Elevated Parental Stress Is Associated With Lower Self-Efficacy in Provider Communication During a Pandemic

BACKGROUND

Effective communication between physician and parent promotes a successful alliance with families. The association of parental stress with self-efficacy when communicating during parent-physician interactions is unknown in the context of a pandemic.

OBJECTIVES

Objectives of this study include quantifying and comparing the stress experienced by parents of hospitalized children before and after onset of the COVID-19 pandemic and examining the relationship of stress with self-efficacy in parent-physician communication during interactions throughout hospitalization.

METHODS

We conducted in-person surveys of parents of children aged 3 months to 17 years hospitalized at a quaternary-level children's hospital, before and after onset of COVID-19. Parents completed 2 validated tools: Parenting Stress Index (PSI-SF) and the Perceived Efficacy in Parent-Physician Interactions (PEPPI), measuring self-efficacy in communicating with physicians. Socioeconomic data were collected. Fisher exact test and t test were used to compare score proportions and means; linear regression was used to evaluate association between PSI-SF and PEPPI with confounder adjustments.

RESULTS

Forty-nine parents were recruited; the majority identified as non-White and female. An inverse relationship was noted between the total stress score and parental self-efficacy, which only attained statistical significance in the post-COVID-19 cohort (P = .02, multivariate P = .044). A significant increase in the mean was observed for subscale scores of Difficult Child (P = .019) and Parent-Child Dysfunctional Interaction after COVID-19 (P = .016).

CONCLUSIONS

Elevated parental stress is associated with decreased self-efficacy during parent-physician interactions and it worsened during the pandemic. Future studies should examine the effect of different communication styles on parental stress and self-efficacy during hospitalization.

Parents' Experiences and Needs Regarding Infant Sickle Cell Trait Results

BACKGROUND AND OBJECTIVE

Sickle cell trait (SCT) has reproductive implications and can rarely cause health problems. SCT counseling improves parent knowledge but is infrequently received by children with SCT compared with children with cystic fibrosis carrier status. There are no national guidelines on SCT disclosure timing, frequency, or counseling content. Parents' experiences with SCT disclosure and counseling are poorly understood but could inform the development of guidelines. We explored parents' experiences with and desires for SCT disclosure and counseling for their infants with SCT identified via newborn screening.

METHODS

Parents of infants 2 to 12 months old with SCT were recruited through a state newborn screening program for semistructured interviews to explore their experiences with and desires for SCT disclosure and counseling. Inductive thematic analysis was conducted.

RESULTS

Sixteen interviews were completed from January to August 2020. Most parents reported that SCT disclosure occurred soon after birth, in person, and by the child's physician. Five themes were identified: parent knowledge before child's SCT disclosure, family planning, the dynamics of SCT disclosure and counseling, emotions and actions after SCT disclosure, and parent desires for the SCT disclosure and counseling process. Two primary parent desires were revealed. Parents want more information about SCT, particularly rare symptomatology, and they want SCT counseling repeated once the child approaches adolescence.

CONCLUSION

Parents report receiving their child's SCT diagnosis in the early newborn period from their child's doctor but indicate they receive incomplete information. Opportunities exist in primary care pediatrics to better align SCT disclosure timing and counseling content with parent desires.

Pediatrician Adherence to Guidelines for Diagnosis and Management of High Blood Pressure

OBJECTIVES

To assess pediatrician adherence to the 2017 American Academy of Pediatrics' clinical practice guideline for high blood pressure (BP).

STUDY DESIGN

Pediatric primary care practices (n = 59) participating in a quality improvement collaborative submitted data for patients with high BP measured between November 2018 and January 2019. Baseline data included patient demographics, BP, body mass index (BMI), and actions taken. Logistic regression was used to test associations between patient BP level and BMI with provider adherence to guidelines (BP measurement, counseling, follow-up, evaluation).

RESULTS

A total of 2677 patient charts were entered for analysis. Only 2% of patients had all BP measurement steps completed correctly, with fewer undergoing 3-limb and ambulatory BP measurement. Overall, 46% of patients received appropriate weight, nutrition, and lifestyle counseling. Follow-up for high BP was recommended or scheduled in 10% of encounters, and scheduled at the appropriate interval in 5%. For patients presenting with their third high BP measurement, 10% had an appropriate diagnosis documented, 2% had appropriate screening laboratory tests conducted, and none had a renal ultrasound performed. BMI was independently associated with increased odds of counseling, but higher BP was associated with lower odds of counseling. Higher BP was independently associated with an increased likelihood of documentation of hypertension.

CONCLUSIONS

In this multisite study, adherence to the 2017 American Academy of Pediatrics' guideline for high BP was low. Given the long-term health implications of high BP in childhood, it is important to improve primary care provider recognition and management.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03783650.

Healthcare team communication training in the United States: A scoping review

The purpose of this literature review was to identify interventions designed to improve healthcare team communication in the United States. We conducted a review of peer-reviewed, English-language articles describing interventions aimed at improving healthcare team communication. We analyzed articles that met pre-specified inclusion and exclusion criteria and characterized who is testing communication interventions, the rationale for testing, and ways of measuring effectiveness. We descriptively categorized the strength and types of study findings. Thirty articles were retained in our analysis. Most assessments were conducted by academic medical centers, the Veterans Health Administration, and teaching hospitals. Interventions sought to improve teamwork, patient safety, clinical outcomes, costs of care, and enhance provider job satisfaction and well-being. Intervention strategies included didactic lectures, simulation, Crew Resource Management, quality improvement, or a combination of these approaches. The vast majority employed a pre-post survey design and measured outcomes using participant feedback. Many assessments failed to utilize a social science theory or communication-specific measures. Interventions with the best training content were conducted at academic medical centers, used a pre-post design, and utilized statistical analysis to analyze results. While interventions for improving healthcare team communication are diverse and have uneven effectiveness, early markers of success merit continued development and assessment.

