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Harris KW, Ray KN, Yu J. Family Caregivers of Children With Medical Complexity: Changes in Health-Related Quality of Life and Experiences of Care Coordination. Acad Pediatr 2024; 24:605-612. [PMID: 38061581 PMCID: PMC11056298 DOI: 10.1016/j.acap.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 11/17/2023] [Accepted: 11/29/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVE Examine the longitudinal association between family experiences of care coordination (FECC) and health-related quality of life (HR-QOL) for family caregivers of children with medical complexity (CMC). METHODS A longitudinal survey of family caregivers of CMC was completed between July 2018 and June 2020. Baseline data were collected at initial contact with a regional complex care center; follow-up data were collected 12 to 16 months later. Assessed receipt of care coordination and caregiver HR-QOL via FECC questionnaire and Center for Disease Control's HR-QOL-14 measure, respectively. Baseline and follow-up results were compared via McNemar's and Wilcoxon signed-rank tests. Relationships between changes in FECC and changes in HR-QOL were examined using multivariable logistic regression. RESULTS Of 185 eligible, 136 caregivers enrolled and completed baseline surveys (74%) and 103 (76% initial sample) follow-up surveys. Caregivers reported significant improvements in 8 of 9 FECC measures after 1 year of care within a complex care center (all P < .05). In contrast, caregiver HR-QOL (general health status, unhealthy days, symptom days) remained stable over the study period (all P > .05) except for monthly days of poor sleep (baseline vs follow-up median; 16 vs 15 [P = .05]). At both timepoints, >20% participants rated their general health status as fair-to-poor, and >50% reported frequent poor sleep and fatigue. No significant associations were observed between changes in FECC and changes in HR-QOL. CONCLUSIONS After receiving 1 year of care through a complex care center, CMC family caregivers report improvement in care coordination but not in HR-QOL. Caregivers' continued mentally unhealthy days and negative mental symptom days highlight the need for a directed intervention.
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Affiliation(s)
- Kelly W Harris
- Division of Palliative Medicine and Supportive Care (KW Harris and J Yu), Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pa.
| | - Kristin N Ray
- Division of General Academic Pediatrics (KN Ray), Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pa.
| | - Justin Yu
- Division of Palliative Medicine and Supportive Care (KW Harris and J Yu), Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pa.
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Schweiberger K, Hoberman A, Iagnemma J, Schoemer P, White GE, Wolfson D, Ray KN. Pediatric Primary Care Clinicians' Perspectives on Telemedicine Use, 2020 Versus 2021. Telemed J E Health 2024. [PMID: 38621152 DOI: 10.1089/tmj.2023.0507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
Objective: We examined the change in pediatric primary care clinician attitudes and perceptions about telemedicine after one year of telemedicine use. Methods: We administered a survey to pediatric primary care clinicians across 50 primary care practices in Pennsylvania in 2020 and 2021. Surveys were linked using a combination of deterministic and probabilistic matching. We used McNemar's test to compare change in responses from 2020 to 2021. Results: Among pediatric primary care clinicians surveyed in 2020 and 2021 (n = 101), clinicians agreed that telemedicine could always or usually deliver high-quality care for mental health (80% in 2020 and 78% in 2021), care coordination (77% in 2020 and 70% in 2021), acute care (33% in 2020 and 34% in 2021), or preventive care (25% in 2020 and 18% in 2021) and this did not significantly change. Clinician perceptions of usability, while high, declined over time with fewer endorsing ease of use (93% in 2020 and 80% in 2021) and reliability (14% in 2020 and 0% in 2021) over time. Despite this, 62% of clinicians agreed that they were satisfied with their use of telemedicine at both time points. Respondents anticipated positive impact on equity and timeliness of care from telemedicine use but did not anticipate positive impact across child health, health care delivery, or clinician experience. Perceptions across these domains did not change over time. Conclusions: With one year of telemedicine experience, primary care clinicians maintained beliefs that telemedicine could deliver high-quality care for specific clinical needs but had worsening perceptions of usability over time.
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Affiliation(s)
- Kelsey Schweiberger
- Division of General Academic Pediatrics, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alejandro Hoberman
- Division of General Academic Pediatrics, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- UPMC Children's Community Pediatrics, Wexford, Pennsylvania, USA
| | | | - Pamela Schoemer
- UPMC Children's Community Pediatrics, Wexford, Pennsylvania, USA
| | - Gretchen E White
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - David Wolfson
- UPMC Children's Community Pediatrics, Wexford, Pennsylvania, USA
| | - Kristin N Ray
- Division of General Academic Pediatrics, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- UPMC Children's Community Pediatrics, Wexford, Pennsylvania, USA
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Wittman SR, Hoberman A, Mehrotra A, Sabik LM, Yabes JG, Ray KN. Antibiotic Receipt for Pediatric Telemedicine Visits With Primary Care vs Direct-to-Consumer Vendors. JAMA Netw Open 2024; 7:e242359. [PMID: 38483387 PMCID: PMC10940962 DOI: 10.1001/jamanetworkopen.2024.2359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 01/23/2024] [Indexed: 03/17/2024] Open
Abstract
Importance Prior research found that pediatric direct-to-consumer (DTC) telemedicine visits are associated with more antibiotic prescribing than in-person primary care visits. It is unclear whether this difference is associated with modality of care (telemedicine vs in-person) or with the context of telemedicine care (primary care vs not primary care). Objective To compare antibiotic management during telemedicine visits with primary care practitioners (PCPs) vs commercial direct-to-consumer (DTC) telemedicine companies for pediatric acute respiratory tract infections (ARTIs). Design, Setting, and Participants This retrospective, cross-sectional study of visits for ARTIs by commercially insured children 17 years of age or younger analyzed deidentified medical and pharmacy claims in OptumLabs Data Warehouse data, a national sample of commercial enrollees, between January 1 and December 31, 2022. Exposure Setting of telemedicine visit as PCP vs DTC. Main Outcomes and Measures The primary outcome was percentage of visits with antibiotic receipt. Secondary outcomes were the percentages of visits with diagnoses for which prescription of an antibiotic was potentially appropriate, guideline-concordant antibiotic management, and follow-up ARTI visits within the ensuing 1 to 2 days and 3 to 14 days. The ARTI telemedicine visits with PCP vs DTC telemedicine companies were matched on child demographic characteristics. Generalized estimated equation log-binomial regression models were used to compute marginal outcomes. Results In total, data from 27 686 children (mean [SD] age, 8.9 [5.0] years; 13 893 [50.2%] male) were included in this study. There were 14 202 PCP telemedicine index visits matched to 14 627 DTC telemedicine index visits. The percentage of visits involving receipt of an antibiotic was lower for PCP (28.9% [95% CI, 28.1%-29.7%]) than for DTC (37.2% [95% CI, 36.0%-38.5%]) telemedicine visits. Additionally, fewer PCP telemedicine visits involved receipt of a diagnosis in which the use of antibiotics may be appropriate (19.0% [95% CI, 18.4%-19.7%] vs 28.4% [95% CI, 27.3%-29.6%]), but no differences were observed in receipt of nonguideline-concordant antibiotic management based on a given diagnosis between PCP (20.2% [95% CI, 19.5%-20.9%]) and DTC (20.1% [95% CI, 19.1%-21.0%]) telemedicine visits. Fewer PCP telemedicine visits involved a follow-up visit within the ensuing 1 to 2 days (5.0% [95% CI, 4.7%-5.4%] vs 8.0% [95% CI, 7.3%-8.7%]) and 3 to 14 days (8.2% [95% CI, 7.8%-8.7%] vs 9.6% [95% CI, 8.8%-10.3%]). Conclusions and Relevance Compared with virtual-only DTC telemedicine companies, telemedicine integrated within primary care was associated with lower rates of antibiotic receipt and follow-up care. Supporting use of telemedicine integrated within pediatric primary care may be one strategy to reduce antibiotic receipt through telemedicine visits.
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Affiliation(s)
- Samuel R. Wittman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Jonathan G. Yabes
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Burns SK, Krishnamurti T, Doan TT, Hanmer J, Hoberman A, Kahn JM, Schweiberger K, Ray KN. Parent Perceptions of Telemedicine for Acute Pediatric Respiratory Tract Infections: Sequential Mixed Methods Study. JMIR Pediatr Parent 2024; 7:e49170. [PMID: 38227360 PMCID: PMC10828946 DOI: 10.2196/49170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 11/01/2023] [Accepted: 12/13/2023] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Since 2020, parents have had increasing opportunities to use telemedicine for their children, but how parents decide whether to use telemedicine for acute pediatric care relative to alternative sites of care is not clear. One of the most common reasons parents seek acute care for their children is for acute respiratory tract infections (ARTIs). OBJECTIVE This study aims to examine parental expectations of care via telemedicine for pediatric ARTIs, contrasting expectations of care delivered via primary care telemedicine and direct-to-consumer (DTC) telemedicine. METHODS We performed a sequential mixed methods analysis to examine how parents assess telemedicine for their children's acute care. We used ARTIs as a case study for examining parent perceptions of telemedicine. First, we analyzed semistructured interviews focused on parent responses about the use of telemedicine. Each factor discussed by parents was coded to reflect whether parents indicated it incentivized or disincentivized their preferences for telemedicine versus in-person care. Results were organized by a 7-dimension framework of parental health care seeking that was generated previously, which included dimensions related to care sites (expected access, affordability, clinical quality, and site quality) and dimensions related to child or family factors (perceived illness severity, perceived child susceptibility, and parent self-efficacy). Second, we analyzed responses to a national survey, which inquired about parental expectations of primary care telemedicine, commercial DTC telemedicine, and 3 in-person sites of care (primary care, urgent care, and emergency department) across 21 factors identified through prior qualitative work. To assess whether parents had different expectations of different telemedicine models, we compared survey responses for primary care telemedicine and commercial DTC telemedicine using weighted logistic regression. RESULTS Interview participants (n=40) described factors affecting their perceptions of telemedicine as a care modality for pediatric ARTIs. Generally, factors aligned with access and affordability (eg, decreased wait time and lower out-of-pocket cost) were discussed as potential incentives for telemedicine use, while factors aligned with perceived illness severity, child susceptibility, and clinician quality (eg, trustworthiness) were discussed as potential disincentives for telemedicine use. In survey responses (n=1206), primary care and commercial DTC telemedicine were rated similarly on items related to expected accessibility and affordability. In contrast, on items related to expected quality of care, primary care telemedicine was viewed similarly to in-person primary care, while commercial DTC telemedicine was rated lower. For example, 69.7% (weighted; 842/1197) of respondents anticipated their children would be comfortable and cooperative with primary care telemedicine versus 49.7% (weighted; 584/1193) with commercial DTC telemedicine (P<.001). CONCLUSIONS In a mixed methods analysis focused on telemedicine for ARTIs, parents expressed more concerns about telemedicine quality in commercial DTC models compared with primary care-based telemedicine. These results could help health systems better design telemedicine initiatives to support family-centered care.
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Affiliation(s)
- Sarah K Burns
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Tamar Krishnamurti
- Department of Medicine, University Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Tran T Doan
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Janel Hanmer
- Department of Medicine, University Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Jeremy M Kahn
- Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, United States
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Kelsey Schweiberger
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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Hanmer J, Ray KN, Schweiberger K, Berkowitz SA, Palakshappa D. Accuracy of a Single Financial Security Question to Screen for Social Needs. Pediatrics 2024; 153:e2023062555. [PMID: 38037433 DOI: 10.1542/peds.2023-062555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVES Screening for social needs is recommended during clinical encounters but multi-item questionnaires can be burdensome. We evaluate if a single question about financial stress can be used to prescreen for food insecurity, housing instability, or transportation needs. METHODS We use retrospective medical record data from children (<11 years) seen at 45 primary pediatric care offices in 2022. Social needs screening was automated at well child visits and could be completed by the parent/guardian via the patient portal, tablet in the waiting room, or verbally with staff. We report the area under the receiver operating curve for the 5 response options of the financial stress question as well as sensitivity and specificity of the financial stress question ("not hard at all" vs any other response) to detect other reported social needs. RESULTS Of 137 261 eligible children, 130 414 (95.0%) had social needs data collected. Seventeen percent of respondents reported a housing, food, or transportation need. The sensitivity of the financial stress question was 0.788 for any one or more of the 3 other needs, 0.763 for food insecurity, 0.743 for housing instability, and 0.712 for transportation needs. Using the financial stress question as the first-step of a screening process would miss 9.7% of the families who reported food insecurity, 22.6% who reported housing instability, and 33.0% who reported transportation needs. CONCLUSIONS A single question screener about financial stress does not function well as a prescreen because of low sensitivity to reports of food insecurity, housing instability, and transportation needs.
