Parent Perspectives on Adverse Childhood Experiences & Unmet Social Needs Screening in the Medical Home: A Qualitative Study

OBJECTIVES

To explore parental perspectives regarding disclosure of child and parental adverse childhood experiences (ACE) and family unmet social needs (USN) and to elicit parental recommendations for screening in the pediatric medical home.

METHODS

We conducted a qualitative study using a purposive sample of English- and Spanish-speaking parents in our urban academic community clinic. Between January 2018 and March 2019, each parent underwent one semistructured interview that was audiotaped, transcribed, and independently coded in Atlas.ti by 2 study team members. Data analysis was based in constructivist grounded theory methodology to identify common themes and subthemes.

RESULTS

We interviewed 25 English-speaking and 15 Spanish-speaking parents who were mostly female, racial/ethnic minorities with ≥1 ACE. English-speaking subjects were more likely to have a high school degree and be single parents. Four themes were identified: 1) Pediatricians should ask about ACE and USN. 2) Disclosure is a longitudinal process, not a discrete event. 3) Barriers to disclosure are significant, involving concrete and emotional risks for the family. 4) Trauma-informed providers and practices support disclosure.

CONCLUSIONS

Families support pediatricians addressing ACE and USN in the medical home despite significant barriers. Even if providers screen using trauma-informed principles, parents may prefer not to disclose ACE initially because they regard disclosure as a stepwise process. These findings contribute to a new conceptual framework for thinking of ACE screening not merely as a way to generate information, but as an interactive, therapeutic relationship-building activity irrespective of whether or when it produces disclosure.

Implementing Emotional Debriefing in Pediatric Clinical Education

Challenging situations and intense emotions are inherent to clinical practice. Failure to address these emotions has been associated with health care provider burnout. One way to combat this burnout and increase resilience is participation in emotional debriefing. Although there are many models of emotional debriefings, these are not commonly performed in clinical practice. We provide a guide for implementing emotional debriefing training utilizing the American Academy of Pediatrics Resilience Curriculum into clinical training programs, with a focus on preparing senior residents and fellows to act as debriefing facilitators. Senior residents and fellows can provide in-the-moment emotional debriefing which allows for greater health care provider participation, including medical students and other pediatric trainees. Training of senior residents and fellows may allow more frequent emotional debriefing and in turn may help to improve the resilience of pediatricians when they face challenging situations in clinical practice.

Screening for Toxic Stress Risk Factors at Well-Child Visits: The Addressing Social Key Questions for Health Study

OBJECTIVES

To determine the prevalence of and demographic characteristics associated with toxic stress risk factors by universal screening, the impact of screening on referral rates to community resources, and the feasibility and acceptability of screening in a medical home setting.

STUDY DESIGN

We developed the Addressing Social Key Questions for Health Questionnaire, a 13-question screen of adverse childhood experiences (ACEs) and unmet social needs. Parents/guardians of children 0-17 years of age received this questionnaire at well-child visits at 4 academic clinics from August 1, 2016 to February 28, 2017. Providers reviewed the tool and referred to community resources as needed. A subset of families completed demographic and satisfaction surveys. Prevalence of ACEs and unmet social needs, community referral rates at 1 site with available data, and family acceptability data were collected. Analyses included frequency distributions, χ² tests, and Poisson regression.

RESULTS

Of 2569 families completing an Addressing Social Key Questions for Health Questionnaire, 49% reported ≥1 stressor; 6% had ≥1 ACE; 47% had ≥1 unmet social need. At 1 site, community referral rates increased from 2.0% to 13.3% (P < .0001) after screening implementation. Risk factors for having a stressor include male sex and African American or Hispanic race. 86% of 446 families want clinics to continue screening.

CONCLUSIONS

Universal screening for toxic stress risk factors in pediatric primary care improved identification and management of family needs. Screening was feasible and acceptable to families. Prevalence of unmet social needs but not ACEs was comparable with prior studies. Further evaluation and modification of the screening protocol is needed to increase screening and identification.

Acculturation Needs of Pediatric International Medical Graduates: A Qualitative Study

Phenomenon: International medical graduates (IMGs) play a key role in host countries' health systems but face unique challenges, which makes effective, tailored support for IMGs essential. Prior literature describing the acculturation needs of IMGs focused primarily on communication content and style. We conducted a qualitative study to explore acculturation that might be specific to IMG residents who care for children.

