Rural Perspectives on Health Services for Transgender and Gender Diverse Youth

As the world grows more diverse, physicians and public health practitioners must become adept at providing care to everyone, including people who identify as transgender or gender diverse (TGD). Although this population is growing in all age demographics, there is a large increase in young TGD individuals who require pediatric health care providers to improve their practices. While a few comprehensive care clinics have been established to serve the TGD community, they are mostly located in urban areas. In addition to the unique barriers faced by rural TGD youth, providers must care for their patients with limited resources. In this commentary, we offer a set of recommendations to improve provider education, build connections between the health system and community, address the fragmentation of health services in rural areas and improve the transition from pediatric to adult health care.

Prematurity, birth weight, and access to a medical home among school-aged children in the US: A cross-sectional survey

Introduction

Prematurity and low birth weight (LBW) are associated with higher health care needs and higher health care utilization in the first few years of life. The aim of this cross-sectional study was to determine how prematurity and LBW were correlated with access to a medical home later in childhood, at ages 6–17 years.

Methods

Data were analyzed from the 2016–2018 National Survey of Children's Health. Non-institutionalized US children 6–17 years of age who had been born preterm were classified as very low birth weight (VLBW, <1500 g), LBW (1500–2500 g), and normal weight (NBW, >2500 g). Term-born NBW children were included as a reference group. Medical home access was determined according to caregiver report.

Results

The analysis included 64,597 infants (preterm VLBW n  =  737; preterm LBW n  =  2869; preterm NBW n  =  3942; and term NBW n  =  57,049). Based on this sample, 44% of children ages 6–17 years were estimated to receive care meeting the criteria of a medical home. On multivariable analysis, none of the preterm groups had higher likelihood of receiving care in a medical home compared to children born at term and NBW (odds ratios ranging from 0.75 to 0.95).

Conclusions

School-aged children born preterm and LBW were equally or less likely to receive care meeting the criteria of a medical home than children born at term and NBW. Although prematurity and LBW are associated with increased health care use early in the life course, this does not appear sufficient to help children establish and maintain access to a medical home.

Telemedicine and Disparities in Visit Attendance at a Rural Pediatric Primary Care Clinic During the COVID-19 Pandemic

OBJECTIVE

To determine whether the introduction of telemedicine at a rural pediatric clinic was associated with reduced disparities in visit attendance.

METHODS

A retrospective cohort study was conducted of all clinic visits from 1 January 2019 to 31 December 2021. Visit types were divided into telemedicine visits, in-person urgent, and in-person non-urgent visits. Visits were stratified into periods based on the statewide pandemic response.

RESULTS

A total of 8,412 patients with 54,746 scheduled visits were analyzed. Visits were less likely to be completed for older patients, Black patients, and patients with Medicaid insurance than their counterparts. Despite a pandemic-era increase in telemedicine utilization, disparities in visit completion that were present in the pre-pandemic era persisted after stay-at-home orders were lifted.

DISCUSSION

The adoption of telemedicine did not reduce pre-existing disparities in visit attendance. Further work is needed to identify the reasons for the disparities and improve visit attendance of historically disadvantaged patient populations.

Development of necrotizing enterocolitis after blood transfusion in very premature neonates

BACKGROUND

Prior studies report conflicting evidence on the association between packed red blood cell (PRBC) transfusions and necrotizing enterocolitis (NEC), especially in early weeks of life where transfusions are frequent and spontaneous intestinal perforation can mimic NEC. The primary objective of this study was to evaluate the association between PRBC transfusions and NEC after day of life (DOL) 14 in very premature neonates.

METHODS

A retrospective cohort analysis of very premature neonates was conducted to investigate association between PRBC transfusions and NEC after DOL 14. Primary endpoints were PRBC transfusions after DOL 14 until the date of NEC diagnosis, discharge, or death. Wilcoxon ranked-sum and Fisher's exact tests, Cox proportional hazards regression, and Kaplan-Meier curves were used to analyze data.

RESULTS

Of 549 premature neonates, 186 (34%) received transfusions after DOL 14 and nine (2%) developed NEC (median DOL = 38; interquartile range = 32-46). Of the nine with NEC after DOL 14, all were previously transfused (P < 0.001); therefore, hazard of NEC could not be estimated. Post hoc analysis of patients from DOL 10 onward included five additional patients who developed NEC between DOL 10 and DOL 14, and the hazard of NEC increased by a factor of nearly six after PRBC transfusion (hazard ratio = 5.76, 95% confidence interval = 1.02-32.7; P = 0.048).