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Affiliation(s)
- Janel Hanmer
- Department of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kristin N Ray
- Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kelsey Schweiberger
- Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Seth A Berkowitz
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Deepak Palakshappa
- Department of Internal Medicine, Wake Forest University, Winston-Salem, North Carolina
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Abstract
Chronic absenteeism is associated with poor health and educational outcomes. School nurses have great potential to address the health and educational needs that contribute to absenteeism. Through qualitative analysis of interviews with school nurses, we characterize their current role in reducing absenteeism and identify barriers 3 that limit their capacity to meet this goal, organized by the Framework for 21st Century School Nursing Practice. Interviewees (n = 23) identified actions perceived to reduce absenteeism aligned with domains of care coordination, leadership, quality improvement, and community and public health. Barriers perceived to limit the capacity of school nurses to address absenteeism were identified within these domains and ranged from student- and family-level to federal-level barriers. Specific healthcare system-level barriers included insufficient communication with community-based healthcare teams and the need for coordinated approaches across health and education sectors to address absenteeism. Strategic opportunities exist to address barriers to comprehensive school nursing practice and reduce absenteeism.
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Affiliation(s)
- Jacquelin Rankine
- Adolescent and Young Adult Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Lauren Goldberg
- Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Elizabeth Miller
- Adolescent and Young Adult Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Lori Kelley
- Pennsylvania Association of School Nurses and Practitioners, Sewickley, Pennsylvania, USA
| | - Kristin N. Ray
- Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
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Bohnhoff JC, Guyon-Harris K, Schweiberger K, Ray KN. General and subspecialist pediatrician perspectives on barriers and strategies for referral: a latent profile analysis. BMC Pediatr 2023; 23:576. [PMID: 37980515 PMCID: PMC10656818 DOI: 10.1186/s12887-023-04400-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 10/30/2023] [Indexed: 11/20/2023] Open
Abstract
BACKGROUND Children in need of pediatric subspecialty care may encounter multiple barriers, and multiple strategies have been suggested to improve access. The purpose of this study was to describe the perceptions of general and subspecialty pediatric physicians regarding barriers to subspecialty care and the value of strategies to improve subspecialty access. METHODS We surveyed a national sample of 1680 general pediatricians and pediatric subspecialists in May and June 2020 regarding 11 barriers to subspecialty care and 9 strategies to improve access to subspecialty care, selected from recent literature. Using latent profile analysis, respondents were grouped according to the degree to which they believed each of the barriers impacted access to subspecialty care. Using chi-squared tests, we compared the profiles based on respondent characteristics and perspectives on strategies to improve access. RESULTS The response rate was 17%. In 263 responses completed and eligible for inclusion, the barriers most frequently described as "major problems" were wait times (57%), lack of subspecialists (45%) and difficulty scheduling (41%). Respondents were classified into 4 profiles: "Broad concerns," "Subspecialist availability concerns," "Clinician communication concerns," and "Few concerns." These profiles varied significantly by respondent specialty (p < .001, with medical subspecialists overrepresented in the "Clinician communication" profile, psychiatrists in the "subspecialist availability" profile, and surgeons in the "few concerns" profile); and by respondents' typical wait time for appointments (p < .001, with physicians with the longest wait times overrepresented in the "subspecialist availability" profile). CONCLUSIONS We found specific profiles in clinician views regarding barriers to subspecialty care which were associated with perspectives on strategies aimed at overcoming these barriers. These results suggest that health systems aiming to improve subspecialty access should first identify the barriers and preferences specific to local clinicians.
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Affiliation(s)
- James C Bohnhoff
- Department of Pediatrics, Maine Health, 1577 Congress St Fl 1, Portland, ME, 04102, USA.
- Center for Interdisciplinary Population and Health Research, Maine Health Institute of Research, Scarborough, ME, USA.
- Department of Pediatrics, Tufts University School of Medicine, Boston, MA, USA.
| | - Katherine Guyon-Harris
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kelsey Schweiberger
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Division of General Academic Pediatrics, UPMC Childrens Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Division of General Academic Pediatrics, UPMC Childrens Hospital of Pittsburgh, Pittsburgh, PA, USA
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Burns SK, Krishnamurti T, Doan TT, Kahn JM, Ray KN. Parent Care-Seeking Decisions for Pediatric Acute Respiratory Tract Infections in the United States: A Mental Models Approach. Acad Pediatr 2023; 23:1326-1336. [PMID: 36871609 PMCID: PMC10475487 DOI: 10.1016/j.acap.2023.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 02/14/2023] [Accepted: 02/24/2023] [Indexed: 03/07/2023]
Abstract
OBJECTIVE To understand US parent health care-seeking decisions in the context of multiple in-person and telehealth care options. As the health care landscape evolves, new research is needed to explain how parents now decide when and where to seek acute pediatric health care. METHODS We applied a mental models approach, focusing on the archetypal example of care-seeking for pediatric acute respiratory tract infections (ARTIs), by first reviewing pediatric ARTI guidelines with 16 health care professionals to inform 40 subsequent semi-structured interviews with parents of young children in 2021. Interviews were qualitatively coded using thematic analysis, with code frequency and co-occurrence informing the final influence model of parent health care-seeking decisions. RESULTS Parent interviewees identified 33 decisional factors which were synthesized into seven dimensions influencing care-seeking decisions: perceived illness severity, perceived child susceptibility, parental self-efficacy, expected accessibility of care, expected affordability of care, expected quality of clinician, and expected quality of site. The first three dimensions (perceived severity, perceived susceptibility, parental self-efficacy) influenced an initial decision about whether to seek care, while all seven factors influenced a subsequent decision about where to seek care (eg, in-person primary care, primary care-based telehealth, urgent care, direct-to-consumer telehealth). Uncertainty was present within many dimensions (eg, severity, access, quality) indicating potential targets to support parent decision-making processes and optimize care-seeking behaviors. CONCLUSIONS A mental models approach identified dimensions influencing parent choice to seek care and choice of care site for children with ARTIs, suggesting targets to advance family-centered practice and policy.
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Affiliation(s)
- Sarah K Burns
- Department of Pediatrics (SK Burns, TT Doan, and KN Ray), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, PA.
| | - Tamar Krishnamurti
- Department of Medicine (T Krishnamurti), University of Pittsburgh School of Medicine, PA.
| | - Tran T Doan
- Department of Pediatrics (SK Burns, TT Doan, and KN Ray), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, PA.
| | - Jeremy M Kahn
- Department of Health Policy & Management (JM Kahn), University of Pittsburgh Graduate School of Public Health, PA; Department of Critical Care Medicine (JM Kahn), University of Pittsburgh School of Medicine, PA.
| | - Kristin N Ray
- Department of Pediatrics (SK Burns, TT Doan, and KN Ray), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, PA.
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Rankine J, Kidd KM, Sequeira GM, Miller E, Ray KN. Adolescent Perspectives on the Use of Telemedicine for Confidential Health Care: An Exploratory Mixed-Methods Study. J Adolesc Health 2023; 73:360-366. [PMID: 37227338 PMCID: PMC10524174 DOI: 10.1016/j.jadohealth.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 03/16/2023] [Accepted: 04/04/2023] [Indexed: 05/26/2023]
Abstract
PURPOSE Telemedicine can improve access to adolescent health care, but adolescents may experience barriers to accessing this care confidentially. Gender-diverse youth (GDY) may especially benefit from telemedicine through increased access to geographically limited adolescent medicine subspecialty care but may have unique confidentiality needs. In an exploratory analysis, we examined adolescents' perceived acceptability, preferences, and self-efficacy related to using telemedicine for confidential care. METHODS We surveyed 12- to 17-year-olds following a telemedicine visit with an adolescent medicine subspecialist. Open-ended questions assessing acceptability of telemedicine for confidential care and opportunities to enhance confidentiality were qualitatively analyzed. Likert-type questions assessing preference for future use of telemedicine for confidential care and self-efficacy to complete components of telemedicine visits confidentially were summarized and compared across cisgender versus GDY. RESULTS Participants (n = 88) included 57 GDY and 28 cisgender females. Factors affecting the acceptability of telemedicine for confidential care related to patient location, telehealth technology, adolescent-clinician relationships, and quality or experience of care. Perceived opportunities to protect confidentiality included using headphones, secure messaging, and prompting from clinicians. Most participants (53/88) were likely or very likely to use telemedicine for future confidential care, but self-efficacy for completing components of telemedicine visits confidentially varied by component. DISCUSSION Adolescents in our sample were interested in using telemedicine for confidential care, but cisgender and GDY recognized threats to confidentiality that may reduce acceptability of telemedicine for these services. Clinicians and health systems should carefully consider youth's preferences and unique confidentiality needs to ensure equitable access, uptake, and outcomes of telemedicine.
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Affiliation(s)
- Jacquelin Rankine
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Kacie M Kidd
- WVU Medicine Children's, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Gina M Sequeira
- Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Elizabeth Miller
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kristin N Ray
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Uscher-Pines L, Kapinos KA, Mehrotra A, Demirci J, Ray KN, Alvarado G, DeYoreo M. Use of and Attitudes About Telelactation Services among New Parents. Telemed J E Health 2023; 29:607-611. [PMID: 35930242 PMCID: PMC10079243 DOI: 10.1089/tmj.2022.0159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 04/25/2022] [Accepted: 05/02/2022] [Indexed: 01/04/2023] Open
Abstract
Background: We conducted a national, cross-sectional survey among new parents to explore use and acceptability of telelactation. Methods: Recruitment occurred between October 2021 and January 2022 on Ovia's parenting mobile phone application. Poststratification survey weights were used, and logistic and linear regression models estimated associations between demographics and telelactation use. Results: Among 1,617 respondents, 33.8% had at least one telelactation visit. Odds of any telelactation visit(s) were greater for parents who gave birth in 2021 versus 2019 (odds ratio [OR]: 1.69, 95% confidence interval [CI]: 1.26-2.25), insured by Medicaid (OR: 1.43, 95% CI: 1.02-2.02), and younger parents (OR: 2.07, 95% CI: 1.32-3.34). In total, 56.0% agreed that they would be comfortable breastfeeding over video to get help, and 27.6% agreed that lactation support over video is as good as in-person support. Conclusions: Telelactation is increasingly common and acceptable to many parents.
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Affiliation(s)
| | | | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Jill Demirci
- Department of Health Promotion and Development, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Maria DeYoreo
- Health Care Division, RAND Corporation, Arlington, Virginia, USA
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Bohnhoff JC, Xue L, Hollander MAG, Burgette JM, Cole ES, Ray KN, Donohue J, Roberts ET. Healthcare Utilization Among Children Receiving Permanent Supportive Housing. Pediatrics 2023; 151:e2022059833. [PMID: 36974602 PMCID: PMC10071430 DOI: 10.1542/peds.2022-059833] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Permanent supportive housing (PSH) integrates long-term housing and supports for families and individuals experiencing homelessness. Although PSH is frequently provided to families with children, little is known about the impacts of PSH among children. We examined changes in health care visits among children receiving PSH compared with similar children who did not receive PSH. METHODS We analyzed Pennsylvania Medicaid administrative data for children entering PSH between 2011 and 2016, matching to a comparison cohort with similar demographic and clinical characteristics who received non-PSH housing services. We conducted propensity score-weighted difference-in-differences (DID) analyses to compare changes in health care visits 3 years before and after children entered PSH versus changes in the comparison cohort. RESULTS We matched 705 children receiving PSH to 3141 in the comparison cohort. Over 3 years following PSH entry, dental visits among children entering PSH increased differentially relative to the comparison cohort (DID: 12.70 visits per 1000 person-months, 95% confidence interval: 3.72 to 21.67). We did not find differential changes in preventive medicine visits, hospitalizations, or emergency department (ED) visits overall. When stratified by age, children ≤5 years old at PSH entry experienced a greater decrease in ED visits relative to the comparison cohort (DID: -13.16 visits per 1000 person-months, 95% confidence interval: -26.23 to -0.10). However, emergency visit trends before PSH entry differed between the cohorts. CONCLUSIONS Children in PSH had relatively greater increases in dental visits, and younger children entering PSH may have experienced relative reductions in ED visits. Policymakers should consider benefits to children when evaluating the overall value of PSH.
