Ada M. Fenick

OBSESSIONALITY IN EATING-DISORDER PATIENTS: RELATIONSHIP TO CLINICAL PRESENTATION AND TWO-YEAR OUTCOME

Obsessionality and obsessive-compulsive symptoms have been regarded as important characteristics in the clinical presentation of the eating disorders. In this report, we examined the relation between obsessionality and the clinical presentation and outcome of a sample of eating-disordered patients. Self-rated obsessional symptoms, defined by the obsessive-compulsive subscale of the Symptom Checklist 90 (revised version), were compared with presenting clinical symptomatology, and scores on the Eating Disorder Inventory (EDI) and Beck Depression Inventory (BDI) in a sample of 110 consecutively evaluated women who met DSM-IIIR criteria for eating disorders. Forty patients were contacted for a follow-up investigation, 2 years after the initial evaluation. Higher obsessive-compulsive subscale scores at presentation were associated with more severe dieting, a greater number of psychiatric hospitalizations, and higher EDI, SCL-90R and BDI scores. Initial obsessive-compulsive scores did not predict the subsequent outcome of a sample of these patients in the community. However, elevated obsessive-compulsive scores obtained at follow-up were associated with the presence of lower body weight and more severe eating-disorder symptoms at that time. These results support the hypothesis that elevated obsessionality is associated with more severe eating disorder symptomatology. In addition, obsessional symptoms change along with those of the eating disorder, and their persistence may be associated with a poorer outcome.

Group Well-Child Care An Analysis of Cost

Objective. To determine if group well-child visits (WCV) can be cost neutral compared with individual WCV by varying health care providers, group size, and physician salary. Method. We created 6 economic models to evaluate the costs of WCV: 3 for individual WCV delivered by (1) advanced practice registered nurse (APRN), (2) resident, and (3) attending and 3 for group WCV delivered by (4) APRN with a nurse and social worker; (5) resident with an attending, nurse, and child life specialist; and (6)attending with a nurse. For group WCV, we performed sensitivity analyses on group size and duration of provider participation. Results. We achieved cost-neutrality at 4 families in the APRN group WCV model; at 3, 4, 5, and 6 families in the resident model with 30, 45, 60, and 90 minutes of attending supervision, respectively; and at 4 and 5 families in the low and high attending salary model, respectively. Conclusion. Group WCV can be delivered in a cost-neutral manner by optimizing group size and provider participation.

A Healthy Weight for Toddlers? Two-Year Follow-up of a Randomized Controlled Trial of Group Well-Child Care

Rapid weight gain during the first year of life is associated with childhood obesity, adult obesity, and all its concomitant morbidities. Over the past 30 years, obesity among children 2 to 5 years old doubled. As pediatric health care providers interact with young families routinely throughout the first few years of life, they may be in an ideal position to influence the rate of weight gain. Innovations in care are needed: although past interventions have demonstrated that intensive anticipatory guidance leads to improved diet and eating habits, within the current system of 12to 18-minute well-child visits, it is unlikely that pediatric providers can provide this additional support. Group well-child care, one such innovation, the provision of well-child care to 4 to 8 infant/parent dyads, allows providers greater interaction with patients. Prior analyses of group well-child care have found that group visits allow increased time for education, modeling behaviors, and parent-to-parent support. In group well-child care, there is an emphasis on maternal/infant relationships and parental selfefficacy, both of which have been associated with less obesity among preschool children, school-age children, and adolescents. We, thus, designed a follow-up study of participants in a group well-child randomized controlled trial (RCT) at Yale New Haven Hospital (YNHH) to determine the impact of group well-child care on childhood obesity. This study is a follow-up of our initial RCT, conducted in 2008-2009. For the initial study, inclusion criteria were a mother/infant dyad with the infant in the mother’s care, gestation ≥37 weeks and born at YNHH, planning to use the YNHH primary care center (PCC), and with English as the primary language. On consenting to participate in the study, the mother/infant dyad was randomized to receive either group or individual care. In both arms, mother/infant dyads received the initial pediatric assessment at 2 to 4 days of life in a traditional model by a pediatric resident or a nurse practitioner (NP). In the control arm, for the first year of life, dyads received standard individual care provided by pediatric residents or NPs in the YNHH PCC. In the experimental arm, for the first year of life, dyads received all pediatric primary care in the group setting, led by NPs. The group well-child care intervention consisted of eight 90minute sessions through the first year of life when the children were 2 weeks, 1 month, 2 months, 3 months, 4 months, 6 months, 9 months, and 12 months old. After 1 year, all dyads received pediatric primary care in the traditional model. Initially, 97 dyads were enrolled; 55 were allocated to treatment and 42 to control. Mothers in both arms completed questionnaires within the first month of the infant’s life and after their children were 12 months old. The data from the children of the 63 mothers who completed the survey at both baseline and 12 months—40 of whom were assigned to group and 23 to individual wellchild care—are included in this analysis. We collected data through retrospective chart review of electronic medical records from the pediatric primary care outpatient records and participants of the original RCT using the infant’s name and date of birth. We abstracted data on health behavior variables, height, weight, and body mass index (BMI) from records at 24 months, 30 months, and 36 months. We defined loss to follow-up as attrition from the sample by the 24-, 30-, or 36-month visit. The Yale Medicine Human Investigation Committee approved this study protocol. To assess nutritional behaviors, we selected variables reflective of the priorities of the 5-2-1-0 Let’s Go initiative by the American Academy of Pediatrics, including the consumption of 5 or more servings of fruits or vegetables in 1 day, 2 hours or fewer of screen time, participation in a minimum of 1 hour of physical activity, and 623230 CPJXXX10.1177/0009922815623230Clinical PediatricsShah et al research-article2016