CONCLUSIONS

Transfusions were strongly associated with NEC after DOL 14. Prospective studies are needed to determine if restrictive transfusion practices can decrease incidence of NEC after DOL 14.

Ethnicity and trends in pediatric specialty care clinic attendance at an academic medical center in the rural southeastern US

Following the 2016 US Presidential election, immigration enforcement became more aggressive, with variation by state and region depending on local policies and sentiment. Increases in enforcement created an environment of risk for decreased use of health care services among especially among Latino families. of Hispanic ethnicity and/or from Latin American origin (as a group subsequently referred to as Latino). For Latino children with chronic health conditions, avoidance of routine health care can result in significant negative health consequences such as disease progression, avoidable use of acute health care services, and overall increased costs of care. To investigate for changes in visit attendance during the periods before and since increased immigration enforcement, we extracted data on children followed by subspecialty clinics of one healthcare system in the US state of North Carolina during 2015-2019. For each patient, we calculated the proportion of cancelled visits and no-show visits out of all scheduled visits during the 2016-2019 follow-up period. We compared patient characteristics (at the 2015 baseline) according to whether they cancelled or did not show to any visits in subsequent years by clinic and patient factors, including ethnicity. Data were analyzed using multinomial logistic regression of attendance at each visit, including an interaction between visit year and patient ethnicity. Among 852 children 1 to 17 years of age (111 of Latino ethnicity), visit no-show was more common among Latino patients, compared to non-Latino White patients; while visit cancellation was more common among non-Latino White patients, compared to Latino patients. There was no significant interaction between ethnicity and trends in visit no-show or cancellation. Although differences in pediatric specialty clinic visit attendance by patient ethnicity were seen at study baseline, changing immigration policy and negative rhetoric did not appear to impact use of pediatric subspecialty care.

Does greater distance from the hospital exacerbate socioeconomic barriers to neonatal intensive care unit clinic attendance?

Objective: To determine if distance from our Neonatal Intensive Care Unit (NICU) follow-up clinic exacerbated risk of clinic non-attendance in high-risk groups defined by socioeconomic status or medical complexity, as geographical distance from the hospital can affect attendance rates at NICU follow-up clinics. Patients and Methods: We retrospectively identified infants born between January 2014 and June 2018, and subsequently discharged from our 50-bed level IV NICU, which serves a predominantly rural population. Patients were included in our study if they had at least one NICU clinic follow-up visit scheduled at discharge. Distance to the clinic was calculated based on family ZIP code. Mixed-effects logistic regression analysis of attendance at each scheduled visit was used to identify independent associations and interactions with distance among study covariates. Results: We included 576 patients in our study, with 74% missing at least one clinic appointment, and 30% not attending any of the three appointments. Median distance between our hospital and families was 53 km. On multivariable analysis, neither distance nor other infant or family characteristics were associated with clinic non-attendance. Only interfacility transfer had a statistically significant interaction with distance and this association only reached statistical significance for patients living furthest from our center. Conclusions: NICU follow-up is important, but clinic attendance is poor. For families living furthest away, transfers of care during the infant's hospitalization may be associated with lower completion of recommended post-discharge follow-up. Further research is needed to understand how clinics can mitigate barriers to attendance.

Trends in Neighborhood Social Cohesion among Families with Children during the COVID-19 Pandemic

The onset of the coronavirus disease 2019 (COVID-19) pandemic had far-reaching economic and social consequences, affecting economic well-being, health, mobility, relationships, and daily routines. What effect did the COVID-19 pandemic have on neighborhood social cohesion? Drawing on data from the National Survey of Children's Health, the authors examine trends in neighborhood social cohesion as reported by caregivers of U.S. children from 2016 to 2021. Despite the substantial changes spurred by the COVID-19 pandemic, the authors find that the pandemic did not lead to a significant change in perceived neighborhood social cohesion. These findings reveal the durability of perceived neighborhood social cohesion, showing that it appears to be unaffected even by sizable changes in social and economic contexts. Moreover, the findings provide additional evidence of disparities in perceived neighborhood social cohesion across social groups and contribute to ongoing debates related to potential declines in neighborhood relationships.

