Well-Child Care Clinical Practice Redesign for Serving Low-Income Children

Coker TR(1), Moreno C(2), Shekelle PG(3), Schuster MA(4), Chung PJ(5).

Our objective was to conduct a rigorous, structured process to create a new model of well-child care (WCC) in collaboration with a multisite community health center and 2 small, independent practices serving predominantly Medicaid-insured children. Working groups of clinicians, staff, and parents (called “Community Advisory Boards” [CABs]) used (1) perspectives of WCC stakeholders and (2) a literature review of WCC practice redesign to create 4 comprehensive WCC models for children ages 0 to 3 years. An expert panel, following a modified version of the Rand/UCLA Appropriateness Method, rated each model for potential effectiveness on 4 domains: (1) receipt of recommended services, (2) family-centeredness, (3) timely and appropriate follow-up, and (4) feasibility and efficiency. Results were provided to the CABs for selection of a final model to implement. The newly developed models rely heavily on a health educator for anticipatory guidance and developmental, behavioral, and psychosocial surveillance and screening. Each model allots a small amount of time with the pediatrician to perform a brief physical examination and to address parents' physical health concerns. A secure Web-based tool customizes the visit to parents' needs and facilitates previsit screening. Scheduled, non–face-to-face methods (text, phone) for parent communication with the health care team are also critical to these new models of care. A structured process that engages small community practices and community health centers in clinical practice redesign can produce comprehensive, site-specific, and innovative models for delivery of WCC. This process, as well as the models developed, may be applicable to other small practices and clinics interested in practice redesign.


Effect of intervention aimed at increasing physical activity, reducing sedentary behaviour, and increasing fruit and vegetable consumption in children: Active for Life Year 5 (AFLY5) school based cluster randomised controlled trial.

Kipping RR, Howe LD, Jago R, et al.  BMJ. 2014 May 27;348:g3256. doi: 10.1136/bmj.g3256. (Original) PMID: 24865166

OBJECTIVE: To investigate the effectiveness of a school based intervention to increase physical activity, reduce sedentary behaviour, and increase fruit and vegetable consumption in children.

DESIGN: Cluster randomised controlled trial.
SETTING: 60 primary schools in the south west of England.
PARTICIPANTS: Primary school children who were in school year 4 (age 8-9 years) at recruitment and baseline assessment, in year 5 during the intervention, and at the end of year 5 (age 9-10) at follow-up assessment.
INTERVENTIONS: The Active for Life Year 5 (AFLY5) intervention consisted of teacher training, provision of lesson and child-parent interactive homework plans, all materials required for lessons and homework, and written materials for school newsletters and parents. The intervention was delivered when children were in school year 5 (age 9-10 years). Schools allocated to control received standard teaching.
MAIN OUTCOME MEASURES: The pre-specified primary outcomes were accelerometer assessed minutes of moderate to vigorous physical activity per day, accelerometer assessed minutes of sedentary behaviour per day, and reported daily consumption of servings of fruit and vegetables.
RESULTS: 60 schools with more than 2221 children were recruited; valid data were available for fruit and vegetable consumption for 2121 children, for accelerometer assessed physical activity and sedentary behaviour for 1252 children, and for secondary outcomes for between 1825 and 2212 children for the main analyses. None of the three primary outcomes differed between children in schools allocated to the AFLY5 intervention and those allocated to the control group. The difference in means comparing the intervention group with the control group was -1.35 (95% confidence interval -5.29 to 2.59) minutes per day for moderate to vigorous physical activity, -0.11 (-9.71 to 9.49) minutes per day for sedentary behaviour, and 0.08 (-0.12 to 0.28) servings per day for fruit and vegetable consumption. The intervention was effective for three out of nine of the secondary outcomes after multiple testing was taken into account: self reported time spent in screen viewing at the weekend (-21 (-37 to -4) minutes per day), self reported servings of snacks per day (-0.22 (-0.38 to -0.05)), and servings of high energy drinks per day (-0.26 (-0.43 to -0.10)) were all reduced. Results from a series of sensitivity analyses testing different assumptions about missing data and from per protocol analyses produced similar results.
CONCLUSION: The findings suggest that the AFLY5 school based intervention is not effective at increasing levels of physical activity, decreasing sedentary behaviour, and increasing fruit and vegetable consumption in primary school children. Change in these activities may require more intensive behavioural interventions with children or upstream interventions at the family and societal level, as well as at the school environment level. These findings have relevance for researchers, policy makers, public health practitioners, and doctors who are involved in health promotion, policy making, and commissioning services.Trial registration Current Controlled Trials ISRCTN50133740.