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Affiliation(s)
- James C. Bohnhoff
- Schools of Medicine
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lingshu Xue
- Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Evan S. Cole
- Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kristin N. Ray
- Schools of Medicine
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Julie Donohue
- Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eric T. Roberts
- Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
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12
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Goldberg L, Rankine J, Devlin B, Miller E, Ray KN. School Nurse Perspectives on Collaboration With Primary Care Providers. J Sch Health 2023. [PMID: 36917956 DOI: 10.1111/josh.13325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 02/14/2023] [Accepted: 02/26/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND School nurses are rarely integrated into primary care teams to their full potential. We aimed to characterize school nurses' perceptions related to current and optimal collaboration with primary care providers (PCPs) and identify actionable solutions to improve efficiency, quality, and coordination of pediatric care. METHODS We conducted and qualitatively analyzed interviews with school nurses to characterize structures, processes, and perceived benefits of optimized school nurse-PCP collaboration. RESULTS School nurse interviewees (n = 23) identified factors important to school nurse-PCP collaboration within 2 domains: information sharing and relationship building. Information sharing themes included health information sharing laws, data sharing systems, and technology-based communication systems. Relationship building themes included health care sector understanding of the school nurse role, PCP knowledge of school health requirements, shared professional development opportunities, and time and personnel. Perceived benefits of optimized PCP-school nurse collaboration were identified for children, PCPs, school nurses, and parents. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY Needs assessments and action plans guided by the domains of information sharing and relationship building can inform local improvements to optimize school nurse-PCP collaboration. CONCLUSIONS School nurses highlighted cross-sector solutions to enhance school nurse-PCP collaboration including integrated information sharing systems and intentional relationship building.
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Affiliation(s)
- Lauren Goldberg
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, 3414 Fifth Avenue, Pittsburgh, PA, 15213
| | - Jacquelin Rankine
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, 120 Lytton Avenue, Pittsburgh, PA, 15213
| | - Bridgetta Devlin
- Pittsburgh Science & Technology Academy, 107 Thackeray Avenue, Pittsburgh, PA, 15213
| | - Elizabeth Miller
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, 120 Lytton Avenue, Pittsburgh, PA, 15213
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, 3414 Fifth Avenue, Pittsburgh, PA, 15213
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13
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Ray KN, Wittman SR, Yabes JG, Sabik LM, Hoberman A, Mehrotra A. Telemedicine Visits to Children During the Pandemic: Practice-Based Telemedicine Versus Telemedicine-Only Providers. Acad Pediatr 2023; 23:265-270. [PMID: 35589062 PMCID: PMC9666718 DOI: 10.1016/j.acap.2022.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/11/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE In March 2020, regulatory and payment changes allowed "brick and mortar" pediatric practices to offer practice-based telemedicine for the first time, joining direct-to-consumer (DTC) telemedicine vendors in the ability to offer visits for common acute pediatric concerns via telemedicine. We sought to characterize the relative contribution of practice-based telemedicine versus commercial DTC telemedicine models in provision of children's telemedicine from 2018 through 2021. METHODS Using January 2018 to September 2021 data from Optum's de-identified Clinformatics® Data Mart Database, we identified telemedicine visits by children ≤17, excluding preventive visits and visits to specialists, emergency departments, and urgent care. Among included visits, we defined "telemedicine-only" providers as those with ≥80% of visits via telemedicine and practice-based telemedicine providers as those with ≤50% of visits via telemedicine. We then described the telemedicine visit volume and diagnoses for these categories overall and per 1000 children per month. RESULTS From January 2018 to February 2020, telemedicine-only providers accounted for 57,815 telemedicine visits (90.8%), while practice-based telemedicine accounted for 4192 telemedicine visits (6.6%). From March 2020 to September 2021, telemedicine-only providers accounted for 38,282 telemedicine visits (6.1%), while practice-based telemedicine accounted for 555,125 telemedicine visits (88.2%). Per month, telemedicine visits to practice-based telemedicine providers increased from pre-pandemic to pandemic periods (0.1 vs 12.9 visits per 1000 children/month), while telemedicine visits to telemedicine-only providers occurred at a similar rate from pre-pandemic to pandemic periods (0.92 vs 0.96 visits per 1000 children/month). CONCLUSIONS We observed a large increase in telemedicine visits during the pandemic, with the growth in visits exclusively occurring among visits to practice-based telemedicine providers as opposed to telemedicine-only providers.
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Affiliation(s)
- Kristin N Ray
- Department of Pediatrics (KN Ray, SR Wittman, and A Hoberman), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa.
| | - Samuel R Wittman
- Department of Pediatrics (KN Ray, SR Wittman, and A Hoberman), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa
| | - Jonathan G Yabes
- Department of Medicine (J Yabes), University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Lindsay M Sabik
- Department of Health Policy & Management ( L Sabik), University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pa
| | - Alejandro Hoberman
- Department of Pediatrics (KN Ray, SR Wittman, and A Hoberman), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa
| | - Ateev Mehrotra
- Department of Health Care Policy (A Mehrotra), Harvard Medical School, Boston, Mass
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14
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Wittman SR, Martin JM, Mehrotra A, Ray KN. Antibiotic Receipt During Outpatient Visits for COVID-19 in the US, From 2020 to 2022. JAMA Health Forum 2023; 4:e225429. [PMID: 36800196 PMCID: PMC9938423 DOI: 10.1001/jamahealthforum.2022.5429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
This cross-sectional study examines prescribed and filled antibiotics for outpatient COVID-19 treatment among children, adolescents, and adults with commercial insurance.
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Affiliation(s)
- Samuel R. Wittman
- Department of Pediatrics, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Judith M. Martin
- Department of Pediatrics, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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15
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Schweiberger K, Verma R, Faulds S, Jonassaint CR, White GE, Ray KN. Scheduled and attended pediatric primary care telemedicine appointments during COVID-19. Pediatr Res 2023:10.1038/s41390-023-02481-w. [PMID: 36690746 PMCID: PMC9869302 DOI: 10.1038/s41390-023-02481-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 12/20/2022] [Accepted: 01/04/2023] [Indexed: 01/24/2023]
Abstract
BACKGROUND The aim of this study was to examine pediatric primary care telemedicine visit scheduling and attendance during the first year of telemedicine. METHODS Using electronic health record data from two academic pediatric primary care practices between April 2020-March 2021, we used Pearson χ2 tests and logistic regression models to identify child-, family-, and appointment-level characteristics associated with scheduled and attended telemedicine appointments. RESULTS Among 5178 primary care telemedicine appointments scheduled during the 12-month period, the proportion of appointments scheduled differed over time for children in families with a language preference other than English or Spanish (4% quarter 1 vs. 6% in quarter 4, p = 0.01) and residing in ZIP codes with the lowest household technology access (24% in quarter 1 vs. 19% in quarter 3 (p = 0.01). Four thousand one hundred and forty-eight of 5178 scheduled telemedicine appointments were attended. Likelihood of attending a telemedicine appointment was highest for children in families with a language preference other than English or Spanish (90%, 95% CI 86-94% compared to Spanish 74%, 95% CI 65-84%), and same-day appointments (86%, 95% CI 85-87%). Attendance among families preferring Spanish language was higher in later months compared to earlier months. CONCLUSIONS We found disparities in scheduling and attending telemedicine appointments, but signs of greater language equity over time.
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Affiliation(s)
- Kelsey Schweiberger
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Division of General Academic Pediatrics, 3414 Fifth Avenue, CHOB 1st Floor, Pittsburgh, PA, 15213, USA.
| | - Rhea Verma
- grid.21925.3d0000 0004 1936 9000Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Division of General Academic Pediatrics, 3414 Fifth Avenue, CHOB 1st Floor, Pittsburgh, PA 15213 USA
| | - Samantha Faulds
- grid.21925.3d0000 0004 1936 9000Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Division of General Academic Pediatrics, 3414 Fifth Avenue, CHOB 1st Floor, Pittsburgh, PA 15213 USA
| | - Charles R. Jonassaint
- grid.21925.3d0000 0004 1936 9000Department of Medicine, University of Pittsburgh School of Medicine, 200 Meyran Avenue, Suite 300, Pittsburgh, PA 15213 USA
| | - Gretchen E. White
- grid.21925.3d0000 0004 1936 9000Department of Medicine, University of Pittsburgh School of Medicine, 200 Meyran Avenue, Suite 300, Pittsburgh, PA 15213 USA
| | - Kristin N. Ray
- grid.21925.3d0000 0004 1936 9000Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Division of General Academic Pediatrics, 3414 Fifth Avenue, CHOB 1st Floor, Pittsburgh, PA 15213 USA
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16
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Wittman SR, Yabes JG, Sabik LM, Kahn JM, Ray KN. Patient and Family Factors Associated with Use of Telemedicine Visits for Pediatric Acute Respiratory Tract Infections, 2018-2019. Telemed J E Health 2023; 29:127-136. [PMID: 35639360 PMCID: PMC9918348 DOI: 10.1089/tmj.2022.0097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 01/12/2023] Open
Abstract
Background: Pediatric acute respiratory tract infections (ARTIs) were a common reason for commercial direct-to-consumer (DTC) telemedicine use before the COVID-19 pandemic, but the factors associated with this use are unknown. Objective: To identify child and family factors associated with use of commercial DTC telemedicine for ARTIs in 2018-2019. Methods: We performed a retrospective cohort analysis of claims data from the Optum Clinformatics® Data Mart Database. Among children with ARTI visits, we fitted logit models to examine child and family characteristics associated with DTC telemedicine use. Results: Of 660,725 children with ARTI visits, 12,944 (2.0%) had ≥1 commercial DTC telemedicine encounter. The odds of DTC telemedicine use were higher for children with age ≥12 years, lower parent educational attainment, higher household income, white non-Hispanic race/ethnicity, and residency in the West South Central census division. Conclusion: In 2018-2019, commercial DTC telemedicine use varied with child age, child race/ethnicity parent educational attainment, household income, and geography.
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Affiliation(s)
- Samuel R. Wittman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jonathan G. Yabes
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Jeremy M. Kahn
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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17
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Fiks AG, Kelly MK, Nwokeji U, Ramachandran J, Ray KN, Gozal D. A Pediatric Telemedicine Research Agenda: Another Important Task for Pediatric Chairs. J Pediatr 2022; 251:40-43.e3. [PMID: 35944724 PMCID: PMC9439872 DOI: 10.1016/j.jpeds.2022.07.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 07/22/2022] [Indexed: 11/20/2022]
Affiliation(s)
- Alexander G. Fiks
- Center for Pediatric Clinical Effectiveness, Possibilities Project, and Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA,Reprint requests: Alexander G. Fiks, MD, MSCE, Director, Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, 2716 South Street, Rm 10-473, Philadelphia, PA 19146
| | - Mary Kate Kelly
- Center for Pediatric Clinical Effectiveness, Possibilities Project, and Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Uchenna Nwokeji
- Center for Pediatric Clinical Effectiveness, Possibilities Project, and Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Janani Ramachandran
- Center for Pediatric Clinical Effectiveness, Possibilities Project, and Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - David Gozal
- Department of Child Health, University of Missouri, Columbia, MO
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18
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19
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Bohnhoff JC, Babinski T, Essien UR, Ray KN. Visit characteristics associated with discharge from specialty care: Results from the National Ambulatory Medical Care Survey. Healthc (Amst) 2022; 10:100656. [PMID: 36156380 DOI: 10.1016/j.hjdsi.2022.100656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/12/2022] [Accepted: 09/07/2022] [Indexed: 01/26/2023]
Affiliation(s)
- James C Bohnhoff
- Department of Pediatrics, University of Pittsburgh School of Medicine, 3414 Fifth Ave, Pittsburgh, PA, 15213, USA.
| | - Tyler Babinski
- Division of Management and Education, University of Pittsburgh at Bradford, 300 Campus Dr, Bradford, PA, 16701, USA.
| | - Utibe R Essien
- Department of Medicine, University of Pittsburgh School of Medicine, 1218 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, USA.