Using a scripted data entry process to transfer legacy immunization data while transitioning between electronic medical record systems.

BACKGROUND Transitioning between Electronic Medical Records (EMR) can result in patient data being stranded in legacy systems with subsequent failure to provide appropriate patient care. Manual chart abstraction is labor intensive, error-prone, and difficult to institute for immunizations on a systems level in a timely fashion. OBJECTIVES We sought to transfer immunization data from two of our health systems soon to be replaced EMRs to the future EMR using a single process instead of separate interfaces for each facility. METHODS We used scripted data entry, a process where a computer automates manual data entry, to insert data into the future EMR. Using the Center for Disease Controls CVX immunization codes we developed a bridge between immunization identifiers within our systems EMRs. We performed a two-step process evaluation of the data transfer using automated data comparison and manual chart review. RESULTS We completed the data migration from two facilities in 16.8 hours with no data loss or corruption. We successfully populated the future EMR with 99.16% of our legacy immunization data - 500,906 records - just prior to our EMR transition date. A subset of immunizations, first recognized during clinical care, had not originally been extracted from the legacy systems. Once identified, this data - 1,695 records - was migrated using the same process with minimal additional effort. CONCLUSIONS Scripted data entry for immunizations is more accurate than published estimates for manual data entry and we completed our data transfer in 1.2% of the total time we predicted for manual data entry. Performing this process before EMR conversion helped identify obstacles to data migration. Drawing upon this work, we will reuse this process for other healthcare facilities in our health system as they transition to the future EMR.

Immunization requirements of the top 200 universities: Implications for vaccine-hesitant families

BACKGROUND The majority of pediatricians encounter vaccine hesitancy in their practices. As part of a broad discussion about vaccination, school requirements arise as a topic yet providers may lack information about the effects of immunization on university matriculation. METHODS We surveyed the top-ranked 200 universities regarding required immunizations, medical, religious, and philosophical exemptions, and noncompliance policies. We examined the legal requirements for involved jurisdictions. RESULTS Of 129 responding universities (64%), 94% had ≥1 pre-matriculation immunization requirement (PIR), with a mean of 3.53 (95%CI 3.17-3.89) requirements. In unadjusted analyses, funding, region, jurisdictional requirements, undergraduate size, and tuition were significant predictors of the number of PIRs. In multivariate modeling, jurisdictional requirements outperformed all other university demographics, but excluding these, Northeast and South region and smaller undergraduate size persisted. The most common PIR was measles (93%). 67% of involved jurisdictions have laws mandating ≥1 university PIR, and 45% of universities surpassed their jurisdictions law. With respect to medical, religious, and philosophical exemptions, 24%, 40%, and 60% of universities with PIRs had the highest hardship category, and 2%, 2%, and 46% disallowed these outright. Frequent responses to student noncompliance were: hold on classes (89%), additional registration fees (13%), and hold on housing (11%). CONCLUSIONS Requirements for pre-matriculation immunizations in top universities are common and exemptions are difficult to obtain. Conversations between providers and vaccine-hesitant families may be enriched by discussion of these future effects of their decision on immunization.

Use of extramural ambulatory care curricula in postgraduate medical training

IntroductionExtramural curricula developed for the purpose of sharing with other institutions have been designed to improve education on important topics in ambulatory care. We sought to assess the usage rates of these curricula among paediatric, internal medicine, and combined medicine-paediatrics residency programmes in the United States.MethodsSurveys on aspects of trainee continuity clinic were sent to paediatric and medicine-paediatrics programme directors in 2012. Surveys contained an item asking respondents about their use of extramural ambulatory care curricula. Since no similar recent data were available for internal medicine, and to verify the accuracy of the paediatric survey data, we queried the editors of four widely used curricula for subscription information. Descriptive and inferential statistics were calculated.ResultsResponses from paediatric programmes indicated that 48 of 111 (43 %) were using an extramural curriculum, compared with 39 of 60 (65 %) medicine-paediatrics programmes (p = 0.007). Editor query revealed a collective subscription rate of internal medicine programmes (300 of 402, 75 %), which was greater than the subscription rate of paediatric programmes (90 of 201, 45 %) (p < 0.001).DiscussionTraining programmes in paediatrics, internal medicine, and combined medicine-paediatrics utilize extramural curricula to guide education in ambulatory care, but internal medicine and medicine-paediatrics programmes employ these curricula at greater rates than paediatric programmes.