PhysioCamp: Cultivating Leaders Throughout Medical School

To prepare medical students for leadership roles, medical student organizations should provide longitudinal leadership opportunities spanning the entire duration of the medical school curriculum. These long-term roles need to be adaptable to medical students' changing and busy schedules, provide a robust structure for communication, improve access to resources and mentors, and allow autonomy for individual decisions to facilitate effective engagement as a leader. We describe the design of a student-led organization, PhysioCamp, which facilitates opportunities for longitudinal medical student leadership through an internship program for high school graduates.

Pathway Programs in North Carolina: A Historical Perspective

To diversify the medical workforce, programs must be developed that enhance and prepare students from minoritized and underresourced communities to compete for admission to medical education. North Carolina has a rich history of providing pathway programs that assist minoritized students in developing into the physicians who will serve the communities from which they emerged.

In-person follow-up visit attendance after telemedicine visits

BACKGROUND

Although Coronavirus disease 2019 rapidly increased the use of telemedicine for pediatric primary care, vaccinations, screening tests, lab draws, and other procedures still require follow-up in-person visits. We investigated in-person follow-up rates after telemedicine visits at our primary care clinic, and what patient or visit characteristics were associated with non-completion of in-person follow-up.

METHODS

A retrospective cohort study was conducted of telemedicine visits completed between April and May 2020. A manual chart review was performed to determine which encounters required a follow-up in-person visit; and was tracked through August 2020. Bivariate comparisons were performed according to completion of in-person follow-up and multivariable analysis of follow-up visit attendance was performed using Cox proportional hazards regression.

RESULTS

Of 500 eligible encounters, 16% did not attend at least one in-person follow-up. The median time for follow-up was 2 days (IQR: 1, 6). Patients older than 1 year of age (32%, p= <0.001) and with Medicaid insurance (83%, p=0.019) were more likely to not complete a follow-up visit. The likelihood of completion was higher for Hispanic as compared to non-Hispanic Black patients (HR: 1.65; 95% CI: 1.28, 2.12; p<0.001) and patients requiring routine screening (HR: 1.40; 95% CI: 1.04, 1.89; p=0.028).

CONCLUSIONS

Not all required in-person follow-ups were completed after telemedicine visits, which could have negative impacts on children's health. Improving the transition between telemedicine and inperson follow-up of primary care can help ensure the quality of care provided in a telemedicine-first model.

Children's unmet need for mental health care within and outside metropolitan areas

BACKGROUND

Rural communities experience a lack of pediatric mental health providers. It is unclear if this leads to greater unmet needs for specialty mental health services among rural children.

METHODS

Data from the 2016-2019 National Survey of Children's Health were used to identify children aged 6-17 years with a mental health condition. Caregiver-reported need and receipt of specialty mental health care for their child (met need, unmet need, or no need) was compared according to residence in a Metropolitan Statistical Area (MSA).

RESULTS

The analysis included 13,021 children (14% living outside MSAs). Unmet need for mental health services was reported for 9% of children, with no difference by rural-urban residence (p = 0.940). Multivariable analysis confirmed this finding and identified urban children as less likely to have no need for mental health services, compared to rural children (relative risk ratio of no need vs. met need: 0.79; 95% confidence interval: 0.65, 0.95; p = 0.015).

CONCLUSION

Children with mental health conditions living in rural areas (outside MSAs) did not have higher rates of unmet needs for specialty mental health services, but they had lower rates of any caregiver-reported needs for such services. Further work is needed to examine caregivers' demand for pediatric specialty mental health services.

Impact of Faculty Training in Health Systems Science on Scholarly Presentation of Resident Physician and Fellow Quality Improvement Projects

The objective was to evaluate whether faculty participation in a Health Systems Science training program was associated with increased presentation and publication of quality improvement (QI) projects involving resident physicians and fellows at 1 institution. The authors evaluated annual, department-level counts of QI projects with resident physician or fellow involvement, presented locally or published, according to residency or fellowship program director and faculty participation in Teachers of Quality Academy. Ten clinical departments had 82 presentations and 2 publications. Each additional faculty member's participation in Teachers of Quality Academy increased the annual count of published or presented QI projects by 9% (P < 0.001). At this institution, participation in a Health Systems Science training program among clinical faculty improved engagement of resident physicians and fellows in local presentation of QI projects.