Associations between adverse childhood experiences and need and unmet need for care coordination

Introduction

Children exposed to adverse childhood experiences (ACEs) may access multiple systems of care to address medical and social complexities. Care coordination (CC) optimizes health outcomes for children with special health care needs who often use multiple systems of care. Little is known about whether ACEs are associated with the need and unmet need for CC.

Methods

Use of the 2016–2017 National Survey of Children’s Health to identify children who saw ≥1 health care provider in the last 12 months. The study team used weighted logistic regression analyses to examine associations between 9 ACE types, ACE score, and need and unmet need for CC.

Results

In the sample ( N  = 39,219, representing 38,316,004 US children), material hardship (adjusted odds ratio (aOR), 1.50; 95% confidence interval (CI), 1.29–1.75), parental mental illness (aOR, 1.31; 95% CI, 1.07–1.60), and neighborhood violence (aOR, 1.33; 95% CI, 1.01–1.74) were significantly associated with an increased need for CC. Material hardship was also associated with an unmet need for CC (aOR, 2.37; 95% CI, 1.80–3.11). Children with ACE scores of 1, 2, 3, and ≥4 had higher odds of need and unmet need for CC than children with 0 ACEs.

Discussion

Specific ACE types and higher ACE scores were associated with the need and unmet need for CC. Evaluating the unique needs of children who endured ACEs should be considered in the design and implementation of CC processes in the pediatric health care system.

Clusters of adverse childhood experiences and unmet need for care coordination

BACKGROUND

The lack of consensus on how to measure ACEs limits our estimation of their impact on health outcomes and understanding of which ACE clusters drive unmet care coordination (CC) needs.

OBJECTIVES

1) Identify latent classes of ACEs among a representative group of U.S. children; 2) Examine the association between these classes and unmet needs for CC.

PARTICIPANT AND SETTING

Using the 2016-2017 National Survey of Children's Health, we sampled children ages 0-17 the who had seen >1 healthcare provider within 12 months (n = 38,758).

METHODS

We conducted latent class analyses and weighted logistic regression analyses to examine associations between latent classes and unmet need for CC.

RESULTS

We identified seven distinct classes: household poverty and parental divorce, household poverty and parental death, household poverty only, household substance abuse and witnessing violence, multiple ACEs, household poverty and child discrimination, and household poverty and household mental illness. Children in the following classes had the greatest odds of unmet need for CC: household poverty only (AOR 2.0; 95% CI, 1.42-2.84), household poverty and household mental illness (AOR 1.67; 95% CI, 1.15-2.44), multiple ACEs (AOR 2.31; 95% CI, 1.53-3.50), and household poverty and child discrimination (AOR 3.55; 95% CI, 1.71-7.37).

CONCLUSIONS

Children who experienced specific combinations of ACEs, have an increased risk of unmet need for CC, with those experiencing both poverty and discrimination having the highest odds of unmet need for CC. Discrimination widens the gap of unmet CC need for poor children.

COVID-19 Cliff Notes: A COVID-19 Multidisciplinary Care Compendium

As we pass the nearly 9 month mark of the coronavirus virus disease 2019 (COVID-19) pandemic in the United States, we sought to compile a brief multi-disciplinary compendium of COVID-19 information learned to date. COVID-19 is an active viral pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that confers high morbidity and mortality. COVID-19 has been associated with: pulmonary compromise and acute respiratory distress syndrome, thrombotic events, inflammation and cytokine, and post-infectious syndromes. Mitigation of these complications and expeditious therapy are a global urgency; this is brief summary of current data and management approaches synthesized from publications, experience, cross-disciplinary expertise (Figure 1).

Vulnerable Child Syndrome and Newborn Screening Carrier Results for Cystic Fibrosis or Sickle Cell

OBJECTIVES

To measure parental perceptions of child vulnerability, as a precursor to developing a population-scale mechanism to mitigate harm after newborn screening.

STUDY DESIGN

Participants were parents of infants aged 2-5 months. Parental perceptions of child vulnerability were assessed with an adapted version of the Vulnerable Baby Scale. The scale was included in the script for a larger study of telephone follow-up for 2 newborn blood screening samples (carrier status for cystic fibrosis or sickle cell hemoglobinopathy). A comparison sample was added using a paper survey with well-baby visits to an urban/suburban clinic.

RESULTS

Sample sizes consisted of 288 parents in the cystic fibrosis group, 426 in the sickle cell hemoglobinopathy group, and 79 in the clinic comparison group. Parental perceptions of child vulnerability were higher in the sickle cell group than cystic fibrosis group (P < .0001), and both were higher than the clinic comparison group (P < .0001). Parental perceptions of child vulnerability were inversely correlated with parental age (P < .002) and lower health literacy (P < .015, sickle cell hemoglobinopathy group only).

CONCLUSIONS

Increased parental perceptions of child vulnerability seem to be a bona fide complication of incidental newborn blood screening findings, and healthcare professionals should be alert to the possibility. From a public health perspective, we recommend routine follow-up after incidental findings to mitigate psychosocial harm.

