreement that easy-to-use guidelines are available for these two disorders is notable.
The majority felt effective safe treatments were available for ADHD and depression. Although 67% prescribed selective serotonin reuptake inhibitors (SSRIs), 65% were reluctant due to concern about the Black Box warning (40%), unfamiliarity with use (29%), and fear of litigation (24%).
Electronic Cigarettes (2014-2015)
(2015) Parental Use of Electronic Cigarettes
Objective: To describe parental use of electronic cigarettes (e-cigs) to better understand the safety risks posed to children.
Methods: Between June 24 and November 6, 2014, parents completed a self-administered paper survey during an office visit to 15 pediatric practices in a Midwestern practice-based research network. Attitudes towards and use of e-cigs are reported for those aware of e-cigs before the survey.
Results: Ninety-five percent (628 of 658) of respondents were aware of e-cigs. Of these, 21.0% (130 of 622) had tried e-cigs at least once, and 12.3% (77) reported e-cig use by ≥1 person in their household (4.0% exclusive e-cig use, 8.3% dual use with regular cigarettes). An additional 17.3% (109) reported regular cigarette use. Most respondents from e-cig-using homes did not think e-cigs were addictive (36.9% minimally or not addictive, 25.0% did not know). While 73.7% believed that e-liquid was very dangerous for children if they ingested it, only 31.2% believed skin contact to be very dangerous. In 36.1% of e-cig-using homes, neither childproof caps nor locks were used to prevent children's access to e-liquid. Only 15.3% reported their child's pediatrician was aware of e-cig use in the home.
Conclusion: E-cig use occurred in 1 in 8 homes, often concurrently with regular cigarettes. Many parents who used e-cigs were unaware of the potential health and safety hazards, including nicotine poisoning for children, and many did not store e-liquid safely. Pediatricians could provide education about e-cig associated safety hazards but are unaware of e-cig use in their patient's homes.
General Health Topics (2009-2011)
(2012) What are parents worried about? Health problems and health concerns for children.
Background: Patient-centered care requires pediatricians to address parents’ health concerns, but their willingness to solicit parental concerns may be limited by uncertainty about which topics will be raised. We conducted surveys of parents to identify current health-related issues of concern.
Methods: Participants rated 30 items as health problems for children in their community (large, medium, small, or no problem) and volunteered concerns for their own children.
Results: 1,119 parents completed the survey. Allergies (69%), lack of exercise (68%), asthma (65%), attention deficit hyperactivity disorder (65%), Internet safety (63%), obesity (59%), smoking (58%), and bullying (57%) were identified as important problems (large or medium), with variation among demographic subgroups. Concerns for their own children included healthy nutrition, obesity, and lack of exercise, healthy growth and development, safety and injury prevention, and mental health issues.
Conclusion: Parents’ health concerns for children are varied and may differ from those routinely addressed during well-child care.
Neonatal Jaundice (2009-2010)
(2012) Neonatal Cholestasis: Opportunities To Increase Early Detection
Objective: To describe primary care management of early and prolonged jaundice in otherwise-healthy term infants to identify opportunities to increase early diagnosis of cholestasis.
Methods: Community-based pediatricians in St Louis, Missouri completed a mailed, anonymous, 29-item survey to assess practice demographics, timing of routine newborn office visits, and the management of early and prolonged neonatal jaundice.
Results: A total of 108 of 230 (47%) of eligible physicians responded (mean years in practice, 15.3, SD, 9.4). More respondents were very familiar with national guidelines for management of early (49%) than prolonged (16%) neonatal jaundice. Eighty-six percent reported all newborns were checked with transcutaneous bilirubin before hospital discharge. For transcutaneous bilirubin results at 48 hours of 7, 10, 12 and 15 mg/dL, 1%, 26%, 70%, and 74% of respondents, respectively, would order a fractionated bilirubin. Although the first routine visit usually occurred in the first week after discharge, 25% of physicians reported the 2nd visit was routinely scheduled after 4 weeks of age. Ninety-four percent reported they would obtain a fractionated bilirubin for infants jaundiced beyond 4 weeks of age. If cholestasis was identified at 6 weeks of age, 32% would obtain additional testing without referral to a subspecialist.