Factors associated with follow-up outside a transplant center among pediatric kidney transplant recipients

BACKGROUND

Transfer of follow-up care after pediatric kidney transplantation (KTx) may jeopardize quality of care and patient outcomes. We sought to determine if minority status and socioeconomic factors were associated with increased likelihood of follow-up outside a transplant center, and whether this transition of care was associated with worse long-term graft and patient survival.

METHODS

We performed an analysis of the United Network for Organ Sharing database, including children age < 18 years who received a kidney transplant between 2003 and 2018. Survival analysis (conditional on survival with functioning graft to 1 year) was performed using a Cox proportional hazards model where transfer of care (place of follow-up recorded as any setting other than a transplant center) was entered as a time-varying covariate.

RESULTS

The study included 10,293, of whom 2083 received care outside of a transplant center during follow-up. Medicare coverage, but not minority race/ethnicity or socioeconomic status, was associated with increased likelihood of follow-up outside a transplant center. Follow-up outside a transplant center was associated with a 10% increased hazard of death or graft failure (hazard ratio: 1.10; 95% confidence interval: 1.004, 1.21; p = 0.041).

CONCLUSION

Follow-up outside of a transplant center increased risk of poor outcomes, though the likelihood of receiving care outside a transplant center did not vary by race/ethnicity or socioeconomic status. Our results highlight the need to improve continuity of care after KTx and to further understand the mechanisms leading to poor survival rates among minority populations. A higher resolution version of the Graphical abstract is available as Supplementary information.

Provider Communication and Fever Protocol for Children With Sickle Cell Disease in the Emergency Department

OBJECTIVE

We assessed whether prior communication between pediatric hematologists and emergency department (ED) providers reduced time to administration of parenteral antibiotics for children with sickle cell disease presenting with fever.

METHODS

Patients 2 months to 21 years of age were retrospectively identified if they were followed up at our center's pediatric hematology clinic and presented to the pediatric ED with fever. Emergency department-hematology communication before patient arrival was ascertained by chart review. The primary outcome was time to administration of parenteral antibiotics after ED arrival, with 60 minutes being the recommended maximum.

RESULTS

Forty-nine patients were included in the analysis. Prior communication occurred in 43% of cases, with a median time to antibiotic administration of 79 minutes in this group (interquartile range, 59-142), compared with 136 minutes for patients without prior communication (interquartile range, 105-181 minutes; P = 0.012). The groups did not differ in hospital length of stay at the index visit.

CONCLUSIONS

Advance communication between the pediatric hematologist and ED physician was associated with reduced time to antibiotic administration for febrile children with sickle cell disease. Further interventions should be explored to achieve timely antibiotics administration within 60 minutes of ED arrival.

Well-child visit attendance of children who have experienced a parental COVID-19 diagnosis

BACKGROUND

Due to the COVID-19 pandemic, rates of well-child visit (WCV) attendance have significantly decreased. We wanted to see how a parent's positive diagnosis for COVID-19 affected a child's WCV attendance along with other factors. Therefore, we hypothesized that in families with at least 1 positive COVID-19 diagnosis, the rates of WCV attendance would be lower than in families that have not experienced COVID-19.

METHODS

Using National Health Interview Survey (NHIS) data from 2020, we analyzed sample adult responses for the sample child to questions about last WCV attendance. We included children whose parents completed the survey during quarters 3 and 4 of 2020. The outcome of this study was WCV attendance in the past 12 months with the exposure of interest being parental diagnosis of COVID-19.

RESULTS

In our sample (N=1,413), 91% of children attended a WCV in the past 12 months, and 5% had a parent with a positive COVID-19 diagnosis. On adjusted analysis, there was a negative but not statistically significant association between a parent with a positive COVID-19 diagnosis and WCV attendance (OR=0.32; 95% CI: 0.09, 1.20; p=0.092).

CONCLUSIONS

Nationwide, there has been a significant decrease in children attending recommended WCVs since the start of the pandemic. Having a parent test positive for COVID-19 may contribute to decreases in WCV attendance in traditional medical office settings. Alternative options exist that may improve WCV attendance; these include telemedicine or virtual visits, as well as visits completed in non-traditional settings such as mobile health clinics and school-based clinics. Further expansion of these options for WCVs must still take into account health disparities that exist among marginalized communities.