How a baby with classic galactosemia was nearly missed: When the test succeeds but system fails

Newborn screening (NBS) is a well-established state-run public health program which has targeted the early identification of treatable diseases like classic galactosemia (CG) for over a decade. We describe the case of a symptomatic newborn with CG and an abnormal screen report, including positive DNA-based test, who still managed to fall through the cracks in a sub-optimally functioning NBS program, despite decades of screening experience. While much attention is paid to testing technology, this case illustrates basic minimum requirements a newborn screening program must fulfill to reliably identify and treat all affected individuals including minimum reporting requirements, case surveillance and a dedicated short-term follow-up program. In newborn screening, success is systematic.

Comparison of Video, App, and Standard Consent Processes on Decision-Making for Biospecimen Research: A Randomized Controlled Trial

Obtaining informed consent for bloodspot research from newborn screening is particularly challenging due to the hectic environment of the postnatal period and the relatively abstract nature of future, unspecified research on the biospecimens. A randomized controlled trial was conducted in three Michigan hospitals to compare two different consent processes (video and interactive tablet "app") with standard brochure-based consent in the Michigan BioTrust for Health. Results indicated higher knowledge scores for the video and app groups as well as significantly higher scores on satisfaction, amount of information, and clarity with the information provided. More research is needed to find the right amount of information for informed decision-making, and additional feasibility studies are needed to assess implementation strategies.

Primary Care Providers' Preferences and Concerns Regarding Specific Visual Displays for Returning Hemoglobin A1c Test Results to Patients

Purpose. Patient portals of electronic health record systems currently present patients with tables of laboratory test results, but visual displays can increase patient understanding and sensitivity to result variations. We sought to assess physician preferences and concerns about visual display designs as potential motivators or barriers to their implementation. Methods. In an online survey, 327 primary care physicians (>50% patient care time) recruited through the online e-community/survey research firm SERMO compared hemoglobin A1c (HbA1c) test results presented in table format to various visual displays (number line formats) previously tested in public samples. Half of participants also compared additional visual formats displaying target goal ranges. Outcome measures included preferred display format and whether any displays were unacceptable, would change physician workload, or would induce liability concerns. Results. Most (85%-89%) respondents preferred visual displays over tables for result communications both to patients tested for diagnosis purposes and to diagnosed patients, with a design with color-coded categories most preferred. However, for each format (including tables), 11% to 23% rated them as unacceptable. Most respondents also preferred adding goal range information (in addition to standard ranges) for diagnosed patients. While most physicians anticipated no workload changes, 19% to 32% anticipated increased physician workload while 9% to 28% anticipated decreased workload. Between 32% and 40% had at least some liability concerns. Conclusions. Most primary care physicians prefer visual displays of HbA1c test results over table formats when communicating results to patients. However, workload and liability concerns from a minority of physicians represent a barrier for adoption of such designs in clinical settings.

Vaccine administration error rates at a large academic medical center and its affiliated clinics - Familiarity matters

OBJECTIVE

The purpose of this study was to track and describe the absolute number of vaccine administration errors and corresponding error rates over time and by patient age and vaccine type.

METHODS

Total vaccines administered to patients aged 0 through 19 years 364 days from 1/1/2006 through 12/31/2017 at a large academic health system in the Midwest United States with primary, specialty and school-based clinics, and a pediatric hospital were obtained from an electronic medical record. Vaccine administration errors over the same time period for the same patient criteria were analyzed from the health system's incident reporting system and further compared to the frequency of all incidents reported. Vaccine administration error rates were calculated. Data were analyzed by patient age, vaccine type and year administered.

RESULTS

Of the 1,431,206 vaccine doses given, 552 vaccine administration errors were identified (0.04%). The highest error rates occurred in children aged 2, 3, and 19 years. Vaccine types with the highest error rate were Td, rabies and pneumococcal polysaccharide vaccines. Overall vaccine doses given and errors reported increased over the study period. However, the increase was disproportionate, resulting in an increase in the error rate initially followed by a stabilization at the end of the study period.

CONCLUSIONS

Vaccine administration errors are uncommon. The error rate appears to be stabilizing. Errors are more likely at ages when vaccines are not commonly given, with vaccines that have age-specific dosing and with vaccines that are given less often. This suggests more safety checks are needed for vaccines that are rarely used or given off-schedule, and manufacturers should avoid vaccines with age-specific dosing.

Misclassification of VLCAD carriers due to variable confirmatory testing after a positive NBS result

The Iowa Newborn Screening (NBS) Program began screening for very long-chain acyl-CoA dehydrogenase deficiency (VLCAD) in 2003. Untreated VLCAD can lead to liver failure, heart failure, and death. Current confirmatory testing recommendations by the American College of Medical Genetics (ACMG) for VLCAD list molecular and functional analysis (i.e., fibroblast fatty acid oxidation probe) as optional. This can lead to misclassification of VLCAD carriers as false positives. Iowa implemented a comprehensive VLCAD confirmatory testing algorithm at the beginning of 2016 that included both molecular and fibroblast analysis. Here, we compare the historic multi-algorithmic confirmatory testing protocol (2005-2016) to this comprehensive protocol (2016-2017). A metabolic specialist reviewed all medical records and NBS data for each out-of-range VLCAD that fell in each testing period. During the comprehensive testing period, 48,651 specimens were screened. Thirteen individuals with out-of-range C14:1 results were classified as follows after review: ten carriers, zero true positives, zero false positives, zero lost to follow-up, and four unable to assess carrier status. During the variable testing period, a total of 486,566 specimens were screened. Eighty-five individuals with out-of-range C14:1 were classified as follows: 45 carriers, two true positives, four false positives, four lost to follow-up, and 30 unable to assess carrier status. Our findings suggest that many out-of-range VLCAD cases that do not receive molecular confirmatory testing could be carriers mistakenly classified as false positives. We recommend comprehensive molecular and functional testing for all children with out-of-range VLCAD NBS results.