Community partnership for healthy sleep: Research protocol

Beginning early in life, sleep health, including adequate quality, quantity, and consistent sleep routines, is critical to growth and development, behavior, and mental and physical health. Children who live in economically stressed urban environments are at particular risk for sleep deficiency and its negative consequences. Although efficacious sleep health interventions are available, few address the context of economically stressed urban environments. The purpose of this paper is to describe a two-phase protocol for an ongoing NIH/NINR-funded community-engaged study designed to understand the perspectives of parents, community child care and pediatric health care providers about sleep habits, factors that contribute to sleep and sleep habits, sleep difficulty, and potentially useful sleep promotion strategies among children living in economically stressed urban environments. The social-ecological model guides this study. Phase I employs a convergent mixed-methods design, in which we are conducting semi-structured interviews with parents, childcare providers, and primary health care providers. We are collecting 9 days of objective sleep data (wrist actigraphy) from children who are 6-18 months (n = 15) and 19-36 months of age (n = 15) and parent reports of sleep and sleep-related factors using standard questionnaires. In Phase I, we will use a qualitative descriptive approach to analyze the interview data, and descriptive statistics to analyze the survey and actigraph data. In Phase II, we will use the information to develop a contextually relevant program to promote sleep health. Our long-term goal is to improve sleep health and sleep-related outcomes in these children.

Integration of Primary Care and Psychiatry: A New Paradigm for Medical Student Clerkships

BackgroundPublic health crises in primary care and psychiatry have prompted development of innovative, integrated care models, yet undergraduate medical education is not currently designed to prepare future physicians to work within such systems.AimTo implement an integrated primary care–psychiatry clerkship for third-year medical students.SettingUndergraduate medical education, amid institutional curriculum reform.ParticipantsTwo hundred thirty-seven medical students participated in the clerkship in academic years 2015–2017.Program DescriptionEducators in psychiatry, internal medicine, and pediatrics developed a 12-week integrated Biopsychosocial Approach to Health (BAH)/Primary Care–Psychiatry Clerkship. The clerkship provides students clinical experience in primary care, psychiatry, and integrated care settings, and a longitudinal, integrated didactic series covering key areas of interface between the two disciplines.Program EvaluationStudents reported satisfaction with the clerkship overall, rating it 3.9–4.3 on a 1–5 Likert scale, but many found its clinical curriculum and administrative organization disorienting. Students appreciated the conceptual rationale integrating primary care and psychiatry more in the classroom setting than in the clinical setting.ConclusionsWhile preliminary clerkship outcomes are promising, further optimization and evaluation of clinical and classroom curricula are ongoing. This novel educational paradigm is one model for preparing students for the integrated healthcare system of the twenty-first century.

Perceptions of Pediatric Residents Regarding Counseling About Use of Social Networking Sites

Increasing use of social networking sites (SNS) among youth prompted professional organizations to urge pediatricians to promote healthy media use. Electronic questionnaires were distributed to 76 pediatric residents at one academic center measuring attitudes, practices, and familiarity with SNS. Of 43 respondents (response rate = 57%), most reported personal SNS use (98%) and familiarity with SNS used by youth (72%), and 88% agreed that pediatricians should provide counseling on SNS use. Only 5% felt they had adequate training on SNS use in children, and just 26% felt comfortable advising families. Residents were less likely to discuss SNS use than general media use (19% vs 56%, P = .007). Media counseling was correlated with SNS counseling (r = .38, P = .01). Pediatric residents recognize the importance of guiding families on SNS use, yet do not routinely provide counseling despite high levels of personal SNS use and familiarity. Focused training is necessary for pediatricians to prioritize practical guidance.

Pediatric Residents' Perspective on Family-Clinician Discordance in Primary Care: A Qualitative Study

Abstract:The engagement of families in health maintenance is associated with better child health outcomes, but demographic discordance between families and clinicians may be a barrier to family engagement. Using a longitudinal qualitative study design, we conducted 15 semi-structured interviews with five pediatric residents who elected to facilitate group well child care (GWCC). Four themes describing residents’ perceptions of the role of discordance in family-clinician engagement include: 1) discordance was not a barrier; 2) discordance leads to a lack of engagement and trust; 3) residents transcended discordance in GWCC because either GWCC led residents to change their communication techniques or because, with GWCC, parents have concordant adults in the room; and 4) the education residents obtained in GWCC allowed them to empathize with the families’ health-related decisions. Finding ways in which pediatric providers can improve skills in family engagement may be an important step in decreasing health inequities.