APPROACH

In a study conducted from November 2011 to April 2012, we performed four 90-minute semistructured focus groups with 26 pediatric IMG residents from 12 countries. The focus group transcripts were analyzed using open and focused coding methodology.

FINDINGS

The focus groups and subsequent analysis demonstrated that pediatric IMG residents' socialization to their home culture impacts their transition to practice in the United States; they must adjust not only to a U.S. culture, different from their own, but also to the culture of medicine in the United States. We identified the following new acculturation themes: understanding the education system and family structure, social determinants of health, communication with African American parents, contraception, physician handoffs, physicians' role in prevention, adolescent health, and physicians' role in child advocacy. We further highlight the acculturation challenges faced by pediatric IMG residents and offer brief recommendations for the creation of a deliberate acculturation curriculum for pediatric IMG residents. Insight: Residency training is a unique period in physicians' personal and professional development and can be particularly challenging for IMGs. There is a significant gap in the identified acculturation needs and the current curricula available to IMG residents who care for children.

Influenza vaccine for high-risk non-elderly adults: a national survey of subspecialists

Despite long-standing recommendations for non-elderly adults with certain chronic pulmonary, cardiovascular and metabolic conditions to receive influenza vaccine, vaccination rates remain low. Visits to subspecialists represent an important vaccination opportunity, but little is known regarding subspecialists' perceptions related to influenza vaccination. In February 2003, we conducted a cross-sectional mail survey of a random sample (N = 2,007) of board-certified cardiologists, endocrinologists and pulmonologists from the entire United States who provided outpatient care to adults aged 18-64 years, to assess their patterns of and attitudes toward administering influenza vaccine to high-risk, non-elderly patients. The overall response rate was 33%. Among 621 eligible respondents, 483 stocked influenza vaccine in their practice (Stockers) and 138 did not stock the vaccine (Non-Stockers). Pulmonologists were most likely to stock vaccine and strongly recommend vaccination; cardiologists were least likely. Among Stockers, barriers to vaccination varied by subspecialty. Among Non-Stockers, the most common factor in the decision to not stock vaccine was the perception that patients will receive the vaccine elsewhere. Most subspecialists who provide care to a large proportion of high-risk, non-elderly persons recommend influenza vaccination to some degree, particularly pulmonologists. To reduce missed opportunities overall, subspecialists should be encouraged to vaccinate patients who say that they plan to get the vaccine elsewhere. For cardiologists in particular, barriers to stocking influenza vaccine and recommending vaccination more strongly must be addressed.

Interventions to curb the overuse of Acid-suppressive medications on an inpatient general medicine service

PURPOSE

We conducted a study to measure the impact of three sequential levels of intervention on prescribing patterns of acid-suppressive medications (ASMs) on an inpatient internal medicine service at a university hospital.

METHODS

THIS RETROSPECTIVE REVIEW COMPARED PRESCRIBING PATTERNS ON FOUR DIFFERENT TIERS: a phase 1 study, conducted one year before the phase 2 intervention study; and three phase 2 interventions. Each group was assessed for the percentage of all patients receiving ASMs and the percentage of patients receiving these drugs with an inappropriate indication. The three phase 2 studies are described in this article.

RESULTS

Intervention A (a beginning-of-year lecture to all interns) was not enough to decrease total in-hospital use of these medications, compared with the phase 1 historical controls (62% vs. 66%, respectively); however, it did decrease the rate of inappropriate use from 59% to 37% (P < 0.001). When Intervention B (an early-in-the-month rotation "reminder lecture") was added, the volume of agents used was significantly reduced to 53% (P = 0.025) and the number of inappropriate prescriptions was reduced to 32% (P < 0.001), compared with rates in phase 1. Finally, when Intervention C (a clinical pharmacist making rounds with the health care team on most post-call days) was added to Interventions A and B, the total volume of drug use in the hospital declined to 53% (P = 0.025) and the number of inappropriate prescriptions fell to 19%, compared with rates in phase 1 (P < 0.001).

CONCLUSION

Providing educational lectures for interns was helpful in curbing the inappropriate prescribing of ASMs, but the benefit was augmented when a clinical pharmacist was added to the team.