Newborn Screening Collection and Delivery Processes in Michigan Birthing Hospitals: Strategies to Improve Timeliness

Objectives This study aimed to determine which steps in the newborn screening collection and delivery processes contribute to delays and identify strategies to improve timeliness. Methods Data was analyzed from infants (N = 94,770) who underwent newborn screening at 83 hospitals in Michigan between April 2014 and March 2015. Linear mixed effects models estimated effects of hospital and newborn characteristics on times between steps in the process, whereas simulation explored how to improve timeliness through adjustments to schedules for the state laboratory and for specimen pickup from hospitals. Results Time from collection to receipt of arrival to the state laboratory varied greatly with collection timing (P < 0.001), with specimens collected on Friday or Saturday delayed an average of 9-12 h compared to other specimens. Simulation estimates shifting specimen pickup from 6 p.m. Sunday-Friday to 9 p.m. Sunday-Friday could lead to an additional 12.6% of specimens received by the Michigan laboratory within 60 h of birth. Conclusions for Practice The time between when a specimen is collected and received by the laboratory can be a significant bottleneck in the newborn screening process. Modifying hospital pickup schedules appears to be a simple way to improve timeliness.

An Assessment of Public Preferences for Newborn Screening Using Best-Worst Scaling

OBJECTIVE

To identify and quantify public preferences for attributes of newborn screening conditions.

STUDY DESIGN

We conducted an online national survey of the public (n = 502) to evaluate preferences for attributes of candidate newborn screening conditions. Respondents were presented with hypothetical condition profiles that were defined using 10 attributes with 2-6 levels per attribute. Participants indicated whether they would recommend screening for a condition and which condition attributes were most and least important when making this decision (best-worst scaling). Difference scores were calculated and stratified by condition recommendation (recommend or not recommend for screening). Regression analyses were used to evaluate the effect of attributes on choice to screen or not screen.

RESULTS

The number of babies diagnosed was important to those who would recommend newborn screening for a profile, and age at which the treatment would start was important to those who would not recommend newborn screening. Cost was considered to be a key attribute, and treatment effectiveness and impact of making the diagnosis through newborn screening were of low importance for both groups.

CONCLUSION

Public preferences identified through survey methods that provide an adequate baseline understanding of newborn screening can be used to inform newborn screening decisions.

Family History Collection Practices: National Survey of Pediatric Primary Care Providers

While family history (FH) collection is a core responsibility of pediatric primary care providers (PCPs), few details about this practice are known. We surveyed a random national sample of 1200 pediatricians and family medicine physicians about FH collection practices. A total of 86% of respondents (n = 289 pediatricians; n = 152 family medicine physicians) indicated that they collect a FH "always" or "most of the time" with 77% reporting collection at the first visit, regardless of whether it is a health maintenance or problem-focused visit. Less than half ask about relatives other than parents, siblings, or grandparents (36.3%). Among respondents, 42% routinely update the FH at every health maintenance visit while 6% updated FH at every visit. Pediatric PCPs use a variety of methods to collect a FH that is limited in scope and variably updated. Our results suggest that interventions are needed to help pediatric PCPs collect a systematic, efficient, and updated FH.

Graphics help patients distinguish between urgent and non-urgent deviations in laboratory test results

Objective: Most electronic health record systems provide laboratory test results to patients in table format. We tested whether presenting such results in visual displays (number lines) could improve understanding.

Materials and Methods: We presented 1620 adults recruited from a demographically diverse Internet panel with hypothetical results from several common laboratory tests, first showing near-normal results and then more extreme values. Participants viewed results in either table format (with a “standard range” provided) or one of 3 number line formats: a simple 2-color format, a format with diagnostic categories such as “borderline high” indicated by colored blocks, and a gradient format that used color gradients to smoothly represent increasing risk as values deviated from standard ranges. We measured respondents’ subjective sense of urgency about each test result, their behavioral intentions, and their perceptions of the display format.

Results: Visual displays reduced respondents’ perceived urgency and desire to contact health care providers immediately for near-normal test results compared to tables but did not affect their perceptions of extreme values. In regression analyses controlling for respondent health literacy, numeracy, and graphical literacy, gradient line displays resulted in the greatest sensitivity to changes in test results.

Discussion: Unlike tables, which only tell patients whether test results are normal or not, visual displays can increase the meaningfulness of test results by clearly defining possible values and leveraging color cues and evaluative labels.

Conclusion: Patient-facing displays of laboratory test results should use visual displays rather than tables to increase people’s sensitivity to variations in their results.

Effect of "Pink Eye" Label on Parents' Intent to Use Antibiotics and Perceived Contagiousness

Parents of children who presented for a pediatrics appointment responded to a clinical vignette that described a child with symptoms consistent with acute viral conjunctivitis. In a 2 × 2 randomized survey design, the physician in the vignette either used the term "pink eye" or "eye infection" to describe the symptoms, and either told parents that antibiotics are likely ineffective at treating the symptoms or did not discuss effectiveness. When the symptoms were referred to as "pink eye," parents remained interested in antibiotics, despite being informed about their ineffectiveness. By contrast, when the symptoms were referred to as an "eye infection," information about antibiotic ineffectiveness significantly reduced interest, Mdiff = 1.63, P < .001. Parents who received the "pink eye" label also thought that the symptoms were more contagious and were less likely to believe that their child could go to child care, compared with parents who received the "eye infection" label, Mdiff = 0.37, P = .38.