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, 3414 Fifth Ave, Pittsburgh, PA, 15213, USA.
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20
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Boyer TL, Sequeira GM, Egan JE, Ray KN, Miller E, Coulter RWS. Binary and Nonbinary Transgender Adolescents' Healthcare Experiences, Avoidance, and Well Visits. J Adolesc Health 2022; 71:438-445. [PMID: 35725539 PMCID: PMC9827712 DOI: 10.1016/j.jadohealth.2022.04.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/30/2022] [Accepted: 04/23/2022] [Indexed: 01/12/2023]
Abstract
PURPOSE To explore differences in healthcare experiences, healthcare avoidance, and well visit attendance between binary and nonbinary transgender adolescents; also, to explore the association between distinct healthcare experiences and healthcare avoidance and well visits. METHODS We surveyed transgender adolescents ages 12-26 (n = 156) recruited from a multidisciplinary gender clinic from July through November 2018. Differences in distinct healthcare experiences by demographics were assessed using multivariable linear regression. Multivariable logistic regression was used to examine independent associations between demographics and lifetime healthcare avoidance and past-year well visit and also, associations between distinct healthcare experiences and lifetime healthcare avoidance and past-year well visit. RESULTS Compared to transfeminine adolescents, more non-affirming healthcare experiences were reported by nonbinary (β = 1.41, 95% confidence interval [CI]: 0.49, 2.33) and transmasculine adolescents (β = 0.78, 95% CI: 0.02, 1.53). Gender-affirming healthcare experiences did not differ by demographics. Transmasculine adolescents had over three times the odds of lifetime healthcare avoidance (adjusted odds ratio [aOR] = 3.58, 95% CI: 1.41, 9.08) than transfeminine peers. Only younger age was associated with past-year well visit (aOR = 3.83, 95% CI: 1.44, 10.17). Non-affirming healthcare experiences were positively associated with healthcare avoidance (aOR = 1.85, 95% CI: 1.47, 2.34). Gender-affirming healthcare experiences were not associated with healthcare avoidance or past-year well visit. DISCUSSION Nonbinary and transmasculine adolescents experienced more non-affirming healthcare experiences than transfeminine adolescents. Non-affirming healthcare experiences were associated with healthcare avoidance, which was disproportionately more prevalent among transmasculine adolescents. Providers must be better equipped to provide inclusive, gender-affirming care to increase receipt of care for transgender adolescents beyond specialized gender clinics.
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Affiliation(s)
- Taylor L Boyer
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Department of Behavioral and Community Health Sciences, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Gina M Sequeira
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington; Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, Washington
| | - James E Egan
- Department of Behavioral and Community Health Sciences, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kristin N Ray
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Elizabeth Miller
- Department of Behavioral and Community Health Sciences, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Adolescent and Young Adult Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert W S Coulter
- Department of Behavioral and Community Health Sciences, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Adolescent and Young Adult Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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21
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Schweiberger K, Bohnhoff J, Hanmer J, Ray KN. Perceived Usefulness of Increased Telemedicine Use by Pediatric Subspecialists: A National Survey. Telemed J E Health 2022; 28:1367-1373. [PMID: 35143360 PMCID: PMC10039272 DOI: 10.1089/tmj.2021.0583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 12/08/2021] [Accepted: 12/28/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Although many studies have explored the perceived ease-of-use of telemedicine, the perceived usefulness of telemedicine for pediatric subspecialty care is less clear. Methods: We invited a national sample of 840 general pediatricians and 840 pediatric subspecialists to participate in a survey fielded in May-June 2020. Respondents ranked perceptions of usefulness of telemedicine for pediatric subspecialty care on a 5-point Likert scale and prioritization of potential strategies to support telemedicine use on a 4-point scale. Results: Of 285 respondents (18% response rate), physicians perceived that increased telemedicine use by pediatric subspecialists would modestly improve child health (mean = 3.5, standard deviation [SD] = 0.7), and access to care (mean = 3.9, SD = 0.6), but would slightly worsen the clinician experience (mean = 2.8, SD = 0.8). Most respondents highly prioritized payment-related strategies to support use of telemedicine. Conclusions: Pediatric clinicians anticipated that increased telemedicine use by pediatric subspecialists would improve child health and health care access but would worsen clinician experience.
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Affiliation(s)
- Kelsey Schweiberger
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James Bohnhoff
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Janel Hanmer
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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22
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Affiliation(s)
- Eric R Coon
- Department of Pediatrics, Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City, Utah
| | - Alan R Schroeder
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - K Casey Lion
- Department of Pediatrics and Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, Washington
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh and Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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23
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Affiliation(s)
- Kristin N. Ray
- grid.21925.3d0000 0004 1936 9000Department of Pediatrics, University of Pittsburgh, 3414 Fifth Avenue, Pittsburgh, PA 15213 USA
| | - David Keller
- grid.430503.10000 0001 0703 675XUniversity of Colorado Anschultz Medical Campus, 13001 East 17th Place, Campus Box C290, Aurora, CO 80045 USA
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24
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Sequeira GM, Boyer T, Coulter RWS, Miller E, Kahn NF, Ray KN. Healthcare Experiences of Gender Diverse Youth Across Clinical Settings. J Pediatr 2022; 240:251-255. [PMID: 34536494 PMCID: PMC8712353 DOI: 10.1016/j.jpeds.2021.08.089] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/25/2021] [Accepted: 08/31/2021] [Indexed: 01/03/2023]
Abstract
We explored gender diverse youth's experiences seeking and receiving gender-affirming care in various health system locations. Results provide evidence for system-, clinic-, and provider-level improvements to promote the development of affirming environments and to improve health outcomes for gender diverse youth.
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Affiliation(s)
- Gina M. Sequeira
- University of Washington, Seattle, Washington,Seattle Children’s Hospital, Seattle, Washington
| | - Taylor Boyer
- VA Pittsburgh Health System, Pittsburgh, Pennsylvania
| | - Robert W. S. Coulter
- University of Pittsburgh, Pittsburgh, Pennsylvania,UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Elizabeth Miller
- University of Pittsburgh, Pittsburgh, Pennsylvania,UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Kristin N. Ray
- University of Pittsburgh, Pittsburgh, Pennsylvania,UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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25
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Shi Z, Barnett ML, Jena AB, Ray KN, Fox KP, Mehrotra A. Association of a Clinician's Antibiotic-Prescribing Rate With Patients' Future Likelihood of Seeking Care and Receipt of Antibiotics. Clin Infect Dis 2021; 73:e1672-e1679. [PMID: 32777032 PMCID: PMC8492129 DOI: 10.1093/cid/ciaa1173] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Indexed: 11/29/2022] Open
Abstract
Background One underexplored driver of inappropriate antibiotic prescribing for acute respiratory illnesses (ARI) is patients’ prior care experiences. When patients receive antibiotics for an ARI, patients may attribute their clinical improvement to the antibiotics, regardless of their true benefit. These experiences, and experiences of family members, may drive whether patients seek care or request antibiotics for subsequent ARIs. Methods Using encounter data from a national United States insurer, we identified patients <65 years old with an index ARI urgent care center (UCC) visit. We categorized clinicians within each UCC into quartiles based on their ARI antibiotic prescribing rate. Exploiting the quasi-random assignment of patients to a clinician within an UCC, we examined the association between the clinician’s antibiotic prescribing rate to the patients’ and their spouses’ rates of ARI antibiotic receipt in the subsequent year. Results Across 232,256 visits at 736 UCCs, ARI antibiotic prescribing rates were 42.1% and 80.2% in the lowest and highest quartile of clinicians, respectively. Patient characteristics were similar across the four quartiles. In the year after the index ARI visit, patients seen by the highest-prescribing clinicians received more ARI antibiotics (+3.0 fills/100 patients (a 14.6% difference), 95% CI 2.2–3.8, P < 0.001,) versus those seen by the lowest-prescribing clinicians. The increase in antibiotics was also observed among the patients’ spouses. The increase in patient ARI antibiotic prescriptions was largely driven by an increased number of ARI visits (+5.6 ARI visits/100 patients, 95% CI 3.6–7.7, P < 0.001), rather than a higher antibiotic prescribing rate during those subsequent ARI visits. Conclusions Receipt of antibiotics for an ARI increases the likelihood that patients and their spouses will receive antibiotics for future ARIs.
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Affiliation(s)
- Zhuo Shi
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael L Barnett
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,National Bureau of Economic Research, Cambridge, Massachusetts, USA
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kathe P Fox
- Department of Analytics and Behavior Change, Aetna/CVS Health, Baltimore, Maryland, USA
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA.,Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Affiliation(s)
- Eric R Coon
- Department of Pediatrics, Primary Children's Hospital and
| | - Molly B Conroy
- Division of General Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Kristin N Ray
- Department of Pediatrics, School of Medicine, University of Pittsburgh and Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Ray KN, Martin JM, Wolfson D, Schweiberger K, Schoemer P, Cepullio C, Iagnemma J, Hoberman A. Antibiotic Prescribing for Acute Respiratory Tract Infections During Telemedicine Visits Within a Pediatric Primary Care Network. Acad Pediatr 2021; 21:1239-1243. [PMID: 33741531 DOI: 10.1016/j.acap.2021.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 02/28/2021] [Accepted: 03/12/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Regulatory and payment changes associated with COVID-19 facilitated wide-spread use of telehealth within pediatric primary care starting in March 2020. Given prior quality concerns about antibiotic management for children during telemedicine visits outside of primary care, we sought to examine acute respiratory tract infection (ARTI) visit volume and antibiotic management for children via telemedicine integrated within pediatric primary care. METHODS Using electronic health record data from 47 practices within a large pediatric primary care network, we identified visits for ARTI from April to September 2020. For these visits, we categorized antibiotic management consistent with clinical guidelines as guideline concordant. We compared telemedicine and in-person visit guideline-concordant antibiotic management, diagnoses, and antibiotic prescribing using chi-square tests and examined trends over time using descriptive statistics. Antibiotic stewardship during the study period included learning collaborative videoconferences and sharing of clinic and clinician-level metrics through an interactive dashboard. RESULTS During the 6-month period, 8332 ARTI visits were identified, with 3003 (36%) via telemedicine. Guideline-concordant antibiotic management occurred in 92.5% of telemedicine visits compared to 90.7% of in-person office visits (P = .004). Telemedicine ARTI visits receiving diagnoses of acute otitis media or streptococcal pharyngitis declined from peak of 52% (May) to 7% (September). Guideline-concordant antibiotic management of sinusitis and viral ARTI during telemedicine visits increased from 88% (April) to 97% (September). CONCLUSION With active antibiotic stewardship, pediatricians practicing within certified medical homes consistently delivered highly guideline-concordant care for ARTIs to their patient population via telemedicine integrated into primary care.