Sistema GRADE: metodología para la realización de recomendaciones para la práctica clínica.

Sanabria AJ, et al. Sistema GRADE: metodología para la realización de recomendaciones para la práctica clínica. Aten Primaria. 2014. http://dx.doi.org/10.1016/j.aprim.2013.12.013

Las guías de práctica clínica proporcionan recomendaciones sobre los beneficios y desventajas de diferentes intervenciones disponibles en la asistencia sanitaria. Su adecuado desarrollo e implementación permitirían reducir la variabilidad en la práctica clínica, así como mejorar su calidad y su seguridad. El sistema GRADE es una herramienta que permite evaluar la calidad de la evidencia y graduar la fuerza de las recomendaciones en el contexto de desarrollo de guías de práctica clínica, revisiones sistemáticas o evaluación de tecnologías sanitarias. El objetivo de este artículo es describir las principales características del sistema GRADE a través de ejemplos relevantes en el contexto de la atención primaria.


Prevention of Dental Caries in Children From Birth Through Age 5 Years: US Preventive Services Task Force Recommendation Statement

  1. Virginia A. Moyer, MD, MPH 
  2. on behalf of the US Preventive Services Task Force
    1. DESCRIPTION: Update of the 2004 US Preventive Services Task Force (USPSTF) recommendation on prevention of dental caries in preschool-aged children.
      METHODS: The USPSTF reviewed the evidence on prevention of dental caries by primary care clinicians in children 5 years and younger, focusing on screening for caries, assessment of risk for future caries, and the effectiveness of various interventions that have possible benefits in preventing caries.
      POPULATION: This recommendation applies to children age 5 years and younger.
      RECOMMENDATION: The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride. (B recommendation) The USPSTF recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening examinations for dental caries performed by primary care clinicians in children from birth to age 5 years. (I Statement)


Brief Approaches to Developmental-Behavioral Promotion inPrimary Care: Updates on Methods and Technology.

Glascoe FP, Trimm F. Brief Approaches to Developmental-Behavioral Promotion inPrimary Care: Updates on Methods and Technology. Pediatrics. 2014 Apr 28. [Epubahead of print] PubMed PMID: 24777220.

Well-child visits are a critical opportunity to promote learning and development,
encourage positive parenting practices, help children acquire behavioral
self-control, enhance the development and well-being of children and their
families, identify problems not amenable to brief in-office counseling, and refer
for services when needed. This article outlines the communication skills,
instructional methods, and resource options that enable clinicians to best assist
families. Also covered is how to monitor progress and outcomes. A total of 239
articles and 52 Web sites on parent/patient education were reviewed for this
study. Providers require a veritable armamentarium of instructional methods.
Skills in nonverbal and verbal communication are needed to elicit the
parent/patient agenda, winnow topics to a manageable subset, and create the
"teachable moment." Verbal suggestions, with or without standardized spoken
instructions, are useful for conveying simple messages. However, for complex
issues, such as discipline, it is necessary to use a combination of verbal
advice, written information, and "teach-back," aided by role-playing/modeling or 
multimedia approaches. Selecting the approaches most likely to be effective
depends on the topic and family characteristics (eg, parental literacy and
language skills, family psychosocial risk and resilience factors, children's
developmental-behavioral status). When providers collaborate well (with parents, 
patients, and other service providers) and select appropriate educational
methods, families are better able to act on advice, leading to improvements in
children's well-being, health, and developmental-behavioral outcomes. Provided
are descriptions of methods, links to parenting resources such as cell phone
applications, Web sites (in multiple languages), interactive technology, and
parent training courses.

PMID: 24777220  [PubMed - as supplied by publisher]

Validityof Brief Screening Instrument for Adolescent Tobacco, Alcohol, and Drug Use.

Kelly SM, Gryczynski J, Mitchell SG, Kirk A, O'Grady KE, Schwartz RP. Validityof Brief Screening Instrument for Adolescent Tobacco, Alcohol, and Drug Use.Pediatrics. 2014 Apr 21. [Epub ahead of print] PubMed PMID: 24753528; PubMedCentral PMCID: PMC4006430.