A Quality Improvement Collaborative to Improve Pediatric Primary Care Genetic Services

OBJECTIVE

To investigate if a national pediatric primary care quality improvement collaborative (QIC) could improve and sustain adherence with process measures related to diagnosis and management of children with genetic disorders.

METHODS

Thirteen practices in 11 states from the American Academy of Pediatrics' Quality Improvement Innovation Networks participated in a 6-month QIC that included regular educational opportunities, access to genetic professionals, and performance feedback. The QIC identified 11 aims related to improving diagnosis and management of children with genetic disorders. The practices evaluated adherence by reviewing patient records at baseline, monthly for 6 months (active improvement period), and then once 6 months after the QIC's conclusion to check for sustainability. Random intercept binomial regression models with practice level random intercepts were used to compare adherence over time for each aim.

RESULTS

During the active improvement period, statistically significant improvements in adherence were observed for 4 of the 7 aims achieving minimal data submission levels. For example, adherence improved for family histories created/maintained at health supervision visits documenting all components of the family history (6% vs 60%, P < .001), and for patients with specific genetic disorders who received recommended care (58% vs 85%, P < .001). All 4 of these aims also demonstrated statistically significant improvements during the sustainability period.

CONCLUSIONS

A national QIC reveals promise in improving and sustaining adherence with process measures related to the diagnosis and management of genetic disorders. Future research should focus on patient outcome measures and the optimal number of aims to pursue in QICs.

Framing optional genetic testing in the context of mandatory newborn screening tests

Background

Parents are increasingly faced with decisions about optional newborn bloodspot screening (NBS) despite no consistent policy for communicating information about such testing. We examined whether framing optional NBS alongside mandatory NBS influenced intention to participate in optional NBS.

Methods

For this Internet-administered study, 2,991 adults read a hypothetical vignette in which optional NBS for Duchenne muscular dystrophy (DMD) was either presented by itself (in isolation), alongside a description including the total number of mandatory NBS tests (“bundled” mandatory context), or alongside a listing of each mandatory NBS test (“unbundled” mandatory context). We assessed associations with participants’ intended participation using ordered logistic regression models, and associations with attitudes towards optional DMD NBS and subjective norms using Analysis of Variance.

Results

Participants were more likely to choose optional DMD NBS if they also read information about mandatory NBS (either bundled or unbundled) versus when DMD NBS was presented in isolation. Participants who read about optional DMD NBS in isolation also reported such testing to be less important and that they would worry more about the results than those who also saw mandatory NBS information.

Conclusions

Future NBS programs should pay attention to the framing of optional testing communication, as it influences parental behavior. Predictors of NBS uptake will become increasingly important as NBS programs continue expanding.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-015-0173-3) contains supplementary material, which is available to authorized users.

Parent and public interest in whole-genome sequencing

OBJECTIVE

The aim of this study was to assess the baseline interest of the public in whole-genome sequencing (WGS) for oneself, parents' interest in WGS for their youngest children, and factors associated with such interest.

METHODS

A random sample of adults from a probability-based nationally representative online panel was surveyed. All participants were provided basic information about WGS and then asked about their interest in WGS for themselves. Those participants who were parents were additionally asked about their interest in WGS for their children. The order in which parents were asked about their interest in WGS for themselves and for their child was randomized. The relationship between parent/child characteristics and interest in WGS was examined.

RESULTS

The overall response rate was 62% (55% among parents). 58.6% of the total population (parents and nonparents) was interested in WGS for themselves. Similarly, 61.8% of the parents were interested in WGS for themselves and 57.8% were interested in WGS for their youngest children. Of note, 84.7% of the parents showed an identical interest level in WGS for themselves and their youngest children. Mothers as a group and parents whose youngest children had ≥2 health conditions had significantly more interest in WGS for themselves and their youngest children, while those with conservative political ideologies had considerably less.

CONCLUSIONS

While US adults have varying interest levels in WGS, parents appear to have similar interests in genome testing for themselves and their youngest children. As WGS technology becomes available in the clinic and private market, clinicians should be prepared to discuss WGS risks and benefits with their patients.

Effects of undergoing multiplex genetic susceptibility testing on parent attitudes towards testing their children

BACKGROUND

Parents may pursue common disease risk information about themselves via multiplex genetic susceptibility testing (MGST) for their children.

PURPOSE

To prospectively assess whether parents who received MGST disclosed their test results to their child, intended to change the child's health habits, or have the child tested.

METHODS

Eighty parents who opted for free MGST completed an online survey about a child in their household before undergoing MGST and a follow-up telephone survey 3 months after receiving results.

RESULTS

Few parents (21 %) disclosed results to the child. Undergoing MGST was unrelated to intentions to change the child's health habits but did increase parental willingness to test the child. Greater willingness to test a child was associated with positive attitudes toward pediatric genetic testing and intentions to change the child's health habits.

CONCLUSION

The experience of receiving MGST had little impact on parents' perceptions or behaviors related to their minor child.

Primary care providers' experiences notifying parents of cystic fibrosis newborn screening results

This study examines primary care provider (PCP) experiences with the initial parental disclosure of cystic fibrosis (CF) newborn screening (NBS) results in order to identify methods to improve parent-provider communication during the CF NBS process. PCPs of infants who received positive CF NBS results participated in semistructured phone interviews. Interviews were analyzed using a qualitative content analysis. PCPs acknowledged the difficulty of "breaking bad news" to parents, and emphasized minimizing parental anxiety and maximizing parental understanding. PCPs used a variety of methods to notify parents, and shared varying information about the significance of the results. Variation in the method of parental notification, information discussed, and attention to parents' emotional needs may limit successful follow-up of children with positive CF NBS results. A multifaceted intervention to improve PCP knowledge, management, and communication could improve provider confidence, optimize information transfer, and minimize parental distress during the initial disclosure of CF NBS results.