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Affiliation(s)
- Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa.
| | - Judith M Martin
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa
| | | | - Kelsey Schweiberger
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa
| | - Pam Schoemer
- UPMC Children's Community Pediatrics, Wexford, Pa
| | | | | | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa
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Burgette JM, Ok SH, Ray KN, Faulds S, Stiles A, Hoberman A, Martin B. Race and payor type for child visits with public health dental hygienist practitioners. J Public Health Dent 2021; 82:53-60. [PMID: 34378198 DOI: 10.1111/jphd.12474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/12/2021] [Accepted: 07/29/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE To examine whether growth in visits to public health dental hygiene practitioners (PHDHPs) providing preventative dental services at a pediatric hospital clinic was predominantly among children receiving public insurance and children of minority background from 2013 to 2017. METHODS Longitudinal descriptive data analysis from electronic health records for 6856 children under age 18 years who visited PHDHPs co-located at a hospital clinic in Pittsburgh, PA, from 2013 to 2017. We compared visits between white versus non-white children and between children with public, private, and no or missing insurance by year. RESULTS Visit volume doubled from 2013 (n = 811) to 2017 (n = 1868). The proportion of PHDHP visits with non-white children increased from 77% (n = 625) in 2013 to 87% (n = 1472) in 2017 (p < 0.001). The proportion of PHDHP visits with children with public insurance increased from 72% (n = 585) in 2013 to 82% (n = 1377) in 2017 (p < 0.001). CONCLUSIONS PHDHPs co-located at a pediatric hospital clinic saw a high proportion of visits from children of non-white race and with public insurance. Visits from children of minority race and with public insurance increased disproportionately as visit volume grew from 2013 to 2017, depicting a vehicle through which historically underserved children increasingly accessed preventive dental services.
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Affiliation(s)
- Jacqueline M Burgette
- Departments of Dental Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sally H Ok
- Department of Pediatric Dentistry, University of Pittsburgh School of Dental Medicine, Pittsburgh, Pennsylvania, USA
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,General Academic Pediatrics, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Samantha Faulds
- General Academic Pediatrics, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amy Stiles
- Division of Pediatric Dentistry, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,General Academic Pediatrics, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brian Martin
- Division of Pediatric Dentistry, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.,Medical Affairs, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Rankine J, Yeramosu D, Matheo L, Sequeira GM, Miller E, Ray KN. Optimizing e-Consultations to Adolescent Medicine Specialists: Qualitative Synthesis of Feedback From User-Centered Design. JMIR Hum Factors 2021; 8:e25568. [PMID: 34383665 PMCID: PMC8380586 DOI: 10.2196/25568] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/21/2021] [Accepted: 05/24/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND e-Consultations between primary care physicians and specialists are a valuable means of improving access to specialty care. Adolescents and young adults (AYAs) face unique challenges in accessing limited adolescent medicine specialty care resources, which contributes to delayed or forgone care. e-Consultations between general pediatricians and adolescent medicine specialists may alleviate these barriers to care. However, the optimal application of this model in adolescent medicine requires careful attention to the nuances of AYA care. OBJECTIVE This study aims to qualitatively analyze feedback obtained during the iterative development of an e-consultation system for communication between general pediatricians and adolescent medicine specialists tailored to the specific health care needs of AYAs. METHODS We conducted an iterative user-centered design and evaluation process in two phases. In the first phase, we created a static e-consultation prototype and storyboards and evaluated them with target users (general pediatricians and adolescent medicine specialists). In the second phase, we incorporated feedback to develop a functional prototype within the electronic health record and again evaluated this with general pediatricians and adolescent medicine specialists. In each phase, general pediatricians and adolescent medicine specialists provided think-aloud feedback during the use of the prototypes and semistructured exit interviews, which was qualitatively analyzed to identify perspectives related to the usefulness and usability of the e-consultation system. RESULTS Both general pediatricians (n=12) and adolescent medicine specialists (n=12) perceived the usefulness of e-consultations for AYA patients, with more varied perceptions of potential usefulness for generalist and adolescent medicine clinicians. General pediatricians and adolescent medicine specialists discussed ways to maximize the usability of e-consultations for AYAs, primarily by improving efficiency (eg, reducing documentation, emphasizing critical information, using autopopulated data fields, and balancing specificity and efficiency through text prompts) and reducing the potential for errors (eg, prompting a review of autopopulated data fields, requiring physician contact information, and prompting explicit discussion of patient communication and confidentiality expectations). Through iterative design, patient history documentation was streamlined, whereas documentation of communication and confidentiality expectations were enhanced. CONCLUSIONS Through an iterative user-centered design process, we identified user perspectives to guide the refinement of an e-consultation system based on general pediatrician and adolescent medicine specialist feedback on usefulness and usability related to the care of AYAs. Qualitative analysis of this feedback revealed both opportunities and risks related to confidentiality, communication, and the use of tailored documentation prompts that should be considered in the development and use of e-consultations with AYAs.
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Affiliation(s)
- Jacquelin Rankine
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Deepika Yeramosu
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Loreta Matheo
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Gina M Sequeira
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.,Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, WA, United States
| | - Elizabeth Miller
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
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Marin JR, Hollander MAG, Ray KN, Donohue JM, Cole ES. Low-Value Diagnostic Imaging in Children with Medicaid. J Pediatr 2021; 235:253-263.e14. [PMID: 33556364 PMCID: PMC8316256 DOI: 10.1016/j.jpeds.2021.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/29/2021] [Accepted: 02/01/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To estimate rates and settings of low-value imaging among pediatric Medicaid beneficiaries and estimate the associated expenditures. STUDY DESIGN Retrospective longitudinal cohort study from 2014 to 2016 of children <18 years enrolled in Pennsylvania Medicaid. Outcomes were rates of low-value imaging for 5 conditions identified by diagnosis codes, healthcare settings of imaging performance, and cost based on paid amounts. RESULTS Of the 645 767 encounters for the 5 conditions, there were 37 525 (5.8%) low-value imaging services. Per 1000 encounters, there were 246.0 radiographs for bronchiolitis, 174.0 head computed tomography (CT) studies for minor head trauma, 155.0 and 33.3 neuroimaging studies for headache and simple febrile seizure, respectively, and 19.5 abdominal CT scans (without prior ultrasound examination) for abdominal pain. Rates of low-value imaging were highest in non-Hispanic White children and those in rural areas. In adjusted analysis, non-Hispanic White children were more likely to receive a CT scan for abdominal pain, and Black children were more likely to have imaging for bronchiolitis and minor head trauma. For individual conditions, up to 87.9% of low-value imaging (CT scan for minor head trauma) was in the emergency department (ED), with most imaging across all conditions occurring in nonpediatric EDs, up to 42.2% was in the outpatient setting (neuroimaging for headache), and up to 20.7% was during inpatient encounters (neuroimaging for febrile seizure). Outpatient and ED low-value imaging resulted in more than $7 million in Medicaid expenditures. CONCLUSIONS Among the studied conditions, more than 1 in 20 encounters included low-value imaging, mostly in nonpediatric EDs and for bronchiolitis, head trauma, and headache. Interventions are needed to decrease the future performance of these low-value services.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, and Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.
| | - Mara A G Hollander
- Center for Mental Health and Addiction Policy Research, Department of Health Policy, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kristin N Ray
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Julie M Donohue
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Evan S Cole
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
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Ray KN, Marin JR, Owusu-Ansah S. Continued Growing Pains in Pediatric Emergency Care Coordinator Availability. J Pediatr 2021; 235:24-25. [PMID: 33901517 DOI: 10.1016/j.jpeds.2021.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Affiliation(s)
| | - Jennifer R Marin
- Department of Pediatrics and Department of Emergency Medicine, University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Sylvia Owusu-Ansah
- Department of Pediatrics and Department of Emergency Medicine, University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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Ravi N, Gitz KM, Burton DR, Ray KN. Pediatric non-urgent emergency department visits and prior care-seeking at primary care. BMC Health Serv Res 2021; 21:466. [PMID: 34001093 PMCID: PMC8128083 DOI: 10.1186/s12913-021-06480-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We aimed to examine how caregiver perceptions of primary care affects care-seeking prior to pediatric non-urgent ED visits. METHODS We performed a cross-sectional survey of caregivers of children presenting to a pediatric ED during weekday business hours and triaged as low acuity. We first compared caregiver sociodemographic characteristics, perceptions of primary care, and stated preference in care sites (ED vs PCP) for caregivers who had sought care from their child's PCP office versus had not sought care from their child's PCP office prior to their ED visit. We then examined odds of having sought care from their PCP office prior to their ED visit using multivariable logistic regression models sequentially including caregiver primary care perceptions and stated care site preferences along with caregiver sociodemographic characteristics. RESULTS Of 140 respondents, 64 (46%) sought care from their child's PCP office prior to presenting to the ED. In unadjusted analysis, children insured by Medicaid or CHIP, caregivers identifying as Black, and caregivers with lower educational attainment were less likely to have sought PCP care before presenting to the ED (p < 0.005, each). Caregivers who had sought PCP care were more likely to prefer their PCP relative to the ED in terms of ease of travel, cost, and wait times (p < 0.001, all). When including these stated preferences in a multivariable model, child insurance, caregiver race, and caregiver education were no longer significantly associated with odds of having sought PCP care prior to their ED visit. CONCLUSIONS Differential access to primary care may underlie observed demographic differences in non-urgent pediatric ED utilization.
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Affiliation(s)
- Nithin Ravi
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue,AOB - Suite 5400, Pittsburgh, PA, 15224, USA.
| | - Katherine M Gitz
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue,AOB - Suite 5400, Pittsburgh, PA, 15224, USA
- Children's Hospital of Los Angeles Medical Group, Los Angeles, USA
| | - Danielle R Burton
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kristin N Ray
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue,AOB - Suite 5400, Pittsburgh, PA, 15224, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Burgette JM, Weyant RJ, Ettinger AK, Miller E, Ray KN. What is the association between income loss during the COVID-19 pandemic and children's dental care? J Am Dent Assoc 2021; 152:369-376. [PMID: 33810832 PMCID: PMC7867385 DOI: 10.1016/j.adaj.2021.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/13/2021] [Accepted: 02/01/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND The degree to which children experience unmet need for dental care during the COVID-19 pandemic and its association with pandemic-related household job or income loss are unknown. METHODS The authors performed a cross-sectional household survey of 348 families in Pittsburgh, Pennsylvania, from June 25 through July 2, 2020. Unmet need for child dental care and pandemic-related household job or income loss were assessed using caregiver self-report. RESULTS Caregivers reported that the greatest unmet child health care need during the COVID-19 pandemic was dental care (16%), followed by medical care for a well visit or vaccination (5%). Approximately 40% of caregivers reported job loss or a decrease in household income due to the COVID-19 pandemic. The authors found a significant association between the probability of unmet child dental care and pandemic-related household job or income loss (P = .022). Losing a job or experiencing a decrease in income due to the COVID-19 pandemic was associated with unmet child dental care (relative risk, 1.77; 95% confidence interval, 1.08 to 2.88). CONCLUSIONS In this sample, 3 times as many households reported unmet dental care for a child compared with unmet medical care. Unmet child dental care was more common in households where pandemic-related job or income loss occurred. PRACTICAL IMPLICATIONS If unmet dental care continues as a result of the COVID-19 pandemic, nontraditional strategies for delivering dental care can be considered to improve access to dental care for children, such as teledentistry and oral health prevention services in primary care settings.
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Hanmer J, Ray KN, McCracken P, Ferrante L, Wardlaw S, Fleischman L, Wolfson D. Uptake of an Integrated Electronic Questionnaire System in Community Pediatric Clinics. Appl Clin Inform 2021; 12:310-319. [PMID: 33853141 DOI: 10.1055/s-0041-1727198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE The study aimed to evaluate an integrated electronic questionnaire system implementation in outpatient community pediatric practices on workflow, completion rates, and recorded scores. METHODS We evaluated the implementation and outcomes of an integrated electronic questionnaire system at 45 community pediatric practices that used standardized questionnaires to screen for autism, depression, and substance use and to measure asthma control. Electronic health record (EHR) data for all well child visits were extracted for the 3 months before and after implementation. We used statistical process control charts to evaluate questionnaire completion rates and Chi-square tests to evaluate screening completion and positive screening rates. The collection and entry of questionnaire information was observed and timed. RESULTS EHR data included 107,120 encounters across 45 practices that showed significant and sustained improvement in completion rates for all questionnaires. The rate of recorded concerning questionnaires decreased for asthma control (19.3 vs. 12.8%, p < 0.001), stayed the same for autism (96.6 vs. 96.2%, p = 0.38), decreased for depression (9.5 vs. 6.7%, p ≤ 0.001), and increased for any substance use (9.8 vs. 12.8%, p < 0.001). Twelve practices were observed, and patient time and staff time managing questionnaires were decreased after implementation. DISCUSSION Electronic questionnaire administration saved staff time and patient time. We report overall improvement in questionnaire completion rates, with notable variation in improvement in completion across practices and in change in concerning recorded result rates across measures. CONCLUSION Conversion of four standard paper questionnaires to an integrated electronic system reduces patient and staff time while increasing completion rates when well integrated into routine care.