Conclusions: Management of early and prolonged neonatal jaundice is variable. Current practices appear to miss opportunities for early diagnosis of cholestasis and referral that are unlikely to be addressed without redesigning systems of care.
Over-the-Counter Cough and Cold Medication Use (2008-2010)
(2009) Physician and Parent Response to the FDA Advisory About Use of Over-the-Counter Cough and Cold Medications.
Objective: The aim of this study was to assess the likely impact of the US Food and Drug Administration (FDA) advisory not to use over-the-counter (OTC) cough and cold products for children aged <2 years on care provided by pediatricians and parents.
Methods: A mailed survey was completed by 105 community pediatricians (53% response rate), and 1265 parents with children aged <12 years completed a self-administered survey while waiting for an office visit.
Results: All physicians were aware of the advisory; 75% agreed with it. Fifty-nine percent did not recommend OTC cough and cold products for children aged <2 years before the advisory, and 35% were less likely to do so afterward. Seventy-three percent of parents were aware of the advisory, 70% believed these products relieved symptoms, 68% did not believe they were dangerous, and 74% had them at home. After the advisory, 21% of parents were more likely to request an antibiotic from the doctor. Among the parents, 225 only had children aged <2 years and 695 only had children aged 2 to 11 years; of these parental groups, 53% and 10% of parents, respectively, did not use these products before the advisory, an additional 33% and 28%, respectively, were less likely to do so afterward, and 15% and 61%, respectively, would continue use them.
Conclusions: Pediatricians must be prepared for requests from parents for antibiotics and other remedies for symptom relief for their children with colds. As no effective alternatives are available, maybe nontreatment should be promoted.
Retail Clinics (2011-2013)
(2013) Pediatric Providers' Attitudes Toward Retail Clinics
Objective: To describe pediatric primary care providers’ attitudes toward retail clinics and their experiences of retail clinics use by their patients.
Study Design: A 51-item, self-administered survey from four pediatric practice-based research networks from the Midwestern United States, which gauged providers’ attitudes toward and perceptions of their patients’ interactions with retail clinics, and changes to office practice to better compete.
Results: A total of 226 providers participated (50% response). Providers believed that retail clinics were a business threat (80%) and disrupted continuity of chronic disease management (54%). Few (20%) agreed that retail clinics provided care within recommended clinical guidelines. Most (91%) reported that they provided additional care after a retail clinic visit (median 1–2 times per week) and 37% felt this resulted from suboptimal care at retail clinics “most or all of the time.” Few (15%) reported being notified by the retail clinic within 24 hours of a patient visit. Those reporting prompt communication were less likely to report suboptimal retail clinic care (OR 0.20, 95%CI 0.10 to 0.42) or disruption in continuity of care (OR 0.32, 95%CI 0.15 to 0.71). Thirty-six percent reported changes to office practice to compete with retail clinics (most commonly adjusting or extending office hours) and change was more likely if retail clinics were perceived as a threat (OR 3.70, 95%CI 1.56 to 8.76); 30% planned to make changes in the near future.
(2013) Parents' Experiences with Pediatric Care at Retail Clinics.
Objective: To describe the rationale and experiences of families with a pediatrician who also use retail clinics (RCs) for pediatric care.
Design: Cross-sectional study
Setting: 19 pediatric practices in a Midwestern practice-based research network Exposure—Self-administered paper survey Participants—Parents attending the pediatrician’s office
Outcome Measures: Parents’ experience with RC care for their children
Results: 1484 parents (92% response) completed the survey. Parents (23%) who used RC for pediatric care were more likely to report RC care for themselves (OR 7.79, 95% CI, 5.13 to 11.84), have > 1 child (OR 2.16, 95%CI 1.55 to 3.02), and be older (OR 1.05, 95%CI 1.03 to 1.08). Seventy-four percent first considered going to the pediatrician but reported they chose the RC because the RC had more convenient hours (37%), no office appointment was available (25%), they did not want to bother the pediatrician after hours (15%), or because the problem was not serious enough (13%). Forty-six percent of RC visits occurred between 8am and 4pm on weekdays or 8am and noon on the weekend. Most commonly, visits were reportedly for acute upper respiratory illnesses (34% sore throat, 26% ear infection, 19% colds or flu) and for physicals.