Primary-care providers' perceived barriers to integration of genetics services: a systematic review of the literature

PURPOSE

We aimed to systematically review the literature to identify primary-care providers' perceived barriers against provision of genetics services.

METHODS

We systematically searched PubMed and ERIC using key and Boolean term combinations for articles published from 2001 to 2012 that met inclusion/exclusion criteria. Specific barriers were identified and aggregated into categories based on topic similarity. These categories were then grouped into themes.

RESULTS

Of the 4,174 citations identified by the search, 38 publications met inclusion criteria. There were 311 unique barriers that were classified into 38 categories across 4 themes: knowledge and skills; ethical, legal, and social implications; health-care systems; and scientific evidence. Barriers most frequently mentioned by primary-care providers included a lack of knowledge about genetics and genetic risk assessment, concern for patient anxiety, a lack of access to genetics, and a lack of time.

CONCLUSION

Although studies reported that primary-care providers perceive genetics as being important, barriers to the integration of genetics medicine into routine patient care were identified. The promotion of practical guidelines, point-of-care risk assessment tools, tailored educational tools, and other systems-level strategies will assist primary-care providers in providing genetics services for their patients.

Screening practices for identifying type 2 diabetes in adolescents

OBJECTIVE

To characterize pediatrician and family physician (FP) screening practices for type 2 diabetes among adolescents and to examine the impact of the 2010 American Diabetes Association (ADA) guidelines, recommending use of Hemoglobin A1c (HbA1c).

METHODS

We conducted a cross-sectional mail survey of a random sample of 1,400 U.S. pediatricians and FPs and we received 604 eligible responses. Our main outcome measure was the types of tests ordered by physicians, particularly HbA1c, when presented with a hypothetical scenario.

RESULTS

The overall response rate was 52% (57% for pediatricians and 48% for FPs). Fasting glucose and HbA1c were the most commonly ordered tests. Overall, at least 58% of physicians ordered HbA1c; 35% ordered HbA1c in conjunction with fasting tests; and 22% ordered HbA1c alone or with nonfasting tests. Only 38% of providers were aware of the new ADA recommended HbA1c screening guidelines. However, a majority (67%) said they would change their screening practices. In the context of the guidelines, 84% of physicians would now order HbA1c. Furthermore, there was a large increase in the proportion of physicians who would shift to using HbA1c only or with other nonfasting tests.

CONCLUSIONS

When screening adolescents for type 2 diabetes, providers are more likely to order HbA1c and order fewer fasting tests in response to the new ADA guidelines. HbA1c has lower sensitivity and higher costs than other testing modalities in children, therefore increasing uptake of this test (HbA1c) in children may have implications for both detection rates and healthcare costs.

Family history in primary care pediatrics

The family history has been called the first genetic test; it was a core element of primary care long before the current wave of genetics technologies and services became clinically relevant. Risk assessment based on family history allows providers to personalize and prioritize health messages, shifts the focus of health care from treatment to prevention, and can empower individuals and families to be stewards of their own health. In a world of rising health care costs, the family history is an important tool, with its primary cost being the clinician's time. However, a recent National Institutes of Health conference highlighted the lack of substantive evidence to support the clinical utility of family histories. Annual collection of a comprehensive 3-generation family history has been held up as the gold standard for practice. However, interval family histories targeted to symptoms and family histories tailored to a child's life stage (ie, age-based health) may be important and underappreciated methods of collecting family history that yield clinically actionable data and supplement existing family history information. In this article, we review the various applications, as well as capabilities and limitations, of the family history for primary care providers.

Genetic services and attitudes in primary care pediatrics

Given the integral role primary care pediatricians (PCPs) play in caring for children with genetic conditions, we aimed to identify current practices of PCPs regarding genetic patients, their attitudes toward genetic medical care and their choices regarding family history taking. We conducted an on-line survey of a national convenience sample of PCPs associated with the American Academy of Pediatrics' Quality Improvement Innovation Networks. Eighty-eight respondents (29% response rate) were included in the analysis. Seventy-four (86%) reported ordering genetic based tests three or less times annually. Eleven (13%) strongly agreed that they discuss with patients the potential risks, benefits, and limitations of genetic tests. Forty-three (49%) agreed or strongly agreed that they feel competent in providing healthcare to patients related to genetics and genomics. Perceived competence was not associated with more recent training (P = 0.29), number of genetic tests ordered annually (P = 0.84) or mean number of weekly patient encounters (P = 0.15). 100% of participants stated that taking a family history is important. 27 (31%) agreed or strongly agreed that they gather a minimum of a three-generation family history. Forty-one of the 63 participants with an electronic health record (65%) reported their system was fair or poor in its ability to easily capture a three-generation family history. PCPs interested in quality improvement reported variation in care practices for children with genetic diseases and a majority did not feel competent to provide genetic related healthcare. Research should focus on improving the care and diagnosis of children with genetic disorders and enhanced integration of genetic medicine into routine primary preventative care.

Effects of hypothetical type 2 diabetes genetic testing on parents' efforts to prevent diabetes in children

OBJECTIVE

To examine the effect of hypothetical genetic susceptibility test results on diabetic parents' intention to prevent type 2 diabetes (T2D) in their children.