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Affiliation(s)
- Janel Hanmer
- Department of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Polly McCracken
- Department of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Lorraine Ferrante
- UPMC Children's Community Pediatrics, Pittsburgh, Pennsylvania, United States
| | - Sharon Wardlaw
- UPMC Children's Community Pediatrics, Pittsburgh, Pennsylvania, United States
| | - Lauren Fleischman
- UPMC Children's Community Pediatrics, Pittsburgh, Pennsylvania, United States
| | - David Wolfson
- UPMC Children's Community Pediatrics, Pittsburgh, Pennsylvania, United States
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Sequeira GM, Kidd KM, Rankine J, Miller E, Ray KN, Fortenberry JD, Richardson LP. Gender-Diverse Youth's Experiences and Satisfaction with Telemedicine for Gender-Affirming Care During the COVID-19 Pandemic. Transgend Health 2021; 7:127-134. [PMID: 35586577 PMCID: PMC9051870 DOI: 10.1089/trgh.2020.0148] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Purpose Telemedicine holds potential to improve access to gender-affirming care for gender-diverse youth (GDY), but little is known about youth's perspectives regarding its use. The purpose of this study was to explore GDY's experiences and satisfaction with telemedicine for gender-affirming care during the COVID-19 pandemic. Methods An online, cross-sectional survey was completed by 12-17-year-old GDY after a telemedicine gender clinic visit. Demographic characteristics, responses to a 12-item telemedicine satisfaction scale, and items assessing interest in future telemedicine use were analyzed using descriptive statistics. Open-ended items exploring GDY's experiences were coded qualitatively to identify key themes. Results Participants' (n=57) mean age was 15.6 years. A majority were satisfied with telemedicine (85%) and willing to use it in the future (88%). Most GDY preferred in-person visits for their first gender care visit (79%), with fewer preferring in-person for follow-up visits (47%). Three key themes emerged from the open-ended comments: (1) benefits of telemedicine including saving time and feeling safe; (2) usability of telemedicine such as privacy concerns and technological difficulties; and (3) telemedicine acceptability, which included comfort, impact on anxiety, camera use, and patient preference. Conclusions Despite their preference for in-person visits, a majority of GDY were satisfied and comfortable with telemedicine, and expressed their interest in continuing to have telemedicine as an option for care. Pediatric gender care providers should continue services through telemedicine while implementing protocols related to privacy and hesitation regarding camera use. While adolescents may find telemedicine acceptable, it remains unclear whether telemedicine can improve access to gender-affirming care.
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Affiliation(s)
- Gina M. Sequeira
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Department of Adolescent Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kacie M. Kidd
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jacquelin Rankine
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Elizabeth Miller
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kristin N. Ray
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - J. Dennis Fortenberry
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Laura P. Richardson
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Department of Adolescent Medicine, Seattle Children's Hospital, Seattle, Washington, USA
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Ray KN, Yahner KA, Bey J, Martin KC, Planey AM, Culyba AJ, Miller E. Understanding Variation In Nonurgent Pediatric Emergency Department Use In Communities With Concentrated Disadvantage. Health Aff (Millwood) 2021; 40:156-164. [PMID: 33400581 DOI: 10.1377/hlthaff.2020.00675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Children in communities with concentrated socioeconomic and structural disadvantage tend to have elevated rates of nonurgent visits to emergency departments (EDs). Using a spatial regression model of 264 census block groups in Pittsburgh, Pennsylvania, we investigated sociodemographic and structural factors associated with lower-than-expected ("low utilization") versus higher-than-expected ("high utilization") nonurgent ED visit rates among children in block groups with concentrated disadvantage. Compared with high-utilization block groups, low-utilization block groups had higher percentages of households with two adults, high school graduates, access to vehicles, sound housing quality, and owner-occupied housing. Notably, low-utilization block groups did not differ significantly from high-utilization block groups either in the percentage of households located within very close proximity to public transit or primary care or in children's health insurance coverage rates. Stakeholders wishing to reduce pediatric nonurgent ED visits among families in communities of concentrated disadvantage should consider strategies to mitigate financial, time, transportation, and health literacy constraints that may affect families' access to primary care.
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Affiliation(s)
- Kristin N Ray
- Kristin N. Ray is an associate professor in the Department of Pediatrics, University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh, in Pittsburgh, Pennsylvania
| | - Kristin A Yahner
- Kristin A. Yahner is the General Academic Pediatrics Division data center coordinator, Department of Pediatrics, University of Pittsburgh School of Medicine
| | - Jamil Bey
- Jamil Bey is the president and CEO of the UrbanKind Institute, in Pittsburgh, Pennsylvania
| | - Katherine C Martin
- Katherine C. Martin is a fourth-year medical student at the University of Pittsburgh School of Medicine
| | - Arrianna M Planey
- Arrianna M. Planey is an assistant professor in the Department of Health Policy and Management at the Gillings School of Global Public Health, University of North Carolina at Chapel Hill, in Chapel Hill, North Carolina
| | - Alison J Culyba
- Alison J. Culyba is an assistant professor in the Department of Pediatrics, University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh
| | - Elizabeth Miller
- Elizabeth Miller is a professor in the Department of Pediatrics, University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh
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Schweiberger K, Patel SY, Mehrotra A, Ray KN. Trends in Pediatric Primary Care Visits During the Coronavirus Disease of 2019 Pandemic. Acad Pediatr 2021; 21:1426-1433. [PMID: 33984496 PMCID: PMC8561008 DOI: 10.1016/j.acap.2021.04.031] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/14/2021] [Accepted: 04/24/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Months after the declaration of the coronavirus disease of 2019 (COVID-19) national emergency, visits among children remained suppressed for unclear reasons, which we sought to understand by examining child visit rates. METHODS Using de-identified claims data for children <18 years old from OptumLabs® Data Warehouse, a large commercial claims database, we compared monthly primary care visit and vaccination rates from January-October 2020 to January-October 2018 and 2019. Visit rates were analyzed by visit reason and by the month after (eg, month +1) the COVID-19 public health emergency declaration using a series of child-level Poisson regression models. RESULTS There were 3.4, 3.4, and 3.1 million children in 2018, 2019, and 2020 cohorts, respectively. Compared to the same months in prior years, primary care visits in 2020 were 60% lower in month +1 (incidence rate ratio [IRR] 0.40, 99% confidence interval [CI] 0.40-0.40) and 17% lower in month +7 (IRR 0.83, 99% CI 0.83-0.83). Preventive visit rates were 53% lower in month +1 (IRR 0.47, 99% CI 0.47-0.47), but 8% higher than prior years in month +7 (IRR 1.08, 99% CI 1.08-1.08). Monthly rates of vaccine administration followed a similar pattern. Problem-focused visits remained 31% lower in month +7 (IRR 0.69, 99% CI 0.68-0.69), with notably fewer infection-related visits (acute respiratory tract infections IRR 0.37, 99% CI 0.36-0.37; gastroenteritis IRR 0.20, 99% CI 0.20-0.20). CONCLUSION Seven months after the COVID-19 emergency declaration, receipt of pediatric care remained suppressed due to fewer problem-focused visits, with notably fewer infection-related visits. By October 2020, rates of preventive visits and vaccination exceeded rates in prior years.
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Affiliation(s)
- Kelsey Schweiberger
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh (K Schweiberger and KN Ray), Pittsburgh, Pa
| | - Sadiq Y. Patel
- Department of Health Care Policy, Harvard Medical School (SY Patel and A Mehrotra), Boston, Mass
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School (SY Patel and A Mehrotra), Boston, Mass,Beth Israel Deaconess Medical Center (A Mehrotra), Boston, Mass,OptumLabs Visiting Fellow (A Mehrotra), Eden Prairie, Minn
| | - Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh (K Schweiberger and KN Ray), Pittsburgh, Pa,Address correspondence to Kristin N. Ray, MD, MS, Division of General Academic Pediatrics, UPMC Children's Hospital of Pittsburgh, 3414 Fifth Ave, CHOB 3rd Floor, Pittsburgh, PA 15213
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Affiliation(s)
- Alexander G Fiks
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brian P Jenssen
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kristin N Ray
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Schweiberger K, Hoberman A, Iagnemma J, Schoemer P, Squire J, Taormina J, Wolfson D, Ray KN. Practice-Level Variation in Telemedicine Use in a Pediatric Primary Care Network During the COVID-19 Pandemic: Retrospective Analysis and Survey Study. J Med Internet Res 2020; 22:e24345. [PMID: 33290244 PMCID: PMC7752181 DOI: 10.2196/24345] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 01/18/2023] Open
Abstract
Background Telehealth, the delivery of health care through telecommunication technology, has potential to address multiple health system concerns. Despite this potential, only 15% of pediatric primary care clinicians reported using telemedicine as of 2016, with the majority identifying inadequate payment for these services as the largest barrier to their adoption. The COVID-19 pandemic led to rapid changes in payment and regulations surrounding telehealth, enabling its integration into primary care pediatrics. Objective Due to limited use of telemedicine in primary care pediatrics prior to the COVID-19 pandemic, much is unknown about the role of telemedicine in pediatric primary care. To address this gap in knowledge, we examined the association between practice-level telemedicine use within a large pediatric primary care network and practice characteristics, telemedicine visit diagnoses, in-person visit volumes, child-level variations in telemedicine use, and clinician attitudes toward telemedicine. Methods We analyzed electronic health record data from 45 primary care practices and administered a clinician survey to practice clinicians. Practices were stratified into tertiles based on rates of telemedicine use (low, intermediate, high) per 1000 patients per week during a two-week period (April 19 to May 2, 2020). By practice tertile, we compared (1) practice characteristics, (2) telemedicine visit diagnoses, (3) rates of in-person visits to the office, urgent care, and the emergency department, (4) child-level variation in telemedicine use, and (5) clinician attitudes toward telemedicine across these practices. Results Across pediatric primary care practices, telemedicine visit rates ranged from 5 to 23 telemedicine visits per 1000 patients per week. Across all tertiles, the most frequent telemedicine visit diagnoses were mental health (28%-36% of visits) and dermatologic (15%-28%). Compared to low telemedicine use practices, high telemedicine use practices had fewer in-person office visits (10 vs 16 visits per 1000 patients per week, P=.005) but more total encounters overall (in-office and telemedicine: 28 vs 22 visits per 1000 patients per week, P=.006). Telemedicine use varied with child age, race and ethnicity, and recent preventive care; however, no significant interactions existed between these characteristics and practice-level telemedicine use. Finally, clinician attitudes regarding the usability and impact of telemedicine did not vary significantly across tertiles. Conclusions Across a network of pediatric practices, we identified significant practice-level variation in telemedicine use, with increased use associated with more varied telemedicine diagnoses, fewer in-person office visits, and increased overall primary care encounter volume. Thus, in the context of the pandemic, when underutilization of primary care was prevalent, higher practice-level telemedicine use supported pediatric primary care encounter volume closer to usual rates. Child-level telemedicine use differed by child age, race and ethnicity, and recent preventive care, building upon prior concerns about differences in access to telemedicine. However, increased practice-level use of telemedicine services was not associated with reduced or increased differences in use, suggesting that further work is needed to promote equitable access to primary care telemedicine.