The Relationship Between Change in Employment Status, Insurance Coverage, and Graft Failure or Death After Kidney Transplant

Introduction: Early change of insurance coverage after kidney transplantation may be associated with worse graft outcomes. We examine how return to employment moderates the hazard of graft failure associated with exit from Medicare within 36 months after transplantation. Design: Patients undergoing kidney transplantation covered by Medicare between January 2005 and December 2016 were identified in the United Network for Organ Sharing (UNOS) database. A composite outcome of graft failure or death was analyzed across four groups: (1) no change in coverage within the first 3 years post-transplant, and no return to work (2) no change in coverage, return to work (3) change in coverage, no return to work (4) change in coverage, return to work. Results: The sample included 46 120 patients; 28% changed insurance coverage from Medicare posttransplant. Among patients who returned to work (36%), change in coverage from Medicare to other insurance was associated with lower hazard of death or graft failure (hazard ratio: 0.93; 95% confidence interval: 0.87, 0.99; P = 0.030). Conclusions: Exit from Medicare was associated with patient and graft survival greater than 3 years after transplant, depending on return to work. Among patients returning to work, changes in insurance from Medicare to private coverage were associated with favorable outcomes.

What Are the Factors Affecting Total Sleep Time During Video Polysomnography in Infants?

OBJECTIVE

The aim of the study is to investigate factors affecting total sleep time (TST) during infant polysomnography (PSG) and assess if <4 hours of TST is sufficient for accurate interpretation.

STUDY DESIGN

Overall, 242 PSGs performed in 194 infants <6 months of chronological age between March 2013 and December 2015 were reviewed to identify factors that affect TST, including age of infant, location and timing of study, presence of medical complexity, and presence of nasal tubes. A continuum of apnea-hypopnea index (AHI) in relation to TST was reviewed. Data were examined in infants who had TST <4 hours and low AHI.

RESULTS

Greater TST (p < 0.001) was noted among infants during nocturnal PSGs, at older chronological and post-menstrual ages, and without medical complexity. The presence of nasogastric/impedance probes reduced TST (p = 0.002). Elevated AHIs were identified even in PSGs with TST <4 hours. Short TST may have affected interpretation and delayed initial management in one infant without any inadvertent complications.

CONCLUSION

Clinical factors such as PMA and medical complexity, and potentially modifiable factors such as time of day and location of study appeared to affect TST during infant PSGs. TST < 4 hours can be sufficient to identify high AHI allowing physician interpretation.

KEY POINTS

· Less than 4 hours of TST is enough for interpretation of infant polysomnography.. · Shorter TST appears related to infant age, medical complexity, and higher apnea-hypopnea index.. · Modifiable factors seen with higher TST were time of day, environment, and presence of nasal tubes..

Timing and Persistence of Material Hardship Among Children in the United States

Objective

Screening for social determinants of health (SDH) has been widely adopted to identify child health risks associated with exposure to material hardship. Whereas SDH screening typically addresses a 12-month span, we sought to compare the prevalence of exposure to present (within the past year) as compared to recent (2–4 years ago) hardship among children in the United States.

Methods

We analyzed the 2014 Survey of Income and Program Participation, a nationally representative survey that interviewed participating households annually between 2014 and 2017. We included data from households with children in all waves. As of 2017, households were categorized as (1) experiencing present hardship (within the last year); (2) experiencing recent but not present hardship (any year between 2014 and 2016); and (3) experiencing no hardship over the 4-year period.

Results

Of 2422 households, 27% experienced present hardship and 29% experienced recent but not present hardship. Households presently experiencing hardship were more likely to have Medicaid insurance, less likely to be married, and had more children than families who had experienced recent hardship. However, these groups were similar on caregivers’ educational attainment, race/ethnicity, language spoken in the home, and age of the youngest child.

Conclusions

Our results suggest that clinical screening tools for SDH that use a 12-month time frame risk missing many children who have recently (within the past 4 years) experienced material hardship and may benefit from interventions to improve social support; a longer time frame could provide clinicians with valuable information for understanding social factors that impact child health and development.