METHODS

Parents with T2D indicated their intention to prevent T2D in their youngest child at baseline and after a hypothetical positive and negative T2D genetic test result. We calculated mean/median "preventive intention scores" for each scenario and examined the association between parents' score change and parent/child characteristics.

RESULTS

A total of 63% of parents reported that their child had "almost no risk" or "slight risk" of developing T2D. Parents' median baseline preventive intention score was 8. It increased to 10 after a positive test result and decreased to 5 after a negative test result.

CONCLUSIONS

Negative T2D genetic susceptibility test results may decrease diabetic parents' intentions to prevent T2D for their children. Future research studies in a real-life clinical context should examine this phenomenon.

Growing up in the genomic era: implications of whole-genome sequencing for children, families, and pediatric practice

Whole-genome sequencing (WGS) has advanced to a point where it is beginning to be integrated into pediatric practice. With little consensus on how to maximize the benefits of WGS for children, there is a growing need for focused efforts that connect researchers, clinicians, and families to chart a path forward. To illustrate relevant concerns, two contrasting applications of pediatric WGS are explored: clinical use with children who have undiagnosed conditions, and population-based screening. Specific challenges for health care services, policy development, and the well-being of children are discussed in light of current research. In the interest of ensuring evidence-based pediatric WGS, strategies are identified for advancing our understanding of what it means for children to grow up with WGS results guiding their health care.

The perils of SNP microarray testing: uncovering unexpected consanguinity

BACKGROUND

Although single nucleotide polymorphism chromosomal microarrays identify areas of small genetic deletions or duplications, they can also reveal regions of homozygosity indicative of consanguinity. As more nongeneticists order single nucleotide polymorphism microarrays, they must prepare for the potential ethical, legal, and social issues that result from revelation of unanticipated consanguinity.

PATIENT

We describe an infant with multiple congenital anomalies who underwent single nucleotide polymorphism microarray testing.

RESULTS

The results of the single nucleotide polymorphism microarray revealed several large regions of homozygosity that indicated identity by descent most consistent with a second-degree or third-degree relative mating (e.g., uncle/niece, half-brother/sister, first cousins). The mother was not aware of the test's potential to reveal consanguinity. When informed of the test results, she reluctantly admitted to being raped by her half-brother around the time of conception.

CONCLUSIONS

During the pretesting consent process, providers should inform parents that single nucleotide polymorphism microarray testing could reveal consanguinity. Providers must also understand the psychological implications, as well as the legal and moral obligations, that accompany single nucleotide polymorphism microarray results that indicate consanguinity.

Influence of "GERD" label on parents' decision to medicate infants

BACKGROUND

The factors that drive overtreatment of gastroesophageal reflux disease (GERD) are not well understood, but it has been proposed that the use of the "GERD" disease label could perpetuate use of medication in otherwise healthy infants.

METHODS

To determine if use of the disease label GERD influences parents' perceived need to medicate an infant, we surveyed parents in a general pediatric clinic. Parents were given a hypothetical clinical scenario describing an infant who cries and spits up excessively but is otherwise healthy. Using a 2 × 2 factorial design, parents were randomized to receive a scenario in which the doctor either gave a diagnosis of GERD or did not provide a disease label; additionally, half of parents were told that existing medications are probably ineffective, whereas the rest were not given any effectiveness information. We measured parent interest in medication, perception of illness severity, and appreciation of medication offer.

RESULTS

Parents who received a GERD diagnosis were interested in medicating their infant, even when they were told that the medications are likely ineffective. However, parents not given a disease label were interested in medication only when medication effectiveness was not discussed (and hence likely assumed).

CONCLUSIONS

Labeling an otherwise healthy infant as having a "disease" increased parents' interest in medicating their infant when they were told that medications are ineffective. These findings suggest that use of disease labels may promote overtreatment by causing people to believe that ineffective medications are both useful and necessary.

Anticipating the arrival of low-penetrance genetic testing to primary care medicine

Primary prevention is a pillar of primary care medicine. Furthermore, the identification of commonly occurring genetic mutations that confer only modest increases in disease risk (i.e., low-penetrance mutations or LPMs) is expanding our conception of how genetic testing supports prevention goals. To date, most predictive genetic testing has focused on identifying the minority of patients who carry mutations that significantly increase their risk for developing future disease (i.e., high-penetrance mutations or HPMs). Genetic tests for LPMs are more similar in structure and purpose to commonly used biomarker tests like lipid testing than to HPM testing. In the primary care setting, LPM testing will likely be presented to patients as one part of a multifactorial risk assessment that contains only a small amount of genetics-specific information. Consequently, preparing primary care clinicians for the anticipated use of LPM genetic tests will not require development of a completely new skill set but rather a re-conceptualization of both genetic testing and biomarker evaluation for primary prevention.

A risk score for identifying overweight adolescents with dysglycemia in primary care settings

OBJECTIVE

To develop a clinical risk scoring system for identifying adolescents with dysglycemia (prediabetes or diabetes) who need further confirmatory testing and to determine whether the addition of non-fasting tests would improve the prediction of dysglycemia.

STUDY DESIGN

A sample of 176 overweight and obese adolescents (10-17 years) had a history/physical exam, a 2-h oral glucose tolerance test, and non-fasting tests [hemoglobin A1c, 1-h glucose challenge test (GCT), and random glucose test] performed. Given the low number of children with diabetes, we created several risk scoring systems combining the clinical characteristics with non-fasting tests for identifying adolescents with dysglycemia and compared the test performance.