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Affiliation(s)
- Kelsey Schweiberger
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.,UPMC Children's Community Pediatrics, Pittsburgh, PA, United States
| | | | - Pamela Schoemer
- UPMC Children's Community Pediatrics, Pittsburgh, PA, United States
| | - Joseph Squire
- UPMC Children's Community Pediatrics, Pittsburgh, PA, United States
| | - Jill Taormina
- UPMC Children's Community Pediatrics, Pittsburgh, PA, United States
| | - David Wolfson
- UPMC Children's Community Pediatrics, Pittsburgh, PA, United States
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.,UPMC Children's Community Pediatrics, Pittsburgh, PA, United States
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Burgette JM, Mestre Y, Martin B, Ray KN, Stiles A, Hoberman A. Success rates of pediatric dental referrals made by public health dental hygiene practitioners. J Public Health Dent 2020; 81:169-177. [DOI: 10.1111/jphd.12428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/13/2020] [Accepted: 11/04/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Jacqueline M. Burgette
- Department of Dental Public Health University of Pittsburgh Pittsburgh PA USA
- Department of Pediatric Dentistry University of Pittsburgh Pittsburgh PA USA
| | | | - Brian Martin
- University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh Pittsburgh PA USA
| | - Kristin N. Ray
- Department of Pediatrics University of Pittsburgh School of Medicine, University of Pittsburgh Pittsburgh PA USA
| | - Amy Stiles
- University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh Pittsburgh PA USA
| | - Alejandro Hoberman
- Department of Pediatrics University of Pittsburgh School of Medicine, University of Pittsburgh Pittsburgh PA USA
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Ray KN, Ettinger AK, Dwarakanath N, Mistry SV, Bey J, Chaves-Gnecco D, Alston KA, Ripper L, Lavage DR, Landsittel DP, Miller E. Rapid-Cycle Community Assessment of Health-Related Social Needs of Children and Families During Coronavirus Disease 2019. Acad Pediatr 2020; 21:677-683. [PMID: 33065291 PMCID: PMC7553869 DOI: 10.1016/j.acap.2020.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 10/09/2020] [Accepted: 10/10/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To identify unmet health and social resource needs during a county-wide coronavirus disease 19 (COVID-19) stay-at-home order and phased re-opening in Western Pennsylvania. METHODS With public health, social service, and community partners connected through an ongoing academic-community collaborative, we developed and fielded a weekly repeated cross-sectional electronic survey assessing usage of and unmet need for health and social service resources. Using 10 weeks of surveys (April 3-June 11, 2020) by Allegheny County residents, we examined variation in responses by week and by sociodemographic characteristics using chi-square tests. We shared written reports weekly and discussed emerging trends with community partners. RESULTS Participants ranged from 229 to 1001 per week. Unmet need for at least 1 health or health-related social need resource varied by week, ranging from 55% (95% confidence interval [CI] 50%-59%) of participants in week 2 to 43% (95% CI 37%-49%) of participants in week 9 (P = .006). Increased use of at least 1 resource ranged from 53% (95% CI 47%-58%) of participants in week 3 to 36% (95% CI 31%-42%) in week 9 (P < .001). Unmet need for food and financial assistance peaked early during the stay-at-home order, while unmet need for mental health care rose later. Unmet need for food assistance varied significantly by race and ethnicity and by household prepandemic income. CONCLUSIONS Over half of families with children reported unmet health or social service needs during the first month of a county-wide COVID-19 stay-at-home order. Unmet needs varied with race, ethnicity, and income and with duration of the stay-at-home order.
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Affiliation(s)
- Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh (KN Ray, AK Ettinger, N Dwarakanath, SV Mistry, D Chaves-Gnecco, KA Alston, L Ripper, DR Lavage, and E Miller), Pittsburgh, Pa,Address correspondence to Kristin Ray, MD, MS, Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, 3414 Fifth Ave, 3rd Floor, Pittsburgh, PA 15213
| | - Anna K. Ettinger
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh (KN Ray, AK Ettinger, N Dwarakanath, SV Mistry, D Chaves-Gnecco, KA Alston, L Ripper, DR Lavage, and E Miller), Pittsburgh, Pa
| | - Namita Dwarakanath
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh (KN Ray, AK Ettinger, N Dwarakanath, SV Mistry, D Chaves-Gnecco, KA Alston, L Ripper, DR Lavage, and E Miller), Pittsburgh, Pa
| | - Sejal V. Mistry
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh (KN Ray, AK Ettinger, N Dwarakanath, SV Mistry, D Chaves-Gnecco, KA Alston, L Ripper, DR Lavage, and E Miller), Pittsburgh, Pa
| | - Jamil Bey
- UrbanKind Institute (J Bey), Pittsburgh, Pa
| | - Diego Chaves-Gnecco
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh (KN Ray, AK Ettinger, N Dwarakanath, SV Mistry, D Chaves-Gnecco, KA Alston, L Ripper, DR Lavage, and E Miller), Pittsburgh, Pa
| | - Kaila A. Alston
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh (KN Ray, AK Ettinger, N Dwarakanath, SV Mistry, D Chaves-Gnecco, KA Alston, L Ripper, DR Lavage, and E Miller), Pittsburgh, Pa
| | - Lisa Ripper
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh (KN Ray, AK Ettinger, N Dwarakanath, SV Mistry, D Chaves-Gnecco, KA Alston, L Ripper, DR Lavage, and E Miller), Pittsburgh, Pa
| | - Daniel R. Lavage
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh (KN Ray, AK Ettinger, N Dwarakanath, SV Mistry, D Chaves-Gnecco, KA Alston, L Ripper, DR Lavage, and E Miller), Pittsburgh, Pa,Department of Biomedical Informatics, University of Pittsburgh School of Medicine (DR Lavage and DP Landsittel), Pittsburgh, Pa
| | - Douglas P. Landsittel
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine (DR Lavage and DP Landsittel), Pittsburgh, Pa
| | - Elizabeth Miller
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh (KN Ray, AK Ettinger, N Dwarakanath, SV Mistry, D Chaves-Gnecco, KA Alston, L Ripper, DR Lavage, and E Miller), Pittsburgh, Pa
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Abstract
IMPORTANCE Telehealth services, which allow patients to communicate with a remotely located clinician, are increasingly available; however, prevalence of telehealth use, including videoconferencing visits, remains unclear. OBJECTIVE To measure the use of and willingness to use telehealth modalities across the US population. DESIGN, SETTING, AND PARTICIPANTS This survey study, conducted between February 2019 and April 2019, asked participants about their use of different telehealth modalities, reasons for not using videoconferencing visits, and willingness to use videoconferencing visits. Questions were continuously posed to panel members and closed after 2555 responses were obtained, at which point 3932 panel members had been invited, for a 65.0% response rate. EXPOSURES Demographic characteristics (ie, age, sex, race, rural/urban residency, education level, and income). MAIN OUTCOMES AND MEASURES Self-reported use of specific telehealth modalities, reasons for nonuse, and willingness to use videoconferencing in the future. RESULTS A total of 2555 individuals completed the survey with a mean (SD) age of 57.2 (14.2) years; 1453 respondents (weighted percentage, 51.9%) were women, and 2043 (weighted percentage, 73.4%) were White individuals. Overall, 1343 respondents (weighted percentage, 50.8%) reported use of a nontelephone telehealth modality, ranging from 873 respondents (weighted percentage, 31.9%) for patient portals and 89 respondents (weighted percentage, 4.2%) for videoconferencing visits. Although 1309 respondents (weighted percentage, 49.2%) overall answered that they were willing or very willing to use videoconferencing visits, respondents who were Black individuals (OR, 0.58; 95% CI, 0.38-0.91), aged older than 65 years (OR, 0.51; 95% CI, 0.40-0.66), or had less education (high school or less vs advanced degrees: OR, 0.37; 95% CI, 0.25-0.56) were less likely to express willingness. CONCLUSIONS AND RELEVANCE Despite the focused policy attention on videoconferencing visits, the results of this survey study suggest that other forms of telehealth were more dominant prior to 2020. Targeted efforts may be necessary for videoconferencing visits to reach patient groups who are older or have less education, and payer policies supporting other forms of telemedicine may be appropriate to enhance access.
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Affiliation(s)
| | - Kristin N. Ray
- Health Policy Institute, UPMC Community Pediatrics, University of Pittsburgh, Pennsylvania
| | - Ateev Mehrotra
- RAND Corporation, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Abstract
BACKGROUND AND OBJECTIVES Although clinical settings are increasingly screening for social determinants of health, essential questions about optimal screening remain. We aimed to assess primary care contexts of individuals choosing not to answer questions about health-related social needs and to compare screening question response with subsequent use of resource information. METHODS We compared caregiver responses to an electronic survey administered during a child's emergency department visit and through telephone follow-up 2 weeks later by responses to questions about health-related social needs (no social needs endorsed, ≥1 endorsed, none endorsed but ≥1 question not answered). RESULTS Of 146 respondents, 42 (29%) endorsed ≥1 health-related social need. Additionally, 19 (13%) endorsed no social needs but did not answer ≥1 question. Compared with those denying all social needs and those endorsing ≥1 social need, respondents who did not answer social needs screening questions reported longer duration since their child's last primary care visit, lower perceptions of primary care, and less social support. For the 61 respondents participating in the 2-week follow-up survey, reported use of a community resource packet was 37% among those who had reported a social need, 26% among those who had denied all social needs, and 0% among those who had not answered ≥1 social needs questions. CONCLUSIONS Clinicians and systems implementing screening for health-related social risks should plan for individuals who choose not to respond to specific items and may also wish to consider strategies that do not rely on screening and disclosure, particularly in communities known to have high prevalence of social needs.
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Affiliation(s)
- Kristin N Ray
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and .,University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Katherine M Gitz
- University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Allen Hu
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Amani A Davis
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Elizabeth Miller
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and.,University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Uscher-Pines L, Ghosh-Dastidar B, Bogen DL, Ray KN, Demirci JR, Mehrotra A, Kapinos KA. Feasibility and Effectiveness of Telelactation Among Rural Breastfeeding Women. Acad Pediatr 2020; 20:652-659. [PMID: 31629118 DOI: 10.1016/j.acap.2019.10.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/08/2019] [Accepted: 10/12/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the feasibility and impact of telelactation via personal electronic devices on breastfeeding duration and exclusivity among rural women. METHODS The Tele-MILC trial, a pragmatic, parallel design trial, recruited 203 women during their postpartum hospitalization in a critical access hospital in Pennsylvania and randomized them to receive telelactation (n = 102) or usual care (n = 101). We used intent-to-treat (ITT) and instrumental variable (IV) approaches to analyze study data for the 187 participants who completed follow-up. The primary outcomes were any breastfeeding and exclusive breastfeeding at 12 weeks postpartum. RESULTS Among participants in the telelactation arm, 50% (47/94) reported participating in video calls. At 12 weeks, 71% of participants in the telelactation arm versus 68% of control participants were breastfeeding in the ITT model (3% difference, P = .73), whereas 73% of participants in the telelactation arm versus 68% of control participants were breastfeeding in the IV model (5% difference, P = .74). Among participants who were still breastfeeding at 12 weeks, 51% participants in the telelactation arm were breastfeeding exclusively versus 46% of control participants in the ITT model (5% difference, P = .47), whereas 56% of participants in the telelactation arm were breastfeeding exclusively versus 45% of control participants in the IV model (11% difference, P = .48). In all models, participants in the telelactation arm were breastfeeding at higher rates; however, differences were not statistically significant. CONCLUSIONS This trial demonstrated that telelactation can be implemented with a rural underserved population. Though this trial was not powered to detect differences in breastfeeding duration and exclusivity, and none were observed, telelactation remains a promising approach for further investigation. ClinicalTrials.gov Identifier: NCT02870413.