BACKGROUND AND OBJECTIVE: The National Institute on Alcohol Abuse and Alcoholism 
developed an alcohol screening instrument for youth based on epidemiologic data. 
This study examines the concurrent validity of this instrument, expanded to
include tobacco and drugs, among pediatric patients, as well as the acceptability
of its self-administration on an iPad.
METHODS: Five hundred and twenty-five patients (54.5% female; 92.8% African
American) aged 12 to 17 completed the Brief Screener for Tobacco, Alcohol, and
other Drugs (BSTAD) via interviewer-administration or self-administration using
an iPad. Diagnostic and Statistical Manual, Fifth Edition substance use disorders
(SUDs) were identified using a modified Composite International Diagnostic
Interview-2 Substance Abuse Module. Receiver operating characteristic curves,
sensitivities, and specificities were obtained to determine optimal cut points on
the BSTAD in relation to SUDs.
RESULTS: One hundred fifty-nine (30.3%) adolescents reported past-year use of ≥1 
substances on the BSTAD: 113 (21.5%) used alcohol, 84 (16.0%) used marijuana, and
50 (9.5%) used tobacco. Optimal cut points for past-year frequency of use items
on the BSTAD to identify SUDs were ≥6 days of tobacco use (sensitivity = 0.95;
specificity = 0.97); ≥2 days of alcohol use (sensitivity = 0.96; specificity =
0.85); and ≥2 days of marijuana use (sensitivity = 0.80; specificity = 0.93).
iPad self-administration was preferred over interviewer administration (z = 5.8; 
P < .001).
CONCLUSIONS: The BSTAD is a promising screening tool for identifying problematic 
tobacco, alcohol, and marijuana use in pediatric settings. Even low frequency of 
substance use among adolescents may indicate need for intervention.

Prenatal Vitamin D and Dental Caries in Infants.

Schroth RJ, Lavelle C, Tate R, Bruce S, Billings RJ, Moffatt ME. PrenatalVitamin D and Dental Caries in Infants. Pediatrics. 2014 Apr 21. [Epub ahead ofprint] PubMed PMID: 24753535.
OBJECTIVES: Inadequate maternal vitamin D (assessed by using 25-hydroxyvitamin D [25OHD]) levels during pregnancy may affect tooth calcification, predisposing enamel hypoplasia and early childhood caries (ECC). The purpose of this study was to determine the relationship between prenatal 25OHD concentrations and dental caries among offspring during the first year of life.
METHODS: This prospective cohort study recruited expectant mothers from an economically disadvantaged urban area. A prenatal questionnaire was completed and serum sample drawn for 25OHD. Dental examinations were completed at 1 year of age while the parent/caregiver completed a questionnaire. The examiner was blinded to mothers’ 25OHD levels. A P value ≤ .05 was considered significant.
RESULTS: Overall, 207 women were enrolled (mean age: 19 ± 5 years). The mean 25OHD level was 48 ± 24 nmol/L, and 33% had deficient levels. Enamel hypoplasia was identified in 22% of infants; 23% had cavitated ECC, and 36% had ECC when white spot lesions were included in the assessment. Mothers of children with ECC had significantly lower 25OHD levels than those whose children were caries-free (41 ± 20 vs 52 ± 27 nmol/L; P = .05). Univariate Poisson regression analysis for the amount of untreated decay revealed an inverse relationship with maternal 25OHD. Logistic regression revealed that enamel hypoplasia (P < .001), infant age (P = .002), and lower prenatal 25OHD levels (P = .02) were significantly associated with ECC.
CONCLUSIONS: This study found that maternal prenatal 25OHD levels may have an influence on the primary dentition and the development of ECC.

Meta-analysis of parental protection of children from tobacco smoke exposure.

BACKGROUND AND OBJECTIVE: Worldwide, roughly 40% of children are exposed to the damaging and sometimes deadly effects of tobacco smoke. Interventions aimed at reducing child tobacco smoke exposure (TSE) have shown mixed results. The objective of this study was to perform a systematic review and meta-analysis to quantify effects of interventions aimed at decreasing child TSE.

METHODS: Data sources included Medline, PubMed, Web of Science, PsycNet, and Embase. Controlled trials that included parents of young children were selected. Two reviewers extracted TSE data, as assessed by parentally-reported exposure or protection (PREP) and biomarkers. Risk ratios and differences were calculated by using the DerSimonian and Laird random-effects model. Exploratory subgroup analyses were performed.

RESULTS: Thirty studies were included. Improvements were observed from baseline to follow-up for parentally-reported and biomarker data in most intervention and control groups. Interventions demonstrated evidence of small benefit to intervention participants at follow-up (PREP: 17 studies, n = 6820, relative risk 1.12, confidence interval [CI] 1.07 to 1.18], P < .0001). Seven percent more children were protected in intervention groups relative to control groups. Intervention parents smoked fewer cigarettes around children at follow-up than did control parents (P = .03). Biomarkers (13 studies, n = 2601) at follow-up suggested lower child exposure among intervention participants (RD -0.05, CI -0.13 to 0.03, P = .20).
CONCLUSIONS: Interventions to prevent child TSE are moderately beneficial at the individual level. Widespread child TSE suggests potential for significant population impact. More research is needed to improve intervention effectiveness and child TSE measurement.