RESULTS

Sixty percent of participants were white and 32% were black; 39.2% had prediabetes and 1.1% had diabetes. A basic model including demographics, body mass index percentile, family history of diabetes, and acanthosis nigricans had reasonable test performance [area under the curve (AUC), 0.75; 95% confidence interval (95% CI), 0.68-0.82]. The addition of random glucose (AUC, 0.81; 95% CI, 0.75-0.87) or 1-h GCT (AUC, 0.82; 95% CI, 0.75-0.88) to the basic model significantly improved the predictive capacity, but the addition of hemoglobin A1c did not (AUC, 0.76; 95% CI, 0.68-0.83). The clinical score thresholds to consider for the basic plus random glucose model are total score cutoffs of 60 or 65 (sensitivity 86% and 65% and specificity 60% and 78%, respectively) and for the basic plus 1-h GCT model are total score cutoffs of 50 or 55 (sensitivity 87% and 73% and specificity 59% and 76%, respectively).

CONCLUSIONS

Pending a validation in additional populations, a risk score combining the clinical characteristics with non-fasting test results may be a useful tool for identifying children with dysglycemia in the primary care setting.

Lessons that newborn screening in the USA can teach us about biobanking and large-scale genetic studies

The intent in establishing newborn screening programs was not to create and sustain a large-scale genetic biobanks. Instead, newborn screening programs were designed as a public health program. As such, they have successfully screened millions of asymptomatic newborns for disease that, undiagnosed and untreated, would cause disability or death. However, historical decisions on retention of residual samples and technological innovation have forced these programs and their proponents to confront the prospect of biobanking and the conduct of large-scale genetic studies. We suggest that the challenges facing newborn screening can provide important lessons for other biobanking and large-scale genetic testing endeavors.

Ethical issues with newborn screening in the genomics era

Continued technological advances have made the prospect of routine whole-genome sequencing (WGS) imminent. To date, much of the discussion about WGS has focused on its application and use in clinical medicine. Relatively little attention has been paid to the potential integration of WGS into newborn screening programs. Given the structure and scope of these programs, it is possible that the early applications of WGS will occur in state-run newborn screening programs. Assessment of the pressing ethical issues currently facing the newborn screening community will provide insight into the challenges that lie ahead in the genomics era.

A policy impact analysis of the mandatory NCAA sickle cell trait screening program

OBJECTIVE

To estimate the impact of the mandatory National Collegiate Athletic Association (NCAA) sickle cell trait (SCT) screening policy on the identification of sickle cell carriers and prevention of sudden death.

DATA SOURCE

We used NCAA reports, population-based SCT prevalence estimates, and published risks for exercise-related sudden death attributable to SCT.

STUDY DESIGN

We estimated the number of sickle cell carriers identified and the number of potentially preventable sudden deaths with mandatory SCT screening of NCAA Division I athletes. We calculated the number of student-athletes with SCT using a conditional probability based upon SCT prevalence data and self-identified race/ethnicity status. We estimated sudden deaths over 10 years based on published attributable risk of exercise-related sudden death due to SCT.

PRINCIPAL FINDINGS

We estimate that over 2,000 NCAA Division I student-athletes with SCT will be identified under this screening policy and that, without intervention, about seven NCAA Division I student-athletes would die suddenly as a complication of SCT over a 10-year period.

CONCLUSION

Universal sickle cell screening of NCAA Division I student-athletes will identify a substantial number of sickle cell carriers. A successful intervention could prevent about seven deaths over a decade.

Commentary: Children and predictive genomic testing: disease prevention, research protection, and our future

Genetic testing offered by direct-to-consumer companies-herein referred to as "predictive genomic testing"--has come under federal scrutiny. Critics claim testing yields uninterpretable and potentially harmful information. Supporters assert individuals have a right to this information, which could catalyze preventive health actions. Despite contentions that predictive genomic testing is a tool of primary disease prevention, little discussion has focused on its use with children. This partly stems from concerns expressed in existing professional guidelines about the potential for psychological and behavioral harm to children engendered by predictive genetic tests for Mendelian diseases. Conducting research to understand the actual benefits and harms is important for policy development and practice guidance and can be ethically justified within the pediatric regulatory framework of research that offers a prospect of direct benefit. Child health psychologists are well poised to contribute to this research effort, and promote the translation of genomic discoveries to improve pediatric medicine.

False-positive newborn screening result and future health care use in a state Medicaid cohort

OBJECTIVE

To compare health care visit rates between infants with false-positive and those with normal newborn screening (NBS) results.

PATIENTS AND METHODS

We analyzed administrative claims of Medicaid-enrolled infants born in Michigan in 2006 and calculated the average number of outpatient, emergency department, and hospital visits for infants aged 3 to 12 months according to NBS results. We calculated an adjusted incidence rate ratio for each visit category, adjusting for covariates and accounting for interaction effects.

RESULTS

Of the 49,959 infants in the analysis, 818 had a false-positive NBS result. We noted a significant interaction between gestational age and NBS results. We found that preterm, but not term, infants with false-positive results had more acute outpatient visits than their counterparts with normal NBS results. We found no difference in adjusted rates of other visit types (emergency department, inpatient, outpatient well) between infants with false-positive and normal NBS results, regardless of gestational age.

CONCLUSIONS

Increased rates of acute outpatient visits among preterm infants with false-positive NBS screening results may be attributable to underlying chronic illness or parental anxiety. The absence of increased health care utilization among term infants may be unique to this Medicaid population or a subgroup phenomenon that was not detectable in this analysis.