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Affiliation(s)
- Lori Uscher-Pines
- RAND Corporation (L Uscher-Pines, B Ghosh-Dastidar, and KA Kapinos), Arlington, Va.
| | | | - Debra L Bogen
- Department of Pediatrics, University of Pittsburgh School of Medicine (DL Bogen and KN Ray), Pittsburgh, Pa
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine (DL Bogen and KN Ray), Pittsburgh, Pa
| | - Jill R Demirci
- University of Pittsburgh School of Nursing (JR Demirci), Pittsburgh, Pa
| | | | - Kandice A Kapinos
- RAND Corporation (L Uscher-Pines, B Ghosh-Dastidar, and KA Kapinos), Arlington, Va
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Sequeira GM, Ray KN, Miller E, Coulter RWS. Transgender Youth's Disclosure of Gender Identity to Providers Outside of Specialized Gender Centers. J Adolesc Health 2020; 66:691-698. [PMID: 32089449 PMCID: PMC8496159 DOI: 10.1016/j.jadohealth.2019.12.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 12/10/2019] [Accepted: 12/11/2019] [Indexed: 01/21/2023]
Abstract
PURPOSE Transgender youth face significant health disparities and multiple barriers to receiving quality health care. Gender identity disclosure to health care providers (HCPs) is an important step in creating affirming relationships for transgender youth. The objectives of this study were to (1) determine the prevalence of voluntary disclosure and intentional avoidance to HCPs outside of gender clinics, (2) identify factors associated with voluntary disclosure and intentional avoidance, and (3) elucidate strategies to increase comfort with disclosure. METHODS A cross-sectional survey was administered to transgender youth aged 12-26 years. Bivariate analyses were conducted using χ2 or Fisher's exact tests. Two logistic regression models for each outcome variable were used to examine factors associated with voluntary disclosure and intentional avoidance. RESULTS Two thirds (65%) of youth (N = 153) identified as transmasculine, and 57% were under 18 years. Three-quarters (78%) had voluntarily disclosed their gender identity to an HCP outside of gender clinic, whereas 46% had intentionally avoided disclosure. Odds ratios (ORs) of ever having disclosed were lower for participants ≥18 years (OR = .33; 95% confidence interval [CI]: .11-.98), those out to fewer people (OR = .12; 95% CI: .02-.81) and out for <1 year (OR = .03; 95% CI: .004-.31). Odds of intentional avoidance were lower among youth with higher perceived parental support (OR = .83; 95% CI: .70-.98). CONCLUSION A majority of transgender youth reported having voluntarily disclosed their gender identity to an HCP outside of gender clinic, but almost half reported having intentionally avoided disclosure when they felt it was important. Parental support may play a protective role in mitigating avoidance.
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Affiliation(s)
- Gina M. Sequeira
- UPMC Children’s Hospital of Pittsburgh Pittsburgh,
PA, USA 15213,Department of Pediatrics University of Pittsburgh
School of Medicine Pittsburgh, PA 15224
| | - Kristin N. Ray
- Department of Pediatrics University of Pittsburgh
School of Medicine Pittsburgh, PA 15224
| | - Elizabeth Miller
- UPMC Children’s Hospital of Pittsburgh Pittsburgh,
PA, USA 15213,Department of Pediatrics University of Pittsburgh
School of Medicine Pittsburgh, PA 15224
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Abstract
This survey study assesses preferences concerning name and pronoun documentation in the electronic medical record and investigates how these preferences differ by demographic and gender-related characteristics among transgender youths seeking care at a specialty gender clinic.
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Affiliation(s)
- Gina M. Sequeira
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kacie Kidd
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Elizabeth Miller
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert Garofalo
- Division of Adolescent Medicine, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
| | - Kristin N. Ray
- Division of General Academic Pediatrics, Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Verma R, Krishnamurti T, Ray KN. Parent Perspectives on Family-Centered Pediatric Electronic Consultations: Qualitative Study. J Med Internet Res 2020; 22:e16954. [PMID: 32084626 PMCID: PMC7180509 DOI: 10.2196/16954] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/19/2020] [Accepted: 01/26/2020] [Indexed: 01/09/2023] Open
Abstract
Background Electronic consultations, which use store-and-forward transfer of clinical information between a primary care physician and a specialist, improve access to specialty care. Adoption of electronic consultations is beginning in pediatric health care systems, but little is known about parent perspectives, informational needs, and preferences for interaction with this new model of care. Objective This study aimed to examine parent perspectives about electronic consultations, including perceived benefits and risks, anticipated informational needs, and preferences for parent engagement with electronic consultations. Methods We recruited caregivers of pediatric patients (aged 0-21 years) attending visits at an academic primary care center. Caregivers were eligible if their child had ever been referred for in-person specialty care. Caregivers participated in a semistructured interview about electronic consultations, including general perspectives, desired information, and preferences for parental engagement. Interviews were transcribed and qualitatively analyzed to identify parent perspectives on electronic consultations in general, information parents would like to receive about electronic consultations, and perspectives on opportunities to enhance parent engagement with electronic consultations. Results Interviewees (n=20) anticipated that electronic consultations would reduce the time burden of specialty care on families and that these had the potential to improve the integrity and availability of clinical information, but interviewees also expressed concern about data confidentiality. The most detailed information desired by interviewees about electronic consultations related to data security, including data confidentiality, availability, and integrity. Interviewees expressed concern that electronic consultations could exclude parents from their child’s health care decisions. Interviewees saw value in the potential ability to track the consultation status or to participate in the consultation dialogue, but they were more ambivalent about the idea of read-only access to consultation documentation. Conclusions Parents identified the potential risks and benefits of pediatric electronic consultations, with implications for communication with families about electronic consultations and for incorporation of features to enhance parent engagement.
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Affiliation(s)
- Rhea Verma
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Tamar Krishnamurti
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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Ray KN, Zickafoose J, Garg A. Advancing the Dissemination of Innovations in Pediatric Health Care Delivery. Acad Pediatr 2020; 20:306-307. [PMID: 31812784 DOI: 10.1016/j.acap.2019.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 11/28/2019] [Accepted: 12/01/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, (Kristin N. Ray) Pittsburgh, Pa.
| | - Joseph Zickafoose
- Mathematica Policy Research (Joseph Zickafoose), Nashville, Tenn; Department of Pediatrics, Vanderbilt University Medical Center, (Joseph Zickafoose) Nashville, Tenn
| | - Arvin Garg
- Department of Pediatrics, Boston Medical Center/Boston University School of Medicine, (Arvin Garg) Boston, Mass
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Abstract
IMPORTANCE Primary care is the foundation of pediatric care. While policy interventions have focused on improving access and quality of primary care, trends in overall use of primary care among children have not been described. OBJECTIVE To assess trends in primary care visit rates and out-of-pocket costs, to examine variation in these trends by patient and visit characteristics, and to assess shifts to alternative care options (eg, retail clinics, urgent care, and telemedicine). DESIGN, SETTING, AND PARTICIPANTS Observational cohort study of claims data from 2008 to 2016 for children 17 years and younger covered by a large national commercial health plan. Visit rate per 100 child-years was determined for each year overall, by child and geographic characteristics, and by visit type (eg, primary diagnosis), and trends were assessed with a series of child-year Poisson models. Data were analyzed from November 2017 to September 2019. MAIN OUTCOMES AND MEASURES Visits to primary care and other settings. RESULTS This cohort study included more than 71 million pediatric primary care visits over 29 million pediatric child-years (51% male in 2008 and 2016; 37% between 12-17 years in 2008 and 38% between 12-17 years in 2016). Unadjusted results for primary care visit rates per 100 child-years decreased from 259.6 in 2008 to 227.2 in 2016, yielding a regression-estimated change in primary care visits across the 9 years of -14.4% (95% CI, -15.0% to -13.9%; absolute change: -32.4 visits per 100 child-years). After controlling for shifts in demographics, the relative decrease was -12.8% (95% CI, -13.3% to -12.2%). Preventive care visits per 100 child-years increased from 74.9 in 2008 to 83.2 visits in 2016 (9.9% change in visit rate; 95% CI, 9.0%-10.9%; absolute change: 8.3 visits per 100 child-years), while problem-based visits per 100 child-years decreased from 184.7 in 2008 to 144.1 in 2016 (-24.1%; 95% CI, -24.6% to -23.5%; absolute change: -40.6 visits per 100 child-years). Visit rates decreased for all diagnostic groups except for the behavioral and psychiatric category. Out-of-pocket costs for problem-based primary care visits increased by 42% during the same period. Per 100 child-years, visits to other acute care venues increased from 21.3 to 27.6 (30.3%; 95% CI, 28.5% to 32.1%; absolute change: 6.3 visits per 100 child-years) and visits to specialists from 45.2 to 53.5 (16.4%; 95% CI, 14.8% to 18.0%, absolute change: 8.3 visits per 100 child-years). CONCLUSIONS AND RELEVANCE Primary care visit rates among commercially insured children decreased over the last decade. Increases in out-of-pocket costs and shifts to other venues appear to explain some of this decrease.
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Affiliation(s)
- Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Zhuo Shi
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Ishani Ganguli
- Department of Medicine, Harvard Medical School, Boston, Massachusetts,Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Aarti Rao
- Icahn School of Medicine at Mt Sinai, New York City, New York
| | - E. John Orav
- Department of Medicine, Harvard Medical School, Boston, Massachusetts,Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts,Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Ganguli I, Shi Z, Orav EJ, Rao A, Ray KN, Mehrotra A. Declining Use of Primary Care Among Commercially Insured Adults in the United States, 2008-2016. Ann Intern Med 2020; 172:240-247. [PMID: 32016285 DOI: 10.7326/m19-1834] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Primary care is known to improve outcomes and lower health care costs, prompting recent U.S. policy efforts to expand its role. Nonetheless, there is early evidence of a decline in per capita primary care visit rates, and little is understood about what is contributing to the decline. OBJECTIVE To describe primary care provider (PCP) visit trends among adults enrolled with a large, national, commercial insurer and assess factors underlying a potential decline in PCP visits. DESIGN Descriptive repeated cross-sectional study using 100% deidentified claims data from the insurer, 2008-2016. A 5% claims sample was used for Poisson regression models to quantify visit trends. SETTING National, population-based. PARTICIPANTS Adult health plan members aged 18 to 64 years. MEASUREMENTS PCP visit rates per 100 member-years. RESULTS In total, 142 million primary care visits among 94 million member-years were examined. Visits to PCPs declined by 24.2%, from 169.5 to 134.3 visits per 100 member-years, while the proportion of adults with no PCP visits in a given year rose from 38.1% to 46.4%. Rates of visits addressing low-acuity conditions decreased by 47.7% (95% CI, -48.1% to -47.3%). The decline was largest among the youngest adults (-27.6% [CI, -28.2% to -27.1%]), those without chronic conditions (-26.4% [CI, -26.7% to -26.1%]), and those living in the lowest-income areas (-31.4% [CI, -31.8% to -30.9%]). Out-of-pocket cost per problem-based visit rose by $9.4 (31.5%). Visit rates to specialists remained stable (-0.08% [CI, -0.56% to 0.40%]), and visits to alternative venues, such as urgent care clinics, increased by 46.9% (CI, 45.8% to 48.1%). LIMITATION Data were limited to a single commercial insurer and did not capture nonbilled clinician-patient interactions. CONCLUSION Commercially insured adults have been visiting PCPs less often, and nearly one half had no PCP visits in a given year by 2016. Our results suggest that this decline may be explained by decreased real or perceived visit needs, financial deterrents, and use of alternative sources of care. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts (I.G., Z.S., E.J.O., A.M.)
| | - Zhuo Shi
- Harvard Medical School, Boston, Massachusetts (I.G., Z.S., E.J.O., A.M.)
| | - E John Orav
- Harvard Medical School, Boston, Massachusetts (I.G., Z.S., E.J.O., A.M.)
| | - Aarti Rao
- Icahn School of Medicine at Mount Sinai, New York City, New York (A.R.)
| | - Kristin N Ray
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (K.N.R.)
| | - Ateev Mehrotra
- Harvard Medical School, Boston, Massachusetts (I.G., Z.S., E.J.O., A.M.)
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