Screening for Suicide Risk in Adolescents, Adults, and Older Adults in Primary Care: U.S. Preventive Services Task Force Recommendation Statement

O'Connor E(1), Gaynes BN, Burda BU, Soh C, Whitlock EP.
Ann Intern Med. 2013 May 21;158(10):741-54. 
[Description: Update of the 2004 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for suicide risk.
Methods: The USPSTF reviewed the evidence on the accuracy and reliability of instruments used to screen for increased suicide risk, benefits and harms of screening for increased suicide risk, and benefits and harms of treatments to prevent suicide.
Population: This recommendation applies to adolescents, adults, and older adults in the general population who do not have an identified psychiatric disorder.
Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in adolescents, adults, and older adults in a primary care setting. (I statement)]
BACKGROUND: In 2009, suicide accounted for 36 897 deaths in the United States.
PURPOSE: To review the accuracy of screening instruments and the efficacy and
safety of screening for and treatment of suicide risk in populations and settings
relevant to primary care.
DATA SOURCES: Citations from MEDLINE, PsycINFO, the Cochrane Central Register of
Controlled Trials, and CINAHL (2002 to 17 July 2012); gray literature; and a
surveillance search of MEDLINE for additional screening trials (July to December
STUDY SELECTION: Fair- or good-quality English-language studies that assessed the
accuracy of screening instruments in primary care or similar populations and
trials of suicide prevention interventions in primary or mental health care
DATA EXTRACTION: One investigator abstracted data; a second checked the
abstraction. Two investigators rated study quality.
DATA SYNTHESIS: Evidence was insufficient to determine the benefits of screening
in primary care populations; very limited evidence identified no serious harms.
Minimal evidence suggested that screening tools can identify some adults at
increased risk for suicide in primary care, but accuracy was lower in studi
eMinimal evidence limited to high-risk populations suggested poor
performance of screening instruments in adolescents. Trial evidence showed that
psychotherapy reduced suicide attempts in high-risk adults but not adolescents.
Most trials were insufficiently powered to detect effects on deaths.
LIMITATION: Treatment evidence was derived from high-risk rather than
screening-detected populations. Evidence relevant to adolescents, older adults,
and racial or ethnic minorities was limited.
CONCLUSION: Primary care-feasible screening tools might help to identify some
adults at increased risk for suicide but have limited ability to detect suicide
risk in adolescents. Psychotherapy may reduce suicide attempts in some high-risk
adults, but effective interventions for high-risk adolescents are not yet proven.
PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.


Eficacia de las políticas institucionales de prevencióndel consumo de alcohol en adolescentes: la opinión de expertos y adolescentesadolescentesCristian Suáreza. Gonzalo del Morala, Gonzalo Musitua,Juan Carlos Sánchez y Bev John Aten Primaria. 2014;xxx(xx):xxx---xxx

ResumenObjetivo: Conocer la opinión de un grupo de adolescentes y profesionales/expertos en adolescencia, familia, escuela, medios de comunicación y políticas locales acerca de la eficacia delas políticas institucionales en la prevención del consumo de alcohol en adolescentes.
Emplazamiento: Cuatro centros educativos de la provincia de Sevilla. Sede central de la Fun-dación Alcohol y Sociedad en Madrid.Diseño: Estudio cualitativo siguiendo el método propuesto por la Teoría fundamentada (Groun-ded theory) (Glaser y Strauss, 1967).
Método: Información obtenida a partir de 10 grupos de discusión guiados por entrevistas semi-estructuradas. Análisis de la información mediante Atlas ti 5.Participantes: Treinta y dos profesionales/expertos nacionales y 40 adolescentes de ambossexos entre 15-20 años residentes en la provincia de Sevilla, seleccionados por muestreo inten-cional teórico.
Resultados: Los expertos consideran eficaces la mayoría de las acciones o medidas preventivasevaluadas mientras que los adolescentes niegan el impacto preventivo de la mayor parte de ellas. Los adolescentes proponen medidas centradas en la reducción de la oferta de alcohol,mientras que los expertos proponen un modelo mixto, en el que se combinen políticas dereducción de la oferta y de la demanda, en función de objetivos específicos a corto y largoplazo.Conclusiones: Se ha obtenido una visión general sobre aquello que según adolescentes y exper-tos es eficaz o ineficaz en la prevención del consumo de alcohol, y acerca de las claves que sedeberían tener en cuenta para diseñar políticas eficaces.